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A
     MANUAL   OF  MIDWIFERY,

                                 OR

                         COMPENDIUM

                                 OF


GYNECOLOGY  AND  PAIDONOSOLOGY;

                             COMPRISING A

       NEW NOMENCLATURE OF  OBSTETRIC  MEDICINE,

                                WITH  A

                    CONCISE ACCOUNT
SYMPTOMS AND TREATMENT OF THE MOST JMrOttlVy>rt("^lS6J3^L£
                 OF WOMEN  AND CHILDREN,
THE  MANAGEME


              PARTURITION:
INT  OF THE  VARIOl/S F(6liftlg OV j\^?v>
             By  MICHAEL JgJ^.N ,   M .  D.
Member of the Royal College of Physicians in London ; Lecturer on Practice of
  Medicine, Obstetricy, and Medical Jurisprudence;  Member of the Council, and
  Secretary oj Foreign Correspondence of the London Medical Society; Member
  of the Council, and Secretary to the Medical Committee of the Medico-Botanical
  Society of London, <J-c. tf-c.
TIE PI de TV? vvvaixsivg (fvOio? xai voor,pariov xa 5t ?.iyo>.
          '                                    inn.
FIRST AMERICAN FROM THE THIRD LONDON EDITION.
      BURLINGTON :
SMITH AND HARRINGTON.

           1835, 
\A/P 
                        TO






JAMES HAMILTON,  Jun.,  M. D., F.  R. S. E.,





      PROFESSOR OF MEDICINE AND MIDWIFERY




                        AND




         DISEASES OF WOMEN AND CHILDREN




                       IN THE





    UNIVERSITY  OF EDINBURGH;





                 THIS VOLUME




                    IS  INSCRIBED




              IN GRATEFUL ACKNOWLEDGMENT




                        OF THX




                 PRACTICAL INFORMATION.




                    DERIVED  FROM




                 HIS LECTURES,





                       BY  HIS OLD PUPIL,





                               THE AUTHOR.





 London, October 1, 1831. 
 
PREFACE.
It has been long remarked that all  our knowledge of any science
might be easily compressed into a small compass, by confining it
to a simple enunciation of fact and  inference.   It appeared to me
that this principle might be applied  with peculiar advantage to the
Science and Practice of Obstetricy; and it was by a rigorous adherence
to it, that I have accomplished this work. My object was to concen-
trate facts and opinions, to describe  them in language as simple as
possible, under such arrangement and classification as would afford
the easiest reference to the  immediate object of research.   I ex-
perienced the want of such a work  during the earlier years of my
practice;  and considered it a great desideratum.  With this  view,
the present "Manual  of Obstetricy" was compiled.  In making
this statement, I wish to be  distinctly understood, as  by no means
insinuating that the elaborate works of preceding writers were im-
perfect.   They were,  however,  too voluminous  for portability,
and not one of them with which I am acquainted, possesses a good
index.  The best of them  contains much  valuable information, of
which there is no account in the contents or index,  and  which is
unobtainable on a sudden emergency.  I have, therefore, endeav-
oured to remedy  this defect, by arranging an alphabetical index ;
which from its  comprehensiveness, approaches in some degree to
a Dictionary of Obstetricy; which  will,  perhaps, prove  conven-
ient and useful. Encouraged by the very flattering approval which
the former editions  of this work have received from the profession
in every part of Europe and in America,  I have spared no  pains
in preparing  this  impression for  the  press.  Every  line of this
Third Edition has been re-written ;  the errata, both typographical 
VI                         PREFACE.
and editorial, have been carefully revised, and such  extensive ad-
ditions made, as to render the  volume  double  its former size.   I
have referred to the last editions of the standard  works on  Obste-
tricy,  especially to those of Professors Hamilton, Denman,  Burns,
Blundell,  Baudelocque, Gardien, Capuron, Maygrier,  Velpeau,
Duges, Hatin, Dewees, Carus, and numerous others,  collated all
important  facts, and condensed them.   Many are the discrepancies
in  the opinions of various authors; many the errors which  have
been committed and carelessly copied into successive treatises, and
which, therefore, require to be exposed and corrected.   In endea-
vouring to correct errors, which is always an ungracious task, it was
my intention not to be too fastidious, nor to find fault without cause
merely to  render this book different from  those  that  preceded it;
on the contrary, I have  maturely  considered  the arguments for
and against every point which  appeared doubtful or dangerous ;
consulted the best authorities upon the subject;  and having given
an impartial view of the matter,  offered my  own opinion, and left
the reader to form his own  conclusion.  In  publishing  this  com-
pendium, my object has been to present students  and young  prac-
titioners with a concise, yet comprehensive, view of the exact state
of Obstetric  knowledge, by compressing into a small space all that
is essential to be known upon the subject.   The  highly favourable
reception which this volume has received, as appears by recorded
reviews, and Gould he  attested  by numerous private testimonies
from many of the most distinguished and celebrated Obstetricians
in these and foreign countries, is the best proof that I did  not  err
in judgement, as some persons imagined, when on its first appear-
ance I ventured to predict success.   The appearance of a Third
Edition in three years is a further proof of the utility of the work.
It is intended as a pocket companion for young and  inexperienced
Obstetricians.  It contains a every fact of importance, and supplies
the deficiencies of the small publications on  this branch of  science
In the smaller works, the Female Diseases of the Genito-Urinary
Organs are not described : Geneseology, or the Physiology of Re-
production ; and Embryology, or the Physiology of the new being, 
PREFACE.
VII
are unnoticed.   Encvonosologv, or Diseases of Pregnancy ;  and
Paidonosology, or Diseases of Infants and children,  are  omitted.
To obviate these defects, the present work  was  undertaken;  and
how 1 have supplied the deficiencies, is not for me to decide.
   Anxious to maintain the importance and utility of this branch of
medicine, and to promote its cultivation, I have  ventured to  pro-
pose an improved nomenclature, which I  am proud to state is ap-
proved of by all men  of classical attainments, and is now univer-
sally adopted by all scientific practitioners, in these and other coun-
tries.  The terminology I have proposed is  the following, and  I
shall  insert it in the order of my classification of the subjects com-
prehended in the terms obstetrics, midwifery, and diseases of wo-
men and children.
   Gynaecology,  gynaecologia (jwcuxsTos feminine, Xo/og discourse,)
history of woman.
   Gynaecotomy, gynaBCOtomia (yuv*j woman, rs^va I cut,) anatomy
of woman.
   Gynaxophysiology, Gynascophysiologia (jvvri woman., (putfig na-
ture, "kayos a discourse), physiology of woman.
   Geneseology,  geneseologia (jivetfig, ysm\ha.i  I  am  born, Xo^og a
discourse), history of generation or procreation.
    Embryology, embryologia (I^Spuov embryo, foetus, Xoyog a dis-
course,) history  of the physiology of the new being.
   Tokology,  tokologia, (roxog birth, Xo/og discourse,) history of
parturition.
   Gynaecopathology,  gynaecopathologia  (yuvrj woman,  iraSog dis-
ease, Xoyog discourse), history of the  diseases of woman.
   Encyonosology,  encyonosologia  (s/xuog pregnant, votfog disease,
Xoyog a discourse), diseases of utero gestation.
   Eutocia (eu well, <roxog parturition,) natural labour.
   Dystocia (5ug  difficulty roxog parturition), difficult labour.
   Chiragotocia  (x^aywxsw  to  draw  with  the  hand, <roxog labour,)
manual parturition.
   Organikotocia (ofyavixog instrumental, roxog labour,) instrumental
parturition. 
Vlll
PREFACE.
    Embryotomy, embryotomia  (t'/x^uov embryo, ts/xvw I cut), dis-
 memberment of the foetus.
    Cephalotomy, cephalotomia (xsqpaXi head, rspw 1 cut), perfora-
 tion of the head.
    Craniotomy, craniotomia (x^aviov head, TSfxvu I cut,) perforation
 of the head.
    Gastrotomy, gastrotomia (yafcr^  belly, rsfivu I cut,) incision of
 the abdominal parieties.
    Gastrohysterotomy,  gastrohysterotomia  (yaoV^  belly,  v<t<rsgu
 womb, ts[ivu I cut,) gastrohysterotomy, Caesarean incision.
    Lochionosology, lochionosologia  (Xo^og a woman in  childbed,
 votfog  disease,  Xoyog disease), history of  diseases  of puerperal
 women.
   Paidonosology, paidonosologia (#ai<5og child, vogog disease, Xoyog
 discourse,) history  of diseases of children.
   In  addition to these terms, I was  the  first to propose  the word
 obstetrician, in place of man-midwife and accoucheur, which was
 soon sanctioned by my distinguished friend Dr. Blundell,  and is
 now generally adopted.
   I have also  introduced the  word  Obstetricy in the London
 Medical and  Surgical Journal (1828), and this is now in use.  M.
 Velpeau published  his  elaborate work,  Traite Elementaire  de
 l'Art  des Accouchemens, ou Principles de Tokologie et'd'Embry-
 ologie, in 1829, and proposed the word Obstetricie for Obsteri-
 que ;  and in a subsequent production  (Remarques sur les Positions
 Vicieuses et de la Version  du Foetus, 1830), does me the honour
 of further notice.   M. Martinet, whose works on Pathology and
 Theraupeutics are so highly estimated in this empire as well as in
 his own country, has approved of my nomenclature, as appears in
 his review of the last edition of this  work, which will be found at
the end  of this volume.  It is but justice to state, that the scien-
tific portion of the profession  in this united kingdom entertain the
same  favourable opinion; but there  are a few persons who, from
 prejudice, antiqated notions, or ignorance, tenaciously support the
old nomenclature, and  prefer such indelicate barbarisms  as  man- 
PREFACE.
IX
midwife, accoucheur, anatomy of the female organs of generation,
&tc, to the more scientific terms.
   The work is divided into four Parts, and each is substituted in-
to Articles and Sections.
   The First Chapter is entitled Gynaecotomy, and comprises the
Anatomy of the Sexual Organs of Women.
   The Second Chapter is headed Gynaecophysiology, and is di-
vided  into  four  Articles; 1.  Nubility ;  2. Utero-gestation, or
Pregnancy;  3. Delivery  ; and 4.  Lactation,  or the  Period of
Suckling.
   The  Third Chapter is  entitled  Gynaecopathology, and is divi-
ded into four Articles; 1. Parthenosology, or diseases of nubility,
or of women in the unimpregnated  state; 2. Encyonosology, or
diseases  of utero-gestation or  pregnancy; 3. Dystocia, difficult
labour, or morbid  parturition; 4. Lochionosology, or diseases of
puerperal women.
   The Fourth Chapter is designated  Paidonosology, or diseases
of infants and children.
   Having now given the reader an idea of the plan and execution
of the work, I  have only  to solicit his indulgence for whatever im-
perfections may occur, for some are inseparable in a production of
this kind.   I owe  it to myself to mention, that no work was ever
arranged amidst a greater multiplicy of engagements.  1  do not
mention  this as a boast, as  my numerous  friends and pupils can
authenticate the  truth  of my  statement.   Actively  engaged in
practice, in lecturing, in conducting a periodical, and  in arranging
my work on Medical Jurisprudence, while my publishers urged
me to supply this  edition, I could have  had little time to attend
to the beauties of style and composition.   The desire of being
concise has sometimes induced  me  to use  elliptical  expressions;
out I  trust they are sufficiently  perspicuous.  I have the great sa-
tisfaction, that the best  judges  have pronounced the work free
from practical errors.  I hope there  will  be found so much useful
aud valuable information in  it, as will counterbalance  its defects,
and introduce it as a text book, a liook of reference and consulta- 
X
PREFACE.
tion;  nor does  this hope originate in  presumption or arrogance;
the favourable reception which my other works have already ex-
perienced from a liberal profession, fully justifies such an expecta-
tion, as I am conscious that I spared no exertions to render this
equal, if not superior to my other productions.
   In conclusion, I beg to express my acknowledgments to the nu-
merous  authors whose works I have laid under contribution;  and
to assure every one of them whose opinions I may have question-
ed, that  my only motive was, to promote the real objects of our
Science—the interests of humanity.
   After the preceding  prefatory  remarks were in print, the  fol-
lowing notice from the  able Editor of the Medico-Chirurgical Re-
view (October 1, lS31,)appeared, which confirms my assertion in
the paragraph before the last.  " We  have,  indeed,  been aston-
ished that Dr. Ryan has been able to  dedicate so much time to
laborious research which this  volume  (Manual of Medical Juris-
prudence,  published  September 1st,)  displays, considering his
other  avocations, as an editor,  a  lecturer, and a practitioner."
The reader will  find further remarks of  a  favourable  kind  from
Dr. Johnson, in  the testimonials annexed; and I may inform him
that I accomplished both works at the same time with the Lon-
don Medical and  Surgical  Journal,  by abridging  the ordinary
time allotted to repose.  This is my  explanation.   I  am, how-
ever, amply compensated,  for the research which was really labo-
rious,  in collecting the materials for this and my other work  when
my efforts are  fairly estimated by the first and best Medical Re-
viewer in these kingdoms,  or indeed in existence.   If my labours
tend to diffuse information, and thereby assist in  the promotion of
science, and the alleviation of human suffering, my object will be
obtained, and I shall have no  reason  to regret  the hours I have
devoted, with the aid  of the midnight  lamp,  to the arrangement
of this or my other productions.
   It may be remarked by  some  cynical critics, that I have esti-
mated this production  too  highly.   They would do well to  look
nearer home;  and before they discover the mote in a neighbour's 
PREFACE.
XI
eye, let them not overlook the very large  beams in their own.
However egotistical they may declare me, they should remember
how fairly this charge applies to some of themselves, when they
puff off their own  vapid and  effete remarks, which are generally-
esteemed contemptible by all who are capable of forming an opin-
ion "Upon them.  They should have common sense enough to be
a little more cautious in  condemning the original labour of others,
which are approved by their superiors, while  they have produced
nothing original themselves.
 
 
         MANUAL

               OF

MIDWIFERY.
The science and art of obstetrics, including diseases  of women
and new-born infants, form  a  very important branch of medical
education, and I have proposed to  denominate them  obstetricy
(ars obstetricia).   This title,  though novel in this country, is not
sufficiently comprehensive, as  we  usually mean by it, not only
what refers to parturition, but all the phenomena which belong to
women, and which are much better expressed by the word gynae-
cology, a term proposed in Germany by Professor Carus, and which
I shall adopt from its accuracy.
  The terms midwifery and obstetrics include the anatomy, physi-
ology, pathology, and  therapeutics peculiar to  women,  together
with the science of  reproduction, its phenomena, its consequences,
parturition,  puerperal, and  infantile diseases.   These  terms are
included with the exception  of the last, in the  word  gynaecology,
and I have expressed them in  the  following language  in  the  first
edition of this work : gynaecotomy, gynaecophysiology, partheno-
sology, geneseology, encyonosology, tocology, lochianosology, and
paidonosology.   Most of these terms are now adopted throughout
the old and the new world.  I  also  endeavoured  to supply the place
of the barbarisms man-midwife, midwifer, accoucheur, and physi-
cian accoucher, and proposed the word obstetrician,—a term sanc-
tioned by Dr. Blundell, and all scientific practitioners.  It is  pre-
ferable to obstetric practitioner. The high terms  of eulogy  in which
the nomenclature above-mentioned has been spoken  of, lead me
to continue it, and to endeavour to render it  more  perfect in  the
following pages. 
2
HYNJCCOTOMY.
CHAPTER I  .
                       GYNiECOTOMY.
 Gynaecotomy comprehends five principal divisions: I. the  pelvis,
 and its annexions; 2. the uterus;  3.  the  internal appendages of
 the uterus;  4. the external appendages; 5. the mammae.

            Article 1.—Of the Pelvis or Basin.
   The obstetric properties of the pelvis can only be  learned  on
 that of an adult female, that is,  of a  subject eighteen or twenty
 years of age, which is that period, in  temperate climates, at which
 a woman is  capable of becoming a mother, with safety to herself
 and to her infant.  At an earlier period of life [the  pelvis is  not
 sufficiently strong or developed, to bear the burthen of pregnancy,
 or force of parturition ; and, at a later period, the  bones which
 form the osseous canal are too firmly articulated,  and their liga-
 ments too firm and strong, to allow the commodious and easy pas-
 sage of the  infant.  Under both of these  circumstances, women
 purchase the pleasures of maternity at a very dear rate, generally
 at the risk of their own and their infants'  lives.  We therefore
 take a pelvis at the adult age as a standard one.

      Section 1.— Of the Bones which compose the Pelvis.
   The pelvis or Basin, in the human subject, is situated below
 the vertebral column or spine, which it supports, and above the infe-
 rior extremities which support it.   It is a bony  canal, which forms
 the lower part of the  abdominal  cavity, contains that portion  of
 the intestinal canal called the rectum, and also the the bladder and
 internal organs of generation.  It is said to be the centre of gravi-
ty of the body, and affords a passage to the principal emunctories
 which convey the residual impurities of digestion, the urinary and
uterine  secretions, various morbid  growths  both  fluid and solid
the process of generation, the progress of  the infant during partu-
rition, and the puerperal discharge.   From its  subserviency to all
these important offices, it is  necessary that it should  be  perma-
nently fixed and immoveable, especially on  account  of the  great 
OF THE PELVIS.
3
force applied to its parietes by the mechanism of parturition.  The
direction of the pelvis will vary  according  to  the  different atti-
tudes of the body ; it is oblique superiorly and inferiorly, and an-
teriorly and posteriorly, and becomes nearly vertical and horizon-
tal, according as the female assumes  the sitting or recumbent pos-
ture.   The obstetrician must study this part distinct from the rest
of the body, as one  intimately concerned with his art;—as the
book of nature, which ought to be consulted, and which affords the
best precepts for practice.   We should therefore study its regions,
dimensions, directions, planes,  axes, structure, connexions, and
varieties.   The knowledge of these properties  is indispensable to
the obstetrician who wishes to practise dexteriously the manoeu-
vres relative to his art, as it would be extremely  difficult, ii not
impossible, to pass the hand or an instrument  to extract  the in-
fant, without knowing the direction he was  to introduce and  with-
draw it.   Without this knowledge a man might practice obstetrics
for thirty or forty years, and be a most ignorant,  inexperienced,
and injudicious practitioner.   Such  a man  could  not  perform  a
manual or  instrumental operation with the  slightest  safety,—and
yet how many thousands of such men are in practice in this united
empire !
   The adult female pelvis  is composed  of four pieces of  bone,
the sacrum and  coccyx posteriorly, or  on  the median line, and
the two ossa innominata, vel coxalia, on each side and  anteriorly.
The ossa innominata are composed of three bones  on each side in
the foetus, os  ilium, os ischium, and  os pubis,  and  these  are de-
scribed separately by obstetricians.
   The sacrum is the most posterior bone of  the pelvis, is  situated
between the last lumbar vertebra and the coccyx, and  is  wedged
between the ossa ilia on each side.   It resembles a triangular pyr-
amid  reversed, having  its  base superiorly,  attached to  the lumbar
vertebra, and  from its union anteriorly a projection is formed, called
the sacro-vertebral point or angle, or, in obstetric  language, the
promontory of the sacrum.   The anterior,  internal, or pelvic sur-
face of the sacrum, is more or less concave, and presents  four or
five quadrangular spaces with transverse  lines,  and five  foramina
on each side near the central  line of the  bone,  converging inferi-
orly,  and destined for the passage of the anterior  crural  nerves.
There are small projections between each row of foramina, for the
attachment of the muscles.   The concave  surface  of this bone is 
4
GYN^COTOMY.
called, in obstetric phraseology,  the  concavity  or hollow of  the
sacrum.   There are also to be seen two rows of foramina, for the
passage of the branches of the posterior sacral  nerves.   Here are
two other small triangular spaces, which terminate the spinal canal
of this bone.   We should also recollect that the eminences afford
attachment to the  posterior sacro-iliac ligaments.  The sides of
the sacrum are articulated with the coxal, or nameless bones,  and
the union is called the sacro-iliac junction, or symphysis, or  syn-
chondrosis.   Inferiorly, the sacrum gives insertion to the large and
small sacro-sciatic  ligaments.  The summit is elliptic and a little
convex, presenting a cartilaginous surface, for the  union  with  the
coccyx.   The sacrum has been  considered a simple prolongation
of the spine, and is formed before birth  by five  pieces of  bone,
like  vertebrae, hence called false  vertebrae.   We  can readily  ob-
serve as many points of ossification.   The breadth of the base of
this bone is four inches, that of its apex two inches, and  its length
four inches and a haif.
  The coccyx  is considered by  many an appendix to the sacrum,
and is of a pyramidal or triangular shape, its base articulated to the
apex of the sacrum, its apex affords insertion to the sphincter ani.
It is composed of three or four pieces at birth,  which are articula-
ted to each other by cartilage, and in some adult  subjects are not
perfectly ossified,  and  hence admit of a regressive motion during
parturition.   This  motion  is denied  altogether  by many eminent
teachers.  M. Velpeau asserts that the coccyx can move on  the
sacrum with most  women until  a late period in  life, while Drs.
Hamilton and Denman assert  the  contrary.  The anterior aspect
of this bone is concave, and  supports the end of the rectum ; while
its posterior  surface is convex and rough, and is separated from
the integuments by the posterior sacro-coccygeal  ligament  only.
Its sides afford attachment  to the sciatic ligaments, coccygei mus-
cles, sphincter, and levator ani.   Dr. Denman  heard the fracture
of this bone and its separation  from the sacrum  ; inflammation  su-
pervened, and  it was  finally expelled.  I have  met with  some
eases of this kind,  caused  by external injury, and one  case  was
observed by some  of my pupils  at the Central Infirmary.  The
nature of the injury can be often ascertained by external examina-
tion ; but,  in  some  instances,  the  index  finger  must be  pas-
sed into the rectum, and the thumb applied, in  apposition, on  the
sacro-coccygeal  joint  externally, when the  state of the  joint can 
OF THE  PELVIS.
5
be  readily detected.  When the sacro-coccygeal joint is  much
injured, we may expect rapid inflammation and its  consequences;
and m such cases leeches,  cupping,  purgation, and the antiphlo-
gistic regimen, should be speedily employed.  Dr. Dewees,  the
eminent obstetric professor, in the university of Philadelphia, de-
scribes a most severe pain of this part, after parturition, which he
could only subdue  by large doses  of comphor, opium, and oil of
juniper, and  which  may  be induced by the  contusion  or disloca-
tion of the joint, during the pressure of  the infants head.  If the
os coccygis admit of regressive motion, of which  I  have no doubt,
it will facilitate the passage of the infant's head, during labour, by
assisting in enlarging the cavity of the pelvis.
   Ossa Innominata, Ossa  Coxalia, haunch bones.—These bones
could not be compared to any known body  by the older anato-
mists, and hence called nameless bones.  The  French writers,
Capuron,  Maygrier, and  Velpeau, adopt the term of Celsus,  and
call them  the  coxal bones, describing each as a  single bone, as
the three  divisions apparent in infancy cannot be traced in the adult.
In this country  we  retain the names of these  divisions, and  de-
scribe each innominatum as consisting of three parts—the os ilium,
os ischium, and os pubis.
   The ilium is the most  posterior and  extended of these bones .
its form is  somewhat triangular: it presents t^h surfaces, an external
and internal, three sides and three angles J u!The external surface is
both convex and concave, and is called i.ne dorsum by anatomists.
The internal surface is called, very improperly, the costa. The su-
perior border of this bone resembles an italic *S*,  and is called the
crest  of the ilium.  From its posterior third towards its termination
is a small  projection, from which a ligament runs  to the  transverse
apophysis of the last lumbar  vertebra.   Towards the termination
of the anterior border are two eminences, the anterior superior and
inferior spinous process of the ilium ; on the opposite end  of the
bone  is the  posterior superior spinous process, and the posterior
inferior process, which is united to the sacrum.   The bone is pro-
longed posteriorly,  and forms the great  and small sciatic notches.
The crest of the ilium, at the anterior side, forms an obtuse angle,
which is the superior anterior spinous process ; the next angle is
formed by the inferior anterior process, and the last by the  superi-
or posterior process.  These angles or points are worthy of atten-
tion to the general anatomist, b..t, I confess, I am unable to com- 
6
GYNJECOTOMY.
 prebend of what use the  knowledge of  them is to the obstetri-
 cian ; and I should have omitted them, had they not been descri-
 bed by  Drs. Burns, Capuron, Velpeau, Duges, and  many others.
 Drs. Blundell and Maygrier omit them and their valuable lectures.
    The pubis, or  share-bone, is so called from the attachment of
 he geaital organs to its antertor part; is  divided into two branch-
 es, the superior or ileopubic or superpubic;  and  the  inferior, or is-
 cheopubio or subpubic.   The superior  branch is nearly triangular
 in its middle  part, is flattened as it becomes enlarged towards  its
 anterior extremity, and is  thickened towards the ilium ;  and hence
 the superior surface is slightly sinuous and concave;  is larger  be-
 hind than before ; and thus the internal and external  surfaces pre-
 sent a  contrary  disposition.   The subpubic branch  descends
 obliquely and latterally, it is flattened on both its surfaces, and is
 larger at its commencement than termination ;  it  is about seven or
 eight lines long.   Each os pubis is united with its fellow in front,
 and the  junction is named the symphisis pubis.  The arch formed
 inferiorly under the symphisis, by the bones on each  side, is nam-
 ed the arch of the pubis.
   The ischium presents  two surfaces, two extremities, and two
 borders.   The external surface of this bone is convex and irregu-
 lar,  and  forms a part of the acetabulum.   The internal face  is con-
 cave, and offers an ing pes plane above downwards,  behind back-
 wards, and without *iion within ;  and this  plane should be recol-
 lected by obstetricians, asxhe child's head sweeps along it, on de-
 scending to the perineum.   The  superior extremity of the bone
 is attached insensibly to the ilium; the inferior is called the tuberos-
 ity of the ischium, and is surmounted by a small branch which joins
 the ramus, or branch  of the  pubis.  The anterior internal border
 concurs in forming the oval or subpubic foramen ; and the posteri-
 or or external border is concerned in the sacro-isichatic notch.  This
 last, at its inferior third, offers a triangular eminence, oblique be-
 hind and inferiorly, which is called the spine of the ischium.

        Section 2.— Of the  Articulations of the Pelvis.
   The articulations of the bones of the  pelvis do not differ from
those of  the same species in the other organs of the animal econo-
my.   They are of a mixed  kind, according  to ancient authors,
and partake of synarthrosis, and more so of amphiarthrosis, which
is the articulation  by  continuity of the moderns.   The articula- 
OF  THE PELVIS.
7
tions of the pelvis are generally called symphisis—as the symphi-
sis of the pubis, of the sacrum, and ilium, of the sacrum and coc-
cyx, and of the sacrum and lumbar  vertebra.   Velpeau asserts
there are  but three pelvic joints, the pubic and the two sacro-iliac,
omitting the  sacro-coccygeal; but afterwards he describes it and
the sacro-lumbar,  which he says constitute  two amphiarthroses.
It is necessary to examine the  pelvic  joints in the recent subject
in order to understand their  structure accurately, when  we disco-
ver the following construction:
  The joints  of the pelvis are the two sacro-iliac posteriorly, the
sacro-coccygeal inferiorly and  the  pubic, anteriorly.  The sacro-
coccygeal and pubic  joints are occasionally inflamed by  the injury
which they are destined to sustain during the parturition, and their
surfaces may  be entirely  separated  from each  other.   The sym-
phisis pubis may also separate,  and when such injury occurs, the
most active treatment is required.   Happily  such separation is  of
comparatively rare occurrence; but many examples of it have been
recorded and some cases have fallen under my own observation. The
sacro-iliac  symphisis may be  similarly affected, but they seldom
separate,  though  there is evidence that they are occasionally re-
laxed.  Speaking generally, however, inflammation,  abscess,  or
separation  of  the pelvic joints, is of rare occurrence.  When these
affections do occur, they  are to be treated upon  the ordinary prin-
ciples of surgery.  It is scarcely necessary to observe,  that  inju-
ries  of cartilages  and  ligaments require active treatment.  The
principal ligaments of the pelvis, in an obstetric point of view, are
the internal and external sacro-ischiatic on each side, and the ob-
turateur, and  these are liable to rigidity or relaxation. The former
assist in the formation of the outlet of the pelvis, and in  an advan-
ced period of life may offer considerable impediment to the partu-
rient process.  The student may be  reminded  that the pelvis  is
lined by muscles,  arteries,  nerves,  and lymphatics, contains the
uterus and its appendages,  the urinary bladder,  and rectum,  all  of
which organs may be injured by natural or  preternatural parturi-
tions.

Section 3.— Of the difference  of the Pelvis relative  to Ages,
                      Sexes and Species.
  At birth, the pelvis is very straight and elongated, the crest of the
ilium rough, and the  ilium is almost vertical;  the cavity of the pel- 
J
GYNjECOTOMY.
vis is conoid, and not excavated.   The lattcral diameter is shorter
than the sacro-pubic.  The pelvic bones are not  ossified, but co-
vered with cartilages, to allow of reduction of this cavity by pres-
sure during delivery.   It becomes more ossified  in two or three
years, and  is completely ossified about the  fifteenth or twentieth
year.   In the male, the pelvis preserves its infantile properties;
it is deeper, its short or sacropubic diameter  not more than three
inches and the transverse or bisiliac diameter measures four and half;
the bisischiatic three and a half. The arch of the pubis is short and tri-
angular, not expanded as in the female.  The sacrum is less hollow,
the bones are  thicker and stronger in general, and more solid. The
pelvis of the female is broader at the hips, as well as in every hotter
part; and here nature seems to have sacrificed the facilities of motion
to the advantages of  pregnancy and parturition.   The articulations   «
of the female are not anchylosed ; while they are firmly ossified in
the male.   The pelvis of the lower classes of animals differ mate-
rially  from those of the  human species, and  are so constructed
that  the lower classes of animals require no aid, and suffer little
pain in bringing forth their young.   In these animals there  is but
one axis in the pelvis, the sacrum is almost parallel with the spine,
the straits  are only  slightly  inclined,  the parietes are  of  equal
depth and of the same length ; the ossa innominata are so straight
and elongated that there are no iliac fossae; and hence expulsion
of the young is not exposed to the  same difficulties as in the hu-
man species.   We find a  vast variety in the pelvic structure of
animals,  which, as we gradually ascend the zoological scale, be-
comes insensibly more  perfect.  Thus the pelvis of  the  monkey
and ourang outang have a strong resemblance to that of the human
species; especially we can trace the shades  between these and
the Boschismans, the Ethiopeans, negroes, Malays, Japanese, and
Caucassians, the  last of which is most  different  from the other
mammiferae;  and thus, we may presume, that parturition is more
painful as the  species is more perfect, and vice versa: a most ad-
mirable  and singular  provision,  that the dangers are increased  and
most accumulated, according  to  the  perfection and degree of in-
telligence of the animal.    In the kangaroo and other species, mar-
supiae, the  pubis is loose, while the pelvis is  so narrow in the mole
as to  be separated during parturition;   In  the  cetaceae there  is
scarcely  a vestige of it; and in birds, reptiles, and fishes, where
eggs are laid,  we perceive the  pelvis decomposed, and finally to 
OF THE PELVIS.
9
disappear.—(Wrolick's Essay Fev. Bull, de sciences Med. 1827.
Velpeau.)

        Section 4.—Of the Deformities of the Pelvis.
   The pelvis may be deformed in its brim, cavity, and outlet, and
offer serious impediments  to the passage of the infant.   On the
contrary, it may be too capacious, or possess excess of amplitude,
thereby affording too ready a passage to the foetus.   In the latter
case, delivery will suddenly take place, often  unexpectedly, and
in extraordinary situations, as in the street, in a stage-coach, in the
water-closet, night-chair, or  in the sitting-room, before the female
can retire to her apartment.   The various  obstetric works afford
ample  evidence of this fact; and it is even occasionally attested
by the newspapers.  Several instances have recently occurred in
Dublin, of women having  been delivered in the street, on the
steps, and in the hall of the hospital.—(Mr. Gregory's Report of
the Coombe Lying in Hospital,  Dublin Hospital Reports, vol. v.
1830.)   It is however of rare occurrence, and unfortunately we
see the opposite condition very frequently prevail.   Observation
abundantly proves that with many women  the  pelvis retains the
form which characterised  it  during infancy and puberty, and which
nearly approaches to that of the male.   In fine, every part of the
true and false pelvis may  be deformed, and diminished in capaci-
ty.  In some cases the ossa innominata nearly approximate; in
other cases, the pubis approaches within  half an  inch of the sa-
crum.—(Weideman, Boivin, Jeuffrion, Maygrier, C. Bell, Nzegele,
Velpeau.)
   The inferior strait may be so considerably diminished,  that the
coccyx will rest upon the pubis, and the ischia approximate to-
wards each other, and there may  be every degree of deformity be-
tween  these extremes.  Exostosis may form upon any of the bones
of the  pelvis, and an immense variety of tumours may be devel-
oped in the vagina and internal or  external genitals, which will
impede parturition.

Section 5.— Of the causes of Vicious Conformation of the Pelvis.
   In order to appreciate  the causes of the malformation of the
pelvis, we should examine them in infancy, at puberty, and at the
adult age.   During the first seven years,  rickets will  afford the
explanation.  When we admit that the softness of the bones pre-
        9 
10
GYN.KCOT0MY.
vails throughout the body in rachitis, it  is clear that  if the infant
is placed too much upon the legs, the base of the sacrum most ap-
proach towards the pubis, and the acetabula must be directed towards
the promontory of the sacrum ; and the sacro-pubic and oblique di-
ameters will be thus diminished. When the infant  leans too much
upon one extremity, the oblique diameter of one side will be con-
tracted ;  when it is allowed to  sit too much, the concavity of the
sacrum becomes deeper, and the antero-posterior diameters of the
superior and inferior straits are  diminished ; if it is placed contin-
ually on  the back, the concavity of the sacrum disappears, so that
the sacro-vertebral junction and the coccy-pubic diameter lose
their ordinary  dimensions; the transverse diameter will also be af-
fected.   It is to be recollected  how imperfectly the  bones are osr
sified in case of rickets,  and therefore how much they must be in-
fluenced by the  action of the many powerful muscles attached to
the pelvis, especially of those connected with the  coxo-femoral
articulation.   The deformities of the pelvis are caused by partial
or general mala-costeon, or mollities ossium, or osteomalaxie, the
irregular action of muscles, and the bad  position of attitude.  Such
persons have generally  the head and  pelvis thrown backwards,
and they never can become mothers without the  risk of great dan-
ger.  I need scarcely observe, that in cases of amputation at the
upper third of the femur, or the hip-joint, deformity of the oppo-
site side  of the  pelvis will occur, from the whole weight  of the
body being principally placed  upon the sound extremity.  Frac-
tures, when irregularly  ossified, luxations, caries and syphilis, will
often give rise to serious obstacles to delivery.   In conclusion I
may observe,  that rachitis is the cause of pelvic deformity in young
infants ;  and after the age of puberty, the chief cause is osteomal-
axie affecting  the vertebral column,  producing spinal curvatures,
which cannot exist to any extent without affecting the pelvis very
considerably.   This fact is attested by the various writers on spi-
nal curvatures.  In France, and other countries, it is usual to as-
certain the extent of pelvic deformity by instruments called pelvi-
meters ;  but as such are never employed in this country, a  de-
scription of them is unnecessary.  The fact is, deformity can
be  ascertained much more correctly with the  finder than with
any pelvimeter.  Those persons  who labor under  spinal  and pel-
vic deformity  to any considerable extent, are clearly  unfit to enter
into matrimonial engagements. 
OP THE PELVIS*
U
        Section 6.— Of the  Dimensions of the Pelvis.
 DIMENSIONS, DIRECTIONS, PLANES, AND AXES OF THE PELVIS.
   The pelvis is divided into an external and internal surface, a base
and summit.  The external surface serves for the attachment of the
coxo-femoral muscles, and is divided into four regions, the anteri-
or, posterior, and two lateral.   The internal surface alone is con-
cerned in the mechanism of natural parturition.  It is divided into
the great, superior, abdominal, or false pelvis;  and the small, infe-
rior, or true pelvis.  The inferior or true  pelvis  is divided  into
the brim or entrance, the cavity and outlet.  It contains  the in-
ternal  genito-urinary organs, the rectum, and  the hypogastric and
sacral  vessels and nerves.   It is also divided into  four regions, an
interior, a posterior, and two lateral.  The pelvis is again divided
into the superior and inferior straits.
   The superior, abdominal, or great strait, or margin of the pel-
vis, is  the osseous margin which separates the true from the false
pelvis, formed by the superior margin of  the sacrum,  the linea
ileopectinea, and the superior margins of the ossa pubis.  Its form
is  variable, frequently oval, cordiform, elliptic,  or  triangular.   It
is  measured  by  four diameters ;  the anteroposterior,  which ex-
tends from pubis to  sacrum, and  is also  named the sacro-pubic,
the conjugate or short diameter of the brim,—a transverse which
extends from one ilium  to the other, and  hence  called  bis-iliac,
and the two oblique, which extend from the sacro-iliac symphyses
to the  opposite acetabula ; and these are denominated the long di-
ameters  of the brim.  The  antero-posterior diameter  measures
four inches, according to British  and French writers ;  the lateral
or transverse five inches; but it is diminished  half an inch on each
side in the fresh subject, by  the  presence of the psoae and  iliac
muscles and  vessels, and does not really present more  than  four
inches during labor ; the oblique,  long, or diagonal diameter, mea-
sures five inches and a quarter, and is considered the longest by al-
most all writers.   The dimensions are subject to numerous varie-
ties, and are scarcely the same in  any two  pelves,  and should not
be understood but in a general manner.   There are scarcely two
writers who agree in their account of the length of the  pelvic di-
ameters.   The inclination  of the superior strait in the erect po-
sition is not horizontal; but its posterior part is more elevated than
its anterior, so that it is directed from above downwards, and from 
12
GYNJECOTOMf,
 behind forwards.   It  varies from  thirty-five to  fifty  degrees.
 Its axis is represented by an imaginary line, drawn lrom the um-
 bilicus to the inferior part of the sacrum.   The cavity of the pel-
 vis is divided  into four regions:  the anterior, posterior, and two
 lateral.  The anterior region is slightly concave from side to side,
 formed by the posterior part of the symphisis and body of the
 pubis.  The posterior region is formed by the anterior surface of
 the sacrum and coccyx, is concave, and presents foramina for the
 passage of the crural nerves.  The lateral regions form a plane,
 inclined above  and inwards, present the sciatic notches, which are
 converted into  apertures by  the sacroischiatic ligaments; a square
 surface which corresponds to the  acetabulum, and the sciatic spine
 more prominent within  the  pelvis than the  parts  situated before
 and behind, offering by this  disposition two inclined planes, an an-
 terior and posterior.   These planes impress on the  head the rota-
 tion  necessary  for replacing its antero-posterior  diameter in  the
 long diameter of  the outlet  or inferior strait.   The  anterior plane
 of the side pushes the presenting part of the head  under the arch
 of the pubis, while the posterior forces the fron^ part of the head
 into the curvature or  cavity of the sacrum.
   Dimensions  of the  Cavity of the  Pelvis.   Antero-posterior
 diameter.—From the middle of the symphysis pubis to the mid-
 dle of the sacrum measures about five  inches, on account of the
 concavity of the latter,  which affords an inch of depth.   The
 transverse  diameter  measures about four  inches and  a half.
 These admeasurements are  diminished as they approach  the infe-
 rior part  of the pelvis.
   The depth of the  anterior parietes is about an inch and a half;
 of the posterior,  four inches and  a half; and of the lateral pari-
 etes, three inches and a half.
   The direction of the pelvic cavity represents a canal very much
curved before, and falling perpendicularly from its axis to its two
sides.
   Its axis is represented by a curved line  passing through the
 middle of the canal following the curvature of the sacrum.
   Inferior Strait.   The Inferior or Perineal Strait, Summit of
 the Pelvis or   Outlet,—is formed by the point and edges of the
coccyx, the edges of the sacro-ischiatic ligaments, the tuberosities
of the ischia, and the ischeo-pubic branch ; it is triangular or cor-
 diform, as it represents the figure of a heart of a playing card. 
OF THE PELVIS.
13
  The  inferior  strait has  four  diameters,  the  antero-posterior,
coccy-pubic, or long diameter,  which extends from the point of
the coccyx to the arch  of  the pubis;  the transverse bis-ischiatic
or short diameter, extending from the posterior and internal parts
of the tuberosity of ischium to the opposite one ;  and two oblique
diameters which extend from the reunion of the ischiatic and pu-
bic branches to the middle of the sacro-ischiatic ligaments.   AH
these diameters  measure four inches ; but the antero-posterior is
said to measure  five inches, on account of the retrocession of the
coccyx during labour.   The arch of the pubis, or anterior part of
the pelvis, is four inches broad at its base,  the length of each
branch of the arch is three inches and a quarter.
   The axis of the inferior strait is represented by an  imaginary
line drawn  from the sacro-vertebral union,  or obstetrically, the
promontory of the sacrum, through  the centre of the vagina, or
centre of this strait.
   The reunion of all the axes forms a curve, the concavity of which
is in front, and the central  lines  of the superior and inferior straits
forming the extremities.   The  practitioner is to recollect the di-
rection of the  planes  of the sacrum, coccyx, and perineum, as
these planes direct the infant's  head  with geometrical precision.
If the axes and diameters of the superior and inferior straits  were
not reversed, the contents  of the gravid uterus would be expelled
on  the slightest exertion, especially in the last months of utero-
gestation.   The young practitioner must perfectly understand this
part of obstetricy, or he can  never comprehend the mechanism of
parturition.  It is proper to observe that the axis of the brim, ac-
cording to the writers of continental Europe,  is a line drawn  from
the umbilicus to the point  of the coccyx.

                Dimensions of Infant's Head.

Of the  Infant's Head, and the passage through the Pelvis du-
                         ring Labour.
  The principal parts of the foetus, with respect to delivery, are the
head, the shoulders, and the breech.
   The head of the foetus separated from the trunk, presents an
ovoid form, slighly  flattened in  different parts.   It is divided by
obstetricians into different regions,—the vertex or summit, the base
the face and the  temporal  regions.   It is said to have two ex-
tremities, the occipital tubercle, and  the chin. 
14
fiYNJECOTOMT.
   The vertex offers peculiarities which ought to be known to the
 obstetric practitioner.   These are the anterior  and posterior fon-
 tanelles, and the sagittal suture.
   The base of the skull cannot present, unless the head is sepa-
 rated from the trunk, or in pedal presentations.
   The face presents peculiarities which  are not likely to be mis-
 taken.
   The temporal regions are recognizable by the presence of the
 ear.
   The head of the foetus presents five diameters and two circum-
 ferences.
   The first is the  occipito-mental, or oblique diameter, and meas-
 ures four inches and a quarter.
   The second is the occipito-frontal, and measures four inches and
 a quarter:  this is usually called the long diameter.
   The third extends from one parietal protuberance to the other,
and measures three inches  and a half: this is the short diameter
of British writers.
   The fourth extends from the vertex to the base of the cranium,
and measures three inches and a half.
   The fifth extends from  one mastoid process  to the other,  and
measures two inches and a half.
   The longest diameter of the head is from the vertex to the chin,
and measures nearly five inches.  Though these are the average
dimensions of the  head, yet they may be considerably diminished
during labour, owing to the looseness of the sutures, and the shape
of the head may be completely altered.   Dr. Clarke, of Dublin,
has ascertained that the size of the male head is ^ or -£■$ larger
than that of the female ; and  this difference he thinks accounts for
the greater mortality of males from tedious labours ;  a conclusion
also supported by Dr. Bland, and almost all writers.
   The head may be bent upon the chest,  the back, or upon either
shoulder.
   The shoulders measure from four to five inches in width •  but
may be reduced an inch by simple compression.
   The breech measures the  same as the shoulders, and  may be
reduced by pressure, as it is composed of fourteen pieces  of bone
separated by  cartilages.
   In natural labour, the long  diameters of the head  are  adapted
to the  long diameters of the pelvis, and if we compare the dimen- 
MECHANISM OF PARTURITION.
15
sions of the head with those of the pelvis, we shall perceive that
the one can readily pass through  the other.  The long diameter
of the superior strait or brim is oblique, that of the inferior strait
is antero-posterior, and it follows that  the largest part of the foetus
is placed  obliquely in the  superior strait, must have  a rotatory
motion to adapt it conveniently to the  inferior strait.  The three
axes of the brim, cavity, and outlet form a curved line, the con-
cavity of which is turned to the pubis, the convexity to the sacrum,
the foetus, in disengaging itself,  must necessarily follow this direc-
tion, and  the obstetrician  must follow  it in any  operation.  The
posterior surface of the cavity of  the pelvis is six inches in depth
the anterior an inch  and a half;  and this difference explains the
reason why the occiput escapes first in  delivery, while  the vertex
is covered by the perineum, and the forehead and face in the con-
cavity of the sacrum, which measures five inches.

      Section 7.— Of the  Mechanism of Natural Labour.
   In this country, we say the vertex of the infant is the present-
ing part in natural labour, though the infant may pass by the head,
the feet, the knees or the  breech.   The French  writers maintain
that all these presentations may exist in natural labour.   There is
much reason in this opinion, as, next to the vertex, these are the
easiest and safest presentations.
   Natural labour by the head may take  place  in four positions,
which correspond to the oblique diameters of the pelvis.
   First Position.—The occiput  is turned to the left acetabulum,
the forehead to the  right  sacro-iliac symphysis.   The  posterior
region of the foetus is forward and to the left, the anterior behind
and  to  the right; the feet are at the bottom or  fundus of the
uterus.
   Pressed by the contractions of the uterus, the head is bent up-
on the chest, and its occipito-mental diameter becomes parallel  to
the axis of the  superior strait; in other words, the  central part of
the sagittal suture presents. The  vertex runs over the concavity
of the sacrum, and on arriving at the inferior strait or  outlet, it
encounters the inclined planes, which impresses it with a rotatory
motion, by which the occiput is placed under the arch of the pu-
bis, and the face in the curvature of the sacrum.   The long diam-
eter of the head is now in the long diameter of the outlet, and  its
 passage is only opposed by the  external genital organs.  The head
v 
16
GYNjECOTOMY.
pressed by the contractions of the womb, advances more and more,
and gradually dilates the vulva or genital fissure;  and after each
pain it recedes more or less into the concavity of the sacrum.
   After labour, more or less prolonged, the resistance of the exter-
nal genitals  is overcome,  the head escapes, the occiput  being un-
der the arch of the pubis, and the perineum  having slipped over
the forehead  and face.  The head being free, the occiput turns
towards the left groin,  and the  face towards the posterior and in-
ternal part of the right thigh, and by this movement the body  of
the infant is turned, so that the shoulders  are brought into the long
diameter of the inferior strait or outlet.   The shoulders are first
obliquely  engaged in the superior strait, run over the cavity of the
pelvis, and when arrived  at the inferior strait, are turned by the
inclined planes in the same manner as the head, and thus adapted
to the outlet.  The right  shoulder approaches the arch of the pu-
bis, and the left is in the curvature of the sacrum.   The relative
position of the head is  changed, the face  turns to the middle  and
internal part of the right thigh,  and the occiput to the same part of
the left.   The inferior  shoulder receives all the  contractions  of
the womb, and presses on the vulva, which it overcomes, so that
the superior shoulder at the pubis serves  as a resting point.  When
the shoulders escape, the body  is expelled with great rapidity,  as
it diminishes in size, and as the  passage has been dilated by more
voluminous parts.
   The Second Position.—The occiput is turned to the right ace-
tabulum, and the face to the left sacro-iliac symphysis.   The pos-
terior region of the foetus is turned forward and to  the  right, the
anterior behind and to the left, and the  feet to the fundus uteri.
The mechanism is the same as in the first;  but the relative posi-
tion of the infant to the pelvis is reversed.
   Third Position.—The occiput is turned to the right sacro-ili-
ac symphysis, the forehead to the left acetabulum.  The posteri-
or region of the infant  is directed behind  and to the ri^ht  the an-
terior before  and to the left.   The feet are at the fundus uteri.
The mechanism of labor in this case differs but little from that ol
the first, as the same diameters of the  foetus correspond  to the
same diameters of the  mother.   This position  may also be con-
verted to the second.
   Fourth Position.—The occiput corresponds to the left sacro-
iliac symphysis, and the face to  the right acetabulum.   The me- 
                   OF THE SEXUAL ORGANS.                 17

chanism is the same as that of the third; but the relative position
of the foetus to the pelvis is inverted.  This position can be con-
verted into the first.  Such then  is the mechanism of natural la-
bour ; but this description is somewhat more minute than that us-
ually employed in.this empire.    I  have described the positions,
the patient being on the back, which is preferable to the side.
             ARTICLE II.--OF THE SEXUAL ORGANS.
  The reproductive organs of both sexes are divided into external
and internal.

     Section 1.— Of the  External Organs of Generation.
  The external organs of generation  in the female are the  mons
veneris, the vulva, and perineum.   Though these parts are secon-
dary in  the act of parturition, they are exposed  to  much injury,
which renders an exact knowledge of them indispensable to  the-
obstetrician.
  The mons veneris is a fatty eminence, covered with hairs after
puberty, situated  on the symphysis pubis, arising on each side from
the groin, composed of common integuments, fibrous and cellular
tissue, and a great number of sebaceous follicles.  It  is from an
inch to two in  breadth, and  bifurcates inferiorly to form the labia
externa.  This part is sometimes the  seat of phlegmonous inflam-
mation, which is  accompanied with acute  pain, and  indicates the
necessity of opening an  abscess in this situation at an early period.
  Labia externa, majora, pudendi.—They arise at  the termina-
tion of the  mons veneris,  and descend to the perineum anterius;
they consist  of common integuments, cellular substance, and fat,
and are covered with capillary growth after puberty.  Their inter-
nal surface is smooth, and of a  rosaceous  colour, with numerous
mucous and sebaceous follicles, which sometimes give  rise to an
acrid  irritating discharge, often mistaken  for gonorrhoea.  The
points at which the labia are  united, above and below, are called
the superior and  inferior commissures.  Before puberty the labia
are dense, and  in apposition ; after marriage they become elonga-
ted, flaccid, and bluish, and lose  their  regularity.   When inflamed
the pain is excessive;  but suppuration takes  place  very rapidly,
and matter is  discharged in  twenty-four  or  thirty-six  hours, by
poultices.   According to Burns, the abscess onght not to be open-
         s 
18
GYN.3ECOTOMY.
ed, as haemorrhage  takes  place;  while Velpeau recommends  a
deep  incision in proper  time, to prevent the formation of fistulous
openings.  My own experience accords with that of  Dr. Burns.
The labia may be the seat of hernia or other tumours.  The fis-
sure formed by the labia is called the vulva, pudendum, or genital
fissure, or sinus pudoris. It contains other parts : the labia minora,
the clitoris, the vestibulum, the meatus urinarus, the vaginal orifice,
the hymen, the fossa navicularis, and the fourchctte.  On separating
the labia externa at the superior commissure, we see the clitoris.
   The clitoris is an erectile, elongated substance, compared by
some  of the palate, composed of two cavernous, spongy, vascular
bodies about two inches in  length,  inserted into  the  ischio-pubic
branches.  It  resembles the male penis, has a round free extremi-
ty, called its glans, which is enveloped  by skin or prepuce, which
terminates in  the labia minora.  A  suspensory ligament attaches
the clitoris to the pubis.   In the first months of intra-uterine life,
the clitoris is as voluminous as the  penis,  but at birth  it is greatly
diminished in size, and at puberty it is a  tubercle of about four lines
in  length.   It sometimes increases to  four  or five  inches  in
length, and then  constitutes a form of  hermaphroditism.   It be-
comes erect during coition, and is the principal seat of voluptuous-
ness.   It is not liable to disease,  though sometimes  the seat of
cancer and cauliflower  excresence.  If elongated or  diseased, it
may be removed  by  excision.
   Behind the  glans of the clitoris and betweeen the nymphae is  a
triangular space, about an inch in  extent, called the  vestibulum,
which does not fulfil  any function relative to generation.  Through
this space Celsus and Lisfranc have proposed  to perform the ope-
ration of  lithotomy  on women.   Posteriorly and  about  half an
inch from the  symphisis pubis, is the meatus urinarius or orifice of
the urethra, a  small  round  aperture, surrounded by small depres-
sions, called lacunae.  The female  urethra is about an inch  or an
inch and a half in length, capable of great dilation, and subject to
much  injury  during  parturition.  It is connected to the pubis by
the ligamentum inferius vesicae.
   The labia minora, or nymphce  are two continuations from the
prepuce of the clitoris and labia externa, compared to the  comb
of a young cock, descend and diverge on  the internal surface of
the labia majora, and terminate insensibly about the middle  of
these last.   Their consistence is firm, their colour reddish;  they 
OF THE INTERNAL SEXUAL ORGANS.
19
 are formed by the fine, thin, vascular, and  spongy tissue  of the
 clitoris, and consist internally of adipose and cellular tissue.  At
 birth they pass the level of the external labia ; in virgins they are
 hidden by the latter ; and in women who have had children,  they
 again project, but loose their  density and  rosaceous  colour.  In
 some subjects they are elongated, naturally or accidentally, and in
 some countries, as Hindostan, Turkey, and Persia, they produce so
 much inconvenience as to require excision—an operation occasion-
 ally required in European nations.  The nymphae  are said to direct
 the stream of urine, and to  increase  veneral enjoyment.
   The hymen, or circulus membranosus, is a thin, extensile mem-
 brane  (muscular; Velpeau,) formed by a doubling of  the inner
 surface of the vestibulum, of a semilunar form, its extremities or
 cornua ascending upwards to the sides of the urethra, where they
 unite.  This  membrane nearly closes  the  vulvo-vaginal orifice,
 leaving a small aperture  superiorly for the  escape of the menses.
 It was long considered a proof  of virginity by the vulgar, the ma-
 gistrates,  and medical jurists, and often  led to very erroneous and
 unjust decisions  by  the  tribunals.   It  is now universally known
 that a thousand causes besides coition may destroy this membrane,
 as sudden exertion  of the lower extremities, leucorrhoea, excoria-
 tions, and various morbid growths, both  fluid and  solid.  It is also
 well known that it is absent  in infants, or may exist at parturition.
 (Mauriceau, Ruysch, Pare, Meckel, Walter, Smellie,  Baudeloc-
 que, Capuron, Naegele.)   Haller fell into this error when he said,
 " Attamen prima Venus debet esse  cruenta."   The hymen was
 said to be ruptured in the first coitus, and its remains  were called
 the carunculae myrtiformes.
   The caruncula myrtiformes are small projections which are de-
 nied by many modern physiologists  to be the remains of the hy-
 men (Hamilton, Velpeau) ;  they are not exactly in the same situ-
 ation, and have been seen in infants and virgins.   Behind these is
 the orifice of the vagina.
   The perineum anterius is that portion of soft  parts which ex-
 tends from the inferior commissure of the labia to the anus.
   The perineumpostcrius is the space behind the anus, which ex-
tends to the os coccygis.
   The fossa navicularis is  a space  situated between the inferior
commissure  of the labia  and hymen  ; the fourchette  or franum
forms the anterior border  of the perineum,  and  unites the labia
 pudendi. 
20
GYNiECOTOMY.
     Section 2.—Of the Internal Organs of Generation.
  The internal organs of generation in the female are uterus, vagi-
na, uterine tubes, ovaries, and ligaments.
  The uterus or womb is a hollow muscle, to contain, nourish and
expel the foetus, and  serving habitually for the secretion of men-
struation.  It is situated in the cavity of the pelvis, behind the blad-
der, before the rectum, under the  small intestines, and above the
vagina.   It is of a pyriform or  conoid shape, thickened before
and behind,  its base  turned upwards.   It  is divided into three
parts;  the fundus or  bottom, the corpus or body, and the cervix
or neck.  Its anterior surface  adheres inferiorly to  the bladder;
its  posterior  surface is convex, covered by peritoneum, and rests
upon the rectum ;  its lateral surfaces are concave towards their
middle, covered by the  broad ligaments, giving origin above to
the ligament of the ovary, the uterine tubes, aiid round ligament,
and receiving below  the vessels  and nerves  called  uterine, and
higher the spermatic arteries.   It opens into the vagina by an ori-
fice called os uteri, or tinea, or  utero-vaginal orifice,  formed by
two lips, an anterior,  which  is thicker and shorter  than the poste-
rior, which appears thinner and longer, on account of the obliqui-
ty of the vagina and uterus.  The interior of this organ offers a
cavity of a triangular form,  having two  surfaces, which are almost
in contact in the virgin,  but separate  and concave  in those who
have had children.   It has  three angles ;  two  superior or lateral,
terminating in the orifice of the uterine  or Fallopian tubes ; the
other inferior, forming the internal or cervico-uterine vaginal ori-
fice or cavity of the neck of the uterus.  Its  posterior surface offers
projecting wrinkles,  disposed in  the form of  a palm,  and hence
CBlled arbor vita.
   Dimensions.—The length of the virgin uterus is twenty-seven
lines; the width of the body, twenty lines, and of the neck thir-
teen  lines;  the thickness of the body, nine lines ;  of the neck
six lines; of the  parietes,  four  lines; of  the body,  four lines •
and of the neck, three lines; the lips in  the  vagina, two or three
lines ; the weight seven or  eight drachms.   After the  female is a
mother,  the uterus  measures two  and a half or three inches in
length :  the body, two inches; the neck,  one inch and a half;
 the base, twenty to twenty-four lines ; the neck, fifteen or sixteen
 lines ;  the body, twelve or fourteen ; each  wall, six  lines; the os 
              OF THE INTERNAL SEXUAL ORGANS.            21

uteri, or utero-vaginal orifice, six lines;  the weight about two oun-
ces.   These dimensions were ascertained by  Rcederer on a great
number of bodies.
   Directions.—The uterus is said to be in the direction of the ax-
is  of the superior strait of the pelvis, and  with  the axis of the  va-
gina forms nearly a right angle ; its  orifice looks downwards and
backwards, and its anterior  lip is lower than  the posterior.  The
direction will vary  according to the  situation of the  woman,  the
fulness of the bladder or rectum, or in a state of spasm or contrac-
tion.   It is generally inclined a little to the right side.
   Organization, Structure.—The whole uterus  is  covered pos-
teriorly by peritoneum ; the body only is covered  anteriorly ;  the
neck is supported by the  bladder.   The uterus consists of an  ex-
ternal and internal membrane, a peculiar tissue, numerous vessels,
nerves,  and some cellular tissue.   The external or peritoneal tu-
nic forms two folds at the sides, called the broad ligaments.   Their
 anterior and posterior layers are closely  united, but  allow a pas-
sage for the uterine and ovarian vessels and nerves and some mus-
 cular fibres.  Their upper borders form three folds, which con-
 tain the round ligament, the tube, and the ovary.
   Muscular Tissue of the Uterus—Vesalius, Malpighi,  Ruysch,
 Noorthwick, Wrisberg, Meckel, Lobstien, Hunter,  Charles Bell,
 Velpeau,  Rosenberger,  Duges,  and a host  of modern anatomists
 maintain the muscularity  of the uterus ; while  Boehmer, Blumen-
 bach, and a few others, deny it.   The course  and direction of the
 fibres were disputed by anatomists.  Malpighi said it was impossible
 to separate them, as they  were so interlaced  ;  Ruysch and others,
 that they formed an orbicular muscle, at the  fundus to expel the
 placenta ;  Hunter, Sue,  &c. that they were intermixed  ; Leroy,
 Meckel,and many German anatomists, that they formed an internal
 and external  layer of muscle.  Baudelocque  and his countrymen
 declined to determine the course of the uterine fibres ; though they
 supposed them to form fasciculi parallel to the axis of the uterus,
 or longitudinally,  or in circles placed horizontally, that  the body
 and fundus were principally formed by the  first,  and the neck by
 the second.  This view  is corroborated  by recent writers.   The
 fibres  are longitudinal,  and oblique  externally   (Rosenberger),
 transverse all the interior of the neck (Verheyen), and circular at
 the tubal orifice (Weitbretch)  the  exterior fibres  form the round
 ligaments ( Rosenberger). 
22
GYN-EC0T0MY.
   Velpeau has dissected a great number of uteri, and arrives at
the following  conclusions:  1.  There  exists under the peritoneal
tunic a thin, dense, elastic, cellulo-fibrous layer, sometimes, but
not always, muscular, in which the fibres have  not a fixed direc-
tion ; 2. a  thick layer  of transverse fibres, united similar to the
constrictors of the pharynx, and most deeply transverse fibres ; but
the fibres were  longitudinal and oblique on the neck and  internal
surface of the organ.   All these layers have for a base a cellulo-
fibrous tissue, surcharged with fibrine ; the  fleshy tissue is devel-
oped in this substance as in the intestines, and the uterus  appears
to result from the re-union of two cylindroid canals.
   The internal  membrane of the uterus to said to be  mucous by
many ; but this is denied by Gordon,  Chaussier, Ribes, Beclard,
and Azzoguidi.   Mucous and  vesicular follicles occupy  the neck
and external orifice, and these were named ova Nabothi.  The ar-
teries  which supply the uterus are the  spermatics and hypogas-
trics.  The veins form a cavernous  tissue,  which is highly devel-
oped during pregnancy.  The lymphatics are large and numerous
during uterogestation, and follow the  course ot the blood-vessels.
The nerves are supplied by  the renal portion of the great sympha-
thetic, are six plexuses  (Tiedeman), and are divided into branch-
es, which supply  the fundus and follow the course of  the uterine
arteries ;  while  the  neck is supplied  by the  first pair of sacral
nerves.
   The vagina is the canal, which extends from the genital fissure
to the uterus.   It lies between the bladder and rectum ; it is close-
ly connected with the  former, and loosely to the latter.  It is
about an inch in diameter in the virgin state, but much  more ca-
pacious in  married women,  and in those who  have had family.
It is  from three  to five inches in length,  and is  capable of great
contraction and dilatation.   Its superior  extremity surrounds  the
cervix uteri; its inferior is  surrounded by a sphincter, and a net-
work of vessels, called  plexus reteformis.   It is lined  by mucous
membrane, its middle tunic is spongy and muscular, and its external
coat superiorly and posteriorly is peritoneum.  Its vessels and nerves
are afforded by the hypogastrics. The mucous membrane affords a se-
cretion to prevent adhesion of its surfaces, and this is increased in leu-
corrhoea, and removed by astringents or continence.  The inferior
surface or floor is longer than the superior, and the vagina is larger 
OF THE INTERNAL SEXUAL ORGANS.
23
near the cervix uteri, which it surrounds, than externally.  It is
a wise and wonderful provision of nature, that the vagina is capa-
ble of adapting itself to the various dimensions of the virile mem-
ber, (see 357).
   The vulva, sinus pudoris, pudendum, genital fissure, is situated
between the labia and is the external orifice of the female genitals.
ARTICLE III.--OF THE INTERNAL APPENDAGES  OF THE UTERUS.
               Section 1.—Ovaries (Ovaria).
  The ovaries have long been denominated testes muliebres, and
are properly called the seminal glands of woman, the secreting
organs of the germs, situated near the sides of the uterus, enclosed
in the posterior fold of the  broad ligament,  attached to the uterus
by  a proper ligament, are oblong, oval, about the  size of an al-
mond or bean, and of a yellow  grey colour.  Composed, 1. of a
peritoneal tunic;  2. of a fibrous membrane, thick and hard, per-
haps  fleshy  like the uterus  and  ovariac ligament, of which it may
be  an expansion  (Velpeau); 3. of a reddish tissue,  dense, and
firm; 4. of miliary vesicles, ova,  from the number  of eight  to
twenty,  filled with an albuminous fluid: 5.  sometimes of a body
of a yellowish grey colour, covered by a cicatrix, and called cor-
pus luteum.  At puberty, the ovaries become active and develop-
ed, producing by sympathy a series of changes in the uterus, its
appendages in mammae, larynx, &c.  The ovary is  an  organ es-
sential to generation, it forms the  germs.   These germs were said
to  pass through different canals to the uterus, and not through the
 tube (Fallopius):  the ligament of the ovary was the chief passage.
 Wharton and Mauriceau admitted one or two others, which open-
 ed into the vagina ; an idea lately revived by Gartner of Copen-
 hagen, as he found them in the large  quadrupeds ; but as yet they
 have not been discovered  in woman.   We shall perceive hereaf-
 ter much reason  in this opinion, as it will  appear in the  article
 < Generation,'  that there  are the strongest grounds for supposing
 the absorption of the semina fluid from the  vagina can  only  ac-
 count for impregnation in many cases.

         Section 2.— Uterine Tubes (Tuba Fallopiana.)
    The  Uterine, or Fallopian tubes are two small canals four or
 five inches long, of the size of a goose-quill, extending from  the 
24
GYNiECOTOMY.
lateral angles of the uterus, with which they are connected, to the
ovary, passing  through  the middle fold of the broad  ligament,
floating loosely in the pelvic cavity, and terminating  in  a  fringed
extremity, called fimbria or morsus diaboli.  The cavity of this
tube is large near the uterus, narrow in the middle, and  again en-
larged towards the fimbriated extremity.   It is  composed of a pe-
ritoneal tunic,  of a  musculo-vascular substance similar  to that of
the uterus, and of  a  mucous membrane, folded  in the longitudinal
direction.   The fleshy substance consists of circular and longitu-
dinal  fibres, arranged as in  the intestinal canal.  The mucous
membrane has been as easily separated as that of the ossaphagus,
consists of  valvular folds, which admit the passage  of  the ovum
towards the uterus, but  prevent its retrograde motion towards the
ovary, and of course the passage of the seminal fluid of the male
(Velpeau, Baudelocque, neveu.)  The cavity of the tube  is often
filled  with whitish mucous like all other mucous surfaces, which
accounts for the mistake of those who said they saw  the spermat-
ic fluid in the tube.  The tube receives its vessels from  branches
of the ovariac, and its nerves  from the great  sympathetic; it is
erectile and contractile, and is put in motion  by the uterus and
ovaries.  It becomes erect  during  coition,  seizes the ovary, and
permits the passage of the  seminal fluid to that organ.  Haller
caused its erection by injections of the uterus in the dead body.

             Section 3.—Ligaments of the Uterus.
  The ligaments of the uterus, are the broad and round.
  The broad ligament (ligamentum latum) is a broad fold of per-
itoneum reflected from the body of the  uterus,  and  connecting it
to the sides of the pelvis.  The uterus and its two broad  ligaments
divide the pelvis into two cavities ; an anterior, which contains the
bladder ; a posterior, in which is found the rectum.   Each liga-
ment  is subdivided into two or three folds, which enclose the tube,
ovary, and round ligament.
  The round ligament (ligamentum  rotundum)  arises  from the
uterus before and under the tube, passes through  the inguinal ca-
nal, and terminates in the groin and mons veneris.  It is a round
long muscular  cord, which supports the uterus in situ, and pre-
vents its retroversion, when pressed on by the distended bladder.
Four  other ligaments are said to exist; two anterior, utero-vesical
two posterior, utero-sacral. 
INFANCY.                        25
CHAPTER  II.
                    GYNjECO-PHYSIOLOGY.
The physiology of woman offers four principal  divisions:  1  Nu-
bility ; 2. pregnancy, or utero-gestation; 3. Delivery ; 4. Lacta-
tion.

                    ARTICLE I.--NUBILITY.
   The term nubility is applied to that period of female life which
is proper for the performance of the generative function.  The
history of nubility  comprehends four distinct periods:  1. puerile
sterility, or infancy  ; 2. the establishment of fecundity, or puberty ;
3. established fecundity, or periodical menstruation ;  4.  the  ces-
sation of fecundity, or menstruation, or the critical age or  senes-
cence.

            Section 1.—Puerile Sterility—Infancy.
   From the period of  birth to the twelfth or fourteenth year, the
genital organs are not proportionably developed with the rest of the
body ; their functions and sympathetic influence  are scarcely  per-
ceptible, and seldom exerted; so  that there is scarcely  any  dif-
ference between both sexes until the age of puberty.  Differences,
however, do exist  in their tastes,  habits, manners, and especially
in the voice, which is much sharper in females.
   The diameters of the pelvis in the first years of life differ little
in both sexes, and  are  nearly reversed, as the longest is the ante-
ro-posterior, or the  transverse : the pelvis has many of the charac-
ters of that  of the male.  The uterus is  about thirteen or fourteen
lines in length in the new-born infant, and eighteen in a girl of ten
years (Roederer.)   Its functions consist of  the  secretion of a te-
nacious mucus ; the neck is larger,  harder,  and more cylindroid
than the  body.
   The tubes and ovaries are proportionably  more developed than
the uterus.   The ovary is  elongated, vermiform, red, and compact, 
26
GYNJEC0-PHYSI0L0GY.
without vesicles.   It is eight or ten lines in length in the new-born
infant; it is sixteen at the tenth year, and twenty at puberty (Roe-
derer.)— The vesicles sometimes appear during the first year; but
generally not before the eighth or  tenth.  The  tubes  do not de-
velope in proportion to the uterus and ovaries.
   The vagina remains strait and wrinkled in  inlancy  and child-
hood: it is two inches in length in the new-born infant, and four in
the adult (Meckel.)—It is more strait below than above, has a re-
laxed fold in the form of the palate at the superior part of  its ori-
fice, which is the hymen, and in latter years becomes semicircular,
and obstructs or contracts the real orifice of the vagina.
   The vulva is small,  uncovered by  hairs ;  the  great labia are
thick, and projecting a little.   The mons veneris is large, and a
little prominent; the nymphae  and clitoris are prominent; the mu-
cous membrane is red or rosaceous, smooth, firm, and  humid.
   The gland of the breast is about the size of the end of the fin-
ger, its tissue is red and firm, and  resembles  that  of  the  thyroid
gland ; it furnishes a lacteous or serous fluid in new born infants of
both  sexes, and remains inert for some years  afterwards.  The
breasts are subjected to great injury by the pressure of stays, which
are seldom made so as to allow space for the growth of the organs:
they compress and waste the nipple ; obliterate the lactiferus tubes,
render suckling extremely difficult, and expose the breast to abscess.
Rachitis  deserves great attention,  as this disease has considerable
effect upon the different parts  of the pelvis.   M.  Duges  advises
that children should be cautioned  against masturbation, which not
only causes rickets, but a variety of chronic and incurable diseases.

      Section 2—Establishment of Fecundity—Puberty.
   The period of puberty will vary according to climate, education,
and constitution;  an  elevated temperature,  as in tropical climates
an excited imagination, and  a  sanguineous  temperament,  accele-
rate it, and induce it at the ninth or tenth year ;  while cold as  in
the polar regions, an inactive life,  and a lymphatic temperament,
do not permit it to arrive until the eighteenth or twentieth  year.
In this country and  in  France it occurs  from the twelfth to the
fourteenth year.  The most remarkable changes take place in the
economy at this time.  The body becomes more  developed the
temperament becomes sanguineous or nervous, the constitution be-
comes stronger and more vigorous.   Many diseases cease  sponta- 
PUBERTY.
27
neously, as scrofula, rickets, tinea, ringworm, epilepsy, &c; while
others become developed, as chlorosis, hysteria, bronchocele, va-
rious inflammations, and  haemorrhages.   The moral and physical
characters  are modified ; those which  distinguish childhood are
lost;  the  tastes are  analogous  to those  of a fully developed fe-
male ; the  passions are more powerful and  durable, the moral and
physical sensibility are greater,  and the  desire for marriage com-
mences.  The character of a  woman's  mind is  chiefly determi-
ned by the part she bears in relation to  generation.   Her destiny
to be united  to a husband and  to  become  a mother, is perceived
in the plays of her  infancy, and  afterwards becomes manifest in
the commencing struggle in her bosom, between her modesty and
her inclination for the other sex, as is seen in her  lovely blushes,
often united with a noble feminine pride and  reserve, until she meets
the man of her heart, when all these feelings are  succeeded by a
full and unlimited abandonment of herself  to the object of her af-
fection.   Soon, however,  conjugal love has to surrender itself to
the stronger feeling  of maternal affection,  of the power of which
we have many and the most extraordinary examples.
  At the approach of puberty the voice changes ; but not so much as
in the male.  The pelvis rapidly enlarges, but it is not completely os-
sified until the twenty-first year, although  in the sixteenth year it ac-
quires its ordinary  dimensions.   The uterus at this period becomes
double its  former size in one  year; it  becomes thicker, rounder,
and  more firm, redder,  congested, and erectile :  there are pains,
heaviness in the loins, groins, and thighs, with bearing down sen-
sations.  This state is accompanied by a local or general plethora,
a general molimen, sometimes  by a febrile state,  or paroxysms of
heat.   At length  a sanguineous exhalation, a critical haemorrhage
takes place, which is the first menstruation.  The quantity of flu-
id discharged is small, is of a  pale red colour, sometimes a vivid
red becoming serous; it  recurs at the  end of four or  six weeks,   #
for the first eruptions are rarely periodical.   The  uterus is now fit
for  reproduction ; but  examples  ol pregnancy occurring before
the age of puberty are well attested, though rare. (Sir E. Home
 Phil. Trans, vol. Hi : Velpeau, vol i. p. 113.)
   The tubes and ovaries enlarge, become  redder, and more sensi-
ble ; the former evince the structure of muscle,  are affected with
a peristaltic  motion and  erection,  and seize the ovary in  fecunda-
tion (Vallisnieri,  Cruickshank); they  contain an abundance of 
2-^
GYN/EC0-PHYSI0L0GY.
white opaque mucus, which has been often mistaken for male or
female sperm.  The ovaries present yellow  spots, corpora lutea,
produced by excitation,  spontaneous or provoked, of the  genital
organs,  without  the  approach of the male  (Home,  Brugnone,
Cruickshank, Haighton,  Blundell).   The  ovaries  appear to be
the centre of general sympathetic  excitation, and of that of the
uterus.   Women have had uteri without ovaries ; but were  de-
prived of all the signs of puberty and nubility, (Pears) :  others,
in whom the  ovaries  were extracted, (Pott, Simon, Lizars,)  had
lost all the characters of nubility and power of fecundation,  though
the uterus remained.  The uterus may be absent, and the ova-
ries healthy, when  sexual desire may remain, and  a molimen exist
which requires  the application of leeches to  the vulva or anus
(Dupuytren).   The vagina  gradually  enlarges,  becomes more
sensible, spongy, and erectile.   The vulva is  more firmly closed
by the  enlargement  of  the labia,  and is surrounded with hairs.
The mucous  membrane  becomes redder, more vascular, sensible,
and humid.   The  breasts become prominent and conoid ; the nip-
ple projects,  is conical and obtuse,  of a red or brown colour ; it
possesses an erectile  power: and  is sometimes painful, and occa-
sionally discharges a serous fluid.   The areola is  of the same co-
lour as in infants, but is  much larger.

      Section 3.—Established Fecundity—Menstruation.
   From the  age of puberty  to  the  forty-fifth or  fiftieth year, the
menses or uterine  secretion recurs monthly, with most women at
the end of each calendar month ; in some  cases every fortnight
or three  weeks, with others every  five or  six weeks,  and with
some every fortnight.
   The duration and quantity of the discharge varies very  consid-
erably ;  the extremes are from  two to eight days, and  half an
ounce to five or six  ounces.   The  menstrual fluid differs in its
physical  and chemical   properties  from blood; it  never  coagu-
lates, is devoid of fibrin, and  has a peculiar  odour.  Its colour
resembles that  of  venous  blood: it is coagulated, black, and foe-
tid in dysmenorrhoea (Duges).  Its eruption  is  often  preceded
or followed by  a sero-mucous discharge, which ceases on  its ap-
pearance or disappearance.  Each eruption  is preceded by symp-
toms of plethora,  of melancholy and mental depression, hysteria,
or lassitude.  The eyes  are encircled by black, especially in wo- 
MENSTRUATION.
29
men of fair complexion  ; there are  pains about the  loins, pelvis,
or breasts, disorder of the stomach and bowels,  sense of heat  or
itching in the uterus or vagina ; the uterus is congested, and some-
times ecchymosed, its orifice is soft  and open, hence  conception
readily takes place  after the cessation  of the evacuation.   The
vagina  is relaxed, and  more  extensible, the  vulva is  turgid and
humid, the breasts  evince  turgidity, and sometimes  the areola
assumes a more marked colour;  the ovary is  very much excited,
and presents corpora lutea,  which are not so  well marked as in
women who have borne children.
   The menstrual fluid is a secretion from the uterus, as attested
by numerous eminent physicians, who  observed it exude from the
organ when inverted (Vesalius, Peyer, Mauriceau,  Littre, W.
Hunter, John Clarke, Hamilton, Money, &c.  fee).   It was said
to depend on local or general plethora (Aristotle, Galen, Simson,
 Astruc, Lobstein) ; on a superabundance of carbon and nitrogen
 (Osiander) ; on the feebleness of the coats of the veins (Clifton) ;
 on fermentation (Paracelsus, Sylvius, De Graaf, he);  on a par-
 ticular molimen (Stahl and Dtiges) ;  on erection, (Emmet) ; on
 amorous phlogosis (Le Cat, Abernethy).
    This secretion was said to proceed from  the vagina (Columbo,
 Sue, Pineau, Bohn. Desormeaux), from the  veins  (Vesalius),
 from the arteries (Ruysch), arterial capillaries (Winslow andMei-
 bomius) from the glands (Lister), from particular small recepta-
 cles (Simson), and from the  veinous  sinuses (Astruc).  It was
 said to depend  on civilization (Emmet, Roussel, Aubert)  ; but  ev-
 ery well-informed  physician is aware  that it  occurs  to rude  and
 uncivilized females, and even to some of the  lower classes of ani-
 mals.
    The presence of this discharge  is vernacularly designated" the
 courses, the change, the flowers, nature,  indisposition,  periodical
 or female health ;" and among the middle  and lower  classes, the
 woman is said to be " ill, unwell, to  have a  change, to be regu-
 lar, or to be well in certain respects. "
    The eruption, or first appearance of the discharge orcatamenia,
 occurs, in  temperate  climates, from  the twelfth to the sixteenth
 year; in the  meridional countries from the eighth to the twelfth
 year; and in  the polar regions from the fifteenth to the twentieth
 year.   It has occurred in  this country so early as two years  and
  a half  (Lond. Med. and Physical Journ. vol. xxviii); at eight 
30
GYN^CCO-PHYSIOLOGY.
 years and a half (Op. Cit. 1810, vol. xxiv.); and between the
 third or fourth year (Sir A. Cooper,  Medico-Chirurgical Trans-
 actions, vol. iv.).   The talented and erudite Professor Velpeau
 has known it occur in Paris from the ninth year and a half to the
 twelfth ;  he does not agree with those  who have said menstrua-
 tion may occur at  birth, which he  very properly thinks was the
 result of disease ; neither can he credit the case lately  published
 at Havannah, in  which  the infant was said to have had  the dis-
 charge at the eighteenth  month, and regularly  every month after-
 wards.  Osiander of Gottingen, has recorded one hundred and
 thirty seven cases, in which nine women menstruated at the twelfth
 year, eight at the  thirteenth, twenty  one at the  fourteenth, eleven
 at  the seventeenth,  thirty-two  at  the  fifteenth,  twenty-four
 at  the sixteenth, eighteen  at  the  eighteenth, from ten to twen-
 ty  at the twentieth, one  at  twenty-one, and one at the twen-
 ty-fourth  year.   The  quantity  of  secreted   fluid afforded du-
 ring  menstruation  varies  in  different  climates.   According  to
 Hippocrates, twenty ounces were   discharged in  Archipelago;
 eighteen ounces,  according to Galen  ;  from six to twelve, accord-
 ing to Haller; from four to six ounces in  this country ;  but the
 quantity will depend upon the physical and social habits of the
 individuals.  Women often die from  excessive menstruation in Ja-
 va ; while in Lapland and all polar regions the discharge is exceed-
 ingly trifling, and recurs but twice or thrice a-year.
   Pliny and his  contemporaries maintained  that  the catamenial
 fluid  was poisonous—a most ridiculous  opinion, though in some
 degree supported by M. Velpeau, who agrees with Pliny, Colu-
melle, and the Arabians, that the miasm arising  from a woman du-
ring menstruation is capable of decomposing  milk and  other flu-
ids ; finally, that  blood retained  in the genitals for any length  of
time acquires  more or less deleterious properties.  The  learned
professor forgets that the  catamenial fluid is not blood, and  has
been  retained for years,  in cases of imperforate hymen, without
producing the slightest local irritation  or disease.   He is also  at
variance with the general opinion when he maintains the fluid con-
tains fibrin, is blood, and coagulates.    In rare cases blood may be
effused with the menstrual fluid, but  this very seldom happens •
nor can I  assent to the statement that the mixture of the fluid
with the mucus and serum of the internal organs prevents  it from
possessing  the  characters of blood from a wound.  The uterine 
MENSTRUATION.
31
fluid differs in  its chemical  and physical properties from  blood
(Brande) : it possesses no  serum, but albumen combined with
colouring  matter  (M. Toulmanche, Arch, de Med., Dec.  1829,
Lond. Med. and Surg.  Journal, 1830, vol. iv. p. 78,) (M. The-
nard, in 1817) ; it possesses no fibrin (Lavagna).
  The menstrual fluid is of a brownish colour;  is sparing  on the
first day, its quantity is increased on the  second, it diminishes on
the third,  and ceases on the fourth or fifth.  The evacuation re-
curs every month, as its name indicates,' sometimes sooner and
sometimes later ;  it  has  returned every  tenth day,  from the
twelfth  year to the fortieth, and the patient  in good health (De-
wees) ;  it has returned every twelfth day, and in one case the wo-
man was almost always menstruating,  though in  good health, but
thin  and of an extreme sensibility (Velpeau).
   It was said  that the recurrence of menstruation was from the
first to the eighth day, or from the eighth to the fifteenth ; but this
assertion is unworthy of credence.  The same woman may men-
struate on any day in the week  or  month.   Again, the periodici-
ty of the catamenia was  ascribed by  Aristotle,  Van  Helmont,
Mead, and Roussel to the influence of the moon, and hence the
adage " luna vetus vctulas,juvenes nova  luna repurgat. "   This
opinion is controverted by  the fact that the same woman will men-
struate in  the different phases of the moon, in the course  of many,
or even a single year.  If menstruation  depended upon lunar in-
fluence,  all women  should have  the discharge at the same time,
which every medical practitioner knows is not the case.
   I  fully assent to the following position  of Mr.  Ashwell: I be-
lieve it to be one of the instances in which the researches of able
and  intelligent men will terminate in their tracing'it to the will of
the Creator ; or, in other words, they will regard it as a law of na-
ture, that the fleshy  uterus of the human female  shall once every
month, by a secretory action, produce a certain sanguineous fluid.
   The use of this secretion is to fit the womb for fecundation ; its
suppression during pregnancy allows the organ to take on  a new
action for  the nourishment of the  foetus ;  it is also suppressed du-
ring lactation or suckling.  There are  exceptions to  all these
statements, as conception has happened before menstruation ; and
the latter  has occurred during utero-gestation (Mauriceau, Deven-
ter, Haller, Heberden, Hossack, Fodere,  Capuron, Francis,  De-
wees, H.  Mayo,) and every one knows during lactation. 
32
GYNJECO-PHYSIOLOGY.
   Section 4.—Cessation  of Menstruation—Senile Sterility.
   The menstrual secretion ceases,  in temperate countries, about
 the forty-fifth or fiftieth year, sometimes  so early  as the twenty-
 fifth (Haller, Dewees, Velpeau,) and again not until the fifty-fifth,
 sixtieth, sixty-fifth.  (I have known a woman delivered  in her six-
 ty-third year,) seventieth (Richerand, Magendie,) eightieth, nine-
 ty-fifth (Lond. Med. and Surg. Journ. 1830, vol. v. p. 33^,) and
 one hundredth (Blancardi).   Desormeaux has known it to con-
 tinue from the sixtieth to the seventy-fifth year.   It appears so
 early as the ninth year in Abyssinia, and ceases at the eighteenth,
 and  hence polygamy is allowed the people (Bruce).   In general
 it continues about thirty years in temperate climates, and during
 the most appropriate ages for the reproduction  of the species.
   When menstruation is about to cease,  the period is called " the
 change, or turn of life ;" and many important changes  take place
 in the constitution.   The breasts collapse, the fullness of habits
 disappears, the skin  shrivels,  and loses its colour and softness,  and
 many diseases appear in the womb and breasts which had lain dor-
 mant for years.   However, when this period has passed, women
 often enjoy better prospects of health  and of  long life than  the
 other sex.   This period  is also designated " the  climacteric,  the
 critical time, the critical age ;" and often  before its arrival the men-
 struation is irregular, absent for weeks or months, the abdomen be-
 comes tumid, there is loss of  apetite in the morning, and the wo-
 man considers herself pregnant, which is  never the case.  Accor-
 ding to the statistical  reports of Finlaison.  Moret,   Chateauneuf,
 and Lachaise, no more women than men die between the fortieth
 and fiftieth years; and Dewees contends that women are not more lia-
ble to diseases a*t this  than at any other period of life.  The cessation
of menstruation, however, is often attended with gradual decrease, or
 sudden increase of the fluid, with nervousness, with all its protean
symptoms, or more serious diseases  appear, so that moderate pur-
gation is often of the greatest advantage.   The internal  and exter-
nal orifices of the uterus become obliterated, partially  or  totally
 (Duges), or the cervico-uterine orifice (Mayer), the uterus and
ovaries are atrophied or  hypertrophied ;  the  rugae  of the  vagina
and mucous membrane of the uterus are relaxed, and pour out a
mucous discharge ; the vulva  is flaccid and dilated;  there is often
prolapsus uteri, the breasts decrease, or disappear.
   In describing the menstrual function I  should have stated that 
CESSATION OF MENSTRUATION.
33
it is sometimes suppressed or denied by nature ; in such  cases its
place is supplied by a vicarious discharge, and blood is periodical-
ly effused from some other parts of the body; from the nose, eyes,
ears,  nipples,  lungs,  stomach, bowels, navel, in  a word, from
every part of the body, especially from ulcers, and hence the hap-
py designation of Sir Astley Cooper to such cases,  of menstrual
ulcer.   We  can  easily  conceive that different parts of  the san-
guinary system may supply  each  other's place ;  that if the secre-
tion of menstruation be suppressed, its want may be supplied by
other parts equally provided with  secreting vessels.  Baudeloc-
que knew a woman, aged forty-eight, who from the age of fifteen
was attacked every month with vomiting  and purging, which las-
ted three or four days: she never had menstruated.   Haemoptysis,
or  haemorrhois, is  often urgent in cases of suppressed menstrua-
tion.
   Dr. Marshall Hall, in his excellent Commentaries on  Diseases
of  Females,  strenuously recommends attention  to the general
health at the cessation of the catamenia, and enjoins the necessity
of regulating the state of the bowels, diet, air, exercise;  and  in
cases in which vertigo or drowsiness appears,  the  occasional ab-
straction of blood, by cupping from the nape of the neck, leech-
ing, and purgation.   He considers  that  the  health  is  affected
several years before and after the climacteric period.
   Every process in the female economy is imperfect until the ap-
pearance  of  menstruation ; it is the sign and establishment  of
health ; without it beauty cannot exist, or will be effaced;  the or-
der of vital actions will be  altered ; the mind is languid, and the
body depressed.   During its  presence women are  weaker, more
delicate, and more  susceptible of  impressions; all their  organs
partake, more or less, in the condition of  the uterus.   The whole
train  of nervous sympathy  is thrown into action, the vascular and
nervous systems, the digestive  and  respiratory organs are liable to
derangement of function at  this time.  Hence,  the general prac-
tice of medical men, a practice  consonant to the prejudices  of wo-
men themselves, is to omit all active medicines during menstruation.
All strong mental and corporeal exertions must be carefully avoid-
ed, as passions of the mind, travelling, riding  in  carriages or  on
horseback, long walks,  dancing,  k.c, and  exposure to  cold and
moisture, every one of  which causes will suppress the  evacuation.
   In the Sacred Writings we find the most precise directions as 
34
GYN.KC0-PHYSI0L0GY.
to every circumstance connected with this function; a separation
was enjoined, and nuptial intercourse interdicted.  The excellence
and wisdom of the Levitical injunctions will be admitted by every
scientific practitioner, when  he recollects the injurious effects  of
sexual commerce under such circumstances, especially to the fe-
male ;  nor does he want evidence to convince him  that the  male
has contracted simple gonorrhoea from this cause.   Every well-in-
formed physician is aware of the numerous disorders to which wo-
men are subject from excessive menstruation.
   The hygienic precautions relating to menstruation are seldom at-
tended to in this country.   The young female at  the  age of pu-
berty is seldom instructed as to the change she is to  suffer; she
is left ignorant, and is much astonished  at the first eruption of the
uterine secretion.  The mental emotion thus excited,  often  inter-
rupts the proper establishment of the  evacuation for  one or two
years.   She is not cautioned to avoid, during each periodical  evac-
uation, exposure to cold, humidity, all strong emotions, violent ex-
ertions, exciting aliments  and drinks, he.   The first appearance
of the catamenia will depend  upon the  constitution, mode of life,
and in the opinion of many, upon the manners of those with whom
young women converse.  In general, women are  weak during the
periodical  evacuation,  and  are averse  to  sexual  congress: the
most abandoned female  will not allow it, unless impelled by the
direst distress and misery.   It is also a general rule, that women
of full habit, those  who live luxuriously, those confined in warm
apartments, and those who indulge in nuptial commerce, menstru-
ate most copiously.  But we often find full habits have the secre-
tion sparingly,  while pale  and delicate women have it copiously.
It is much increased by marriage, though it may recur during the
first week of that state and not again for years, and  the woman
bear seven children (Hamilton's Lectures).—There is no truth  in
the opinion that the menstrual fluid nourishes  the  foetus and is
suppressed for that purpose;  but the correct  explanation of the
cause of its suppression  is afforded by the physical changes which
take place in the uterus after conception ;  and the established phy-
siological axiom, that  two functions or diseases cannot affect the
same organ at the same time.
   Again, animals that are deprived of this secretion by nature
still nourish their offspring.
   When menstruation returns during lactation, conception very 
GENESEOLOGY—REPRODUCTION.
35
 soon follows;  the milk is considered by women to be deteriorated,
 and unfit for the nourishment of the infant.
   From the preceding remarks, it  is very manifest every process
 of female economy to the climacteric period is affected by the pe-
 riodical secretion; and women very properly ascribe all their dis-
 eases to the derangement of this most important function.

        Article II.—Geneseology.—Reproduction.
   The terms reproduction, generation, fecundation, or impregna-
 tion and conception, are generally employed as synonymous, though
 each has a distinct grammatical acceptation.   The word reproduc-
 tion is applied to the function by which living beings are perpetu-
 ated, the word generation to the creation of the germs, the term
 fecundation expresses the action by which the germs  are  united,
 or by  which one of the germs vivifies the  other.   Conception
 means the action by which the fecundated  germ is retained in the
 sexual organs, and coition or copulation the approach of the sexes
 by which fecundation is established.   It  appears, therefore, that
 reproduction is the generic term, and that the others refer to dis-
 tinct phenomena.

 Section 1.—General Remarks  on  Geneseology—Reproduction.
   The term generation is expressive of the power inherent in an-
 imals of reproducing their kind, by the concurrence of both sexes
 of the same species.  The term conception  is more immediately
 applicable to the influence of those means on the female.  It is ne-
 cessary that both animals should be in health ; that the male should
 secrete semen, and have sufficient vigour to transmit it to the prop-
 er organs of the female, and that the organs peculiar to the latter,
 have a corresponding soundness of structure and functions, to com-
 plete the generative act.   There must be a fecundating fluid, con-
 veyed  from the male to the female of all  animals, in order to re-
 produce and perpetuate the species.  The human semen is never
 emitted  in a pure state, for the mucus of the  vesiculae seminales
 forms the greatest part of it;  and  it  is this  latter that eunuchs
 emit in  such considerable  quantity.  The fluids  of the prostate
 gland and urethra are emitted before the sperm, but in general are
 mixed  with  it.  The Abbe Spallanzani proved,  that the male se-
 men of the  inferior animals should be diluted, before it was fit for
impregnation.   The penis does not  enter the womb, but it is sup- 
36
GYN^CO-PHYSIOLOGY.
posed that the semen does; the orifice of the womb is too small,
and besides, there is much reason to believe that the penis is sel-
dom accurately applied to it.   Richerand, Blumenbach, Magen-
die, and others, assert that the womb sucks in the semen after its
effusion ; but can this be ever positively ascertained ? Prevost and
Dumas  assert that animalcules are indispensable, and must be sup-
plied by the male ; that they arrive at the upper part of the womb,
but do not enter the  Fallopian tubes, and that a small grain es-
capes from the vesicle or ovum, some days after coition, and meets
animalcules in the tube ; and that fecundation occurs several  days
after the approach of  the sexes.  This is the most modern  theory
of conception, and is fully as objectionable as  any ever offered on
the subject.  If the womb remained open several days after  con-
ception, an assertion  almost  unanimously denied by physiologists,
there would be other conceptions formed, and the doctrine of su-
perfoetation established.  Before the conclusion of this article, we
shall perceive other arguments still more powerful against the new
theory.
   At the epoch of puberty, in  both sexes, a lively sensation, irre-
sistible, and hitherto  unknown, breaks forth;  leads  to  a  union of
the sexes, and inclines  them to copulation.   This sensation has
hitherto been attributed to the  genital organs,  until Gall has made
it one of the faculties of the soul, and asserts  it  is placed in the
cerebellum, as  old men and very young boys have sexual  desire.
At this time man is endowed with more principles of life than are
necessary for his body; and this  superabundance is intended for
the perpetuation of  his species.   An accumulation of these vivi-
fying particles induce the  most vivid sensation, which causes erec-
tion of the penis, which is affected by an afflux of blood into that
organ.  The  penis  acquires considerable strength by its active
congestion, surmounts every resistance offered by the vagina, and
penetrates deeply into the cavity, towards the neck of the  womb.
The burning heat, communicated by the female organs, the vo-
luptuous pressure it experiences,  propagates its orgasm  to the
whole organs of fecundation ;  the testicles are drawn nearer the
abdomen,  and tightened in  their coverings;  the  seminal vesicles
contract, and propel  the  semen they contained into the urethra
and from that moment, by the convulsive motion of the perineal
muscles and urethra, it is propelled by that  delightful  sensation
which words cannot  describe—which throws the subject  into  a 
GENESEOLGY—reproduction.
37
kind of convulsion, similar to an electric shock ;  sometimes even
forcing cries from him ; this powerful nervous sensation is more or
less protracted, and the penis soon collapses afterwards, and is re-
stored to its primitive state.
  The sensation of desire in females, causes a  congestion in all
the erectile parts of the vulva and  vagina, the approach  of the
other sex, and particularly the introduction of the penis, throws
her into a voluptuous orgasm, which sometimes causes cramp or
convulsions, and terminates by a secretion, more  or less consider-
able, from the mucous membrane of the vagina, which  is  succeed-
ed by a total prostration, that is far from being void of pleasure.
  Fecundation is the creation of a new being, by the contact of
elements, applied by two individuals of different sexes.   It is pro-
ved, beyond all doubt, that the male semen is the fecundating li-
quor, by the artificial impregnations  of eggs of frogs, by Spallan-
zani, and by  those of Jacob upon fishes.  These experiments
were successfully reported by Dumas and Prevost, who also re-
marked,  as  Spallanzani  had done, that the seed,  in order to be fit
for  fecundating, required  to  be  diluted.   Thus we can perceive
the utility of the prostatic fluid, and of the mucous emission of the
vagina.  The most extraordinary opinions have been  entertained
in the  mechanism  of conception ; a few of the leading ones only
will be enumerated, as the history of them all, about two hundred
and fifty  in number, would consume too much time, and serve no
purpose.   The first opinion was  that of Pythagoras.   He  suppo-
sed, that a vapour  descended from the brain and  nerves  of the
male, during coition, from which the embryo was formed.   All
the grosser parts were formed from the blood in the  uterus: he
maintained that forty days elapsed in the completion of the infant,
and some months in its perfection, according to  the laws of har-
mony.   Impressed  with this idea, the Scythians cut the veins be-
hind the  ears, when they intended to procure impotence  and ster-
ility ; an idea so justly ridiculed by Sterne.
  Empedocles was of opinion, that some parts of the embryo were
contained in the male  semen ;  and others in that of the female ;
and  that  by their mixture, the embryo was formed.  He also
maintained that the desire of procreation was caused by the natu-
ral tendency of the separated parts to be united.
  Hippocrates thought the infant was formed in the womb by the
mixture of the male and female seeds.   Aristotle  denied that there 
38
GYNJECO-PHYSIOLOGY.
 was any female semen, and in this he was correct; but the ovari-
 an fluid answers the same purpose.   He was of opinion that the
 embryo was formed in the womb, by the menstruous blood, and
 vivified by the male semen.  He held, that the  female supplied
 the material which was modelled by the male : the woman furnish-
 ed the marble, man was the sculptor,  and the embryo the statue.
  Galen said, the embryo was formed by the substance of the
 male semen, and the fluid supplied  by the  female  nourishes it;
 this is nearly correct.
  De Graafe maintained, that all animals were produced from eggs
 (ova) omne ab ovo, and that the  germs existed  in ovary of the
 human female.
  Josephus de  Aromatariis, Swammerdam, and Harvey, our im-
 mortal countryman,who devoted great attention to the subject of
 generation, after his discovery of the circulation of the blood, as-
 serts that  as iron by friction becomes magnetic, so the womb, du-
 ring coition, acquires a plastic power of conceiving an embryo, as
 the brain  is capable  of thinking and apprehending.  It  appears
 from his work on generation and parturition, published 1603, that
he was a practical  obstetrician, as he describes instrumental ope-
rations he performed.   He was in practice more than half a centu-
ry before M. Clement, who is said by some English writers to be
the  first medical obstetrician.
  Hamme discovered the animalcules  in the semen of all male
animals, which required a bed or habitation, from the female, for
their abode and  expansion.  Leewenhoeck deprived him of this
discovery.  The principal arguments brought against this doctrine
were hybrid productions—as the mule, which is procreated by dif-
ferent animals ;  and secondly,  that  animalcules are observed in
soup and  gravies, and  in  vegetable infusions.  The lascivious
Charles ordered that the animalcules of the male semen should
be presented to  him, frisking in their native liquor.
  Harvey examined the womb  of the doe, an hour after coition,
but  he never found it contain semen ; hence he concluded there
was an aura seminalis or vapour, which asceuds and impregnates.
Ruysch, however, found the semen in the uterus of a young mar-
ried woman, who was detected by her husband in a criminal connex-
ion, and killed by him in the very act of copulation. Leewenhoeck
and Hartsocker attested the same fact.   Mr. Hunter killed a bitch
during coition ; he then opened the  womb, and saw the male se- 
GENESEOLOGY--REPRODUCTION.
39
men entering by jerks.  Haller found the semen in the Fallopian
tube, and thought with Fabricius ab Aquapendente, that the germ
of the  embryo was in the  female, and was  vivified by the male.
Dumas and Chaussier say, that the  male semen fecundates the
ovum,  or vesicular egg;  and that the Fallopian tube becomes
erected during coition, seizes on the ovarium, and conveys the ovum
or egg  into the uterus, to meet the fecundating liquor.   De Graafe
and Magendie have found the fringed extremity of the tube strong-
ly applied to the ovary, a few hours after copulation, and the abdo-
minal or  the extra-uterine  pregnancies^ and the  fact,  that Nuck
could  produce  those of the tube  at will,  by a ligature, seems  to
substantiate  the opinion.   Again, if the tubes  are impervious,
there will be no pregnancy.   Harvey was the first who contended
that an egg dropped from  the ovary ; and De Graafe demonstra-
ted this fact, by precise experiments.   Dumas and Prevost have
proved that subsequently to a fecundating coition, a vesicle unfolds
itself in the ovary, increases in size for four or five days, and then
bursts; and that the ovule escapes through the small opening, and
leaves  a yellow spot after it.  Brissiere saw this  diminutive body,
partly  in the interior of the tube,  whilst it still adhered to the ova-
ry.  All the theories that have been brought forward, respecting
generation, may be reduced to the following:  First, Epigenesis—
that the materials are produced by the two  sexes, which are called
the force of formation.  Second,  Evolution—Bonet was of opin-
ion, that the first female contained all the  eggs, one within another;
and that the human race  will ultimately  become extinct, by  the
exhaustion of the reproducing ovules.  Lamark contends, that or-
ganized bodies arise from spontaneous generation, caused by light
and electricity.  Descartes speaks of a kind of ferment in the two
semens.   Pascal, and the  older chemists, maintained that the seed
of one was acid, and the other alkaline.  Buffon maintained, that
there were living organic molicules, which combined with a por-
tion of dead matter.   Others assert,  that every female produces
her eggs by secretion.   Dumas and Chaussier hold, that the ani-
malcules contain the nervous system of the embryo.
   The semen of the male is said to be conveyed to  the ovaries
by the penis, and  from thence back  into the uterus.   The chief
objection to this is the disproportion between the generative organs
of sexes ; for example, if a large  woman be married to a small
man, as often happens, the male  organ may not  reach the orifice 
40
GYNJECO-PHYSIOLOGY.
of the womb, which may be distant from three  to six inches, from
the external parts;  and besides  the width of the  upper part of
the vagina, which may  not close tightly on the penis ;  and there-
fore  the semen will not be injected accurately into the  orifice of
the womb.  Again, if a large man be married to a small woman,
the penis may pass up beyond the mouth of the womb, that is, by
pushing up the loose vagina; and thus the emission of the semen
will not be thrown into  the  womb.  We meet with many cases
where the mouth of the womb is not  two inches from the exter-
nal parts ; and there are few male organs that do  not exceed this
length.   The penis is not perhaps in  contact with the mouth of
the womb in nine cases out of ten—It passes far  above it.  Im-
pregnation  has  taken  place,  and the hymen perfect, where no
complete penetration could  have happened.  I have been  confi-
dently assured by a gentleman, that he impregnated a female, al-
though he scarcely penetrated the vagina.   The woman consulted
me,  unconscious of her condition, as the connexion  had  taken
place when  she was intoxicated,  and she absolutely averred she
never knew any  man ; yet my opinion was unchanged, and  she
was delivered in due time.   I knew a  man who lost two inches of
his penis, yet he had children, his wife being rather over the mid-
dle size.  The penis had been amputated close to the pubes.  The
wife supposed her husband impotent, and was highly offended when
informed he might propagate ;  but she bore him offspring, of his
own similitude (Lond. Med. and  Surg. Jour., 1830, vol. iv.—Mr.
Hurd's  case).   These cases favour the doctrine of absorption.
The orifice of the womb may be scirrhous, and nearly closed up.
Drs. Munro and Farquharson, of Edinburgh, found it completely
closed, and  the woman pregnant; there must have been a small
opening, to  admit of conception.  Another doctrine  is, that the
male semen is absorbed from the vagina, oarried into the circula-
tion, and brought into the ovaries.  To this  it is to be  objected,
that the semen, if taken into  the circulation of the blood, would
be so changed by admixture, as no longer to be semen, and there-
fore could not impregnate.   If true, a women would conceive, if
the male semen were injected into her veins.
   From the experiments  of Spallanzani, the semen must be slight-
ly diluted to effect impregnation, but still it must be semen. Oth-
ers say there would be no  use for the Fallopian tubes if absorp- 
GENESEOLOGY--REPRODUCTION.
41
tion took place ;  but this is an error, as they would still be requi-
site to convey the impregnated ovum to the womb.
   Some assert, that the semen makes an impression upon the.la-
bia, vagina, or the womb, and that impregnation  takes  place by
the ovaries sympathizing with the impression.   Others are of opin-
ion that the semen is absorbed from the vagina and labia  by a set
of vessels, whose whole duty it is to convey it  to  the ovaries.
Such ducts have been discovered in the elephant, and by Dr. Gart-
ner, of Copenhagen, in the  cow and sow. This modified  doctrine
of absorption  is  the most  simple  that nature could adopt in this
process ; but,  if true, super-foetation ought always to occur.
   If the germs existed in the female, they would  have been form-
ed in the first  of the species; and all infants would be like the fe-
male parent, which we know not to be the case.   Again, the ass
and the mare  produce a different species of animal, which is in-
capable of reproduction. This doctrine would not account  for mon-
sters, or defective infants.   The internal functions of both parents
are deeply concerned  in the production of the foetus, as  we often
see scrofula of the one parent conveyed to the offspring; hence
the objection to marrying delicate and diseased persons. Dr. Cul-
len remarks, that infants of both  sexes will  become  scrofulous.
Physiologists have asserted, that the right testis and ovary formt he
male, and the left the female.  Scotus.asserts that a soldier, who
lost his left testis, had twenty-six children, all boys;  and he re-
moved the right testis of a dog, and caused the animal to impreg-
nate a bitch, when the puppies were all female.   However, Rich-
erand asserts, that a man with one testis will beget male and female
infants.   Velpeau describes a woman with one  ovary, who  had
male and female offspring.   I should  have observed, in refuting
the doctrine of animalculism, that many were horrified  at the idea
of supposing  that only one animalcula, out of so many millions as
were said to exist in the male semen, should be vivified, a doctrine
so opposite to the  wisdom  and beneficence of Omnipotence.  On
the whole, the doctrines of the aura seminalis, or vapour,  and of
absorption, are decidedly the most feasible, because the orifice of
the penis is seldom applied to that of the womb;  but we are per-
fectly ignorant of the phenomena of conception, even  in these
times.
   In order to have coition  effectual, there is a mutual relation ne-
cessary—a union in mind and pleasurable enjoyment as well as in
         6 
42                   GYN^CO-PHYSIOLOGY.
body, and unless this union of love be mutual, conception will sel-
dom, if ever happen ; for it has been long observed, that frigidity
and reserve in either party will defeat procreation—a want of love
being a certain cause of barrenness.  Hence, in unequal marriages,
where one of the parties is old and the other young, there is scarce-
ly ever offspring.   Again, it has  been observed, that  in  cases of
rape, impregnation seldom occurs.
   In order to effect procreation, there must be an ability and fit-
ness of disposition in the sexual organs of both parties.  The dis-
proportion of the organs impede or prevent conception.   This is
observed very often when persons of extreme difference of stature
cohabit.   The most frequent cause of want of family is too fre-
quent intercourse;  the male  semen will be too weak, and the fe-
male will  become  relaxed,  have  increased mucous vaginal dis-
charge, which will extinguish the vivifying principle  of the  male
altogether.  Hence, we see strong, young, vigorous, and amorous
persons remain married five, six, and seven years without children.
I know three respectable families in this predicament.   I am in-
clined to think that the  male semen is not sufficiently strong  when
only allowed to accumulate for a day; in fact, all healthy persons,
who desire children, should cohabit but once or twice a week, and
they will seldom be disappointed in their expectations.   The sex-
ual act is not performed well when repeated  too often.   Hence,
when boys or  extreme young persons get married,  they seldom
propagate. 'It is an opinion, that the greater the  quantity of se-
men, the more perfect the formation, and  even  future disposition
of the offspring, and the greater the pleasure experienced by both
sexes.   The first opinion is  attested in the inspired writings, Gen.
xlix. v. 3.  The more the semen is preserved, it is more power-
ful, and ought to be retained for a few days, in order to render the
sexual congress effectual.
   Care, thoughts of business, sorrow, sadness, and depressing pas-
sions should be avoided, as they have a bad effect  on  the concep-
tion.   This has been long the prevailing opinion among mankind,
especially among physicians, naturalists, and  I  might add,  senti-
mentalists too.
   The most frequent causes of failure on  the male  side  are too
frequent  copulation, malformation  of the penis as the  urethra
opening at the  side of the perineum, or on the back of the organ,
or near the scrotum; in all of which states, the semen will not be 
GENESEOLOGY--REPRODUCTION.
43
applied to the orifice of the uterus.  Stricture is another cause of
impotence, as the semen may escape into the bladder;  there may
be want of erection, or that function  may cease  before  the com-
pletion of the act.  Frequent intercourse is injurious to conception,
causes debility of the organs, and unfits them for generation. Pros-
titutes seldom conceive; on the other hand, a woman very readi-
ly becomes  pregnant  by a  single  intercourse.   If the  semen of
the male be  vitiated or depraved,  the infant  will be  affected.
Thus the venereal  disease  is communicated  to the  foetus in the
womb; infants have been born  with the copper-colored eruption,
and cured only by mercury.
   All healthy persons,  at the time of puberty, most  certainly feel
the passion  of physical love.   It  is  a part of their health, and as
natural a consequence as hunger or thirst.  It is the  most delight-
ful of all  the passions, and makes  the greater part of human hap-
piness ; it exists independently of the human will; it may be restrain-
ed, but not  extinguished.  Reproduction seems to be  a common
law  of animal and vegetable  life, and the disposition to  repro-
duce, in all healthy subjects, is most powerful.  It is a passion
that must be gratified.  In the  male, the semen will  only accumu-
late  for a certain time, and must be disposed in some manner, nat-
ural or unnatural. Those who think intercourse with  the other sex
criminal, unless  in the married  state, allow the semen to be dispo-
sed of by nocturnal effusions.   Others, who fear offspring, dispose
of it by the abominable practice of onanism, self-pollution, or those
other disgusting and unjust means  recommended in  our times  as
wholesome checks and salutary preventives of conception.   The
practice of introducing substances  into the vagina before coition,
will not prevent impregnation.
   In cases  of precocious puberty, in which seminal  emissions and
menstruation have occured before  the fifth  year, it would be worth
enquiring, whether conception could happen between such per-
sons, and also in cases of old age, as  at eighty in  the male and
seventy in  the female.   The  French physiologists  maintain the
affirmative of the latter supposition.  Magendie asserts that men-
struation  has returned  after  the  seventieth and eightieth  year
(Physiol., 1826); and  Dr. Elliotson informs us, in his most inter-
esting notes on  the translation of Blumenbach's Physiology, 1828,
that Thomas Parr, who died at the age of 152, was compelled to
do penance in a white  sheet,  for an  illicit amour,  committed at 
44
GYN^CO-PHYSIOLOGY.
the age of 105;  from which it is evident that he not only enjoyed
the longevity, but also the vigour of his antediluvian progenitors.
Mr. Callaway, the eminent surgeon of Guy's Hospital, presented
a child at the London Medical Society, in  June 1828, whose age
was three years and eight months, and whose organs of generation
were fully developed.  He had whiskers, hoarse voice, erections,
and sensual desires;  but it was doubtful whether he  had seminal
emissions.  There is a  similar case recorded in the Medical and
Physical Journal;  the boy was five years,  of age, the generative
organs were  fully developed, and he had  nocturnal emissions.
Could impregnation be caused by them ?

Section 2.—Fecundation.—Conception.—Phenomena with  re-
                     spect to the Mother.
  In my Inaugural Dissertation on Man, and the apparent varie-
ties  of the human  species,  I maintained, " that  a fluid was  af-
forded by each sex for the formation of the human embryo ; but
that something besides the mechanical commixture of these  fluids
was requisite for the  purpose of procreation, and a Power, far dif-
ferent from brute matter,- was exerted, by which  the future off-
spring became endowed with animal as well as rational existence."
This opinion, to me original, is now maintained by one of the most
eminent physiologists and distinguished surgeons of modern  times
—Mr. Abernetby. When speaking of conception, he says, " Now
I pause  here, that you may think of the positive absurdity of sup-
posing  that the foetus can be formed by either parent.  How can
it be !   What is the testicle: for  that undoubtedly secretes the fe-
cundating liquor ? Is it not a congregation of vessels ? Why, then
it must be formed by aggregation of parts, after the secreting pro-
cess has  taken place.  And  what is  the  ovary, but a vascular
part?  I say it is impossible, therefore, to suppose  that  a young
animal can be secreted ; it must be formed ; and then  the only  ques-
tion is, where is it formed, and how is it formed ?—Lectures, 1828.
  The ovaries are much concerned in  the phenomena of concep-
tion ; they become red and tumified, one of their vesicles swells,
bursts, and escapes, having its parieties thickened and pulpy, and
being about the size of a small cherry (Duges), and containing a
fluid, and the ovule,  or rudiments of the embryo.  The opening
through which  it escapes becomes cicatrized, and is called the cor-
pus luteura: it is described by Fallopius, Malpighi, De Graafe, and 
GENESEOLOGY—REPRODUCTION.
45
Roederer; and its development is not the effect  of the male se-
men, but is a peculiar function of the ovary ; it is an indispensable
preliminary necessary for conception ;  it has been found in women
who had not conceived, by Roederer, and in virgins by Haighton,
Vallisnieri, Santorini, Bertrandi, Sir E. Home, Brugnone,  and
Cruickshank : in mules, by Brugnone; and in animals whose Fal-
lopian tubes were tied before coition, by Haighton.  The male semen
is said to be carried by absorption, or by a peristaltic motion of the
womb and tubes (Galen, Fallopius, Morgagni, Hunter, Magendie,
Richerand Blumenbach, and Ruysch); and Haller found the sperm
in the Fallopian tubes of women and animals, who were killed imme-
diately after coition.  Dr. Haighton tied the Fallopian tubes of rab-
bits and incised them ;  the animals lost all desire, were barren, and
yet the  corpora lutea were developed.   Impregnation took place
when one tube was cut, but that of  the divided side contained no
ova (Phil. Trans., vol. lxxxvii. p. 175).   Ovarian and extra-ute-
rine conceptions prove that  the process  of  impregnation takes
place in the ovary, and beyond the  womb and  Fallopian tube.
Mr. Stanley  has published an account of a case of ovarian preg-
nancy (Med. Trans., vol. vi.  art. xvi.); and Dr. Granville a more
extraordanary example, the foetus being perfect, and  four months
old (Phil. Trans., 1820). Yet it must be admitted that the penis
is not always in absolute contact with the orifice of the womb du-
ring seminal emission, and from the smallness of the orifice, in ma-
ny cases, cannot inject the  semen into the uterine cavity.   " It
would be difficult," says Richerand, " to conceive that this straight
passage, the orifice of the womb, should admit even  the  seminal
fluid, if it were not  known"  (who knows it ?)  " that  in  the  mo-
ment of copulation, the womb from  irritation draws together,  and
inhales, by real suction, the semen which it craves."   I would ask
how can this  theory  be ever  proved ?   Mr. Abernethy was right
when he declared, "  we know nothing of the phenomena of con-
ception."  All that has been said concerning it must not be recei-
ved as fact, but merely as probable;  such is the darkness with
which nature has chosen to envelope this great mystery of the li-
ving economy.  But to proceed with the received opinions : The
Fallopian tube is said  to become erected during orgasm of coition, to
embrace the ovary, which  embracement was observed in different
animals killed after coition, by Haller, De Graffe, and Cruickshank;
in women, who died  soon after coition, by Littre ;  and in a virgin, 
46
GYN.a£CO-PHYSIOLOGY.
who died of hysteria, by Vallisnieri.   The peristaltic and anti-pe-
ristaltic motion of the tube, the  conveyance of the semen to the
ovary, and the  re-conveyance  of the impregnated ovum to the
womb, have been proved by ocular demonstration, by Beclard, De
Graafe,  Prevost,  and Dumast, and by the experiments of Nuck
and Duverney,  who  arrested the impregnated ovum in the  tube,
by a ligature applied three days after coition ;  again by the  tubu-
lar and abdominal pregnancy, in which the tube has allowed an ovulo
to escape (Lallemand). It  is probable that the increased dilatation
of the tube, after fecundation, is intended for the retention of the
ovum for some time.   How can we explain the fact, that but one
tube only is concerned in  conception ?   What was the object of
nature, in forming two tubes, two  ovaries, two testes, two seminal
receptacles, if one organ in each sex be sufficient for the  propaga-
tion of the  species ?   Or  are the double organs in each sex  in-
tended for the formation of the  distinct sexes ?
  The same orgasm that affects the  ovary and tube is said to ren-
der the  womb  vascular, and  lightly inflamed (Harvey, Ruysch,
Hunter, and others).   Its  internal surface thus irritated, secretes
the albuminous  concretion, called decidua, by Hunter, and epicho-
rion by Chaussier.  These effects  are purely  sympathetic, be-
cause they exist in extra-uterine pregnancies ;  they are more per-
fect, however, when produced by  the presence of the ovule.
  The  volume, form, and direction of the uterus are  changed;
its parietes  are  enormously thickened;  its weight, at the comple-
tion of the  term of gestation, is two or three pounds, and  compa-
red with that of a woman  who  has been  a mother  (two ounces),
and with  that of a  virgin (half an  ounce),  we find it multiplied
by nearly  twelve and twenty-four.  Its fibres are muscular (Lob-
stein) ;  but not invariably  so, as attested  by Dr. Malins  and my-
self, in  a case lately published  (Lond. Med. and  Surg. Journ.,
Jan. 1831,  vol. vi.)  Drs. Dewees and Ramsbotham deny that
new matter is added  to the uterus after conception ; an opinion at
variance with that of the profession  in all countries.

    Section 3.—Fecundation.   Phenomena of the new being?
                  the product  of Conception.
   It  has been  attributed by the ovarists to the exclusive  produc-
tion of the female, to the male by animalculists.  Haller, Hunter
Buffon, Haighton, De Graafe,  Cruickshank,  Vallisnieri, Prevost, 
DEVELOPMENT OF THE  EMBRYO, &CC.
47
Dumas, Rolando, and all the modern physiologists agree that the
foetus is produced by both  sexes, the ovary affording the ovule or
germ, and the male  the principle of life.  Some assert that the
male produces the nervous, and the female the vascular systems,
as the vessels of the foetus in birds are  connected with the yolk
before fecundation.
   The doctrine  of the ovarists,  as to exclusive evolution of the
germ of the female, is now abandoned, and that of theepigrnesis,
or the adscititious property of the male, is  now generally recei-
ved.   It did not require the illumination of the physiologi.: is  of
ages to inform us that neither sex can individually  propagate the
new being; nor that male and female must be  concerned in the
formation of the offspring.   After all the speculations and experi-
ments of physiologists, for two thousand years, they have only ar-
rived at a conclusion universally  known to every grade  in society,
and in every clime—that the union of both sexes, of the same
genus of animals, must take place, in order  to form the new be-
ing.  I say of the same  genus, as  there is  but  one exception to
this assertion in  the  whole class of animals, namely, the fecun-
dation between the horse and the ass;  but  even here  nature has
provided against the indiscriminate mixture of animals ;  the mules
are formed with  imperfect genitals, and cannot continue their spe-
cies.  The seminal fluid of each animal is a specific stimulus, and
is incapable of fecundating in another; for if it had  such  power,
there would be an endless  confusion of animals, and  no distinct
genera.   This clearly proves the monstrous absurdity  of suppo-
sing that fecundation could take place between the human and in-
ferior species of animals.

  Section 4.—Development of the Embryo  and its Membranes.
   The impregnated ovum contains the elements of the  new being,
is detached from the ovary, and  has been perceived in  the Fallo-
pian tubes of rabbits three days  after conception, by Cruickshank
and De Graafe; and about the sixth or eighth day in bitches, by
Prevost and Dumas ; and Sir.  E.  Home found the ovum in the
womb, eight days after conception.  Med. Chir. Trans, vol. 2.
Cruickshank was of opinion, that it remained  detached for two
days after its descent into the womb, and then became attached
to the organ by  vascular filaments.
   Meckel asserts, that the human embryo can be observed on the 
48
GYNiECO--PHYSIOLOGY.
fifth day  after conception ; and that the ovum measures from six
to eight lines in diameter.  The embryo at that time appears ver-
miform, with a small head;  the trunk separated from the head,
and attached at a certain point to the decidua,or epichorion, with-
out members,  or  without apertures, of a homogeneous appear-
ance ; three lines long, and weighing three grains.  Sir. E. Home
describes it at the eighth day, as a  vesicular, glutinous, pellucid,
oval body, attached to the bottom of the womb;  that it is compo-
sed of two oval bodies, joined as if  by a neck ; the one the head,
the other, the trunk.   On another occasion (de  Genere Humano
ejusque varietatibus) I  have  given a description of the impregna-
ted ovum, and said that about the fourth week it  resembles a tad-
pole,  and  probably  that its tail is  the spinal marrow.  A small
point is perceived below the head, which pulsates, and this is the
heart; and  below this the abdomen appears.  Thus the brain,
medulla spinalis and heart are formed before  the other parts.  The
ovum resembles a cone, somewhat  curved,; the head and trunk
equal; no distinct neck ; face small; the spinal column perfect,
and turned forward at the coccyx; the umbilical cord is short, and
contains  the intestines, the extremities appearing;  it is six  lines
long,  and  weighs eighteen  grains.  About the sixth week two
small black spots proclaim  the development of the eyes; the
mouth appears shortly after ;  and the  inferior and superior limbs
soon become discernible.  The  intestinal tube is perpendicular,
running along the spine ; the anterior wall of  the abdomen forms
a projection, which still adheres to the  membranes  of the ovum.
The ovum presents an ovoid form, and it is one inch and a half
long, and one  inch and a quarter broad.   The embryo soon sepa-
rates from the membranes of the ovum; other parietes of the ab-
domen assume a funnel-like extension, to form the umbilical cord
or naval  string ; and the anus and genital organs appear.  At two
months,  the eyes and eyebrows are visible ;  the limbs are devel-
oped ; the fingers are closed on  each other;  the head forms the
third part of the  body.  Between the ninth and  tenth weeks the
mouth closes,  by the  lips drawing  together,  but the cavity still
communicates with the nose  ; the eyelids close the eyes ; the au-
ricular openings begin to appear; the  spinal  tail shortens ; and
the fingers assume their positions.   I have a small embryo in my
possession,  about this age, which is quite perfect, and the organs 
DEVELOPMENT OF THE EMBRYO, &C.
49
of generation quite evident.*   The parent assured me positively,
that it was not more than two months and a half old.  Towards the
third month the face is distinct; the mouth open ;  the brain casei-
form ;  the meconium  in the stomach, the anterior part of the chest
is covered in by the sternum: the intestines, hitherto contained in
the umbilical cord,  enter the abdomen; the skin begins to be or-
ganized ; and the embryo is from four to six inches in length.  At
the fourth month, the upper and lower extremities are equal;  the
skin is  downy; the  muscles  contractile;  the meconium in the
small intestines ; the auricles of the heart are larger than the ven-
tricles ;  the  foetus  measures four  inches  long, and weighs about
two ounces.  About the fifth month, the auricles and ventricles of
the heart are equal; the nails are consistent; the skin is still  red ;
there are points of  ossification in the sternum ; the bowels capable
of contraction ; the length of  the foetus, ten inches;  the weight
sixteen  ounces.   At  the sixth month, the hair appears ; the brain
is  homogenous ;  the  meconium brown, greenish  in the coecum ;
and the testicles are  under  the kidnies ; the length is twelve in-
ches ; weight, nearly two pounds.  At the seventh month,  the
skin is of a  rosy colour; the cellular  substance becomes  develo-
ped ; the eyelids are covered ; the membrana pupillaris is  bro-
ken ;  the testicles descend to  the  abdominal rings; the  valvulae
conniventes are observable in the small  intestines: the meconium
descends into the colon ; the bile is bitter ; the length of the body
is fourteen  inches ;  the weight about three pounds.   At the eighth
month all  the  parts  become  more developed ; the testicles de-
scend into the inguinal canals ;  the infant measures sixteen inches,
and weighs between four  and five pounds.  At nine months, the
infant has acquired the perfect form of the  human species;  the
two substances of the  brain are quite distinct ; the auricles of the
heart are smaller than the ventricles ; the meoonium  is in the rec-
tum ;  the bladder full of urine; the skin is covered with an oily
caseiform matter ; the breasts contain a serous  whitish fluid :  the
thymus and  thyroid glands are red ; the length of the body is gen-
erally twenty inches ; and  the weight  seven or eight pounds.
There is a considerable  variety in the weight  and dimensions of
different infants,  during the   different  periods  of development.

  «  M. Duges asserts, that the sexes are not to be discerned sooner than the
fourth month.—Manuel Obstetrique, 1826.
            7 
50
CYNJKCO-PHYSIOLOGY.
How wonderful the development of the infant ! its  body, consist-
ing of a viscid gelatinous fluid after conception, and ultimately be-
coming the most varied and complicated machine in the universe.
   Immediately after conception, the womb  becomes excited and
more vascular, it is softer and more spongy, an albuminous fluid js
thrown out on its surface, which is organized in the shape of a
membrane ;  which, from being afterwards cast off, was called mem-
brana dccidua by Dr. Hunter, and epichorion by Chaussier, and
caduca by others.   This membrane lines the womb, and  covers
its orifice ; and also the Fallopian tubes,  so that the fecundating
ovum, in passing through the Fallopian tube, pushes the mem-
brane before it, and thus makes it fallback upon itself; the ovum
s not  in its  cavity, no more  than the lungs are  in that  of the
pleura; as Moreau, Velpeau, andBreschet have  demonstrated.
This reflected membrane does not belong to the ovum, only sup-
ports it as the decidua  reflexa  in the  early months of gestation.
The ovum is covered by  two membranes ; the external  one na-
med chorion, which is thin, transparent,  and provided  with  nu-
merous vascular  villosities that connect it with the decidua re-
flexa, except at that part where the latter is reflected by the ovum,
at which  point the villosities are to form the placenta.
   The internal surface of the chorion is equally vascular and vil-
lous, and is  separated from the internal covering of the embryo
named amnios, by a quantity of serous fluid.  The chorion  is said
to consist of two lamina by Burns and  others ;  but Velpeau has
proved that it is a single sheet, and  distinct so early as  twelve
days after conception.   The amnios is a thin, white, transparent
membrane, separated from the chorion during the two first months
of pregnancy, by a fluid called liquor amnii, or " the waters  of the
amnios; " but it afterwards coheres to that membrane, it lines the
foetal surface of the placenta, it ascends along the cord, and is lost
on the cuticle of the infant, according to Velpeau.
   This membrane has been injected from the mother, by Monro,
and Weisberg, and from the foetus, by Chaussier.  It  is some-
times inflamed (Mercier, Beclard, and Lee ; Lond. Med. Gazette
vol. vii. 1830.)
   Some assert that the water of the amnios proceeds from the foe-
tal excretions, others from the mother.  It has been analyzed by
the celebrated Vauquelin, who found  it contain water,  albumen,
soda, hydro-chlorate of soda and  lime, and  phosphate of lime. 
DEVELOPMENT  OF THE EMBRYO, &£C.
51
Berzelius  found it contain fluoric acid;  Scheele, oxygen, and a
respirable gas, according to Lassaigne and Geoffroy-Saint-Hilaire,
but this is refuted by Chevreul.
  The  vesicula umbilicalis is a small  sac  situated  between  the
chorion and the simnios at  the origin or root of the umbilical cord,
runs towards the  embryo, whose abdomen it embraces, and forms
a passage to the intestinal canal.  It is analogous to  the  vitellin
canal in oviparous animals, and runs from  the yolk to the small in-
testines (Meckel, Oken, Bojanus), and exists in the human em-
bryo (Wolff,  W. Hunter, Oken, Bojanus, Meckel, Velpeau, Pock-
els, Duges, and Tiedemann).  The arteries and veins on its ex-
ternal surface, are named ompholo-mesenteric.   The artery is con-
nected  with  the  superior mesenteric ; the vein enters the vena
porta under the liver.  These vessels have been observed in  the
foetus near birth by Duges, and in the adult by Spangemberg.
   The use of the vesicula umbilicalis is to nourish the embryo by
the albuminous yellow fluid it contains.   The vesicula allantoides
is a sac reflected from the chorion and  amnion, and communi-
cates with the bladder in animals.   Its existence in the human
embryo is denied by many, but attested by Hales, Dutrochet,
Breschet, Pockels, Duges, and  Velpeau.  Duges  asserts that it
contains the fluid which is expelled in large quantities some weeks
or  months before delivery,  a case of which  I have  recorded in
this work ;  this  is the hydrorrhaea of German writers.  (Lond.
Med. and Surg. Jour. 1830,  vol. v.)
   The vesicula erythroides or Isis, is a sac described by Pockels,
as will appear hereafter;  but its existence is denied by almost all
obstetric writers.
   The placenta,  after-birth,  hepar uterinum, is a spongy, vascu-
lar mass, destined for the  sanguification of the foetus.   It  is com-
mon to all mammiferous  animals, and  presents  different forms.
It is produced by the villosities of the external surface  of the cho-
rion, which become united with  the epichorion or decidua.  Du-
ring the first  two months the  villosities only exist;  but about two
months and a half they are much developed, and cover more than
three-fourths of the ovum, at the middle period of gestation two-
thirds only,  and  at the full period a third or a fourth.  Velpeau
questions the accuracy of  these conclusions, and is of opinion  that
the placenta exists as soon as the ovule descends into  the uterus.
   The placenta in  a human subject is a vascular,  spongy body, 
52
GYN.EC0-PHYSI0L0GY.
 flattened, circular, oval, pyriform, and reniform ; its centre  is an
 inch or an inch and a half in thickness, and it becomes  thinner to-
 wards the circumference, where  it presents only a few lines.  It
 is six or eight inches in diameter ;  and from eighteen  to twenty-
 four in circumference.   Its weight is about a pound.
  It has two surfaces, an external and internal.   Its external, ute-
 rine, or maternal surface is attached to the uterus at any point of
 its cavity, at the side,  anteriorly, posteriorly, superiorly, or inferi-
 orly, but generally at the fundus or right side.  Its  surface is soft,
 spongy, porous, and consists of several lobes (cotyledons) sepa-
 rated by fissures, named sinuses, and covered by a very fine mem-
 brane.
  The internal or foetal surface  is attached to the chorion, which
 adheres to the amnios,  the latter at the centre or origin  of the um-
 bilical cord,  from which it may be easily separated by traction.
  At the end of gestation, the circumference of the  placenta is in-
 sensibly  lost on the uterus,  and  is often  detached with difficulty
 by young practitioners.
  Organization of the  placenta.—Various eminent  anatomists
 have maintained that the  placenta  was composed of two layers,
 a maternal  and foetal, between which cells existed ;  but this is
 denied by all modern  writers.   The  objection to this  doctrine is
the existence of the membrane between the  placenta  and uterus
which  is  described by Arantius, Littre, Hunter, and Lobstein,
 Chaussier, Meckel, and many other eminent  anatomists among the
 moderns ; while it is  rejected  by Ruysch,  Mary,  Rohault, and
others.   The uterine portion was said to consist of arteries which
deposited the maternal blood in the cells, whence it was absorbed
by the ramifications of the umbilical  vein,  and conveyed to the
foetus.   It will  appear  hereafter,  that  this doctrine is untenable.
The placenta was said to. contain lymphatics  by Wharton, Cruick-
shank, Mascagni,  Wrisberg, De Michaelis, De Schrager, and
 Lauth ; a point denied by the moderns.  The existence of nerves
in this organ is maintained by Verheyen. Chaussier, Sir E. Home,
Bauer, and Ribes, but controverted by anatomists in general.  The
 white cords  observed in the placenta, and said to be lymphatics
 and nerves,  were proved to be obliterated vessels by Velpeau  in
 1823 (Arch. Gen. de Med.), and also by  Carus, in  1827.  In
 separating the  uterine surface  of the  chorion, arteries and veins
 are divided,  but no nerves or lymphatics. 
DEVELOPMENT  OF THE EMBRYO, &X.
53
   Osiander, Stein, and others accounted for the situation  of the
placenta by ascribing it to the position of the woman after fecun-
dation ; but they forget that the  ovule does not descend into the
uterus for some days  after conception.   Velpeau offers an ingen-
ious explanation.  He says, that if the decidua be more firmly
attached at the fundus, the  ovule will fall towards the cervix ute-
ri ; and if  the attachment be looser at the fundus than  below the
uterine tube, then  the attachment  will take  place superiorly.
These conclusions were drawn from thirty-four dissections, in twen-
ty of which the centre of the placenta corresponded with  the ori-
fice, three  times  anteriorly, twice behind, and three times under
one of the tubes, and six times only at the fundus uteri.
   The mode of union of the placenta with the uterus is as yet a
disputed point among physiologists.  Some maintain that the great
venous canals of the uterus are continuous with those of the pla-
centa  (Northwyck, Astruc,  Haller, Mary, Baudelocque, he.)
   The moderns  hold, that villosities or fungosities  are produced
on  the part of the uterus in  contact with  the chorion,  and inter-
mixing with those of the latter, from  the  placenta  (Wharton,
Reuss, Stein, Asdrubali, &c.) ; while Velpeau maintains there is
a fine  membrane  between the uterus and the lobes of the  placen-
ta.   Duges, on the other hand, is convinced that the spongy tis-
sue of the  placenta is nothing but an  assemblage of the ramifica-
tions of the umbilical vessels and the filaments  produced  by the
chorion; the maternal blood is effused into their interstices, which
may be compared to the areola of a sponge (Manuel  d'Obstre-
tique,  1830).   According to the  same author, the umbilical veins
and arteries anastomose, as injection passes from one set  of ves-
sels iuto the other, if made from the arteries, but a certain portion
of the placenta  remains  uninjected.  We also find  that we  may
render the  placenta turgid by injection through the foetal vessels •
but some parts of it remain uninjected, as the vessels do not  pass
all the way to its surface.  If  the  injection be made through the
uterine arteries, the placenta is affected  in the same manner, but
the umbilical vessels are  not injected.  Hence we may  infer, says
Dr. Burns, in his last edition, 1829, that the placenta is compo-
sed of two portions.   Williams, however, has injected linseed oil
through the aorta and hypogastric arteries,  which penetrated  to
the organs  of the fetus; and Bianchini  has frequently repeated
similar experiments.   Other objections will  appear in a future ar-
ticle. 
54
GYNfCO-PHYSIOLOGY.
   Wrisberg asserts that the arteries and veins of each lobe of the
placenta anastomose, but have no connexion with those of the vi-
cinal lobe.   The use of the placenta is to vivify the blood of the
foetus and to supply it, as will appear more satisfactorily when  we
come to describe the foetal circulation and umbilical cord.
   The  placenta is sometimes scirrhous, ossified, hydatic,  and hy-
pertrophied, softened, and affected with fleshy tumours.   In such
cases there  will be danger of haemorrhage from retention of the
organ, hysteritis; and the child may be born alive, unless the dis-
organization is considerable.   In twin cases  there are two distinct
placentae, or one with two cords, or more commonly a bilobulated
organ, with  vascular anastomoses.  It has  been  attached to the
head of the infant (Nouv. Bibliotheque Med., 1830).
   The umbilical cord, navel-string, funis umbilicalis, extends
from  the abdomen  of the foetus  to the  membranes of the ovum
and placenta.   It was observed by  Velpeau, in many cases, at the
fifteenth day, and from that  to the  third week  after  conception.
About the fifth  week  it is composed of the vesicula umbilicalis,
ompholo-mesenteric, or vitelline vessels, a portion of the allantoides
and intestines.   At the second  month the intestinal canal enters
the abdomen, the allantoides and  vitelline vessels are  obliterated,
and from the third to the ninth month,  the  cord is composed of
two arteries, one vein, a gelatinous and spongy  tissue, and an am-
niotic tunic.  It was said that the cord contains lymphatics  (Diem-
broeck,  Wrisberg, Schroeger, and Michaelis), and nerves (Chaus-
sier, Reuss, Darr, &c); but Velpeau is inclined to suppose these
authors  were deceived  by the  vestiges of the allantoides vitelline
canals;  and Lobstein  and Meckel have denied the  accuracy of
their researches.
   Sometimes there is but one  artery and two veins, specimens of
which were described  by Blandin  and  Velpeau.  The  vein  is
double the size  of the arteries, has no valves, and both are spiral
from left to right.
   The vessels of the cord may separate near the placenta or ab-
domen,  and  present a double cprd, a fact attested by Velpeau and
Deneux.  The cord presents other  anomalies ;  it has been inser-
ted into the head, chest, and extremities.  M.  J.  Cloquet has
seen the cord attached to the head,  in the Anatomical Museum at
Brussels.   The length of the funis at birth is generally about from
fifteen to twenty inches; but it may be five or six feet, according 
             DEVELOPMENT OF THE  EMBRYO.               55

to Mauriceau, Hebenstret, Haller, Wrisberg, Denman, L'Heritier,
Morlanne, and Maygrier.   It is of  a  greyish  yellow colour,  less
than the size of the little finger in thickness; its veins  are  some-
times varicose ; it sometimes presents nodosities, and is knotted, or
is partially filled with hydatids.

           Section 5.—Development  of the Embryo.
  The following account of the development of the  embryo is
given by Dr.  Pockels, of Brunswick,  1825, who has examined
fifty ova within the first six weeks of pregnancy.  He examined
four, taken between the eighth sixteenth day, and arrived at these
conclusions:  First that the ovum is about the  size of a small  nut,
up  to the day of conception.   There is no connection  by vessels
between the  layers of the chorion.   The chorion contains a  red-
dish, gelatinous, transparent fluid, of  the consistence of  white of
egg, in  which a delicate, colourless  membrane floats  in  different
directions.    He never saw an instance of allantoides,  or the coat,
which is said to  line the chorion.  Second, in this fluid lies the
amnios, which is about the size of a pea,  or a small bean ;  in  the
first fourteen days of gestation it is  pyriform or globular; it is at-
tached  to the chorion, at a point,  by a  pedicle ;  its parieties are
transparent,  and contain a  clear fluid.  Third, the embryo  ap-
pears to the naked eye at fourteen days, is one twelfth of an  inch
in size  (a line),  flat, and pressed together in the  middle,  at  both
ends thicker, and a little rounded, and has the  consistence of jelly.
It lies external to the amnios to the twelfth day of conception, and
communicates to it by a clear cellular membrane ; it can be remo-
ved from the amnios without opening the latter.  About the eighth
day it adheres by its back to the external surface of the amnios,
and soon sinks into the cavity of the amnios.   Towards the  six-
teenth day  it is in the cavity  of the amnios, with a navel-string.
The head and posteriors may be recognized as small, white  pro-
jecting  knots, and the back is still  concave.   The vesicula  ery-
throides is  a small,  pyriform bladder, resting on the amnios,  over
the lower part of the embryo;  its smaller end opens into the ab-
domen  of the foetus.   In the  foetus of eight  to twelve days  it is
three times as large as  the  foetus,  and disappears in  the fourth
week of conception.   It can be readily  separated from the em-
bryo ; a cord passes  from it into the  abdomen of the foetus ; it
becomes the umbilical cord  ; its remains are seen, as white lamel- 
56
GYNJECO-PHYSIOLOGY.
Ik, at the origin of the cord, at the fourth  or fifth week.   The
vermiform  string of this vesicle coils itself into several folds, and
turns towards the abdomen of the infant; the intestines in part arise
in the vesicula erythroides.
   The vesicula umbilicalis, a globular vesicle, larger than the em-
bryo, on which it rests, is attached to the amnios, to which it is ex-
ternal ;  it is communicated with the vesicula  erythroides.  Both
these vesicular distentions serve to develope  the  embryo, before
the  formation of the placenta.   It is doubtful whether the umbil-
ical vessel originate from the foetus  or erythroides.  The want of
evolution in  both these vesicles is often a cause  of miscarriages.
Dr.  Pockels found only one in four ova,  in which  the develop-
ment of these vesicles  was perfect,  though  he examined  thirty
ova, to ascertain  this point.   This description is  received by all
the continental anatomists ; but requires further investigation before
we can admit it.

      Section 6.—Development of the Embryo and Foetus.
   The term embryo is applied to the germ during the  three first
months of  utero-gestation, or until its different parts are distinct
from each other: it is called foetus during the  remainder of its so-
journ in the uterus, and infant after birth.
   Much discrepancy of opinion exists among physiologists as to
the period after conception, in which the embryo is visible.  Hip-
pocrates said, the ovum was visible on the sixth day ; Meckel, on
the fifth ; Pockels,  Sir E. Home, and Bauer, on the eighth ;  and
Haller,  from the fifteenth to the  twenty-first.  Velpeau  dissents
from all these writers, and denies that  the present state of  sci-
ence  is such as to enable us to fix the exact hour of conception,
or to prove  that the embryo will descend into the uterus of the
same animal at the same  period after different conceptions.   On
the other hand, Pockels asserts he examined for ova between the
eighth and sixteenth day;  and Beclard  says,  the  ovum is visible
when only  three lines in diameter.
   According to  Meckel,  the ovum can be distinctly seen the fif-
teenth day after conception: it is six or eight lines in diameter, is pyri-
form, elongated, curved, large, and round at the extremity, which ap-
pears to  be  the head, fixed to the membranes  by  the opposite ex-
tremity, which is small; it offers a homogeneous appearance, and 
FUNCTIONS OF THE EMBRYO.
57
with difficulty a white fibre is seen, which is said to be the spinal
marrow.  (Velpeau.)
  Sir E. Home describes it at the eighth day as a vesicular, gluti-
nous,  pellucid, oval body, attached to the  fundus uteri;  that it is
composed of two oval bodies joined by a neck, the one the head,
the other the  trunk. (Phil. Trans.  1817; Med.  Chir.  Trans.
vof. ii.)  M. Velpeau informs us, that before the end of the third
week  the embryo is elongated, and he believes consists of the ce-
rebro-spinal system ; it appears to him, from numerous recent ob-
servations, that the vertebral column is the fundamental part of the
body, and that all other parts proceed from  this as branches do from
a tree.  He dissents from Tiedemann, Meckel, Serres,  Geoffroy-
Saint-Hilaire, who think the organic evolution is from the sides to-
wards the median line.  This, however, is the received opinion.
  It is held that each organ is double at first, but as development
advances  the two lateral parts are joined together.  It is said by
the last author,  if  any  impediment is given to the progressive
growth of organs, as when an  artery does not supply proper mate-
rials in an organ, such organ will be imperfectly developed,  and
thus monstrosity produced.  He refers to the influence of the moth-
er's mind and corporeal exertions on the foetus,  and deems them
sufficient causes of deformity  in the early stage of  foetal develop-
ment.   This theory, though ingenious, is by no means satisfactory.

       Section 7.—Functions of the Embryo and Foetus.
   The sensibility of the foetus must be admitted, though it is not
exposed to external objects. Its motions are often violent and trouble-
some towards the completion of the term of gestation, and are purely
instinctive.  Its caloricity is less than that of the adult. (Edwards.)
   Nutrition.—Of  all the questions of physiology, this  has been
the most  disputed.  Some have  placed the source of nutrition in
the water of the amnios, more than in  the placenta, some in the
vesicula  umbilicalis and allantoides, others in the  gelatin of the
cord,  and some in the decidua or  epichorion.
   Harvey and Diemerbroeck  considered the water of the amnios
highly nutritive and lacteous ;  and with Rudbeck, Haller, Darwin,
La Courve, maintained it passed by the  mouth to the  stomach ;
while Alcmeon, Boerhaave, Buffon, and  Van-den-Bosch alleged
it was absorbed  by  the skin.   These opinions are refuted by the
fact, that in cases of imperforation of the oesophagus, in acephalous
         8 
58
GYN.KCO-PHYSI0LOGY.
 monsters,  and when the infant is born with all the outlets imper-
 vious, it is fully developed.   It is foreign to the nature of this man-
 ual  to  notice all the physiological  reveries upon this and other
 parts of my subject; but I cannot help inserting a  few more upon
 this point.   Lobstein held the fluid was partly absorbed  by  the
 genitals;  Osiander, Oken, and Muller,  that it was absorbed and
 modified by the mammae, then conveyed to the thymus gland, and
 finally to the thoracic duct; while Schurigius, David, Boederer,
 Scheele,  Winslow, Heroldt, Beclard, and Geoffroy-Saint-Hilaire
 believe it to enter the trachea and bronchi, and to be there elab-
 orated  for the purpose of  nutrition.  The  general and received
 opinion of almost all physiologists  is,  that  the   placenta is the
 source of nutrition to the foetus.   It has been said  that the placen-
 ta is a respiratory organ to the foetus, and supplies it with oxygen.
   During  the  early  period  of intra-uterine  life,  the embryo is
 nourished by the umbilical  vesicle,  which is continuous with the
 intestinal  tube, which  absorbs the fluid, which is  carried by the
 omphalo-mesenteric vein to the heart of  the embryo.  The anal-
 ogy of  these vessels to the  yolk of the egg renders this opinion
 probable.  The  absence of  the meconium in acephalous cases
 (Elben), which,  according to others, was the residuum of diges-
 tion, was considered  an argument in favour of the passage of the
 amniotic fluid into the stomach.  This fluid does depend upon the
 bile, and is only absent when the  liver is wanting.  (Tiedeman.)
 The female nourishes her offspring with her blood, through the
 medium of the placenta; while  the foetus possesses an organ  for
 the further depuration of the  blood,  and the  liver is that organ.
 (Bichat and  others.)   Tiedemann and  Gmelin  considered it the
 same in the adult.  The researches of Dr. Stoker of Dublin  in
 his Pathology upon this point, are exceedingly interesting and sat-
 isfactory.
   The  uterine arteries,  which are continued  to the decidua fur-
 nish blood to the amnios in the spongy tissue of the  placentae
 where it is in contact with the extremities of the umbilical  vessels
 of the foetus.   The  blood  is  mixed  with  that deposited  by the
umbilical arteries, and absorbed by the veins  of the same name
 and conveyed to the foetus, and again returned to the placenta by
 the umbilical arteries, and absorbed by the maternal veins.
   Circulation of the  foetus.—At a very early age, the heart of
 the embryo is nothing but a reservoir, composed of  the umbilical 
            FUNCTIONS OF THE EMBRYO AND FQ2TUS.         59

vessels;  at a later period, the right ventrical and pulmonary arte-
ry appear.  When the organ is perfect,  the circulation of the foe-
tus is said to be effected  in the following manner.
   The umbilical vein  arises from  the  placenta  by innumerable
branches, runs along the cord to  the umbilicus of the foetus, pen-
etrates the abdomen behind the peritoneum, and divides into three
branches, at the  transverse  fissure  of the  liver.   One proceeds
to the vena cava inferior, this  is  the  ductus venosus ; the other
two enter the right lobe  of the liver, and anastomose with the  ve-
na porta.  The inferior  cava carries the greater part of the blood
into the right auricle, from whence it passes  into the  left auricle
through  the foramen  ovale, then  to the ventricle  and ascending
aorta, and thence to the  head  and superior extremities.  It  is  re-
 turned  by the jugular and subclavian veins to the superior cava
 which throws it  into the right auricle,  where it is  mixed with a
 portion  conveyed by  the inferior cava ;  it then enters the right
 ventricle  and pulmonary artery.  As the lungs are impervious, a
canal runs from the pulmonary artery to  the aorta, called ductus
 arteriosus, through  which the blood passes to the descending aorta,
 and thence to the abdominal viscera and lower extremities ;  but a
 part of it escapes  from  the foetus by the internal iliac  arteries,
 which are prolonged  into the umbilical, and these  run along  the
cord to the  placenta, where their blood is deposited.
   Much diversity of opinion exists with respect to the circulation
 of the foetus.   Haller, Wolf, Sabatier, Portal, Richerand, say that
 the currents of blood  from the inferior and superior cavae do  not
 mix in the right auricle, that the blood of the inferior cava passes
 entirely into the  left auricle, that  of the  superior  cava  into  the
 right ventricle.   Bichat and Magendie dissent from this doctrine,
 and think it extremely improbable that two columns of blood  can
 pass through the same  cavity without  intermixing; and as  the
 two auricles contract simultaneously, it is not likely that the vivi-
 fied blood of the umbilical  vein goes entirely to  the upper parts
 of the body, and that the venous blood only supplies the remain-
 ing parts.   But as the  inferior  cava surmounts  the  Eustachian
 valve, it appears to be  continuous with the foramen ovale,  while
 the superior cava opens anterior and opposite the orifice of  the
 ventricle, so that  no such  mixture of the blood of these vessels
 need necessarily take place.  Nevertheless,  it is  not correct to
 state, that the head and superior extremities are nourished by  pu- 
60                   GYN^CO-PHYSIOLOGY.
rer blood than the inferior parts of the body ; for it is to be recol-
lected how the blood of the umbilical vein  is mixed with the ve-
nous blood of the abdominal  viscera, through the vena porta, and
with that of the inferior extremities by the ascending cava.
   The circulation of the placenta is also differently explained.
Some say the foetal arteries deposit the blood in the cells  of the
placenta, whence it is absorbed by the maternal veins, is carried to
the maternal lungs to be vivified, and afterwards  brought by the
arteries to  the placenta.   Others maintain that  a portion of the
blood deposited  by the umbilical arteries is absorbed by the veins
of that name, and returns to the foetus.   M. Velpeau  raises a for-
midable objection  to the first  opinion.  He says, if the blood of
the umbilical arteries is deposited in the  placental sinuses, it must
evidently mix with that of the uterine  arteries, which is effused
in the same place ; it is therefore necessary to  suppose that the
absorbent mouths of the umbilical vein  have the faculty of choo-
sing the arterial blood from this mixture, as the  uterine  veins do
not take but the venous (arterial ?) blood.   On the other hand, an
injection will pass with the greatest facility  from the arteries  into
the veins of the placenta, without effusing itself  upon the uterine
surface of that body ; therefore the blood of the foetus  is not taken
up by the uterus.  The reader should refer to the remarks upon
the placenta in a former page  for solid objections against this  rea-
soning, where he will find strong arguments against this conclusion.
M. Velpeau  is inclined to suppose that the arterial blood of the
foetus undergoes  its  changes by  a  molecular action in  the  pla-
centa, which though inexplicable may be still correct.   He thinks
it may be compared to  the capillary system after birth ; to what
takes place in secretory organs, and  in the lung itself.   The fluids
of the ovum are in mediate contact with those of the woman ; but
a change may take place analogous to  that in the lungs  between
the atmospheric air  and the  venous  blood.  However  ingenious
this  hypothesis  appears  on  paper,  it  is decidedly  erroneous.
It is only necessary to reflect upon the  utter impossibility of  sup-
posing the foetus to  form its own blood, that is, to grow and daily
increase in size without a supply from the mother.   Again, every
one at all  conversant with obstetrics is aware of the innumerable
vessels  which pass from the uterus  to  the placenta, and the he-
morrhage  consequent to their rupture.  It is really  astonishing
that a physician so intimately acquainted with obstetrics, and ev- 
       INFLUENCE  OF IMAGINATION  ON CONCEPTION.       61

ery branch of medical science, as Professor Velpeau is, could se-
riously propose such a doctrine.
   It has long been supposed that the  great size of the liver in the
foetus served some purpose, and, it is  said, is  the organ which ef-
fects certain changes in  the blood.  Lobstein thinks it the organ
which effects the colour of the blood (hematose) : Fourcroy, that
itcausesadecarbonization and a deshydro-genisition ; and Stoker, a
change in the hydro-carbonous principle of the blood ; Prevost and
Dumas, that it forms the globules of blood in the foetus ; Geoffroy-
Saint-Hilaire, that it secretes a large quantity  of bile, which passes
into the small intestines, and there determines the formation of an
abundant quantity of mucus, which the foetus digests, and on which
its development depends.  Dr. Robert Lee has endeavored to
prove, that the liver secretes an albuminous nutritive matter, which
he found in the hepatic duct, duodenum, and  small intestines ;
while he found an acid fluid in the stomach, and meconium in the
large intestines.  All these theories  require  further corroboration
before they can be admitted.  Like all other points in the physi-
ology of the foetus, this is extremely  doubtful and  unsettled. In-
deed the  function of the liver in the adult is  by no means deter-
mined.

Article III.—Of Conception with regard to the Sex of
                         THE FffiTUS.

Section  1.—Is  it possible to know the Sex of the  Foetus during
                         Pregnancy.
   In the primitive archives of medicine, we  find this subject dis-
cussed, and more especially the influence of the mother's imagin-
ation upon conception and the foetus.   Even  in  our own day, we
find women of all ranks alarmed about marks and blemishes, which
they suppose can be induced by their own imagination.   Medical
men, too, are found among the advocates of this silly doctrine, as
will appear in the course of this article.  It  is therefore  worthy
of attention.
'  The  annals of history afford evidence  that great interest was
felt by females in all  countries in endeavouring to ascertain the
sex of the foetus in utero.   The Egyptians  and Indians referred
to the state of the heavens, and to the conjunction of the planets,
at the moment of fecundation.   The  Greeks, and most other an- 
62
CYNJECO-PHYSIOLOGY.
cient nations,  invoked the phases of the moon, and consulted as-
trologers, soothsayers, sorceresses.   Even Livy had the folly to
assist his wife in completing the incubation of a  pullet's egg with
the heat of the hands, persuaded  that  if the male  appeared the
infant would be a boy, and this practice continued to the time of
Augustus.
   Hippocrates and Aristotle were of opinion, that a male was de-
veloped more slowly than  a  female ; that pregnancy  was more
protracted ;  that the mother  was more active, vigorous,  and in
better health than when she carried a female.  I have known  ma-
ny women  entertain this  idea, and one who foretold the sex in
two instances.  I need scarcely mention, that it is  impossible to
discover the sex of the foetus in utero.
  Another question which engaged physiologists was the possibil-
ity of creating the sexes at will.
  Hippocrates was opinion, that the right testis and ovary suppli-
ed the male germs, and the  left  the female ; and  this doctrine
prevailed in many ages, indeed to  the  present  century.   Millot,
and recent continental  writers, have advised the  adoption  of  one
side or other, during a fecundating  copulation, to ensure the  sex
which was desired to be obtained.   This hypothesis  is false  and
absurd,  as Le  Gallois removed an ovary from a rabit, and yet  the
animal produced male and female ; and Velpeau dissected the bo-
dy of a woman at  the Maternite, who was the mother of ten or
twelve children, male and   female,  and  who had but one ovary.
Both sexes are found in one lobe  of the uterus of animals.   Dr.
Edwards, however, has determined that the mollicules of confer-
va? may be modified so as  to produce male and female at will,  and
also many insects.
  M. Velpeau, in discussing this point,  informs  us, that the agri-
culturists of France have long observed  the influence of season
in determining the sex of  animals.   If the wind be north, the sea-
son dry and cold, then mares, sheep, and heifers, produce  less fe-
males than in an  opposite  state of weather.   Agriculturists,  are
persuaded that to produce males,  nothing is more  advantageous
than to have animals impregnated by the most  vigorous of their
species.  An  agriculturist, who has lately paid great attention to
this subject, confirms  the statement, and  proves that where one
male, as in the  gallinaceous  tribes, serves a number of females 
         INFLUENCE OF IMAGINATION ON CONCEPTION.       63

the female sex  predominates.   This fact  has been  observed in
countries in which polygamy is allowed, as in Persia and Turkey;
whereas, in European nations, where the custom is not tolerated,
the proportion of the sexes is equal.   " It is therefore probable,"
says Velpeau, " that the sex is determined by  that of whichever
enjoys the most prolific  power at the instant  of conception.   Ma-
ny researches are as yet necessary to transform this proposition in-
to a mathematical certainty ;  but if ever it comes to be confirmed
by authentic observations, it is evident  that the act of procreating
the sexes at will, will not be a chimera, and  that the hope is to re-
main, that pregnant women can be informed  of the sex of the in-
fant of which they will  be delivered."
   It has been said, that the inhabitants of prosperous nations and
a salubrious climate, produce more males than females ; but this
is denied by M. Villerme and others, who prove that the propor-
tion of the sexes does  not differ in  the poorest countries.   This
must  appear manifest when we consider that the  inhabitants, male
and female, of  such countries, are subjected to the same luxuries
or privations.   As they manage these things better in France than
in this country, I must insert  the  report of  Villerme, read before
the Academy of Sciences in Paris; of 12,000 births, 1093 hap-
pened in January, 1136  in  February, 1117 in  31 arch, 1057 in
April, 1000 in  November, 981 in December, 981 in September,
964 in October, 965 in May, 9-27 in August, 896 in June,  884
in July ; and  therefore that  the  proportion of conceptions is far
from  being the same in  all months in the year.   He thinks  that
balls  and public rejoicings at  the time of marriage, privations, fast-
ing, prosperity, civilization, liberty,  misery, and  calamnity, have
different effects upon reproduction ; and he demonstrates that more
infants are born under a fine sun,  in  countries where  the arts, in-
dustry, and the sciences flourish,  where the atmosphere  is pure
and the country fertile,  than in opposite conditions ; and that scar-
city and famine produce great changes  in  the progress of popula-
tion.   1 have only to observe  in conclusion, that "to those  who
wish  to create the sexes at will, fine  infants, infants of spirit, and
without  passions," 1  cannot but  recommend  the Callipedie of
Quillet, the Megalanthropogenesie of Robert, and the Traite de
la Philopedie;  and at the same time request their perusal  of the
following remarks: 
64
GYN^CO-PHYSIOLOGY.
 Section 2.—Influence of the Mother's Imagination upon the In-
               fant during Pregnancy—Marks.
   The older writers supposed that certain positions, as laying on
 the right side after coition, would form  a male, and on the  left, a
 female ; but the  will has no power over fecundation ;  it is not in
 our power  voluntarily to create the sexes, neither with respect to
 the number of children, nor with regard  to their future  physical or
 moral qualities.  This  is the most modern opinion of physiolo-
 gists, and  of course controverts the vulgar notion that the imagi-
 nation of the woman can disfigure or injure the infant, an idea that
 clearly shews the low ebb of physical knowledge of former times,
 and the gross materialism with which the philosophy of the human
 mind was contaminated  and  degraded;  a doctrine inconsistent with
 right  reason, experience, and  anatomical knowledge.   The belief
 in the power of imagination is, however, of very high antiquity,
 as appears  by the contrivance of Jacob, to mark the lambs, calves,
 and kids, which were to fall to the share of  Laban, (Gen. c. xxx.
 37, 39.)   But the Divine influence had  interposed  in that in-
 stance, and therefore  it is out of the ordinary course  of nature.
 The  ideas  of mankind, at  this early age, on this  subject,  were
 vague and  ill defined.   The popular opinion prevailed  in Greece,
 and  was sanctioned by  Hippocrates and Galen.  The Spartans
 had their pregnant women to gaze on pictures, or figures of Nire-
 us, Narcissus, Hyacinthus,  Castor and  Pollux,  and on the more
 youthful divinities.   Hesiod and  Hippocrates speak of imagina-
 tion ;  Galen and Oppian on  the force of mere vision.  The doc-
 trine  was adopted by the Arabian physicians,  Avicenna and oth-
 ers, and in time by the  schoolmen of the twelfth and  thirteenth,
 and by the  physiologists of  the fifteenth and sixteenth centuries.
 Albertus Magnus, an ecclesiastic, described  the power of imagina-
 tion,  and said  it arose  from celestial influence.   He enters on a
 long discussion  on the influence of the  planets on the foetus in the
 womb.  These mysterious and extravagant notions were first im-
 bibed  by Thomas Aquinas,  the angelic doctor, and made more
unintelligible by  a mixture  with universals,  substantials,  elemen-
tary qualities, he.; and these opinions were received by the most
eminent physicians of the age, even by  Roger Bacon,  Arnold de
 Villa  Nova, and the Hon. R. Boyle, the distinguished philosopher
and chemist.   Fiennius, of Lou vain,   published a work on the
subject, in 1608, and the greater part of the seventeenth  century 
         INFLUENCE OF THE MATERNAL IMAGINATION.       65

was  remarkable  for this imaginative  philosophy, and its offspring
—the gross credulity in the  collection of all sorts of marvellous
and  prodigious stories.   An  unanswerable  objection to all these
stories is, that not one of them is sufficiently authenticated.   To-
wards the end of the seventeenth century, even  Stahl, Hoffman,
and Boerhaave, believed in this doctrine.  Van Swieten and Tur-
ner  were also strong advocates in favour of this view of the sub-
ject.  In the year 1716 M. 3Iarcet wrote against it in the Trans-
actions of the Society  of Medicine, at Montpelier.   He denied
that there was either a direct vascular  or nervous connexion be-
tween  the  mother and infant, and also that the  infant cannot see
or hear  in  the  womb of  the mother, as asserted by  the  Abbe
Malebranche ;  and that although there are  hereditary diseases,
they are independent of the imagination of  the mother.   He rid-
icules the idea, that James the First was terrified at the sight of a
sword, because Queen 3Iary  had been  frightened at  the  mur-
der of David  Rizzio in her chamber,  during pregnancy ;  for he
proves that the fears of the mother are generally discovered after
the birth of the infant, and then laid hold of  by  the friends to ex-
plain the deformity.  The best work against  the imaginative doc-
trine, which I have seen,  wTas published by Dr.  Augustus Blon-
dell, of London, in 1728  ; and he was opposed by De Superville,
a German, in  the Transactions of the Royal Society of London,
1740.   This writer was opposed, in  turn, by the celebrated  Buf-
fon, who contended that marks were more  dependent on the fan-
cy of others, as to resemblance, than of the mother; he explain-
ed the influence of change of season, and why marks on the skin
were redder in summer.   He maintained  that  it was  as easy to
suppose a  hen on her  eggs, who sees the neck of a cock twisted
off,  can produce chickens with crooked necks, as for a woman to
bring forth  a dislocated  child, by seeing  a  man broken  on the
wheel.   As to  dislocations and fractures  of infants before birth,
the  imagination could not cause them ; but  scrofula, syphilis, rick-
ets,  or mollities ossium, may.   The  doctrine was also opposed by
Eller, in the Transactions  of the Berlin Academy, by Krauv and
Roederer, at Petersburgh, and most successfully  by the illustrious
Haller, in 1766.  This latter eminent physiologist admitted that
he saw  marks that might arise from any cause capable of corro-
ding the skin, which might, by a lively imagination, be transform-
ed into fruits, mice, sparrows, flames, Sec.;  but most of themhap-
         9 
66
r.YNJF.CO-PHYSIOLOGY.
 pen without any affection of the mind, or disorder of the female.
   The case of Malebranche  and others Haller regarded as  erro-
 neous.   No nerves pass directly from the mother to the foetus, and
 hence no mental power can directly affect the latter.  The ques-
 tion had  been settled by Haller, sixty years ago, and was never
 doubted until 1825,  when Sir E.  Home opposed it in  the  Phi-
 losophical Transactions.   Where is the instance that can be indu-
 bitably shown,  in which any object that can act on the mother's
 imagination has unquestionably influenced the foetus ?  Is it proved
 in the relation of cause and effect ? In truth, we have in medicine
 more  false  facts than false theories.   Sir E.  detected  nerves in
 the placenta, by the assistance of Mr. Bauer,  of  microscopic ce-
 lebrity ; but it is surprising that no other anatomist or  physiolo-
 gists should have observed the placental nerves  to this time.   It is
 rather extraordinary that these nerves should have eluded inspec-
 tion if they  proceeded in a body  from the placenta to the child;
 yet Sir. E. found them in a preparation of a placenta belonging to
 Mr. Brookes, which had been in spirits for forty years !  He thinks
 small-pox and ague caused by the nervous communication.   The
 transmission of  small-pox, or the venereal  disease,  is caused by
 the circulation of a poison in the maternal blood, which is depos-
 ited in the  tissues ;  and even  in ague,  it is well known  that
 the disease depends on some material agent, which affects the cir-
 culation.   That instances of deformity occasionally occur, cannot
 be denied ;  but if they  depended  on  the  mother's imagination,
 they would happen almost in  every case, as there is not a preg-
nant woman  whose imagination is not more or less affected during
 utero-gestation.
  It is extraordinary, that the human female, the most lovely ob-
ject of the whole creation, who is endowed with so many charms,
 and also with an extraordinary love and  tenderness for her off-
spring, instead of answering those noble ends, should be capable
of producing monsters by her imagination.    The thino- is unnatu-
ral and ridiculous.   The  female passions, we know, act on the bo-
dy, by accelerating the circulation of the blood, or by exciting or
depressing the nerves; but there is no direct circulation, or nervous
communication between the woman and her offspring   Physiolo-
gists account for this wise interruption of the circulation • for if di-
rect, the foetus, in the first months, might be destroyed by the in-
creased circulation of the mother.  The foetus, when  only peroep- 
            MATERNAL INFLUENCE ON CONCEPTION.          67

tible by a miscroscope, and not larger than the  smallest atom,
would be destroyed, if the circulation of the mother were power-
fully accelerated and pressed on it.   Again, it is certain that con-
ception is independent of the mother's will; she cannot  cause or
prevent it by her imagination or volition.  If the blood passed di-
rectly  from the mother to the infant, all her agitalions would affect
it;  but we  know that nervous mothers have  healthy ^children.
But the great question is, whether the attention of the mother's
mind  to a certain object can cause a determinate or specific effect
on the infant's body in the womb, without any exciting force or vi-
olence ; and whether the application  of the  mother's hand (chi-
rapsy) to any particular part  of her  body, although accidental,
and not premeditated, can work the  same by  sympathy, and in-
duce  an organic change  on the same  part of the foetus.  Most of
the middle and lower classes believe the affirmative  of these ques-
tions ; yet they are contrary to reason, to anatomical science, and
to genuine and unsophisticated experience ; and hence  they  are
discredited by every person of information and common sense.
The theories of the imaginationists have varied in every age ; and
it is impossible  that experience can  support  such contradictory
and different assertions.   Thus the supporters of the doctrine are
not agreed as  to the person  whose imagination is excited, when it
is excited, or  the  exact extent of its influence.   For example,
Pliny  was of opinion  that  the imagination of both sexes, male
and female, was reputed to imprint  or confound the similitude
(Book vii. chap. 12).  Others  asserted that it was the foetus that
caused the longings ; and  where they have not been duly gratifi-
ed, the wise women,  thinking that  the infant was in want, have
supplied all deficiencies  afterbirth, by making it suck a piece of
roasted pork, as a certain panacea to supply all former disappoint-
ments.   This custom  still  prevails  among the  vulgar, and  no
doubt it is rather obscurely consonant  with physiological science,
with fair logical deduction, and with the due connexion between
cause and effect.  The  variations of the power of the imagina-
tion, as to time, are very remarkable ; some say  it is  effected at
the moment of conception (Pliny, opus citatum) ;  others, before
quickening, that is,  between the third  and fifth months, and that
there is no danger afterwards ;  and others, that  the imagination is
most powerful after quickening  (Turner on Diseases of the Skin).
But monsters, or imperfect infants, can be accounted for in a more 
68                  GYNJECO-PHYSIOLOGY.
rational way:  from a redundancy, deficiency, or viciousness of the
semen, from deformities of the parents, from  malformation of the
womb, from violent accidents, and, lastly, by the will of Divine
Providence.   These causes are, more rational, and account for de-
formities  of offspring far better than  supposing that the imagina-
tion can produce a change in the foetus.   It must be admitted that
there will be often powerful imagination, and afterwards no marks
or deformities  on the infants.  A patient  of Dr. Hamilton's had
her abdomen grazed by  a pistol shot, yet no deformity took place.
Again, there are often marks and  deformities, without any influ-
ence of the imagination.
   Every obstetrician could give a long catalogue of pregnant wo-
men, who had had ungratified  longings, who had been frightened
by dismal objects, and even met with dreadful accidents, and yet
their  infants have been  perfect,  and  without any marks or blem-
ishes.  In fact, no woman can arrive at the end of utero-gestation,
in this or any  other crowded city,  without encountering some of
these longings,  frights,  or accidents, and yet how few  deformed
children are produced !  Again, look to the reports of our lying-in
hospitals, and see the small proportion of imperfect or monstrous
births—scarcely one in  five thousand.   Is not this an unanswera-
ble argument  against the  assertion,  that  the imagination is the
cause of them ?  We know the imagination to be  exerted in  al-
most every case, but not followed by the reputed result;  here we
have a constant cause,  but not a constant effect.   If we inspect
the bills of mortality in  the different nations, we must observe how
few cases of monstrous births are  recorded.   If we examine  the
reputed cases detailed by  Dr. Turner and others, we shall in every
instance  discover the credulity of the witnesses, the inconclusive-
ness of the evidence, and the absurdity and folly of the narrations.
Thus, a  woman in Italy longed for a lobster, and not being gratified
brought  fort a lobster.   Such is  the story of Aldrovandus.  There
was a child said to be born in Normandy, in  1682,'with horns and
cloven feet, because his father, having represented a satyr on  the
stage, had connexion with his wife in his stage dress.   Zodiacus
 Martius  Hildanus was  informed by  Hornicoeus, a physician  of
 Frankfort, that a  woman being  frightened by a  musket shot,
 brought forth a child with a wound in  its back, as if made by a
 musket ball.   I would  ask, was this wound made by the imardna-
 tion, and what stopped the bleeding ?   The Abbe Malebranche 
MATERNAL INFLUENCE ON CONCEPTION.         69
relates various incredulous stories of this kind ; one where all the
bones of the foetus were broken in the womb, because the mother
bad witnessed the breaking of a malefactor on the wheel; another,
when the child was born,  resembling Saint Pius,  as  the mother
had gazed on his  picture.  About the  year 1700 % boy was ex-
hibited in Moorfields, in  this  city, who had the word " Elohim,"
in Hebrew characters, round one iris, and " Deus" round the other
This deceit was managed by two thin  pieces of glass, or artificial
eyes.  A child was lately exhibited in London, with the words
" Napoleon Empereur" on each iris, and said to have been caused
by the mother having cried  over a  French  coin,  which was left
her  by  her  brother.   I visited this case,  and aver that there
was no letter whatever visible,  but  the  usual  appearance of the
blue eye of an infant  for the  first  three  months.  Malebranche
asserts, that the  infants in the womb see and hear, as their mothers
have the same passions, &c.  I would ask, how can an infant, en-
closed in the membranes, see without light ; and  surrounded by
the  womb, the membranes, and a  considerable quantity  of fluid,
hear external sounds, without vibration of  the air?  The  good
father relates  a  case where the bones were soft from imagination,
the mother having witnessed the execution of a criminal; but will
not mollities ossium, or softening of the bones, better explain such
an  occurrence ?   Hesoid recommends  men not  to cohabit with
their wives after the latter returned from a funeral; but in this coun-
try people are not so  fastidious or cautious, and pregnant  women
attend funerals;  and although the mind is naturally depressed, we
never hear of or observe a child marked  with a coffin, scarfs, or
white feathers.   There is no truth  whatever in the fabulous  sto-
ries that Ethiopians  have  produced white children, or Europeans
children perfectly black.  There  is good reason to suppose that
there were other very solid and more legitimate causes to account
 for the phenomena. Bartholin relates the case of a woman who, in
 1638, produced an infant with the head of a cat ; but a flat nose,
a short chin, and a few hairy moles would account for that sage
report.  The same writer describes a  case where a rat  was pro-
duced.  Howt unfortunate it was that the cat was  not in the neigh-
bourhood.   This writer  also speaks of a woman who  was brought
to bed of two small fishes, with scales, which were no sooner born
than they  swam  in the neighboring waters !!  But the  semen of
one species of animals will not impregnate another; for if the con- 
70
GYN.KC0-PHYSI0L0GY.
verse of this held good, there would be an endless confusion, and
no distinct generation.   One of Pope  Nicholas's family (the Ur-
sini), brought forth a substance like a  bear;  but  how very singu-
lar that the lady should be frightened by looking on her own  coat
of arms.  I should not dwell on these absurd stories, had not Sir
E. Home lately attempted to revive this  ridiculous  and absurd
doctrine.
  Ludovicus Vives informs  us,  that a loose  fellow at Brabant,
who personated the devil in a play, said he should have to do with
his wife in his stage-dress, which so frightened the poor woman,
that  she in due time brought forth an infant of a diabolical figure.
An  American woman is said to have brought forth a child with a
wooden leg, and a ferrule at the  end of it,  exactly  similar to her
husband's.  Though physiologists assure us that the blood produ-
ces  all the tissues in the  human body,  they have overlooked the
power of  its producing a  wooden leg with  an  iron ferrule.   In this
country the blood does not take on that action, as fathers with one
leg  produce infants  with both natural, neither of them cork, wood,
nor iron.
  Women have been said to have their children marked with frogs,
mice, rats, lizzards, he.;  yet thousands of women are daily fright-
ened by these insects, and no marks appear on  their infants. Marks
and deformities often exist On the offspring, without any previous
imagination.  Conception is independent of the mother's will and
pleasure.  How many  women are desirous of children, and yet
have none ;  while others not only conceive, contrary to their wish-
es, but go to their full time,  in despite of the various means they
wickedly and designedly  employ  to destroy  the  foetus.  Again,
the  nutrition and growth of the infant go on according to the laws
of nature, whether the  woman wishes or not.  It  is  also out of
the  mother's powrer to choose a boy or a girl;  to have one or more
children at a birth ; to  cause the infant to  be  fair, dark, lar^e or
small, weak or strong, or  to give it her own or the father's features.
If, then, women  cannot, by imagination or will,  promote or im-
pede conception, how can  any one believe,  without dero°ating
from the power and wisdom  of God, that  they can disfigure the
infants, and injure the works of nature ?  Is it not absurd to sup-
pose that  the mother has  more influence over her child than over
her own  body ?   The  idea  is preposterous.  If she cannot,  by
the strength  of her imagination, make any  mark on her own body, 
MATERNAL INFLUENCE ON CONCEPTION.         71
or change the figure, situation, quantity, and number of her  own
limbs, why should we  believe she can  do so  to the body  of the
infant?  Is it not silly  and ridiculous to think that if the affright-
ed mother apply her hand to any part of her bodv, which may be
done accidentally and undesignedly, this can effect the  same part
of the infant ?  Does she mark that part of her own body by such
application of the hand ?  But the child hears and sees, and  feels
the passions of the mother.   How can this happen when there is
no nervous connexion  between  the  mother  and  infant ?   Surely
every obstetrician has observed, on dividing the naval-string,  that
the child suffers no  pain whatever, neither does the mother.  And
can nerves be divided in any other part of the body without pain ?
Again, how can the mother communicate her thoughts to the child
when her soul is  distinct from that  of the infant ?  That marks
and  deformities frequently happen, cannot be denied ; but  they
can be accounted for in a much more scientific and natural manner
than by the influence of the mother's imagination.
   Why should we be surprised at some irregularities on the skin
and other parts of the body,  when we observe the same happen to
vegetables, though  incapable of imagination ?  They have their
moles, their hairy parts, their discolorations, their excrescences,
their unnatural shapes,  which resemble animals and  other bodies,
and all  without the help of  fancy.   There are many deformities
never referred to the imagination, as the irregular  conformation of
the viscera.   Is the whole empire of the  microcosm, or world of
the human body, so divided  between nature and imagination, that
one governs the internal  and the  other the external parts ?  We
ought to be little amazed at the deformities, when we consider the
wonderful uniformity that exists among all living creatures.  We
should remember that  the rudiments of all animals  are infinitely
small, and composed of an infinite number of minute parts, which
the least shock may  put out  of order; and yet they remain whole
and entire, except in a few  extraordinary cases, which we can
readily account for by the following reasons : firstly,  the variety of
particles, and  of  their  combination;  secondly, the distempers of
the children in  the womb;  thirdly, the interrupted developments
of some parts in the children: fourthly, force and violence upon
the body of the infant;  and  lastly, diseases from inheritance.
  The variety of particles, and of their combinations, is the first
cause of marks in children.   If we examine  ever so many bones 
I
72                   GYN^CO-PHYSIOLOGY.

of the same kind, and as near as  possible of the  same  kind, we
shall find a vast difference in their shape, in their cavities, in their
extremities, and surfaces, and in the number, situation, and dispro-
portion of the foramina or holes through which the blood-vessels
pass.   This proves that the arteries and  veins have not the same
diameters, situation, or branches, in  all individuals, a fact known
to every anatomist;  thus the particles  which make up one body,
differ from those of all others.   This accounts for the several ir-
regularities and deformities  of different bodies,  and for  the congen-
ital diseases of new-born infants.  The diseases of children in the
womb are numerous, and known to all practical obstetricians; and
these are causes of defects, marks, and deformities.
  The excessive development  and  unnatural growth  of  any of
these parts will  cause deformity, and is  of frequent  occurrence.
The same  development  accounts for deformities on the  external
surface of the body ; thus the various tumours.
  Every part of an infant in  the womb may be more  or less dis-
eased or defective !   We often observe cataract,  amaurosis, aneu-
risms, varices,  jaundice,  hydrocephalus, and various other con-
genital defects in infants ; but who could seriously think that  any
of these defective diseases, these  marks and deformities, depend-
ed on the imagination of the  mother.  The passions  or imagina-
tions  of the mother can only act  in an indirect manner on the in-
fant, by debilitating the mother  only ; but all marks  deformities,
and diseases  of the infant depend upon unnatural development of
certain particles or parts which compose  its body.  The parts of
the foetus are delineated in the ovum,  but they do not increase in
the same  proportion ;  and  the  increase of some parts being pre-
vented, will induce deformity.   Force or violence upon the body
of the foetus, or pressure of  the womb  by tight lacing, will cause
deformity in the infant.   Dr. James Augustus Blondel,  about 1728,
published a curious  work on this subject,  which was the best that
bad appeared against the power of the imagination of the moth-
er.   He  maintains,  among many other original and  interesting
opinions, that the rudiments of all plants and animals now existing,
have existed from the creation ;  and that there  is  no new creation
or equivocal generation.  He contends that there is no child born
but whose linaments have existed somewhere since the first cre-
ation, and in that somewhere, are liable  to  many  vicissitudes.
This somewhere was the  primitive ovum, which  had several ova 
            MATERNAL INFLUENCE ON CONCEPTION.          7'3

within one another ;  and that, although there is no transmigration
of soul, there is of body, and that each foetus has been succes-
sively  in different women.
   That the ovum, undergoing to many revolutions,  may receive
some damage, as these mothers must have been liable to bruises,
cuts, and wounds,  to many  diseases, scrofula, consumption, can-
cer, he. ; and therefore, that infants must be affected with various
defects and diseases.   He contends, that the largest oak has been
a small single  acorn ; and that a single acorn not only  contains the
oak, but also all the trees and acorns which shall be produced from
thence successively,  as long as the world lasts.  If we look back
to first causes, we shall readily perceive the force and authentici-
ty of these opinions ; for it is manifest that the whole human race
must have existed in the  first of the species.   M.  Geoffroy St.
Hilaire proposes a hypothesis of monstrosities or deformed infants,
which has been  already  noticed (p. 80),  and may be considered
the latest and most satisfactory as  yet offered ; but is by no means
established.
Article IV.—Medico-legal Questions relative  to the
        Signs of  Conception and Utero-gestation.
              Section 1.—Signs  of Defloration.
   The questions which may be submitted to medical men onder
this head,  are as follow :
   1.  Are there certain signs of defloration? 2.  Can  we  distin-
guish between forcible violence against the consent of the accuser,
and whether the signs of violence be not attributable to  the introduc-
tion of other extraneous bodies into the external sexual organs ?
3.  And whether a woman can be violated without her knowledge?
And 4, whether pregnancy can follow violation ?
   1.  Are there certain signs of defloration?   To determine this
question, we must decide whether there be certain signs  of vir-
ginity.   We have to refer to anatomical  and obstetric works  for
a description of the  external genitals in the virginal state, to ena-
ble us to form a correct decision upon this  question.   The exter-
nal genital organs are those connected with the subject.
   In virgins the external labia are  thick, firm, elastic, and internal-
ly of a vermillion or rosaceous  colour, their edges in apposition,
so as to close completely the orifice of the vulva.   They are soft,
pale,  and separated  in women accustomed to venereal enjoyment.
        10 
"14
GYNJECO-PIIYSIOLOGY.
 But these characters are not to be  depended  on,  as women of
 strong constitutions may have the signs  of virginity;  and virgins
 the latter signs from leucorrhoea, or fluor albus.   In fact, no posi-
 tive conclusion can be deduced  from the state of the  external or
 internal labia.   The same must be said  of the froenum labiorum;
 it may or may not be ruptured during coition, and every obstetri-
 cian, of ordinary experience, can attest its perfect condition during
 parturition.  Besides, it  may be ruptured by falls,  external inju-
 ries, or by the passage  of solid  morbid  growths.  The  orifice of
 the vagina is ordinarily narrow,  but it may  be relaxed by leucor-
 rhcea, or may be larger in a virgin than  in a woman  who has been
 violated.   In some women it is  closed by the hymen, a membrane
 long held as the surest sign of  virginity.
   It is now universally known,  that a great variety  of causes be-
 sides coition may destroy this  membrane, as sudden  exertion of
 the lower extremities, leucorrhoea, masturbation  excoriation,  con-
 fined menstrual fluid,  and various morbid growths, both  solid  and
 fluid.  It does  not always exist even  in  infants, and sometimes
 does not entirely close  the vagina at  puberty, so that the  intro-
 duction of  the  penis  may be  effected, if not  disproportionate.
 (Teichmeyer,  Brendel, Severin, Pineau, he.)    Indeed, women
 have been in labour, and the hymen perfect.   (Mauriceau, Ruysch,
 Pare, Meckel, Walter, Baudelocque, Smellie, Capuron,  Naegele,
 he.)   It is therefore no infallible sign of virginity, nor is its  ab-
 sence alone a positive proof of defloration.   The carunculae myr-
 tiformes were long  considered as the  remains of  the hymen ;  but
 this is denied by Hamilton, Conquest, and Velpeau.    They have
 been seen in infants and virgins, and  are no proof of defloration;
 because, like the rugae of  the vagina,  they are only effaced by re-
 peated coition.  Dr. Beck admits, that many of  the above si°ns
 are equivocal; but if taken in connection with one and other, he
 thinks it cannot be possible that all mentioned in the chaste state
 can be absent without a strong suspicion against the  female.   I
 cannot assent to this conclusion, as  I think  experience  has proved
 that all the physical signs of virginity are equivocal, and  all may be
 absent from causes already enumerated, without  room  for a well-
grounded suspicion  against the  female.   From  my  own experi-
ence, and the result of my researches, I can arrive but at  one con-
clusion, that there are  no positive  signs of virginity, and conse-
quently those of defloraljtott are extremely uncertain  ;  this, I find,
t 
9IGNS OF FEMALE VIOLATION.
75
is the opinion  of Leipsig,  of Metzer,  and of  Morgagni.  The
presence of the reputed signs of virginity afford no decisive  proof
of chastity, nor their absence no  decisive proof of incontinence.
If all the reputed signs described above exist, the female feels of-
fended at the  examination, or rather displays evidence of shame,
if her morals and education have been good, then there are strong
grounds  for supposing her  in possession of her chastity ; and if all
the contrary signs exist with a suspected reputation, and an equiv-
ocal  virtue,  then there is reason to pronounce a contrary opin-
ion.
   It is necessary to recollect the habit of the body and age of the
patient,  as the signs of virginity are most perfect between puber-
ty and the twenty-fifth year, after which period they become more
equivocal.
   When defloration of a young female has  recently taken place,
the signs are  very evident.   The  laceration of the hymen (if it
exist,) the presence of its remains covered with clotted blood, the
contusions of the labia  majora and minora,  of  the clitoris,  and
carunculae myrtiformes, the redness and tumefaction, or laceration
of all the  external genitals, leave no room to doubt.  But  almost
all these marks will generally disappear in  three or four days.
They disappear almost instantaneously in chlorotic and  leucor-
 rhoeic females.   (Briand,  Manuel  de Medicine-Legale.)
   2. Can we distinguish  between defloration,  the  result  of vol-
 untary  carnal commerce, or that which has been effected by vio-
 lence,  or by the  introduction  of a foreign body into the va-
 gina ?
    It is extremely difficult to determine this  question in a positive
 manner.  Many  medical  jurists are of opinion,  that contusions,
 lacerations, inflammation of  the vulva, ecchymoses  of the  thighs,
 arms, breasts, and other parts of  the body, prove that violence had
 been used, and that the female  did not consent.  But it is to be
 recollected, that many women will   not  consent  without some
 force, which  may be followed by  ecchymoses, and also that inju-
 ries  of the genital  organs may follow a first congress,  when the
 sexual organs are disproportionate.
    Every person knows, says a French jurist, that at the epoch of
  puberty,  young  girls of  an  erotic temperament employ foreign
 bodies for the gratification of their desires, and may cause lacera-
  tion or  contusion of the external genitals ; and who does not know 
76
liYNJECO-PIIYSIOLOGY.
that these excesses have brought ou delirium,  and who is ignorant
of the deplorable effects of onanism.   (Briand.)   Again, women
have injured the organs for  the purpose of accusing  an  innocent
man of rape.   (Fodere.)
   In all cases of defloration  we must consider  the  age,  strength,
and state of mind of both parties.  When this crime is perpe-
trated on children of a tender age, the disproportion of the organs
will  be  followed by  the marks  of injury  already enumerated.
On the other hand, a strong woman  may accuse  a delicate man
or boy,  or one who  is impotent.  It is  held by most jurists,
that it  is almost impossible ;  at all events  exceedingly doubt-
ful, that one man can violate an adult female.  (Mahon, Farr, Fo-
dere, Capuron, Beck, Briand,  &c.)  The exceptions to  this rule
are when the female  labours  under insensibility  from  violence,
syncope  or :fainting, narcotics,  intoxication, and according to the
faculty of Leipsic, when she is asleep.
   It is indispensably necessary to examine the sexual  organs of
both parties.  The man may  be impotent from a  variety of cau-
ses ; the penis may  have been destroyed by sloughing or cancer,
he. ; or the organ may be so  small as to cause no pain on its in-
troduction into the vagina.  Zacchias mentions a  singular case of
this  last kind.   The woman may labour under a variety of mal-
formations which preclude the generative act.  A speedy exami-
nation  should be made in  all cases, for the reasons stated in a pre-
ceeding paragraph.
   The state of mind of the woman  must be kept in view,  as an
idiot at twenty or upwards can make less resistance than a girl of
fourteen.
   Venereal infection is  a proof of violation,  when it  coincides
with the time at which the crime is alleged to have been perpe-
rated,  that is, if it appears from the third to the eighth day ; and,
above  all, if the  accused is affected  with the disease.  Every
well-informed  practitioner is aware  that  gonorrhoea or syphilis
cannot manifest itself immediately after congress, and  therefore
if found on the female, it is a strong proof against her.
   Every well-informed physician  and surgeon is  also conversant
with the purulent discharge of female children of scrofulous  and
delicate habits, from the period of dentition to the age of  puberty ;
such discharge is seen  almost every day in  dispensary and hospi- 
SIGNS OF FEMALE VIOLATION.
77
tal  practice among the poor.  It is described by John Hunter,
Hamilton,  Astley  Cooper, Dewees, Jewel,  and myself,  and is
often mistaken by ignorant practitioners for gonorrhoea.
   There is no  fact better attested than this, that purulent dis-
charge from the genital organs  of both  sexes,  from the period of
infancy upwards, may  arise from  causes purely physical, chemical
or specific.  Venereal excess between two  persons  whose organs
are healthy, may cause a discharge more or less intense in one or
both ;  but  still the symptoms are not so violent as in gonorrhoea,
Even children of both sexes are subject to genital discharge before
and during dentition, from worms, or from local injury of the sex-
ual organs, as  in cases  under notice.   The last  fact is one of great
importance to those who are called on to give evidence before ma-
gistrates, or in courts  of justice, in charges of rape.  The accu-
sed may be free from gonorrhoea, and declare  that  if the  child is
infected it  is not by him.  The medical man  should ascertain all
lesions,  and  discriminate  between purulent discharge  the conse-
quence of violence and  inflammation, and that arising from infec-
tion.  The history of the  case will enable him to form a correct
opinion in  the majority of instances,  and he  ought to ascertain
whether the  child has  not been subject to  discharge  previously
to the  supposed  offence.   In a  case in which 1 was  consulted,
and which is recorded in the Lond. Med. and Surg. Journ. 1830,
 vol. v., the girl had laboured under purulent discharge five years
 before, and was then  eleven years old,  and exceedingly delicate.
On that occasion  I afforded abundant evidence of the liability of
female infants, and of girls to the age of puberty, to purulent dis-
charge from the vagina.   We know that equitation,  injury on  the
 perineum,  calculus in the  bladder, stricture  of the urethra, hae-
morrhoids, gout,  rheumatism, certain  cutaneous diseases, as her-
 pes, impetigo, serpigo,  lepra,  he., the  terebinthinate  medicines,
lytta,  spices,  diuretics,  sexual intercourse during  the  catamenial
 or lochial  evacuations,  the  introduction and  long  retention of a
 bougie in the urethra, irritation in different parts of the alimenta-
ry  canal,  constipation,  certain aliments and  medicines,  as new
 beer,  asparagus, he. ; in a word,diseases of organs  which strong-
 ly sympathise  with the genito-urinary system may cause simple
gonorrhoea.   Cases are recorded  in which gastro-enteritis, diseases
of the respiratory system,  coryza, cynanche, pneumonia, and asth-
 ma, had terminated by a copious discharge from the urethra.   It 
78                   gynjeco-physiology.
is admitted that  there is a reciprocity of action between the mu-
cous, serous, fibrous tissues, the digestive, respiratory systems, tho
urinary apparatus, the urethra, and uterine system, and that these
systems when irritated or inflamed will often affect the urethra or
uterine apparatus.  So  also the latter organs  cannot be affected
without implicating the former tissues in  various degrees.   Dr.
Titley relates a  case in which he  supposed venereal gonorrhoea
existed for a period of three days, and for which he prescribed the
usual remedies;  but before the patient  had taken the medicine,
he was seized with a smart attack of gout, and in a few hours the
urethral discharge had vanished.
  Capuron  was consulted in a supposed case  of defloration, in
which a purulent discharge escaped  from the  vagina;  the exter-
nal  genitals were ulcerated ; but that able physician ascribed it to
influenza, and the girl was soon restored to health.   M. Biessy,
of Lyons, relates a case,  in which  all the surgeons  of that town
certified a child had been violated in consequence of  the presence
of a discharge.   He denied  it,  which induced the Mayor to re-
quest  five physicians to  examine the child  separately, without
knowing  the application to each, and they all agreed that she on-
ly laboured under a simple mucous discharge.   (Manuel Medico-
Legale, he.)
  The following case is related by the revered  Dr. Percival in
his  admirable  Ethics :—   "Jane  Hampson, aged  four, was ad-
mitted an out-patient of the Manchester Infirmary, February 11,
1791.  The female organs were highly inflamed, sore, and pain-
ful ; and it was  stated by  the mother, that the child had been as
well as usual, till the preceding day, when she  complained of pain
in making water.  This induced the mother to examine the parts
affected, when she was surprised to  find the appearances above de-
scribed.   The child had  slept two or three  nights in the same
bed with a boy fourteen years old, and  had complained of being
very much hurt by him during the night.   Leeches, and other ex-
ternal applications, together  with  appropriate  internal remedies,
were  prescribed ; but the debility increased,  and on the 20th of
February the child died.  The coroner's inquest was taken; pre-
vious to  which,  the body  was inspected, and the  abdominal and
thoracic viscera found free of disease.   From these circumstan-
ces, Mr. Ward,  the surgeon attending this case, was induced to
give it as his opinion, that  the  child's death was caused by extor- 
                SIGNS  OF FEMALE VIOLATION.              79

nal violence; and a verdict of murder was accordingly  returned
against  the boy with whom  she had  slept.   Not many  weeks
elapsed, however, before several similar cases occurred,  in which
there was no reason to suspect that external violence had been of-
fered, and  some in which it  was absolutely certain that no such
injury could  have taken  place.   A few  of these patients died.
Mr.  Ward was now convinced  that he  was under a mistake in
attributing the death  of Jane Hampson to external violence, and
informed the coroner of the  reasons which induced this change
of opinion.   Accordingly, when the boy was called to the bar  at
Lancaster, the judge informed the jury, that the evidence addu-
ced was not sufficient to convict; and that it would give  rise to
much indelicate discussion, if  they proceeded to the trial; and that
he hoped,  therefore, they would acquit him,  without calling wit-
nesses.   With this request the jury immediately complied.  The
disorder in these cases, says Dr. Percival, had been a typhus fe-
ver, accompanied with a mortification of the pudenda. "
   Mr.  Kinder Wood relates  cases of a disease somewhat similar,
in which there is fever for three days, inflammation of both labia,
clitoris,  nymphae,  and  hymen,  followed by sloughing and death.
The mortality was ten in twelve, and the disease considered a pe-
culiar kind of eruptive fever.   (Med. Chir. Trans, vol. vii.)
   I have already recorded a case of a delicate scrofulous girl, aged
eleven years, who had purulent, or rather mucous discharge from
the external genitals, and accused a young man of eighteen, whoso
genitals were developed in an extraordinary degree, of having vi-
olated her person.  Two apothecaries swore the girl had been vi-
olated,  a  rape  committed, and  gonorrhoea communicated.  Dr.
Gordon Smith, Mr. Whitmore,  and myself, were of a different
opinion.  The  froenum labiorum was perfect, the hymen absent,
a discharge without  any sign of inflamation the day  after the al-
leged intercourse, and a small dark spot observed  by Dr. Smith
only, on the thigh.   The examinations of the medical men were
made at different times.   The case  was grievously  mismanaged
for the  prisioner; the only evidence in  his favour was Dr. Smith's
which was contrasted with that  of the  two medical witnesses for
the prosecution.  The  man  found guilty,  and  sentenced to six
months' imprisonment, and reminded by the chairman of the Mid-
dlesex sessions (Mr.  Const) "of his good fortune  that he was not
hanged"—for a crime he never committed.  The mother inform- 
80
GYN-flECO-rilYSIOLOGY.
ed Dr.  Smith that  her daughter had had the discharge since she
was five years old.   The  medical  witnesses  for the  prosecution
declined examining the person of the  prisoner, though  those  on
his side had  assured them he had no discharge from the urethra,
nor had not had  any for six months previously.  The  case was
tried in November sessions, 1829.   When, the girl was examined
at the trial , and asked why she did not tell the domestic who dis-
turbed the parties during the alleged intercourse, she replied "she
forgot it."   A girl of eleven years old, violated by an adult, for-
get it!  Cases like the present are unfortunately of too frequent
occurrence, and are  attested by Sir A. Cooper in  the following
impressive language :
   " There is a circumstance which I am exceedingly  anxious to
dwell on.   I allude to a  discharge from  young females ;  and I
hope that there is not one here this evening but will be strongly
impressed with the importance of the subject.   Children from one
year old, and even  under,  up to  puberty, are frequently the sub-
jects of a purulent discharge from the pudendum, chiefly  origin-
ating beneath the preputiumclitoridis ;  the nymphae, orifice  of the
vagina,  and the meatus urinarius are in an inflamed state, and pour
out a discharge.   The bed-linen and rest of the clothes are  mark-
ed by it.   It now and then happens to a nervous woman,  to  be
alarmed at such an  appearance, and she suspects her child of ha-
ving acted in an  improper  manner ; and, perhaps, not quite clear
herself, she is more ready to suspect others, and says, ' Dear me!'
(if she confesses)  'it is something like what I have had myself.'
She goes to a medical man, who may  unfortunately not beware
of the nature of the complaint I am  speaking of,  and he says,
'Good God! your child has got a clap.'   (A  laugh.)  A mis-
take of  this kind, gentlemen, is  no laughing  matter;  and though
I am glad to make  you smile sometimes, and like to join you in
your smiles, I cannot do it on the  present occasion,  for it is too
serious a matter.   I can assure you a multitude of persons have
been hanged  by such a mistake.   I will  tell  you exactly what
takes place in such cases ;  the mother goes home, and says to the
child, ' Who is it that has  been playing with you ; who has taken
you on his knee lately ?'   The child innocently replies, ' No one,
mother; nobody  has, I declare to you.'  The mother then says,
' Oh, don't tell me such stories ;  I will flog you if you do.'   And
thus the child is driven to  confess what never happened, in  order 
SIGNS OF FEMALE VIOLATION.
81
to save herself from being chastised.   At  last she says,  ' Such  a
one has taken me on  his lap.'   The person is questioned,  and
firmly denies it; but the child owing to the mother's threats, per-
sists in what she has said.  The man is brought into a court of
justice; a surgeon who is ignorant of the nature of the  discharge
1 am now speaking about, gives his evidence ; and  the man suffers
for that which he never committed.  The mother is persuaded, if
there be a slight ulceration on the parts, that violence  has  been
used, and a  rape committed.  She immediately says,  ' What a
horrid villain must he be for forcing a child to such an  unnatural
crime, and communicating to her  such a horrible disease ! I should
be glad to see him hanged.'
   " If I were to tell you how often  I have met with such cases,
 I  should say that I have met with thirty in the course of my life.
The last case I saw was in the city ; a gentleman came to me, and
asked me to see a child with him, who had a  gonorrhoea on her
1 went, and found that she had a free discharge from the preputium
clitoridis. I said that there was nothing so common as this. There
was considerable inflammation, and it had even proceeded to ulcera-
tion, which I told  him would soon give way to  the use of the li-
quor calcis,  with  calomel.   'Do you tell  me so?' he replied,
1 why, suspicion  has fallen  on one of the  servants; but he  will
not confess.   If he  had appeared at the Old Bailey, I should have
given my evidence against him, for I  was not aware of  what you
have just told me.'   I told him,  that if the man had  been hang-
ed by his evidence,  he would have deserved to be hanged too.
   " I am anxious that this complaint should be known by every
one present, and  that the remarks which I have made should be
circulated throughout the kingdom.   When a  child has this  dis-
charge, there is  a heat of the parts, slight inflammation, and this
sometimes increases, and goes  on to ulceration.  This  disease
sometimes occurs in children at the  time of cutting their teeth."
(Lectures on Surgery.
   Dr. Dewees,  the  eminent  professor of midwifery, in  the  Uni-
versity of Philadelphia,  has  also  given an excellent account  of
the morbid discharge under notice, in his Treatise  on the Physic-
al and Medical Treatment of Children, pp. 326, 435.  He says,
" We occasionally find that very  young children have a discharge
from  within  the  labia of a thin  acrid kind, or of a purulent ap-
pearance.   When this occurs in  very young subjects,  it almost
         n 
82
GYNJECO-PHYSIOLOGY.
always proceeds from a neglect of cleanly attention to these parts,
either by withholding a frequent use of lukewarm  water,  or per-
mitting  the child to remain  too long  wet.  * *  * * Children,
however,  of a  more  advanced  age,  have also discharges of a
purulent character, that seem to  arise from a morbid action of the
mucous membrane of the vagina or labia.   This frequently shews
itself about the fifth year, and may continue, if neglected, to  al-
most any period.  Parents, therefore, cannot be too much on the
alert when this discharge is discovered on their children, nor too
early in the application of suitable remedies for its removal.  It is
in a great measure owing to this  neglect,  that fluoralbus or whites
become so  common, and of such  difficult management  in adult
age.  If not interrupted in the  beginning of its career, it is apt
to continue until the period of puberty over the phenomena, of
which it but too often creates an unfriendly influence."
   Orfila gives a table to enable medical jurists  to discriminate in
all cases of stains on linen,  whether by  spermatic, leucorrhceal,
gonorrhoeal lochial, mucous, and salival fluids. The evidence afford-
ed  by this table is far from being positive,  and I therefore omit it.
   3. Can a woman be violated  without her knowledge ?   Deci-
dedly she  can if under the influence  of insensibility  from vio-
lence, fainting,  asphyxia, narcotics,  or   intoxication.   I  have
recorded a case in  which a female  was  impregnated during in-
ebriation, and was of course unconscious of it during the first seven
months of utero-gestation.   She felt much offended when I hint-
ed  my  suspicions  as to  her being pregnant, but soon afterwards
her paramour revealed the secret to  me.   Though it  is difficult
to suppose a woman can be  violated during sleep, yet under some
circumstances it seems to me very possible.  A married woman
who has had children,  whose sexual organs are dilated,  may  be
violated during sleep;  but a virgin could not be deflowered with-
out her  being awoke.   Drs.  Beck, Gordon, Smith,  Bartley, Fo-
dere, and Capuron, doubt the possibility of a married woman be-
ing violated during sleep.
   4. Can violation be followed by conception ?  It was long deci-
ded in the negative, as it was supposed, that women who  were in-
fluenced by the  depressing passions could  not conceive.   (Bart-
ley and Farr.)   Capuron, Fodere, Beck, Good, &,c.  agree with
a majority of the profession, that conception may happen, and is
not accelerated or  prevented by  the volition of the sexes.  This 
                 SIGNS OF FEMALE VIOLATION.              83

is the  received  and only rational opinion.   How many wTomen
anxiously  wish  for  children, and  have  none, and  vice versa.
From  the foregoing observations, it  is evident that medical sci-
ence does  not furnish  positive proof of any of the questions dis-
cussed in this article, but merely probable and presumptive evi-
dence.  I may  observe  in  conclusion, that the probabilities are
greatest when a child of five, seven,  nine, or ten  years of  age is
the accuser, after due consideration of the sexual diseases of this
period of life.   Her age excludes all appearance of consent, as
she cannot have desire, her organs being undeveloped, as stated
in the  section on disqualifications for marriage and impotence ;  nor
is it likely any  foreign body will  be  introduced.  The case will
be stronger attested by any other marks of violence.   However,
great caution is  required in these cases, as depraved mothers have
induced their children to make accusations against innocent per-
sons.

       Section 2.—Signs of Utero-gestation.—Pregnancy.
   This is a subject which requires great attention  from the  medi-
cal jurist, on  account of the numerous relations it has to civil and
criminal proceedings.  It affects the honour of husband and wife ;
it arrests the administration of justice, when offered as a plea for
reprieve ;  it  aggravates  an assault when abortion occurs, which
renders  the crime  a felony ; it may  be pretended, and deception
attempted on the  medical  attendant and others ; or the female
may  accuse a  person of causing abortion; it may be concealed,
and it may affect the honour and property of parents  and chil-
dren, as in its protracted state, which involves legitimacy.
   For the better understanding of this important  subject, it will
be necessary to enumerate  the  signs  of conception and pregnan-
cy, superfoetation or  second  conception, and duration of preg-
nancy ;  all of which will be described in the course of this work.
   Signs of ordinary Pregnancy.—The signs of pregnancy may
be divided into rational  and sensible.  The first  result from  the
influence of the uterus on the moral  and physical systems of  the
female, and these are disorders  and  derangements of the organ-
ic functions or vital properties.  The  second result from the de-
velopment of the uterus, and the presence  of the foetus in that
organ.
   Rational Signs.—It was an opinion professed by Hippocrates 
84
GYNJECO-PHYSIOLOGY.
 and Galen, that a fecundating copulation is accompanied by more
 vivid enjoyment than an  ordinary  coition.   The following signs
 usually  occur after conception ; there is  a change in the moral
 and intellectual faculties, in the  temperament and constitution of
 the female ;  the  eyes lose their vivacity,  their brilliancy,  and
 become  languid ;  the eyelids are surrounded by a blackish, livid,
 or leaden-coloured circle ;  the  nose is  elongated,  the mouth is
 smaller, the countenance  is changed, the voice  is  stronger, the
 neck fuller, transpiration more odorous, the character more deci-
 ded, and  the passions  more violent; the menses  are generally
 suppressed, the mammae are firmer, more sensible and more  de-
 veloped, sometimes secreting  a thin, whitish, serous  fluid ;  the
 nipple is more prominent, the areola is enlarged, and of a browner
 colour.   Immediately after conception the female  experiences
 unaccustomed sadness, a tendency to fainting, or complete syn-
 cope, horripilations, colic, and a vermicular motion of the uterus,
 which extends to the  abdomen, borborygmi, and rigors.   There
 is sometimes  anaphrodisia,  sometimes increased  salacity.  The
 pulse  becomes  more  frequent, weaker, or fuller and softer,  the
 temperature is increased, the transpiration is more abundant,  the
 urine is more copious, turbid  and  cloudy, the secretions are in-
 creased,  there is often  ptyalism, the hepatic functions are disturb-
 ed, and there  are spots and  ephiledes on the face and skin.  The
 taste and digestion  are depraved; anorexia, nausea, inappetence
 and vomiting supervene, the female  desires innutritious or dis-
 gusting foods, as  chalk, cinders,  putrescent animal food,  vegeta-
 bles, fruits,  acid drinks,  vinegar, he.  This inappetence  and  de-
 praved taste are followed in a few  months by a keen, voracious
 appetite, but towards the last month of pregnancy the digestive
 functions become deranged, as the stomach is so confined by  the
 gravid uterus, that it can contain  but a small quantity of aliment.
   The moral state is subject to numerous changes, some women
 naturally gay and amiable,  become sad, melancholy, and  insocia-
ble, and  vice versa.   Many diseases appear, others disappear as
hysteria, chlorosis,  chorea,  and  epilepsy.   The  whole of these
signs are seldom observed in all cases, and are doubtful and  un-
certain.  If all are  present they afford strong proof of pregnancy
but never that positive  certainty  which enables us to give decisive
evidence before magistrates.
   Sensible  Signs,~~These  signs consist in augmentation of  the 
           SIGNS OF CONCEPTION AND PREGNANCY.         85

abdomen, in the active and passive movements  of the foetus, in
the perception of the foetal and placental pulsations by means of
auscultation, in the evidence afforded by the touch, or vaginal  ex-
amination, or ballotement, as to the state of the os and cervix uteri
in the different stages  of gestation and the  development of the
uterus.   The  most certain of these signs  are the touch, or  bal-
lottement, and auscultation.  The touch consists of the introduc-
tion of the finger into the vagina,  and the application of the other
hand  above the pubis, the uterus will be felt enlarged, and if gen-
tle percussion be applied to the pubis, the foetus will be made to
strike the finger, which  cannot  happen unless  there be a foetus
and a  fluid in the uterus.  However, the sign is not always con-
clusive, for it  has existed in extra-uterine foetation.  The sign can
only exist  about the fifth or sixth month,  and has led to mistake
even  at the approach of  parturition.   (Capuron, Malad. des Fern.
p. 72.)—The results of auscultation exist  in  some degree, when
the foetus is dead, and also in extra-uterine  foetation.  The chan-
ges of the neck and body of the womb enable  us to distinguish
pregnancy from hydropsy,  tympanites,   hydrometra, hydatids,
moles, polypi, &c.
   The spontaneous  motions of the foetus take place about the fifth
month, but some women never perceive them  during the whole
period of gestation, others imagine them present when there is no
conception.   Nervous and hysterical women very frequently make
the last  mistake.  The  spontaneous motions of  the foetus  and
quickening, are not infallible proofs of pregnancy.  Auscultation
has been called into action to enable us to  decide this point.   M.
Le Jumeau de Kergaradec has  applied the  ear  and  the stetho-
scope to the  abdomen, and  discovered the double motion of the
foetal heart, and also the pulsation of the placenta, which was syn-
chronous with the maternal pulse.  It  is to be recollected, that the
first must change with the infant, and consequently must  be heard
in different parts of the  abdomen, at different examinations.  Dr.
Kennedy, of  the Dublin Lying-in Hospital,  has written  in favour
of auscultation, in the Dublin Hospital Reports, vol.  v. 1830.—
M. Velpeau  has tried it in a  great number  of cases in vain.—Dr.
Elliotson is in  favour of it,  1831.—Dr. Fergusson,  of Dublin,
thinks it an unequivocal proof.  Dub. Med.  Trans,  vol. i. 1830.
Dr. Nagle,  of the same city, thinks it equivocal. 1831.  From
the preceding considerations, the following  conclusions may  be
drawn : 
86
GYNJECO-PHYSIOL0GY.
   1.  That the foetal and placental pulsations, when discovered by
auscultation, are positive proofs of pregnancy.
   2.  That in all  cases before the fourth month, the  diagnosis is
extremely uncertain.
   3.  That  during the five succeeding months, better evidence is
afforded by  the progress of uterine development.
   4.  That there  are no infallible signs of pregnancy, except per-
haps  those afforded by auscultation.
   Previous to the application of auscultation,  it  was held by the
following authorities, that there was no infallible sign of pregnan-
cy in  the early months.  (Hamilton,  Burns, Mahon, Fodere, Ca-
puron, Farr, 3Iale, Beck, Smith; Edinburgh Med. h Surg. Journ.
1833, vol.  xix; 3Ied. Chir. Rev.  1824;  Med. h Phys. Journ.
1825, Gooch,  1829.)
   Dr. Beck concludes, that it is impossible to decide on pregnan-
cy before  the sixth month;  but this  opinion is  refuted by subse-
quent experience.  We may derive advantage  from attending to
the signs of the different epochs of pregnancy, which are afforded
by the development of the uterus.

   Section 3.—Signs of the  different Epochs  of Pregnancy.
   During the two first months the diagnosis is extremely obscure,
and cannot be attempted with  any degree of certainty.  At the
end of the third month, the  fundus  uteri  is  on  a level with the
superior margin of the pubis ; at the end of the fourth month, the
uterus is in  the hypogastrium the spontaneous motions of the foetus
are perceived by the mother, and the diagnosis, styled ballottement
is afforded to the obstetrician.   At the end of the fifth month, the
uterus touches the inferior boundary  of the umbilical region, and
the cervix uteri is elevated in the vagina.   At the end of the sixth
month, the uterus is  felt at  the  umbilicus, and this part projects;
the motion of the foetus my be felt by the practitioner.   We can
now avail ourselves of auscultation.  Morgagni proposed the fol-
lowing plan for discovering  the motions of the foetus.   In  warm
weather, let the hand be immersed in  cold water and suddenly ap-
plied  to the abdomen of the  female,  and in cold weather, let the
hand be immersed in warm water and applied, when the motion of
the infant will be  distinctly felt.   I have often acted on these sug-
gestions with success.  It is also  to be remarked, that the cervix
uteri begins to diminish in length at this period, as well delineated 
         SIGNS OF DIFFERENT EPOCHS OF PREGNANCY.       87

by Gooch and Maygrier.  At the end of the  seventh month, the
uterus approaches the  inferior margin  of  the  epigastric  region.
The abdomen affords a dull fluctuation,  which differs from that of
ascites; percussion affords  a  dull sound, which is  distinguishable
from tympanites or meteorism. At the end of the eighth month the
uterus is in the epigastrium, the cervix nearly developed, directed
towards the  sacral  concavity, round, gaping, and thickened ; the
limbs of the foetus may  be  often felt through the abdomen.   At
the end of the ninth month, the uterus becomes depressed under
the epigastrium, the orifice of the uterus is more easily felt, round-
ed, and  often open ; the head of the infant can be readily felt.  In
women  who have had former  pregnancies, the uterus does not  as-
cend  so high as in first cases, as the  abdominal muscles have been
relaxed, and it therefore inclines more forward.  In diagnosticating
in cases of doubtful pregnancy, we should not forget to  bear in
mind the appearance  of the abdomen in ovarian dropsy, and here
a careful history of the  symptoms  will enable  us  to arrive at a
correct conclusion. I have frequently known young women affected
with this disease, and have all the appearances of pregnancy ; the
general  health suffers little, and sometimes not at  all; the catamenia
are regular—the usual symptoms of pregnancy are absent, and
upon close  inquiry, it will be found that pain commenced  in the
ovary, and the tumor was first in one side.  In this, as in all other
cases, a knowledge of disease will alone enable us to  diagnosticate
correctly.  This knowledge is to be obtained by reference to the
best systems of obstetricy, and by actual experience.   It would  far
exceed the limits  by  which I am circumscribed,  were I to describe
the various  diseases  which may  be mistaken  for pregnancy.   I
must refer the reader  to  the standard works  upon this subject.
After a  luminous  description of the  diagnosis  in  the case before us
and all its difficulties, M. Velpeau concludes : " But it is danger-
ous to forget that there exist  causes without  number (of decep-
tion), and that before the tribunals one ought never to give a deci-
sive judgment, without  having previously acquired a mathematic-
al certitude of the fact upon which he pronounces."  This  is the
received opinion of the  present time.
  Dr. J. C. Fergusson has published one hundred cases of con-
cealed pregnancy in the Dub. Med. Trans., 1830, in  all  of which
he was enabled to discover the pulsations of the foetal heart and 
88
GYN^CO-PHYSIOLOGY.
of the placenta.   He says, " I conceive  it to be sufficiently es-
tablished, that either a  placenta or foetal heart being heard, con-
stitutes infallible evidence of pregnancy ; evidence upon  which a
medical  man may, if  required,   conscientiously  and  positively
swear to the fact, which I believe all admit, and our legal records
show, could not be done under ordinary circumstances.   * * *  *
The absence of these  phenomena  amounts,  if not to positive,
at least to presumptive proof of the  contrary. "  I cannot  agree
with these  conclusions, because many  practitioners may not be
sufficiently dexterous with the stethoscope to detect  the pulsa-
tions ;  and as further evidence is  required to warrant  the  latter
conclusion.   It is very manifest, however, that auscultation  ought
to be employed in  doubtful cases of utero-gestation.
  In cases of extra-uterine  foetation, should the Caesarean opera-
tion, or .rather gastro-hysterotomy be performed, the infant cannot
inherit property according to the  laws of this country.  (Black-
stone.)  This  is the  only medico-legal point connected with the
subject.  A point  of much importance to be decided is, whether
twins be  the result of one  coition, or  of superfoetation.  The
decision will  affect primogeniture.   The  question  has not been
discussed by any British writer on forensic medicine except my-
self.

              Section 4.— Generation of  Twins.
  Superfoetation.—Physiologists  are at issue  upon the question
of superfoetation, that it is possible for a pregnant woman to con-
ceive a second time.  According  to Aristotle, a female  was de-
livered of twelve infants, and another of twins, one of  which re-
sembled her husband, the other her lover.  Some writers main-
tain that superfoetation is possible during the first two  months of
pregnancy ; the majority  hold it possible in a  few days after con-
ception, before the uterine tubes are closed by the decidua.  This
is the  received opinion, though cases are on record which justifi-
ed Zacchias  and  other jurists, to conclude,  that superfoetation
might  occur until  the  sixtieth day, or even  later.   Nothing is
more common than to see a  full grown infant  born,  and another
of the second, third, fourth, fifth, or sixth month expelled imme-
diately after.  I need not  cite authorities  upon this point, as ob-
stetric works abound with examples.   But  a few examples may
be given.   Dr.  Maton  published an  account of a woman who 
SUPERF02TATI0N.
89
was delivered of a full grown infant, and in three calendar months
afterwards of another, apparently at the full time.   (Trans. Coll.
Phys. vol. iv.)—A woman was delivered at Strasburgh, the 30th of
April, 1748, at ten o'clock in the morning, in a month afterwards
M. Leriche discovered a second foetus, and on the 16th September,
at five o'clock in the morning, the woman was delivered of  a heal-
thy full-grown infant.  (31anuel  Complet  de Med.  Leg.  par Bri-
and.)—Degranges, of Lyons, attests a case ; the woman was de-
livered at the  full  time, the  20th of January 1780 ;  in three
weeks afterwards she felt the motions of an  infant,  and  her  hus-
band had no intercourse  with her for twenty-four  days  after de-
livery.  On the 6th of July (five months and sixteen days subse-
quent to delivery) she brought  forward a  second  daughter, per-
fect and healthy.  On  the 19th January 1781,  she  presented her-
self and  both  infants before  the notaries at Lyons, to  authenti-
cate the  fact.   (Fodere,  vol. i.)  These cases prove the possi-
bility of superfoetation, four, five, and  six  months after concep-
tion.   This may be possible, as menstruation has occurred during
pregnancy.   Mauriceau,  Deventer, Heberden, Francis, Hosack,
Dewees, Capuron, and Mayo.)—Buffon  related a case  of a wo-
man in South Carolina, who brought forth a white and a  black in-
fant; on inquiry, it was discovered that  a negro had entered her
apartment after the departure of her husband,  and threatened to
murder her, unless she complied with  his wishes.  Dr. Mosely
relates a similar  case.  A negress of Guadaloupe brought forth
a black and mulatto, having had intercourse with a white and black
man the same night.   Another negress produced  a white, black,
and a piebald infant.   A  domestic of Count 3Iontgomery's  pro-
duced a white and black child at one birth (Velpeau).   Gardien
relates  a  similar case on the  authority of  31.  Valentin.   A
mare has produced  a foal  and a mule, she  having  been impreg-
nated by a horse, and  five days afterwards by an ass.   In treat*
ing of this subject in the first edition of this work, 1828, I made
the following remarks:
   Another  argument, which I have never seen, occurs to me from
analogy, which deserves mention, namely, that each dog will pro-
duce a distinct puppy ; this no  one can  deny, for the  offspring
will resemble the different males that fecundate the bitch  in suc-
cession.   If a number of healthy, vigorous men were to have in-
tercourse in succession, immediately  after the  first conception, I
          13 
90                  GYNJECO-PHYSI0LOGY.

think it probable and  possible that similar superfoetation would
happen.   I am proud to say, that Dr. Elliotson is an advocate of
superfoetation ;  he explains Buffon's case this way.  Magendie is
of the same opinion.   3Iedical men must bear in mind that wo-
men have had three,four, and five children atone birth.  Various
cases of infants of different sizes,  being expelled in  succession,
are recorded in  our own  periodicals.   (Medical and Physical
Journal, vol.  xxii, p. 47, vol. xxiv, p. 232; 3Iedico-Chirurgical
Transactions, vol. ix ; Philosophical Transactions, vol. 60.)
   One  of the  Pennsylvania newspapers, in 1827, recorded the
case of an Irish lady, who in eighteen months had at three births
twelve living children, all  born prematurely.   She  and her hus-
band were healthy fresh-looking people, and only two years  mar-
ried.   This case is not recorded, as yet, in any of  the Ameri-
can  Medical  Journals;  but if it prove to be authentic, it will be
the most extraordinary case of fecundity recorded in any country.
Cases of twins, triplets, quadruple, and quintuple  births  are of
very rare occurrence; but  of these  more particularly hereafter.
Dr.  Golding of this  city, delivered a woman of six infants during
the year 1829.
   I  am happy  to add that  Professor Velpeau, of Paris, is of the
same opinion.  He says, "  In  according all possible authenticity
to these observations, regarding their exactitude  as demonstrated,
the  idea which prevails in physiology on generation, permits an
easy explanation.  Two ovules can be fecundated, one after the
other, in a woman who accords her favours to two or more men
the same day, or in  two or three days afterwards ; that is to say,
to the moment when the excitation of the first coition causes the
effusion of coaguable lymph into the uterus, to form the caducous
membrane (decidua).   These  ovules may  not descend through
the uterine tube at the same time,  and may be differently develo-
ped. "   But he thinks superfoetation impossible  after  the decidua
is formed,  op. cit.   The closure of the os uteri,  after concep-
tion, does not take place  for some days, weeks, or months (De-
wees) ;  but if  the male semen be absorbed from the  vaginal sur-
face and conveyed directly  to the  ovary, as  in the elephant, cow,
sow (Gertner), such closure is no objection.   Twins  have gen-
erally but one amnios and placenta;  but in cases of superfoetation,
each infant has its own membranes and placenta.  I once attend*
ed a female who  was delivered of one infant on Monday ; the par- 
            DURATION OF PREGNANCY—LEGITIMACY.        91

 turient action ceased, and on the following  Thursday the mem-
 branes presented, and she was delivered of a second infant.  There
 was no haemorrhage, and the placentae  were united.   My friend,
 Mr. Whitmore, sent me a similar  union  of the  placentae a short
 time ago.   Whether we suppose superfoetation or twins, the med-
 ical practitioner ought to notice which  was born  first, male or fe-
 male,  when the disposal of  property or  title  depends upon  the
 decision.   The question is,  which was born first, not which  was
 conceived first.  Admitting superfoetation to be possible, and it can-
 not be denied in the early weeks of gestation, we cannot decide
 paternity, unless, perhaps, when one infant is black or brown,  and
 the other white ; but if both males were of  the  same colour, the
 decision might be difficult, unless some physical mark on the  in-
 fant existed in one  of them.  The following conclusions are ad-
 mitted in cases of pregnancy.  It is now decided  that a female
 may become pregnant, and be ignorant of it until the time of la-
 bour.   (Fodereand Sanders, of Edinburgh.)—This may occur
 in cases of  idiots (Desgranges) ; when the female is in a state of
 stupor, either from inebriation, narcotics, coma, syncope, or during
 sleep.  (Fodere, Orfila, Beck, Hebenstreit, and the  author.)

       Section 5.—Duration of Pregnancy.—Legitimacy.
   Hippocrates,  Aristotle, Galen, Pliny, Avicenna, 3Iauriceau,
 Riolan, La  Motte, Hoffman,  Stchenk,  Haller, Bertin,  Lieutaud,
 Petit,  Levret, Louis, Astruc, &c, maintained that pregnancy usu-
 ally terminates at the end of  the ninth calendar month, but might
 be  protracted to the tenth, eleventh,  twelfth, and some  of  them
 said to the fifteenth.
   It is also decided by a preponderating majority of the profession,
 in  all  countries, that the  term of utero-gestation  is not uniform ;
 in other words, not invariably  limited to nine months.  This  po-
 sition is strongly attested by  the  analogy  afforded by the inferior
 animals ;  for it appears  by the extensive observations of 31. Teis-
 sier ,on the gestation of heifers, mares, sheep, swine,and rabbits, that
all these animals exceed their usual period of delivery.  (Trans.
de I'Acad. des Sc, Paris 1817.)—Further evidence is afforded by
the vegetable kingdom,  in which we observe  in the same field, on
the same tree, shrub, &c., different parts  of vegetables arrive at
maturity with  more or  less celerity.   Petit informs us that many
faculties of medicine, forty-seven celebrated authors, and twenty- 
92
' GYNVECO-PIIYSIOLOGY.
three physicians and  surgeons, concluded  pregnancy  might be
protracted to the eleventh or twelfth month.   He cites a case on
the authority of Schlegel, in which  pregnancy  was protracted to
the thirteenth month; the child was admitted to be legitimate, an ac-
count of the probity and virtue of the mother, which induced her
shopman to marry her, and she bore two children by him, each at
thirteen months.  Tracy, a naval physician, relates a case at  the
fourteenth month.   Dulignac, a French surgeon, positively asserts
that  his own wife quickened at four months and a half, and on two
occasions she went on  to the thirteenth month and a half,  and on
the third to  the  eleventh month.   Desormeaux relates a case of
a woman who  was  maniacal, who had three children, and whose
physician, after all  means  had  failed, recommended pregnancy.
Her  husband had intercourse with her once in  three months, of
which he kept  an exact account.   She was closely watched by
her domestics,  and she  wTas extremely religious and moral;  she
was delivered at nine months and a half.  (Velpeau.)—The  last
author  attests a case which went to  three hundred and ten  days
and Orfila two of  ten  months  and  a  half.  I have repeatedly
known  women  mistake expected  delivery four, five, and  six
weeks.
   The  medical  evidence  in the  Gardiner  Peerage cause, tried
before the House of Lords, in  1825 and 1826, throws no light
upon the subject.  It  is right, however,  to observe, that the wit-
nesses spoke from their personal experience, lost all sight of  phys-
iological science, and of the  numerous  opinions  of ancient  and
modern writers; that  " one and all have shown an  extraordinary
ignorance  on the principles of  evidence,  will be conceded by ev-
ry one who examines  carefully their  testimony.  But it may  also
be doubted whether the question  admits of better evidence than
has been already proved, or at  least arrived at by  them and their
professional  predecessors."   (Dr. Duncan, Edin. Med. and Surg.
Journ., 1827,  vol. xxvii.)
   The majority of the medical  men, examined in  the Gardiner
Peerage cause, were in  favour  of protracted pregnancy,  as Drs.
Granville, Conquest, Blundell, Hopkins, Hamilton (of Edinburgh),
and Power.   Dr. Granville proved that his own wife went to three
hundred and six days, even admitting pregnancy  to have occur-
red the day  before  the interruption of menstruation;  and  three
hundred and eighteen  days, if from the middle of  two of the last 
           DURATION OF PREGNANCY--LEGITIMACY.        93

and expected periods.  Dr. A. T. Thompson, who attended her}
was of the  same opinion, that the child was ten months old at birth.
Dr. Granville knew  other cases of two hundred and eighty-five,
two hundred and ninety, and three hundred ;  and one doubtful at
three  hundred and fifteen days.  Dr. Conquest knew two or three
cases  at the tenth month.
   His patient was a most sensible woman, who had been the mo-
ther of six  children,  and had engaged him and the nurse to attend
her at a certain time, went five weeks after, and four with the next;
she had other children afterwards at the ninth month.  Dr. 31er-
riinan knew  cases at two  hundred  and eighty, two hundred and
eighty-five, three hundred and three, and three hundred and nine
days, and thought  the Gardiner case possible ;  Drs. Blundell and
Hopkins, two hundred and eighty-five ; Dr. Power, eleven months;
Dr. Hamilton, ten calendar months ; and Dr. Collins,  of Liver-
pool, published a case at eleven months  soon afterwards, which
occurred two years before.  (Edin.  Med.  and  Sourg. Journ.,
April 1826, vol. xxv.)—This is well worthy of perusal.  I know a
delicate woman, who menstruated the last week in February 1826,
quickened  in July, and engaged me to attend on her in November.
She had spurious pains in November,  December, and  January,
1827, and  was  delivered on the 28th of February, 1827, nearly
twelve months  from  her previous menstruation.   I had  most seri-
ous business from home in November, but by her intreaties defer-
red my journey in that, and even the next month, and of course I
then  daily expected her  delivery,  yet  she went two months
later.  The infant was  a girl, and of the ordinary size, and she
and all her friends thought she would die undelivered, from her
protracted  pregnancy ; yet her labour was only of two hour's con-
tinuance, and perfectly natural.  I shall ever have  cause to  re-
member this case,  as I neatly lost some considerable property by
deferring my journey to attend upon it.  It was a first  pregnan-
cy.   1 most  solemnly declare that the  case was a true  one, and
not fabricated to support any particular opinion.   This is the long-
est instance of  protracted pregnancy which has hitherto been  re-
corded in British medicine.   Another argument in  favour of pro-
tracted gestation is, that children often grow more in one year than
in seven years before, which would prove the development may
not be the  same in the  womb.  The following accoucheurs were
produced against  the doctrine of protracted  pregnancy, on the 
94
GYNJECO-PHYSIOLOGY.
 Gardiner Peerage cause.  Dr. Charles Clarke, who in twenty ca-
 ses of unmarried females, never knew one  exceed the term of
 nine months; his evidence does not controvert the opposite  side
 of the question.  Dr. Blegborough had practiced  extensively for
 thirty-four years, and never knew pregnancy exceed  the ninth
 month.  Mr. Pennington contended for forty weeks and three or
 four days ; and Drs. D. Davis and Gooch were of the same opin-
 ion.  It is a strange,  but positive fact, that these gentleman who
 came forward to prove pregnancy to be immutable and definite at
 a certain period, all  admitted it might exceed nine  months  by
four or six days;  hence the  justice of Dr. Duncan's critical sneer
 at their evidence.   In the case  under consideration, the claimant
 Jadis, otherwise Gardiner, was born eleven months after his father
 went abroad, and his  mother had cohabited with Jadis, the father,
 soon after  Lord  Gardiner  had  been  absent.   On his  lordship's
 return, he obtained  a  divorce against her, and married again;  and
 the offspring of the second marriage, on claiming his father's title
 and property, was opposed by Jadis, who, at the adult  age, took
 the name of Gardiner ;  and  under these circumstances,  and con-
 trary to the medical evidence of the majority of the obstetricians,
 the House  of  Lords decided against him.  The  evidence  in fa-
 vour of the legitimacy of Jadis  was founded  on too few cases, to
 warrant a perfect confidence  in it, or to settle  the question of pro-
 tracted pregnancy.  The  Edinburgh  Medical  Jurist  justly con-
cludes, by  stating that there  was not a single new fact  advanced
by the medical men, in elucidation of the subject at issue ; and the
reviewer smiles, and  " wonders  at the want of knowledge of the
witnesses, who appeared to  be  unacquainted  with the  nature of
legal evidence; and neither  their evidence, nor that of  the other
side, was sufficiently accurate, in  not being deduced from physiolo-
gical science, which,  however,  in the present  state of medical
knowledge  on the question, could not perhaps be more accurate."
On the whole, the weight of the testimony  was in favour of the
advocates of protracted pregnancy ; but the mother having cohab-
ited with another, proved her incontinence, which  fact  influenced
the House of Lords  against the legitamacy.   After all, the subject
remains as obscure as before, and will require much more scientific
medical evidence to decide it one way or the  other.
   Dr. Dewees relates a case of  a lady, whose  husband was ab-
sent on account of embarrassment of his affairs.  He returned one 
           PARTURITION IN  A STATE OF NATURE.          95

night clandestinely, had intercourse with his wife, whose menstrual
period was expected within a week, and  occurred, yet she  was
delivered  in  nine months and thirteen  days from the coition.
(Work, 1825.)—The question of protracted  gestation,  and more
especially the Gardiner Peerage case, was discussed at the  West-
minster iMedical Society, in December, 1829, when Dr. Granville
adduced the following authors, in favour of the affirmative side of
the question.   Among the ancients, Hostius, (Horstius?) Sylvius,
Harvey, Mauriceau, Levret, Lieutaud, Heister, Dulignac, La Cla-
ture, Benedictus,  Petit,  Smellie, and W. Hunter.  Among  the
moderns are Osiander, Fodere, Schoreider, Lentosseit, Spregnel,
Adelon, Bardt,  Capuron, Orfila, Burns, Desormeaux, Dewees,
Hamilton  of Edinburgh, and 3Ierriman.   I have already mention-
ed many others.  On the occasion in question, Mr. Chinnock re-
lated  a case of a  female  who  menstruated October 14, and  had
intercourse with her husband on the 29th.  She was delivered on
the 20th of February, a  space of two hundred and ninety-eight
days after the connexion, but labour commenced three days previ-
ously.  1 mentioned the cases narrated in the extract from  my
work  inserted  above, and Dr. Ley and 31r. North took the same
side of the question.   The  whole of the  Society were of  the
same  opinion, with one or two  exceptions.   (Lond.  3Ied.   and
Surg. Journ.,  1830, vol. iv ;  3Ied.  Gaz., 1830, vol', v.)—There
is no  doubt but the  weight of medical authority,in ancient  and
modern times, is  in  favour of protracted  pregnancy ;  but  in  the
present state  of  science it is impossible to assign  the exact limit.
The  law  of this country assigns  no limit to uterogestation ;  the
law of France limits it to three hundred days, or ten months,  and
allows legitimacy  to be contested after this period.   (Velpeau.)

Article  V.—Tocology—Parturition—Natural Labour.
   Tocology, partus, puerperium,  couches, accouchement, parturi-
tion, is a function which consists in the expulsion of the foetus from
the womb, and comprises the series of phenomena which immedi-
ately  precede, accompany, and follow the exit of the infant.   It
is spontaneous or  natural, which  will  now occupy our attention.
Artificial, manual, or instrumental, which will be considered un-
der the head of gynaeco-pathology.  It is uniparous or multiparous,
as in cases of  twins,  triplets, he.
  Happily for humanity, the process of labor is safe and free from 
96
GYNJEC0-PHYSI0L0GY.
danger, in a vast majority of cases, especially where females live
according to nature's primitive laws ;  but among the  higher and
middle classes, where these laws are violated or forgotten,  where
the constitution is impaired by the luxury and  dissipation of mod-
ern times, the  process of child-bearing is attended with consider-
able danger, both before  and after it is completed.   These obser-
vations are equally applicable  to  the lower classes in our cities,
whose customs, habits, pursuits, and  constant inebriation,  render
them liable to many accidents during parturition, and to  a  vast
number of inflammatory  and febrile  diseases after delivery. The
universal  testimony of all unprejudiced medical  men confirms the
truth of this assertion.   It is well for suffering humanity, the pro-
cess of parturition may be greatly accelerated, and the greatest of
mortal suffering relieved by the skilful exertions of the  obstetri-
cian, and  with the most perfect safety to the parent and offspring.
It is well known that the very presence of  a medical  man  will of-
ten  afford relief, without the performance of any manual  opera-
tion  whatever.   The confident  assurance  to the patient of her
safety will inspire that balmy hope,  which will hasten  delivery
much better than any other means.   On this account there are
few intelligent females who do not prefer medical attendance du-
ring labour to that of any other description.   This is the  casein
every civilized country,  as women are well aware of the superior
knowledge which medical men possess of their constitutions ; and
hence, in modern times,  we observe  a wise and judicious  prefer-
ence given to male obstetricians,  and midwives  are scarcely ever
exclusively employed, unless among the  ignorant or lower classes.
   Among the savage tribes of all nations, the process of labour is
perfectly safe and expeditious.  This universal declaration of trav-
ellers authenticates  this position.   We  also find that many emi-
nent medical  men  have practised  obstetric  medicine for many
years, and had  no occasion to use instruments.  Dr. Dewees de-
livered  three thousand  women, and  did not meet  with  one case
that  required the crotchet.  Dr. Bland assures us,  that  out of
one thousand eight hundred and ninety seven women, delivered in
the Westminster Lying-in Hospital, one thousand seven hundred
and ninety-two had natural labour; and Dr. Smellie was of opin-
ion, that  out of one thousand  cases,  eight only  would require in-
struments.  Dr. Hagen, of Berlin,  delivered three hundred and
fifty  patients, and employed  the  forceps ninety-three times, and 
PARTURITION IN A STATE OF NATURE.          97
 the crotchet twenty-eight,  and no less than twenty of his patients
 died.   Dr. Clarke,  of the Dublin Lying-in Hospital informs us,
 in  the first  volume of the  Transactions of the  Dublin College of
 Physicians, that in seven hundred and twenty-eight cases of labour,
 the forceps were but once employed ; and he  is of opinion, that
 once in one thousand times would be  nearer the point of accura-
 cy.  He further states, that in ten thousand cases there  were but
 forty-nine examples  of  deformed pelvis ; and he never saw a case
 of spontaneous evolution, or the passage of the full  grown  infant
 doubled,  as described by  Dr.  Denman,  and  Dr.  Douglass, of
 Dublin.  I have met with two cases of spontaneous evolution  at
 the full time.   In ten thousand cases he met but four instances of
 sloughing of the bladder, or the vesico-vaginal fistula ; and yet I
 solemnly  aver, that I have met as many  examples of it, in  ten
 year's private practice.   In ten thousand three hundred and eighty
 seven cases, the placenta was retained but twenty-one times, which
 required the introduction of the hand for its extraction.  This re-
 port of obstetric practice is one of the most valuable in  the med-
 ical annals of this or any other country.   Again, if we peruse the
 bills of mortality in London, we will observe  that twenty thou-
 sand deaths occur annually ;  and  out of these two hundred and
 thirty in child-bed, and after delivery.   While  at the Hospice de
 Maternite, at Paris,  Leroux reports the deaths  to be one in twen-
 ty-five, in the year  1817 ; and Lobstein  states, that in  the civil
 hospital at Strasbourg,  there  were seven hundred and seventeen
 deliveries,  and sixty-one deaths.   (Observations  des  Accouche-
 mens.)—In  the Lying-in  Hospital at  Florence, there were five
 hundred deliveries, four deaths, five hundred and six  children, six
 twins, four hundred and eighty-five head or natural cases, two hun-
 red and seventy-nine males, and two hundred  and twenty-seven
 females ; three hundred delivered by day, two  hundred at night;
 twenty-one  births premature ;  one child weighing sixteen pounds
troy weight, and  only  three  cases  of deformity  in the  whole.
 (Lond.  Med.  and Phys. Journ., 1824, vol. lii. p.  438.)—Dr.
 Smellie reports, in one thousand cases, that there were nine hun-
dred and twenty natural, seventy laborious,  and  ten preternatural.
Dr. Bland reported,  that out  of one thousand eight hundred and
ninety-seven deliveries in the Westminster Lying-in Hospital, one
thousand seven hundred and ninety-two were natural, sixty-three
preternatural; and nearly the same proportion  in the British Ly-
            13 
98
GYN^ECO-PHYSIOLOGY.
ing-in Hospital.  In  two thousand eight hundred and sixty-four
cases at the Hotel Dieu at Paris, there was but one case of Caesari-
an section.  Baudelocque reported, that at the  Hospice de  Materni-
te, in Paris, there were twelve thousand six hundred and five delive
ries, twelve thousand seven hundred and  fifty-seven infants, twelve
thousand one hundred and eighty-three  head presentations, three
of the knee, thirty-six of the navel-string, and one Caesarian sec.
tion.  The frequency of  preternatural to natural labour is estima-
ted at about one in seventy or eighty.   From these reports, and I
might have multiplied them  to  an indefinite  length,  we perceive
that natural labour is by  far the most common ; but  yet the pre-
ternatural  or untoward, may be the first we might have to encoun-
 ter.  Various, indeed, were the opinions advanced as to tht cause
of the  time of  utero-gestation being  limited to nine  calendar
months.   All these opinions  are purely speculative and theoretical,
and are  unsatisfactory and  uncertain.   I think  they all resolve
themselves into one—that proposed by  Avicenna, namely, " that
 the appointed time having arrived, labour comes  on  by  the com-
 mand of  God."  This exposition  will  also  enable us to under-
 stand protracted  pregnancies.  The  opinion that natural labour
 should be easy and expeditious, has been held since the  sixteenth
 century, when Rhodion,  the first popular writer on midwifery, re-
 marked, " that in all labours the birth should be easy and instan-
 taneous, or in a single pain or two ; " and Raynold, the  first Brit-
 ish writer on the subject,  translates the passage,  " that if the
 byrthe be natural, the deliveyrance is easye  without longe tarrey-
 enge or lookynge for it." (Byrthe of Man  Kynde,  b.  ii.p. 48.
 A.  D.  1540.) Diodorus  Siculus  informs  us, that in his time the
 Corsican  women had no care or  attention paid them  in child-bed,
 and that as soon as they were well, the husbands were put to bed,
 and nursed in their place.  (Biblioth. Hist. fol. lib. v. p. 341.)—
 Strabo gives an account of  a similar custom prevailing in Spain, in
 his time.  (Rerum Geograph, fol. lib. iii. p. 165.)—It  is little to
 our purpose  to inquire into a custom so absurd, but it affords us
 proof, that woman in a state  of natural simplicity  did  not suffer
 severely in labour.
    In a state  of nature  there  is  little solicitude  entertained, and
 very little preparation made for delivery.  It appears from the ac-
 counts of various writers, that  a seclusion of a few hours in some
  retired spot, or in a rudely  constructed hut,  is all that women liv- 
             PARTURITION IN A STATE OF NATURE.          99

ing in a state of quiet simplicity require, for the completion of their
deliveries ; and after  some slight  ablutions, if religious customs
do not ordain a separation, they almost immediately return to their
ordinary states of life.  Bruce, the unfortunate but deeply lamen-
ted Abyssinian traveller, informs  us  that the women of Galla, a
nation near Abyssinia, do not confine themselves, even a day after
labour, but wash  and return to their work immediately.  (Travels
to discover the Source of the Nile,  b. ii.  p. 2.)—Cangiamilia
gives a similar  account of the Abyssinian women, who retire by
themselves, and are delivered with  great  ease   and expedition.
(Embryologia Sacra, p. 113.)—The same simplicity, expedition,
and  freedom of danger, attend the process of labour  among the
natives in most parts of Asia, Africa, West-Indies, and America.
Hennepius states, that the Spaniards in the Brazils perform the
duties of midvvives for their teeming consorts, receive the infant,
tear the navel string, and wash  and  paint it.  The woman goes
and  washes  herself, and immediately sets about  her work ; and
he records the same of the Livonian  peasants in North America.
(Ceremonies and Religious Customs of various Nations, vol. iii.
p. 30.)
   Sagnier and Brisson assert  that the Moorish women on the coast
of Africa have no  midwives, but are laid  on the ground  under
a tent, and the day after delivery, depart to encamp fifteen or twen-
ty leagues distant.   Voyage to Coast of Africa, p.  494.—Dr.
Hutchinson,  the  quandam editor of  the Medical and  Physical
Journal,  has  included the  unintellectual Irish, as being delivered
without any  preparation or  concern;  but  that  is not  the  fact.
Dr. Power has cut the Gordion knot, by asserting " that women
in labour are free from pain  in the tropical climates, in Persia,
Africa, Cape of Good  Hope, Abyssinia, Tonga Islands, ISexv Ze-
land, Greenland,  and America;"  but no taveller has asserted this,
at least so far as my researches enable me to state;  and how could
any traveller ascertain the fact, for surely none of them attended
parturient women ?
  Dr. Dewees of  Philadelphia, was of Dr. Power's  opinion,
that natural labour is not attended with pain, among those who live
according to Nature's laws. (Lond. Med. and  Phys. Jour., 1819.
Review of his first  work.)—But the Doctor  in  his work, 1825,
speaks of pain and suffering.  Dr. Power, in his second edition,
1823, attempts to prove that there is  no pain in natural labour, nor 
100
GYNJECO-PHYSIOLOGY.
any uterine contraction during severe pain.   This gentleman ap-
pears to have forgotten the  primeval malediction, which for ever
doomed the human  female to the agonies  of child bed ;  and I
am not aware that there is another accoucheur, in this or any other
country, who coincides in his opinion.   How  unjustifiable  for all
profane and medical historians, in every age, to have  described the
painful process  of parturition.  I  believe that the  quickest and
most easy labour is attended with more or less pain  wherever it
happens.   I need scarcely remark,  that in  all countries where a
high degree of  civilization prevails, the parturient process excites
much attention, and is conducted with  great care; and the  annals
of mankind and medicine fully confirm the truth of this assertion.
If the converse held  good,  there would be no need of medical
practitioners being engaged as obstetricians ; and their voluminous
writings on obstetric medicine,  from the  time of Hippocrates to
the present  period, would be equally unnecessary.

              Section 1.—Parturition in general.
   Parturition usually occurs at the  expiration of the ninth  calen-
dar month, or two hundred  and  twenty-fifth day ; but the period
varies very much with different individuals, as well as  with domestic
animals.  This was amply attested in the article on duration of utero-
gestation.   The exact moment of conception cannot be determin-
ed ;  the date of it is differently estimated by  women and medical
practitioners.   Some reckon  the date of conception  from the sec-
ond  week after the last menstrual evacuation, others  from the time
when the next  appearance of the secretion ought to occur.  Again,
it is confidently  asserted by Dewees  and Duges, that  menstrua-
tion  may occur once after conception, and others say during preg-
nancy.   (Vide p. 32.)—The exact duration of utero-gestation is
not ascertained, but is limited by the  French law  to  the tenth
month ; while  in this empire there  is no limitation.  In general,
an infant born before the seventh month does not survive ; but Dr.
Rodman, of Paisley, recorded an instance  in which one of five
months was reared.   When the foetus is expelled before the sev-
enth month of utero-gestation, the delivery  is  called abortion;
when after the eighth month it is designated premature labour.
   Remote causes of parturition.—The causes of parturition have
occupied physiologists of  all ages, some of  whom ascribed them
to the foetus, to the uterus, to the abdominal muscles and diaphragm. 
PARTURITION IN  GENERAL.              101
Hippocrates and the ancients held that the foetus, like the chicken,
ruptured its membranes when capaule of independent existence ;
but this idea is refuted by the facts of abortions, and of delivery
when the foetus is dead, or after the death of the mother.   Again
it has been ascribed to the violent motions of the infant excited by
hunger, by a desire to respire and to expel the meconium ; but  a
dead foetus is not retained longer than a living one.  The opinions
of Lovvder, that the uterus admitted of a certain degree of disten-
tion, and of Levret, Baudelocque,  Desormeaux, and others,  that
the uterine fibres were developed  more  than the  cervix, do  not
explain the case  labour.   All explanations  as yet offered are ob-
jectionable, and of  these Avicenna's is the best.
   Galen, Fabricus, Harvey,  Levret, Lowder, he.  maintained,
that delivery was effected by the contractions of the uterus, of the
abdominal muscles, and of the diaphragm ; while Petit  contended
the uterine contractions alone were the true cause.  That this  is
the true cause  must be admitted, when we recollect the direct
observation afforded during  labour,  by placing the hand over the
uterus when contracted ; and also when  we refer  to the  cases  of
prolapsus uteri, in  which delivery  took place.   (Peu, Jalouzet,
Mme. Lachapelle,  Ashwell, and Kingdon, in Lond. Med. &Surg.
Journ.  1830. vol.  iv.)—Again women enfeebled by  haemorrhage
and a variety of diseases,  ascites,  asphyxia, mania, coma,  &.C.,
whose abdominal muscles  have nearly  lost their power of con-
tractility, are delivered in due time.
    Haller maintained  that the contractions of the uterus, aided by
those of the abdominal muscles  and diaphragm, effected delivery;
but he  ascribed too much power to the  last; for if these had  so
much to do  in the  phenomena, parturition should  be a voluntary
 and not an involuntary process.  Bourdon  explains the action  of
the diaphragm more correctly ;  he  observes  that during each  par-
turient  effort, the chest  is  dilated,  the lungs filled with  air, the
glottis is closed, the diaphragm  contracts, and gives the distended
lungs an immobility  and solidity a point d'appui, which enable
the muscles to act exclusively on the contents of the uterus.
    The uterus first  contracts, presses the infant into the pelvic cav-
ity, which excites  a heaviness, an irritation, and pain that produce
the action of the abdominal muscles, which are fixed to the pelvis
and chest, and  make considerable pressure on the fundus uteri.
The repeated contractions of all  these  muscles  gradually dilate
the os uteri, and finally expel the infant. 
102                   GYNJECO-PHYSIOLOGY.
   Such are the natural causes by which the process of parturition
is accomplished in a healthy stfbject; but these may be diminish-
ed or arrested by moral  affections, by a great variety of diseases,
which prostrate the vital powers, as fevers, phthisis, over  disten-
sion of the uterus, by dropsy  of the amnios, distended bladder,
preternatural presentations and deformities of the infant, deformi-
ties  of  the mother, rupture of the uterus ; in fine,  all causes of
preternatural labour, which will be hereafter enumerated, demand
the intervention of medical aid for the completion of parturition.
   Parturition divided into periods or stages.—The word labour
or travail is applied to the whole of the phenomena which  consti-
tute parturition or delivery.   As these phenomena  are  numerous
and  successive, they have been divided into classes, so  arbitrary
and conventional, that they are different in almost all works on ob-
stetricy.   Petit divided them into three classes, without assigning
their limits ;  Stein into four, as vaguely ;  Millot into four:  1. the
secret time  (temps secret),  in which women  experienced the va-
rious symptoms which are often manifest four, five, or six days at
the end of pregnancy; 2. the  stage which extends from the com-
mencement of pains to the effusion of waters (liquor amnii); 3.
commences after the rupture of the  bag  of waters ;  4.  when the
infant is on the point  of being  expelled.   Chaussier and Adelon
have five stages;  and Maygrier  four.  Denman's division  is the
best, and  is usually adopted in this country; it is as follows: 1.
stage is dated from the commencement of pains to the dilatation
of the os uteri, or discharge of the waters ; 2. extends  from this pe-
riod to the complete expulsion of the infant:  3. the expulsion of
the  placenta, or what is vulgarly called delivery.  This is the ar-
rangement of Hamilton, Burns, and  most British  obstetricians.
Desormeaux adopted  this arrangement without any regard to the
rupture of the membranes,  or amniotic sac.  Velpeau holds there
are two stages :  1. the complete dilation  of  the cervix uteri  ; 2.
the expulsion of the infant.   Duges, in his last edition, 1830, di-
vides the phenomena  into five  distinct periods  : 1.  precursory ; 2.
preparation ; 3. expulsion of the  foetus;  4. delivery  (expulsion
of the placenta) ;  5.  the consequences.  Dewees adopts the fol-
lowing division;  1. into nervous symptoms ;  2. into those which
affect certain organs besides the uterus, as  inclination to evacuate
the bladder, suppression  of urine, tenesmus ;  3. into those which
affect the uterus,  subsidence  of the uterine tumour, secretiou of 
PERIODS OR STAGES OF PARTURITION.          103
mucus, dilatation of the uterus and its alternate contractions.Blun-
dell  divides  the process of labour into two parts,  " the first of
which terminates with the birth of the child, and the second with
the expulsion of the secundines. "   It is unnecessary to multiply
the arrangements of authors to a greater extent;  and of all before
us, Denman's division is the best, which I shall follow.

First Stage or Period.—Precursory Signs of Parturition, Di-
   latation of the  Os Uteri, Rupture of the Amniotic  Sac, and
   Escape of the Amniotic Fluid.
   The process of parturition is sometimes completed without any
premonitory symptom ;  but this  is a rare occurrence, as we usu-
ally  observe  a series of signs, for two, four, six,  eight, ten,  or
twenty  days  before delivery.   In general the volume of the ab-
domen diminishes, the fundus uteri is depressed, the weight of the
uterine  contents is felt  much lower than usual, the external labia
are tumified by infiltration,  they become soft and sometimes pain-
ful ;  the movements  of the foetus  are stronger, there are pains
about the loins and pelvis, and a  frequent desire to evacuate the
rectum and bladder.  The  ligaments of the pelvic cavity are soft-
ened and relaxed,  and the patient  is fatigued in making  ordinary
motion.  A secretion of mucus takes place in the genital passages,
and escapes from the  vagina and vulva, which is designated " the
shoivs " by midwives.  The orifice and neck of the womb become
softer and dilated ; the  abdomen is hard  at intervals in all points,
which correspond  with  the uterus; at the same time the  orifice
contracts, and the  membranes  become tense, these contractions
are succeeded by relaxation of the abdominal parietes and os ute-
ri, the  latter  being dilated.   The recurrence of these contractions
and relaxations effect the expulsion of the foetus in the manner
hereafter mentioned.  These different phenomena vary in num-
ber,  progress, and  intensity in different cases,  and indicate in gen-
eral  a favorable termination.  The explanation of these symptoms
is  afforded by the change of the position of the uterus, the descent
of which into the pelvic cavity  causes pressure more or less in-
tense on the rectum, bladder, nerves, and vessels; and hence the
tenesmus and sharp cutting pains, the tumefaction of the labia and
the formation of mucus.   The precursory signs of labour vary in
duration from one  hour to a period of many days ;  when  they are
succeeded by spasmodic pains resembling colic, during which the 
104
GYNJJCO-PHYSIOLOGY.
uterus contracts and  descends into the cavity of the pelvis;  the
number, frequency, and duration of these pains are very variable.
In general, they are at first short,  continuing for a minute or two,
and recurring with the greatest regularity every fifteen or  twenty
minutes, but gradually returning at shorter intervals every ten,
five, or three minutes, and  finally they are continued.   During
these pains, the lips of the  os uteri become thin and effaced, and
the orifice forms a circle, in  which the amnios or membrane, which
surrounds the foetus, becomes engaged, is tense, and forms a soft
wedge, which assists in dilating the uterine orifice.   At this peri-
od women often become dejected, and apprehensive of danger or
of death, or they are silent or weeping,  and  often attacked with
shivering of the whole body.  Even the inferior animals  are de-
pressed, and refuse to eat or drink, at the approach of delivery.
  When  the  labour pains increase, the neck and  orifice of the
womb dilate, the  mucous discharge  is  streaked with blood, the
membrane surrounding the  foetus  descends, and is vernacularly
called " the  bag of waters" and the blood proceeds from the rup-
ture of the vessels of the membrane which attached it to the ute-
rus.   After  the  pain ceases, the  membranes and  head recede,
there is a period of tranquility until its return.   Each pain is fol-
lowed by the same series of phenomena,  and  by a remission  of
less and less duration.  The neck of the womb  gradually yields
by the contraction or shortening of the longitudinal fibres of the
body of the organ, the liquor amnii  and the  inferior part of its
membrane are  pushed downwards, the  dilation is  gradually but
steadily increased after each  pain, until the sides of the orifice  of
the womb rest on the parietes of the  pelvis, and thus afford suffi-
cient space for the escape of the  infant's head.  The membranes
are propelled more and more by each pain and by the pressure of
the foetal head, and sometimes through the vulva or genital  fissure,
which is a strong proof of  a natural well  conducted labour (Den-
man, Hamilton,  he.)  ; but, in general, the  membranes are rup-
tured in the  vagina during  the pain, a portion of amniotic  fluid es-
capes, and this is called " the breaking of  the waters, " by wo-
men and midwives.   When  this occurs, the first state of parturi-
tion is completed.
  During the progress of  this stage, and  according to the  intensi-
ty of the pains, a great general irritation occurs, women are irrita-
ble, restless, impatient, and  often  governed with difficulty; they 
             PERIODS OR STAGES OF PARTURITION.         105

cannot retain a certain posture, sometimes thirst and feverish symp-
toms supervene, and also nausea or vomiting; sometimes wild-
ness of countenance and delirium, or convulsions  appear.  This
stage  may continue from half an hour to six hours in general; but
I have known several cases in  which rupture of the  membranes
were not followed  by labour for three, four, five and six days.
   Second Stage or Period.  Descent of the Foetus, dilatation of
the external genitals, expulsion of the infant.—The duration of
this stage is usually from half an hour to three or four hours ; but
in some cases I have known  it continue  for  twelve and twenty-
four-hours, without any morbid  symptom.  In such cases the wo-
man is young, or advanced in life.   Again, this stage may be com-
pleted in half a minute, and by a single pain.
   After the rupture of the membranes, the foetal head presses up-
on the uterus ; pain is increased in intensity, as the uterus can
now act more powerfully upon  its contents,  a portion of the am-
niotic fluid having escaped.   The sufferings of the woman are  so
much increased that she seizes upon any fixed object, as the bed-
post,  an attendant, he. ; makes a full inspiration ; the face and
neck  become red or  livid,  the jugular veins  acquire an  enormous
size ; the carotids  pulsate  violently; the  pulse is strong and fre-
quent ; the face,  neck,  and  chest are  covered with perspiration,
or  signs  of cerebral congestion  may  become apparent  ; these
symptoms are diminished when the  uterine pain ceases.   Some-
times the pain diminishes in force, and the woman enjoys a tran-
quil sleep for a longer or shorter period.  On the   recurrence  of
each  pain or uterine contraction, a small quantity of amniotic fluid
escapes, until the head  becomes impacted in the orifice of the
womb.   The head is forced through the orifice into the upper
part of the vagina, which it gradually dilates, and then presses on
the rectum and bladder, causes strangury and tenesmus,  cramps
of the thighs and legs ;  the  faecal matter  is expelled, and the va-
gina is dilated in every direction.  The head approaches the infe-
rior strait or outlet;  the coccyx is  pushed backwards;  the anus
projects more or less; the perineum is elongated, forming " the
perineal tumour " of obstetricians ; the occiput presenting under
the arch of the pubes ;  the  vertex and forehead covered by  the
perineum, and the face in the  concavity  of the sacrum; and the
parietal protuberances resting  on the tuberosities of the ischia.
When the pain ceases, the  head  recedes,  and when  it returns,
            14 
106
CJYNJECO-PHYSIOLOGY.
the descent is greater, the labia more dilated,  and  much more of
the cranial surface denuded.   The reiteration  of the pains and
pressure at length overcome the  resistance of  the  perineum, and
render it as thin as parchment, when  it slips over the forehead of
the infant, and  the head is protruded through  the genital fissure.
After a few  seconds, though sometimes  not  before the lapse of
fifteen or twenty minutes, another pain  expels the body, which
is followed by the discharge of the remaining portion of the am-
niotic fluid.  The mechanism of labour has been already descri-
bed in the chapter onGynaecotomy, and here I need only observe
that the longest diameters of the  infantine head are adapted with
mathematical precision to those of the pelvis.   The nymphae are
not obliterated, according to some French writers (Velpeau, Du-
ges) ; the froenum labiorumis generally lacerated, and sometimes,
though 1 think very rarely,  the  perineum.  After the expulsion
of the infant, the genital orifice contracts almost to its natural size,
while the uterus  contracts,  and occupies the hypogastric region.
According to the obstetric writers of these countries, the forehead
of the infant is turned to either sacro-iliac symphysis, or is in the
transverse, or bis-iliac diameter,  and is  propelled into the pelvic
cavity, the long diameter (occipito-frontal) of  the  head being in
the short  (bis-ischiatic)  of the outlet, and  this  malposition is rec-
tified  by  the contractions of the uterus in the axes of the brim,
cavity and outlet, which produce a  rotary  motion of  the head,
which is further  promoted by the  pressure of the planes of the
ischia, and thus  is the face turned into the  concavity  of the sa-
crum, and the rest of the process completed in the manner alrea-
dy  mentioned.
   Third  Stage,  or period.    The expulsion of the Placenta and
Membranes ;  Secundines or After-birth.—The  expulsion of the
human  offspring  is the most painful  occurrence that can befal hu-
manity.   It is one of the most pitiable scenes and the most capa-
ble of exciting the  finest feelings of the  human heart.   To the
piercing cries, the excessive sufferings,  the transports of despair,
excessive efforts, inexpressible agonies, lacerating pains, which ap-
pear intolerable,  instantly succeed a delicious calm, full of charms,
says Professor Desormeaux, and which is only interrupted  by the
sufferer's  good fortune in knowing she is a mother.   The new-born
infant cries, and then all the  evils that  the mother had so cour-
ageously suffered are forgotten;  expressions of  satisfaction replace 
PERIODS OR STAGES OF PARTURITION.
107
those of pain ; the sobs of joy succeed those of despair, and excite
our greatest admiration for a sex which contributes so much to our
happiness.   This delightful scene is, however, of short duration ;
it is soon interrupted by the  recurrence of pain, arising from far-
ther contraction of the uterus, for the detachment and  expulsion
of the placenta and its membranes.  About a quarter of an hour,
or half an hour after parturition, the fundus uteri becomes painfully
contracted, presses upon the placenta and detaches it, and two  or
three pains are sufficient for the purpose, and are popularly termed
"afterpains."   The membranes are separated from  the  uterus
during labour,  and also the placenta  if the  process  is tedious.
The placenta is pushed into the vagina; the vessels which attach-
ed it to the uterus are closed by the contraction of the organ, and
by the total  obliteration of its cavity.  Haemorrhage is thus pre-
 vented.   The  placenta may remain a longer or shorter period in
 the vagina, in consequence of the contraction of the external parts
 but in general it  passes in the curved line traced by the three axes
 of the pelvis ;  it descends first downwards and then forwards, and
 we must bear this in  mind when we are called on  to extract  this
 body.  After the expulsion  of the placenta and membranes, the
 volume of the uterus is reduced by a firm  contraction, and can be
 felt, about the  size of a child's head, above the pubes, and is still
 attacked with pains,  which  may continue one, two, or three days,
 and cause an effusion of blood,  called lochia.  This  is the name
 given to the puerperal discharge,which continues for eight or ten days
 after delivery, becomes serous, and acquires a disagreeable odour,
 and ceases at the period already described, though sometimes pro-
 tracted to the  period of a month, or until the next menstruation,
 which is generally more abundant  than usual.
    Sometimes before, but generally not until  the second  or third
 day after delivery, the secretion of milk takes place ;  the  breasts
 become hot, tumefied, and painful, accompanied  with the usual
 symptoms of fever.  This state continues about twenty-four hours,
 when the  milk appears, which is at first yellow, oily, and of a dis-
 agreeable  taste, and  is technically denominated colostrum, and pur-
 ges the infant.   In some rare cases, the  secretion of milk does
 not take place, and the infant must be  nourished  by  other food,
 which is hereafter described.  Such are the  series of phenomena
 of natural parturition. 
108
GYN.ECO-PHYSI0LOGY.
          Article VI.—Arrangement of Labours.

         Section  1.—Of the Classification of Labours.
   Every writer and teacher  of obstetric  medicine has a peculiar
 classification of labours;  but, after all,  that  proposed by Hippo-
 crates is the best,  because most simple, viz. natural and preternat-
 ural.  To these two classes can all others be  reduced with ad-
 vantage.   Denman divided labours into four classes:  natural, dif-
 ficult, preternatural, anomalous, or complex ; and  to  these Blun-
 dell  adds  one  already included, namely, flooding.  Hamilton
 adopts the classification of Denman.  Burns divides them into
 natural, premature, preternatural, tedious, instrumental,  and com-
 plicated.   31.  Baudelocque divided labours  into  three classes;
 natural, manual, and instrumental.   Natural when no  assistance is
 required as in presentations of the vertex,  feet, knees, and thighs;
 unnatural, when the hand is required from vicious positions or ac-
 cidents during labour; and laborious, when  instruments  are re-
 quired from  diseases of the  sexual organs, monstrosities  of  the
 foetus, or impotence of the organism.   Dubois, Desormeaux, Bo-
 ivin,  and Lachapelle, agree with  Baudelocque ; but include face
 presentations among natural.   Conquest,  Dewees,  Blake, and
 Merriman, divide them into natural, or Eutocia and preternateral,
 or Dystocia; and the last-named author has  given the  following
 orders of the second class, in his learned and excellent Synopsis.
 Dystocia diutina, lingering  labour;  D. anenergica, powerless la-
 bour ; D. perversa, labour with  malposition of the  head ; D. am-
 orphica, labour with deformity of the pelvis; D. obturatoria, ob-
 structed labour; D. ectopia, labour with displacement of the womb;
 D. transversa, preternatural labour; D. gemina, plural labour; D.
 laceratoria, labour with laceration ; D. haemorrhagica, labour with
 flooding ;  D. syncopalis,  labour  with fainting;  D.  epileptica, la-
 bour with epilepsy ; D. inflammatoria,  labour with fever; D. re-
 tentiva, labour with retained  placenta ;  D. inversoria, with inver-
 sion of the uterus.   Power  has  added several other orders to those
 now described, and they might be continued, perhaps to thousands
 more, including each and  all the  causes that may impede labour.
 Ashwell divides these into three classes : natural, difficult or pre-
 ternatural, and complex.  D.  Davis  divides labours into natural,
 preternatural, complex, and  instrumental.   Baudelocque has giv-
en ninety-four positions of the foetus, and  Gardien  and  Capuron 
CLASSIFICATION OF LABOURS.
109
limit them to forty-eight;  but we know that almost every part of
the infant may be the presenting  part.
   Velpeau's classification is, eutocia or natural labour, which com-
prises all cases that terminate spontaneously, whether vertex, face,
or pelvis; dystocia or preternatural  labour, comprising all labours
which require succour.
   The following is the classification  which I  adopt in my lectures,
and  is  most accordant with nature and phenomena of  the parturi-
ent process.

               TOCOLOGY--PARTURITION--LABOUR.

   1st  Class:  Eutocia,  Natural  Labour.—2d  Class:  Dystocia,
Preternatural Labour.—3d Class: Chiragotocia,  31anual Labour.
4th  Class :  Organikotocia, Instrumental Labour.

           First Class :  Eutocia, Natural Parturition.

   Eutocia verticalis,  in which  the  vertex or crown of the head presents, the
passage of the mother being natural, and the process being completed from the
space of one minute to twenty-four hours.
Order  I. E. protracta, protracted labour, in which the process is not completed
            in twenty-four hours.
  II.    E. phrenalgica, in which the  labour ceases from mental affections.
  III.    E. anenergica, powerless labour, the process ceasing from want of
              power.
  IV.    E. gerriina, or twin labour.
  V.     E. triplex, when three infants are born,
  VI.    E. quadruplex, when four infants are born.
  VII.   E. quintuplex, when five infants are born.
  VIII.  E. sextuplex. when six infants are born.

          Second Class :  Dystocia, Difficult Parturition.

  Dystocia preternaturalis, preternatural labour, when any part of the infant, be-
sides the crown of the head, presents.
Order  I. D. frontalis, when the forehead presents.
  II.     D. occipitalis, when  the back of the head presents.
  III.     D. auralis,  when the ear, or side of the face, presents.
  IV.     D. facialis, -vhen the face  presents.
  V.      D. transversa, when the infant is across.
  VI.     D. nuchalis, when the neck presents.
  VII.   D. dorsalis, when the back presents.
  VIII.  D. abdominalis, when the abdomen presents.
  IX.    D. brachialis, when the arm presents.
  X.     D. manualis, when the hand presents.
  XI     D. glutealis, when the breech or buttocks presents.
  XII.   D. femoralis, when the thigh  presents. 
no
GYNJECO-PHYSIOLOGY.
Order XIII.  D. genualis, when the knee presents.
  XIV.  D. cruralis, when the leg presents.
  XV.   D. pedalis, when the foot presents.
  XVI.  D. placentalis, when the placenta, or after-birth, presents.
  XVII. D. funicalis, when the navel-string presents.
  XVIII. D. embryonosologica, when labour is  impeded by diseases of the in-
            fant, as dropsy in the brain or abdomen, hydrorachitis, &c.
  XIX.  D. gynaeconosologica, when labour is impeded by diseases of the mo-
           ther.
  XX.   D. amorphica, when labour is impeded by distorted pelvis.
  XXI.  D- ectopia,  when labour is  impeded by displaced uterus,  as inversion,
            antiversion,  retroversion, and lateral obliquity.
  XXII. D. vesicalis, when the bladder is prolapsed, or distended.
  XXIII. D. haemorrhagica, when labour is connected with flooding.
  XXIV. D. syncopalis, when labour is connected with fainting.
  XXV. D. convulsiva, when labour is connected with convulsion.
  XXVI. D. epileptica, when labour is connected with epilepsy.
  XXVII.  D.  febrilis, when labour in connected with fever.
  XXVIII. D. inflammatoria,  when labour is connected with inflammation.
  XXIX.  D. laceratoria, when labour is  connected with  laceration of the
            womb,  or vagina.
  XXX.  D. retentiva, when the placenta is retained.
  XXXI.  D.  pluralis, when labour is connected with plurality of children,

   Third Class, Chiragotocia, Parturition effected by  Manual
                            Operation.
  Manual labour, which is applicable in most of the orders of Dystooia, or pre-
ternatural presentations.

    Fourth  Class :  Organikotocia, Instrumental Parturition.
  Order I.—O. tractativa, where instruments are applied as tractors.
  Order II,—O. incisiva, where cutting instruments are required, as in embry-
otomy, gastro-hysterotomy, and gastrotomy.
   There are numerous  other varieties in  the class  Dystocia, be-
sides these enumerated; for example, the  face may be turned to
the sacrum, symphysis pubis at the brim,  or may be turned to the
side in the outlet of the pelvis.   The head may present with one
or both arms or legs, or with  the naval string.   Labour  may be
impeded  by too great distension of the uterus,  or partial action of
that organ, rigidity of the  membranes, imperfect discharge of the
waters, shortness of the funis, weakness of the constitution, want
of due irritability, by the rigidity  of the soft parts in advanced age,
scirrhus or adhesion of the os  uteri, by disproportion between the
dimensions  of the cavity of the pelvis, and the head of the child. 
CLASSIFICATION OF LABOURS.
Ill
original smallness of the pelvis, unusual size of the child's head,
as by disease; by suppression of  urine, stone  in  the bladder, ex-
crescences, and tumours in the uterus, ovaries, vagina, bladder and
rectum.   (See Gynaeco-pathology.)
   The part of the child which descends lowest into the pelvis, is
called the presenting part.
   The intention of manual operation is to  rectify the presentation,
and save both mother and infant; and that of using the first order
of instruments is the same :  while that of  using the  second,  is to
preserve the life of the mother or infant.
   The instruments now in use, which  are intended to save the life
of both mother and child  are, the short forceps, long forceps, vec-
tis or  lever, and blunt hook,  all  of which  act  on the  principle
of artificial hands or tractors.   Those in use for the safety of the
mother, at the destruction of the life of the  child,  are the perfora-
tor, craniotomy forceps, crotchet, and scalpel; and when the child
is to  be preserved at the  risk of  the mother,  a scalpel only is ne-
cessary for the division of the abdomen.   The last class are na-
med  incisive instruments.

       Section 2.—Eutocia—Parturition, Natural Labour.
   The parturient power is a property essential to the uterus, and
it may be exerted at any period  of gestation.   It  may also be ex-
erted by the womb, to rid itself of morbid formations.
   Numerous conditions are necessary  for the completion of  natu-
ral or spontaneous  labour.  The pelvis and genital organs of the
woman must be in  a healthy state; the head of the foetus must be
the descending or presenting part according to British writers;  it
is as  well as all parts of the body must not  be preternaturally en-
larged, as in cases of hydrocephalus ;  or ascites, hydrorachitis, the
existence of two heads on one trunk,  or two  trunks for one  head,
or the union of two bodies by the sternum  (as in the  case of the
Siamese twins,) or by the side or back (as in the case of the  Hun-
garian sisters, who  were exhibited in this city in 1723), or in the
various other examples of deformity related^in my paper on  mon-
strosities  in  the  London  Medical and  Surgical  Journal,  1830,
vol. iv.
   However numerous the impediments to natural labour, it occurs
most  frequently in a very large proportion of deliveries.  This po-
sition is admitted by alf obstetric writers ; but we have  always to 
112
GYN^CO-PHYSIOLOGY.
 remember, that the worst forms of preternatural labour may be
 met with by the young practitioner;  and hence the imperious ne-
 cessity of his  being competent to manage all cases.  In a former
 paragraph, p. 96,  I have given some clinical reports, shewing the
 comparative frequency of natural and preternatural labours ;  and I
 shall now add further evidence upon that subject.
   Merriman gives a table of one  thousand eight hundred caseSj
 one thousand seven hundred and forty six of which were natural;
 in one thousand six hundred and fifty-four, the vertex or crown of
 the head presented, in four the inferior extremities, in twenty-three
 the face, in forty-two the hips,  and in twenty-three there was plu-
 rality of infants.   Bland has recorded one thousand eight hundred
 and ninety-seven cases, of which one thousand  eight hundred and
 sixty were natural.  At  the Maternite of Paris, from 1791 to the
 end of 1811, there were twenty thousand three hundred and fifty-
 seven deliveries, of which twenty thousand one hundred and eighty-
 three were natural.  Madame Lachapelle had observed, in 1811,
 fifteen  thousand six hundred and sixty-two labours,  of which fif-
 teen thousand three hundred  and eighty were  natural, and  two
hundred and seventy-two difficult ; and from  January  1812 to
 December 1820, twenty-two thousand two hundred and forty-three,
 of which  twenty-one  thousand nine  hundred and  seventy-four
 were spontaneous, and two  hundred and  sixty-nine required the
 resources of art.   Clarke, of the Dublin  Lying-in  Hospital, has
 recorded a table of ten thousand three hundred and eighty-seven
 cases, of which nine thousand  seven hundred and forty-eight were
natural, that is, the head  presented, and  the  labour' terminated
within  twenty-four hours ;  of  these  seventy-one died ;  one hun-
 dred and seventy-four  had tedious labour, twenty-one died ;  for-
ty-nine were crotchet  cases, of these sixteen died ;  one hundred
and eighty-four presented by the feet, one  died ; sixty-one by the
breech, four died ; forty-eight,  the  superior extremity, six died ;
in  fourteen there  was  uterine  haemorrhage ; in four  the placenta
presented, there were  seventeen cases of convulsions before deliv-
ery, sixty-six  presentations  of the  funis,   seventeen born alive,
there were seventeen fontanelle, and forty-four face  presentations,
and these did not  give rise to  tedious labour; one  hundred and
eighty-four were twin cases.   (Transactions of Dublin College of
Physicians, vol.  i.  p.  367.)—Granville reports six hundred and
forty cases, which  occurred at  the Westminster General Dispen- 
         EUTOCIA--PARTURITION,  NATURAL LABOUR.      113

sary in  1818, of which six hundred and  nineteen were natural,
thirteen manual, and eight instrumental; two vertex cases requi-
red forceps;  one face, one ear, one  arm, two  nates, three feet,
two placental; proportion of forcep cases, one in one hundred and
twenty-eight;  of perforator  cases, one in two hundred and thir-
teen ; of placental, one in  ninety-two ;  proportion of manual la-
bours to the sum total, two in one hundred ;  of instrumental, one
in eighty.   (A Report of  the Practice of Midwifery at West-
minster General Dispensary during  1818.)—Cusack gives a re-
port of three  hundred and ninety-eight deliveries in the Welles-
ley Female Institution in Dublin in  1828, of which one required
the forceps, two the perforator, twelve were presentations of the
superior extremities, and eight of the breech and inferior extrem-
ities.  (Dublin Hospital Reports, 1830, vol. v.)—Gregory gives
a  report of the Coombe  Lying-in  Hospital,  in  the same work,
and of six  hundred and ninety-one cases, six  hundred and forty-
five were  natural, two face, fourteen  breech, seven  feet, three
arm, one shoulder, one funis, twelve twin cases.  Boer gives an
account of nine hundred and fifty-seven cases, which occurred in
the Obstetrical School of Vienna, from  September  1787 to the
same month 1790, of which seventeen required turning, the  for-
ceps, and perforator;  in 1791, nine hundred  and fifty, eighteen
dystocial ;  in  1792, fifteen  hundred,  eight turning cases, and seven
forceps ;  from January 1801 to December 1802, of two thousand
two hundred and thirty-four cases, thirteen required turning, ei^ht
the forceps, and two  the perforator; from January 1803  to De-
cember 1805, of two  thousand three hundred and ninety-nine de-
liveries,  five turning,  eleven  forceps, and  three perforation ; in
1806, of two  thousand and thirty  cases, seven turning,  two for-
ceps, and one perforation.   Naegele records one thousand two hun-
dred and ninety-six cases, of which one thousand two hundred and
thirty were natural, sixty-four unnatural, which is a proportion of
one in twenty ; while that  of Boer, of nine  thousand five hun-
dred and ninety, two  hundred have required turning,  the forceps,
and perforator,  which is one in  ninety-five.  Duges  informs us,
that during a period of eighteen years, thirty-seven  thousand  one
hundred  and  twenty-six  deliveries  occurred  in the Maternite of
Paris ; the head presented  in thirty-five thousand three hundred
and  seventy-five cases; in  twenty-seven thousand four hundred
and forty-three, the back was forward and to the left, or in other 
114
GYNJECO-PHYSIOLOGY.
words, the forehead was to  the  right  sacro-iliac symphises; to
the opposite symphisis in seven thousand five hundred and twelve ;
the occiput was to the right in two hundred and seventy-six, and
to the left in  one  hundred and forty-four ; the  pelvis presented in
one thousand three hundred  and ninety,  to the left in eight hun-
dred and fifty-seven, to the right in four hundred and ninety-four,
anteriorly fourteen, posteriorly  twenty-six ;  the face  in one hun-
dred and seventy-five, to the left ninety-nine, to the right seventy-
six ; the right shoulder in one hundred and three, anteriorly in fif-
ty-seven, posteriorly forty-six ;  left shoulder, eighty-three, anteri-
orly fifty-two,  posteriorly thirty-one.   According to  this  author,
the classes of labour are five—vertex, pelvis, face,  right shoulder,
left shoulder; the species fourteen.   Lovati, of Pavia, states,that
of sixty-seven cases, twenty-two required succour.  From all the
reports I have been able to examine, it appears that practitioners
have recourse to art in the proportion of one  in six,  ten,  twenty,
thirty, forty, fifty, sixty, seventy,  eighty, ninety, and one hundred
cases.   It also appears  that dystocial labours  are  more numerous
in public charities than  in  private practice;  and yet that fewer
operations are performed in those  institutions than  in civil life, be-
cause  nature is allowed fair  play by men  of science.   On the
other hand, how  many, imprudent, rash, ill-timed, and unnecessa-
ry operations are performed in  private practice, where men, from
ignorance, or a desire to boast of difficult cases, are so fond of op-
erations.  I  believe with my distinguished friend, Dr.  Blundell,
that it would be much better for humanity had no  obstetric instru-
ments ever been  invented ;  and with Denman, " that the abuses of
the  art were more numerous  and grievous  evils than  all the im-
perfections of nature."   Such are the causes  that render difficult
labours more common in civil than in hospital  practice.
   From the preceding reports it  is manifest that the infant in the
natural labour  presents by  the head, and all  other presentations
may be fairly considered unnatural, or anomalous. This fact has
been attested from  the  earliest cultivation of medicine,  and led
Hippocrates and his eminent successors to give  the name of nat-
ural labours  to those  in which the head presented, and preternat-
ural to those by  the feet, breech, or knees.   Some of the French
writers hold a labour to be  natural when it is completed by nature
or spontaneously, and hence include those of  the  feet, knees, and
breech ;  but they loose  all  sight of the fact that in these cases the
infants are generally born dead. 
MECHANISM OF NATURL LABOUR.
115
      Section 3.—Of the Mechanism of Natural Labour.
   Labour may terminate naturally by the presentation of either
the head, or the feet, or the knees, or of the breech ; but the three
last presentations are so rare, they are excluded from the class of
natural labours by British writers, and also by Velpeau.
   Of Natural Labour by the  Head.—Natural  labour  by  the
head may take place in the four positions which correspond to the
oblique diameters of the pelvis ;  the position of the woman on the
back.

             First Position.   Principal Relations,
   The occiput answers to the left cotyloid cavity,  or acetabulum,
and the forehead to the right sacro-iliac  symphisis.  The  posteri-
or surface of the  foetus looks forwards and  to the left;  the anterior
looks backwards and to the right; the feet are towards the fundua
of the uterus.
   Mechanism.—Pressed by  the contractions of the  uterus, the
head  is bent forward on the chest, and its occi pi to-mental diame-
ter becomes parallel to the axis of the superior strait.  It thus trav-
erses  the whole cavity of the pelvis; but, arrived near its  inferior
strait, it meets with the inclined planes,  which give to it the rota-
tory motion by means of which the occiput is at length placed un-
der the arch of the pubis,  and the face in  the hollow  of  the sa-
crum.   Then the largest diameter of the  head is in  conformity
with the largest diameter of the inferior  strait, and there is no op-
position to the escape to this  part of the child, but the resistance
from the  external  parts of generation.   Continually pressed by
the contractions of the uterus,  the head advances further and  fur-
ther, and thus gradually effects the dilatation of the vulva;  but af-
ter each pain  it reascends,  more or  less,  into the cavity  of the
pelvis.
   At  length, after a labour more or less  protracted, the resistance
from the external parts of generation being  overcome,  the head
escapes through the genital fissure.   At this moment the  occiput
ascends under the arch of the pubis,  and the different  points of
the face appear in front  of the  posterior commissure.  Having
become free, the head resumes its  relations  with  the trunk;  the
occiput is directed towards the groin of the left side, and the  face
towards the posterior and internal part of the right thigh.  This
movement of replacement  has nothing in it surprising, since the 
116
GYNJECO-PHYSIOLOGY.
trunk has not participated in the  movement of rotation which the
head has experienced, in order to escape the inferior strait.
   The shoulders, obliquely engaged at the superior strait, traverse
the cavity of the pelvis, and when  they are arrived  at the inferior
strait they meet with the inclined planes, which gives  to them the
same rotatory motion as to the head ; the right shoulder is brought
under the arch of the pubis, and the left into the concavity  of the
sacrum.  At the same  time the  bead  changes its  relations, the
face gradually turning to the middle and internal part of the right
thigh, and the occiput to the middle and internal part of the left
thigh.  The shoulder, which is   behind, constantly  receiving the
contractions of the  uterus,  soon  appears at  the vulva, which  it
passes, whilst that  which  is under  the  pubis serves as a point of
support.
   When once the shoulders are  without, the rest of the body  is
expelled with great rapidity, which is  easily explained, since the
parts of  the foetus  become  smaller, and as the passage has  been
dilated by more voluminous parts.

            Second Position. Principal Relations.
   The occiput answers  to  the right cotyloid cavity, and the face
to the left  sacro-iliac symphisis.  The posterior surface of the
foetus looks  forward and to  the right, and the anterior backwards
and to the left;  the  feet are  to the fundus of the womb.
   Mechanism.—The mechanism of the second position  is  com-
pletely the  same as that of the  first,  with the exception of the
movements of rotation being in an inverse sense.

             Third Position.  Principal Relations.
   The occiput  answers  to the right sacro-iliac  symphisis, and the
forehead  to the left  cotyloid cavity.   The posterior part of the in-
fant is directed  backwards  and to the  right, and the anterior for-
wards and to the left.  The feet  are to the fundus of the  uterus.
   Mechanism.—The mechanism  of natural labour in this third po-
sition differs but little from  the mechanism of the first, since the
same diameters  of the foetus are found to correspond to the  same
diameters of the pelvis of the mother.
   Thus,  at the superior strait, the  head is bent on the chest, the
occiput escapes first into the pelvic  cavity.   Arrived near the in-
ferior strait,  the head  meets the  inclined planes which give to it 
MECHANISM OF NATURAL LABOUR.
117
the rotatory motion ;  the occiput glides on the posterior and right
lateral  inclined plane,  in order to place itself in the hollow of
the sacrum, while the face slides on the  anterior and left lateral
plane, to place itself  under the arch of the  pubis.   The occiput
then receiving  all the  contractions  of the  womb, traverses the
hollow of the  sacrum, of the  coccyx, and perineum, at the  same
time that the  face reascends  into the   pelvis, and is  bent  further
forwards on the chest.   The occiput soon appears at the vulva,
which it gradually dilates ; after each pain it reascends more or less
into the hollow of the pelvis.   At length the resistance offered b-
the external parts of generation  being overcome, the occipital
region of the head escapes through the genital fissure, the forehead
resting  on the  posterior commissure,  and the different points of
the face disengage themselves  from  beneath  the symphisis pubis.
   Having become free, the head of  the foetus resumes  its natural
relations with  the trunk, the occiput  answering to the posterior
and internal part of the right  thigh, and the face to the groin of
the left side.
   The shoulders, obliquely engaged at the superior strait, traverse
the  cavity of  the pelvis.  Arrived  near the inferior strait, they
meet with the inclined planes, which  give to them a rotatory motion.
The right shoulder is placed in the  curve of the sacrum, and  the
left shoulder under the arch of the pubis.  The head at the same
time changes its  relations, the  face looking directly towards the
middle part of the left  thigh, and the occiput to  that of the right
thigh.
   The shoulder, which is behind, receiving all the contractions of
the womb, escapes the first,  whilst that situated under the  pubis
serves to it as a point of support.
   The shoulders being without, the rest of the foetus follows with-
out difficulty.
   Note.  This third position is sometimes naturally  changed into
the second ;  this favourable change  takes place when the rotatory
motion impressed on  the foetus is suitably directed.

            Fourth Position.   Principal Relations.
   The occiput answers to the left sacro-iliac symphisis, and the
face to the right cotyloid cavity.  The posterior part of the  foetus
is directed bacwards and to the left,  and the  anterior part forwards
and to the right.    The feet are to the fundus of the  womb. 
118
GYNJECO-PHYSIOLOGY.
   Mechanism.   The mechanism of the fourth position is entirely
the same as that of the third, if it does not happen that the rotato-
ry movements are made in an inverse sense.
   Note.  This position may naturally change  itself into the first.

Section 4.—Duties of the  Obstetrician  in the First Stage of
   Labour—Dilatation of the  Womb, and the Rupture of the
   Membranes.
   The first  rule to  be  observed by  the practitioner  of obstetric
medicine is, to obey the summons to give his personal attendance
to a parturient female, as soon as possible.  This  duty admits of
no compromise, for it is of the first importance to ascertain the pre-
senting part, before the disruption of the  membranes ; because, if
preternatural, it can be more easily rectified before the completion
of the first stage;  for in such case, the practice is to  rupture the
membranes, when  the os uteri  is sufficiently dilated, to seize on
the feet, and deliver the infant by the operation of turning.  If
the membranes have burst, the uterus is in close contact with the
body of the infant ; and if the pains be violent, as it mostly hap-
pens,  the operation of  turning cannot be performed, as the  womb
would be lacerated, which is a very fatal  occurrence.   Again, an
early  examination is most necessary, as flooding may destroy the
patient, or the  feet of the infant may  be expelled,  the body re-
tained in the vagina, and such pressure made on the navel string
as to impede the circulation of the blood between the mother and
child, and kill the latter.
   The obstetrician, on his arrival, should  ascertain all delicate  in-
quiries from the nurse or other female  attendant, and not  in the
sick chamber.   He should learn the duration of labour, the state
of the bowels, and the history of the case, and impress the neces-
sity of admittance to the patient as soon as possible.  After ad-
mission into the sick chamber, he should approach the patient with
his countenance contemplative, cheerful not grave or melancholy ;
his look pleasing, mixed with mildness and humanity, and expres-
sive of a sincere desire of affording her alleviation.   He ought to
be polite and attentive, never proud, insolent, nor  haughty,  which
would alarm the patient,  who is  generally  timid  and dejected.
There should be nothing indecorous in his aspect or conduct, no-
thing  rough or uncouth.   He should display those good manners
and politeness that characterise the well-educated medical practi- 
MECHANISM  OF NATURAL LABOUR.
119
tioner and the polished gentleman.  Sympathy engages the con-
fidence and affection of the patient;  she feels the approach  of the
practitioner, who displays it, like that of an angel;  while that of
an unfeeling man, as  of an executioner.  Of  all the diseases in-
cidental to humanity,  those of the  female  are most deserving of
sympathy  and attention.  The weakness and peculiar delicacy of
her constitution call forth our greatest tenderness and compassion,
and on no occasion so powerfully  as in  the  agonies of child-bed,
when she  is stretched upon the rack on which she is laid by na-
ture.   On entering the chamber, the practitioner should approach
the patient with all  the mildness and amenity of manners he may
possess, and assure  her, that from the history he has heard from
the  nurse, he is perfectly confident of her  safety.  After two
 pains have occured, he should pass his hand over the bed or body
clothes on the abdomen, in order to ascertain whether  there  be
pregnancy ; for it has often happened that females and their med-
ical attendants have expected  delivery for days, when there was
no  pregnancy.  Drs. Hamilton and Blundell record such  cases,
and I can bear testimony to the same fact.  I have known a med-
 ical man remain four successive days and nights in  attendance on
a patient, who was  not pregnant, so confident was he of delivery ;
yet the pains gradually ceased, and in  eight years afterwards she
expelled an immense quantity of hydatids  from the uterus.  Af-
ter having ascertained the fact of pregnancy, we should next pro-
ceed to discover all the essential characters of labour,  by an ex-
amination through the vagina,  called by the French " the touch."
Before we proceed to examine, the proposal ought  to be  made
through the nurse,  its importance strongly dwelt  on, the length of
time the  labour has continued,  the urgency of the pains, and,
above all  the  necessity of ascertaining whether the labour be nat-
ural.  Some women  of high  delicate feelings will not  permit  an
examination, until the labour becomes severe : but then we need
little persuation or reasoning, to induce them to comply.   A med-
ical  friend informed me, that a patient, on his entering her  cham-
ber, covered  her face with her hands,  and exclaimed, " You shall
not touch me  ; I'll  loose my life first."   He withdrew;  but in a
short time, when the  pains  became severe, he was  anxiously re-
called.  In such cases, an intelligent nurse will be able to  report
whether the labour  be natural  or  not.    Other women are greatly
terrified at the approach of the medical attendant, if never  atten- 
120
GYNiECO-PHYSIOLOGY.
ded previously by an accoucheur; they are alarmed,  lest they
should experience violence  and harsh treatment, which are now
unknown;  and these foolish fears are carefully  fomented, rather
than appeased, by the nurse, whose peculiar province she consid-
ers invaded.   This is mostly the case in first labours, for  women
once attended by a medical man, who can never be guilty of rude-
ness, violence or harsh treatment, without a gross dereliction ofduty
and breach of established obstetric  rules, will never submit to the ig-
norance  and  temerity of female attendance afterwards.  Surely ev-
ery educated female must  be convinced, that an illiterate and igno-
rant nurse knows nothing  of the  mode  in  which  nature  accom-
plishes the wonderful mechanism  of labour.   How then can  she
render assistance in  cases of difficulty  and danger ?   What idea
can such a one form of the almost  innumerable difficulties that
may impede  labour ?   Hence  the extensive employment of med-
ical practitioners in every civilized nation in  modern times.  All
doubts and fears, which a  parturient female entertains must be ob-
viated by reason and good sense, and the examination  by the va-
gina instituted as soon as  may be convenient.
   Examination.—The patient  is  to lie on her left side, a coverlet
being thrown over her, and her hips as near the edge of the  bed
as possible, her knees  drawn up  towards  the  abdomen, and the
bosom bent downwards  and forwards, towards her  knees.  The
nurse and another  female  should  be  in  the apartment, the light
is to be excluded in some  measure, and  the  curtains  drawn close.
The index and  middle finger  of  the right  hand, the nails being
pared  closely, are  to  be  lubricated  with  some oleaginous sub-
stance,  which  is generally  prepared by the  attendants, as lard,
butter, pomatum, olive oil, and passed  under the right  thigh, du-
ring the  next  pain, from the perineum into the vagina, when they
are to be directed downwards and backwards, as the  orifice of the
womb in  the first stage of labour is low down towards the sacrum. The
orifice of the  womb will be found dilated or not; if it admit the point
of the finger, it is to be considered dilating, and will be  pushed down
during the pain.  If it be dilated as  large as the disc of a shilling,  the
head or other presenting'part  of the infant may be guessed at; and if
the pains be those of labour, the vagina will be more or less lubricated
with mucus increased by parturition. The presentation may be discov-
ered throrj'b the uterus, and the capacity of the pelvis ought to be
ascertained by passing  the fingers  round its parieties.   The object 
DUTIES IN THE FIRST STAGE OF LABOUR.        121
is to ascertain the commencement of labour, the part of the infant
which presents, and the capacity or size of the pelvis.  Then the
hand  should be withdrawn, when the pain ceases,  and wiped un-
der the bed-clothes with anapkin, previously in readiness by the
nurse.
  The introduction of the fingers is to be accomplished as speed-
ily  and gently as possible, and the greatest delicacy is to be obser-
ved.  The examination gives no pain,  and hence removes the
dread, which  many women, either  from  some misconception or
former harsh treatment, entertain of this operation.  A  vast deal
of useless suffering and fatigue will be saved the patient by an ear-
ly examination ; for if the labour be preternatural, it can be recti-
fied readily before the rupture of the membranes.   If labour be
about to  commence, the practitioner is  generally  consulted, and
his superintendence requested, concerning the arrangement of the
sick chamber, and of the bed  especially.  The  nurse usually at-
tends to  the adjustment  of the  bed, but often enquires, especially
of young men, how the bed is  to be arranged, in order to discover
whether they  have had much  practical experience.   In the  bet-
ter ranks, the mattress is covered with a skin of red or brown leath-
er, and over this a folded sheet or blanket is  placed, to absorb  the
moisture.  A sheet is pinned over all, to keep  them in their pla-
ces.  Others recommend a folded blanket alone, having turned up
the pallet and blankets towards the head of the bed, and this mode
is most prevalent  among  the  middle and lower classes.   A cov-
erlet is  to be thrown over the patient,  or more  covering if  the
season require it.   The woman is to put on a night wrapper, or
other loose dress; but when the head of the child has descended
low down into the cavity  of the pelvis, she  must undress  and re-
main in  bed.   The chemise may be folded up on the hips, and its
place supplied by a loose petticoat.  A long napkin is tied around
the bed-post, by which  the woman takes hold  during the pains,
lest she  frustrate the assistance of her  obstetrician, by seizing his
hands during her suffering.  The bed-clothes ought  to  be light
and comfortable, the chamber to be  kept cool; no  fire in summer,
although a small fire tends to ventilate the chamber ;  and no more
persons should be admitted into the  apartment than are absolutely
necessary.  One  female friend, to whose kind  and sympathising
ear the poor sufferer may communicate her sorrows and anxieties,
and the nurse, are quite  sufficient for every useful purpose.  The
          16 
122
GYN^CO-PHYSIOLOGY.
relation of all bad cases and frightful stories should be avoided, es-
pecially during a first confinement; as  they do infinite  mischief,
by depressing the mind of the suffering patient, who naturally be-
comes alarmed, lest her case might be equally unfavorable ; she
loses confidence in her own power, and retards, or perhaps entire-
ly impedes, the process of labour.  All nurses, and  some medical
men, are  guilty of great imprudence, in  narrating such stories.
Dewees observes, " the poor suffering woman is entitled to all the
consolation  a well-grounded  assurance of a happy termination of
her case can afford ; yet she must not be betrayed by false prom-
ises, as to a  speedy issue ; for it  requires great experience to be
able to state  with certainty,  when any case will  terminate.   Her
mind should be  keep as free from anxiety as  the nature  of her
situation  will  permit; therefore  no conversation should be indul-
ged in, which might for an instant excite her apprehensions.  Con-
versation should be cheerful,  and free from idle  discussions of dan-
ger from similar situations, and  should be as  void of levity or  want
of feeling  and sympathy,  as of gloominess.  Levity  ill suits the
situation  of a woman  in labour, and  moroseness  or ill-humour is
quite brutal, when the poor sufferer has a reasonable  claim  to pity
and compassion. "  The patient's  mind should be diverted by  a
well-chosen and  general  conversation, always combined  with  a
confident assurance of her safety.  The practitioner can afford
no assistance during the dilatation  of the womb in natural labour,
and therefore he ought to withdraw from the parturient chamber,
as his presence is a restraint; and  his absence will allow the evac-
uation of the bowels and bladder,  and also  abridge  the  period of
his watching.   He may even visit other patients, as  the first stage
of labour  may  occupy several hours.  The  woman  may  walk
about, sit, lie in  bed, or lie on a  sofa, during the dilatation of the
womb; and she may  have any  light food, such as tea, toast,  cof-
fee, water gruel, sago, arrow root, tapioca, broths, &,c, but no cor-
dials, unless she  is really debilitated, which is not the oase once in
a thousand instances.   The exhibition of ardent liquors, although
a popular custom, is highly improper; for few  women ever die of
weakness during natural labour.  The middle and lower classes
are greatly prejudiced in favour of the use,  or rather the abuse, of
ardent and  fermented liquors  during labour;  and hence the fre-
quency of  inflammations,  fevers, and deaths among them.  There
is no medicine necessary during the first  stage of labour, except 
            DUTIES IN THE FIRST STAGE OF LABOUR.        123

the bowels be confined,  when they are to be regulated by  some
castor oil, or a clyster.  If the pains be trifling and very inert, for
twelve or twenty hours, a  dose of tincture of opium will be of ad-
vantage.  These are called " false  pains,  " and are known by the
irregularity  of their return and situation,  by cardialgia, borboryg-
mi, or diarrhoea.   These  are dissipated also by an enema of starch
and laudanum, from g ss  to  3J of the latter. I agree with Dupuy-
tren,  that danger may arise even from  3ss, though a  gj is often
used with impunity.   Mr. Appleton,  of  Holborn,  can also attest
the fact.  Every accoucheur should carry about him  some tinc-
ture of opium, some ergot of rye, a catheter, a tracheal pipe, and
a lancet.  The  opium is invaluable in allaying irritability, pro-
duced by false or spasmodic pains, and the other articles are equal-
ly valuable  under certain  circumstances.   During the dilatation of
the uterus,  or first stage of labour, it is  an established rule, that
the practitioner need  not  examine by the vagina, more than two
or three times ;  Velpeau  says three times during the three stages.
Frequent examinations, or attempts to dilate the vagina or uterus
prematurely, a common practice  with nurses, are highly injurious,
by  inducing irritation, inflammation,  and swelling  of these  parts,
which not only oppose  invincible obstacles to delivery, but also
lay the  foundation of many of the fatal fevers and inflammations
so common  after parturition.  Osborne used to remark, "that the
practitioner  should sit quiety and observe nature."   The less man-
ual interference  in natural labour the better.   Nature is the best
obstetrician—" a meddlesome midwifery is  bad."  How  many
thousand women are delivered annually on the face of the globe
without any assistance !

  Section 5.—Duties of the  Obstetrician in the Second Stage
              of Labour—Passage of the Infant.
  As soon as the  head of the infant is about to escape through
the womb, and descend into the cavity  of the pelvis, the female
should be confined to her  bed, and lie on her left side, in order to
be assisted by the  right hand of  the  medical  attendant.  This is
not always practicable,  from the  position  of the bed ; and some-
times we must deliver on  the other side, or back, as recommended
by the French, German, and American obstetricians. In strictness?
a strong  woman may be delivered in all imaginable positions, in a
chair, on the floor, he. but the left side or back is  the best  posi- 
124
GYNJECO-PHYSI0LOGY.
tion to enable us to afford a proper aid.   In cases of hydrothorax,
ascites, asthma, and rachitis, women must be delivered in the sit-
ting posture, on the  knees,  he. but these are exceptions, and do
not belong to eutocia.  The back is the best position, and that se-
lected  by women themselves.   During  the  intervals of pain it is
cruel and unnecessary to  confine the woman  to a certain position
unless  the  head press on  the  perineum.  The position varies in
different  countries ; thus  the German  and  Swiss ladies were for-
merly delivered while sitting, so that the full effect of the  pains
was exerted over the child's head, when over the centre of the os
uteri.   Formerly  the lower orders of women  in Scotland and Ire-
land, were placed  upon their knees and elbows; but this practice
has been  discontinued for  some  years,  in consequence  of the in-
crease of male practitioners, and also from the education of medi-
cal men in both countries being  similar, and  derived from the  same
Sources.   Immortal thanks to the medical press, for this diffusion
of knowledge  and assimilation of scientific opinions in every part
of the  British  dominions.
   When the second stage of labour commences, the nurse should
procure pomatum, a number of  napkins, a pair of scissors,  some
strong  thread or tape, and a flannel  cloth to receive the infant.
Here also the practitioner has nothing to do, until the head comes
to press on the perineum.   He  then places  his hand during each
pain across the perineum,  in order not  to permit the sudden es-
cape of the head, which in  general does not  take place until sev-
eral pains have gradually dilated the supported part  and vulva.
The  perineal tumor is well illustrated in Smellie's plates.   The
pressure  with the  naked hand should be made with the index fin-
ger on  the infant's head towards the pelvis, and not much on the
perineum, which would impede  its expansion.  When the perine-
um is expanded by the head, so as to  be as thin as  paper, the
palm of  the hand is to be  applied against it, and the head is to be
pressed in the natural course of its transit,  towards  the pubis.
The fingers are never to be passed between the scalp and perine-
um to expedite the delivery, for laceration  of the part, which is
our most anxious endeavour to  prevent, would  be produced.  A
lever has been introduced  over  the  head and forehead   to elevate
them, by Roonhuysen and Gehler.   Sometimes the head will ex-
pand the perineum, after a pain  or two, in  one minute  ; at  other
times,  an hour may elapse, and  the pains be urgent, before the 
           DUTIES IN THE SECOND STAGE OF LABOUR.        125

head will escape.  The pain  becomes  severe  when the head  is
descending into the outlet of the pelvis, because  its progress  is
impeded by the  sacro-ischiatic ligaments,  the spinous  processes
of the ischia, and by the position of the shoulders,  as  they are
opposed to the  short,  or antero-posterior  diameter of  the  brim
of the pelvis.   Pain in the back is now very severe, and may be
greatly relieved by pressure of the hands on the affected part, and
this pressure is to be made during the pains only.   Some women
will not bear it; but in general  it  affords  great relief.   Various
constitutional symptoms may  arise,  during  this part of the partu-
rient process.   The  pressure of the head  on the  nerves in the
pelvis, causes  pains and cramps  in  the  parts  they supply, as  in
the front of the thigh or leg  of one side.   These  are  favorable
symptoms; but the patient  complains of " the cramp," which  is
best relieved by tying  a piece  of roller or  a handkerchief tightly
below the knee.   Rigors, vomiting, inclination to pass water, and
to discharge the bowels, are now experienced ; but these last are
not natural, they arise from the pressure of the head on  the  blad-
der and rectum, and the former are sympathetic of the irritation
in the womb.   They are all indicative  of the rapid descent of the
head, and require no attention.   The patient should be  cautioned
against inducing pain, but should allow it to come on of itself; for
such pain will be  of no  use, and will  tend to injure the sufferer;
she should save her strength as much as possible.  The chief du-
ty of the  practitioner in this stage of labour, is to prevent the head
from  suddenly escaping through the perineum, before the latter is
sufficiently dilated.  Many women  force down  the head under
such circumstances, and lacerate the perineum partially  or  com-
pletely, causing a most deplorable accident.  If the  laceration be
complete, the contents of the bladder and rectum will have to pass
through a common outlet, and  render  the  patient  a most misera-
ble object.  Although  we use every precaution, a partial lacera-
tion may occur, especially in  first labours.   In some rare cases,
the membranes are dense and flattened, the  os uteri  undilated.
The rupture of the membranes almost  causes  an  immediate dila-
tation by the head pressing down, and delivery is rapid.  Such ca-
ses are very rare, and nothing is more  injudicious than  a prema-
ture rupture of the membranes,  which is sure to  protract labour.
When the head  is  expelled, great caution ought  to be employed
lest the woman force the body away, without real uterine contrac- 
126
GYNJECO-PHYSIOLOGY.
tion ; for the pain usually ceases after the  expulsion of the head.
The shoulders should be impeded, under  such circumstances, as
recommended by  Osborne  and Clarke, of Dublin, who pressed
against the infant with one hand, and on the womb with the other;
thus preventing the too rapid descent of the shoulders, and allow-
ing the uterus gradually and regularly to expel  them,  which  will
prevent hour-glass contraction,  and flooding after  delivery.  The
body should never be drawn forwards, it should be left to  be  ex-
pelled by the regular contraction of the uterus.   It is generally
expelled by the next pain or two,  which  occur after the birth of
the head, and the perineum is  to be protected during the passage
of the shoulder next to it.   As soon  as the body is expelled,  the
infant is to be raised, so that the gush of the  water which  follows
may not suffocate it; the next  pain will contract the uterus so as
nearly to annihilate its cavity, and the womb will feel hard  below
the navel,  and the parieties of the  abdomen will be wrinkled.
The woman is now to be left at rest for some  time, a warm cloth
applied to the genital fissure, and a spoonful of brandy and water
given her,  and the infant  to be attended to.   In these countries
the woman is placed on her left side, a pillow  between her knees,
and perineum supported with the right hand.

       Section 6.—Management of the new-born Infant.
  As soon as the infant breathes, which it does after a few seconds
it is to be drawn from under the clothes, and a ligature, consisting
of a piece of tape, or a few threads, is to be firmly tied round the
navel-string, about two inches from  the  infant, and a second liga-
ture is to be placed an inch nearer  the mother, w hen the funis or
cord is to be  divided by the scissors between both, and care is to
be taken  that no other part be included in the  incision.   Dr. Con-
quest observes on  this point, "  all this should  be done under  the
bed-clothes, it being indelicate  and unnecessary to expose  either
mother or infant."  I have  dissented from  this assertion, so far as
the infant is concerned, because there would be  evident danger of
not applying the ligatures  properly, and  of including other parts
of the infant in them and the incision, as the  records of obstetric
medicine fully prove, if the operations were performed under the
bed-clothes.  The infant has bled to death by an imperfect appli-
cation of the ligature ; and cases are recorded where  its fingers,
toes, and the genital organ of the male have been  included in the 
          MANAGEMENT OF THE NEW-BORN  INFANT.        127

incision.   This could scarcely  happen, if  the  body of the child
were exposed during operation.   There is no pain inflicted on the
mother or infant, by the division of the navel-string, which proves
the want of nerves in the latter, a fact that is very much opposed
to the opinion of Sir E. Home, who maintains  that there is a di-
rect nervous communication  between the mother and  the child.
(See  p. 66.)  After the division of the navel-string, the infant is
to be  transferred to the  nurse, and then enveloped in a warm flan-
nel cloth.  Its body should be  washed with tepid water and soap;
and should this ablution fail to remove the unctious matter attach-
ed to it, some hogs'-lard ought  to be applied to whatever part such
matter adheres.   It is a cruel practice to wash a  new-born  infant
in cold water; it has left a blood-heat, or perhaps  a higher temper-
ature, and therefore should  never  be suddenly  subjected  to  so
great a difference of temperature as that of cold water.   It is also
a  cruel  and reprehensible practice  to wash the face  and  head
with  ardent spirit, a portion of  which  may get into the  eyes, and
bring on  severe inflammation.  A piece of soft rag is to be  rolled
round the navel-string,  and then the part turned upwards, and se-
cured with a soft roller  against  the abdomen.  There is no neces-
sity for a burnt  rag, as  most  nurses imagine; and this is the only
remnant  of  the  ancient  treatment of the cord, which was a very
ceremonious proceeding.  The infant is next to  be  dressed, and
the fewer pins employed the better.
   As soon  as the  obstetrician has  separated the infant from the
mother, and given the necessary directions for its management, he
is to  pass a broad bandage round the abdomen of the mother, so
as to  cause  gentle  pressure on  the womb, which will render the
patient comfortable, prevent the dilatation  of the uterus, and ma-
terially aid that organ  in expelling the placenta  and membranes.
This  roller is to be  left on during the first month after delivery, as
it prevents  much unpleasant feeling in the stomach.  It  ought
never to  be neglected  by delicate  women.  It  is sometimes ap-
plied during labour, and tightened as the  process advances;  but
the pressure produced  on the  abdominal  muscles and uterus,  in-
stead of promoting, absolutely  impedes the uterine action,   The
greater number of women have no bandage applied during labour;
and few judicious practitioners,  if any, employ it.
   When the infant does not breathe after birth, or shew  other
signs of vitality, it  is said to  be still-born.    This effect is produ- 
128                 GYN^CO-PHYSIOLOGY.
ced by  pressure on the navel-string, or the  head being too long
compressed in the pelvis.   The best mode of resuscitation is ar-
tificial inflation of the lun^s,  by means of the tracheal  pipe.  Le
Gallois, of Paris, decapitated a rabbit, and secured the larger ves-
sels of the neck ;  the animal seemed dead, but when artificial re-
spiration was commenced, signs of vitality soon became apparent
the heart acted, and pulsation went on through the wThole  system,
for one, two or three hours.   No stronger proof could be adduced
of the  efficacy of pulmonary inflation, in renewing and supporting
the action of the heart and arteries.   This operation was perform-
ed on still-born children, and  with success.  A woman,  in  the last
stage of pregnancy,  was run over  by a coach, and  died in a few
minutes after her removal to St. Thomas's Hospital.  The infant
was extracted by hysterotomy, by Mr. Green, in  thirteen  minutes
after the  last respiration  of the  mother.  In two minutes more
Dr. Blundell commenced the artificial respiration, and in fifteen
minutes, that is seventeen minutes from the death of the  mother,
the infant was resuscitated.  The  tracheal  pipe  is a little silver
tube, somewhat similar to a female catheter,  but with a fissure on
each side,  to allow the escape of air  and mucus.   The finger is
to be passed down to the rima glottidis, and the tube inserted with
the right hand into that opening.   The  practitioner is now to in-
flate the child's lungs from his own, and force out the air by pres-
sing on the ribs.   Pulsation will soon be felt in the heart, and af-
ter a little  time  the respiration will commence.   The operation
ought to be persevered in  for  an  hour and a half, and the warm
bath may be  used during that time.  As soon as the respiration
has commenced, the tube may be withdrawn  and  passed  into the
oesophagus, and a  little warm  brandy conveyed into the stomach.
This is  another splendid discovery in obstetric  medicine, and one
that will  save  many lives.   Hitherto there were  little attempts
made to resuscitate the still-born infant, and thousands of them
were consigned to  the tomb, whose lives might have been preser-
ved.  The  operation will prove  valuable in all cases,  where the
pregnant  woman,  near the approach of  her delivery, shall  unfor-
tunately lose her life.   *
  I have succeeded in resuscitating infants by this process, aided
by warm bathing.  It is objected to by Piorry and other French
writers, as it is not atmospheric air that is employed, and  to obvi-
ate this defect they attach  a  gum elastic bottle, with a valve, to the 
           MANAGEMENT OF THE NEW-BORN INFANT.        129

pipe.  The former proposes a new  method, which  consists  in
compressing the ribs and abdomen  with the hands, and thus di-
minishing the thorax.  On removing such pressure, the elasticity
of the ribs amplifies the chest, and air rushes through the trachea.
By  reiterating  this  operation, respiration  is finally established
Lancet Franchise, Lond. Med. and Surg. Journ., 1829, vol. iii.)

Section 7.—Duties of the  Obstetrician in the  Third Stage of
             Labour—Expulsion of the Placenta.
   The exact time in which the womb, by further contraction, ex-
pels the placenta, is  uncertain; it may vary from a few minutes
to an  hour or more, but generally the expulsion takes place in a
few minutes after the birth of the infant.  The  woman  experien-
ces slight or severe pains, which  are caused by  the contraction of
the uterus, which soon detach the placenta, and force it into the
vagina ; but here it is usually retained, on accout of the contrac-
tion of that passage and  the  external genitals, which occurs  after
the birth of the infant.   The navel-string is to be coiled round the
index and middle  fingers of  the left hand, and  two fingers of the
right are to be passed along it into the vagina;  and if its attach-
ment or root  can be felt, the placenta is detached.   We are  then
to desire the woman to cough or bear down, when we are, if pos-
sible,  to hook down  an  edge of the  placenta,  when  the whole
will readily  follow.   We are to  recollect that the  foetal  sur-
face of the placenta is smooth, and may present; and that if the
cord be in the centre, which  is generally the case, then we cannot
easily hook down an edge for some time.   But  if the placenta be
in the vagina, and the womb properly contracted, there is no cause
of alarm,  for there can be no haemorrhage.  I am satisfied that in
nine-tenths of the reputed cases of retained placenta, that organ
is in the vagina, and retained there by the contracted state of that
canal and of the external parts.   This is  generally the case in
young muscular subjects. Dr. Hamilton recommends the cord to
be seized with the left hand, as  now stated, and Dr.  Conquest
with the right hand, a difference for which I am unable to account.
The operation can be performed either way, but  I would certainly
prefer the  former, though I employ the latter when the  positition
of the bed obliges the patient to lay on the right side.   The ex-
traction should be made  in the axis of the inferior strait  or outlet.
  Dr. Conquest makes a very valuable and scientific observation
        17 
130
(JYNJECO-PHVSIOLOGY.
on this subject, which I think has been unattended to by ordinary
practitioners, which is, " in order to  facilitate  its extraction, the
funis should always be directed in the axis of the brim, cavity and
outlet of the pelvis, as the placenta passes those parts."   If the
insertion of the cord is not felt,  and the afterpains slight, gentle
friction should be made over the uterus, or the  secale cornutum
exhibited, after the expiration of an hour from the birth of the in-
fant.  As soon as the placenta is expelled, it should be placed on
a napkin or in a basin, and an aired napkin applied to the genital fissure;
it is then to be examined, in order to ascertain whether it be entirely
expelled, as also the membranes. This satisfies the mind of the practi-
tioner, patient, and attendants, and should never be neglected.  The
parturient woman always enquires," Is all right?" and if answered in
the affirmative, she thanks Heaven in the most flowing and emphatic
language for her safety.  She is next to have some wine, or bran-
dy and water, and remain tranquil for a  few minutes; her soiled
plothes being withdrawn, she may, after  half an  hour, be drawn
up to the  head  of the bed;  but on no account  is she  to arise for
that purpose, lest haemorrhage, fainting, or inversion of the womb
should supervene.   She may have some  light covering,  so as to
be made comfortable, and then may compose herself to  rest, her
infant being first given to her.  Such are the duties of the obste-
trician, during the wonderful mechanism of the nativity of man, and
they are but few and simple.   No attempt should be made to ex-
tract the placenta for one hour after the  expulsion of the infant,
unless haemorrhage come on, and then it must be  removed as soon
as possible.

Section 8.—Remarks on the different  Orders of Natural Labour.
  The uterus is to be examined as soon as  the woman is  put t0
bed, in order to astertain that  it  is duly contracted ; the  pulse is
to be felt, and if found natural, we may conclude that the patient
is safe, and " as well as may be expected."  We are then to give
directions as to her diet, which is to consist of any of  the  vegeta-
ble jellies, and to order a  draught, composed of twenty-five min-
ims of tine, opii, and an ounce of aq.  pulegii, to be given if the af-
ter-pains  become  troublesome.   These  are excited  by  clots of
blood in  the uterus, are periodical,  unattended with rigors, and
ought not to be confounded with those caused by hysterities ; they
constitute  hysteralgia, when violent.  These pains arise  from  a 
       REMARKS ON THE ORDERS OF NATURAL LABOUR.     131

further contraction of the uterus.   The infant may be  applied at
the breast, if there be milk ; if not,  a few teaspoonsful of sweet
milk with loaf sugar, or some sweetened arrow-root, may be sub-
stituted.   The infant may have some aperient, as half a teaspoon-
ful of caster-oil, a little manna,  soft sugar, or treacle and water, to
purge off the meconium.   If the woman have milk, these are un-
necessary.  Pap, panado, biscuit  and water, and water-gruel, are
too tenacious and indigestible for infants; they cause acidity, flat-
ulence, gripes, he. he., and, in nine cases out  of  ten, the infant
receives  too much food.   The  stomach of a new-born infant is ve-
ry small  and delicate,  whereby we can understand  why it vomits
so frequently after being fed, for  it is generally crammed  to the
throat by mothers and  nurses.  It will be a considerable  time at
the breast, before it extracts a  tablespoonful of milk, and this ought
not to be forgotten.
   The whole process of labour may be completed in  an  instant,
or  may be protracted for several  days.  The different periods of
labour are often indistinctly marked.   Thus the pains may be se-
vere for  an hour or more, and  the orifice of the womb not dilated ;
it may be indiscernible,  or  have  its  unimpregnated  feel;  on the
other hand it may dilate quickly.   If it feel soft and rough, it will
dilate freely ;  but if smooth, like the  leather of a glove, it general-
ly dilates slowly.  It is  supposed, that if it requires three hours to
dilate the orifice an  inch, it will require two  to dilate  it another
inch, and three more  to dilate it completely.   This  calculation
is merely hypothetical, for the dilatation may be completed in a few
minutes.  It is impossible to determine the duration of labour in
any case, and young practitioners should  never state  that it will
be completed at a certain hour.  I give this caution, as  the patient
and her  friends invariably inquire, "When will it  be  over?"  or,
" Will it in one, two, four, six, or twelve hours ?"
   The different stages of labour are distinguished  by a difference
in the mode of expressing  pain.   In the first stage the pains are
sharp, the patient moans, frets, or bears in silence.   The comple-
tion of the second stage, or expulsion of the head, is distinguish-
ed by a  groan, indicating a straining exertion, or the woman holds
in her breath, and is scarcely heard to complain, or  screams aloud.
The epithets in common use,  as to the kinds of labour pains, are
small, short, regular, true or false, sharp, spurious,  bearing, linger-
ing, strong, violent, thundering,  &c.  The labour is said to be 
132
GYNjECO-PHYSIOLOGY.
quick, slow, tedious, lingering, dry, wet, sleepy, sick, hard, labori-
ous, weak, strong,  good, bad, he.   It should be borne in  mind,
that according to the definition of Eutocia verticalis, or natural la-
bour, the  pains are  to be regular and  constant for twenty-four
hours, before it can fairly come under the definition  of E. protrac-
ta,  protracted, tedious,  lingering,  or laborious labour.  In  the
greatest number of cases, the pains are not continued in the first
order, but go off,  so  that in the space defined there may not be
three hours of real  labour.   The woman  in a first labour thinks,
from rather acute  pains, that she is really ill three or four days be-
fore the uterus begins to dilate ; and this has been confounded by
obstetric writers  with Dystocia.   I  have  had numerous cases of
this kind, and assured  the patient and her  friends, after examina-
tion, the pains being very severe, that the labour had not commen-
ced ; and  I reiterated this declaration until the fourth  day, when
the uterus began to dilate.  In such  case,  the  labour is natural,
and not difficult, as almost  all other writers have asserted.   Tho
treatment  in such cases  consists  of giving  an  opiate, twenty-five
or thirty minims of tinct. opii,  and a clyster, composed of half a
pint of starch and half a drachm of laudanum, at bed-time.  This
plan may be  repeated daily, the bowels being duly regulated.  If
the labour be delayed  after  the dilatation  of the womb, so as to
come fairly  under the second order, the  same  treatment as now
described is proper, if the patient be delicate; it relieves irritabil-
ity, arrests useless pains for some time, causes sleep, and such re-
freshment, that the labour becomes active  and  efficient in a short
time.  If the patient be of a full  habit, or a young subject, Dr.
Hamilton asserts that bleeding from the arm is the best remedy, and
that it expedites  labour in  a most wonderful  manner,  a truth I
have often witnessed.   In this country women  have a strong pre-
judice against blood-letting.   Dr. H. explained its mode of  action
by relieving  the respiration  and  circulation.   The secale cornu-
tum, or ergot of rye, has superseded in a great measure.  For an
account of this medicine, see next section.)—The  second  order,
or E. phrenalgica, is to be relieved by soothing the mind and re-
moving the mental affection.  The other treatment  must vary, ac-
cording to the urgency of the symptoms.
   The third   order, or  E. anenergica, powerless labour, may oc-
cur in cases of extreme  debility, but  is seldom met with.   It  is
more frequently induced by  haemorrhage, or some other preternat- 
       REMARKS ON THE ORDERS OF NATURAL LABOUR.     133

ural cause.  Opiates and the ergot of rye are the chief remedies.
  The fourth, fifth, sixth, seventh, and eighth orders, or plural la-
bours, are to be treated as the first.
  Women are to be relieved in the first, second and third orders
of natural labours, by time  and patience, encouragement to hope
for a happy event;  and no manual or instrumental aid ought ever
to be given until the labour  has been active and  uninterrupted for
twenty-four hours   (Hamilton); for  six hours  (Denman,  Apho-
risms).   It is an established general rule in the  practice of mid-
wifery, that instruments are never  to be used ;  and the very few
cases in which they are necessary are to be considered exceptions
to this rule.  Many eminent accoucheurs, in very extensive prac-
tice, have never used the second class of instruments.   Again, it
is an  established rule, that three examinations by the vagiua, in
each of the two first stages of  labour are  sufficient.  Some olea-
ginous matter is to  be smeared  on  the fingers during such  opera-
tions.   It is  a useless, dangerous,  and barbarous practice to  at-
tempt to expedite  labour by any mechanical  force;  the  uterine
contractions alone  can effect it  with safety.  I have already men-
tioned the authorities of the most extensive practitioners of every
country, as to the  very few and rare  instances  in which  instru-
ments are necessary.  It  appears  from  the records of obstetric
medicine, that the  best, safest,  and  most successful obstetricians,
are those who employ manual or instrumental aid the most infre-
quently.
  From what has  been already stated,  it is evident that labour
may be protracted by an immense, perhaps an innumerable varie-
ty of causes, and to a few only of the  most frequent of these do
my limits allow me to allude.  The various depressing passions of             V
the mind are among the most frequent of the causes of protracted
labour.   These  are to be obviated by consolation,  sympathy, con-
fidence, amenity of manners, he.   Feeble  and irregular  uterine
action have the same  effect,  and arise from all  the causes that de-
bilitate the constitution.   Nutritious aliments, opiates, and the er-
got are  the best remedies.   A premature rupture of the mem-
branes, and the disturbance  of  the natural progress of labour are
the most frequent causes of  protraction.  These are always to be
avoided.  The over-distension of the womb, by the amniotic fluid,
is a very rare cause of protracted parturition ; and therefore punc-
turing  the  membranes on this  account is  seldom  necessary.  In 
134                  GYN2ECO-PHYSIOLOGY.
cases of rigidity of the membranes the labour may  be delayed;
and here disruption of them, where the  womb is fully opened, by
a strong piece of wire, probe,  he. is useful.   In cases of rigidity
of the vagina, or womb, blood-letting and opiate clysters are to be
employed, otherwise labour may be  protracted  for several days.
The French apply two  drachms  of  extract of  belladonna to the
affected parts, in such cases, to  dilate them, a practice disregar-
ded in this country.  This is  a  rare occurrence, except in cases
of scirrhus, when an incision must be resorted to.  If the exter-
nal parts be rigid, a frequent occurrence in those who marry  late
in life, lard and other similar substances are to be applied freely.
The perineum in spite of  all our efforts, will be more or less lacer-
ated in such cases.   The  os uteri becomes tumefied  by the pres-
sure of the  child's head, and so  congested as to  feel like a roll of
dough, and consequently impede labour.   The orifice, in such ca-
ses, must be dilated by the fingers, gradually and cautiously. If
pain be produced, we must cease; take  blood  from the arm, if
the pulse  warrant it; exhibit  an opiate, and order  an anodyne
clyster.
   An undeveloped band  of fibres of the neck of the uterus  is a
frequent cause, and is to be relieved  as the last.
   The various malpositions of the womb, as stated  in the second
class, twenty-second order, will impede labours.    In all these ca-
ses the os uteri is to be hooked on the finger, and brought into the
proper axis  of the  pelvis,  and  the  position rectified.   Dr.  De-
wees's directions on these subjects are highly valuable,  and de-
serve attentive perusal.  Unless the orifice be brought in the nat-
ural direction, the woman will suffer  very severely.
   Labour sometimes continues two, three, four,  six,  or eight days,
especially in first cases : 1. in young, nervous women, of irritable,
rigid fibre; 2. in those of a delicate, feeble, lymphatic constitu-
tion, in whom the orifice of the womb is soft for some time before
the end of pregnancy.  In the former, the orifice resists from too
much sensibility ; and here depletion, mild narcotics, and the appli-
cation  of belladonna,  are advantageous.  Chaussier,  Conquest,
Lachapelle,  and Velpeau, speaks in favourable terms  of the last
remedy.   It is prepared by mixing a gj of  the extract of bella-
donna, with § j of simple cerate or adeps, about the size of  a fil-
bert of which is rubbed on the circumference of the neck of the
womb.   It is said to act in the same manner as on the  iris, and 
        REMARKS ON THE ORDERS OF NATURAL LABOUR.     135

often with surprising promptitude.  I have not as yet employed
it.
   In the second  case,  nutritious aliment, and a moderate  use of
wine and cordials is beneficial.
   In other cases, the pains are strong and regular, but soon cease
for long intervals, and sleep supervenes.  A dose of opium is of
great value in such cases, when unattended by sleep.   This rem-
edy sometimes increases  or diminishes uterine action, and is there-
fore uncertain.   Here the good old remedies, "time and patience,"
are of infinite value.
   In cases of muciparous, plural or twin labour, we are to treat
them as natural, or effect delivery by turning, which will be de-
scribed hereafter.   In general the  vertex  of one, and the feet of
the other infant  present.   Immediately after delivery, in all cases,
the hand is to be placed  on the abdomen to ascertain whether an-
other infant be present, and if such is the case, the labour should
not be provoked for ten or twelve hours, unless some  untoward
symptoms  occur.  I have known a woman delivered of one infant
on Monday, and the second on the following Thursday, without a
bad symptom during the  time ; both infants were born alive.   An-
other case  fell under my  care,  w here there was  a period of thirty-
six hours between the births, and  not a pain during the time; the
second infant was born dead.  The secale cornutum had its usual
good effects in this case.   When the inferior extremities present,
we must ascertain if they belong to the same individual.   If  both
heads present at once, a case  of  which  was mentioned by  Dr.
Hamilton,  we should endeavour to return that which is less advan-
ced.  It is difficult  to comprehend how  the Siamese  twins, and
other similar monstrosities, could have passed through  the pelvis.
The division of  the funis of the first infant may cause a fatal hae-
morrhage,  unless a second ligature  be applied, both to the mother
and  infant, either by an union  between the placentae, or by  the in-
sertion of both  navel strings into the same placenta.   From the
great distension of  the uterus  in twin cases, the  organ does not
contract from the inertness, and fatal haemorrhage to the mother
may be the consequence, unless prevented by  the use of the se-
cale cornutum.
   From time immemorial, various  oxytocic remedies, that is, such
as promote speedy delivery, have been employed.   Among these
borate of soda was strongly recommended by the ancients as  pos- 
136
GYNJECO-PHYSIOLOGY.
sessing a specific power on the uterus.   Homberg, and lately Lob-
stein, have  lauded it; but I have tried  it without the slightest ef-
fect.   There is only one remedy which possesses a specific effect
on the uterus, of which I must speak in detail, and this is the se-
cale cornutum, or ergot of rye.
   The ergot of  rye, secale cornutum, seu calcaratum, secale  lux-
urious, secale mater,  secale  cereale, clavus secalinus, seleroticum
clavus, ergot ou  siegle ergote,  ble farouche, ble noir, blc cornu^
ble ivre, siegle eperone, clou de siegle, siegle matrice of the French,
Mutterkorn or Rogenmutter of the Germans,  and ergot or spur-
ed rye of the British, was employed from time  immemorial for ex-
pediting labour, and was described  under the name of siegle mat-
rice in the Actes des Curieux  dela Nature for 1668.  Its poison-
ous effects, and its powers of producing gangrenous  ergotism, or
the creeping sickness, the Kriebelkrankheit of the Germans was
described by the Marberg Faculty  of Medicine in  1597.   Its ox-
ytocic properties were first described by Desgranges in  the Ga-
zette  de  Sante for  the year  1777.   It was noticed  by  Stearns,
New York Med. Rep. 1807 ;  by Bigelow, New England Med. and
Surg. Journ.; and Prescott, Lond, Med.  and  Phys.  Journ.,  vol.
xxxvi.   Since this period, it has been  noticed in the American,
French, and British  Journals, especially  by  Chapman, Bordot,
Goupil, Chevreul,  Legras,  Bigeschi,  Gendrin  Neale,  Mitchell,
Villeneuve,  Velpeau, and myself, all of whom attest  its efficacy;
while Desormeaux,  Gardien,  and Madame Lachapelle in France,
and a great number of young  and  unknown practitioners in  this
country, deny its powers.  I have lately arranged a paper on the
physical, chemical, and medical properties of this medicine, which
was read before  the  Medico-Botanical  Society ; and I  regret I
cannot insert it  at full length here; but a few extracts  may be
given, especially on its chemical composition and medicinal prop-
erties.                   '
   Chemical Properties.—The chemical constituents  of the ergot
are, a  deep  yellow colouring  matter, soluble in alcohol ; a white
oily matter,  a violet matter, insoluble in  alcohol ; a free acid which
appears to be phosphoric, and free ammonia,  an  azoteous matter
very putrefiable.  Water and alcohol extract the active principles
of this substance.  Such is the analysis of M. Vauquelin ; but Dr.
Neale and others assert, that it contains  an alkali.  It is found on
the continent of Europe, in America, in  this country,  by Mr. Ha- 
            ON THE EFFECTS OF SECALE CORNUTUM.        137 •

merson, of Elland, Yorkshire, and  has been first employed medi-
cinally in  Germany, and afterwards in France.  It must be kept
in  closely-stopped bottles,  and  is impaired  by exposure to air or
moisture, by  which it contracts a black mould and becomes inop-
erative.
   Medical Properties and Uses.—If employed as an aliment, the
ergot produces very injurious effects, such as violent convulsions,
acute and burning pains in the extremities, followed by gangrene
and death.  Its noxious effects are comprehended in the term, er-
gotism.  Like almost all medicines, it acts as a poison in large do-
ses.   In small quantities it is a safe and valuable remedy, and has
a specific  effect on the uterus, exciting gradual but  powerful  con-
traction of that organ, when the natural parturient action is dimin-
ished, or has entirely ceased.  It does not  produce permanent
contraction, but merely renews the labour, pains,  and  augments
their force.   Such are its ordinary effects when properly adminis-
tered.  It has therefore been resorted to in tedious and powerless
parturition, arising from cessation of the parturient action, or  from
inertness  of the uterus;  in uterine haemorrhage dependent on the
same cause.   Dr. Neale, who  has written  an instructive work in
defence of the efficacy of this substance, corroborates this opinion.
I have been frequently called to cases of supposed  incipient  par-
turition, in which the ergot had been  prematurely and improperly
exhibited, it produced more or less tormina;  but delivery did not
take place for days or weeks afterwards.   In describing the use of
this remedy, in the former edition of  this work, I have laid down
a  rule for its administration, which ought never to  be  forgotten ;
namely, " that the parturient process must have commenced, the
os uteri be considerably dilated, or dilatable, that the presentation
and pelvis be natural, and  the digestive organs in a healthy state."
If this simple but important  rule were followed, we should  have
heard much less of the failures of the medicine.   If we examine
the assertions of those who have denied its efficacy, we shall inva-
riably discover, either that the medicine was improperly preserved
and consequently  inert, or that it  was administered prematurely,
or in preternatural cases, which ultimately required operation, in
which no man acquainted with the mechanism of parturition, or
the numerous  difficulties which may  impede  it, would  have  em-
ployed the medicine at all.  It should never be used in preternat-
ural cases, either arising from presentations, disease, or  malforma-
        18 
138
GYN.KC0-PHYSI0L0GY.
tion of the mother or infant. In such unfortunate cases it is only cal-
culated to produce rupture of the uterus, or the death of the in-
fant, by causing useless but  powerful uterine action, which may
either  interrupt the circulation between  the  uterus and infant, or
cause such compression on the latter, as to  produce asphyxia or
death.  If practitioners would trust more to  the good and safe old
remedies, " time and patience," and follow the rules laid down by
all eminent obstetricians, to wait for twenty-four hours in all natu-
ral cases,  that is, until labour has really continued for that period,"
their interference would be seldom necessary.   Were it not invid-
ious, I could easily enumerate a long catalogue  of reputed failures
of the ergot, selected from  our medical periodicals, in  which the
medicine  was most improperly employed.  But this can be readi-
ly explained, when  it is  recollected,  that obstetricity formed no
part of the medical  education in this section of the empire until
within the last two years.   Hence it is  that  the great majority of
practitioners are unacquainted with the principles or scientific prac-
tice  of obstetrics;  and hence it is  that we peruse a series of cases
in which the secale cornutum had failed to effect delivery, and in
which, if it had effected parturition without manual or instrument-
al aid, it would have effected an impossibility.
  Another cause of the depreciation of  the  effects of this remedy
is its exclusion from  our pharmacopoeias, and consequently a want
of information on its physical, chemical, and medical  properties.
The only works published  on its  properties were those  of Dr.
Neale, Mr. Mitchell, and this Manual, all of which have appeared
within the last three years, and of course are only partially known
to the profession.  These reasons  satisfactorily explain the divers-
ity of opinion that prevails on the  properties  of the medicine.  In
fact  no two practitioners agree as to the  quantity and mode of its
exhibition.  I shall therefore state the formulae which I have found
most successful, and the remaining portion of the cases in  which
it is  of invaluable service.   First of all, the labour must be natural
and  somewhat advanced, or, in other  words, the pelvis must be
natural, the vertex the presenting  part, and the  os uteri considera-
bly dilated or dilatable.   This is the general rule, to which there
are some  exceptions. Thus,  in presentation  of the nates or breech,
and  in  cases of haemorrhage, in what is called the natural  presen-
tation, forming (the complex labour of some writers,) in cases of
hour-glass contraction, adherent placenta, and  after  dilatation of 
ON THE EFFECTS OF SECALE CORNUTUM.
139
the uterus, the ergot expedites delivery, thereby prevents haemor-
rhage, and saves the strength and lives of parent and offspring.
In the other cases it contracts the uterus, expels the  placenta, and
arrests haemorrhages.   Besides effecting these  important objects,
it saves the medical attendant much time, and that extreme anxi-
ety which depresses the mind of every humane individual, when
he beholds the lives of two of his helpless fellow creatures on the
brink of destruction.  In making these statements, I  am  fully sen-
sible of the great responsibility  which every  man  ought  to feel
when giving evidence upon a subject which  involves  the  welfare
and lives of such a  great proportion of society ;  and  it is this feel-
ing, and the  firm conviction that the injudicious  employment of
the medicine, is now productive of incalculable mischief to  science
and humanity, that impel me to attempt to  inform  young practi-
tioners on the use and abuse of the remedy.
   Various objections have been raised against  this medicine.  It
has been  said, that it destroys the infant; and that the proportion
of still-born or dead infants has considerably increased since its in-
troduction into practice.   I have been unable to discover any con-
clusive or  satisfactory evidence in support of this assertion.  I am
ready to admit that the indiscriminate employment  of the medi-
cine has done mischief;  but so  far as I have read the  details of
the cases  in which  the infants were still-born, they were  first de-
liveries, which every practitioner must admit are generally tedious
and destructive  to  the infant, where no recourse is had to  the me-
dicine.   In such cases the importunities of the  sufferers and the
remonstrances of relatives, too often lead to premature interference,
where there is no actual necessity, and to the exhibition of the er-
got, where unassisted nature would have more auspiciously effect-
ed her object. Another objection has been urged by Dr. Hossack,
of  Philadelphia, in  a letter to  Dr. Hamilton, of Edinburgh, that
the violent contraction of the uterine parietes compresses the ves-
sels, and interrupts the circulation between the  placenta and foe-
tus.  This objection appears to me invalid, when I  consider the
immense size of the uterine vessels  at  the  period  of parturition,
the presence of the infant in the uterine cavity, and  the utter im-
possibility under such circumstances of the  uterus, by any degree
of contraction, being capable of compressing the vessels complete-
ly, and arresting the flow of blood through them.   In corrobora-
tion of this position, it may be stated,  that frightful haemorrhage 
140
GYNJECO-PHYSIOLOGY.
from the uterus may occur during labour though the organ be pow-
erfully contracted, so that here the circulation  in the uterine ves-
sels is not arrested.   Dr. Houston,  of the  same city, agrees with
my opinion ;  but contends that " the powerful  and  constant com.
pression of the placenta between the firmly contracted uterus and
solid parts of the highly compressed infant must impede the circu-
lation."  To this I reply, that there is  no  constant compression
of the placenta or permanent contraction of the uterus,  if the er-
got be not improperly pushed too  far: for every man  who has
employed it in proper doses will and must  admit, that  though it
increases the violence of the pain, yet the contraction produced is
periodical.   The same answer  refutes his assertion of constant
contraction of the  uterus destroying the infant  by compressing its
brain.   If the uterus were permanently contracted  on an impact-
ed head, or on a transverse  presentation,  the compression of the
funis umbilicalis, or detachment of the placenta might as readily
destroy the infant, while rupture of the  uterine  parietes  must fre-
quently destroy the mother.   From these  facts it  is obvious that
great caution is required in the administration of the medicine, and
especially as  to the quantity to be employed.   The last  objection
is, that the medicine may  poison the infant.  This position is too
ridiculous to deserve a serious notice ; but I may remark, that the
medicine acts before it can pass through  the  circulation of the
mother, and often  effects  delivery before  it can be transmitted to
the infant.   I have exhibited the medicine in numerous cases, and
can aver, I have never seen it injure the infant.  There  is anoth-
er observation I should make in this place,  which is, that an over
dose of the remedy may produce such  contraction  of the uterus
after the birth of the infant, as to cause retention of the  placenta
for some hours.   Again, it would  do much mischief if the soft
parts were rigid; in such cases repeated pressure on the  infant's
head would destroy it, and rupture of the uterus might be produ-
ced.  Dr. Cusack,  of  Dublin, has lately related a case,  in which
it produced apoplectic symptoms;  but  he is not completely con-
vinced of the fact.   (Dublin  Hospital Reports, 1830, vol. v.)—
This leads me to describe  the  dose  and mode of administration of
the remedy.
   Dose  and Mode of Administration.   It is recommended in
powder,  infusion, decoction, watery extract, spirituous  tincture,
spirituous extract,  syrup,  oil, and in the  alkaloid form.   In this 
ON THE EFFECTS OF SECALE CORNUTUM.        141
country the  powder, infusion, and decoction are most commonly
employed, and the tincture occasionally.  This  medicine cannot
be reduced  to fine powder, unless very  much dried, and the heat
necessary to effect this exsiccation, I apprehend almost destroys its
properties.   If the powder be exposed to the air it becomes use-
less, and ought to  be kept in a closed bottle, a piece of camphor
introduced to preserve it from the attacks of insects, which injure
it very much when kept in drawers.   It is also very often reject-
ed by the stomach.  If purchased from druggists and  chemists, it
is so much adulterated, that no reliance can be placed on it. The
dose of the  powder is a 9j in some warm  tea, and to be repeated
every ten minutes, until it produces its effects.   The  maximum
quantity in any case is  3iss, which seldom fails to produce its ef-
fects, if the medicine be good, and have been properly preserved.
I have known the powder given in  drachm doses without effect;
but  the medicine had been exposed to the air.   An ounce of this
powder  was given  in  infusion with  the same results  ; but how
could it be expected that any quantity of a substance, deprived of
its properties, could have effect.   It  is  seldom necessary to ex-
hibit more  than three scruples.   The  infusion is prepared by ad-
ding gi-ijofthe contused ergot to § vj of boiling water—the dose
 § j every ten minutes.  The decoction is prepared by boiling  3j
of the contused ergot in § iij of  water  to § iss—the liquor to be
poured off, and  some  milk and sugar added to it: the  dose a ta-
blespoonful  every ten minutes, or at longer intervals, according to
the effects   produced.   This is the  form of prescription which I
have found  most certain; the addition of the dietetic articles ren-
ders the medicine more  palatable, and  seldom  need the quantity
be  exceeded.  The  uterine action is gradually  but steadily in-
creased, the infant advances slowly but satisfactorily, and parturi-
tion is  usually completed from half an hour to an hour after the ex-
hibition of the medicine.  Here again time and patience are re-
quisite ;  nature is  to be assisted,  but not superseded,  anticipated,
or hurried.   Of its efficacy there can be no doubt, if properly pre-
served and judiciously  administered.   It abridges human suffering,
which  might continue hours and  days unalleviated ; it supersedes
the use of instruments in many cases; and  it saves the attendant
much anxiety and useless loss of  time.   It has superseded the use
of the short forceps in a very large number of cases, which I need
scarcely observe  is an  important improvement in obstetric medi- 
142
GYN.KCO-PHYSI0LOGY.
cine.  Dr. Marshall Hall states, that the ergot possesses consider-
able powers in controlling chronic uterine discharges.   In a case
of menorrhagia  of four years'  continuance,  alternated  with leu-
corrhoea, five grains of the powder were  given four times a day
before the expected catamenial appearance, with the effect of re-
tarding the evacuation and suppressing the leucorrhoea.  In seve-
ral cases of the  latter disease, he has employed the medicine with
decided success.   Its good effects were apparent about the fifth
day  ; but it ought to be continued longer.   When we recollect
the pathology of leucorrhoea, and  the  various grades  of inflam-
mation of the mucous surface of the vagina,  which cause many
forms of the disease,  it is not easy to comprehend the efficacy  of
a medicine which acts on the uterus only.   In the simple or com-
mon form of the disease,  perhaps uterine irritation may diminish
the diseased action in a  vicinal tissue, and  thus act beneficially.
From the former  account of the medicine,  it appears to be the
general opinion,  that it has little, indeed no action on the unimprei*-
nated uterus ; but that is not easily reconciled to physiological in-
duction.   Dr. Chapman,  of Philadelphia,  who has  written well
upon the subject, does  not consider the  medicine  an emmena-
gogue ; yet it is often  given in  America  to  produce abortion, and
was  interdicted  in Germany for this reason.   I  am  disposed to
admit its efficacy on the  uterus in the unimpregnated state ; or in
early months  of utero-gestation;  for  in  cases  of abortion before
the fifth month,  when the ovum  was expelled, but the placenta
retained, I ,have exhibited it  with  much effect; its  action was
slight and transient, but scarcely  ever was the placenta expelled.
This can be readily understood, when we 'recollect the  compara-
tive  size of the uterus in  the early and latter months of pregnan-
cy ;  and more especially when  we remember, that there is a great
disinclination of  the organ to part with its contents in the former
period.  If the  statements of Dr. Hall  be borne  out by the ob-
servations of others, the  power he ascribes to the ergot is calcula-
ted to enhance its value  very considerably.   As yet we have, no
fixed formula for the tincture.   Some order an  ounce, others two
ounces, to the pint of alcohol.   I shall endeavour to ascertain the
exact quantity necessary for  the  tincture.  This  form  would be
the most convenient.   The extracts,  oils, and alkali are not used
in this country ;  nor have I been  able to discover them in any of
the  European or  American pharmacopoeias.   It has lately been 
MEDICO-LEGAL PROOFS OF ABORTION.
143
tried by Dr. Spairiani with success in menorrhagia, uterine conges-
tion, haematuria, epistaxis, and haemoptysis.  He  thinks it a con-
tra-stimulant, and possessing a peculiar action on the minute vas-
cular ramifications.  (Annali Univer.  de Med.  1830.)—In doses
of ten  grains three times  a day, it was said to have cured five out
of seven cases  of intermittents.  (Mehlhausen, in Rust's Maga-
zine, vol.  xxix.)—In conclusion, I  have to state that  repeated
experiments and  careful  observations  have  convinced me of the
power  of this medicine in promoting uterine action during partu-
rition ;  and  I   am as  certain  of its effects when properly preser-
ved, and judiciously administerad, as  I  am of those of any medi-
cine in our pharmacopoeias.   I  have lately ordered the tincture
composedof § ij to Oj of alcohol, in case of menorrhagia, with suc-
cess :  the effect was witnessed by Mr. Matthews, of Hunter-street,
Brunswick-square.

Article VI.—Medico-Legal Questions relating to  Ab-
   ortion—Premature Labour—Delivery—FoeTiciDE and
   Infanticide.

   Section 1.—Medico-Legal Questions relating to Abortion.
   In judicial  investigations relative  to abortion, medical jurists
are required to decide the following questions:  1. Has there been
abortion produced ?  2. Is abortion natural or provoked ?  3. Has
the foetus quickened ?
   Signs of Abortion.—To determine whether  abortion has  ta-
ken  place, we  must always examine the product of abortion, and
also the female who is said to have aborted.   If  we do not see
the substance expelled, we cannot give a satisfactory, much less a
decisive opinion.
   Examination of the Embryo  or Foetus.—During the two first
months of utero-gestation, we must be extremely cautious, and
take care not  to confound the foetus  with a mole or false concep-
tion, or with a  sanguineous concretion or false mole.  At this pe-
riod  the  embryo  is enveloped in a  capsule; formed by two mem-
branes  (the  chorion and the amnios,) united to a spongy mass
(the placenta,) more voluminous than  itself.   The first of these
membranes is torn, and allows the second to escape,  in  the form
of a membraneous sac, to which  is  attached a clot of blood.  On
opening this sac, a quantity of fluid escapes, and the embryo will be 
144
fiYNJECO-PHYSIOLOGY.
found in  an organized condition.   It is  a gross  mistake in those
works on obstetrics, in which it is stated that the foetus cannot  be
reorganized at this period.   I have a preparation which shews it
perfectly formed at two months and a  half.   There is also an il-
lustration of the embryo at the forty-fifth day, in a perfect form,
in the excellent plates of Maygrier.  We seldom see the substance
expelled in  early abortions, as it is generally destroyed by the fe-
male attendants ; and every obstetrician must have been embar-
rassed by this circumstance, and  must  have  seen cases of suppo-
sed abortion, in which the expelled substance was a clot of blood.
Hence the necessity of  washing such substance, when any doubt
exists, in order to determine whether the substance  be blood, a
mole, or a  real conception.  We should also remember  the fre-
quency of  catamenial obstruction  for two  or three  months, and
how often women suppose  themselves pregnant when they are not
so.  In such cases, the want of coagulation in the menstrual fluid
proves it not to be blood.   In  the cases before us it is absolutely
necessary to know the appearances of the foetus at the  different
periods of  gestation.  These have been already described, p. 47.
   The law of  this empire  is extremely defective on abortion, for
it abounds  with the greatest absurdities. Its intention is  humane
and excellent, but it is based upon erroneous physiological princi-
ples.   It enacts, for instance, that the embryo is not animated un-
til after quickening, that is, until  half  the  period  of utero-gesta-
tion has elapsed, though the foetus is alive from  the very moment
of conception.  I have described  its development before the pe-
riod of quickening, which, I  need scarcely observe, could not
happen if it were inanimate.
   Again a jury of matrons is to decide  whether a woman be preg-
nant or  have  quickened,  questions which  the whole faculty of
physic, in every part of the world, could not  determine in the
early months of pregnancy.   It would  be as wise to appoint a ju-
ry of infants to determine  these  questions.   The  law also enacts
it felony to procure abotion before quickening, and subjects the
person who does so by any means, or even advises it, to transpor-
tation for seven or fourteen years ; and to death, if after  quicken-
ing.  Every man must applaud this philanthropic legislation; but
it places the medical practitioner in a most dangerous predicament.
Thus, in thousands of acute diseases, where life is in the greatest
danger, treatment must  be  employed which may produce abortion; 
MEDICO-LEGAL PROOFS OF ABORTION.
145
 and is the practitioner to allow his patient to die without the ben-
 efit which his art affords ?  In some cases of uterine haemorrhage
 the life of the female can only be saved by extraction of the  in-
 fant; yet this is producing abortion in the eye of the law.   Again,
 if the woman  is so deformed that a full-grown infant  cannot  be
 born at the full time, that is, at the termination of the  ordinary
 period of utero-gestation, without a fatal operation, is the medical
 man to allow the female to be placed in this predicament,  when he
 can save her life and that of her infant by inducing premature de-
 livery ?   If the infant arrive at the full term of utero-gestation, it
 must be destroyed by nature or by art, and by the latter  to save
 the life of the mother.   I have lately been consulted in a case of
 this kind  by my friend, Mr. Appleton, of  Holborn.   As the stat-
 utes now  stand, this is felony; but a talented legal writer observesj
 " It may  be presumed the operator, in such  cases, only commits
justifiable homicide, and not the  crime of abortion."   (Cabinet
 Lawyer,  1831.)—Surely the operator  can be  influenced by  no
 clandestine or  sinister motive in endeavouring to save the lives of
 the parent and offspring.  BHt to resume the medical part of the
 subject.   We should examine the woman, to ascertain  whether
 abortion has really  happened.   It is impossible to determine this
 point during the first two months of pregnancy,  as the foetus is too
 small to leave any  trace  of its passage.  When it occurs in  the
 last months of gestation,  the usual signs of delivery will be pres-
 ent which will  be described  hereafter.   The expulsion of moles,
hydatids, or other morbid  growths, should not be lost sight of, and
should be carefully examined.   The phenomena presented by the
abdomen and external genitals can only be valuable in proof of ab-
ortion when conjoined with the following circumstances: 1. When
there is a certainty of pregnancy, and a comparison made between
the development of the  foetus  and the period  of gestation.   2.
When the pregnancy is so far advanced that the changes in the os
and cervix uteri are appreciable.   3.  When examination is made
immediately  after abortion has taken place.
   The practitioner  should bear in mind the immense number  of
causes which produce abortion, and therefore ought to be extreme-
ly cautious in making a judiciary report in such cases.  Many  of
these causes are peculiar to the woman, as excessive sensibility,
and too great contractility of the neck  of the uterus,  rigidity  of
the fibres of the body of the organ, or  laxity, or flaccidity of its
             19 
146
GYNJECO-PIir.SIOLOGV.
neck; habitual delicacy of health, menorrhagic disposition, or de-
bility of constitution; all acute, and a great number  of chronic
diseases, fevers, continued and intermittent, inflammations of the
various organs, peritonitis, gastris, enteritis, cystitis, hysteritis, rheu-
matism,  pleuritis,  variola,  scarlatina, hemorrhoids, convulsions,
pertussis, chronic catarrh, colic, cholera,  diarrhoea, dysentery, con-
stipation, gonorrhoea, leucorrhoea, scirrhus  (Bonetus,)  cancer, re-
troversion,  polypi (Levret,) dropsy,  and various diseases  of the
uterus, hydranmios, hysteria, moles with the foetus, he. (Morgag-
ni.)   The  diagnosis of these diseases is  easily established.  When
abortion depends on the rigidity of the fibres  of the uterus, it re-
curs at latter periods in successive pregnancies, as the uterus grad-
ally expands; but when abortion is caused  by laxity of the neck
of the organ, the laxity increases in each pregnancy, and the ab-
ortion happens earlier.   Among the ordinary or hygienic causes,
may be enumerated violent mental  emotions, the  impression  of
strong odours, the fright caused by thunder, noise of artillery, sight
of extraordinary and frightful objects, errors  in diet,  stimulating
food and drink, abuse of spirituous liquors, too much exercise,  as
walking, riding, dancing,  running,  the agitation of carriages,  or
other vehicles, accidental falls, or blows on  the  abdomen, wounds,
tight clothing, immoderate laughter, abuse of venery, surgical op-
erations of any kind, even the extraction of a tooth, &c.   Some-
times abortion depends on  the death  of the foetus,  from debility,
ill-cured syphilis, monstrous conformation, diseases of the placen-
ta,  or amnios, its implantation over the  neck  of the uterus, scir-
rhus, calculus, hydatids,  he.  Again, we  know that  a peculiar
constitution of  the atmosphere will produce abortion,  as  an epi-
demic   (Hippocrates,  Fodere.)—All  powerful  medicines,  as
emetics,  purgatives, mercury, &c. may cause the  premature ex-
pulsion of  the foetus.  Venesection has been  employed to produce
abortion, but it seldom or never  succeeds.   A woman has been
bled forty,  and another ninety  times, and yet arrived  at the  full
period.   (Mauriceau.)—This remedy is successfully employed to
prevent miscarriage, and has been  repeated seventeen  times in a
case with  success.   (Dewees.)—Emetics and purgatives often
fail to produce the  desired effect, and the latter often destroy the
female  by  inducing abdominal  inflammations.  Emmenagogues
also fail in  most cases.  Various herbs are employed by the vul-
gar, mentha pulegium, sabina, secale cornutum, artomisia rubra, 
MEDICO-LEGAL PROOFS OF ABORTION.          147
&cc, and sometimes with effect.  But we must conclude that there
is no medicine of abortive means which always produces abortion
and nothing but abortion;  there is none which does not endanger
the lives of the mother and infant.  Irritation of the cervix  uteri
by mechanical means, and  piercing the membranes, justify the
truth of the remark, " Sape, suos utero qua necat, ipsa perit."
" Every  woman who attempts to promote abortion, does it at the
hazard of her life."   (Bartley.)—" There is no drug which will
produce miscarriage  in women who are not  predisposed to it, with-
out acting violently  on their system, and  probably endangering
their lives."  (Male.)—" It has frequently occurred," says Dr.
G. Smith, " that the unhappy mother has herself been the  sacri-
fice, while the object intended has not been accomplished."
   When called on in courts of justice to  report on an abortion
supposed to be provoked or criminal, we should duly consider the
causes already enumerated, the circumstances which preceded it,
whether the female  has denied her pregnancy, procured abortives,
used drastic medicines, applied to various practitioners without ac-
knowledging her real condition, and a  variety  of other inquiries,
which will suggest themselves to every well-informed practitioner,
before we can decide that she premediated the crime.   If the wo-
man had died, we should examine the uterus, to discover wounds,
and also the abdominal viscera, as it often happens death is produ-
ced by enteritis or peritonitis,though the uterus may have been  punc-
tured a few hours previously. This was the fact in a case tried  at the
Old Bailey, during the last  year.   The  medical  witness for the
prosecution ascribed the cause of death to  the  punctures, which
were not inflamed ;  but the witnesses for the prisoner, to enteritis.
According to the law of this country, the exhibition of any  medi-
cine, for the purpose of causing abortion, renders the accused lia-
ble to a  prosecution for felony;  and therefore those  young men
who sell medicines ought never to commit  themselves  by vending
the most harmless drug to applicants  in  the  case under notice.
Should the female acknowledge that a certain apothecary sold her
medicine for the purpose, he  could have no witness  to disprove
her allegations, and  consequently must incur the greatest danger
to his liberty or life.  Too many young men forget that the crime
of abortion is the  destruction  of a human being, and hence they
incautiously supply  medicines, in general  harmless ones, without
the slightest recollection of  the perilous  situation  in  which  they 
146
GYNJECO-PHYSIOLOGY.
place themselves.  I trust that this caution may be useful to my
junior readers.
   Medical jurists designate criminal abortion foeticide, that is, de-
struction of the foetus in utero ;  and apply the term infanticide to
the destruction of the new-born infant.  Both terms are included
in the word prolicide.   Before we consider this part of our subject
it is necessary to describe the phenomena of parturition, and the
viability of the infant.

   Section 2.—Medico-Legal Questions relating to Delivery.
   The  medico-legal  questions  relative to delivery are, 1. Do
signs exist by which we can determine that a woman has been re-
cently delivered ?  2.  At what period afterwards can we find tra-
ces of delivery ?  3.  Can a woman be delivered unconsciously ?
4. When the mother and infant are found  dead, which was the
survivor ?
   Signs of recent  Delivery.—The signs of  recent  delivery are
observable in the sexual organs, uterus, abdomen, the lochial dis-
charge, state of the breasts, and secretion of milk.  In  the first
days after delivery  the labia majora et minora are dilated, red, tu-
mified,  and often inflamed ; the vulva is open, the fourchette is
partially or completely  torn, the orifice  of the womb is so dilated
as to admit the introduction of one or  two fingers into the cavity
of the organ; the posterior lip is elongated  and thickened; both
lips are much thicker than during pregnancy.   The womb  itself
is  more voluminous, can be felt above the pubis, or may  be felt
enlarged by placing one hand on the hypogastrium and a finger in
vagina.   The size  and  flaccidity of  the abdomen,  its wrinkled
condition, the lochia and milk, are signs of recent delivery ; but
all may be present  after the expulsion of a  mole, or other morbid
growth  in the uterus.   The lochial discharge has a peculiar odour,
and when present is a good sign ;  but  it is liable to be suppressed
from a variety  of causes, and is  entirely absent in some  natu-
ral cases.  Any one of these signs is  not conclusive, and does
not prove recent delivery, but taken  collectively, and above all,
if we can learn the history  of the pregnancy,  or anterior condi-
tion of the woman, we may arrive at a correct conclusion.
   We can only arrive at a proper conclusion during the first  six or
eight days , for  at the  end  of ten or  fifteen days, it is impossible
to decide the reality of delivery.  It is now  decided that  a wo- 
MEDICO-LEGAL PROOFS OF DELIVERY.        149
man may  be delivered without her knowledge, if completely in-
toxicated ; if stupified by  narcotics, a case which I have recently
witnessed; if attacked with apoplexy, syncope, delirium, or idio-
cy ; and this fact ought never to be forgotten when we are called
on to decide questions of infanticide.  Another question of great
interest is to determine the survivorship of the mother or  infant,
when both are lost in parturition ; for in some cases, if the  infant?
survives the mother, the father inherits the property he had by his
wife ; and if the mother, the property passes to her own family.
This is the law of tenant by courtesy.   It is impossible to  decide
this question unless some person has been present at the delivery.
It was decided by the Court  of Exchecquer,  in  1806, that the
motion of the lips  of  the infant proved its vitality. (Smith.)—It
is now  universally known to judiciary  physiologists,  that  a still-
born infant may be resuscitated an hour after birth ; and one case
is recorded, in  which the infant was pronounced dead, and  placed
in the comer of the apartment, and at the  next  visit, which was
at the end of twenty-four hours, it was found alive.
   It is almost unnecessary  to  allude to  the substitution of a dead
child for a living one, as such cases are of rare occurrence.
   Women have shewn  dead children,  to  appease the wrath of
their husbands, who accused  them of sterility.  Male's Forensic
Med., p. 211 ; Capuron,  p. 110 ; Beck, p. 99.)—A woman has
substituted a living for a dead child.  The  law only requires that
the medical  witness shall prove whether the signs of conception
were present or not.   An infant must be found in order to bring
the charge of infanticide.   A woman  may be  delivered  uncon-
sciously, if labouring under coma, or the effects of narcotics (Fo_
dere, vol.  ii. p. 10);  and a woman who died before delivery was
placed on the bier for interment, when the child was born, op.cit.
11.   These are exceptions to the general rule, namely, that heal-
thy women must be conscious  of labour.  Dunlop records an in-
stance of a lady having a child, though she  and her husband did
not think she was pregnant.  (Edition of Beck, p.  107.)—Again,
a womarT  without assistance may have  her  child so suddenly on
the floor, in the street,  or water-closet,  and not  be able to pre-
vent its death.
  Circumstantial evidence on the incidents  of time and place, of
situation and character, most generally guide the decision.
  With regard  to the death of the child before or after delivery, 
150
GYNJECO-PIIYSIOLOGY.
 it is a question that may be  agitated in  civil and criminal cases ;
 as  when the succession to inheritance is  mooted, or when a preg-
 nant woman has been mal-treated, and her child supposed to have
 died in  consequence.
   The  life of the  infant is inferred from the  good health of the
 mother, the progressive increase of the abdomen, and the  motion
 of the foetus ;  but healthy females may bring forth dead children.
 Delicate females have produced healthy  children, and the increase
 of the abdomen may depend  on  moles, hydatids, dropsy, &tc,
 while the  motion  of quickening has been caused by  flatulence.
 A woman may suppose  she feels the motion of the infant during
 delivery, yet a putrid infant may be produced.  Various  causes
 may act on the mother and destroy the infant,  as unhealthiness  of
 habitation, mode of dress, want of food,  or improper use of it, vi-
 olent exercise, too great labour, violent passions of the mind, ven-
 ereal excesses, intemperance, haemorrhage, convulsions, syphilis,
 small-pox, falls, wounds, and accidents, inordinate evacuations,  in
 fact, all the  causes of abortion  which were enumerated.  Pres-
 sure in  difficult labours  may  destroy  the  infant; improper use  of
 instruments,  fainting, and  diseases of the placenta,  will produce
 the same effect;  yet the child may recover in  despite of  most  of
 these causes.
 l>  The  following signs occurring  during  pregnancy are  indicative
 of the  death  of the  infant; want  of motion  in the child ; the
 womb feels as if it contained a  dead weight, which rolls according
 to the position  of the woman ; the navel is less  prominent; the
 milk disappears ; the  breasts are brown,  flaccid; the mother ex-
 periences  a sense  of  lassitude and  coldness,  accompanied  by
 head-ache  and  nausea.  If actually dead, and long retained in the
 womb, putrefaction  sets in, the membranes become black, and fe-
 tid discharges take place.   Maceration of the  body,  presence  of
 the meconium on the  skin, violet  or brownish-blue colour of the
 lungs, these sinking partially or entirely in water, weighing about
 the seventieth part of the body, and  the mouth and throat being
 filled with a glary sanguinolent  fluid.
  Many of these symptoms are equivocal.  The fetid discharges
 and state of the skin and bones cannot be depended on.   If the
 medical examiner be  called  immediately after birth, he can dis-
tinguish these symptoms ;  but he  is seldom called  so early, and
generally not for many days  afterwards.   The  skin will  exhibit 
             MEDICO-LEGAL PROOFS OF DELIVERY.          151

marks of putrefaction, and will be of a purplish-brown or red co-
lour.  The umbilical cord is livid, soft, and easily torn.  The cra-
nium and thorax are flattened, the  sutures of the head are disuni-
ted, the brain is almost fluid,  and has a fetid odour.   If the death
takes  place after birth, there  will be  characters of viability and
complete development, signs of external violence, fractures, brui-
ses, perhaps omission of the ligature on the cord, development of
the pulmonary vessels; the arterial and venous canals are straight-
ened or obstructed, lungs  spongy, rose-colour,  swimming in wa-
ter, also after compression  of them ; but this happens, if filled
with gas, by putrefaction ; but if the gas escapes by compression,
the lungs will  sink ;  the lungs will weigh about the thirty-fifth
part of the body.   The  lungs of an infant already dead, if infla-
ted by the trachea, will  preserve  the  air, as if respiration took
place, but they will not weigh more than  compact lungs.   From
the fourth to the eighth  day  after birth,  the  cord  desiccates and
falls off, there is a slight  desquamation of  the epidermis, a yellow
colour of the skin,  disappearance of the  thrombus,  ecchymosis,
or inflammation, and  oedema  of different  parts ; on  pressing the
breasts of either sex a serous fluid appears.   From  the eighth to
the thirtieth day after birth, the navel will be  healed, the foramen
ovale, arterial,  venous ducts,  and umbilical vessels will be obliter-
ated by adhesion, the sutures  will be more solidified,  and the fon-
tanels diminished.  Such are  the chief signs of the death of the
foetus before and after delivery, which  must  be borne in mind in
deciding questions  of infanticide.

     Section'^.—Medico-Legal Questions relating to Proli-
                  cide, Fiiticidc, Infanticide.
   Medical jurists have employed the word prolicide to designate
the destruction of  the offspring, and divided  the subject into foe-
ticide, or the destruction of the  foetus in utero, and infanticide,
or the destruction of the new-born infant.  1 have already stated
the law on this subject, 9 Geo. IV.  cap. 31, which makes no dis-
tinction between the murder  of an infant not  viable,  that cannot
live, and one  that is viable.   A woman  who destroys her infant
not likely to live, for example, soon after conception, is assuredlv
less criminal than one who destroys  the foetus at a more advanced
period, which,  if left  undisturbed,  may become fully developed,
and arrive at maturity.   The  first commits an act upon an imper- 
  152                 GYNJECO-PHYSIOLOGY.

  feet being, which has not acquired the perfection necessary to du-
  rable existence, she acts almost on a dead body, non homo est, qui
  non futurus est;  the other acts  upon an  imperfect being, which
  nature destines to occupy a place in the class of her family and of
  society.   If the death of a  non-viable  infant is less criminal than
  abortion,  the  punishment of infanticide ought  not to be inflicted,
  for this is  inflicting  the greatest punishment for  the lesser crime.
 But as the law stands at present, the researches which the  medi-
 cal practitioner has to make in cases of infanticide are as follow:
    1. After having ascertained the external appearance of the in-
 fant, its volume, length, and respective proportions of its different
 parts, it is necessary to  determine  whether  there exist any origi-
 nal defect of conformation,  or any  pathological  condition which
 could induce the death of the infant at the moment of birth, or
 whether it has not  been destroyed by  pressure during a laborious
 parturition.
   2. After this examination we should inspect the internal organs^
 and decide whether respiration has  been complete, and  conse-
 quently whether the infant has been born  alive.
   3. To determine how long a period has elapsed since the infant
 was living, and  what was the cause of death, whether natural or
 violent.
   4. To determine whether the woman to whom the infant is at-
 tributed be really the mother.
   The  most important of these inquiries are the following:  Has
 the  infant died  before  delivery ?  Has  it  died  during delivery ?
 Has it died at the moment of birth, in consequence of the  defor-
 mity of the mother, or congenital disease ?   In the first place, we
 are duly to consider the  various causes of abortion,  and the signs
 which indicate  the death of the foetus in the utero.   The  former
 have been already enumerated :  the latter are the cessation of the
 motion of the foetus; the perception of it in different positions by
 the motions of the  woman ;  the tumefaction or  diminution of the
 breasts, signs which are extremely equivocal.  But if during de-
 livery the foetus is not  felt to move, the waters are black and fetid,
 the scalp soft, flaccid, wrinkled, and easily  excoriated, if the cra-
nial  bones are more mobile than ordinarily, there is much  reason
 to suppose that the  foetus has been  deprived of life for some  time.
 The proofs of the death of the foetus having taken place after de
livery are the flaccidity of its limbs, desquamation of  the  cuticle, 
          MEDICO-LEGAL PROOFS OF INFANTICIDE.          153

the skin purple or brown in certain parts, a serous or sanguineous
infiltration of the subcutaneous cellular  tissue, especially of the
scalp; the umbilical cord soft, flaccid, livid, easily  lacerable; the
thorax flattened, and its viscera in  a state which shews  that res-
piration could not have happened.
   If the infant  has been destroyed by  pressure, by a  premature
rupture of the membranes, there will be tumefaction of the superior
part of the head from uterine pressure,  the head will be deformed
and the brain will be found apoplectic;  or the  last sign  may de-
pend on compression of the umbilical cord, either by being round
the neck or body  of the foetus, or by compression of the  parts  of
the parent.  On the other hand, if the foetus has died from haemor-
rhage during labor, in consequence of detachment of the placenta,
or rupture of the umbilical cord, the body will be of a pale, livid
colour, the sanguineous system will be empty and collapsed ; and
if there is rupture of the cord, its extremity will be jagged or  ir-
regular.
   It would far  exceed my  limits, were I even to .enumerate the
various defects  of conformation of the woman, or mal-presentation
of the ftetus, which may destroy the life of the latter.   Most  of
them are described  in  this work.   I can  only advise the practi-
tioner to exert  his knowledge of anatomy, physiology,  and pa-
thology, in any case on which he may be  called upon to give his
opinion.   He should most cautiously consider  the defects of con-
formation  and pathological conditions of the pelvis and foetus, and
those which may impede the functions of respiration.   Though it
will be seen hereafter,  that  the proofs afforded by  respiration are
inconclusive, and that  too  much importance has been ascribed to
them.
   Let us  examine  the degree  of  certainty  of an  infant's being
born alive, which is presented by signs afforded by the anatomical
examination  of the foetus.   Daniel considered that the  thorax
was amplified by  respiration, and this he determined by measuring
the cavity  before and  after respiration.   (Comment, de  infantum
nuper natorum  umbilico et pulmonibus.)—But the conformation of
the chest is subject  to too much irregularity, to enable us to arrive
at a satisfactory conclusion.  Ploucquet  laid great stress  upon the
position of the  diaphragm, whether depressed towards the abdo-
men, or elevated towards the thorax ; but artificial respiration will
affect  these  positions  as well as natural.  The size of the lungs
         20 
154
GYNJECO-PHYSIOLOGY.
         affords no positive evidence.   Schmitt has seen them fill the chest
         before respiration, and so much compressed after that process had
         continued thirty-six hours, as to render it difficult to decide wheth-
         er respiration had been established.  Besides, there may be ute-
         rine, vaginal, and extra-uterine respiration before the complete ex-
         pulsion of the foetus,  and  death occur after the birth.  The rosa-
         ceous colour of the  lungs may or may  not exist, and is subject to
         great variety, so that  no dependence can be placed on this sign.
         It may exist in the foetus long before maturity.  The obliteration
         of the  umbilical arteries and vein, of the foramen  ovale, and of
         the ductus  arteriosus, evidently  prove  that  the infant has been
         born alive.   But these changes do not happen at the moment of
         birth, nor sooner than  two  or three days,  often, not before the first
         or second week; and  consequently this  evidence, in most cases,
/        is of little value.
           Ploucquet  instituted experiments to ascertain the weight of the
         lungs before  and after respiration, in comparison with that of the
         whole body, and concluded that the weight was 1 :  70 before, and
         2 : 70 or 1  : 35 after respiration.   The accuracy of these conclu-
         sions is denied  by Chaussier, Orfila, and Schmitt, of Vienna.
         Daniel proposed to  immerse the  lungs, before and  after respira-
         tion, in a vessel of water, to the  side of which a graduated scale
         was attached to mark  the elevation of the fluid.  He said that the
         condensed lungs would  occupy less space than after respiration ;
         this is true, but more delicate instruments are required  for the ex-
         ecution of this  experiment,  before we are justified  in  adopting it
         in the practice of legal medicine.
           Schreger  proposed the immersion of the lungs and heart, the
         large vessels being tied,  in water, so far back as 1682  ; and con-
         cluded, that when they sunk no  respiration had taken place, and
         if they floated the respiratory function had been established.  This
         is what is called the hydrostatic test, or pulmonary docimacy, upon
         which little reliance is placed  in any part of Europe at the pres-
         ent period.   Numerous  objections may  be made to this  test :  1.
         the infant may respire before birth  ; 2. it may respire and be de-
         stroyed before birth  ;  3. an  infant may be alive, and may  not have
         respired ; 4.  the lungs may  float before respiration ; 5. the lungs
         may not float after  respiration.  The  infant  may respire before
         birth, and be  born dead. (Hunter.  Marc,  Siebold, Capuron, Osi-
         ander, Sabatier, Mahon, Hutchinson,  Ilossack.)—There may be 
            MEDICO-LEGAL PROOFS OF INFANTICIDE.        155

 intra-uterine respiration.  (Trans.  Royal  Soc.  of London, vol.
 xxvi ;  Edin. Med. and Surg. Journ. No. 73 ;  Hufeland's Journ.
 1M-2:} ; Lond. Med. and  Surg. Journ.  1829.)—The foetus may
 be asphyxiated, or remain enveloped in its membranes and be
 alive,  without  respiration.  (Buffon, Schurig, Le  Gallois.)—A
 delicate immature infant may  respire, and yet the lungs will sink
 in water ;  and the infant may  be born with pneumonia, pulmonary
 engorgement, or hepatization.  (Billard.)—In the two first cases,
 the air cannot  arrive in the bronchial vesicles, and  consequently
 respiration will be incomplete.  In the last, we often find the sub-
 cutaneous  cellular tissue of the mouth and limbs  gorged with san-
 guineous effusion, which induces some persons to suppose violence
 has  been  employed.  Billard has  pointed out this error.  The
 lungs may float before respiration, from putrefaction  (Orfila), em-
 physema (Chaussier), or insufflation (Morgagni).  Dr. Bernt, of
 Vienna, has put an end to the ancient hydrostatic test, and propo-
 sed  a new  one in its place which is equally objectionable, in conse-
 quence of  the complication  of his instruments.   (Programma quo
 nova pulmonum  doscimasia  hydrostatica, proponitur.  Vienna,
 1821.)                                        ,
   It is a matter of great importance to determine how  long it is
 since the infant was living ;  or how long  it has been dead.   If the
 skin be soft and covered with  the white unctious matter, which is
 seen at birth, if the stomach contains  but a small quantity  of mu-
 cus, the large intestines are  filled with meconium, and the bladder
 with urine, it is probable that life had ceased at or immediately
 after birth.  If,  on the contrary, the stomach contains any alimen-
 tary substance, and the intestines any matter except meconium, it
 is certain that the infant has lived for some time.  I  have already
 described the change in the  vessels peculiar to  the circulation of
 the foetus.   Imay mention, however, that the umbilical  cord re-
 mains soft and humid for fifteen or sixteen hours, and begins to de-
siccate about the fortieth.
  To determine how long the infant  is dead, we  must consider
the state of putrefaction, and all circumstances which hasten  or
impede  it.   Warmth and humidity promote decomposition, and a
body putrefies more rapidly in running than in stagnant water,  or
in  humid earth, than in an  argillaceous,  sandy or chalky soil.
  The next question is, what has been the cause of death.   This
is often involved  in impenetrable obscurity, as lesions, purely acci- 
156
GYN.KCO-PHYSIOLOGY.
dental, frequently present the appearances of crime.  We should
endeavour to  determine those that are accidental  or involuntary,
and those that are criminal.
  Death of the foetus from involuntary causes.—I have already
enumerated  the most of the causes of the death of the foetus in
utero, and may now caution  the young practitioner to bear them in
recollection, for otherwise he may commit the most serious errors
in giving evidence on  the question under notice.   Let him remem-
ber that  diminution  or deformity of the pelvis, or preternatural
presentations of the foetus, may cause elongation  of the head, tu-
mefaction of  the  scalp, fractures of the cranial bones, blackness
of the face, congestion of the brain,  ecchymoses of different parts
of the surface of the  body, fractures of the limbs and various oth-
er lesions, which may be readily  mistaken for the result of exter-
nal violence.   Again, the twining of the umbilical cord round the
neck, or the compression of the os externum, may induce cerebral
congestion, as well as marks of strangulation.  If the appearances
on the head are caused by external injury, they will often exist in  '
situations on  which  no pressure could have  been made.  We
must always bear in mind the presentation of the foetus during la-
bour ;  and by so  doing we can  often distinguish  natural lesions
from injuries.
   In those cases m  which  the neck is compressed by the cord,
there will be no excoriation, or desquamation of the cuticle.  When
there is a rupture of the cord during labour, there will  be fatal
haemorrhage ; but if this accident happens after birth, that is, after
respiration, fatal haemorrhage will not always result.  U the cord
be lacerated by  violence, its extremities will be irregular, but the
flow of blood will cease.   The infant will  not  be destroyed by
hamorrhage, unless the cord is divided with a sharp instrument.
Should the infant have been destroyed by detachment of the pla-
centa, the pale waxy colour of the foetus, the discolouration of the
viscera, the vacuity of the heart and large  vessels, explain  the
cause of death.  The infant may be expelled suddenly, and fall-
ing on the floor or on any other hard substance,  the skull may be
fractured, and the cord torn.  Such cases are related by many ob-
stetric writers.  I have narrated three examples, and  others are
attested by Hamilton, Chaussier, Henke,  Klein,  Pasquier, Mei-
rieu.   (Journ.  Univ. des se Med. 1820 and 1823.)—M. Klein
collected a hundred and forty-three observations on this point, and 
      DEATH OF THE FCETUS FROM INVOLUNTARY CAUSES  157

asserts there was not one infant in the kingdom of Wurtemburg  ,
whose skull was  fractured,  all recovered.  Many fell upon the
pavement, two of which were affected with momentary asphyxia.
Though the cord was lacerated, there  was no  fatal haemorrhage.
When sudden expulsion of the infant  is  alleged as the cause of
death, it is  necessary to examine all circumstances anteriorly and
subsequently, to compare the dimensions of  the pelvis, and the
volume of the infant's  head, to consider  the duration of  labour
the position of the woman when the infant had escaped, the height
of the fall, the substance with which the  head came in  contact,
and finally, the state of the umbilical cord, which ought to be rup-
tured at the placenta or at the umbilicus, but not in the  middle,
the extremity of which  ought to present the sign of laceration.
   When an infant  perishes at the moment of birth,  by  choking
of the air passages, and is afterwards thrown into water or into the
water-closet, it may be supposed it has been destroyed  by sub-
mersion or drowning.   Every  practitioner  is aware  that infants
have  been  precipitated into the latter situation,  and that it is ex-
tremely difficult to distinguish whether the fluid in the air  passages
be niucosity, liquor amnii, or an extraneous fluid introduced. When
the fluid contained in the trachea is frothy,  we cannot positively
affirm that the infant has respired, as insufflation or inflation would
produce the same effect;  or a morbid secretion of gas, or the ev-
olution of air by decomposition.  If, on  the other side,  the fluid
is limpid and free from air bubbles, we can  affirm that the infant
has not respired ; but this is no proof that it was dead at birth, or
at the moment of  submersion.  The rigid examination of the
physical and chemical  properties of the fluid, will alone enable us
to determine its real nature,
   Death of the Foetus from voluntary   Causes.—The new-born
infant may be the victim  of external violence wilfully  inflicted up-
on it, and it may also  perish by the voluntary omission  of that
succour which is necessary to it in the first moments of its exist-
ence ;  hence we distinguish infanticide by commission, and infan-
ticide by omission.
   Infanticide by omission may occur from exposure of the new-
born infant to a temperature too cold or too  warm, if it be depri-
ved of nourishment  or respirable air, and from  umbilical haemorr-
hage, caused by disruption of the cord.   It is difficult to deter-
mine  what thermometrical degree of heat or cold  would  destroy 
158
GYNJECO-PHYSIOLOGY.
life in these cases ; but if we find the  body of an infant naked, or
nearly so, stretched on the ground, discoloured, the  great internal
vessels congested, and the external  or superficial contracted, and
almost empty, and with evidence  that respiration  has taken place,
and at the same time there exists  no trace of external injury, there
is every probability that death has been caused by cold.
  The defect of nutriment is generally  combined with abandon-
ment of the infant; and to  this  cause we  should attribute death,
when atmospheric temperature is  not sufficiently cold to be de-
structive, and when we find the alimentary canal  dry and con-
tracted.
  The neglect of  tying the umbilical cord will expose the infant
to fatal haemorrhage ;  but this is  not always  the case, and does
not afford sufficient evidence of mortal haemorrhage, as the large
vessels should be empty, there should  be  paleness  of the body,
viscera and muscles, to prove that death  has been caused by loss
of blood from  the cord.   Again,  death may take place from this
cause, where it was impossible for the mother to afford the neces-
sary aid to the new born infant.
  Thus, in cases of placental presentation, the infant may be de-
stroyed by haemorrhage, but there will be manifest signs in the
woman under  such circumstances; she may be in a state of syn-
cope from this occurrence, and be unable to save the infant from
perishing.  The foetus is often destroyed from separation of the
placenta during protracted labours ; in both  of these cases the pla-
centa will be attached to the umbilical cord.  It has been  said
that the mother, during convulsions, may possibly rupture the cord,
or that  this may happen from the motion of the infant, or when
the woman is  delivered in the erect position, the  foetus having fal-
len  on the floor.   In the last case,  disruption may  happen ; but
it appears very doubtful in either  of  the former.
  It will be recollected that M. Klein  has  recorded one hundred
and eighty-three cases of  sudden  labours, in  many of which the
cord was ruptured  near the abdomen, and in twenty-one  cases
within the abdomen, yet there was no fatal haemorrhage.
  It is also to be remembered that the infant's head, in its passage
through the external genitals, is so situated, that  its face may be.
in contact with the liquor amnii or blood, and in this way may be
deprived of air, or asphyxiated by impute air ; or the head may
be expelled, respiration established,  the labour cease, and stran- 
INFANTICIDE BY COMMISSION.
159
gulation be effected before delivery.   This case  is by no  means
unfrequent, every practical obstetrician has met with it, and should
it happen in the first labour, it is evident, that from the ignorance,
pain, or syncope of the woman, the infant may be destroyed.   It
therefore appears evident that we must duly consider all these cir-
cumstances before we can safely conclude there was  criminal in-
tention on the part of the mother.
  Infanticide by commission,  is indicated by contusions, wounds,
luxations of the cervical vertebrae, fractures of the extremities, tor-
refaction or burning, and asphyxia.
   Contusions and wounds.—The ordinary  effect of contusions is
ecchymosis, which will be more extensive, according to the situa-
tion in which it may be placed; but great care must be taken not
to confound this appearance with the cadaverous lividity.
  Ecchymosis, is  an extravasation of blood by rupture of capillary
vessels ; and hence  it follows  contusion; but it  may exist, as in
cases of purpura haDmorrhagica, scurvy and other morbid condi-
tions, without the latter; and we often  see persons arise from
sleep with numerous ecchymoses, which are sugillations, and call-
ed by the vulgar,  " dead men's pinches."
  When ecchymosis  is caused by injury, it generally appears  in
a short time,  or in a  few hours, but sometimes not  for days.   The
part appears  red and bluish, then black  or lead colour,  violet and
yellow, and is marked most  in  the centre.   Its progress and dura-
tion will be modified by age and constitution.
  It too often happens that  ecchymoses are confounded with  ca-
daverous lividities, which are more or less extensive, of a brown,
black, red or violet colour, forming rapidly after death, particularly
on the back, thighs,  sides, anterior surface of the body, upon those
parts upon which  the body  has lain  while  it has  been  becoming
cold.   These also appear where pressure is made by the clothes;
and from their resemblance to  the injuries caused  by flagellation
with rods, are called by the French  vergetures.   A more appro-
priate term is, cadaveric lividity or  sugillation.   These are fre-
quently observed in  the  most dependent parts of the lungs and
abdoiiiinial viscera.  Professor Andral's remarks upon this subject
are deeply interesting, and may be seen in the second volume  of
his Pathological Anatomy, translated  by  Drs. Townsend and West,
1831.   These sugillations will be modified by age, constitution,
state of the weather, progress to putrefaction, he.  They cannot 
160
GYNJECO-PIIYSIOLOGY.
be confounded with ecchymoses, as there is no effusion or infiltra-
tion of blood in the cellular tissue.   (See my work on Forensic
Medicine.)   Wre should also be cautious to distinguish ecchymo-
ses of the scalp, produced by parturition, from  those  that result
from violence.   The former are generally superficial, and situated
most commonly upon the vertex, occiput, or parietal bones; while
those produced by violence are  deep and  brown, and  in  various
situations, often on the temples.  When caused by labour, the in-
fant cannot have respired, and this  will be discerned in the manner
formerly mentioned.  If considerable  ecchymoses,  contusions, or
tumours exist upon an infant that has respired, there is just ground
for the suspicion of criminal violence.
  In some cases ecchymosis of the neck may be ascribed to pres-
sure of the orifice of the womb, or of the vulva, or by the twining
of the  umbilical cord round the neck, and  present the appearance
of strangulation; under such  circumstances, the respiration may
be impeded or prevented, the infant destroyed, the lungs evince
the signs of respiration, and the case will be involved in great ob-
scurity and difficulty.   Other facts must exist to warrant a correct
conclusion.
  Luxations of the cervical vertebra.—When death is produced
by luxation  of the cervical vertebrae, the ligaments of the vertebrae
will  be torn, the spinal marrow will be bruised or torn ; ecchymo-
sis,  and sanguineous infiltrations, will indicate  that the injury has
been inflicted during  life, as these phenomena cannot exist after
death.  It is to be recollected, however, that  such  luxation may
be the effect of injudicious attempts to extract the infant during
labou; and it is therefore necessary to ascertain if the parturition
has been difficult, and whether any action nas been applied to the
infant.
  Fractures of the bones or wounds often depend upon parturition
or upon the violence offered by ignorant and bad practitioners; it
is therefore  necessary to keep these facts in mind, in determining
questions of infanticide from such injuries.
  Torrefaction or burning, is a  horrible method resorted to  for
the  destruction of infants; a case of which, I grieve  to indite, has
occurred in this city within a few days.   Here it will be necessa-
ry to examine all injured parts, and to apply the ordinary proofs
to ascertain  if respiration had  existed.   In  the case to which I
have alluded the coroner (an attorney) was of opinion that a ver- 
INFANTICIDE BY COMMISSION.
161
diet of manslaughter could not be received.  The prisoner, a nur-
sery-maid, was acquitted !
   Asphyiia.—A new born infant may be asphyxiated  by priva-
tion of rc>pirable air, by'mechanical obliteration of the air passages,
by stiangulation,  by  submersion, or  by the  action  of  the dele-
terious  gasses.   The infant  will be  deprived  of air  by  being
placed  in a chest, or under  a pallet, &ic, but as some minutes
must elapse between its birth and death, the  usual  tests will  de-
cide that it has  respired.   Infants have been destroyed, whose
nostrils and mouth were filled with linen, hay, earth, he., to the
prevention of respiration: the presence of these  substances will
enable us to form a proper  opinion.   Infants have also been  de-
stroyed by pressure upon the  mouth and nostrils, trachea, and tho-
rax, and by forcing the tongue into the fauces; in all of which ca-
ses a few inspirations take place, and the pulmonary proof will be
decisive.
   In all these cases the rupture of the froenum linguae, the ecchy-
moses  of the  neck, the marks of injuries upon the chest, and in
the interior of the mouth, with the  signs of cerebral congestion,
afford very strong evidence against the accused.
   The introduction of fluids  into the trachea or lungs, is another
cause of suffocation ;  the discovery of the nature of the fluid by
chemical  analysis, enables  us  to arrive at a  positive decision
against the accused.   Submersion or drowning is a frequent mode
of infanticide.   The pulmonary evidence of  respiration, and the
similarity of the fluid  found to that which surrounds the  dead body,
 enable us  to decide that death was caused by submersion.  In such
cases there is  usually more  or less fluid in the stomach.   When
 death is produced  by strangulation, there will be ecchymoses on
 the neck and face, with cerebral congestion.   The most frequent
 mode of infanticide is the precipitation of the infant into the water
closet or privy, which may  be the effect of accident; but the pul-
 monary docimacy  will decide if  the  infant has respired.   In the
cases recorded by  Klein, the majority of the women were primi-
 parous.  I have known a woman of low  stature delivered of her
 first child  by  a single pain.
   In all cases of infanticide, we must  be certain that  the woman
 has been recently delivered,  and that this event  coincides  with
 the age of the infant.  The  signs of recent delivery have been
 already enumerated.  It is  right to  mention that infanticide has
         si 
162
GYNflSCO-PHYSIOLOGY.
been effected by the introduction of needles into the brain (Gui-
Patin, Brendel, Belloc) and into the temples, internal canthus of
the eye (Brendel), the neck, region  of the  heart (Fodere), and
the  abdomen.   Infants have been destroyed  by poisons, which
have been applied  by  inhalation  into the  lungs,  by commixture,
with food, absorption through the skin, and by  enema.  These are
to be discovered by the usual tests.
   Before concluding this subject, it  is necessary to  prove the  va-
lidity of the  statement, that the hydrostatic test is no longer con-
sidered conclusive.   Some of our best jurists cling to it with a de-
gree of tenacity, which, to speak in the mildest terms, is exceed-
ingly remarkable.   Drs. Beck and Gordon Smith  think it decisive
with due precautions;  and a reviewer in the Edinburgh  Medical
and Surgical Journal, in 1826, perhaps Dr. Duncan, thinks it affords
presumptive  evidence.  The opinions of these  talented and distin-
guished professors are  of course entitled to respect and much con-
fidence ;  but  it is to be recollected, that the Judges of the land will
not receive the evidence afforded by this  test.  This is not the place
to discuss the propriety of this  conclusion.  Whether the recent
modification of the  law on the subject is a sufficient reasons, law-
yers only can determine.   As the law now stands in this country,
the questions to be decided in cases  of infanticide are, has death
been caused  by violence, neglect,  or ill-treatment?   The same
evidence is required as in  cases  of homicide.   The  question of
child-murder is still, however interesting; for if the infant has been
born alive, there is  presumptive evidence against the accused ;  and
secondly, the decision  of the question will  affect the disposition of
property in cases  of tenant  by courtesy,  as  already  mentioned.
The law in this United Kingdom, Scotland  excepted, and in  al-
most all nations in Europe, is, that  a child is  born  alive, when it
evinces the slightest voluntary motion.   A curious decision, made
on this point  by the Court of Exchequer at Westminster, has been
already recorded.   According to the law  of Scotland, the infant
must cry  to  prove its  vitality.  This is manifestly  absurd, as
asphyxiated infants  have been resuscitated after  an hour and a half,
as I have often witnessed; and infants have been declared dead,
the undertaker sent for, and every preparation  in  progress for bu-
rial,  though resuscitation was finally established after some hours.
   In cases of still-born infants, I have more than once succeeded
in establishing the action of the heart, and one or more inspirations 
VALUE OF HYDROSTATIC TEST.
163
 though complete respiration could not be established ; and in such
 cases no physiologist can doubt the vitality of the infant.
   Dr. Blundell and others have succeeded in resuscitating infants,
 extracted  by gastro-hysterotomy, a quarter of an hour after the
 death  of the mother;  and  a case  was recorded in the Lancet,
 where the infant was pronounced  by the medical attendant to be
 dead, it was placed as  if dead, and on  his visit next  day it was
 alive.
   The unanswerable objection to the hydrostatic and other tests,
 is this, that when  the infant breathes before delivery, which every
 practical obstetrician can attest, no test can prove it out-lived birth.
 Again, if we credit the records of medicine, we can have no doubt
 but that there may be intra-uterine, vaginal, and  extra-uterine re-
 spiration  before complete delivery.  Dr. Beck  and other jurists
 seem to doubt the reality of respiration in the first and second case;
 but it is fair and reasonable to inquire  what object could influence
 those who have narrated such cases ?   Europeans and  Americans
 are among the number.
   Dr. Beck, who is an ornament to his  profession, and an honour
 to his country, employed all his argumentative powers against the
 probability of an  infant, whose head was expelled, and who  had
 respired,  losing its  life  during delivery.   His  countryman,  Dr.
 Hossack,  has recorded a case in point.   But suppose the accused
 do not allege uterine, vaginal, or extra-uterine respiration, before
 complete  birth,  are not the judges warranted to temper justice with
 mercy, and to give the prisoner the benefit of the reasonable doubt
 in such a  case ?   Most decidedly.
   To return to  the hydrostatic test, from which I have so far di-
 gressed ; I have to state  in conclusion,  that Drs. Duncan, Beck,
 and Gordon Smith, maintain  it may afford  presumptive evidence
 in infanticide.
   But the following facts must be  kept in recollection:  1.  the
lungs of a still-born infant will sink in water, but float on the sixth,
seventh, or eighth  day, when  putrefaction has commenced (Muyer
in Schlegel,) and  so early as the third  day, in warm weather,
(Beck.)
   It is  universally  known, that the body of a  drowned  person
sinks at first, floats when putrefaction has generated air, and ren-
dered it lighter than water; and sinks again, after the extrication
of the air  so generated.   When the lungs of an infant are  putrid, 
164
GYN^CO-PHYSIOLOGY.
the air is near the surface (W. Hunter, Jaeger,) and can be readi-
ly squeezed  out by pressure, wdien the lung will  sink; whereas,
when respiration has taken place, no pressure will cause the lung
to sink.   (Marc. Beclard.)  The lungs are the last organs in the
body which  undergo  putrefaction.   (Camper, Mahon,  Beck.)
Marc is of opinion that the lungs which have respired, and are af-
terwards in a state of putrefaction, will always crepitate on inci-
sion, which never happens unless  respiration  has occurred; se-
condly, on squeezing the putrid lungs of a still-born infant they
will  sink, whereas those of a child born alive will float.
   2. Squeezing the lungs  after  artificial  respiration   will not
cause them to sink ; in such cases, the lungs swam even with the
heart attached,  and also  when cut in pieces, and carefully com-
pressed.   (Mendel, in Hufeland's Journal  der Practischen Heil-
kunde, Aug. 1812 ; Bernt, Experimentorum Docematian Pulmo-
num Hydrostaticam illustrantium centuria, Vienna, 1823 ; Merz«
dorff in Horn's  Archiv. fur Medezinische, Erfahrung, 1823.)
   All authors are  now agreed, that  there is  not  any difference
between natural and artificial  respiration in the cases under notice,
(Edinb.  Med. and  Surg. Journ. 1826, vol* xxvi.) " and the hy-
drostatic test can never prove positively that the child was still-
born, but only that it had not breathed. "   Op. Cit. p.  389, "  at
the same time, it will yield strong presumptive evidence. "   " On
the whole, then, it follows, from the preceding statements, that
when due precautions are observed,  and when certain exceptions
and  corrections are  made, the floating of the lungs affords at least
strong  presumptive evidence that the child out-lived delivery. "
p. 374.
   Dr. Beck arrives at the following  conclusions on this point:
   1. That when the lungs float in water, it must  be from one of
these causes ;  natural respiration, putrefaction, or the artificial in-
troduction of air.
   2. As the lungs may float  from other causes besides respiration,
there mere floating is no proof that the child was born alive.
   3. As whenever it is possible to discriminate between the float-
ing of natural respiration and of that which is the result of other
causes, it follows,
   4. That with  due precautions, the floating of the lungs may  be
depended upon  as a safe and certain test that the child has been 
VALUE OF HYDROSTATIC TEST.
165
  born alive.  The same distinguished jurist arrives at the following
  conclusions, on sinking of the lungs in water :
     1. That  when the lungs sink  in water it must be from one or
  other of the following  causes :  the total want of respiration, feeble
   and imperfect respiration,  some  disease  of the lungs,  rendering
   them specifically heavier than water.
     2. As the lungs may sink from other causes than the absence of
   respiration,  their mere sinking is no  decisive proof of the child's
   having been born dead.
     3. As, however, the sinking from the  want of respiration may
   easily be distinguished from that which is the result of other cau-
   ses, it follows,
     4. That with due precautions, the sinking of the lungs is  a safe
   test that the child was not born alive.
     It is very evident from the preceding statements, that a great de-
   gree of caution is necessary in every  case, before a decision can be
   given with  confidence ;  and from  the difficulties of the subject,  a
   few practical rules may  be laid down for the guidance of physi-
   cians and surgeons, when called on to give evidence in  cases of in-
•   fanticide.
     The general appearance and condition of the body should be
   carefully noted, and also the situation in  which it had been found,
   all instruments which might be used criminally, the size, weight
   and length of the infant, the proportion of different purts, the de-
   gree of development, the  signs  of putrefaction,  desquamation of
   the cuticle, the appearance of the navel, and of every part of the
   body.   We  should examine whether there be contusions, ecchy-
   moses, excoriations, and be careful not to confound them with ca-
   daverous lividity ;  if any lesion is  found, its precise situation and
   extent must  be described.  If wounds  exist,  their form, length,
   breadth, depth, must be accurately  noted.  The appearances of
   the head must be observed, and care taken not to confound those
   which are  produced by  parturition with those  produced by  exter-
   nal injury.   We should ascertain  whether or not there be foreign
   bodies in the ears, nose, eyes, and mouth, or marks of injury up-
   on the neck,  dislocation of  the cervical vertebra?, whether the chest
   be arched  or flattened, and when compressed, if a fluid escapes
   from the mouth or nose;  whether the abdomen be soft or tense, if
   the umbilical cord be flaccid, dry, moist, detached,  cut, or lacera-
   ted, and its exact length,  or if the navel be red, in a state of sup- 
166
GYNJECO-PHYSlOLOGY.
puration or cicatrization ; if the testicles  have  descended ; and
finally, whether there are dislocations or fractures of the superior
or inferior extremities.
   Such  are the  principal points to he attended to  in  the inspec-
tion of the external condition of the body ; all appearances should
be taken down in writing, and  the document carefully preserved,
as  the witness may produce it  at  a trial,  or refresh his memory
from it ; whereas he cannot use a copy  in either case, especially
in this country.  The next part of our duty is to examine the ex-
ternal  parts of the body, and here  also the appearances are to be
recorded.
   Autopsy-Dissection.—Medical jurists are not agreed upon the
method of  dissection, in cases  of infanticide,   Drs.  Beck and
Smith  think it most convenient  to commence the dissection with
the mouth and cavities  leadjug  tothe  chest.   M. M.  Chaussier,
Renard, Briand, and others, commence with the spinal  canal, then
proceed to  open the headj'trtOrax, mouth, pharynx, and  passages
to the  chest and abdomen, and the abdomen.   The former mode
is  more  convenient, and I think the best.  It  is briefly as fol-
lows :
   The neck is to be placed on a block of wood, so as to render its
anterior surface prominent.  We must first observe whether the
mouth  be open or closed, if the tongue  is protruded, or turned
back into the  fauces.   An  incision is then to be made from the
lower lip to the upper extremity  of the sternum, and another along
the lower edge of the  inferior maxillary bone ; the integuments
are to  be dissected back, and all marks of  violence,  ecchymoses,
he. noted.   The lower jaw is now to be  divided at its symphy-
sis, the parts attached to  its internal surface divided ; the tongue
should be depressed,  when  there  will be a complete view of the
mouth and pharynx.  We should carefully observe whether there
be any foreign body or  sanguinolent appearance, and if the glottis
and epiglottis be natural, and if there be fluid in the larynx or tra-
chea.   The abdomen is next to be examined, an incision is to be
made  from the sternum to the  spine of the ilium  on each  side,
the flaps turned back, and the umbilical vessels observed and tied.
We are next to observe the appearances of the abdominal viscera,
and to note every thing unusual.   We should ascertain if the um-
bilical  vessels be empty, or contain coagulated blood, if cut  or la-
cerated, if the ductus venosus be permeable or obliterated.   The 
MODE OF DISSECTION IN INFANTICIDE
167
Bize of the liver should  be noticed, its large vessels tied, and the
organ removed  and weighed ; but previous to its removal the gall
bladder is to be inspected, the colour of its bile noted, or whether
it be entirely empty.  The stomach should be  removed, its aper-
tures having been tied,  and its contents,  if any, carefully  exam-
ined.   We should further  observe  whether the intestinal  canal
contains meconium, faeces, or other matter, or presents any sign of
disease ; and lastly, if the  bladder be empty, or full of urine.
  The cavity of the thorax may be opened in the ordinary  man-
ner; but on dissecting the  integuments, every  appearance  of le-
sion is to be noted, and a minute examination instituted, in  order
to discover if the chest has been punctured.   The cartilages  of
the ribs are to be divided  with a scissars, in preference to a scal-
pel.   We should next examine the size and colour of the  lungs;
if of a dull red,  or  rosaceous ;  if these organs fill the thoracic
cavities ; and if the tendinous centre of the diaphragm be depress-
ed.  \\ e are to take  into account the size of the heart, the dimen-
sions of its cavities, if they contain blood, the colour of its tissue,
the degree of opening or closure of the foraman ovale and  ductus
arteriosus, the presence  of  fluid or coagulated blood, always recol-
lecting that the most  dependent  portion of the lungs is  engorged
with blood and brownish, and that  the site of this engorgement
will vary according to  the  position  in which  the  body had lain
while becoming cold, and that this appearance  will be greatest in
proportion  as the patient has not lost blood.  After having exam-
ined the (esophagus  and trachea, and noted their appearances, the
large vessels are to be tied, the lungs and heart removed, and the
former subjected to the  hydrostatic and other tests, in the manner
hereafter mentioned.  In examining the vertebral column or spine,
an incision is to be made from the occiput to the sacrum, the  in-
teguments and  muscles carefully removed, and the annular portion
of the vertebrae divided  with a strong scissars, which may be intro-
duced under the fifth lumbar vertebra.   During this examination,
we must observe  all  lesions, ecchymoses,  dislocations,  fractures,
wounds and punctures ;  but we must not consider the congestions
of the spinal veins, or the  presence of limpid, yellow or  viscous
serosity, the effect of violence, as these are ordinary occurrences,
and will be found in  such situations as the posture of  the  body
favours.
  The best mode of opening the head  is to make an incision from 
168                  GYNKC0-PHYSI0L0GY.
the root of the nose to the third or fourth  cervical vertebra, and
another from ear to ear ; the integuments are to be dissected back,
and all legions carefully examined and noted, wounds, punctures,
fractures,  he.   A small opening is to be  made with a  scalpel,
through the anterior fontanelle, and the  sutures divided by a scis-
sars, great care being taken  not to wound the  sinuses or larger
vessels ; the bones of the cranium  can be easily separated in this
manner.   We are now  to ascertain if there be blood in the ventri-
cles, or on the base of the brain, to remove the cerebrum and cere-
bellum, and carefully dissect both.
   The examination of all the organs having been  completed, the
inferences to be drawn  will be evident.   But to render the  infor-
mation as  complete as  possible, it  is necessary to describe the
method of instituting the hydrostatic test.
   The water  in which  the lungs are to be placed must not be too
hot nor too cold, but of the temperature of the atmosphere;  it
should contain no salt.  If  these  precautions  are observed, the
lungs, with the heart, will  float or sink in water ; if they float it  is
proper to  notice, whether upon or under  the  water; if they sink,
whether gradually or rapidly.
   The lungs are to be taken out of the vvater, the large vessels tied,
the heart separated, and the organs then  weighed, to ascertain the
proportion they bear to the weight of the body.   They are  to be
immersed  again, then the lobes separately, and lastly, each  to be
cut in  small  pieces; on incising it, we  should  note  if there be
crepitus,  the  tissue compact, or in a morbid  condition.   Should
the fragments  float, they are  to be firmly  squeezed in the hand,
and again  placed in the water.  The inferences to be  drawn from
these experiments are  the following, according  to Dr. Beck.—
When  there is nothing on the body of the infant to account for its
death during delivery, the lungs untouched  by  putrefaction, or ar-
tificial respiration, affording a  crepitus on incision, floating entire
or in segments on the surface  of the water; and if the segments
float, after firm pressure, then the  evidence is irresistible that the
infant was born alive, and  enjoyed  perfect respiration.   If only
the right lung or its pieces float, the respiration  has been less per-
fect.  If some pieces only float while  the greater number sink,
respiration has  been still  less  complete.  If neither  the entire
lungs nor  any  section of them float in water, the evidence is deci-
sive that the child never respired. 
            MODE OF DISSECTION IN INFANTICIDE.          169

  It is right to mention  that  Professor Bernt is of opinion that
Ploucquet's test affords  decisive evidence in  a few cases, and  no
more than presumptive evidence in the  rest.   It is scarcely neces-
sary to remind  the medical  jurist that  he should  ascertain if the
woman has been  recently delivered, and learn the whole history
of her case.  The signs  of recent delivery have been already enu-
merated.   He should inquire whether the labour  was sudden ; in
what position  it took place ;  if the infant was born  immediately
after the rupture of the membranes, or  how soon  after ; if delive-
ry took  place without assistance,  or what assistance was afforded ;
if there  was  haemorrhage before,  during, or after  delivery ;  on
what day and  hour  did labour commence, and did the birth take
place :  if the woman was insensible before, during, or after deliv-
ery ; if the infant respired, if not what  attempts were made to  re-
suscitate it.  All these questions should be put in a mild  manner,
the solemn  duty of the  medical jurist being to ascertain the facts,
and to take no interest  in the prosecution or acquittal of the  ac-
cused ;  he should confine himself solely to the duties of  his pro-
fession, and strenuously  avoid putting, what lawyers call " leading
questions, " or intimidating the  accused, or  violating one of  the
best principles  of  our humane laws, by extorting a confession, or
inducing a suspected female to  criminate herself.   His sole duty
is to give the received opinion of his profession, regardless of con-
sequences,  but,  on  all doubtful cases, leaning to the side of mer-
cy.
   In the foregoing  dissertation  I have  only  discussed the princi-
pal  points  which claim  attention in cases of infanticide.  Many
more particulars will be found in my work on Forensic Medicine,
more especially in the article on homicide, where the danger  and
mortality of wounds, contusions and fractures, are duly considered.
Enough, however, has   been  said to warn the young practitioner
against  committing errors, which have but too often led to the ex-
ecution of innocent  women.   1 might illustrate this  assertion from
the authority of  Dr. W. Hunter, but  his opinions  are  too well
known to require  expression in  this place.  The most scrupulous
caution must be observed in  estimating all the morbid appearan-
ces, and distinguishing  those  which  result  from  accident  and
crime.
■x 
170
GYNJECO-PATH0L0GY.
                    CHAPTER  III.

                 gyn^eco- pathology.

                    Diseases of Women.

Under this head we have to consider every  morbid condition of
woman, relating to her genital functions.  The subject may be di-
vided like the last into lour  parts :  1.  Parthenosology, or Disea-
ses of Nubility ;  2. Encyonosology,  or Diseases of Pregnancy ;
3.  Dystocia, or Difficult Labour, or Morbid  Parturition :  4. Lo-
chianosology, or Diseases of the  the Puerperal State.

   Article I.—Parthenosology—Diseases  of Nubility.

    Section  1.—Diseases of the External Genital  Organs.
   Besides irritation and inflammation,  the  external organs pecu-
liar to the female sex are subject to warty and fungous excres-
cences,'scirrhous, polypous, fungoid, cedematous, and hernial tu-
mours.  The external labia  are  often attacked  with  excoriation
and ulceration, especially in young infants, sickly girls  (see p. 76),
and adult females, particularly in warm climates, in consequence
of want of cleanliness.   The surfaces of the labia very frequent-
ly  cohere, so  as  to close  up the genital fissure,  leaving only a
small aperture  for  the  passage  of the urine.  I have  met with
some cases of this kind, where there  was  no appearance of the
outer fissure, except a small  opening at the superior part.   This
cohesion is induced by  want of proper attention  to  cleanliness,
and especially in irritable subjects, who seldom wash, unless after
indisposition.  (Riolan, Moinichen, Boivin.)—When this adhesion
of the  surfaces occurs  to children,  it may  be often relieved by
pressing on the labia in opposite directions ; and should this not
cause separation, an incision must be made, simple dressings ap-
plied, the surfaces healed, and reunion prevented, by the intro-
duction of pieces of lint during the healing  process.  I know two
young ladies who have  perfect cohesion of the labia, a small ori- 
i
            DISEASES OF THE EXTERNAL GENITALS.         171

flee  remaining superiorly, while  the remaining three of the same
family are naturally formed.
   Sometimes an epidemic  ulceration of the labia,  extending to
the groin, has been observed.  This is ushered in by small grey-
ish  pustules, which become  inflamed.  The ulceration takes on
the  appearance of hospital  gangrene,  is accompanied  by fever,
great prostration of the vital powers, and often by  death.  This
disease was described  in  the article Violation  of  Women.   It
mostly attacks weakly and  delicate children, and seldom proves
fatal to the robust.   It  is a fatal  disease,  though Duges asserts it
is readily cured by nutritious diet, change of air, and the antiphlo-
gistic regimen.
   In the first stage of this disease we have  to treat phlegmonous,
and  often  erysipelatous inflammation,  by  leeches,  fomentations,
hip-baths, and the  antiphlogistic  regimen.   When  sloughing  sets
in, accompanied by typhoid symptoms, we must employ quinine,
wine, porter, and nutritious aliment ; and locally, chlorate of so-
da or lime,  port-wine poultice, with laudanum, and if the pain is
violent, lint moistened with a solution of theextr. opii, over which
a warm linseed meal poultice should be placed.   The  bowels should
be regulated with castor oil, and if the pain continues very urgent,
a  draught composed of camphor julep, ether, andtinct. opii. must
be given every three  or four hours.   When  the slough remains
undetached, the application of strong nitric  acid, every third  day,
will  often afford great relief.   (Travers.)—The London treacle
poultice is often highly useful.  When the colour of  the surround-
ing skin is pale, a lotion composed of ten  drops of diluted nitric
acid in an  ounce of water, is the best remedy,  Mild nutritious
diet, as eggs, milk, jellies,  both  animal and  vegetable,  mutton
chops, and a free use of port wine, with quinine, and broth, are in-
dispensable.  This fatal disease  sometimes attacks   infants,  and
also  adults,  who are infected  with syphilis, and generally proves
fatal  to the latter when mercury is employed.  (See  Sir A. Coop-
er's Lectures on Surgery, and Travers on the Pathology of Ven-
ereal Affections, 1830.)
   Inflammation of the labia is generally of the phlegmonous kind,
aud comes on rapidly, and usually terminates in abcess within thir-
ty-six hours.  If we  be called early,  resolution may be affected
by leeches, fomentations,  hip-bath, or purgatives.   The abcess
generally  points on the inner surface  of the labia, and  is to be 
172
GYN .SCO-PATHOLOGY.
 promoted, when inevitable, by warm fomentations and  poultices.
 The pain is so  great in this disease, that we must resort to large
 doses of opiates,  and  much relief will  be also  experienced  by
 keeping the limbs separated by means of a pillow.  This was well
 illustrated in a case which I saw with Mr. Hughes, of High Hol-
 born,  in  Burton  Crescent.  When severe throbbing, pain, and
 tension have continued for thirty  or forty hours, we  are often
 called on to open  the  abcess, in  order to afford  relief.   Such
 an operation ought to be avoided, if possible, as considerable bleed-
 ing may occur from the smallest puncture, owing to the vascular-
 ity of the  part.  This is not  always  the case.   I opened  an
 abcess of the left  labium,  in the presence of Mr. Woodhouse, of
 Ilford ; there  was  no  haemorrhage.   (See Gynaecotomy.)—It  is
 also worthy of mention, that if the abcess be opened, the opening
 will  appear indisposed  to  heal, and frequently becomes fistulous;
 while if it bursts of itself, it will heal kindly. The opening, wheth-
 er natural  or artificial, should be dressed with the mildest ointment
 and  the  irritation of the urine obviated  by the  application of a
 cloth dipped  in cold water during  the discharge of  the fluid.—
 Sometimes the  inflammation will be arrested  in  its progress, and
 an enlargement of the  labia be produced.  This may  be removed
 by the use of cold  applications, as  the solution of the acetate of
 lead, or even plain cold water.
   The labia may burst during labour, or become filled  with blood ;
 but of this I shall treat hereafter.
   Vai-ious kinds of tumours and morbid excrescences  may appear
 on the labia, and are to be treated on the usual principles of sur-
 gery, by ligature, pressure, or excision.
   The labia may be attacked with dropsy, when that disease at-
 tacks the limbs or abdomen, but will generally disappear by the
 usual  treatment.   Simple  purgation will in general  remove  it.
 We  occasionally observe hernia,  or  rupture, presenting  at the la-
 bia.   The best treatment is the application of pressure, and the T
 bandage.
   The most troublesome  disease of the labia  is a violent itching
or stinging, called pruritus.  There is a slight  redness and  an in-
 creased mucous discharge in some cases.  This disease is often so
 urgent as to put decency at defiance, the desire to scratch the af-
 fected part being so  indomitable, that it must be indulged.   The
worst species of this  troublesome disease occurs during pregnane), 
            DISEASES OF THE EXTERNAL GENITALS.         173

and according to Dr. Denman, when the  child is dead.   It may
appear at any period of life,  and may be induced by diseases of
the bladder, vagina, or  womb.
   The treatment consists in  attending  to the  general health, ad-
ministering purgatives, and applying various  lotions and ointments
to the affected parts.  Solutions of alum, zinc, and acetate of lead,
or ointments of these, are sometimes  used with advantage.   Dr.
Denman found simple  ablution with cold water, or  vinegar and
water, the most useful remedies.  Dr.  Clarke, of Dublin, recom-
mends the application of warm water,  which afforded great  relief
to a patient about whose case I was also consulted.   Sulphur is
employed in some cases with success.   The  disease will  often
withstand  all treatment, especially if it occurs during pregnancy ;
and yet it will disappear immediately after delivery.   Dr. Hamil-
ton, of  Edinburgh, had once  a  lady under his care,  who was so
distressed with this disease, that she threatened to commit suicide.
Dr. Dewees recommends a solution of borate  of soda, or common
borax, as  he discovered an aphthous eruption on the inner surface
of the labia, which  he thinks is the cause  of this  complaint.   I
have tried this remedy without the desired effect.   A lotion com-
posed of hydrocyanic acid is  also beneficial in  many cases. Some-
times a milder form of itching arises from insects.  The applica-
tion of  strong mercurial ointment, solutions of oxymuriate of mer-
cury, of sulphate of zinc, spirits of wine or brandy, will give im-
mediate relief.   When  the disease arises  from irritation in the vi-
cinal organs, as the vagina, womb, or bladder, our attention must
be directed to them.
   Ulcers  of the  labia are sometimes mistaken for venereal chan-
cres, but the history of  the case, and the appearance of the sores,
will always determine their real character.   There is a great vari-
ety of these ulcers; they appear from  the size  of  a  split pea to
the size of a sixpence.  I have seen an ulcer of  this  kind on  the
internal surface  of the labium cause the  intolerable  itching just
described, and withstand both constitutional and  local treatment.
It yielded to nitrate of  silver.  Sometimes ulcers of this  descrip-
tion will be foliXved by sore throat, and may disappear without the
use of  mercury.   Mr. Abernethy has  described  ulcers on  the
male organs which produced  the same  effect, though not venereal.
The labia  are liable'to soft, fungous, or warty excrescences, which
may arise without any venereal or syphilitic cause.   They gene- 
174                 GYN.EC0-PATHOLOGY.
rally yield to escharotics, savine cerate, or nitrate of silver; they
may require  the  use of mercury or ligatures; but, in general, a
saturated solution  of alum, with compresses, will  stay such hae-
morrhage.   The  solution is prepared  from an ounce of powder-
ed alum and a pint of water.
  The mons veneris or pubes,  may  be attacked with  a herpetic
eruption, which  produces great itching.  The greatest relief will
often be  obtained from washing the part with warm water.  Evi-
dence has been  afforded  of this  disease  producing miscarriage.
The various lotions enumerated, when treating of pruritus, or itch-
ing, may be also employed, or ointments prepared  from the vari-
ous antipsoric remedies.   The compound  sulphur ointment will
sometimes afford relief.   Cleanliness is of the first  importance in
the treatment of all cutaneous diseases.
  The clitoris is subject to nearly all the  diseases incidental to
the labia; but elongation and  enlargement are the  most common.
The removal of the part by excision is  the  only remedy in  these
latter diseases.  Cases are on  record,  where it  had increased to
the size of a cauliflower.   If  over stimulated by masturbation,  it
may cause general debility and epilepsy; and when such  propen-
sities are unrestrainable, excision  becomes necessary.   Idiocy and
fatuity are said to have been induced by this practice.   Malform-
ation of this and the other external genitals  has given rise  to what
is called  herrnaphrodism, and   of this  I shall speak in the article
Sterility.   The clitoris may be attacked with scirrhus and cancer,
when it becomes thickened and enlarged. It has formed a tumour
nine inches  in length, and fourteen in  circumference at the larger
end;  the circumference of the  small end was five inches,  and the
tumour has  been cut off by Mr.  Simmons,  as related in the Lon-
don Medical and Physical Journal, vol. v.  (De Graafe, Bartholin,
Richerand,  Riolin.)—The clitoris has  been the seat of cauliflower
excresence, and then must be  removed by  excision, an operation
common on the Continent, but rare in  the British dominions.
  The nympha are  subject to all the diseases  incidental to the
outer labia,  which are to be treated on the  same principles.  This
part is most liable to elongation.  So long as the elongation is not
productive of inconvenience, it is not  to be considered a  disease.
It is a rare  occurrence  in  this country, and may continue for  a
long time before  it produces  any inconvenience.  If the growth
be considerable, it becomes irritated, inflamed,  and ulcerated, so 
           DISEASES  OF THE EXTERNAL GENITALS.       175

as to impede the ordinary motions of the female, and also sexual
congress.   It then must be  removed by a simple  incision ; and the
operation may be in general performed without exposing lt\e fe-
male.   Dr. Burns observes, that the part is  so vascular as to re-
quire a  ligature, or pressure, to restrain the bleeding after excision;
for by neglect the patient may lose blood to fainting ; while Mau-
riceau and  Denman, names that cannot be mentioned without the
highest  respect, assure us that there is no  danger of  haemorrhage
after excision, or no necessity of applying a single ligature.   In
some  countries this elongation of the nymphae is natural and com-
mon to  the other  sex.   The  nymphae may be ulcerated and irri-
tated  by cohesion of their surfaces.  These parts may be distended
with blood  during labour, producing a black  and painful tumour.
This  tumour  has been mistaken for  the  membranes,  and pierced
by the  midwife, causing a considerable discharge of blood.  This
disease  mostly occurs  after  labour, and is so  painful as to induce
fainting.  It has caused sloughing,  and  destroyed the  perineum,
the vagina  and anus forming  a common  opening.   The tumour
may burst, and  allow the discharge  of  clotted  and  fluid blood.
This event may be promoted by warm fomentations and poultices,
and the pain abated by opiates ;  but when the  pain was almost in-
tolerable, Baudelocque opened the part,  evacuated the contents,
and then applied  pieces of  lint, dipped in a solution  of alum, to
prevent haemorrhage.   Plenck relates a  case, in  which five pints
of blood were lost by the  sloughing  process.   Perfect  describes
a case nearly similar.   Burns and Dewees have  given very inter-
esting accounts of this disease.  If  the tumour be opened,  burst,
or slough,  a proper compress is to be  applied,  to prevent the  loss
of blood ;  and when inflammation or gangrene supervenes, they are
to be treated  in the usual manner.   The external orifice  formed
by  the labia,  named os externum, may  be lacerated, contracted,
cicatrized,  or ulcerated ; and these states  are to be treated as  al-
ready described.
   The hymen may close up the  orifice of the vagina, and prevent
the escape  of  the menses;  the womb becomes distended, the va-
gina protruded, so as to resemble  polypus, or  inversion  of  the
womb ;  even  the perineum may be put  on the stretch, as if  the
child's head were in  the  pelvis.  National and foreign authors
confirm  the truth  of these assertions.  Smellie and Denman  de-
scribe such cases ; and Benevoli relates  a case, in which  he per- 
176
GYN.ECO-PATHOLOGY.
forated the hymen, when thirty-two pints of dark-coloured fluid
escaped.  Cases  are  related by  F. Hilden, Fab.  Abaq.  Wier,
Benevenius, Chamberlain ; Frye, in Medical Facts and Observa-
tions, vol. viii. p.  135 ;  Sherwin,  Medical Records,  he., p. 279;
Koeyner, in Medical Annals, vol.  vi. p. 347 ; by Eason, in Med-
ical Commentaries, vol. ii. p. 187 ;  and  numerous other authori-
ties might be quoted.   Smellie mistook the protruded hymen for
he membranes ; he ruptured it, and two quarts  of  blood escaped
Denman ordered an incision  through the hymen of a female, aged
twenty-two, when the menses escaped in  a fluid state.  Bardy
relates the case of a girl, aged fifteen, whose hymen was imperfo-
rate, and covered with  scab.   The external parts were  greatly
protruded, and pain,  like that of  labour,  was urgent.   He made
an incision through the  hymen, and allowed six  pints of gelatin-
ous fluid to escape.   Medical and Chirurgical Review, 1807.)—
These cases prove the necessity of caution, in exhibiting medicines
to promote menstruation, in  those cases  in which  the  discharge
has not yet appeared, lest there be imperforate hymen, or cohesion
of the labia or vagina.   Brown, the African traveller, states that
in certain parts of that  country there  was an operation performed
on girls between the eleventh and twelfth year, to render the va-
gina imperforate (infibulation,) in  order to preserve  virginity until
the time of marriage.   When the menstrual secretion is retained
behind the hymen, it always remains fluid;  and when  allowed to
escape, after the incision of  that  membrane, it  resembles tar or
liquid pitch.   Sometimes this membrane is so rigid as to prevent
the completion of marriage, so that it must  be  divided by incis-
ion.
   The perineum, or remaining part of the external  organs of gen-
eration of females, may be lacerated more or less, by the  passage
of the infant during labour.   This laceration is induced by attempts
to dilate the vulva.   In order to  prevent its occurrence, pressure
as always made with the palm  of the hand against  the  protruded
part  of  the head,  while  distending on this part.   When the peri-
neum is  torn, it is to be united by the first intention, the limbs  of
the patient are to be kept closly together.  Sometimes sutures must
be employed ; one or two are  sufficient.   Again it may become
necessary to irritate  the  surfaces of the lacerated parts, to induce
their union.   This is rarely requisite.  The bowels  ought to be
kept  relaxed, and  the  urine  should be  prevented  from irrita- 
           DISEASES OF  THE  EXTERNAL GENITALS.        177

tin* the parts.  A cloth dipped in cold water, or pieces of lint
smeared with simple cerate, should be applied, when the bladder
is about to  be emptied.   This disease  has been induced by  vio-
lence as in  cases of defloration.  The  bladder in some cases is to
be evacuated  by the catheter.
   The rectum also suffers  during labour, and  may be  torn inside
the perineum, when the faeces will escape into the vagina, and
cause much irritation.  Pledgets of lint are to be applied, so as to
Obviate that offensive and  troublesome disease.  The principal
operations to  be performed on the  external organs peculiar to fe-
males are, separating the labia ; opening abscesses in these parts ;
extirpating the clitoris, or nymphae; perforating the hymen ; mak-
ing sutures in the perineum ;  and introducing the catheter.

  Section 2.   Diseases of the  Internal Organs of Generation.
   The internal  organs of generation are the vagina, uterus, Fallo-
pian tubes, ovaria, broad and  round ligaments of the womb ;  and
to those may  be added urethra  and bladder.
   The vagina may be wanting, unusually small, impervious from
adhesion, tumours, or a  froenum passing across, above the hymen,
or its middle  may  be filled  with a fleshy growth.  If too narrow,
it may be dilated with a bougie, or tent of sponge ; and when unat-
tended to, must  be divided by|inscision,  to admit the passage of the
infant.   It has  closed up after impregnation.  There is sometimes
a great congenital  confusion of  parts :  indeed, it would be tedious,
if  not  impossible, to  describe  the  varieties of conformation.   It
may open  into  the bladder, urethra, or rectum ;  and  these devia-
tions  do  not prevent impregnation.   It  may be attacked with
phlegmonous, ande rysipelatous inflammation,  abscess,  gangrene,
adhesion of its surfaces, ulceration, scrofulous, cancerous, scirrhous,
polypous, fungous, sarcomatous, and various other tumours, with
leucorrhoea, gonorrhoea, morbid  dilation, from tumours, or inversion
of the uterus, calculous, concretions;  and it may be  implicated in
the morbid diseases of the vicinal organs.   It may be inverted
partially, or completely; it may be the seat of hernial or dropsical
protusions, or of prolapsion of portions of the bladder;  it may be
implicated  in perineal hernia, or in  indolent abscesses and encysted
tumours, of the contiguous organs.   When labour is too long con-
tinued, the pressure of the  infant's  head on the vagina and neck of
the bladder causes sloughing  of these  parts, forming the disease
        23 
178
CYNJECO-PATHOLOGY.
called vesico-vaginal fistula.   The  urine escapes  through  this
opening into the vagina, and produces  inflammation  and abscess.
It is of rare  occurrence, as  Dr. Clarke, of  Dublin,  had seen but
four cases of it out of ten thousand.  Yet I have now been called,
after the accident had happened, to ten cases out of one hundred.
It is a most painful disease, as the  urine soon irritates the vagina;
and  from its constant discharge into that part, renders the  female
a most pitiable object.
   This disease will be relieved, and  ultimately cured, by keeping
a catheter constantly in the bladder,  and plugging the vagina with
soft  pieces  of old  linen or calico,  smeared with simple ointment.
The woman  should lie on either side or on her face, so that the
urine may be retained  by the  sound  part of the bladder.   If this
caution were attended to, we should  have heard less of incurable
cases of this sort.   This plan succeeded in a case deemed incura-
ble by the surgeons in  the Middlesex Hospital, which I  saw under
the care of Mr. Cooper, and which was finally cured by the mea-
sures here recommended.   The  plug prevents irritation  produ-
ced  by the  urine.   The general  health  should be attended to,
and  an opiate given at bed-time.   I have had  a case at the Royal
Western Hospital during the  last summer, which was of fifteen
years' duration.   The woman  had been  under the care of  Dr.
Colles of Dublin, Dr. D. Davis, and Dr. Ramsbotham.   She sta-
ted,  that each of these gentlemen had assured  her  the opening
was  so large as to  admit the whole of the fingers.    On examina-
tion, I found the opening not larger than the disc of a shilling, and
scarcely capable of admitting the point of the index finger.  This
case shews  bow far these  fistulae  may contract in  the course of
time.  It was six years since any of  the former examinations  had
been made.   I have never seen the recommendation of attending
to the position of the patient, which  is of primary importance in
the  treatment of  these cases.   Dupuytren has used  the actual
cautery, as burns usually contract, and in  one case he repeated  it
three times in the  course of a month  with success.    Mr. Earl has
tried it without success in some cases during the last year  in St.
Bartholomew's Hospital.  Dr.  M'Dowel, of the Richmond Hos-
pital in Dublin, has tried it successfully, as appears by a case pub-
lished by Mr. Swift in  the London Medical  and Surgical Journal,
1831, vol. vi.  Mr. Earl has constructed a needle for the purpose
of applying sutures in  such cases,  but  has not as yet described it. 
DISEASES OF THE INTERNAL GENITALS.
179
By the catheter, the urine will pass through the natural canal, the
sides of the bladder will be in apposition, and healing and union of
the opening will in time be effected.   When the disease becomes
chronic, and the sides of the  fistula indurated, it has been necessa-
ry to stimulate them by savine cerate, or blistering plaster, in or-
der to facilitate the healing process; and even the sides have been
kept in apposition by the suture.   Mr. Hobart  of Cork, has in-
vented an ingenious instrument for this purpose.   His Essay is to
be found in the London  Medical and Physical Journal, 1825, vol.
liv.  I have known the  disease become chronic, and produce no
inconvenience; and in one instance, a  portion of the bladder, a9
large as a crown piece, had come away, and the woman recovered
without any treatment whatever.   The proper  treatment  of this
disease so  far as the plug is concerned, was  unknown ten year3
ago.  In some cases, the bladder unites with  the vagina, and the
os externum becomes closed up, so that the urine and menses can
scarcely escape ; and pain in the part, and even convulsions, have
been the consequence.   Calculous concretions may happen in the
vagina,  as  recorded by  Puzos and Purton, in the  Medical and
Physical Journal, vol  vi.
   If after labour a tender state of the external genitals sets in,
these are  to be fomented with tepid  water, or  some of that fluid
may be  injected into the vagina, to promote cleanliness.   Solu-
tions of acetate of lead have been injected, warm and cold ; but
care must be taken not to force them into the womb.   If the ex-
ternal orifice, or cavity of the vagina, become contracted, and ap-
pear disposed to close up, the use of  bougies, or a round  pessay,
may be applied, to prevent obliteration.  The vagina may be fill-
ed with varions tumours, all of which  are to be removed by liga-
ture.   This canal may be closed  up,  by  pressure of enlarged or
scirrhous  glands, which  tumour  require the ordinary treatment.
(Colles.)  This part  has been attacked with ulcerations, and va-
rious excrescences, which are to be treated in  the usual manner.
I have been consulted, concerning a girl, aged twelve years, whose
vagina was closed at birth, and thougli excised, both in Bristol and
in this city, is now impervious.   There is a  fleshy mass, appa-
rently the  hymen, that  closes the entire orifice, and  formerly im-
peded the passage of the urine.   The sister of this girl aged ten
years, has  also the vagina impervious, from the same cause; and
the mother thinks her children have been thus afflicted by a Di- 
180
GYN-KCO-PATHOLOGT.
 vine Judgment, as she had always wished for boys.  It is a strange
 coincidence, to find two of the same family thus affected ; the oth-
 er sisters labour under no such deformity.
   The vagina may be partially or totally inverted.  In  such ca-
 ses, a  small tumour appears at the external orifice, aptly compared
 to a ripe cherry.  This part will  be irritated, inflamed or ulcera-
 ted.  The presenting part  is to be replaced in its natural situation,
 and the  vagina plugged with cloths, moistened with a  solution of
 alum ; and thus the canal  will be contracted, and prolapsion pre-
 vented.   If the canal be very much dilated,  a  saturated solution
 of alum is to be injected, and afterwards  a globe pessary applied.
 This disease has been cured by pregnancy,  though it  may  recur
 after delivery.  In all these  cases, the bowels are to be kept relaxed,
 as an  accumulation  of faeces in the rectum  would aggravate the
 diseases.   When  the vagina  is completely  inverted, the  rectum
 will be carried forward, and will  be  much relaxed.
   In ascites, or dropsy of  the abdomen, the  fluid may  pass  down
 between the  vagina and rectum,  impeding the  discharge of  urina
 and faeces.   When the patient  stands, the tumour presses down;
 and it  disappears when she lies in a horizontal posture.  The fluid
 has been discharged by tapping,  through  the vagina ; but it is best
^removed by the cure of the dropsy.   Much relief will be obtained
 by a judicious application of the  plug.
   A portion of  the  bowels may  pass  down between the vagina
 and rectum, and form  perineal hernia.   This has been described
 by Sir Astley Cooper, in  his work on hernia, and also by  Den-
 man.  It has been mistaken  for  the last described disease; and
 also for retroversion of the  uterus.  If faeces be allowed to  accu-
 mulate in  it, strangulation  may  take place.  Care is to be taken
 that it be  replaced before the passage of  the  head in labour, lest
 the pressure might induce inflammation or gangrene.   In abdom-
 inal, or intestinal tympanites, an elastic tumour may present in the
 same  situation.   The history 'of the case will  enable us to dis-
 criminate the real  nature of recto-vaginal  tumours.   Retroversion
 of the womb will  occupy the  same space  ; but of this hereafter.
   The vagina may be implicated in the various abscesses and tu-
 mours of the vicinal parts.  These tumours are indurated, elastic,
 and incompressible ; and thus differ from those above  described.
 In one of  the vesico-vaginal  fistula  that  fell under my care, the
 urine caused inflammation, and an abscess occurred  between the 
            DISEASES OF THE EXTERNAL GENITALS*        181

vagina and lower surface of the rectum, and pointed at the tube-
rosity of the ischium.   On opening the  tumour, nearly a pint of
bloody purulent matter escaped ;  the hectic became  more aggra-
vated, and the patient sunk in about a month afterwards.
   Sometimes tumours in the vagina prevent the evacuation of the
bladder and rectum, and impede  delivery.   Many such cases are
on obstetric record.   Dr. Drew, of Cork, relates  a most  interest-
ing case of this kind, in the Edinburgh Medical and Surgical Jour-
nal, IdOo, vol. i., where it was  necessary to divide the perineum,
to extract the tumour, in order to  allow the  passage of the infant.
Dr. Beatty, of Dublin, records a case nearly similar, in the Tran-
sactions of the  Dublin college of Physicians, 1824, vol. iv.   I
have  met with one case of this kind in private practice.   The fe-
male was frequently attacked with bearing-down pains, similar to
those  of  parturition, and  attended with a  copious  discharge of
blood.  Plugging the vagina with opiates always afforded her re-
lief.  The neck of the tumour was high up in the womb, and no
ligature could be applied.  The patient continues in  good health,
unless when she takes  much exertion, but then the womb endea-
vours to expel the tumour.   It is now six years  since I first saw
her;  she  resides at present  in  Ireland.  This subject will again
come under consideration, when I shall  have to describe  the cau-
ses of tedious labours.   The vagina may be the seat of  varicose
and aneurismal tumours ; but these are  of  extremely rare occur-
rence.  The best mode of treating them  is  by pressure, either by
plugging the  vagina, or applying  a pessary.   This canal may be
attacked with sloughing, scirrhus,  cancer, and fungus  haematodes  ;
and these deplorable diseases are to be  treated  with palliatives or
excision.
  The vagina, labia, nymphae, hymen and clitoris, may be attack-
ed with erysipelatous inflammation.  This disease may happen at
any period of life, to infants, girls, and women.  It has extended
even  to the womb, and it generally proves  fatal, as it usually ter-
minates in gangrene.   The parts are tumid,  painful, and of a dark
colour.   It is almost invariably  fatal  to  infants and children.  It
may first attack  the womb, and extend  outwards to all the above
parts.   The constitution  becomes speedily  affected, and hence
we must  administer sulphate  of  quinine, small doses of calomel
and opium with nourishing  diet ;  while anodyne fomentations, as
decoctions of poppies, camomile,  with  a large  portion of tincture 
162
GYNJECO-PATHOLOGY.
of opium, are to  be applied locally.  Solutions of sulphate of
zinc,  acetate of lead, and diluted camphorated spirits, have  been
advantageously employed  ; but in  some cases tepid  milk and wa-
ter fomentations can only be borne.  (See p. 243.) We  are in-
formed by continental writers, that in nymphomania, or furor ute-
rinus, a disease  unknown  in this country,  the organs of genera-
tion are highly sensible and inflamed,  and that the parts are found
black after death.   Astruc gives a most minute description of this
disease ;  but to the British obstetricians it  is unimportant.   The
vagina may end in a cul de sac, or be so contracted,  as scarcely to
admit the point of a probe, or it may  be entirely wanting.   The
most common disease of the  vagina is an  increased secretion of
mucus from its surface ;  and  when  the discharge  is  so copious as
to escape at the external orifice  or genital fissure, it has been call-
ed fluor albus, leucorrhoea, or whites.
   This  disease is one of the  most common to which women are
subject.  It proceeds from an  increased secretion of the natural
mucus of the  vagina, and may vary in  colour and consistence, from
a thin watery fluid to a thick yellow purulent matter.  It was said
to be produced by the lining membrane of the neck  and cavity of
the womb.   (Gardien and Capuron.)—But this is now denied, as
the disease is common during pregnancy, when the  orifice of the
womb is completely closed.  Blatin examined twenty-four bodies  ;
the fluid  proceeded from the  uterus in nine cases, from the cervix
uteri and vagina in thirteen, and the uterine tubes in two cases.—
Dr.  Dewees  asserts, that during thirty  years'  practice, he only
found the discharge  proceed from the  womb in three  cases  ; and
in these the women  were barren.  Dr. C. M. Clarke, in  his ex-
cellent  work  on the discharges  of females,  1821,  describes five
different species of discharges from  the vagina ;  1st, the transpa-
rent mucous ; 2d, the white mucous;  3d, the  watery ; 4th, the
purulent ; and, 5th, the sanguineous.  The 1st species arises from
increased secretion  in the vaginal surface ; the 2d,  from inflamed
cervix uteri or vagina ;  the 3d, from cauliflower excrescence, hy-
datids or oozing excrescence of the labium ; the 4th, from inflam-
mation of the mucous membrane of the womb or  vagina ; and the
5th, from ulceration, scirrhous,  cancer, or abscess.  Dr. Hamilton
describes many other species of the  disease ; while Dr. Dewees
limits them to three in number.  The purulent  form of the dis-
ease has often been  mistaken for gonorrhoea,  especially  where the 
DISEASES  OF THE INTERNAL GENITALS.         183
male becomes affected with  a discharge from  the penis; but the
symptoms of such discharge are quite different  from those arising
from impure sexual connexion.   When the ordinary secretion be-
comes excessive,  it produces depression of mind, and great ener-
vation of body.   The  countenance  becomes  pale, languid,  and
yellow ;  the digestive organs become affected  ;  there will be loss
of appetite, nausea, flatulence, heart-burn, acidity of the stomach,
and all  the multitudinous symptoms of dyspepsia or indigestion;
or the newly discovered and universal disease, styled bilious affec-
tion.
   Another  class of diseases is  generally connected with, or su-
pervenes on that just described ;  namely, that denominated  ner-
vous disease, and both I have described succinctly and  plainly  in
my work on all the known Mineral Waters.
   Besides  nervous and bilious diseases, the patient is often attack-
ed with palpitations, oppressed respiration, irregular bowels, pains
in the back, loins, or uterine region :  and,  at length, with oedema-
tous swellings of the feet.   All these symptoms arise from the
sympathy that exists between the  womb and various other organs.
   Dr. Hamilton described five  species of fluor albus.  First, when
the fluid resembled white of egg, is  not profuse, and arises from
an increased  secretion  in the mucous glands of the  vagina.  He
recommends cleanliness, frequent ablutions, balsam copaiba, injec-
tions of sulphate of zinc, and acetate of lead,  or a saturated solu-
tion of alum,  as  the best means of cure.  To these may be ad-
ded, the tinctures of buchu,cubebs, and rhatany.  Second species,
when the discharge  comes off  by  jerks,  and  is said to proceed
from the glands of the womb;  and here we should  endeavour  to
establish menstruation.   Third  species bears the strongest  simili-
tude to gonorrhoea, has all  its symptoms,  and  requires  the  same
treatment.   This species often  appears after marriage, and there-
fore young practitioners must be very cautious in giving opinions
as all domestic happiness may be destroyed  by  their decisions.   I
have met with several cases of this  kind, but never were  the symp-
toms so violent as in gonorrhoea, though the husband had been af-
fected with discharge ; nor were his symptoms so severe, as if they
arose  from  impure connexion.   It  is well  known, that the husband
is generally the offending party ; and, if labouring  under a gleet,
though it may be six months before  he had had gonorrhoea, yet
he will infect his  bride.   Sir A. Cooper confirms the truth of this 
184
GYN.KCO-PATH0L0GY.
assertion in bis invaluable Lectures;  he had a patient who infect-
ed  his  wife,  though  his  disease was  of fourteen months'  dura-
tion ;  and every man in  active obstetric practice can  testify the
same.   I have known a  case in point ;  the  gentleman assured me
he had no appearance of gonorrhoea for six  months before his mar-
riage ;  and at  that time,  only  a very  slight  gleet; yet he infected
his wife, and incurred the highest displeasure of her and her rela-
tions.  The fourth species of fluor albus, described by Dr. Ham-
ilton, in his excellent Lectures, is compared to calves'  feet jelly ;
and the able professor asserts, that change  of climate is the only
cure for this disease,  and that the female labouring under it is gen-
erally barren.   The fifth species he described,  is where  the dis-
charge resembles milk and water, and is said to proceed from the
menstrual vessels;  as pregnancy never occurs while this  form  of
the disease continues.  Dr. Burns, in his valuable  work  on mid-
wifery, gives a most clear and scientific account of the origin and
causes  of fluor albus; a  work that should be in the hands of every
medical  practitioner.  He observes, that in the natural state, the
secretion of  mucus in the vagina and absorption is so balanced, that
unless on particular occasions, no fluid is discharged from the vagi-
na.   When  the discharge arises from the  womb, the function  of
the organ is so much injured,  that menstruation becomes irregular,
and conception seldom happens.   In  some cases, menstruation ap-
pears regularly, but is preceded or succeeded by fluor albus.   If
conception occur, the mucous discharge ceases, though it may soon
recur even copiously, and cause abortion.
  Leucorrhoea occurs in  full plethoric or in weak and delicate hab-
its.   It may be produced by increased  vascular action, acute  or
chronic inflammation, congestion, or local irritation, or by  debility
It is sympathetic  with the  diseased conditions of the womb, and
contiguous organs.   It will be induced by polypus, prolapsion,  or
other diseases of  the  womb or internal  or  external  genitals;  by
menorrhagia,  miscarriage,  frequent parturition, excessive   venery,
cold, or fatigue after marriage, or delivery, protracted lactation, and
by various other diseases of the pelvic viscera.   Delicate, nervous
females are most  subject to the derangements of the stomach, liver,
and bowels,  already  alluded to under the  terms bilious and ner-
vous affections.  Females of  full habit  are rarely affected with the
latter diseases.  It accompanies chlorosis,  or often precedes it, it
follows  menstruation, it  is often caused by too much nuptial com- 
            DISEASES OF THE INTERNAL GENITALS.         185

merce, and it occurs after the critical age.  It is most common  to
lymphatic women, who are subject to chronic catarrh  or mucous
fluxes.
   Leucorrhoea is a disease which  is  extremely difficult of cure,
whether it  occurs before or after marriage,  or  in  the  pregnant
state.
   Treatment.—When idiopathic, or where it is  unaccompanied
with organic affection, the first indication in treating it, is attention
to the general health ;  removing the bilious and nervous symptoms
in all their Protean forms;  and then applying topical remedies,  iu
the form of injections;  and at the same time exhibiting those me-
dicines that are said  to have a specific action on the secreting parts,
as balsam copaiba, oil of turpentine, tinctures of cantharides, cu-
bebs, bucbu, rhatany, resins, diuretic, salts, conium, arnica, &,c. &ic.
If the patient  be  robust, the diet should be  sparing, consisting
chiefly of vegetables ;  and in order more efficiently to lower the
fullness of habit, laxatives should  be freely employed.
   Exercise in the open air,  but not taken to fatigue,  is of great
utility.   We next recommend injections of a solution  of alum, or
decoction of oak bark, which are to be thrown into the vagina,  by
a syringe with a long pipe, or by the  tubes attached to the patent
syringes, which answer the latter purpose very well.
   When the stomach and bowels are affected, as in weak, delicate
women, mild pirrgatives, with the  various tonics, are to be employ-
ed.  The various bitter infusions, as those of gentian,  calumba,
quassia, camomile, with magnesia; rhubarb, carbonate of soda, or
liquor of potass, may be used with advantage.   Dr. Dewees is of
opinion, that there are three stages in this disease and each requir-
ing a slight difference  in management.   The first  is, when the
discharge is like thin starch, and accumulates in the  vagina, by  its
tenacity, but escapes on the  slightest  exertion.   This never be-
comes acrid, except by the most reprehensible inattention to clean-
liness.   The parts to be washed three  or four times  daily, with
warm water, the bowels regulated, and then thirty drops of tinc-
ture ofcantharides are to be exhibited in some sugar and water, three
times a  day, increasing the dose every  third day, in the propor-
tion of five  drops at  a time ;  and continue the remedy until stran-
gury shall be  produced.  The disease  is generally  cured before
strangury  is produced ;  but where a cure  does not  happen, the
medicine is to bo resumed, and continued as before.  If strangury 
166
OYNJEC0-PATH0L0GY.
 or pain in passing water, sets in, he directs the free use of linseed-
 tea, barley-water, or mucilage of gum arabic, and thirty-five drops
 of tincture of opium, in order to afford relief.  Should these  fail,
 he recommends a clyster, composed of a gill or quartern of starch,
 a tea-spoonful of tincture of opium, and thirty grains of camphor,
 which he asserts never fails.  The tincture he used is double as strong
 as the common laudanum.  I have experienced the greatest success,
 by administering a drachm  of carbonate of soda, in  linseed-tea, or
 barley-water, four or five times a day.  This affords  great relief
 in the ardor urinae caused by gonorrhoea ;  and 1 have never obser-
 ved  it produce a deposit of the phosphates in the urine, as stated
 in works on pharmacy.   This is  the best remedy  for strangury.
 Much benefit will also be derived from pills composed  of three
 grains of camphor, and  two of extract of hyosciamus, to be given
 every third, fourth, or  sixth hour ; or twenty  drops of liquor of
 potass, one  ounce of camphor mixture, and from  three  to  five
 grains of extract of conium, will often procure relief.  Dr.  De-
 wees has used  the tincture of cantharides  to two hundred drops
 three times a day, without producing strangury; and he persevered
 with this immense quantity for several days consecutively.  This
 plan is recommended by Robertson, in his  work on cantharides.
 Dr.  Dewees also prefers the use of soap and water, as a wash for
 the vagina;  and he also praises a lotion of five grains of acetate
 of lead, in an ounce  of water, or half  a  drachm  of sulphate of
 copper to eight ounces of water.   The vagina is to  be washed out
 with soap and water, by means of a  common or patent syringe
 before the use of either  of these injections.   Plasters and liniments
 are sometimes applied to the back with advantage.   In the second
 stage, the matter discharged is  of a white  or yellowish  purulent
 appearance, and is attended with much  pain in  the back and loins
 and here the orifice or neck of the womb is often  found tender to
 the touch.   There is no disease of  structure, in the  opinion of
 Dr. Burns, but  merely  an  affection of the glands ;  while Dr. C.
 Clarke asserts,  that there is more or less inflammation.  The  for-
 mer recommends warm sea-water hip-bath, mild mercurial prepar-
ations, laxatives, and avoiding all irritation;  and when the tender-
ness  is subdued, and the discharge becomes  chronic, the cold bath,
tonics  and  mild  vegetable astringents, are  proper.  The  latter
gentleman recommends  leeching, or cupping, the back and loins;
and the hip bath twice daily ; fomentations of poppy, and  the in- 
DISEASES  OF THE  INTERNAL GENITALS.
187
Jection  of tepid water into the vagina, which  is a direct fomenta-
tion to the affected parts.   He advises saline purgatives in  full
habits, and castor-oil for weak and relaxed persons.  Strangury is
to be  relieved by  sitting over  the steam of  warm water, and in
some cases the urine must be  drawn  off by the catheter, an ope-
ration, if  properly performed,  attended with neither pain, difficul-
ty, nor exposure  of the person.   Dewees coincides  with Burns,
but further recommends the use of cantharides, as already pointed
out;  he also insists on frequent  ablutions with soap  and water.
This form of the disease differs very little from gonorrhoea, and its
treatment is precisely the same.   The patient  will  derive great
relief from heat and scalding in passing urine, by applying a cloth
wetted  in cold water to the vulva.  I have  found much  benefit
derived from the free application of cold lotions to the pubes  and
genital  organs, on the  principle of diminishing vascular action, as
in the other inflammations.   I have employed this practice in  the
case  of a lady under  the care of Mr.  .Mathews, with great success,
and in another case with Mr. Hughes, of Holborn.  The injection
of cold water into the vagina  might  also  be  probably tried with
advantage.   No obstetric writer,  with whose works I am acquaint-
ed, recommends this plan, although there is good reason  to sup-
pose  that  injections of alum and acetate of lead are often employ-
ed when inflammatory action is proceeding, both in the vagina  and
womb.
   The  proper time for employing injections  is said to be  when
the discharge  becomes thin, greenish,  or transparent.   Dr. De-
wees has succeeded with  copaiba, when cantharides had failed;
and he  has found five grains of alum and ten of nitre, given three
times a day, prove successful,  when every other  remedy had been
tried  in vain.   There is no objection to this combination, although
a very unchemical one, provided the bowels be kept regular ; and
we know  that many unchemical formulas have the best effects. If
the discharge  be decidedly purulent,  it must proceed from an  in-
flamed or ulcerated state of the parts,  from abscess or cancer.  In
the latter  disease  excision is the only certain remedy.    Mr. Jewel
recommends an injection composed of nit. argenti,gr. xij Aq. § vj,
which he  says is effectual in  obstinate ca-^es of leucorrhoea;  but
he has not stated the  exact form  of the  disease in which the  ap-
plication is to be tried.  He has adopted the  remedy  from obser-
ving its  good effects upon  morbid secretion of the mucous mem- 
188
GYNJECO-PATHOLOGY.
brane  of the fauces and larynx ;  and he affirms that it is equally
efficacious in arresting  vaginal discharge not dependent on disor-
ganized structure.   It produces a new  action in the part.  It is
difficult to explain the existence  of leucorrhoea, independently of
morbid action and  more  or less disorganization,  and  hence  the
French describe the disease before  us under  the  words  metritis
and vaginitis.
   Again, if  the discharge be watery, it may arise from the cauli-
flower tumour, from hydatids,  or from  an oozing excrescence of
the labium.   When fluor albus arises from  the cauliflower excres-
cence, there is  first a copious watery  discharge, and soon  an alar-
ming  haemorrhage ; and this tumour baffles all remedies,  and  has
hitherto proved fatal.   It  is covered with  a flesh-coloured mem-
brane, which pours out a copious aqueous secretion, and, if handled,
will be ruptured by the  slightest touch,  when  copious haemorr-
hage  will take place.   The tumour is not sensible, as no pain will
be experienced by its rupture.   It grows  rapidly  in married, and
slowly in unmarried  women.   It may occur in all persons, about
the age of twenty, married, single, healthy, or not, and arises with-
out any evident cause. The tumour cannot be injected after death,
as the injection escapes very rapidly through it;  and it becomes
so collapsed that it only appears an  elongation of the lining mem-
brane of the vagina.   Dr. Clarke,  therefore, thinks it a congeries
of small arteries, and  that  it resembles  the placenta  in structure,
causes death by copious aqueous  secretion, or  haemorrhage.   No
treatment can arrest it.   Local bleeding from the hips, groins and
sacrum  has been used ; also tepid astringents injected into the  va-
gina,  without any force, and all in vain.  The mucous membrane
of the vagina is subject to melanosis, in different parts.  The op-
erations to be performed on the vagina are excising morbid cohe-
sions, removing various tumours,  puncturing the bladder,  perfora-
ting the hymen, applying pessaries, injections, and plugging (the
tampon).  The intimate  connexion of the urethra and bladder
with  the vagina,  and the great  influence that diseases of those
parts  have on the functions of the latter, induce me to make a few
practical remarks on these  organs.
   The urethra and bladder are liable to all these diseases of  soft
parts, as irritation,  inflammation,  abscess, gangrene,  sloughing,
scirrhus, cancer, fungus, fungus hoematodes, various tumours, ul-
ceration, warty and other excrescences, spasm, retention, and in- 
            DISEASES OF THE INTERNAL GENITALS.        189

continence of urine,  strangury, or pain in voiding that fluid, and
stone ;  and  these diseases are to  be treated on the principles in-
culcated by  medical and surgical writers.   I shall  therefore con-
fine my remarks to the most common derangements of these or-
gans.
   Irritation and great  pain  are often experienced in the urethra
and bladder, by irritable females, and by girls previous to the ap-
pearance of menstruation ;  and these symptoms are so violent as
to induce a  belief that inflammation or some disorganization is go-
ing on ;  but such morbid conditions seldom happen to the  latter,
who invariably get well on  the eruption of  the menstruous  secre-
tion.  The treatment  already described for strangury, in my re-
marks on leucorrhoea,  will, in general, procure relief, although
sometimes it may be ineffectual.  The warm bath, with anodyne
fomentations, or even  the cold bath,  or cold applications, will of-
ten assist in the cure.  Buchu, soda, liquor  of potass, camphor,
hyosciamus, or conium, should be  employed.  The soda and pot-
 ass decompose the urine,  and  prevent it irritating the affected
 parts ; and the greatest advantage will be derived from the con-
 slant use of the catheter, the instrument being left in the bladder,
 and the urine allowed to escape, according  as it arrives  from the
 kidneys.  This practice gives the most certain  relief, in cases of
 irritable  bladder  in the male,  according to Sir Astley  Cooper.
 The instrument should be  withdrawn daily, and cleaned,  to pre-
 vent calculous deposit on its surface.
    Catheterism.—The introduction of the  female  catheter is an
 operation often requisite  in  obstetric practice,  and is one that can
 be always performed witli  ease, and without any exposure of the
 person.  The orifice of the urethra, or urinary passage,  can be
 always found by drawing the finger  along  the bladder, in  a line
 with the symphisis pubis,  when a short thick  cord  will  be felt,
 about two inches in length  ; and at the extremity  of this, on the
 pubis,  below the clitoris, is a small protuberance, about the size of
 a split pea, or it sometimes resembles  a dimple, which is  the ori-
 fice of the  urethra.  The best position in which we can place the
 patient is on  the back, with the knees drawn  up and separated,
 and her face  turned to one side.   The greatest delicacy should be
 observed in  the performance  of  this  operation.   The operator
 may stand on either side of the patient.   Should he prefer stand-
 ing on the  right side, he is  to take the catheter, previously oiled; 
190                  GYN.ECO-PATHOLOGY.
in his right hand ;  with the index finger of the left he is to sepa-
rate the labia, find the clitoris, and pass the finger an inch lower
than the pubes, when he shall readily discover the orifice of the
urethra.   He is next to place the finger on it,  and then introduce
the point of  the catheter with the  other hand.  If the orifice be
not easily detected  in  this manner, the  finger of the right hand
may be passed into the vagina, and drawn along the  bladder to-
wards the pubes, when the orifice of the urethra  will be readily
discovered.   The stilet may  or may not be  left in  the  catheter,
and as soon as the instrument shall be introduced, a  small  basin,
or other vessel, is to be applied  under its handle, to receive the
fluid.  The adjustment of the vessel  is  vastly  inconvenient,  as
the patient may be exposed,  and is liable to cold, while the bed is
invariably wetted on removing it.   To obviate these defects, Dr.
Conquest recommends a bladder to be tied to the catheter,  to re-
ceive the urine ;  but if there be a large quantity  of fluid  in the
urinary  bladder, this proposal is  objectionable, as the catheter
should be withdrawn as soon  as the attached receiver became full,
and this would at least be rather embarrassing to young practition-
ers, who might  have experienced difficulty in  introducing the in-
strument.  The best proposal made to remedy this defect is that
of  Dr.  Montgomer),  Professor of Obstetric  Medicine,  in  the
School of Physic, Dublin.   His essay appeared  in the Edinburgh
Medical and  Surgical Journal, 1828, and is  well worthy of atten-
tive perusal.    He proposes to place a stop-cock near the  handle
of the common catheter, in  order to prevent  the escape  of the
urine,  which invariably occurs as soon as the common instrument
is passed into the  bladder; by the  proposed improvement not a
drop could escape  until a vessel should have  been applied to re-
ceive the fluid.  His next suggestion is, that a small tube is to be
fitted to  the catheter,  and  to the end  of this  a calfs or sheep's
bladder is to  be tied, so that as soon as this latter is filled, it can
be  separated  and reapplied,  without withdrawing the catheter   I
have seen male catheters of this construction  with Mr.  Costello,
for the purpose of injecting the bladder, previous to the use of  his
lithotritic instruments ; and here I must add  my testimony in fa-
vour of the safety and efficacy of this valuable operation, which I
have often witnessed with much gratification.
   When catheterism is  performed in the ordinary way, there is
considerable  inconvenience  to the patient.   First, the urine es- 
DISEASES OF THE INTERNAL GENITALS.
191
  capes as soon  as  the  instrument  passes  into the bladder, before
  any  vessel can be  applied ;  secondly, the  vessels met  with in
  bedchambers are,  from height and size, particularly unfit and diffi-
  cult to apply under the extremity of the catheter, and  their appli-
  cation is attended  with more or  less exposure ;  thirdly, in the re-
  moval of such vessels, a quantity  of-urine is spilled on  the bed,
  or the bed-clothes fall into the vessel, in either case causing much
  discomfort to the  patient  ; fourthly, the introduction of the vessel
  under the  bed-clothes, both exposes  the patient to cold, or to the
  chilling contact of the  vessel itself, and increases that excessive
  confusion of shame  with which  the female is overwhelmed  at the
  time of the operation ;  fifthly we cannot always prevail or insist
  on a patient to assume the best position ; she may be totally help-
  less, and unable to turn, and may be laying sunk in the middle of
  the bed, a position that impedes the operation  very much.
     Sometimes the  bed  may be  so placed that the operator must
  stand at the left side of  the patient.  It is therefore incumbent on
  him to be able to use the instrument with his left hand, whjle the
  discovers the urethra, in the manner already  described,  with the
  fore finder of the  right.   The instrument may  be passed  under or
  over the thigh of  the patient ; but the former is more  convenient,
  as the vessel to receive the water can  be  passed or withdrawn in
  the same posture.  The  operation, if properly performed, is un-
  attended with  pain, difficulty or exposure of the person.   In or-
  dinary cases, the catheter should be passed upwards and forwards  ;
  but if there be retroversion of the womb, its fundus being turned
  down on  the rectum,  and its neck  pulling  down the bladder, or
  when the  womb  is  partially  inverted and outside the genital fis-
  sure, the point of the catheter must be passed  for a short distance
  in the usual course, and  then  its handle raised towards the abdo-
  men, so as to  follow the  reversed  curve  of the urethra ; some-
  times a male catheter must be employed.
    Again, if there be antiversion of  the womb, or pendulous abdo-
  men, the bladder  will  be thrown forward over the pubes, so tha1
  the urethra is  now  curved in  the  opposite  direction,  and conse-
  quently the handle of the catheter must be  depressed, as soon as
  its point has cleared the symphisis  pubis.   If these observations
  be borne  in mind, there  never need be any exposure of the fe-
'  male, which should  be avoided.
    The urethra may  be  attacked with spasm, which will produce 
192
GYNJECO-PATHOLOGY.
heat and pain in passing water, or complete retention  of urine.
The best remedies for this affection are anodyne,  tepid  fomenta-
tions, laxatives, muriated tincture of  iron,  warm bath, and the
catheter.
  The bladder is liable to acute and chronic inflammation, to ulcer-
ation, fungus, scirrhus,  cancer,  and the various kinds of tumours
which appear in the other  soft  parts  of  the body.   Leeeching,
cuppping, fomentations, laxatives, warm bathing, with large doses
of carbonate of soda, or liquor  of  potass, camphor,  hyosciamus
and bucbu  are the best remedies.   If  cancer attacks this organ, it
will generally extend to the  vagina and  other  soft  parts.   The
bladder may be so contracted  by chronic  inflammation, as scarce-
ly to contain a quartern or gill; and it may be sometimes so dila-
ted as to contain  two gallons, and cause a resemblance to the last
sta^e of pregnancy.  I have seen such cases in  the last stage of
typhus, and have  heard of an instance  where  the woman  was
supposed to be pregnant, and the mistake discovered on dissection.
Little relief can be afforded in   all  organic derangements of this
organ, especially where ulceration, excresence,  or  fungus appear
on its internal surface, and  exposed to the constant irritation of so
saline and acrid  a fluid  as  the  urine.   In chronic diseases of the
bladder there is  generally a discharge  of mucus, or purulent  mat-
ter mixed with blood.  When the quantity of mucus is consider-
able, the disease is called catarrh of the bladder, and is sometimes
relieved by uva  ursi,  lime-water, soda, potass, balsam copaiba, and
conium.
   The  bladder,  like all other  muscular parts, is liable to  spasm.
This affection causes great pain and irritation, and has been mista-
ken for inflamation, gravel, and fungus.   The remissions of pain
that occur, clearly demonstrate the nature  of this disease,  and prove
it cannot depend on  any  of the above conditions of the organ.
Warm bath  and tepid fomentations, and a  free use of camphor and
hyosciamus generally afford relief, and finally the complete remo-
val of the disease.
   Hydatids have been found in the  bladder, and  may produce
great irritation ; it is a strange, but certain fact, that those parasi-
tic animals have  been found in every cavity  and structure of the
body.
   Ascarides have been seen in the bladder, and have produced ve-
ry  great irritation.   The injection of tepid  water, olive  oil,  castor 
DISEASES OF  THE  INTERNAL  GENITALS.        193
 oil, and weak solutions of soda and potass have been recommended
 in such cases.  Washing out the bladder is now become a frequent
 operation, since the invention of the double syringe ; and there is
 some reason to suppose it may  prove beneficial.  1 have repeat-
 edly witnessed this operation in the practice of Mr. Costello.  The
 chief operations to be performed on the bladder  are  lithotomy,
 puncturing the organ, passing the catheter, and vesicae lotura,  or
 washing out the bladder.
   Females, like the other sex, are attacked, although very rarely
 with calculus.  The symptoms of this disease are heat, pain, and
 great irritation in voiding urine, the fluid being often very sudden-
 ly arrested in its evacuation, and a gravelly matter being occasion-
 ally deposited.   Warm bathing, fomentations, alkalies, buchu, and
 uva ursi  are the usual  remedies, and large doses of carbonate  of
 soda, with  pills of camphor and hyosciamus, will often afford re-
 lief.  The urethra being very short  and dilatable, may allow large
 calculus to pass through it; while, in some  cases, the stone has
 passed through the vagina,  the rectum, and  abdominal  panetes,
 by the process ulceration.   It has been  necessary to perform the
 operation  of  lithotomy,  even  during  pregnancy.*    Excresen-
 ces may form at the orifice, or in any other  part of the urethra,
 occasioning  great  pain  in passing urine, and have  been mistaken
 for urinary  calculi.   When  placed externally, they can be readily
 discovered, and are to be removed by excision or ligature; when
 situated in the passage, bougies are quite necessary.  In a case  in
 which I  was consulted by  Mr.  Foote, of Tavistock-street,  Co-
 vent-Garden, the savine cerate was the  most  effectual  remedy.
 The blood-vessels of the urethra, bladder, and womb may become
 varicose  or aneurismal, and  must  be treated by pressure and as-
 tringents.
   The womb has been found wanting,! or double, or divided by a
 septum, as  observed  by  Dr. Baillie.   It may be double,  a speci-
 men of which is in the museum of theRoyal College of Surgeons.J

  * The great discovery of Civiale obviates the formidable and dangerous ope.
 ration in future, and is now practised daily on the other sex, by his only English
 pupil, Mr. Costello.
  t Columbus, Schiegel,  Fronondusi, Morgagni,  Meyer, Ford, Hamilton and
many others.—(Vide Article on Sterility.1
  J Haller, Purcell. Phil. Trans. 54;  Med, Facts, vol. iii; Mem. Med. Socie.
ty, vol. iv;  Lond. Med.  Journal. 1782, vol. iii; Diet, des Sciences Medicales.
vol. vi. Ac. Ac.
        96 
194
GYNJECO-PATHOLOGY.
  The womb may be undeveloped, a curious case of which is re-
corded in the Journal Genneal de Medecine, vol. xli.  The os ute-
ri has been closed by adhesion,  scirrhus, or in consequence of ori-
ginal  formation.  The substance of the os uteri  has been  found
cartilaginous, ossified, inflamed,  and ulcerated, and completely ob-
literated after impregnation ; so  that an operation has  been per-
formed to allow of delivery.  If the os  uteri is entirely closed,
the menses will be retained, the  uterus will become distended, and
an operation must be performed to allow the  escape  of the  fluid ;
the womb has been tapped under such circumstances, but inflam-
mation, of  course, supervened.   Metritis, or inflammation of the
womb, is of very rare occurrence in the unimpregnated state, and
such condition is generally caused by external violence.   It is of-
ten a consequence of marriage,  according to the testimony of Drs.
Dewees and C. Clarke.   The  disease is ushered in by pain in the
hypogastric region, shooting to the back and loins;  the organ is
tender |o the touch, the bladder is irritable, pain in voiding  urine,
and febrile symptoms are  also present.   General and local bleed-
ing, fomentations, warm bathing, blisters, soda, potass, and purga-
tives, as in peritonitis, are the means  of cure.   When  the  neck,
or orifice of the womb, is  attacked with chronic  inflammation, be-
sides  the symptoms of irritation and inflammation, there is gene-
rally  a discharge of  mucous,  or purulent matter, which is often
mixed with blood, or even there will be considerable haemorrhage.
The patient becomes weak, from the discharge  or irritation.  In
such cases the woman should live absque marito, and use the warm
hip-bath,  mild purgatives, sedative injections as opium, poppies,
hemlock, hyosciamus, and mild diet.   After  the disease shall have
been  subdued, tonics, sea-bathing, and exercise, and mild astringent
injections ought to be employed.  A course of mercury has cured
this disease, when all other remedies had failed.
   The womb is liable to irritation, which is soon followed by ul-
ceration, purulent discharge, more or less copious, and pain during
sexual congress.   Nauche, in France, and Gooch, in this country
have  described irritation of the uterus;  the  former designates  it
neuralgia, or spasm ;  the  latter, irritable  uterus.  We. are inform-
ed by Nauche, that the fixation of scrofulous, syphilitic, rheumat-
ic, scorbutic, psoric,  cancerous, and gouty  diseases  may induce
spasm of the uterus, or  even  neuritis ; while  Gooch  maintains
there is no change of structure, even though  the disorder contin- 
DISEASES OF THE INTERNAL GENITALS.        195
ues for years.  He compares it to the irritable mammae described
by Sir.  A. Cooper,  and the irritable  joints,  described by Mr.
Brodie.   Hysterical women are most liable  to it.  The pain is
constant for months or years,  and may finally disappear by  the
use of appropriate  remedies, horizontal posture,  narcotics,  warm
hip-baths, occasional local bleeding, sometimes mercury and coun-
ter-irritants.   I have found sedative vaginal injections of great use
in painful affections of the uterus.
   We should remember that gastralgia may  continue for ten  or
twenty years, and indicate the idea of change of structure; but,
on dissection, no disorganization exists.  Dr. Gooch gives the fol-
lowing semeiology  of irritable uterus  :
   " Pain in the lowest  part  of  the pelvis, along the brim of the
pelvis, and often  also in  the loins.  The pain is aggravated by the
erect posture and by exercise; it is diminished in the horizontal
position, but is not removed.   It is always  present, and often cau-
ses severe paroxysms, although  the patient has  been recumbent
for a long time.  The  uterus is  exquisitely tender on  pressure.
The severe paroxyms come on a  few  days  before or after the men-
struation, and this  secretion continues regular, but sometimes di-
minishes or ceases  altogether.  On  examination, nothing is  dis-
covered  except exquisite tenderness and slight swelling, or  rather
tension.   The disease does  not terminate  in change of structure.
The causes to which the complaint has been attributed are consid-
erable bodily exertions  at times when the uterus is in a susceptible
state."
   M.  Lauyer Villermay defines  hysteralgia, pains in  the uterus,
which are common to a large number of women, from the age of
puberty  to the critical epoch, and  sometimes long after the  latter
period.   These pains sometimes precede the  first eruption of the
catamenia accompany  their periodical return, and are most  acute
when the discharge is slight; they are located in the cervix or
body of  the uterus, are  consequent to defloration and marriage, es-
pecially  with those  in whom the uterus is situated low, and in those
cases where there is a disproportion between the reproductive or-
gans of the sexes.  These pains  may supervene  during or after
sexual congress, or after laborious labours.   Irritation of the  womb
is more or less habitual.  This etiology is  partly corroborated by
Drs. C. Mansfield,  Clarke, and Dewees, who deem marriage a fre-
quent cause of metritis.   Dr. Addison's history of the symptoms
and causes of irritable uterus is nearly similar. 
196                  GYNJEC0-PATH0L0OY.
   The most frequent symptoms of uterine irritation are irregular
menstruation, the discharge being  preceded or accompanied by
pain in the back, loins, or thighs, or in the region of the uterus it-
self, and  attended with forcing or bearing  down ; the discharge
being in excess, either  in  point of mere quantity,  or in continu-
ance, or  in recurrence ; tenderness of the womb itself upon pres-
sure, made either externally or per vaginam, a tenderness in some
instances so great  as to interfere with the privileges  of matrimo-
ny ; and, lastly,  leucorrhceal.  The  most frequent symptoms
however, are  unquestionably painful  menstruation and leucorr-
hceal discharge,  although  the  former is often  the only symptom
acknowledged by the patient herself.
   The most powerful  pre-disposing cause of uterine irritation is
constitutional irritability, especially in persons naturally of a del-
icate frame of body, a state rendering its  possessor acutely sus-
ceptible  of impression generally, and which has not unfrequently
and certainly not  very  unaptly,  been distinguished  by the term
nervous temperament.  The rest of the predisposing  causes are
such as tend  either to produce or to increase morbid susceptibil-
ity ; such as  sedentary and luxurious habits,  late hours, and
passions of the  mind.  Natural  irritability of uterus itself may
undoubtedly prove a pre-disposing cause, but of this it is difficult
or  impossible to speak with certainty, as the refinements and re-
straints of society will always furnish, at the same  time, other co-
operating causes.
   " The exciting  causes  again, are active exertion of any  kind,
during the flow of the menses ; frequent child-bearing, especial-
ly if the patient suckles her  children herself; excessive venery,
and, indeed, venereal excitement of every kind.   Married wo-
men, I think, perhaps suffer  most from child-bearing,  and  from
imprudence during the menstrual period; unmarried women, on
the  other hand, from similar imprudence,  and peradventure from
causes of excitement of the genital organs,  concerning which it is
unnecessary to be very explicit. "
   He next describes the painful affections of the abdominal vis-
cera, which are often experienced, and generally mistaken for in-
flammation.  These are—
   " 1st.  A  pain seated under the left mamma, or  under the mar-
gin of the ribs of the same side.   2dly.  A pain under the margin
of the ribs of the right side.  3dly. Pain in the course of the de- 
DISEASES OF THE INTERNAL GENITALS.
197
scending colon.   4thly. Pain in the  course of the ascending co-
lon, especially towards the right hypochondrium.   5thly. Pain af-
fecting  the abdomen generally.  6thfy. Pain in  the region of the
stomach.  And lastly, Pain  in the region of the kidneys, some-
times extending down in the course of the uterus to the bladder."
   These pains arise from neuralgia of the spinal  nerves (Copland,
Whitlock, Nicholl, Shirley, Palmer, Teale, Tate,) are generally
mistaken for pleuritis, splenitis, hepatitis, colitis,  duodenitis, peri-
tonitis, gastritis, or gastralgia, nephritis  and cystitis.   One or more
of these pains exist at the same time, or alternate with each other
and sometimes there is pain over the whole abdomen, which  may
be called neuralgia  of the abdomen, or we  would say with Dr.
Marshall Hall, intestinal irritation.
   Dr. Addison observes that the diagnosis is often difficult—
   " Whenever a female complains to you of  pain  under the left
breast, with or without palpitation or pulsation  of  the heart;  of
pain in  the right  hypochondrium ; in the situation  of the  left  or
right colon ; or of acute pain generally over the whole belly, or in
the region of the kidneys or bladder, always  be  upon your guard,
and if on inquiry you  find a few, or many  of the constitutional
symptoms I have described, together with indications of uterine
irritation, as shown by pain in the pelvis, in the  loins, or in the
thighs, before  or during the  catamenial flow ;  by too frequent or
too profuse menstruation, or by leucorrhoeal   discharge ; I say,
when you find such an assemblage of symptoms and circumstances
your suspicions will amount to a  high degree of probability, that
the complaint is not of an inflammatory nature.
   " It  must, nevertheless, be carefully  remembered  that all  or
most of the symptoms I have enumerated, as emanating more im-
mediately from the uterus itself, may and often do result from organic
changes, either in the uterus or in the parts adjacent.  Whenever,
therefore, we have  the least  suspicion of the existence of such
causes,  an examination of the patient ought on no account whate-
ver to be neglected.  The necessity of such precaution may be
said to  increase  with the age of the patient; but when  obstinate
or repeated flooding prevails, whether slight  or  profuse, suclv an
examination becomes quite imperative, especially when it  occurs
in females somewhat advanced in life."
   He next describes the  treatment, and adds some interesting ca-
ses in illustration— 
198
GYN^CO-PATHOLOGY.
   " The indications are, 1st.   To correct the  morbid condition
of the uterus.   2dly.  To  remove or  mitigate the violence  of
troublesome symptoms in any individual case ; and 3dly.   To re-
store tone and vigour to the general constitution."
   Dr. Addison  enumerates the remedies  recommended  by Dr.
Gooch, which he has not found successful.   These are depletion
cupping the loins, leeching the region of the pubis, purgatives, an-
odynes, warm baths, and confinement of the patient to the recum-
bent posture for months at a time.  Our author prefers the follow-
ing plan, which consists of making applications to the uterus itself.
He recommends  the liquor aluminis  compositus of  the  London
Pharmacopoeia,  to be injected per vaginam, two, three,  or four
times a day, by means of a proper syringe.   The injection is to be
introduced  with  a sufficient  degree  of force as shall secure its ap-
plication to the upper part of  the vagina and to the os uteri.  The
remedy is not to be employed immediately before or during men-
struation.   He advises  it in dysmenorrhoea without leucorrhceal
discharge.   He says—
   " But when there is a decidedly  painful  menstruation,  or pain
felt in the womb, loins,  or thighs, before the appearance, although
there  be no leucorrhceal discharge  whatever in the interval, 1 ne-
vertheless apply the cold wash to such  subjects, precisely in the
same manner as if such leucorrhceal discharge  were  present, on
the principle that this leucorrhceal discharge is itself a mere symp-
tom or effect of the state of the uterus and neighbouring  parts,
which I am anxious to remove.
   " I would only remark further, that, very recently, Mr.  Jewell
has recommended the nitrate of silver, either in substance or in so-
lution, as an application in leucorrhoea ;  and I have no doubt from
what we observe in its general  use, that it will have a powerful ef-
fect in destroying morbid sensibility; but  I have had no experience
with it myself, whereas  I have  extensively  employed the astrin-
gent wash before mentioned for the last ten years, and  declare  to
you that I have  never known  any serious inconvenience to result
from it in a single instance; if  ever injurious, therefore, it is un-
known to me."
   I cannot assent to the pathology and practice laid down in either
of these extracts, and simply  for this reason, that there are seve-
ral species of leucorrhoea, arising from  very slight or intense in-
flammation or ulceration of the mucous membrane of the vagina. 
DISEASES  OF THE  INTERNAL GENITALS.         199
(Hamilton, Burns, Mansfield, Clarke, Dewees, he.)—I should be
very sorry to employ the liq. alum, c, much less  nit. argenti, in
certain kinds of leucorrhoea, and I am not a  little surprized to see
such  recommendations.  In  the simple form of the disease,  the
astringent injection does  more good in a (exv days, than tonics in
several months.   Here we  must observe, that the  common  mode
of injecting is inefficient; for the fluid regurgitates almost imme-
diately after its application, unless a napkin be applied to  the  ge-
nital  fissure.   To obviate that occurrence,   I usually  recommend
the introduction of pieces of soft calico or muslin,  moistened with
the wash,  into the vagina, and  these to be  renewed twice a-day.
Our author has also omitted two other remedies  of great value in
cases  of uterine irritation, opiate clysters and opiate injections, per
vaginam.  In all severe  cases of this complaint  the patient should
live absque marito, and great benefit is to be obtained from a seton,
issue, or pustulation  from  antimony, in addition to the means al-
ready mentioned.  The  application of morphine, by the endermic
method,  over the lumbar vertebrae, might be productive of great
benefit.
   The next indication is to remove  or allay troublesome symp-
toms.  Dr.  A. has known  pain of the side unrelieved by cupping,
leeching, blistering, &c., and he  has observed the internal  and ex-
ternal use of sedatives,  with due attention to the digestive organs,
afford signal benefit.  He  has not alluded to the condition of the
spine in  such cases.   The application of anodyne  fomentations is
recommended in  all  the  local pains of the sides and abdomen.  In
speaking of cases connected with menorrhagia, our author uses the
latter term and flooding synonymously.   This is an oversight for
which I  cannot account.   He is surely aware that the menstrual
fluid  differs  in its physical  and chemical principles from venous or
arterial blood.   If it be  a secretion,  it cannot be blood ; and this I
believe is the  received  opinion.  He  never gives  lead  in such
cases, as he  has known  it to  produce colic,  and  as he cures
the disorder without it.   I have given it with opium  in some hun-
dreds of cases, and with  invariable success, and I  have never known
it  to induce  colic, though pushed to a considerable extent.   The
last indication is to restore  the strength and  vigour of the general
habit.
   Simple ulceration is very rare, and will heal by the use of mild
tepid  injections.   Ulcerations  of various sizes  have  been found 
200
GYN.ECO-PATHOLOGY.
on every part, on the  interior of the womb, arising during men-
struation, perhaps from repletion of the part, opening into the rec-
tum or bladder.   There is a phagedenic ulceration of the womb,
that arises from  a morbid poison.   It commences  at  the orifice,
extends along the neck and fundus, and destroys all those parts. This
disease is called malignant ulcer of the womb, and is attended with
severe burning pain, copious, foetid,  or  purulent discharge, often
alternating with  haemorrhage; small frequent pulse, great emacia-
tion, and sometimes swelling of the  glands.  There is no tumour
or enlargement found  in the uterus, by examination, but we can
easily ascertain the exact destruction of the parts.  The disease
generally  proves fatal, and is different from cancer or fungus. On
examination after death, the pelvis is usually found filled with in-
testines, glued and  matted together,  by inflammation, in the midst
of which will be found an abscess containing  healthy  purulent
matter.  In general, no part of the womb remains, except a small
portion of  the body, or fundus, which  resembles  soft cartilage.
The ulcerated  surface has a  dark  livid appearance, while the
substance in its immediate vicinity is dark and livid.  I was pres-
ent at a dissection made by Mr. Hughes, in which such morbid ap-
pearances existed, and I exhibited as much  disorganization as was
removable  to the London Medical Society, in 1829.
   It is extremely difficult to  cure  this  ulcer.   It  has, however,
been cured by mercury alone, or combined with hemlock, hyosci-
amus, and  other narcotics.   Injections  of morphine, or sedative
fomentations or plasters must be resorted to, and large  doses  of
opium  become indispensable.   This disease is nearly  as severe  as
cancer uteri.   There are various other ulcerations of  the  womb,
ail of which are  accompanied with irritation and  copious purulent
or leucorrhceal discharges.  Excrescences are often  attached  to
the orifice of the womb, and grow to a large size, having the base
larger than the  neck; they discharge a great  quantity of serous
fluid so as to resemble  the liquor  amnii.  These tumours  bleed
profusely on the slightest touch, and are best removed by ligature
so as to intercept the circulation ;  astringent injections have little
effect in this disease.   Dr. Clarke denominated  a tumour of this
kind " the  cauliflower excrescence."  The discharge of thin, trans-
parent, or leucorrhoeal  secretion was so great,  as  to wet ten  or
twelve napkins a-day,  and thus produce great debility.  This fluid
stiffens linen  similar  to starch.  This tumour is more or less rapid 
            DISEASES  OF THE INTERNAL GENITALS.        201

in its progress, and has been found to fill the pelvis in nine months.
The  ligature is the only  means to be  depended upon in this case,
but is not effectual.
   The womb may be attacked with venereal ulcer, which will ex-
tend over the whole surface of the organ, destroying  the entire
part.  The disease is attended with  a degree of heat and pain,
with  purulent discharge, or  followed  by bleeding  after coition.
The history of the  case  is the only certain mode of ascertaining
the  nature of the  complaint.   Mercury is  the only thing to be
depended on in this disease.
   The interior of the womb is often attacked with  ulceration,
which may  be superficial or  deep  seated, sometimes  resembling
aphthae, or fissures ;  at other times, deep excavated ulcers.  Such
ulcerations  are attended  with  mucous, purulent, or  sero-purulent
discharges, the colour of which varies in different cases, is white
ash-coloured, yellow, or  green.  This disease is accompanied with
dull pain in the commencement, which  soon becomes sharp and
acute.  These pains  extend  towards  the  hips, groins, thighs, or
loins, and will be soon followed by discharge.  The causes of ul-
ceration of the womb are inflammation, abscess, fluor albus, acrid,
corrosive, or strongly astringent injections applied in fluor albus,
or inversion of the womb, or vagina.   It is  said  that depraved or
venereal semen  may  produce ulceration;  it certainly communi-
cates the venereal  to the foetus in  utero ; and in  such case there
will  be premature labour, and a putrid child expelled, an event to
be expected so  long as the venereal poison remains in force, and
only to be prevented by  the  usual  means.   But I think it doubt-
ful, and indeed very improbable, that  the male semen could cause
ulceration, as stated by Astruc and others.   Ulceration also arises
in consequence of  injuries done by  the midwife or accoucheur, or
by the introduction of extraneous substances; all of which causes
induce inflammation  and  its consequences.
  Some of  these ulcers are quite superficial, others deep seated,
excavated, sinuous, or fistulous, and may open into the rectum
vagina, or bladder.   In all cases of ulceration of the womb, there
is a purulent or muco-purulent  discharge, which  may be  tinged
with blood,  in proportion to  the exposure of the blood-vessels of
such ulcer.  When ulceration is slight, and advances slowly, al-
though adjacent  to  the  orifice of the womb, menstruation  may
remain natural; there will be considerable pain during nuptial  con-
              26 
202
GYNJECO-PATHOLOGY.
gress.   Sometimes the  purulent  discharge is mild  and inodorous
at other periods it will be found acrid, fetid, and irritative, so as to
excoriate or inflame the  vagina and  vulva.   If the ulcer is near
the rectum, there will be inflammation or irritation of the part and
costiveness ;  if contiguous to  the  bladder, micturition, strangury,
or great pain in voiding water ; and if either symptom be long con-
tinued, and the ulceration increasing, there  will be  emaciation,
hectic,  aud colliquative diarrhoea.   This disease can  be distin.
guished from leucorrhoea, as there is no deep-seated pain in the
latter disease ;  from cancer,  by the  history  of the case,  the ab-
sence of all cachexia in the constitution,  the regularity  of the
menses, and the  age  of the  patient, which  diagnostics will  also
enable us to distinguish the complaint from chancrous ulcer.  Du-
ring the treatment the  patient should be confined  to the recum-
bent position; the least motion or  pressure on the womb increases
determination of blood thereto, and consequently pain and increase
of discharge, therefore sexual commerce ought  to be avoided.
Mild, light, and nutritious diet, laxatives, cleanliness, and sedative
astringents and injections, and warm baths, form the mode of cure
in this disease.
   The womb is often  attacked with steatomatous, polypous, car-
cinomatous,  atheromatous, sarcomatous,  fungous, and  schirrhous
tumours, all of which  produce the usual effects of uterine irrita-
tion.   Steatomatous tumours are small in the beginning, gradually
increase, and acquire an enormous size ;  happily they are of rare
occurrence.  They have one cavity, sometimes  two or three, full
of the same tallow-like substance.  They are colourless, but may
become hot, painful, red, in a word, inflamed ;  and such inflam-
mation will terminate in abscess or scirrhus.   These tumours  are
generally attached to the interior  of the  womb, and also may be
found in its substance.   This disease is likewise  found in the  va-
gina and labia.   This form of tumour may grow  to a considerable
size, before the patient will  suspect that she labours  under any
disease.   When it is discovered, it is observed to augment in size
daily, and  produces more or less  uneasiness, and may be mistaken
for pregnancy.   According  as the  tumour  increases, a dull pain
will be experienced, especially if it be so large as to cause a sense
of bearing down.  In such  case, the patient finds  most relief by
lying on the back.  When these tumours are small, menstruation
remains uninterrupted, because  there is only a small  portion of 
            DISEASES OF THE INTERNAL GENITALS.        203

the womb affected by the disease;  but this secretion ceases when
the tumour increases, because then the greater part,  if not the
whole, of the interior of the womb  may be compressed.  These
tumours are usually attached by  broad strong  connections to the
womb;  now and again  the  connexions may be narrower, and so
that by concussion or violent motion, the tumours have been sepa-
rated, and expelled with uterine  pain, as perfect and severe as in
natural parturition.   When these tumours  are large, and attach-
ed to the  orifice of the womb or vagina, they prevent  sexual  in-
tercourse, and are often mistaken for inversion  of the womb or va-
gina.
  The prognosis in this disease is mostly unfavorable, as it gener-
ally  terminates in  death.    Should a woman become pregnant du-
ring this malady, there will be  danger of miscarriage,  or contu-
sion, or separation of the tumours.
  These  tumour?  are common  to all parts of the body, as the
whole  skin, all the cavities, to  the nose, oesophagus,  intestines,
womb and vagina.   On dissection this form of tumour  is found to
be composed of tendinous strings,  or membranes ;  the interstices
of which  are  filled with a fatty  matter, thicker and more fibrous
than common fat, and  among which are distributed  blood-vessels,
nerves, and fleshy  structure.   This disease  is  not always  incura-
ble, but being unattended  by  heat  or  pain, may exist  for a long
time ,without producing much inconvenience.   The chief annoyan-
ces it causes to females, when of long standing, are that of  great
weight in the hypogastric region, the trouble it causes  in walking,
and the mild or acrid discharge  attendant  on it.  These tumours
may inflame, suppurate, or ulcerate,  and terminate  in scirrhus or
cancer;  but fortunately all these  conditions  are of rare occur-
rence.
  The chief indications of cure  in this disease are,  1st. to dimin-
ish  the  growth;  2dly, to  lessen the  inconveniences.  Like  all
other tumours   of these organs, palliation is only to be expected,
and thus melioration can be afforded in most cases.   In the disease
under consideration, the chief inconveniences are, sense of weight
in the hypogastric region and trouble in walking, together with a
continual disagreeable discharge.  The first of these inconvenien-
ces  will  be in a great  measure relieved by the application of a
proper bandage, first hav'rog plugged the vagina, or applied a pes-
sary.  The discharge will be obviated by  frequent  ablutions and 
204
GYNJECO-PATHOLOGY.
injections.   Dr. Mackintosh  relates a case in which the abdomen
was as large as at the  fourth month of pregnancy,  which was cu-
red by the internal and external use of iodine, leeching, counter-
irritation,  &tc.
   When these tumours are  attached to the orifice  of the  womb,
vagina,  or  vulva, they can be often removed  by ligature  or  ex-
cision.
   Fungus hamaiodes, or cerebriform cancer, occasionally  attacks
the organs  of generation in both sexes, and is often coexistent with
cancer.   The tumour  is said to vary in consistence, may be very
hard or soft, is elastic, and bears a strong resemblance to brain, con-
tains cysts  of different sizes, filled with red serum, blood, or bloody
fungus.   There is no certain sign by which this tumour can be
distinguished from the others already described ;  it increases rap-
idly, and can be felt through the abdomen.   There may be two
or more tumours, of unequal sizes,  which may or may not be con-
nected with each other.   After some time, a fungus will be found
protruding into the vagina, which will bleed on the slightest touch.
There is generally little or no pain  until the tumour is about to ul-
cerate;  and there is little inconvenience experienced, except when
the tumour presses on  the bladder,  and causes pain  in passing wa-
ter, or complete suppression of urine; and may  also impede  the
evacuation from the bowels.   This disease  may or may not be at-
tended with discharge, similar to fluor  albus.   The complexion is
sallow, though the general health is  good, till ulceration takes place.
When the tumour ulcerates, we will find the bladder or rectum in-
volved in the disease; the uterus has been filled with this  morbid
growth;  it has penetrated its parieties, and got into the abdomen,
where the bowels become  inflamed and glued together; the  tu-
mour has adhered to the parieties of the abdomen,  ulceration set
in, and a fungus shot out from the abdomen.   There is great pain
and constitutional irritation, with loss of appetite ;  strength, ema-
ciation, and hectic soon appears,  and destroys the sufferer.  The
whole treatment consists  in palliating  such symptoms as  appear
most  urgent.
   Polypous tumours may  occur in  the  uterus at any perod of life,
and produce all the uneasy sensations in the back, joints, and hy-
pogastric region, so usually attendant on all uterine irritation.  The
tumour may project into the vagina; prevent impregnation, or even
intercourse; impede the  functions of the  bladder and rectum; 
DISEASES OF THE INTERNAL GENITALS.
205
 and impede delivery, when  it has  increased after  conception.
 When  the  polypus passes into the vagina, its base becomes aug-
 mented in size, and its neck may be so pressed on by the orifice of
 the womb, as to interrupt the circulation in it;  so that this press-
 ure acts as a ligature, and the tumour will often fall off, or previ-
 ous to its separation, the veins  in its substance  will be divided,
 if there be to much pressure, and copious haemorrhage  may take
 place.  Polypous  tumours may be attached to any part of the in-
 ner surface of the womb, and seem to arise from  a diseased state
 of  the lining membrane of the organ, as the structure of the pari-
 eties of the womb is scarcely ever affected by the  disease.   In
 most cases, this tumour is of a pyriform shape, with its base de-
 pendent, and its smaller end attached to the womb.  Its structure
 is generally semi-cartilaginous; but may be lymphatic, soft, gelat-
 inous; covered with the lining membrane of the womb, and through
 it veins of a considerable size and  number can be  detected.   If
 of  long standing, the  tumour ulcerates; and  the ulcer will be su-
 perficial, or watery, or deeply excavated with thick rough edges,
 and often  fungous; the latter form is most common.   This disease
 causes great uterine and constitutional derangement, which symp-
 toms are aggravated in the latter stages of ulceration ; when copi-
 ous discharge, haemorrhage, and pain, induce great debility, hectic,
 and death.  Treatment.—The older obstetricians recommend ex-
 traction, by forcibly pulling the tumour away, caustics, and excis-
 ion ; methods which exposed the patient to fatal haemorrhage, and
 hence now abandoned.
  The plan now generally employed, is the application of a tight
 ligature to the pedicle, or neck of the tumour, in order to impede the
 circulation ; and of course kill the part, by sloughing.  The best
 ligature is silk, cat-gut, or hempstring covered with wax, or a var-
 nish of elastic gum.   This is preferable to silver wire, which is so
 apt to  get into spiral turns, and impede the operation; and often,
 prematurely, cut the tumour.  While the  polypus remains in  the
 womb,  the ligature  cannot be  well  applied; but as  soon as
it descends into the vagina,  the operation should be  performed.
The ligature should be passed through each tube, at the same end
of a double canula, and be brought through ; so that a loop may-
be formed, which is to  be  carried over the tumour, either with the
fingers or a probe,  with a forked end ; and then the ligature to be
drawn tightly and knotted, so as to make tight  pressure  on  the 
206                 GYNJECO-PATHOLOGY.
neck of the tumour.   If  the  polypus be large and in the vagina,
there will be much difficulty in applying  the ligature; in truth,
there will be often a complete failure, even by the  best operators,
to the  great irritation of the parts, vexation, and  disappointment
of the patient.  The operation is  facilitated by using a double ca-
nula, with the tubes made separate, but  to  unite  at pleasure, by
means of a sheath.  The ligature  is passed through each tube, and
there is no loop left at the middle.   One tube is to be carried un-
der the pubes, to the neck of the  tumour, so as to meet its fellow;
both tubes  are then  to be  united by the sheath, and tightened.
The finger and forked probe, or a  piece of ratan, forked at the end,
must be employed, to assist the adjustment of the ligature round
the tumour.   Great care is to be taken, while tightening the  liga-
ture, lest any  of the womb be included; for if that were enclosed,
the patient would complain of acute pain,  vomiting, convulsions,
and might be destroyed;  the womb, however, has  been  included,
with fatal results.
   If the ligature be properly and  carefully applied, there is gene-
rally no fever, or irritation produced ; it is to be daily drawn tight-
er, and will  soon make its  way through ;  and when  applied, if pro-
ductive of pain, it should  be loosened.   When the tumour is  lied,
it will  become more turgid and harder; and, if visible, it soon ac-
quires a livid colour, and exhales a  putrid odour; signs that are to
be deemed  most favourable.  The diet should be light and nutri-
tious, and all general or local irritation avoided, during cure. Should
the bowels  or bladder become affected from their contiguity to the
part diseased,  they are to  be carefully attended to; and,  if vomit-
ing, or other derangements of the stomach supervene, effervescing
draughts, with opium, soda water, and the usual treatment, is to be
employed.   Dr. Denman has given a most valuable and interest-
ing account  of the application of ligature in his work.
   Levret described a kind of fungoid tumour, which  was attach-
ed  to  the  womb;  was soft, resembled  cords of  clotted  blood;
these he  called vivaces, and on dissection they were found spongy,
with cavities of various sizes.   They have been mistaken for pie-
ces of  retained placenta, and pieces of fetid fungi  have been torn
away in attempts to extract the supposed placenta or ovum.  The
tumour, when  felt in the  vagina,  is not  very painful at the hypo-
gastric region; and  at other times, there is little  pain felt in the
tumour, unless the womb be pressed.  The tumour bleeds,'on be- 
DISEASES  OF THE  INTERNAL GENITALS.        207
ing touched, and  discharges a sanious matter;  it grows into the
vagina; and thus differs from the polypus, which getting into the
vagina, leaves the  swelling of the  womb much diminished, often
scarcely to be discovered.
   Palliatives only can be useful, with  opium and cleanliness ; as
the disease, though  removed  by  extirpation, with  immediately
sprout forth again.
   There is  a  fleshy unorganized  substance found in the womb,
even of women who have not had children, after natural delivery,
miscarriage, or a diseased state of the  womb,  which is  called a
mole.
   M'jles are polypi, blighted foetuses, or organized coagula. This
substance is accompanied by all the  symptoms of pregnancy, as
nausea, fastidious  appetite, enlargement of the  breasts and abdo-
men ; but these enlargements come on more suddenly than in real
pregnancy, and appear more prominent at the second month, than
in latter cases at the fifth month of gestation. In general the mole
will be expelled about the third month, before the period of quicken-
ing, and attended with considerable haemorrhage, in such  a degree,
that the cases  to be managed as a real abortion. The expulsion can
be promoted,  or rather assisted, by the  finger  ; but great care
must be taken not  to lacerate the mole, so as to leave any part of
it behind.   Should it  remain  after the time  of quickening, the
abdomen does not  increase in  magnitude as in  pregnancy ;  nor
will there be any  motion or quickening  perceived.  The older
writers called moles false gatherings, or conceptions, and have left us
most  incredulous narrations concerning them.   We  often meet
with the disease in practice.  There is no  cure for a mole, except
to endeavor to cause its expulsion ; but this must be left  to nature
alone, for its retention is not followed by bad consequences.  The
general  health of the female should be attended to.   Mauiiceau,
and others, recommend the hand to be introduced into the vagina,
and two fingers to  be passed through  the  orifice of the womb, if
possible, in order to reach the mole ; it is  then  to be  seized  and
extracted.   If the fingers could  not  accomplish it, we were de-
sired to pass up an instrument, called a crane's bill, a kind of  for-
ceps,  to seize on it,  and  extract it.  Now few men can  pass the
hand into  the vagina in the virgin state, or  even where the woman
has borne a family, in the early  months of gestation ;  and hence,
when miscarriage occurs about the fourth or fifth month, the great 
208
GYNJECO-PATHOLOGY.
difficulty in restraining haemorrhage, as the os uteri  will be found
closed, or  nearly so; but so  much,  that two  fingers cannot be
passed into the womb.   I have seen cases, where tedious haemor-
rhage continued for six  weeks, from this  cause, where the foetus
was under  three months ; but  where even one finger could not be
passed through the os uteri, which was nearly closed.  The ergot
of rye is highly useful.
   Experience and  observation enabled me to speak confidently
on the impracticability  and  impossibility of passing  the  hand, or
two fingers, into the womb,  so early as the third or fifth month of
gestation;  and of course the same objection is good against doing
so within the same  period  in  cases of moles, or  other tumours,
situate in the womb. Dr. Dewees seems to sanction the operation
in early miscarriages ; but during an extensive  practice, as obste-
trician, I never met any case in  which I  could accomplish it, in
which the woman could suffer me to proceed.  If this were prac-
ticable, no  man would  remain watching a  patient, attacked with
flooding, after abortion, for weeks;  and yet we find the most able
practitioners in this and other countries often obliged to do so.
  Another kind of  tumour which frequently attacks the womb, is
the hydatid.   It is generally observed, in consequence  of destruc-
tion of the foetus, in the  early months, retention  of some part of
the placenta after delivery, or  abortion.  There are no diagnostic
symptoms,  and consequently the disease often mistaken for pregnan-
cy, or varions other morbid affections, already described. The size
of the womb does not correspond with the supposed period  of preg-
nancy, and  there is no motion, or quickening peceived.  In some
cases, the health does not suffer.    I have known a case of hyda-
tids continue for fourteen years, and during the greater part of the
time, there was no derangement of  health.  This case was mista-
ken for  pregnancy,  by several medical men, during  the period  ;
indeed, one of them sat up  four  nights, expecting delivery, the
uterine pains were so severe ; and yet there was  no pregnancy,
and of course no delivery took place. This woman, in eight years
afterwards,  was attacked  with uterine pains, fully as severe  as those
of labour, and expelled a number of hydatids, with a large quan-
tity of  water ; she  discharged  some  pints, mixed  with  purulent
matter.   When the  orifice  of the organ is enlarged,  and the tu-
mour extensive, the hand may  be  introduced into the womb, to ex-
pedite the process of expulsion, and to excite the  contractions of 
            DISEASES OF THE INTERNAL GENITALS.        209

the womb ; but this should only be resorted to in case of haemorr-
hage, or when some violent symptoms become  urgent.
   There is generally pain, fever, and constitutional disturbance du-
ring, or after the  expulsion  of the hydatids ;  in  the case that I
have just described, the most violent symptoms  of peritonitis set
in, and nearly destroyed  the patient.   In such disease, the usual
remedies are  to  be employed.   The  expulsion of hydatids  has
been mistaken for abortion, even by the justly celebrated Dr. Cul-
len.   Dr. Hamilton stated, in his Lectures, that one of his father's
patients being ill,  Dr.  C. was called in his  absence, and declared
the lady bad miscarried.  This opinion was the innocent cause of
destroying domestic  happiness in  that family ever afterwards, as
she and her husband had lived separately for two years.  On  Dr.
Alexander Hamilton's return, he declared the bodies expelled were
hydatids, and  that there  was no  abortion ; but the  parties were
never after happy.  Dr.  Hamilton also  mentioned, that a Dum-
fries practitioner wrote to  him concerning a wonderful case, where a
female who had aborted, expelled seventeen ova;  of course these
were  hydatids.   Hydatids  vary from  the size of a pea to that of
an ox's bladder ;  they are small oval bodies, composed of a mem-
brane, which  surrounds a quantity  of fluid, and have a strong re-
semblance to the  ovum in the early months of gestation.   Some-
times there is  but one hydatid ; at other times there will be seve-
ral, and various sizes ; they may be attached to  each  other,  like
bunches of grapes, or included  one within the other.   There is a
living  animal, floating  in  the centre  of each  hydatid. Though
the abdomen  maybe  swelled as large  as  in  the  last months of
pregnancy, yet there  will be no motion  felt ;  the breasts  will be
flaccid, and no child  can  be discovered.  There may be some
slight pain ; but there will  be indistinct fluctuation in most cases.
We can distinguish this complaint from ovarian dropsy ; the swel-
ling being in  the womb, in the one, and in a side in the other.
   The duration of the complaint varies very considerably.  I have
observed the disease continue for fourteen  years ; I have seen it
so early as the tenth year.   Tliere is  often a copious discharge of
water from the vagina when an  hydatid bursts, and the tumour of
the abdomen will become suddenly diminished.   Dr. John Clarke
knew a lady to whom this happened, while sitting in an eating house,
and she literally  deluged the floor.  The disease usually termi-
nates in this way, after  any sudden  or  violent  exertion.   It has
        27 
210
GYN^CO-PATHOLOGY.
 been attempted  to remove  the fluid through the orifice of the
 womb, but that is a very  doubtful operation ; because, if there
 be more than one hydatid, the sac of one may be evacuated, but
 that of every one else  left untouched.   Sometimes the bag or sac
 comes away, and without much pain.   Hildanus mentions the case
 of a woman, who supposed herself  pregnant; but, dumnoctuma-
 rito  rem haberet, a sudden inundation swept away  all her hopes.
 I have seen a female, aged thirty, who,  during menstruation,  ex-
 pelled a  number of small white worms,  resembling white silk, cut
 short, and these were from hydatids; the expulsion of them was
 always accompanied by  a discharge  of water, and not from the
 bladder.   There is a  similar case,  recorded  by a  Mr. Wellson,
 in one of the early  numbers of the  Edinburgh Medical Commen-
 taries, vol. iii. p. 36.   This disease  is often combined with preg-
 nancy, or with a mole,  and rarely appears alone.   Dr. Monro
 secundus proposed  the injection of  some bitter  infusion  into  the
 uterus, as recommended  by Cockson ; which  now can be accom-
 plished by means of the patent syringe.   When expulsion is like-
 ly to be  effected and uterine contraction or pain present, some think
 the ergot of rye might be used with great advantage, by increas-
 ing uterine contraction ; and more probably expelling the whole of
 the hydatids  from the womb.   I  have been told  of a case where
 the obstetrician introduced his hand, and brought away a basin-full
 of these  substances.   Very early in my practice, I  was requested
 to tap a girl,  ten years  old, who  had ascites, evident  fluctuation,
 tense abdomen, on the  parietes of which numerous  veins were ev-
 ident.  To my great astonishment, no more than six ounces of flu-
 id escaped, though the canula  was clear, and the fluctuation most
 evident;  this was decidedly a case of ovarian or saculated dropsy, or
 perhaps hydatids. When we bear in mind that hydatids are vesicles,
 formed of a thin membraneous coat, filled with serum ; sometimes
cemented together in the form of a great bunch, and hanging by
one or more pedicles; sometimes distributed  into separate divisions,
fixed by  different pedicles; which may be filled with limpid, turbid,
or purulent fluid, we can  readily conceive how the  perforation  of
one of these, which may  vary from the size of a millet seed to that
of an inflated ox's bladder, may  be followed by  a considerable
discharge, and yet that  the abdominal tumour will not be much di-
minished, and fluctuation  will remain very evident.  This disease
was  described by iEtius. 
            DISEASES  OF THE INTERNAL  GENITAL9.       211

   There is is another disease of the womb, where a quantity  of
 watery fluid, perhaps a  pint, may be discharged daily, without
 any hydatids or other tumours being present.  Hoffman and Burns
 describe this case.   The latter recommends improving the gene-
 ral health, and the use of mild astringent injections.   Dr.  Hamil-
 ton denies that there can be any accumulation of water in the ute-
 rus, that is dropsy of the womb, hydrometra, on account of the
 openings of  the Fallopian  tubes and the os uteri;  while Astruc and
 others minutely describe the disease.  It is strange that the most
 eminent obstetric writers  have not met with it.  Dr. Denman
 thought he saw one case,  in  which a sac was expelled, but was an
 hydatid.
   Gas or air may be  secreted in the  womb, and escape involun-
 tarily.  Astringent injections often do  good ;  and as  the  disease
 rarely causes sterility, it may be permanently cured by  pregnan-
 cy.   Astruc and  Mackintosh  describe  tympanites of the womb
physometra, ructus vaginalis, and say that the air gets into it after
 delivery, in  the cases where  its parieties do not close; that  the
 womb becomes distended, the orifice closed, and sterility produced.
 Drs. Denman and  Hamilton described  a case somewhat  similar,
 where air was expelled from  the  vagina.   The  true  tympanites,
 says Astruc, agrees as to magnitude with all the other tumefactions
 of the womb, with steatoma, sarcoma, dropsy, moles, scirrhus, and
 pregnancy, but can be  easily distinguished from them.  Although
 generally engaged  in obstetric practice, 1 never saw a perfect  in-
 stance of tympanites of the  womb.  The  best plan of treatment
 consists of invigorating the system, using astringent injections, and
 ordering the patient to  wear  acanula in the  vagina.
   Scirrhus  and cancer of the  womb  were first accurately descri-
 bed by Boerhaave.   They may occur  at every period of  life,  af-
 ter puberty, but generally happen to unmarried or barren women,
 to those whose conjugal rights have been interrupted, and espe-
 cially about the cessation of  the menses.  These diseases are pre-
 ceded by irregular menstruation ; and  are  ushered in with symp-
 toms of pain, uneasiness,  or irritation  in the back, loins, and ute-
 rine region,  and mostly preceded by discharge of the leucorrhceal
 or purulent kind.  There is  pain or heat in passing water, and of-
 ten itching of the vagina, or  pudendum, and also tenesmus.  The
stomach becomes affected, from its sympathy with the womb;  and
hence we observe nausea, loss of appetite,  and indigestion ; con- 
212
GYNJECO-PATHOLOGY.
sequently the general health suffers, the strength declines, the pa-
tient will be emaciated, the countenance changed,  and the pulse
rapid.   There is stinging, lancinating pain in the womb often ex-
perienced ; and aggravated by sexual intercourse, especially when
the disease is situated in the neck or orifice of the organ, which is
its usual site.   When there is disproportion between  the sexes, the
pain will be worse during coition than even during labour, by the
passage of a large infant.   Scirrhus uteri is a slow,  tedious, insid-
ious disease, and  often harasses the patient for months  or years,
before  it ends in ulceration.  Dr.  Hamilton  has  seen sixty cases
of this description, many of which  were palliated by diet and me-
dicine ; and he asserts, that it does not  prevent impregnation  ; and
also, that the discharge is  often so  fetid, that the smell  of it can-
not be  washed from the finger for  a  long time.   As  soon as the
discharge decomes purulent, bloody, and copious, there is evidence
of ulceration.   The pain is now most severe, burning, lancinating
and constant ; there are,  too often copious haemorrhage, and pro-
fuse purulent discharge; hectic  and  emaciation  daily increasing,
and  death soon  closes the  scene.   In the commencement of this
disease, the orifice of the womb will be found open, irregular and
fringed, tender, thickened, or indurated  ; and therefore the patient
will  experience pain during coition.  Dr. Beatty relates a case in
which the restoration of conjugal rights was followed by pregnan-
cy and the re-establishment of perfect health, which yet continues.
He says, the disease usually occurs to those who are  deprived of
nuptial rights.   (Dublin Hospital  Reports,  1830.)—The orifice
will be often found fringed, and studded with a number of indura-
ted bodies, like piles or fungi, or deep excavations; there will be a
discharge of blood, after examination, by the vagina.
   The neck of  the  womb  is most liable to this disease;  the bo-
dy rarely. The neck or body of the womb will become indurated
and  enlarged, will in time  become  attached to the pelvis or  blad-
der, or rectum, and the tumour will impede the natural evacuation
of these organs.  These  parts, the ovaria, Fallopian tubes, and
linings of the  pelvis, and  even bowels, will  be  implicated in the
disease, and may be destroyed by it.  When the disease is advan-
ced the vagina becomes contracted in different parts, from the en-
largement of glands in its course.   This disease has been confoun-
ded with  many others, as the  various kinds of tumours, fluor albus, 
DISEASES OF THE INTERNAL  GENITALS.         213
menorrhagia and  dyspepsia, but its  very peculiar symptoms are
sufficiently diagnostic by ordinary attention.
   On examination after death, the parts are found  to  consist of
cancerous structure ; the substance is of a whitish or darkish col-
our, intersected with firm membranous divisions, containing  num-
bers of small cysts, and composed of a substance, when wiped, of
a light olive colour, highly  vascular; these cysts are  found to con-
tain abscesses or fungi.   We should  be  very  guarded  as to  our
prognosis of the disease, as in some cases death will  happen at an
early period, in others not for many years.  Dr. Hamilton saw one
case,  where a lady died in  a fortnight after the commencement of
the disease.   The prognosis is hopeless, and always unfavourable.
The nature of the disease is best ascertained by the speculum uteri,
invented by Recamier.   When  the  parts take on  an  inflamma-
tory action previous to ulceration, which is indicated  by  throbbing,
heat, pain, &c. in the lumbar or uterine regions, cupping,leeching,
and warm  bathing, with  mild laxatives, should be employed. The
patient should be kept in the horizontal posture, and avoid sexual
intercourse.   The patient  should wear  warm clothing, avoid  all
motion when pain is present, regulate the bowels, leech  and  apply
counter-irritation.   When  the pain is urgent, ten  drops of the se-
dative solution of opium, with two ounces of starch, should  be in-
jected into the rectum.
   Harrowgate water, saline purgatives, and the antiphlogistic reg-
imen  should be employed ;  for the longer inflammation and ulcera-
tion are kept off the belter.  Powerful sedatives  must be given to
allay  pain, and produce rest, as morphine,  black drop, sedative
liquor of opium, hyosciamus, hemlock, and  four or  five grains of
opium pushed into the rectum,  will often give considerable relief;
astringent and chalybeate injections are strongly recommended, as
a solution of sulphate of iron, which was found extremely  useful
by Mr. Carmichael and others.   Decoctions and sedative substan-
ces have also  been used  with advantage.  Iodine has been  found
useful in scirrhus  of the womb, by Drs. Thetford and Montgomery,
of Dublin, by Dr. A. T. Thompson, and others.
  The state of the bowels  and  general  health should be particu-
larly attended to.  The  various preparations of mercury,  antimony,
arsenic, iron, hemlock, &c. have been tried in this species of can-
cer, and with  ordinary  want of success.  Excessive vomiting is
Sometimes allayed by solid  opium, or by applying a  small  blister 
214
GYNJECO-PATH0L0GY.
 to the epigastrium, and afterwards dressing  the  part with extract
 of opium, or morphine and adeps.   When  all remedies fail, as
 they invariably do, it has been proposed to remove the womb by
 excision ; an operation, however  formidable, which has been per-
 formed with success several times on  the Continent, and lately in
 this  country, by Mr. Weatherill,  of Liverpool;  by Dr. Blundell-
 and  by Recamier and Roux of Paris.  In all ages death took place
 from six to twelve months after the extirpation,  the pelvic viscera
 and  linings were found  diseased.   Dr. Blundell has since written
 against this operation.   The womb is pulled down by  ligatures or
 forceps, as recommended by Baron Dupuytren, of Paris, and when
 brought through, the genital fissure  is removed with  a bistoury
 either entire, or in part, according to the  extent of the disease.
 Caustic was applied with success  by Recamier, Delpech, and Del-
 mos.   (Duges.)
   Extirpation has been performed in  Germany six  or eight  times
 within  the last thirty years.   First, in 1808, by Osiander; but
 it was performed in 1540, by Zacutus Lusitanus.  (See the works
 of Professor  Siebold, and  Dr. Holscher, on  Extirpation of the
 Uterus, 1824.   Also Edinburgh  Medical Journal, April  1825.)
 Dr.  Weatherill, of Liverpool, extirpated the neck and  part of the
 body of the womb, 1828; and  the patient has done well.   (See
 Lancet of June 7th, 1828; and  also see same  work for August,
 for the account of Dr. Blundell's case.   London Medical and
 Surgical Journal, 1829 and 1830, for the French cases.)
  There is an interesting paper in the Edinburgh Medical Jour-
 nal,  by Professor Osiander, of Gottingen, which  contains a valua-
 ble account of Cancer of the Uterus.  (1816,  vol. xii. p. 286.)
 The professor operated for this species of cancer in  1801; and
 the patient recovered, after a most inhuman operation, at the end
 of the  fourth week.   He operated on nine patients in  1808, and
 always with  similar success.   Even one  of these  patients,  after
 enjoying good health for three years, came to him  to be operated
on a second time, for the cancer broke out again  ; and he perform-
ed it with the same  success as  before.   He asserts, that cancer
and scirrhus of the womb begin almost always  on the external ori-
fice of the uterus, and proceed from thence to its body ; and often
before the disease destroys half of the womb, death puts an end
to the agonies of the sufferer.  An ulcer is sometimes formed in
the bottom of the womb, which degenerates into a cancer, that ad- 
           DISEASES OF THE  INTERNAL GENITALS.        215

mits of no cure.  But in the first case a  perfect cure may be ob-
tained, by cutting out in time the scirrhous and cancerous portions ;
when  the cancer spreads from the orifice  of the womb down into
the vagina, which it very often does, no cure is  to  be expected
from excision.   The continuation of this  paper is well worth the
consideration of the reader.
   Since the publication of Osiander's essay, Manzoni, Recamier,
Dubois, Lisfranc, Roux, and Dupuytren, approve of removing the
diseased portion of the uterus.  Signor Guiseppe has extirpated
scirrhous tumour from the  uterus.   (London Medical  Journal,
1820, vol. xliii.  p. 460.)   M. Dupuytren  grasped the os uteri
with a forceps, and brought it to the  orifice of the vagina, removed
it with a curved scissars.  The disease returned, and caustic was
obliged  to be applied.   Dr. Canella has given this account; and
also a description of an instrument for  the excision of the neck  of
the womb, in  cancerous  cases.   (Cenni sull' Estirpatione della
Bocca e del Collo  dell' Utero.)—Dr.  Charles Johnson  removed
a portion of an  inverted uterus, by a ligature, with  success; and
relates two cases, in which he operated with happy results. (Dub-
lin Hospital Reports, vol. iii.)—Recamier and Marjolin performed
a similar operation.   M.  Avisard  removed the neck of the uterus
by excision.  Journal Univ.  des Sciences Medicales, 1820.)  Dr.
Sauter removed the uterus  by extirpation, about  five years ago,
with success.    There is a concise but complete history of the ex-
cision of the uterus, given by the  learned editor of the Edinburgh
Medical and Surgical  Journal, July 1824, vol. xxii; and  in the
twenty-fourth volume of  the same work, there is an account of a
large  fungus,  found in the uterus,  by Mr. Lightfoot.
   The  last cases of extirpation of the uterus are there detailed  by
Dr. Siebold, professor of Midwifery, in Berlin.  The first extirpa-
tion of  the uterus was performed  by Osiander, in 1808, on a wo-
man from whom he had seven years before removed a cancerous
tumour  of the uterus.   In 1813,  a tumour was removed from the
cervix uteri,  by Professor  Rust, of Vienna ;  but unsuccessfully.
In 1817, Langenbeck extirpated a prolapsed uterus with success.
In 1S22, Sauter removed an unprolapsed uterus; and since that
it has been attempted in Berlin, Hanover, Vienna, Liverpool, Lon-
don and Paris.   Extirpation of the uterus was  performed success-
fully in  1560, by Andreas a  Cruce, physician  and professor at Vi-
enna; it was  also  performed on  the prolapsed uterus,  1540,  by 
216
GYNiECO-PATHOLOGY.
Carpus ;  and in the beginning of the seventeenth century, the same
operation was performed by Zacutus Lucitanus.  (Sue's Historie
des accouchmens,  1786.)   Dr. Siebold's case was one of prolap-
sed uterus, the body and fundus of the organ were scirrhous.
  The operation was painful, the woman died in  sixty-five hours
afterwards.   It was considered  as cruel, bloody, and ill-judged an
operation, as any recorded in the annals of surgery.  (Medico-Chi-
rug. Rev. 1825, vol. iii. p. 266.)
  Dr. Holschar's case was one in which the uterus was encircled
with projecting fungi.   The carcinoma was  separated with a scal-
pel ; he could not  pull it away.   He next tried to pull down the
uterus, by  means  of a  hook,  in vain.   He extirpated the cance-
rous mass.   The  uterus  was  now more easily got  at; a sharp
pointed knife was introduced as  far back as the fundus.  An open-
ing being made, the circular knife was introduced, and the uterus
separated from all  its lateral connexions ; after which  it was easily
removed. The intestines did not protrude.   The operation lasted
thirty-five minutes.  The woman died in twenty-four hours; the
opening in  the peritoneum  had  closed,  to  the size of a hen's egg,
and nothing wrong was seen in any part  of the  pelvis.  For an
admirable account  of cancer in every organ,  the reader should con-
sult the Diet, de Med. and Chir.  Pratiques, Article  Cancer,  by
M. Begin,  1830, torn, iv.,  in which extirpation of the uterus is
utterly condemned.
   Calculus, or earthly concretion in the womb, is a very rare dis-
ease,  and can only be  discovered by examination with  the finger
or probe.  The stone  produces irritation, inflammation, and ulcer-
ation, and may escape through  the rectum and vagina, or bladder.
The treatment consists in  palliating the urgent  symptoms.  Indu-
ration and enlargement of the womb is  often mistaken  for cancer;
but the various symptoms of the latter disease are absent. I have
seen a most extraordinary specimen of diseased uterus; the organ
weighed  ten  pounds,  and contained  various  disorganizations, as
cancer, scirrhus, calcareous depositions, muscular thickening, fun-
gus, and bone.
   Dr. Mackintosh relates a case in  which the  uterus weighed
above fifty pounds, the whole anterior surface of which  was at-
tached to the parietes of the abdomen ; it was  tapped three times
at the recommendation of some eminent practitioners but no fluid
escaped.   The tumour pushed the diaphragm  so high  that it en- 
            DISEASES OF THE INTERNAL GENITALS.          217

croached upon the thorax, and lay over the heart and lungs so as
to conceal the respiratory sound over  the  whole anterior part of
the chest.   The  diaphragm was  in  contact with the first rib on
the right side; the  lungs were reduced to  a third of  their natural
size; and the heart was flattened by the pressure  it sustained.
(Practice of Physic, 1831, vol. ii.)   The  neck of the uterus has
been elongated nine inches.   (Leroux, Segard, Lallemand, Bi-
chat.)
   (forms have  escaped from the  womb, after having produced
much local and constitutional  irritation.  They are destroyed  by
the injection of some of the bitter infusions.
   Besides the numerous diseases  now described,  the  womb is lia-
ble to partial or complete inversion, technically denominated pro-
lapsus uteri, or prolapsion.   This is one of the most  troublesome
and common diseases of women.   It is divided into three species:
1. When slight, it is called relaxation ; 2. When greater, styled pro-
lapsus, vaginal prolapsus ; 3. When protruded beyond the genital fis-
sure it is called procidentia. Weakness,pain,and uneasiness in the small
of the back ; sense  of weight, and bearing down in the uterine re-
gion or  vagina, as if something were protruding, which often  is so
troublesome as to oblige the patient to sit down and cross her limbs,
in order to prevent  it.   There is generally a  Ieucorrheal, or pur-
ulent discharge,  excessive or  painful menstruation, and great dis-
order of the stomach  and digestive  organs,  together with strong
hysterical symptoms, or the person is extremely dejected and ner-
vous.  The disease is very often  confounded with what is called
a nervous or bilious complaint; and too often  not discovered, un-
til great debility and emaciation are obvious.   This disease some-
times happens to young females, from using much  exercise, as
walking, dancing, or experiencing falls, during  menstruation ; but
it is generally produced by sitting up too soon  after delivery. The
young practitioner  should always  keep  this  in view, and he can
readily understand how the disease will be  produced, by recollect-
ing that the  womb is considerably enlarged after delivery, for eight,
ten, or twenty days; and hence its weight, if the patient  assume
the erect posture, which  is frequently done by the lower classes,
will very readily cause its descent into  the vagina.   The  woman
will complain of painful sense of weight and bearing down, as be-
fore the birth of the child ;  these sensations will be more or less
removed, by her assuming the recumbent  posture.   Sometimes.
        98 
218
GYNJEC0-PATH0L0GY.
 however, they will not disappear in any position; and  are  most
 severe in  married women, who  feel pain in connubial  congress.
 Haemorrhage may follow from the first to the sixth week after de-
 livery, as I have repeatedly witnessed, and recently in cases with
 Mr. Terry, of Southampton Buildings, Chancery Lane, and with
 Mr. Matthews, of Hunter Street.   All the ordinary symptoms
 may proceed from the thickening of the  neck of the bladder.  The
■patient may also feel pain, heat  and uneasiness in passing water,
 or discharging the rectum ;  and there is often very severe dragging
 pain in the back and loins.  The disease may be caused by sud-
 den exertion before or after pregnancy, or during  parturition, car-
 rying heavy burdens, and by all sudden or violent exertion of the
 body.   On examination the womb will be  found lower down  than
 usual,  and vagina relaxed; it may be in every position,  until its
 orifice  protrude through  the external  parts.  In some cases of
procidentia, the whole womb and vagina protrude, forming a large
 tumour between the thighs, from  the surface  of which the menses
 have been observed to proceed freely.   The surface of the womb
 is either ulcerated or assumes the appearance of skin.  In such
cases coition is impracticable; but instances are recorded  in which
the uterus was beyond the external orifice  for two, and  eighteen
years,  and in the latter the woman had six children.  (Ashvvell,
London Medical and  Surgical Journal,  1830, vol. iv.)—The in-
testines descend in this latter case low down  into  the cavity of the
pelvis, into the space  naturally occupied by the womb; and hence
increase the protrusion, and often cause inflammation. The womb
may be retroverted, its base or fundus towards the rectum, and its
orifice  towards the anterior part of the tumour. The bladder may
be carried down with  the protruding  parts, as it  usually is, unless
enlarged by scirrhus, or calculus ; and hence  the natural course of
the urethra is changed, so that if  we must  use the catheter,  it is
to be introduced downwards and backwards.   If the profusion be
great, and extend to the vulva, there will be  pain in voiding urine
and faeces: and  often pain, inflammation, ulceration, and slough-
ing, in  the surface  of the  tumour.  In some cases, however, its
surface ceases to secrete, and becomes covered with common in-
teguments.   This  disease is sometimes  complicated with various
tumours, which appear in the female organs of generation, or may
be complicated with stone. The cause of this painful and  distress-
ing disease is relaxation of the ligaments  of the womb of the vagi- 
            DISEASES OF THE  INTERNAL GENITALS.         219

 na, and their other attachments before or after parturition.   Fre-
 quent labours, fluor albus, excessive venery, falls, or severe exer-
 cise during menstruation, will often produce  the disease.   It  is a
 curious and certain fact, that the uterus cannot be easily  inverted
 in the dead body after the division, or excision of the broad liga-
 ments ; hence, Dr. Dewees contends that the  vagina  is the chief
 support of this organ ;  and, therefere, frequent  deliveries, large
 children, habitual  poughs, severe vomitings,  and  instrumental la-
 bours, all  tend  to destroy the tone of the vagina, and cause it to
 prolapse.   I have known it  to be  produced by  a healthy young
 woman falling in the  street.
   The chief indication of cure  is to restore the uterus  to its prop-
 er situation ; and  to retain, or support it, when replaced.   When
 the complaint is suspected, we should examine how far the uterus
 has descended, and this after the  patient has been standing for
 some time, and then assuming the recumbent position,  or being
 still erect.   Examination is always requisite, in order  to ascertain
 the real nature of the disease.   If there be partial descent,  we
 should endeavor to remove the relaxation,  by  frequent injections
 of solutions of sulphate of alum, either in water or oak bark ;  re-
 peated ablutions of cold water,  cold bath, gentle aperients; all ex-
 ertion to  be avoided, and  the recumbent  posture observed.  If
 these remedies fail, we must have recourse to mechanical means,
 which consist of supporting substances,  called pessaries, which are
 passed into the vagina, rest on the perineum, and keep up the
 uterus.   In recent cases, they generally give relief.  Pessaries
 are made of wood, box, ebony, cork, sponge, or of silver, strongly
 gilt, with a hole in the centre, to  permit the escape of the menses;
 are of different shapes;  some oval, some flat, and circular; some
 like spindles, or the figure of eight, and others globular; the latter
 is considered the best. Whatever form is used, it is to be so large,
 as not to fall  out of the vagina, when  the woman  walks or moves,
or evacuates the bladder or bowels, and ought to be frequently re-
moved, in order to be cleaned ; its size is to be gradually diminish-
ed, and astringents are to be used ;  so that, after some time, it may
be altogether discontinued.   A broad bandage should  be  applied
round the  abdomen,  to relieve the pain in  the back  and pubis.
The instrument should have a piece of  strong tape attached to it,
to enable us to  withdraw it; a proceeding that may be resorted to
every night, or at all events twice  or thrice a week, for the  pur- 
220
GYNJECO-PATHOLOGY.
pose of cleaning the instrument and preventing irritation.   When
the instrument is not withdrawn, as here  recommended, it may
produce irritation, increased mucous discharge, hysteritis, peritoni-
tis, and death.  The tape rots in a few days, and then much diffi-
culty will be experienced  in  removing the  instrument.  I once
saw a case of an old woman at one of  the public  institutions to
which I am attached, in which there was a copious fetid purulent
discharge  from the vagina.  On enquiry, I learned that a pessary
had been  worn for three years, and never  withdrawn during the
period; it was of the circular  kind, and removed with  much dif-
ficulty.  By proper treatment  the purulent discharge was cured.
In some months afterwards, I was requested to visit the same per-
son, when I found her dying of enteritis.  I enquired if she had
had occasion to employ an instrument, and she replied in the af-
firmative ; and stated that to it she owed  ber  present  illness, as
one had been passed which produced great pain, and all her pre-
sent suffering.   On examination, I found I could not remove the
instrument.   She sunk in a few hours ; and  next day it required
great force  to remove  it.   It  was a gum  elastic one, which rest-
ed  against the perineum  and  uterus.  It was  much too large.
There were hysteritis,  enteritis, and peritonitis.   There should
be no pain produced after the instrument is placed in the vagina;
on  the contrary,  the patient  should  experience complete relief
from her former sufferings.  I have repeatedly had the  gratifica-
tion to hear women who had been  several years labouring under
the symptoms of prolapsion, declare themselves free from suffer-
ing in five minutes  after  the application of the  pessary.  I have
known the disease mistaken for years, as no  vaginal  examination
had been  instituted, and the various tonics and antispasmodics tri-
ed  in vain to relieve dyspepsia and hysteria.  The  complaint is of
very  frequent occurrence, and is generally overlooked.  I have
known a pessary not more than an inch in diameter  afford great re-
lief;  and  here it is  to be recollected, that the size must  vary with
the dilatation or dilatability of the vagina.  In old women, who
have had  several children, the instrument must vary from the size
of an orange to that of the foetal  head at the  sixth or  seventh
month.  This is only a temporary  remedy ;  it affords great relief,
but not a  cure.  In married persons, the disease is often cured by
pregnancy,  and after delivery the  woman should  be confined to
her bed for  ten days after convalescence. 
DISEASES OF THE INTERNAL GENITALS.
221
   In some instances, pessaries have been retained for fourteen years-
they must be varied according to the circumstances of every case,
and must often be tried in succession.   The circular form does not
prevent connubial intercourse, or even impregnation.  If the cen-
tral openings  of the pessaries be too large, the uterus  may  pass
down through them, and be strangulated ;  hence a tape  is general-
ly passed through the opening, and  round  the circumference of the
instrument, in order to pull it away when necessary ;  if this fail,
and the strangulation be urgent, the rim of the instrument must be
divided, with a sharp strong forceps,  or with one of Mr. Liston's
bone forceps.   When the  instrument is globular, Dr.  Merriman
proposes a kind of screw for  its extraction, which is to be introdu-
ced like a common gimblet.  (See Medical  Gazette,  1831, vol.
vi.)—When  a woman has procidentia, in a slight degree, it is a
great service that she should live with her  husband, as pregnancy
generally cures the complaint, I have observed this  in  numerous
cases.   The treatment of  prolapsus will vary, if it occurs soon  af-
ter delivery, by the woman sitting up too soon to suckle  her infant;
but when the uterus, or its appendages, are tender, no one would
think of  applying a pessary.   In such cases,  fomentations, laxa-
tives, he. he. must be  used  to relieve the sensibility of the part,
in the first instance.   The long diameter of the oval pessary should
vary from two inches and a half to three  inches and a half in  di-
ameter, according to the degree of relaxation ;  it sometimes falls
out, when the perineum may be supported with a soft pad and T
bandage,  with a spring,  on  a  similar principle with that used  for
prolapsus ani; a  contrivance of this kind, and a  globe pessary,
must be used when the  perineum is much  lacerated.  Where the
procidentia is extensive, and  of  long continuance, the bowels  fall
into the pelvis, and are often  connected to its cavity by  adhesions.
In such cases, great care must be  taken  in the reduction ;  for if
much pain be produced, it  ought not to be persisted in, lest inflam-
mation be produced, by rupturing the adventitious adhesions.  We
should attend to the bladder,  in such cases, preventing an accumu-
lation of urine;  fomentations and the  horizontal position, and opi-
ates should be employed, if much irritation be experienced ;  but
attention   to posture is of primary  importance in  managing  this
kind of disease.   If the tumour is long protruded, its surface may
be irritated and inflamed, or ulcerated ; all which states may  be
removed   by  fomentations, saturnine  applications, laxatives, and 
222
GYNJECO-PATHOLOGY.
blood-letting, before it can be reduced.   In some  cases, it cannot
be reduced ;  and then it has been proposed to remove the part by
ligature, which has been done with success.  The bladder has been
included in the ligature  (Ruysch, Obs. Anat. 7,) and the intes-
tines have also been divided,  (Henry abHeers. Obs. Med. p. 192,
Burns, 99,) having been  down in the inverted vagina.   If violent
exertion is used, or the woman receives  a fall, the uterusmay pro-
lapse during pregnancy, although the woman has not formerly had
this disease.   In such cases,  we should first attend to the blad-
der, lest a  fatal suppression of urine should take place; our  next
object is to replace the uterus, and retain it, by rest and a pessar).
If it cannot be reduced,  as sometimes happens, until after delivery
(Haller, Disp. Chir. torn. iii. p. 434. Lond. Med. and Surg. Journ.
1830);  it is to be supported by a bandage (Sabatier, in Mem. de
I'Acad,  de Chir. torn. iii.  p. 370) until after delivery, when it is to
be reduced.   If prolapsus happens soon after delivery, by sitting
up too early, the part should be carefully reduced,  and the woman
confined to the horizontal posture, and the  use of mild laxatives
employed ; the bandage already described will be used with advan-
tage.   The cervix uteri  may  be elongated, and grow  down into
the vagina, which is not  to be confounded with prolapsus ; it has,
however, been removed by ligature.  It may be useful  to describe
the mode of introducing pessaries.
  Introduction of Pessaries.—Before  the application of the in-
strument, the bowels and bladder are to  be evacuated, and the wo-
man should be in bed an hour previously to the operation ; she is
to be placed in the horizontal  posture, near the edge of the  bed,
and the genital fissure, as well as the instrument,  are to be lubri-
cated with hog's-lard.   The labia are next to be  separated,  and
the circular silver or other instrument applied  to the os  externum,
and carefully and gradually introduced downwards and backwards,
having the introduced part looking towards the sacro-iliac synchon-
drosis.    Pressure is to be continued in the direction just named,
until the whole is received into the vagina.  The  breadth of the
pessary is to  be placed  in  a  transverse position,  so that it may
correspond with the  inferior  strait ;  and  the hole in  the centre
should correspond with the axis of the os externum.
  The cervix  uteri ought to be placed in the  aperture of the pes-
sary, which can be readily effected by the finger.   If the instru-
ment be too large, it  will give pain ; if too  small, it will escape 
            DISEASES  OF THE INTERNAL GENITALS.         223

when the woman  sits up.   Dr. Dewees uses an injection of half
an ounce of alum to a pint of water, for two  or three weeks; and
after the instrument is adjusted, two or three  syringes  full of soap
and water ought to be thrown up daily ;  the gilt pessary is prefer-
able to all others, as it need not be removed more than once in two
or three  months.   In most cases the instrument will not be requir-
ed longer than three or four months ; but in very obstinate cases it
must be used for years.
   The French writers assert that the womb may present as  hernia
in consequence of previous intestinal protrusion.  This must be a
very dangerous disease, and should be reduced when  practicable.
Examples  are  recorded in the Recueil  Periodique Societe  de  la
Sante vol. v; Med. de la Societe Med. de l'Emulation, vol. iii. and
by Nauche des Maladies de l'Uterus.
   There is sometimes a morbid growth imbedded in the substance
of the womb, called tuberose tumour by Dr. Baillie.  Its struc-
ture is tougher than that of polypus.  It varies from the size of a
nut to  that of a cricket-ball.  It may also grow into the organ, and
occasionally to an immense size.   It differs perhaps very little
from the fibrous tumour described by Martinet, which  consists of a
collection of whitish fibres, closely united, very firm, and extreme-
ly tenacious; much more  flexible  than cartilage, but less so than
cellular substance.   See  Quain's Translation of Martinet's Man-
uel of  Pathology, 1827; Hodgkin Med.  Chir.  Trans. 1830, vol.
xvi. Part II.
   The womb may be  partially converted  into bone,  or into an
earthy or calcareous substance.  Lieutaud also records a case  of
ossification of this organ, in his Hist. Anat.  Med., vol. i.  Obstet-
ric writers describe instances of the foetus becoming an earthy sub-
stance, when retained in the womb for many years.
   Some  of the late French writers have asserted  that the sub-
stance  of the womb may be softened, and want all the  appearance
of muscular structure.  (Medico-Chirurgical Review, July 1828.)
  The other diseases of uterus are masses  of bone  in its cavity,
calculi, ascarides, and stricture of its cavity. It is also liable to rup-
ture during pregnancy and  parturition, of which hereafter.
   Section 3.—Diseases of Menstruation.   Uterine  Fluxes.
  The diseases of menstruation are, 1.  Amenorrhoea,  2.  Dys-
menorrhea, 3.  Menorrhagia, 4. Metrorrhagia, or Uterine Haemor-
rhage. 
224
GYN^ECO-PATHOLOGY.
  Amenorrhoea.—This disease is divided  into  two species, 1.
Emansio Mensium, or retention  of the menses when the uterine
secretion does  not appear at the age of puberty; 2. Suppressio
Mensium, when the secretion has appeared once or oftener, and is
suppressed, independently of utero-gestation, or lactation.  I have
already described the phenomena and physiology of menstruation
in the  chapter  Gynaeco-physiology, in the  sections  Puberty and
Menstruation, to which I must refer the  reader lor information on
the  importance of this function ; and also the chapter Gynaecotomy,
in the sections on the Uterus and Ovaria.   The term amenorrhoea
may be strictly applied to the retention of the menses at puberty,
or to their suppression during the remainder of  life, except during
pregnancy  or lactation.  Under this  term we  comprehend many
physiological and pathological conditions.  It is obvious that the
retention of the catamenia at puberty is  very different from that
which occurs at the critical  age,  or depends upon organic disease
of the uterus, or upon inertness of that organ, produced by haemor-
rhage.  All these conditions require very different treatment, and
ouo-ht not to be confounded under the same denomination.   The
real amenorrhoea depends upon defect of vital  activity in  the ova-
ries or womb; and this is what must engage our attention.
  When the ovaries are undeveloped at puberty, they cannot per-
form their  functions, and influence the rest of the economy (seep.
23).   Menstruation will not take place ; the  general health will
be  impaired ; the appetite defective or depraved ;  the mind depres-
sed ; the countenance pale, as also the whole body ; and this con-
dition is called  chlorosis.   Persons of a  lymphatic  temperament
and scrofulous habit, who reside in low damp situations, whose food
is innutritious, and whose pursuits are sedentary, are most liable to
tardy menstruation and chlorosis.  Hence we observe  these disea-
ses are  most common among the poor of crowded cities; and those
who are confined  in manufactories at sedentary employments.
   Persons of a nervous temperament,  who indulge in all causes
which excite their feelings, as vivid passions, tea, coffee, &c., men-
struate freely.   It has been long observed, that  chlorotic subjects
did not possess a sufficient quantity of blood, and hence the  prac-
tice of administering chalybeates, which  were supposed to impart
the colouring matter of the blood.  This opinion  appears  to be
correct, as there is a general anemia of the system, which will not
allow a large supply  of blood to a particular oagan  without incon- 
            DISEASES OF THE  INTERNAL GENITALS.       225

venience  to the other parts of the body.   This condition  of the
body is characterized by general pallidity of the skin, the eyes are
dull,  the  hair is weak  and lank, the appetite is depraved, the de-
sire for food unnatural, the mind is depressed, there are dyspnoea,
palpitations, an insurmountable sadness, constipation, and a com-
plete aversion  to motion or exertion.
   This species of  amenorrhoea is to be treated by nutritious food,
by tonics, mild aperients, habitation in a dry, airy situation, chaly-
beates, sulphate of quinine, and exercise  on foot, horseback, &c.
   Dewees has judiciously observed that we should not exhibit em-
menagogues, unless  signs of development exist.   The most inju-
rious effects will be produced by the employment of drastic reme-
dies under other circumstances.  I have often been struck with the
force of this remark, when examining the bodies of chlorotic girls,
on observing the uterus and ovaries no more developed than in chil-
dren of eight or nine years of age.   Repeated experience has con-
vinced  me that the best mode of treatment consists in regulating
the digestive organs, and improving the general health, by the  rem-
edies described  above.  I believe that the practice  of exhibiting
drastic  purgatives  and emmenagogues is injudicious and injurious.
Iodine may be used  with benefit when the digestive organs are re-
stored to  a  healthy  condition.  Various  aperients have been re-
commended in  this form of the disease.   The aloetic pill, with
myrrh or assafoetida, to which a few minims of some  of the es-
sential  oils  are  added,  as  those of peppermint, savine  rue, he-
are  highly  efficacious.  The compound iron  pill,  with  either
of the above,  will be  found of infinite service.   The compound
aloetic  pill,  with sulphate of iron, very frequently produces  the
best  effect.  Dr. Hamilton considered there was a want  of ab-
sorption from  the oedema, and  therefore recommended digitalis,
squill, and nitrous ether.  He has ordered ten drops of digitalis
every hour, watching the effects, and thought that benefit was de-
rived.  He said the patient should be visited  four or five times dai-
ly. Dr. Dewees has  strongly recommended the tincture of guaia-
cum  with  subcarb, of soda  and  potass and pimenta, a formula I
have found of  essential service.  I  have tried the tincture prescri-
bed by  the London Pharmacopoeia with the  liq. am.  acet.,  so lau-
ded by  Masuyer of Strasbourg, and J. Cloquet and Patin, of Paris,
w ith  the greatest success. Dr. Mackintosh speaks in strong terms
ol tine. Iytt;i\  ton drops three times a day, and increased to thirty, 
226
GYNJECO-PATHOLOGY.
 forty ,and sixty drops ; to be discontinued should strangury appear.
 In such case, camphor and  hyosciamus are of great value.  The
 ammoniacal  injection, composed of one drachm of liq.  ammoniae
 and  a pint of milk, a fourth of which may be  injected into the va-
 gina four times a-day.  This remedy was strongly recommended
 by Lavagna, in Italy, and I  can bear testimony in favour of its val-
 ue.  Electricity has been applied to the region of  the womb, ova-
 ries, and back, with advantage.   The warm foot or hip bath should
 be tried every night or every other night.  Some recommend cold
 sea-bathing, but this seems to be injudicious in delicate cases, where
 the abstraction of heat can be badly borne. The chalybeate waters
 of this and other countries are of much service in  the removal of
 this  form  of  chlorosis.  An ample  enumeration of these will  be
 found  in  Professor  Thomson's   London Dispensatory,  extracted
 from a paper of mine, and  also in my own work on Mineral Wa-
 ters.   External frictions with a  flesh-brush are highly beneficial.
 The clothing should be adapted to the constitution of the patient and
 season of the year; the application of cold to the feet must be  care-
 fully avoided.  Blood-letting is injurious, and  always increases the
 oedema,  a fact overlooked by Dr. Ayre and others, who advocate
 the lancet in most cases of  dropsy.   When pains about the loins,
 groins, and thighs  are urgent, sedative liniments afford relief; but
 in some  cases  counter-irritants, as the antimonial ointment,  must
 be employed.
  Chlorosis occurs in opposite conditions  of  the constitution;  in
 pale, sickly,  delicate, ill-grown girls, or in those of a  florid com-
 plexion and full habit.  In  the  latter,  a low diet, purgation, de-
 pletion, cupping, or  leeching the groins, vulva, or verge of the
 anus, irritating foot baths, warm  fomentations  over the hypogastri-
 um,  and fumigations, or tepid injections by the vagina, are the best
 remedies.
  Determination of blood towards the uterus  should be promoted,
 especially when the  pains about the pelvis recur periodically, by
 drastic purgatives, or clysters, drachm doses of oil of turpentine,
 dry cupping-glasses to the loins and  hypogastrium,  galvanism, aro-
 matic fumigations, and  warm hip-baths.   The most efficacious
remedy in this form of amenorrhcea is marriage.
  When the uterus is undeveloped  it cannot  respond to the so-
 licitations of  the ovaries, and the changes which characterize pu-
berty, already described, will not take place.  This is a rare oc-
currence, but exemplified in the course of this work.  Sometimes 
DISEASES OF THE INTERNAL GENITALS.
227
the os and cervix uteri are not developed in proportion to the re-
mainder of the organ; the secretion of the menses occurs but can-
not escape.   This is the  dysmenorrhcea, or  amenorrhoea distillans,
of  Frank, and lately much dwelt upon by  Mackintosh ; it is the
painful menstruation  of other writers.  In  such cases during the
haemorrhagic effort, there are pains in the  hypogastrium,  groins,
thighs, and uterus, amounting to violent spasm in some instances,
which may produce uterine phlogosis.  (Friend, Royer-Collard.)
   These pains precede the expulsion of a few drops of menstrual
fluid, and sometimes some clots covered with a membrane. Again,
albumen may be thrown  out on the internal surface of the uterus,
and form a membrane, which may be detached, in part or entire,
or fill up the uterine orifice.   (Chaussier.)—This substance may
be  expelled in shreds, and has been compared to the skins of boil-
ed  gooseberries, by some writers.  Mackintosh relates a case of a
healthy young woman who  had  not  menstruated, whose os uteri
was very small, and  covered by a membrane similar  to that which
sometimes  covers the urethra of the male at birth. He perforated
this membrane with  a small silver probe, and gradually dilated the
orifice  with bougies, and cured the patient.  (Practice of Physic,
vol. ii. p. 346.)—Such cases are extremely rare, and are only  to
be suspected when a healthy female  does not menstruate at or af-
ter puberty.  Cohesion of the external genitals is sometimes found
in such cases ; and the practitioner ought to  enquire of the patient's
mother, or other near relative, whether any deformity was observ-
ed during infancy.   I have met with two cases of this kind, where
the persons were twenty-one years of age,  and refused to submit
to  a vaginal examination, which was  only granted when I threat-
ened to discontinue my attendance.   I observed cases of amen-
norrhora at  the same age,  without  vicious conformation, which
yielded to  ordinary measures.  Further information on this subject
will be found in the  physiological  and pathological  parts of this
work.   I have only to remark in  conclusion, that the former spe-
cies is often confounded with  phthisis.   The diagnosis is easily
formed.   In chlorosis, the cough  comes on by fits; there is no fix-
ed pain in  the chest; the  pulse  is  not permanently quickened;
the appetite is depraved; the patient devours chalk, unripe fruits,
vegetables, he.;  the mind is greatly depressed;  and the signs of
phthisis, afforded  by ausculation, are absent.   In  phthisis, the
cough  is continued ;  the  pulse permanently accelerated; the ap-
petite is good; the mind exhilarated; the stethoscopic evidence 
228
GYN^CO-PATHOLOGY.
conclusive.   When  the  menses  are  suppressed  in consumption,
women often mistake the effect for  the cause  of  the disease, and
are convinced if the periodical evacuation could be re-established,
health would speedily return.  I need scarcely observe that this is
a delusion.   In real  amenorrhoea I am  convinced that emmena-
gogues are generally injurious.   This must be obvious when there
is  defective development, or vicious conformation of the internal
or  external genitals.  Such  remedies are proper in  suppressed
menstruation, as will appear by the  succeeding remarks.
   Suppression of the Menses.   Obstruction.—This is the second
species of amenorrhoea, and occurs under  two circumstances:
when the secretion is suppressed during its expulsion, and when
it does not recur at the usual  period.  The first  description may
be induced by mental emotions, grief, joy, &tc, or by exposure to
cold and moisture.   The second kind may be induced by preg-
nancy, by exposure  to cold, by any serious disease, by debilita-
ting causes, by leucorrhoea, frequent  abortion, and all  diseases of
the pelvic viscera.
   When the menstrual secretion is  suppressed, its place may  be
supplied  by some vicarious discharge of blood from  some other
part of the body.  (See p. 32.)
   The lower classes often expose themselves  to  cold  and damp
during menstruation, which is the general cause of obstruction with
them.   There will  often be  little inconvenience experienced  by
obstruction, and no notice is taken of it, until it  ceases to appear for
several periods, and  until symptoms of ill health set  in; but in
some cases, the suppression, especially when caused by cold, will
be followed by very  serious  illness, as violent pain  in the back,
womb, bowels, and head, which require very active treatment, as
bleeding, purging, warm bath, opium, camphor, assafoetida, he.
he.  When the pain in  the womb continues severe, after these
remedies, a clyster of a quartern of starch, a tea-spoonful of lauda-
num, thirty grains of camphor, and two or three tea-spoonsful of
tincture of assafoetida;  the latter, if hysterical symptoms be  ur-
gent,  is the best remedy that can be used.  This form of remedy
was found most  beneficial by the  experienced  Dr.  Dewees, of
Philadelphia. He also has given half-ounce doses of the compound
tincture of aloes and myrrh, when colic was urgent, until the bow-
els were opened with the best effects.  He has laid down an  ad-
mirable rule in the treatment of obstruction, which is,thatnomed-
cine ought to be  given  in  a recent obstruction,  or until it causes 
DISEASES  OF THE INTERNAL GENITALS.         229
 some evident disease or disturbance in the system.   This rule is
 well worthy of general adoption.  The menstruation will often re-
 appear after months of suppression, without the use of any medi-
 cine.  When  it is deemed  necessary to exhibit any medicine, we
 ought cautiously to employ those remedies recommended in chlo-
 rosis.  Bad health is often ascribed to obstruction, when on inqui-
 ry it will be found to have  existed before the suppression ; in fact,
 the effect is mistaken for the cause.  It often happens that a vari-
 ety of medicines will be tried in such cases, to remove the obstruc-
 tion,  but  without avail.  I have  been often  consulted  in  well-
 marked cases of consumption, where menstruation had  not ceased
 for months after the  disease in the chest had set in; and yet such
 obstruction was put down as the sole cause of the disease.   In a
 word, women  are of opinion, that obstruction  is the cause of most
 diseases to which they may become liable.   We should carefully
 distinguish, however, when obstruction is the  cause, and not the
 effect of the disease; and this we can always do, by carefully at-
 tending to the history of the case.   When the  disease occurs in
 consequence of consumption,  dropsy,  enlarged liver, or  other
 chronic maladies, it would be injurious to endeavour to remove it.
 When it occurs in  debilitated  habits,  as a primary  disease, we
 should then remove it, as soon as it induces any real derangement
 in the system, and employ  the remedies described for the removal
 of chlorosis.
   Before concluding this subject it is worthy of remark, that great
 caution is requisite in discriminating female obstruction from  preg-
 nancy.  I was once consulted by a female in  consequence of ob-
 struction, who had tumid abdomen, and other signs of pregnancy.
 When I hinted this, she felt greatly offended, and most solemnly
 asserted 1 was mistaken.   However 1 was of the same opinion.
 Her paramour called on me soon  after, on account of  his own
 health, and inquired after her's, " as he was sure she was pregnant,
 though unconsciously, for he had  made  her intoxicated in order to
 effect his purpose."   She was delivered  in due time.  There is
 no swelling of the womb  in  obstruction of a short duration, and
 the appearance of the countenance and bosom will further assist us
 in our diagnosis ;  the breasts are never swelled in obstruction, but
 on the contrary, are  flabby and relaxed; they are always tumefi-
 ed in pregnancy.  (See Signs of Utero-gestation, p. 83.) Though
cold is the most common  cause  of obstruction,  yet  it   may 
230
GYNJECO-PATHOLOGY.
not have that  effect.   Thus  Dr. Denman informs us, that the
guides who attend ladies bathing in the sea, will go into the water
while menstruating, without any inconvenience.  This can be ex-
plained by the force of habit; the body being constantly exposed
to water, is not affected by it in the ordinary manner.  We should
be cautious in  attempting  to  remove obstructions after  the thirty-
fifth year, as the discharge will often finally cease so early as that
period.  Dr. Dewees knew it cease, in two cases, at the  twenty-
fifth, and in two others before the thirtieth year.   It often happens
that women have a very slight menstrual evacuation, and ytt re-
tain good health.   I  knew a young lady, who used scarcely to
perceive the fluid, and that only  on one day, and for about an
hour;  yet was in good health, and became pregnant very soon af-
ter marriage.
   Preparations of iron have long held great repute in female ob-
structions, and  are  known to women under  the names of " steel
drops," " steel pills," he.  I believe  these  medicines of much
value in chlorosis, as tonics, but  not as emmenagogues.  It is ex-
tremely doubtful if we know  any medicine that has a direct influ-
ence upon the uterus, except secale cornutum, whi$h has been al-
ready  described, (p. 136.)   It  must be admitted, however, that
the ordinary emmenagogues are  generally attended with  success,
perhaps from improving the  digestive organs and general health.
When amenorrhoea depends  on  plethora, M. L. C.  Roche has
found  great benefit from opening a vein in the arm or foot, a few
days before the expected return.   (Diet, de  Med. et Chir. Prati-
ques, 1829, torn, ii., art. Amenorrhoea.)   When the patient suffers
much  pain in  the pelvic region, opiates afford relief.
   Dysmenerrhcea.  Painful  or difficult Menstruation.—When
the evacuation is sparing, irregular, and  attended with pain, it is
named dysmenorrhcea, or  painful menstruation.  This form of dis-
ease is very common, and extremely obstinate.   It may occcurat
any period during menstruation, is generally  induced by a natural
narrowing of the orifice of the wromb, or by the growth of a mem-
brane  in the womb;  and, according to Dewees and others, by the
consummation of marriage.   The woman experiences  severe pain
the first day of menstruation, and suffers as severely as  if in labou^
or by  abortion.   She often experiences relief by the expulsion of
one or many  membranous  substances from the womb.  These
membranes are  somewhat like  the skin of a gooseberry, and are 
           DISEASES OF THE INTERNAL  GENITALS.        231

smooth on each surface, thus  differing from  the decidual  mem-
brane.   The membrane is so like the covering of the infant in the
early months of pregnancy, that a lady, who was a patient of Dr.
Hamilton's, thought she  miscarried  ten  times  a-year, for  three
years.   Denman and Dewees were of opinion that a female, thus
affected, could not have children ;  but Morgagni asserts  the con-
trary, as also Hamilton and Burns.  If one healthy period without
pain occurs, even  at an interval of seven years, conception may
take place.  Hamilton described cases of pregnancy under these
circumstances.  If pain occurs for two or three periods after mar-
riage, there will  be no conception.   I  have known pain  attend
menstruation for months after marriage, and conception took place.
I attended a patient with Mr. Bradford, of Fleet-street, aged twen-
ty-three, who laboured under dysmenorrhoea since the occurrence
of the evacuation in her fourteenth year, and still she was preg-
nant.  She never passed any membranous shreds. I know another
lady, aged twenty-one, who  always  suffered severe  pain  during
menstruation, which was  much increased  by marriage.  She is
pregnant however.  She never discharged portions of membrane.
I published these  cases in the London  Med. and Surg. Journal,
1830, vol. v.
  Dr. Mackintosh considers smallness of the os uteri the  most fre-
quent cause of the disease ; but thinks inflammation of the lining
membrane of the  uterus, or inflammation of the substance  of the
cervix, or encroachment of tumours, as causes of painful  menstru-
ation.   Every museum contains specimens, which shew the os ute-
ri so narrow as scarcely to  admit  the passage  of a hog's bristle.
In such  cases, when the menstrual secretion is formed it cannot es-
cape, and must induce uterine irritation or inflammation.  In some
cases the pain is as severe as  that  of labour, and the patient is
obliged to confine herself  to bed.
  Treatment.—Mackintosh informs  us  that in  fifteen  cases he
succeeded in curing the disease by gradually dilating the os uteri
by means  bougies, the size of which was slowly increased.  Of
these four became pregnant.  As the disease may depend  upon a
variety of  other causes, this plan of cure cannot always  succeed.
In fact, dysmenorrhoea is a vague term, expressive of irritation and
pain in the pelvic  region, depending upon a variety of causes, it is
a symptom, and not properly a disease.
  Hamilton recommends  the patient to go to a warm bed,  take a 
232
GYN-ffiCO-PATHOLOGY.
mild purgative, and a draught composed of tincture of hyosciamus,
with or without volatile tincture of valerian, in  the  proportion of
one, two, or three drachms of  the latter, to be given at the ap-
proach  of the discharge; to have  four grains of opium, or one
drachm of the tincture and some starch, injected into the rectum.
   Besides these  remedies,  the patient  will derive benefit from a
residence in a warm climate for some time.   Other practitioners
exhibit  large doses of laudanum during the pain, as a tea-spoonful;
and repeat it in a short  time,  if necessary, unless it cause  sleep.
Dewees advises a scruple of camphor, to be given in a draught, or
ten grains every  hour, until relief be  obtained.   If  the  stomach
reject this, thirty or forty grains  are to be dissolved in spirits of
wine, a drachm of laudanum and a gill of thin starch are to be in-
jected into the rectum.   Should this  be  suddenly discharged, it
may be repeated.  He also recommends tincture of  guiacum, ex-
tract of cicuta, and tincture of cantharides ; the two last succeed-
ed in cases where the guaiacum had failed, and he informs that the
last-named medicine cured a lady, who was  affected for nineteen
years.  I have tried the guaiacum during the interval, and certain-
ly with great benefit;  but large doses of the tincture of opium I
found most efficacious during the urgency of the pain ;  however, I
have not yet sufficiently tried the camphor, to enable me to speak
of its value from personal experience.
   The acetate of ammonia  in  solution, in the proportion of fifty
drops wras given  twice a-day, in some sugar and water, by Profes-
sor Masuyer, of  Strasburg, and by M.  Cloquet, of Paris, in cases
of difficult and painful menstruation, and with decided relief.  The
medicine is to be repeated in half an hour, unless the pain gradu-
 ally subsides.  I add this medicine to the guaiacum for some days
before  the  period, and give large doses of laudanum with it when
the pain is urgent.
   Menorrhagia.—This state consists of unnatural frequency of re-
turn, or copiousness of quantity of the menstrual fluid.   The dis-
ease is attended  with pains in  the back, loins, and abdomen, often
resembling parturition.   Some obstetricians of considerable expe-
rience, assert that this complaint is of  very rare occurrence, and
that in general what is described as such, is absolutely a discharge
of blood, and not of menstrual fluid.  The disease, however, is
 most certainly one of frequent  occurrence in this country.   It ap-
 pears under two  conditions,  in  full or delicate habits.  It happens 
DISEASES  OF THE INTERNAL GENITALS.
233
 to women who  live luxuriously and indolently, and to those who
 suffer fatigue, abstinence, or  profuse discharges, debility  of the
 womb by frequent miscarriages, by tedious severe labours, by ex-
 cessive sexual intercourse, by irritation in the neighboring organs,
 as tenesmus, piles,  or costiveness.  It is most common in the mar-
 ried state, and seldom happens to virgins.   The discharge is to be
 considered excessive and injurious when it weakens the woman ;
 but it may occur every ten days, and be as copious as on ordinary
 occasions,  and the patient be  in perfect  health.  Dewees  records
 an interesting case, where the lady had at first menstruated at the
 twelfth year, and continued to do so every ten days to her fortieth
 year, unless  during pregnancy or suckling, yet she was in  perfect
 health.  Excessive menstruation is  to  be considered a  disease
 when it induces debility,  dyspepsia, hysteria, and the Protean
 symptoms of a complication  of these affections.
   The treatment consists of lessening febrile action, by blood-
 letting, when necessary ; of  keeping the patient in bed, with light
 covering, allowing a free admission of air; of  giving licdit nour-
 ishing diet,  and avoiding  stimulants.   Emetics of ipecacuanha
 have  lately been given  with great success,  by Dr. Osborne, of
 Dublin.   Saline purgatives, in solution, with  nauseating doses of
 tartar emetic, are often used  with great benefit.  Pills, composed
 of acetate of lead and opium, in the  proportion of  one  or two
 grains of the former, and a third of a grain of the latter, may  be
 given every  three or  four hours.  The  muriated tincture of iron
 is a powerful astringent.   Cold cloths, wetted with  water and vin-
 egar, are  to be applied to the vulva, back, and abdomen.  Injec-
 tions  of the  saturated  solution of alum, in the proportion  of half
 a drachm to  an  ounce of water,  are to be thrown into the vagina
 and womb ; or equal parts of the compound  liquor of alum °and
 water, will answer the  same purpose.   Others employ the  decoc-
 tion of oak bark and alum, or twenty  grains of acetate of lead,  a
 drachm of  laudanum, and three or four ounces of water or starch,
 as an  injection into the rectum.   The use of the tampon, or plug-
ging the vagina,  when  the womb  is unimpregnated and not dilata-
ble, will often arrest the discharge.  This plan is said to cause co-
agulation by many obstetricians, all of whom  deny that the men-
strual  fluid  ever coagulates, and therefore here is a manifest con-
tradiction.  It is highly beneficial however.  In cases attended with
debility, soups, jellies,  broths, wine, and cordials are to be  exhib- 
234                  GYNJECO-PATHOLOGY.

ited, and warm flannels are to be applied to the pubes.   The parts
affected will be strengthened by the daily  use of the bidet, cold
water injections into the  vagina, and cold bathing.  Opium, in
the quantity of five grains at first dose, and three grains every lour
hours has been used in cases of extreme  weakness, and with the
greatest success.   The Italians recommend the application of cup-
ping-glasses to the loins in this disease.  Formerly,  ligatures were
applied above all the joints, in order  to arrest the  circulation of
the blood, and thus prevent the discharge.   Drs. Hamilton and
Burns condemn the internal use of  acetate of lead ; but others, of
equal authority, recommend the  remedy.   I  have frequently giv-
en it freely, from  six to twenty grains in two ounces of water, two
of vinegar, and two drachms of laudanum, a table-spoonful  three
or four times daily, and never knew any bad effect result from it.*
The astringent injections ought never to be omitted in  this disease.
Astringent medicines are also exhibited internally.
   Metrorrhagia.—Uterine Haemorrhage.  It often happens during
menstruation, or  in the absence of the periodical  evacuation, that
blood is discharged from the  uterus.   This is  designated metror-
rhagia by the French, while Burns and Mackintosh term it me-
norrhagia.  These writers make a distinction between excessive
menstruation and menorrhagia, applying the latter term to haemor-
rhage from the uterus, thus confounding to opposite diseases.  How
men of such talents could have thus  blundered, is really astonish-
ing.   Both admit the menstrual fluid is not blood, while they ap-
Iy the word menorrhagia, excessive  menstruation, to  uterine hae-
morrhage.  A better and more correct term  is metrorrhagia.
   When  we  consider  the  congested state of the  uterus during
menstruation, we are able to understand  why haemorrhage may
take place, and blood and menses may be commixed.  We may
have menorrhagia or excessive menstruation, and metrorrhagia  or
uterine haemorrhage at the same time, and this complication ac-
counts for the presence of coagula  in the  menstrual  fluid.
   Treatment.—The same plan of  treatment recommended in me-
norrhagia is to be employed in this disease, in addition to which,
venesection will be used with advantage in plethoric  subjects. The
case should be treated like haemoptysis and other haemorrhages. Some

  * See Papers on Acetate of Lead, by Dr. Ryan, of Kilkenny, Lond. Med and
Phys. Journ., 1826-7.  Also Dr. Burke's Paper, Edin.  Med. and  Surg. Journal,
1826.  Lond. Med. and Surg. Jour., 1831, vol. vi. Paper by Dr. A. T.Thompson. 
DISEASES OF THE INTERNAL GENITALS.        235
 writers advise the application of leeches to the  hypogastrium, to
 relieve uterine pain, and assure us that the haemorrahage ceases be-
 fore a table-spoonful of blood has been abstracted.   (Mackintosh.)
 Of course rest in the horizontal posture, with the head and shoul-
 ders low, is to be insisted on.  The application of cloths, moisten-
 ed with vinegar and  water, and  applied over the pubes, will often
 be followed with good effects, as I have lately observed with  my
 friend, Mr. Mathews.  The free use of the  acetate of lead  and
 opium, with injections of  a solution of alum, are  indispensable j
 the latter may be used before the plug or tampon,  or after it  has
 been removed.  The patent syringe is the best instrument for ap-
 plying the injection, and a napkin should be pressed upon the ge-
 nital fissure.
   Cessation of Menstruation.—In the  physiological part of  this
 work,  p. 32, I have described the circumstances which require at-
 tention at the cessation  of menstruation, and have now only to
 observe, that should continued  pain be experienced in the pelvic
 viscera,  we have  reason  to suspect  incipient inflammation,  and
 ought  to have recourse to cupping, leeching, hip-baths, purgation,
 low diet, and the various other remedies which will suggest them-
 selves  to every well-educated practitioner.  Should any local in-
 flammation of other organs display itself, it is  to be treated on or-
 dinary principles.   Women at  this period of  life complain of an
 immense number of  anomalous symptoms, which are generally re-
 moved by proper regulation of the  bowels.  The young practi-
 tioner must not mistake obstructions  of the catamenia  of two or
 three months' duration for pregnancy ;  the latter seldom happens
 at the  " climacteric period."
   The ovaries are often inflamed after  delivery, and suppuration
 or scirrhus, cancer, or  considerable enlargement, may take place.
 These organs  are subject  to  dropsy, scirrhus, vascular,  sarcoma,
 and atrophy, but of all diseases  dropsy is most easily distinguish-
 ed ; the others can  scarcely be discovered during life.  Ovarian
 disease is generally slow though sometimes rapid and  fatal.   When
 inflamed, the  ovary  adheres to  the vicinal parts, the uterus,  the
 rectum, the bladder, or external  integuments, and the matter  will
 be discharged  from the vagina, by urine, stool, or external abscess.
 Inflammation of the ovary is a very obscure disease, and can scarce-
ly be distinguished from the many other affections of the pelvic
viscera, all accompanied  with irritation  and pain in the back and 
236
GYN.KCO-PATH0L0GY.
loins.  We must therefore be content with palliating  symptoms,
and  the  constitution  will in general cure the disease.   In simple
enlargement of the ovary it continues detached, and free from any
adhesion ; but it will sink down low in the pelvis on one side, or in
the  hollow of the sacrum, producing inconvenience, according to
size  and  situation,  by obstructing the functions of the rectum and
bladder, or process of labour.  Sir E. Home describes a case where
the ovary became the size of a  hen's egg, fell down between the
vagina and rectum, and impeded the functions of both.  The ca-
theter was obliged to be passed daily. The ovaries have been found
at Poupart's ligament,  in the groin (Verdier, Lasnes, Deneux),
and  the  operation for hernia  has been performed, to afford relief.
Mr.  Pott mentions  a case where both ovaries were extirpated ; the
woman recovered, but never  menstruated afterwards.   Hairs and
teeth were  found,  by  Dr. Baillie, in ovaries before conception,
(Morbid Anatomy, 1812.)
   Scirrhus of the  ovary is a frequent disorganization of this part.
The ovaries are sometimes wanting, or  may be imperfectly develo-
ped.   Le Dran asserted that scirrhus  always  preceded dropsy of
that organ, but Dr. Hunter never found  a  dropsical ovarium in a
truly scirrhous state.   Dr. Burns asserts that dropsy is the  most
common disease of the  ovarium.  The  ovary may become enor-
mously distended with solid and fluid growths, so as nearly to fill
the abdomen.  In one instance it weighed  fifty-six pounds (Mem.
of the Medical  Society, vol. ii.);  one hundred  pounds (Haller);
thirty-five (Mackintosh) ; the usual  weight is twelve  or  thirteen
pounds.   Dropsy of the ovarium is a misnomer, as  the fluid which
it contains is not serous, but gelatinous.   This fluid is contained
in different cysts or compartments,  and  its colour varies; for in
some it is whitish, in others yellow, like  pus, and in others coffee-
coloured.  It is thick and fetid, and mostly contains  portions of
fleshy matter, sometimes tufts of hair, teeth, bones, and hydatids.
Tumours containing all these substances  have been found in the
male sex, which prove such contents do not depend on conception.
Hence, when the operation of evacuating this tumour is attempted,
its contents cannot  pass through a small  opening, and besides we
only open into a single sac.  The disease causes scarcely any con-
stitutional disturbance in its incipient stages; the  health  is good,
and menstruation regular.  It is only when it has  advanced  that
its weight and bulk, pressing on the rectum and bladder, impede 
           DISEASES OF THE INTERNAL GENITALS.          237

the regular functions of these parts.   It is almost impossible to
distinguish it from other diseases in its early stages.   The history
of the case and the situation of the first uneasiness will enable us
to form a correct opinion.  It is  often combined with dropsy and
tympanites.  It occurs after  the  adult  age.   The women refers
pain to either groin, and  after weeks, months, and years, discovers
a tumour in one side, which gradually distends the abdomen  and
bears a close resemblance to  pregnancy.  When the  disease has
advanced, the constitution suffers severely; the  appetite and  di-
gestive functions become  impaired ;  severe pain may  be experien-
ced in the affected part;  the  urine and contents of the bowels will
be retained.
   The urgent symptoms are  to be alleviated ; the functions of the
stomach are  to be improved by the usual remedies; the bowels
to be regulated, and the urine is to be  drawn off by the catheter.
If there be local pain, we should apply leeches and  fomentations
or blisters, but  perhaps  there is  no certain  cure for the disease.
Iodine has been tried with success  in  some recent cases.   When
the abdomen becomes distended, we must tap the tumour, which
may be done as often as thirty times, with relief.  Care must be
taken not to wound the uterus, which may be carried up with the
rumour.   It has been proposed to  throw in a  stimulant injection
after the operation, and to enlarge  the  opening, and  to extract a
part of the sac  ; but these measures have proved both useless and
fatal.  The contents of the tumour have been passed  through the
vagina, rectum, and parietes  of the abdomen, and also into the ab-
dominal cavity.  Sedatives must be employed,  to allay pain, and
the urgent symptoms can only be palliated.
   The ovarium is subject to  scrofulous  enlargement;  and when it
suppurates it contains a whitish, filamentous, grumous, and ill-di-
gested fluid, or a cheesy substance, such as is found in the mesen-
teric and  other glands.  Iodine is the best remedy for this disease,
but mercury, coniurn, electricity, laxatives,  leeches,  and  blisters
have been also tried, although seldom with benefit.   The ovary is
remarkably susceptible of morbid changes:  viz. of  enlargement,
induration, conversion into tuberose sarcoma, into a substance half
earthy and half bony, into a fatty substance, and into  a  pulpy,
medullary matter, like brain.  (Lizars.)
  Dr. Mackintosh informs us, that he has, occasionally, observed
in the bodies of children vesicles of the size and shape of small 
238
GYNJECO-PATHOLOGY.
 grapes, others like large currants, full of fluid, and attached by a
 long pedicle to the broad ligament near the ovary.  He has seen
 these attached to the left  ovary in a child two  or three months
 old.
   In general, the adult female complains of pain in the region of
 the ovary, which extends to the groins and front of the thighs, and
 is only occasionally experienced.   The appetite, catamenia,  and
 general health, are good.  The fact is, unless we make close in-
 quiries, the symptoms are  seldom referred to  by the patient.  At
 length a tumour is felt in one  side, which soon extends  across the
 abdomen, and gives the  feel of the graved  uterus.  I  have seen
 several cases of the disease in young unmarried women, which led
 their relatives to suppose them pregnant.   I  had lately a case in
 point, in which this supposition  could  only  be  removed by  my
 certifying the name of the disease in writing,  and by recommend-
 ing the patient to place herself in one  of the  hospitals.  I have
 also seen some cases with  Mr. Whitmore, of Cold-bath  Fields, in
 which the patient had been long married, and supposed themselves
 pregnant, but refused to  take medicine, or submit to tapping.  In
 one of these cases, the disease  became developed in eight months,
 the woman had dead children, the catamenia were suppressed,
 and she supposed herself pregnant.  The diagnosis was difficult,
 the uterus was undeveloped,  the legs  anasarcous,  the abdomen
 larger than at the end of gestation, and the respiration  very diffi-
 cult.   The  operation of tapping was resorted to,  and with the us-
 ual temporary benefit.  I was consulted in another  case by Mr.
 Kitching, of Aldersgate Street; the patient was twenty-two years
 of age, and had been delivered of her first child ;  but  a  tumour
 larger than the uterus after delivery was found in the right side.
 On inquiry, we learned that she received an injury in that situation
 seven years before, after which a  painful tumour  appeared  and
continued ever since.  I have known an old lady, whose abdomen
was greatly  distended, fluctuation evident, general health good, no
anasarca, no inconvenience unless  on  motion,  who  had  remained
in this condition for some  years.   During the vicissitudes of the
spring of this year, she died  suddenly;  and an examination was
not allowed.   On making a va*ginal examination, where the dis-
ease is advanced, we find  a  tumour between the vagina and rectum,
offering some characters of retroverted uterus.  The  os uteri is
turned towards the pubis in some cases; but the real nature of the 
DISEASES OF THE INTERNAL GENITALS.         239
 disease will be discovered by passing the finger into the rectum.
   The prognosis is unfavorable, for we know no cure for the dis-
 ease.  It may burst into the abdomen, and cause fatal peritonitis
 (Delpech) ;  but from the case narrated below, this event may not
 happen.
   Treatment.—Diseases of  the  ovaries  are, perhaps among the
 most intractable incidental to humanity, and may be set down in-
 curable, when fully developed.   In their  incipient stage, much
 benefit may  be derived from  local bleeding,  leeching, cupping,
 counter-irritation,  and  attention to  the bowels.  At one  time,
 those medicines which were  employed in scrofula, were  much in
 use ; but with the exception of iodine are now abandoned.  Li-
 quor potassae was urged to the  fullest  extent, and said to produce
 suppuration ; but  this is obviously very doubtful.  Dr. Seymour
 observed, in his Lectures on  the  Diseases of the Ovaria, deliver-
 ed before the Royal College of Physicians, 1829, that Dr.  War-
 ren thought this remedy  caused the dispersion of disease in one
 instance ; but Dr. S. is not  convinced rty the result of this case.
 Dr.  Hamilton, of  Edinburgh, has recorded seven cases, in  which
 the muriate of lime, pressure by a well-applied bandage, and gen-
 tle percussion  of  the tumour twice a day, effected  its removal.
 Others have recorded similar cases,  in which iodine alone  remo-
 ved the disease.   The general impression of the profession,  I be-
 lieve, is, that there is no cure for the various forms of ovarian dis-
 ease ; hence the bold and  desperate  operation of extirpating the
 diseased part  has  been attempted without success.   This opera-
 tion has been attempted several times by that able anatomist and
 surgeon Mr.  Lizars, of Edinburgh, with the following results ;
   In  one case nothing was discovered in the intestines but flatus,
 and the woman died in forty-eight hours.  In another there was
 curved spine,  with lumbar abscess, " the uterus  and ovary were
 healthy ;" the woman is still alive.   In the third case there was
 ascites, a tumour was removed from the left side, another could
 not be separated from its firm adhesions in the right, the uterus
 was slightly enlarged ;  the woman died three years after the op-
eration.  In the fourth case,  a tumour was removed by separating
its adhesions  from  the viscera; the  woman died from mortifica-
tion.   In the fifth, a large tumour was so covered with large  blood
vessels, the operation was abandoned.   In the sixth case,  a tu-
mour was removed from the  fundus  uteri, which was supposed to 
240
GYN.EC0-PATHOLOGY.
 be the ovary ;  the woman was destroyed by inflammation in a fc\i
 days ; the ovaries were healthy.   Such  is the account of these
 operations given by Dr.  Mackintosh in his excellent and graphic
 Practice  of Physic  ; and he argues most powerfully against the
 operation, unless the tumour be moveable, which can can  be as-
 certained by the motions of the patient.   He advises close atten-
 tion to the state of the bladder, catheterism, camphor, and hyos-
 ciamus,  laxatives, local  bleeding,  tepid  injections, counter-irrita-
 tion, and places little  confidence  in iodine.   He also agrees with
 Denman and others, that tapping should be put off as long as pos-
 sible, as  the fluid is rapidly secreted after the operation.  He nar-
 rates some valuable and  instructive cases, in which he  could not
 consent to extirpation, though strongly advised  by others, and af-
 ter death the ovaries  and uterus  were  healthy.  The following
 case is so instructive, that I must  insert it:
   Case of Parturition complicated with hydrops  Ovarii, by Dr.
 Mighels, of Minot, Cumberland, County Maine.  Mrs. C. an. 30,
 of a good constitution, sanguineous temperament, and  strong and
 athletic,  and  the mother of two  children,  presented  the usual
 symptoms of ovarian dropsy in February, 1827, and in  six weeks
 afterwards the  tumour extended to the epigastrium.  The  diges-
 tive functions were disordered, for which the usual remedies were
 employed ; the abdomen was as large as at the completion of the
 term of utero-gestation.  She was  taken with labour November,
 29, when her size was enormous, measuring in circumference fire
 feet four inches, and from the sacrum to the utmost extent in front,
 two feet  three  inches;  " in the sitting posture she literally held
 her child in her lap."   On  vaginal examination theos uteri could
 not be  discovered.  Very violent parturient action  supervened,
 the membranes burst while the hand was in the vagina, the breech
 of the infant presented,  but  the narrator brought down the feet,
 during which the sac burst, and its contents escaped into the cavi-
 ty of the abdomen.  The labour was finished  in  a  few minutes,
 and the child still born.   During the four or five subsequent days
 she discharged  enormous  quantities  of urine;  in  one night five
 quarts.   In three weeks she was able to  resume her ordinary oc-
cupations, and no larger  than in  health.
  The disease re-appeared in January 1828, continued to increase
 until June, when it burst (I presume into the abdomen,) and was
 carried off by the kidneys.  It very soon re-appeared, progressed 
            DISEASES  OF THE INTERNAL GENITALS.        241

with rapidity, burst in August, and passed off as before.  She re-
mained feeble for several weeks, but perfectly recovered.
   In January, 18^9, she was  again in labour,  and as  large as in
1827 ; the sac was found to fill  the whole of the  brim of  the pelvis,
the membranes burst, and the funis presented.   Paracentesis was
performed through the linea semilunaris, about four inches superi-
or to the crista ilii,  " and eighteen pints  of bloody water resem-
bling dirty claret, perfectly limpid and inodorous, were evacua-
ted."  This afforded  great relief, the uterus resumed  its natural
position,  and had the presentation been favourable,  the labour
would have been completed in a short time ; the left arm had pro-
truded before the operation, and the uterus was strongly contracted
" with unyielding firmness about the child."  An attempt to turn
was now made, and  persevered in for two hours, without effect;
"so far as I could introduce my hand,"  says the  narrator,  "the
uterus presented the  appearance of being encircled  with strong in-
elastic bands, three fourths of an inch in breadth, and drawn round
it with incredible force.   The cervix  was preternaturally elonga-
ted; but so well  dilated as to  admit the  hand  readily."   Failing
to turn under such circumstances, it was decided in consultation to
remove the infant (which was dead,)  by  embryulcia (!!!)   The
arm with the scapula and clavicle were removed, the chest pene-
trated, and the operator's hand introduced to grasp the heart and
lungs, " when she became impatient and bounded out of our reach,
absolutely refusing any further assistance.  One object was to re-
move the thoracic and  abdominal viscera, in order to make  room
to introduce the hand  to  the feet, or  to  enable us to  fix a blunt
hook on the pelvis;  but  we were defeated, we  could not prevail
on her to suffer another trial."  She was  bled  to o xx, and had a
large anodyne.   The operation was  attempted in the  evening;
but the patient would not suffer it to proceed.   She had a  large
anodyne  and a comfortable night's rest.  Next  day she appeared
"more pliable."  The external  parts were very little swollen.
The right arm presented, and was easily  separated with the sca-
pula by  the blunt hook, as putrefaction had set  in.   The woman
refused  to allow any further  attempt; and in  the evening  " re-
quested  the  benefit of the Caesarian  operation."   She was not
much exhausted, but had a fixed idea that she should die undeliv-
ered ; she was then left to her fate for two  days,  when her judi-
cious  attendant visited her, and received  the following  account:
        31 
242
GYNJEC0-PATH0L0GY.
" that she was exercised with incessant throes till Thursday even-
ing (the preceding day,) although  during  the  time she  took half
an ounce of laudanum, when  it seems complete evolution had ta-
ken place, and the child was  expelled " head foremost;" the pla-
centa was extracted by the midwife.  The  patient presented all
the symptoms of acute peritonitis, face scarlet, pulse  120, quick,
hard, and wiry;  tongue dark, coloured, unquenchable  thirst, head
painful, and  abdomen  considerably distended, and  tender: uterus
appeared unaccountably large ; mind serene.   Bled her to  § viij.
ordered fomentations, and adopted the antiphlogistic regimen to its
full extent."  The symptoms increased on  the next day, when
suppressed lochia and bilious  diarrhoea came  on ; she was ordered
calomel and rhubarb, a large  epispastic to the abdomen, and an
anodyne at bedtime; she lingered for three  days, when the pla-
centa was expelled putrid, the lochia returned, and signs of amend-
ment appeared.  There is no account of her symptoms  from this
time, January 25th to February 4th, when the sac was much dis-
tended, and  caused much uneasiness.   It was  perforated (I pre-
sume through the abdomen, as no  part is  mentioned,) when five
quarts of offensive fluid of a chocolate colour  were evacuated. She
dragged on a miserable existence to the 24th,  when from sponta-
neous bursting of the sac, she succumbed."  I  give the account
of the autopsy in the narrator's own words:
   " On examining the body,  an hour after death, we were almost
suffocated with the most  offensive stench.  About two  quarts of
matter had escaped into the right  side of the abdominal cavity,
which was perfectly separated from  the left by the firm attach-
ment of the  great sac to the peritoneum, mesentery, and intestines.
The dropsical effusion evidently commenced in  the  peritoneal cov-
ering of the ovarium.   The  ovarium itself was  but a very little
diseased, being only a little indurated and enlarged, and so com-
pletely imbedded in the sac as to appear to make part  of its walls.
We discovered the spontaneous laceration at the upper part, where
it was in contact with  the liver.  From all we  could discover, we
were of the opinion that this was the point at  which it had burst
formerly; being at all other  parts perfectly  smooth and regular,
but here  considerably thickened and hardened, excepting  at the
centre where  the  rupture  appeared.  The sac itself contained
about ten quarts of very offensive  pus.   The small intestines were
crowded into the epigastrium, being firmly attached to the vertex 
DISEASES OF THE  INTERNAL GENITALS.        243
of the sac.  The liver, spleen, pancreas, and kidneys were sound.
The uterus appeared as usual at this period of puerperal state, but
removed from its natural situation,  and  crowded firmly into the
right hypogastrium.  The peritoneal covering  of  the bladder and
sac had so firmly united as to appear like one membrane.  (Ame-
rican Journal of Med. Sciences, Nov. 1829.)
   The ovary is also subject to fungus hcematodes, which has burst
through the abdominal parietes,  and thrown  out a large fungus.
Cancer of the  ovary is very rare.  Mr. Abernethy  informs us,  in
his valuable Lectures, that after tapping the ovarium he  has pre-
vented the re-accumulation of the fluid by a succession of blisters,
confining the patient to bed, and  attending to  the general health.
This treatment has  also relieved  other chronic affections of the
ovary.  His observations on diseases of the  ovary are highly im-
portant, and worthy of the most serious attention.  (See  Lancet,
1827, vol. xi.)—The Fallopian tubes are subject to inflammation,
abscess, adhesion of the fimbriated extremity to the ovary of the
same  side;  the  uterine  extremity of the tube may be  also ob-
literated,  and  stricture may happen in  any  part  of its  course.
When both ends of the tube had been found obliterated, its body
contained  a quantity  of  fluid, which might  amount  to  several
pounds, according to Portal, (Anat. Med. vol.  v.,)  and cause the
dropsy of the tube.  The canal has  terminated in  a cul  de sac,
tuberous tumours have grown on the tube, and are described by
Dr. Baillie, in his Morbid Anatomy.  Aneurism may occur in the
tube, burst, and destroy the patient by haemorrhage.  In a case of
this kind,  a gallon  of blood was found in the pelvis.   The tube
may be filled with hydatids, a  foetus,  or  be entirely obliterated.
The uterine ligaments may be implicated in  diseases of vicinal
parts.
   Hysteria.—This is a nervous affection, having  its primitive seat
in the uterus, causing spasm of that organ and  its  nerves, which is
propagated to  the whole ganglionic system, and thence to  the ce-
rebral system.  The sage of Cos  maintained  the axium, that all
disorders peculiar to women arose from the uterus:

    Taj-vvatxtia roaquata xaliviitra at igcoai jiu\ tiov roouaTwr uinai tiotr.
By far the greatest  proportion of the profession agree to this etio-
logy of hysteria; while  the disciples of Gall, and Dr.  Elliotson
among the number (Clinical Lects.), maintain that the malady is 
244
GYN^CO-PATHOLOGY.
seated in the  cerebellum.   In support of the first opinion it may
be stated, that hysteria accompanies  amenorrhoea, is often caused
by continence, and  by abuse of venereal pleasure.   It is always
present in catamenial suppression, insufficiency, and depravity, in
scirrhus of the ovary, uterus, and in  the  various disorganization of
these viscera.   Its primitive seat is not in the encephalon, as this
organ is often  not affected, and is always secondarily so.  It is no
argument against  this doctrine to state, that chagrin and various
mental emotions excite the  affection, as  these are only  occasional
causes, in those predisposed  to  the complaint.   Almost all the
spasmodic phenomena of an unknown nature, to which womerj are
subject, are ascribed to hysteria, as cephalalgia, lethargy, syncope,
eclampsy (for which see Puerperal  Diseases), the vesaniae, cata-
lepsy, pain in  the left side arising from neuralgia of the  intercostal
nerves (see p. 197), protean malady, peculiar spasmodic affection,
leaping ague,  he.  he.  "  The hysteric  passion," says  Galen, "is
a name under  which various and innumerable diseases are compre-
hended," The phenomena of hysteria are as follow ;  spasm is prop-
agated from the uterus to the abdominal and thoracic ganglia  of the
trisplanchnic  nerve  (Bonetus, Nauche, Lobstein),  and  extends
universally,  producing a violent sensation of cold.  There is palpi-
tation of the  heart, and pulsation of the arteries in the epigastric
region.   The  pulse becomes small and  irregular, the skin is pale
and cool, a ball or globe is supposed by the patient to proceed from
the hypogastrium through  the abdomen and thorax to the  throat,
where it produces  a sense  of suffocation, and this is called globus
hystericus by  writers.  This sensation is caused by  spasm of the
uterus and the intestinal canal, and is often induced  by develope-
ment of  gas in the stomach and bowels, which causes a  loud rum-
bling called clangor intestinorum, and is relieved by frequent eruc-
tations.  The  spasm  is propagated to the superior extremities, the
forearm is flexed, the fingers are clenched, and the inferior extremi-
ties  are rigid; in a word, the features, extremities, and  the  whole
body are thrown into involuntary action, and in some cases the hand
is firmly pressed against the left side.  The patient may have one
or many fits in  the day.  I saw a patient with  my friend Mr. Wood-
house, of Ilford, who had fits almost every  half hour.  After re-
covery, there  is a  good deal of pale urine dicharged.   This is de-
nied by Tate in  his work on hysteria.  The best  illustration of
spasmodic and transient neuralgia of the uterus and ovaries that I 
            DISEASES OF THE INTERNAL GENITALS.        245

have  known,  was in a lady about whom I  was consulted by my
friend Mr. Matthews.  These pains were removed by nuptial in-
tercourse, which was instinctively proposed by the  sufferer.  The
internal and external use of opium with fomentations afforded but
very  slight  amelioration.   The natural  remedy was  successful.
The lady was not  hysterical, but of a nervous temperament and
delicate habit.   Hysteria is generally complicated with dyspepsia,
when the symptoms become so  numerous as to baffle description.
It may be combined with chorea, an  obstinate case of which I at-
tended with  Dr. Addison and Mr. Bradford, near the Coburg The-
atre.   When  the  sufferer complains of pain  in the left side, the
corresponding dorsal vertebrae will be found painfnl, which may re-
quire leeches and free pustulation  by antimony.   (Teale, Shirley
Palmer, Tate, Brown, Darwall,  he.)
   Hysteria is not a dangerous disorder, even when it causes cata-
lepsy ; but  Mr. Tate has narrated cases in  which the spinal neu-
ralgia  was  present, which  proved  fatal.   (Work on  Hysteria,
1830.)
   The chief indications of treatment are,  the evacuation  of  the
bowels, the  regulation and restoration of  the menses, and the pus-
tulation of the spine over  the tender and painful parts.   Antispas-
modics are of little use, they may afford a temporary relief.  When
hysteria precedes amenorrhoea, the establishment of the catamenia
is the only certain cure.   Mr. Tate  affirms,  that antimonial inunc-
tion along the spine, when there is pain or heat, and this repeated
every sixth hour untill eruption appears, is the most successful rem-
edy.   He sets  out  with  regulating the bowels.   The cases  to
which I referred in  this  article were  cured by this  remedy, after
the usual plan of treatment had been tried in vain.  Many spinal
curvatures have arisen from overlooking  the cause of  the  lateral
pain.   The best purgative, according to Tate, is calomel and jalap;
and the next point of importance is to establish a healthy and vig-
orous menstruation.   The  secretion is always unnatural  in this
disease, it is irregular in its return, is sparing, grumous, black, pale,
but invariably unhealthy.   Drastic  purgatives,  secale cornutum,
hip-baths, fomentations to the pubes, leeches to the vulva, and in
delicate habits, bark, iron, bitters, and aromatics are useful.  Should
hysteria  arise from  the  repression of  any  eruption or old ulcer,
ring-worm, he., we must endeavor to re-establish the primary af-
fection.  During the fit, the patient's dress should be loosened, so 
246                  GYN.S2C0-PATH0L0GY.
that the circulation and respiration be not embarrassed, cold water
is to be sprinkled upon the face, the  body to be laid in a recum-
bent position, the head elevated.   Should signs of cerebral con-
gestion appear after a  fit, we  must deplete generally, and locally
from the temples.  If all measures fail, which seldom happens,
tincture of opium, assafoetida,  ether, amber, camphor, castor, va-
lerian, have been used with  success.  The former plan is much
more scientific and successful.   Hysteria is said to produce nym-
phomania, or fur&r uterinus;  a disease unknown  in these coun-
tries, and of  which farther notice is unnecssary.   The  best cure
for hysteria is marriage.

Article II.—Of the Causes and  Treatment of Impotence
                       and Sterility.

          Section 1.—Disqualifications for Marriage.
   There are  many bodily imperfections which are not sufficient to
deprive married persons  of mutual succour.   The principal end
of conjugal union is the establishment of a contract, by which the
parties promise the exchange  of mutual  succour ; and many of
the ordinary  infirmities are not a sufficient motive to prevent con-
solation being given by those affected.  Marriage is defined a civil
and religious contract between male and female,  by  which they
engage to live together in mutual love and friendship for the pur-
pose of procreation.   Some diseases  are aggravated by marriage,
as inveterate scrofula, epilepsy, confirmed  phthisis, caries  of the
vertebrae, aneurism of the heart and large vessels;  and as some of
these and other diseases  may  be communicated  to the offspring,
they are considered by many as impediments to matrimonial union.
Again, rachitis is often  transmitted  to infants;  and this rachitic
predisposition in  the female,  predisposes  her to spinal and pelvic
deformity, and it  too often happens in such cases, that the  female,
the day she hopes to be a mother, is consigned to the tomb.  Fo-
dere says, marriage should be interdicted when  the sacro-pubic
diameter of the brim  of  the pelvis is less than  the four  inches;
Orfila, when it is less than three inches; but defects of the outlet
or  perineal  strait are as  strong objections.   (See pp. 9, 10.)
Mania, and other forms of mental imbecility, are impediments to
the marriage  contract.   It is necessary for  this compact that there
should be capacity to contract, and the consent  of both  parties. 
OF IMPOTENCE AND STERILITY
247
The various requisites for conjugal union are seldom duly consid-
ered by society;  in  fact, few  persons  trouble  themselves  about
them.   The age, constitution, or health of the parties, is scarcely
ever considered, though highly important.   All physiologists agree
that early or premature procreation is objectionable  on many ac-
counts, from the imperfect development of the parties, the small-
ness of the pelvis, which exposes the woman  to protracted suffer-
ing during parturition, and  too  often to loss of life.   It  is univer-
sally known to all practical obstetricians, that females who become
mothers at an  early age purchase the honour of maternity at a very
dear rate.  Such persons are liable to numerous disorders during
gestation, the  pelvis is unable to support the gravid uterus, it is too
small for the passage of the infant, consequently parturition will
be laborious and protracted, and finally must be completed by ar-
tificial means;  while the degree of pressure produced by parturi-
tion on the important organs of the  pelvis, causes great suffering
and  danger to the woman,  and  may  be followed  by deplorable
disease, or death itself.  It is also generally admitted by the most
eminent  writers,  that the  present mode of female education is
highly injurious to health, predisposes to spinal curvature, and con-
sequently to pelvic deformity, thereby rendering procreation highly
dangerous to the  other sex.  Writers on spinal diseases  have very
fully illustrated this positon.   Again,  great injury  is inflicted on
the natural development of females, by the custom of tight lacing,
the functions of the thoracic and abdominal viscera are impeded,
the development of the  mammae and nipples is prevented, these
parts are removed by absorption from pressure, the lactiferous ducts
are almost obliterated; the nipple is undeveloped,  and  therefore
lactation is impeded, and the natural food of the offspring greatly
diminished.   Duges, and other foreign writers, allude to unnatural
excitement of the generative organs,  and contend that  masturba-
tion is the cause of rickets, and of various chronic  and incurable
diseases.   British females are  not infected with the vice, and no
practitioner could allude to it.   In the  male sex,  it  is productive
of the worst consequences, and often causes impotence and  sterili-
ty.  The female is unfit for the purpose of procreation  until after
the twelfth or fourteenth year, or until menstruation  is established;
for at an earlier age the sexual organs are undeveloped, there is
no venereal desire, and sexual  intercourse is painful.  Hence  the
cruelty and barbarity of violating female children of tender  age, 
248                 gynjeco-pathology.

which have been described in the section on  Violation of  Wo-
men.
   The male is also incapable of performing his part in the myste-
rious process  of  procreation until after puberty, and according to
the law of  this country before the fourteenth year.  He is not
qualified to  enter into matrimonial engagement until the  comple-
tion of the  twenty-first year.
   There is  no subject which distresses married persons so much as
want of family, or leads to so much domestic feud and unhappiness,
and finally  to the nullification of marriage.  It is  necessary for
the medical practitioner  to be fully  informed of  all  the causes
which disqualify both sexes for the object of procreation.  All dis-
qualifications for matrimonial union may be divided into two class-
es,  1. those caused by defect of  mental power; 2. those caused
by defect of sexual organization.  The disqualifications are there-
fore moral and physical, and are expressed by the terms impotence
and sterility.   These terms are often used synonymously, though
widely different.   Impotence consists in the incapacity for copula-
tion,  or in the impossibility of exercising the venereal act; steril-
ity consists  in the aptitude of the organs for procreation, without
the power of reproduction.  Thus a person may be impotent, but
not sterile ;  and vice versa.  Some writers apply  the term impo-
tence to the male, and sterility to the female; but'such a distinc-
tion is arbitrary  and unscientific ; the female may be  impotent
from  malformation, and  the male sterile from excessive  venery,
self-pollution,  and ablation  of the testicles.  We  may observe here,
that sterility does not afford a just plea for the nullity of marriage.
We have to consider the manifest causes of impotence in both sex-
es,  physical and moral.
   Physical, manifest,  natural or accidental impotence  of the
male.—The causes of manifest impotence of the male, are absence
of the penis or testicles.   There must be total loss  of the penis,
as the slightest penetration into the vagina is sufficient for procre-
ation.   (Blundell, Richerand, Sedellot, Manuel de  Med. Legale,
1830, see p. 40.)—The absence of the testicles from the scrotum
is no  proof of  their non-existence in the abdomen ; unless the pe-
nis be small, the voice puerile, the beard absent, the form delicate,
and  the whole physical  and  moral  constitution feminine.   It  is
well known  that the testicles may not descend  into the scrotum,
and be fully developed in the abdomen, and  perform  their  func- 
OF IMPOTENCE AND STERILITY.
219
 tions perfectly, and according to some writers, much better than in
 the natural situation.   The destruction of one  testicle by castra-
 tion or disease, is no impediment to procreation. (Astley Cooper,
 Marc. Diet, des  Sc. Med.)—When  both  testicles are diseased,
 their secretion is injured or destroyed, and sterility is  the conse-
 quence.  Frequent seminal  emissions, or the sudden secretion  of
 semen will be a bar to reproduction.   The secreting  power  may
 be very much increased or diminished.  The more fluid  parts of
 the spermatic secretion must be absorbed, or it must be retained
 some time to fit it for procreation.  Both testicles may be remo-
 ved by castration ; yet procreation be effected, as the vesiculae se-
 minales may contain a sufficient quantity  of semen for  one or two
 prolific emissions, after which the person will be sterile,  but not
 impotent.   M. Boyer  was consulted by a man whose testicles
 were removed in  consequence of sarcocele.   He saw his wife, and
 she became pregnant.   He feared he was not the father;  but M.
 Boyer assured him he might be, and  if so, this should  be his last
 infant.  (Sedillot, Manuel de  Med.  Leg. ut supra.)   But such
 persons, and also eunuchs, have erection  and emission,  which con-
 sists of the prostatic fluid, the mucous of the seminal vesicles and
 urethra.  (Sir Astley Cooper on the  Testis,  1830.)
   The uterus may open above the pubes  in monsters (Duncan
 and others,)  and in such cases the individual is  sterile.  Mahon,
 and many other jurists, contended that individuals were impotent
 who were affected with hypospasdias; that is, when the  urethra
 opens through any part of that canal from its orifice to  the  scro-
 tum.  If the opening  is so placed that  it  may enter the  vagina,
 impregnation will follow.  Frank relates a case in point. He knew
 a father so affected transmit it to his son, and even  to  three gen-
 erations.  Another individual had three sons.   (Bull,  de  la  Fa-
 culte de Medicine, 1810.)   Morgagni, Petit-Radel, Sabatier, who
 was hypospasdiac; Gauthier and Richerand have observed analo-
 gous facts.  (Diet.  de.  Sc. Med. art.  Hypospasdias.)
   Sometimes the urethra opens along the dorsum penis; this con-
 stitutes epispasdias.  It is evident that the reasoning employed in
 the preceding case is applicable to this.  It may end in a cul de
sac.  (Goupil, Cloquet, &c.)
   Dimensions of the penis, extraordinary thickness and  length,
are considered by some writers as causes of impotence.  Fodere
is of opinion that  the respective organs may be so disproportion-
        32 
250
GYN^ECO-PATHOLOGY.
 ate as never to be adapted to each other; and the physical incon-
 veniencies are such  as  to  expose  the  female to great injury and
 danger to her health.   It must be admitted, however, that thick-
 ness  of the  penis, which excites great  pain in some women, pro-
 cures voluptuous sensations in others, and that  the vagina is ca-
 pable of great dilatation, which may be effected  by gentle  and
 gradual efforts, and reduced  to a state capable of receiving the
 virile member.   Though extreme  length of the penis may pro-
 duce contusion of the  os and cervix uteri, it cannot be deemed  a
just cause of impotence, because, by certain precautions, this dan-
 ger may be avoided, unless there is great difference between the
 age of parties.  Diminutiveness or shortness of the penis  is no
 proof of impotence, for the reasons  already  stated.  Obliquity,
 tortuosity, or bifurcation of the penis, bad stricture of the  urethra,
 pbymosis, paraphymosis, warts,  chordee, chancres, or excessive
 length of the fraenum, cannot be considered absolute causes of im-
 potence, as  they  can be remedied  by surgical operations.   Large
 scrotal herniae cause recession of the penis, and render coition im-
 practicable ;  but  in some cases relief may be afforded. The same
 observations apply to large .hydrocele.   Sarcocele  or scirrhus of
the testicle does not cause absolute impotence, as it may be remo-
 ved by  operation  ; and one testicle remaining is sufficient  for pro-
creation.  The testicles may disappear  by disease (R. Hamilton,
 Lallery, Fodere), or by the use  of iodine.   Three  conditions are
necessary on the  part of the male for copulation—erectio et intro-
missio penis, cum seminis emissione.  Impotence in men depends
on defect of some one or more of these conditions ; erection, intro-
mission, and ejaculation of the spermatic fluid.   The causes of im-
potence are more commonly observed in man than  in the  other
sex ;  and this is easily accounted  for, by the greater  part of the
male has to perform in nuptial congress.   This is evident from the
phenomena  which gave the virile member  the form and  disposi-
tion proper for erection, the  introduction of the organ,  and  the
ejaculation of the semen, effected  by a violent and  complicated
action, which requires a concurrence of many indispensable condi-
tions, as the organs not  only contract  spasmodically to effect  the
expulsion of the male fluid, but all the body participates in this
convulsion at  the moment of emission, as if nature  at this instant
forgot every other function.   The  causes  of  impotence  in  man
arises from two sources, from malformation  of the genitals, or from 
OF IMPOTENCE AND STERILITY.
251
want of action in them ; but in  females, impotence can only de-
pend on malformation, natural or acquired, as the organs have lit-
tle  to  do in the  act of copulation, they being merely auxilliary
to it.
  The causes of want of erection may be divided into physical
and moral.  The physical causes depend  on defects of the body
as paralysis of the penis, curvature of the spine,* frigid and apa-
thetic temperament.  The moral causes are such as act powerful-
ly on  the imagination, and suddenly produce an atony of the geni-
tals, or induce an inactivity in  organs  properly developed.   The
genital organs, says M. Virey,  offer two states during life,  in the
young and old, which are the frozen zones of existence, the inter-
mediate state is the torrid zone of life.  The   infant has nothing
to give, the  old has lost  all.  Immaturity of age and  senescence
are causes of want  of  erection.   This doctrine, though generall)
correct, admits of exceptions, as children have been precociously
developed even before the fourth year, examples of which  I have
already cited ;  and  our author described a boy, aged seven years,
a native of the department of Lot, who was as fully developed  as
an adult, and who made the most furious  comic attacks on  his fe-
male  acquaintance, and absolutely deprived one  of them of that
which she could never regain.  On the other  hand, a Frenchman,
aged ninety-nine, married a  tenth wife, and was  a father at 102
(Bosquet) ; and Thomas Parr, married at 120, and performed his
nuptial duty so well at 140, as to make  him  forget his old age.
He was even compelled to appear in a white sheet at  one  of our
churches, for an amour, in his  150th year.    He outlived nine
kings of England.   (Elliotson.)   But in general, the power of
procreation continues from puberty to the 65th year.   Immaturity
of age, or senescence may be put down as the first causes of want
of power of erection.   Among  such causes, we must reckon a
frigid or apathetic constitution,  a total  insensibility to sexual desire,
and this is said to be an aggravated  or profound  lymphatic tem-
perament.  Descourtliz describes persons of this temperament in
these words:  " The hair is white, fair, and thin, no beard, coun-
tenance pale, flesh  soft and  without hair, voice clear,  sharp, and
piercing: the eyes sorrowful and dull, the form round, theshould-

  * Dr. Harrison has lately published  some cases of this kind, which were cured
by the removal of the spinal disease.  (Essay on the Powerful Influence of the
Spinal Nerves on the Sexual Organs,  1831.) 
252
GYNJEC0-PATHOL0GY.
ers straight, perspiration acid, testicles small, withered, pendulous,
and soft, the spermatic cords small, the scrotum flaccid, the gland
of the testicles insensible,  no capillary growth on  the  pubes, a
moral apathy, pusillanimity and  fear, on  the least  occasion, are
symptoms of anaphrodisia or impotence or sterility, and  any one
having the majority of these  signs is incapable of copulation or
generation."  (Propositions sur l'Anaphrosidie.)
   A habitude of chastity is another opponent to erection, such as
with the ancient fathers of the desert, and in those who, by fast-
ing and  other forms of church discipline, extinguish  those feelings
implanted by nature, but, in their opinion, contrary to that purity
which should distinguish those who have  made  vows of chastity.
The organs of such persons decay, like all corporeal organs whose
functions are not exerted.   Long continued  debauchery, whether
with women or by masturbation, will  cause impotence.  Every
practitioner has met with cases of both these kinds.   " The impo-
tence,"  says Pinel, " caused by  the  latter excess, reduces youth
to the nullity of age, and is too often incurable."   Long watching,
great fatigue, mental  or corporeal, want  of nutriment,  excessive
evacuations, sanguineous or otherwise, of  blood, bile, faeces, silvia,
menses, scorbutus, cachexia, marasmus, peripneumony, hydrotho-
rax,  anasarca, malignant fevers, diseases of the  brain, and spinal
marrow, whether from external injuries or poisons, and numerous
other diseases, are  temporary causes of impotence.  Sexual de-
sire  is  suppressed  by  acute diseases, and returns after convale-
scence.   Zacchias  and Beck  relate  numerous  cases in  proof of
this position.  We see this further illustrated during the  convales-
cence after fevers, when  erection often  occurs.  Some diseases
stimulate the generative organs, as calculus in the kidneys or blad-
der,  gout,  rheumatism, consumption, piles,  mania, itch, leprosy,
and other cutaneous affections.   Others may diminish or suppress
venereal desire for  twenty-four years, when the functions will be
restored.   (Zacchias.)
   Excessive venery is a frequent cause of want of erection and
impotence.  I have been consulted in cases of this description, es-
pecially after marriage.   This is  a frequent cause of want of fami-
ly in young married persons.
   The abuses of narcotics, saline refrigerants, acids, acid  fruits,
iodine, camphor, and  nitre are causes of impotence.  Of all cau- 
IMPOTENCE.
253
ses cold is the most powerful.   Thus, in the Polar regions, there
is neither love nor jealousy.
   Moral  Causes.—There are  no facts which so evidently prove
the influence of the moral  over the physical state of man as the
phenomena of erection.  A lascivious  idea will arise in the midst
of our gravest meditations;  the virile organ will answer its appeal,
and will become  erected, and  fit  for the functions which nature
has confided to it;  but another thought arising, will instantaneous-
ly extinguish, with the most frigid indifference, all  our amorous
transports.
   This statement is well exemplified by the effects of the passions.
Chagrin, inquietude, and debilitating passions, prostrate  the whole
economy ; jealousy and  profound meditation  impede the faculty
of procreation.   Thus, at the very moment  when  enjoyment is
about to be commenced, too eager desire, the trouble which seiz-
es on too ardent an imagination, the  excess of love, the fear of
not being loved, timidity, respect, doubt of capability, the fear of
being surprised, the shame of excessive modesty on being in the
presence of  witnesses, antipathy, the sudden knowledge of some
physical defect in the  female, aversion from filth, odour, and pre-
occupations of the  mind, are sufficient to oppose the erection, and
to abate it most suddenly.  But who can enumerate all the moral
causes capable of impeding  or  destroying erection ?   A sigh,
doubtfully interpreted, a recollection, an equivocal word, are suf-
ficient to destroy  the  illusion, and congeal the  most violent pas-
sion.   A  newly-married  man  has become suddenly impotent on
discovering his bride was without a hymen ; and a debauchee has
as suddenly  become impotent,  on  finding the membrane perfect.
(Diet, des Sc. Medical.)—And thus with a literary man, philoso-
pher, or those who  have a ruling idea, which excites the brain more
than the sexual organs.   The  fear of being impotent is the most
frequent and powerful cause of this condition.   Thus the cases
related by the illustrious Hunter,  and  the absurd impressions  of
former times, as to the influence of his satanic majesty and his
worthy  colleagues, the  witches.   Men supposed  there was no
physical power when the moral state had consumed their desires,
and they were impotent as long as they supposed themselves so.
Such is the power  of  the moral over the physical state of man.
How many impotent persons of this class were  cured with  bread
pills, by Hunter;  and how many are annually cured by mere pla- 
254                  GYNJECO-PATHOLOGY.
cebos ?   In remote ages men allowed the illusions of the imagina-
tion to have a  most  extraordinary  power  over their minds and
bodies.   This was most remarkable in the subject before us.
  Thus, we cannot easily comprehend how the power ol rue, or St.
John's wort, could prevent a man, properly developed, from per-
forming his nuptial duties on his bridal night; nor how the  pro-
nunciation  of a few  obscure and unintelligible words, could have
a similar effect.  These words were to be written on paper with the
blood of a bat, sewed up with a needle whiclf was used in making the
shrouds of the  dead, and then the charm was to be tied round the
neck of the new married man  (Venette ; also Les Secrets du Pe-
tit Albert,) or merely pronounced.   To cure this  enchantment
the church prescribed prayers, the doctors physic, and the law se-
vere punishment.  Bacon descrides  it in his Natural History as
prevalent in  Germany and France ; in  the latter country it was
designated nouer Veguilette, or trying the  point.   Mr. Hunter's
plan was best.   He ordered timid bridegrooms  to refrain from any
venereal combats for a week, no matter what might be their desires,
and then to try their prowess.   This cure was effectual, and many
of his patients  succeeded sufficiently to remove all unfavorable
impressions of impotence ever  afterwards.   They  casually took
some mild form of medicine, and a few drops of tincture of opium
each night, during the  period of preparation.
  Impotence, natural, manifest, or  accidental,  in women.—It has
been long held, I think erroneously, that the generative organs of
the female are more complicated than  those of the male, and there-
fore  that the causes of impotence are  more numerous and  less ap-
parent than in  the other sex.   If we examine the genital organs
of both sexes anatomically, we  shall  find them equally complica-
ted,  and  possessing an equal  adaptation or arrangement of parts,
as well as an identity of structure.  Thus we find the structure
of the penis  very similar to that of the genital fissure and vagina,
the double fold of prepuce, the cavernous structure, its perform-
ance of a part of the genito-urinary functious, the openings of the
vesiculae seminales and uterine tubes, the vesiculae seminales and
uterus, the testes and ovaries, the spermatic cords and the uterine
tubes.   We also find the diseases of one sex as numerous as those
of the other; and those who doubt the assertion, need not refer
to the  works of  Chopart, Titley, and others, on diseases of the
genito-urinary organs  of  the  male, for ample proof of the posi- 
IMPOTENCE.
255
tion.  I need scarcely observe, that diseases of the vasa deferen-
tia, vesiculae seminales, the pressure of tumours, hydatids, &tc.,on
these parts, diseases of the prostrate glands, urinary calculi diseas-
es of the urethra, fistulae in perineo, diseases of the bladder, penis,
and scrotum, will be found as numerous as those of the generative
system of the  other sex.   Besides, it would be inconsistent with
the wisdom and beneficence of Providence that one sex should
have more to do in the perpetuation of the species than the other.
   The causes of impotence in women  are  malformations or dis-
eases of the  organs subservient  to procreation.   Some of these
causes are apparent, others obscure.  The  apparent  causes are,
obliteration of the external sexual organs, both soft and hard, ab-
sence of the vagina and uterus, and great deformity of the pelvis,
with numerous diseases of the external and internal genitals. The
vagina and uterus have  been  found  to consist of a dense, fleshy
substance (Morgagni, Mott, Fodere), and the vagina has been
partially closed  by such substance.   (Pare,  Ruysch, Fabricus,
Physick, Fodere.)—It may be  absent  (Haller,  Vicq. d'Azyr,
Journ. des Savans, Boyer,  Caillot, and Willaume), unusually small
impervious from adhesion, tumours or  a froenum passing  across
above the hymen, or it may be filled with a fleshy growth.   If too
narrow, it may be dilated with  a bougie or a tent sponge, and when
unattended to  must be divided by incision, to admit the passage  of
the infant.   It has closed up after conception.   There is some-
times a  great  congenital confusion  of parts, so much so, that it
would be tedious, if not imposible, to describe it.  In cases of ex-
treme narrowness, impregnation may take place, and the canal be
gradually dilated during parturition.  I  have  seen four cases  of
cohesion of the labia externa,  at the age  of puberty, so complete,
that only a small probe could be introduced at the superior commis-
sure. The vaginal canal may be totally or partially obliterated, and
in such cases an operation is  impracticable, and impotence  abso-
lute.  The vagina has opened into the bladder (Sue), rectum, an-
terior parietes  of the abdomen, and pregnancy has occurred in the
two  latter cases.   Morgagni  attests  that of the abdomen, lib.  v.
epist. 67 ; and the other is given in the Annales de Med. de Mont-
pellier, which  led  the celebrated Louis to propose the following
question to the casuists; " An uxore sic disposita uti fas vel non, ju-
dicent theologi morales?" Barbaut cites  two examples of pregnan-
cy of this kind.  (Diet, des Sc. Med., art. Impuissance.)—Orfila 
256
GYN.8EC0-PATH0L0GY.
 contends  such malformation is a cause of impotence ;  for though
 coition is  not physically imposible, it is contrary to the laws of mor-
 als and of nature.   The royal court of Treves annulled a  marriage
 in such a case.  In cases of vesico-vaginal, recto-vaginal, fistulae,
 and  amplification  of the vagina  from laceration of the perineum,
 inflammation  and  ulceration may occur and impede sexual inter-
 course ; but such cases could not warrant a divorce, as they occur-
 red  after  marriage.   Excessive  straitness  or  partial occlusion of
 the  vagina, is no impediment to procreation, as fecundation may
 occur, if the spermatic fluid  be applied inside the labia, as already
 mentioned.   Besides,  fecundation has happened, and hymen per-
 fect.  (Ruysch, Pare, Smellie, Hildanus, Mauriceau, Baudelocque,
 Naegele, Nysten, Journ. de Med. de Corvisart, and Leroux.)—
 Prolapsion and  some forms of ulceration of the vagina,  are only
 temporary causes of impotence.    Cauliflower tumours of the clito-
 ris or nymphae may be temporary causes of impotence, as also tu-
 mours in  the vagina.   (Burns,  Trans. Dublin College of phys.
 1824, vol. iv; Edinburgh Med. and Surg. Journ.,  1805.)—Leu-
 corrhoea is one of the most common causes of sterility.
  The uterus may be absent.   (Columbus, Schlegel, Morgagni,
 Meyer, Renauldin, Hamilton, Bousquet,  Theden, Engel, Lieu-
 taud, Caillot, Ford, and  Breschet.)—I might  quote  numerous
 writers who describe the cavity of  the uterus divided by a  septum,
 but it is not stated whether or not  procreation was impeded.  Ma-
 ny authors have also described partial or total obliteration of the
 uterine cavity, among whom are Bichat, Lallement, Segard, Gar-
 dien, &c.   The uterus may be double, that is there may be two
 uteri.  (Haller,  Purcell, Med.  Facts, vol. iii; Mem. Med. Sci-
 ence, vol. iv ; Lond. Med. Journ.,  1782, vol. iii; Diet, des Sc.
 Med., Medical Transactions, vol.  vi;  Duges, Journal de progress,
 vol.  xxii.)—A vicious  direction  of  the os and cervix uteri, and
complete occlusion of the former,  are irremedial causes of sterility.
The   whole of the causes of impotence  and sterility in  females
may  be arranged under three classes; 1. those depending on the
organs which  receive the male fluid, namely, the genital fissure,
the vagina, and  uterus ;  2.  malformation or disease of the organs
that  transmit  it  to the ovaries, and reconvey the embryo to the
uterus, and these  are  the fallopian or uterine tubes ; 3. the mal-
formation  or  diseases of the ovaries,  or organs which supply the
germ for fecundation.   Inflammation, ulceration, scirrhus, cancer, 
IMPOTENCE.
257
ossification, calcareous deposit,  or tumours in any of these organs,
may be the cause of sterility. In fact, any disease of the female geni-
tals, attended with much constitutional disturbance, may be held a
temporary cause of sterility.  Tumours of various kinds, callosi-
ties, cicatrices, adhesions, from disease or mechanical violence, dis-
placement of the uterus, prolapsus,  procidentia, retroversion ante-
version, lateral obliquity, and the various disorganizations incident
to muscular,  serous, and mucous tissues, when present in the fe-
male organs,  are causes  of  sterility.    In the London  Medical and
Surgical Journal, 1830, vol. iv, is an  account of two singular cases
of procidentia uteri;  in both impregnation was effected  through
the natural orifice, though  permanently fixed without the genital
fissure for years.   I have also  published cases of  dysmenorrhcea3
in which pregnancy occurred.  In the disease called  irritable  ute-
rus, so well described by Gooch and Dewees, a cure may be ef-
fected.   In absence of  the ovaries  and uterine tubes  there can be
no conception ; or in  dropsy, or enlargement of the former;  or in
occlusion or adhesion  of the latter to  the uterus or adjoining parts.
There are some cases of constitutional  sterility, which are inex-
plicable ; for example,  those in which a woman has  had  no fami-
ly for years, and at length becomes a mother.
   The  principal  moral  causes of  impotence are hatred, disgust,
fear, timidity, an excessive ardour  of desire, divers  ramblings of
the imagination ; in a word, every passion strongly excited, that is
to say,  all cerebral action so strong as to diminish  that of the ge-
nital organs,  which require  for coition great exaltation.   Concep-
tion seldom  happens under such  circumstances.  Fodere  is of
opinion that complaisance, tranquility, silence, and secresy are ne-
cessary for prolific coition ; it is arrested,  as if by enchantment, by
noise,  dread, fear, publicity, jealousy, contempt, repugnance, slov-
enliness, by love too  much respected, and by every thing that can
illumine the imagination.
   Many of the causes of impotence  in both sexes may be remo-
ved, but many are beyond the reach  of art.  It has been  long
maintained that the  powers of the mind have great influence in
promoting and  impeding  the  process of procreation.   (See p.
41.)
   From the  preceding statements we may,  I  think, deduce the
following general principles:
   1. To declare either  sex impotent,  it  is necessary that certain
        33 
258
GYN.S2CO-PATH0L0GY.
physical causes be permanent, malformations or accidental lesions,
and be evident to our senses, which art cannot remedy, and which
prevent the faculty of exercising a fecundating coition.
  2. These causes, when rigorously examined,  are few in num-
ber.
  3. The  moral causes of impotence ought not to be taken into
consideration,  as they would  serve  as an excuse for an individual
accused of impotence.
  4. That if  there is the slightest penetration into the vagina, it
is sufficient to excite in the other sex a degree of erethysm neces-
sary  for fecundation ; or if the spermatic fluid is applied at the en-
trance of the vagina, virile impotence cannot be admitted.
  In this country the medical jurist  is seldom required to decide
questions of impotence or  sterility  in our courts of justice;  but
every medical practitioner may be consulted in private, either  be-
fore or after matrimonial  engagements.   He may be the cause of
great domestic trouble, and embitter the life of  male  or  female.
He should  be  exceedingly  cautious in fixing the stigma of impo-
tence or  sterility  on  either  party.  The  legitimacy  of children
may be contested on a plea of impotence, and such a plea may be
offered by a man accused of rape.  It is  therefore evident that a
proper knowledge  of the subject is necessary to the medical prac-
titioner.
  Ambiguity  of Sex.—Hermaphrodites.—There may be malfor-
mation of the genitals in both sexes, but  there is no example of
one individual possessing the perfect organs of both.   Again,  the
organs may not resemble those of either male or female.   There
is no truth  in the statement, that hermaphrodites have married and
propagated ; the obstetrician is aware of the physical impossibility
of a full-grown infant passing through the male pelvis.   It is evi-
dent that hermaphrodites must be impotent and sterile.  The  an-
cient physicians were  of opinion  that such persons might propa-
gate.   Even a canonist went so far as to  maintain one individual
could propagate within himself or herself, " tanquam mas generare
ex alio, et tanquam foemina generare in  se ipsa."   There is no
case on record of a perfect hermaphrodite, and no truth whatever
in the assertion that such class of  beings  can propagate the spe-
cies.   I  can  see no difficulty  in  supposing that persons of both
sexes, with malformations of the genital organs, may marry, when
I recollect  the curious and well-attested  case of a female, who 
IMPOTENCE.
259
dressed in  male  attire, and  assumed  the name of James  Allen,
married another female, and lived  as a husband for several years
without detection.  This case happened  in London, in 1830, and
was discovered when Allen died; and  on dissection was found to
be a  well-formed female.  Also the case of Marie  Marguerite.
who was born  in 1792, and  considered  a female till  1813, when
her real sex was determined,  as mentioned by the French jurists.
   Voltaire, that enemy to religion and disgrace to mankind, ex-
erted his depraved mind to prove  that hermaphrodites, or andro-
gyni, might beget offspring.  He said there were many insects of
both sexes, and why not the human  race be  of the same nature ?
I answer, because  the union of the reproductive organs  in the
same individual must prevent all possibility of generation.   In such
a case, and no  such is  on  record, or could  happen, there  should
be  two distinct sets of arteries, veins, nerves, and  organs, which
have never been discovered by anatomists.   Would it not be  in-
consistent in our species and in almost all classes of perfect  ani-
mals, to be amorous and to be the object loved; to be ever pres-
ent with the object  of desire,  and every instant to have the means
of gratifying desire ?   Human life would be  a tissue  of  amorous
transports and of luxurious sacrifices, which would  render man to-
tally unfitted for the performance of the  social duties  allotted  to
his condition.
  The idea is absurd,  erroneous, unscientific unnatural unscriptu-
ral, and could only  have  been cherished  by a miserable man, ig-
norant of anatomical and  physiological science, an enemy to na-
ture, morals, and the divine principles  of Christianity.
  Rochefort relates in  his dictionary a  case of a Scotch  servant,
an hermaphrodite, who was condemned to be buried alive, for hav-
ing  impregnated the master's daughter, and  that the French par-
liament permitted persons  of this class to marry, whether they
were men or women, but  never to deviate from the  functions  of
the  sex which they  had adopted.
  Skenchius asserted  he knew a reputed hermaphrodite married
to a  man, and who  had sons and daughters, and yet that this per-
son  impregnated  servant maids.  Here  is a medical  fact  with a
vengeance, one of the mendacious stories of the  dark ages.   If
we  examine this case critically,  we find it unsatisfactory  and  in-
credible.  It is a hearsay  fable, a reputed case, with no descrip-
tion  of the genital  organs, no proof that the  individual possessed 
260
GYN^CO-PATHOLOGY.
male organs.  Admitting that this  person had  elongation of the
clitoris, it was more likely that the servants distributed their fa-
vours,  after a  partial taste of the sweets of Venus, than confined
themselves to the  embraces  of this individual.  Such was the
gross  credulity of physicians in ancient times,  and  the  wisdom
and infallibility of canonists,  who held the maxim, "  that a  man
could propagate in himself, and a woman in herself. "
   Blackstone  says, " a monster having deformity in any part of its
body, yet if it hath human shape, may inherit ;  and every heir is
male or female, or hermaphrodite ;  that is, both male and female,
and shall be heir according to that kind of sex which doth pre-
vail, and accordingly it  ought to be baptized.   The same is ob-
served in cases concerning tenants by courtesy.  "  As the brain
is  generally perfect in monsters, and the mind  perfect, it is  clear
that such  persons ought to  inherit property.   When two per-
sons are united at the chest  or back, as in the cases of the Siam-
ese youths, lately exhibited in this city, and the  Hungarian sisters
exhibited in 1723, it would be difficult to determine primogeniture
or right to property.
   Before I consider the treatment of impotence, a few words may
be said on the law relating to divorce, on account of  this defect.
   Divorce.—Marriage cannot be legally contracted in these coun-
tries without the  full  and free consent of the parties, and hence
medical men may be called on to decide whether one of the par-
ties was incompetent to perform the compact from mental imbecil-
ity, inebriation, or narcotism.  Adultery, of either party, or ex-
ternal violence, is a sufficient cause for divorce in  this country.
The former can be  proved  by the  temporary  impotence  of the
husband at the time of conception, or by the birth of an infant in
the absence of the latter (See Legitimacy and duration of Preg-
nancy)  ; or by the existence of syphilis in either party.  By the
law of this empire  the parties may marry again  ;  but in all Cath-
olic countries there can be no second  marriage  during the life of
either party.  A  divorce  is  granted whenever  it is  proved that
corporeal  imbecility existed before marriage.  The  contract is
declared null and void, ab initio.  Imbecility after marriage is not
a sufficient cause,  because there was no fraud in the original contract
(Blackstone)  ; and  to provide for  this case, the  ritual prescribes
in  the  marriage ceremony,  by compelling  each  party to swear 
TREATMENT OF IMPOTENCE.
261
" that he or she takes each other for better for worse, in sickness
and in health, until death do them part.  "
   Treatment of Impotence.—There is  no work in the English
language which gives a complete account of the causes and treat-
ment of impotence ; and hence I have  undertaken the  task of
supplying this want, with what success the reader must determine.
The subject is one of importance to  all classes of society, and de-
serves as much attention as any other malady.   How much is one
to be pitied who never felt the desires of  love, whose  icy heart
never palpitates at the  sight of a lovely woman.   His existence
resembles the insensible marble ; his soul is as  cold  as the stones
of the  grave ; his life resembles death.  But how much more is
he to be pitied, who has  extinguished his  desires, and languishes to
obtain that pleasure which his organs refuse, and which he cannot
obtain at the expense  of all  his  tenderness for a sex  which he
adores.   The first must remain in the sad apathy in which he is
plunged ; the second may be ensured hope in the  majority  of ca-
ses.  Persons affected  with  impotence must avoid the alluring
promises of  empirics, who, one and  all,  are perfectly ignorant of
the innumerable causes of the affection, and  whose nostrums do
much more harm than good.   It will appear  by the subsequent
remarks, that no single plan of treatment is effectual :  that  a va-
riety of causes must be  removed by  a variety  of remedies.  Many
of these causes are removable by  medicine or by  surgical opera-
tion ; many  are beyond  the power of either.   In corroboration of
the  truth of these remarks I  am happy  to quote the authority of
Sir A. Cooper.
   " There  are," says he,  in his  last course  of lectures,  1823,
" several causes which produce a  destruction  of the virile power.
These  may sometimes be traced to a peculiar sluggishness of  con-
stitution, to a general torpor of the  procreative system,  on which
the usually attractive animal affinities exert no influence.  To such
persons a Venus might display her  charms, and  on such her son
might  exhaust his quiver in vain.   No  genial spring is here, no
blooming summer or fruitful autumn ;  but all  is winter, a dreary,
desolate and barren  winter ; in  which  the springs of life are fro-
zen up and  the animal propensities destroyed.   Some men are so
constituted  that they may be said never to possess a venereal stim-
ulus, and some of  the other sex are equally frigid.   I knew a per-
son who remained unwarmed by the flame from the  hymeneal al- 
262
GYN.EC0-PATH0L0GY.
tar for seven years, and who was incapable of performing the du-
ties which devolved on him.
   " Gentlemen,  it is  likely you  may hereafter be consulted on
these subjects;  but these  are some of the arcana of the profes-
sion into which  you will  not readily  be admitted.  No, it is not
until  yon have  contended long with popular prejudices that you
will be made acquainted  with important secrets. When forty years
of practice, or perhaps more, shall have rolled over you, when you
shall  have the  snow on the  tops of the mountains (here the es-
teemed professor, with great good-humour, passed his hand through
the white locks which grace a  well-formed front) : then it is, and
not till then, that you will be required to give your opinion on such
weighty  matters !  (A laugh.) When  consulted by persons about
to enter the marriage state, you should ask if they have any de-
velopment  of  sexual power in the morning? and if they have,
depend  on it they will not  be  deficient in energy in the after part
of the day; but if otherwise, advise them by no means  to marry.
   " Another cause which might produce the calamity we are now
considering, is an excessive irritability of the vesicula seminales,
which  produces a  premature  expulsion of the seminal fluid, and
this is almost as bad as the  former cause.  Sometimes it is the re-
sult  of debauchery, but  most frequently it occurs in irritable and
delicate  young men.   In such cases we have to support the con-
stitution by a generous diet and bark, giving at the same time opi-
um, to allay the  irritability.   In addition JffTwhich, let the person
stand over a large pan of cold  water, and dash it over the genitals
two or three times in the day.  Turpentine and rhubarb are some-
times given, but I am not sure that they do any good.
   " Another cause  of  impotence is the frequency of nocturnal
emissions, and this is most commonly the case with young people.
It is frequently the  effect of bad habits at school, and it occasions
a great degree of anxiety.   We must try to lessen this, by repre-
senting to the  party that  it is an occurrence which  frequently hap-
pens to persons in a state of health every nine days or a fortnight,
although in the patient's case it may happen two or three times
during the night.  The treatment of this species will be  very much
as the preceeding.
   " Sometimes it arises from a wasting of the testicle, or from an
abscess of this gland, producing absorption of its structure.   The
removal  of one testicle does not destroy, neither does it seriously 
TREATMENT OF IMPOTENCE.
263
impair the generative power.   The removal of both, emasculates.
There is an opinion to  the contrary, but it is an  erroneous  one.
This loss of power does not  happen at once,  the secretion of the
semen continues for a short time, and the inclination and the power
remain ; but gradually  the desire, and afterwards the power  is
extinguished.
   " Impotence sometimes arises from the testicles not having de-
scended.  Mr. Hunter has said that the  testicles, when confined
in the abdomen, do not exercise their functions.   This is the case
when the testicle is pressed upon by a congenital  hernia, when  in
the inguinal canal;  but in the case of an apprentice of mine, who
shot himself because his testicles had not descended, the secretory
ducts were found full of semen. Impotence sometimes arises from
the state of mind, generally  from too great an impetuosity and ea-
gerness to cohabit.   A gentleman,  for example, is recently mar-
ried, and if not able to  perform his wishes in two or three days, he
is very  full of anxiety,  and the imbecility is considered by him  to
be permanent.  When consulted by such a person, you must not
try to laugh him out of it, but tell him that it is not uncommon, but
 that  it  is necessary that he should promise you to abstain from the
attempt for three or four days, or until  he has taken  all the pills
which you will give him.  These may be made of some harmless
material, and  that if he  will observe what  he has  promised,  he
is sure  to get quite well.   He takes two or  three pills ; but the
very  promise  he has made,  and the impression made on his mind
by the  promise; induces him to do  the very contrary, and  it sel-
 dom  happens that he can return with any complaint."  (Lancet,
 1821.)
   Such are the very brief observations of the first surgeon in the
 world,  on the causes  and treatment of impotence.  That there is
 much room for  a further consideration of the  subject 1 shall en-
 deavour to prove in the succeeding remarks.
   In the first place, we should endeavour to remove all defects
 of conformation  that are curable  by surgical  operation, restore  di-
 minished function, regulate  disordered  action, and tranquillize  all
 parts, especially the brain, whose excessive activity affects the gene-
 tive  organs.   Every well-informed  physician  and surgeon must
 admit that a great variety of medicines and of operations may  be
 resorted to with  advantage.   It is to be recollected, however, that
 most of the pretended aphrodisiacs, external and internal, electri- 
264
GYNJEC0-PATH0LOGY.
city, flagellation, and urtication are without  effect, or produce a
momentary effect, and that a  complete change of regimen and
of life can produce the necessary effect on the economy.
   In the second place, to avoid  excess, to appease  the imagina-
tion, to regulate the  digestive  functions, that is, to attend to the
morbid conditions of the brain and  stomach, which so often cause
impotence, is the only method upon which we can hope for legi-
timate success.
   In the last place, we must regulate the function of menstruation.
   Impotence may  arise from excessive venery, natural or other-
wise.   Thus we find young persons, before the adult age, incapa-
ble of  procreation ; others equally  so in  the  prime  of life, and
others  in this condition about the middle age.  These unfortunate
persons seldom consult  respectable  physicians or surgeons,  or if
they do, are too often derided and unrelieved ;  and hence the ap-
plication to ignorant quacks, who fatten upon  the fears of their
victims.
   I have now a gentleman under my care, who was treated in this
manner, and driven to a rapacious empiric, who in a time fleeced
him of fifty pounds, for much injury received.  Such cases are  of
daily occurrence.   Derided by  the  profession, or exposed to ac-
quaintances, such persons are almost afraid to consult their ordina-
ry medical attendants, too many of  whom forget the sacred pledge
they have given, on obtaining their diplomas, to  keep secret all
delicate cases which come  before them.   Hence, an unreserved
disclosure of the symptoms is seldom given, from fear of exposure,
or through bashfulness, though the most implicit confidence may
be placed in all eminent and honourable members of the profes-
sion.  I shall not prosecute these remarks,  but proceed to consider
the subject under notice.
   It is universally admitted  by all  medical writers that excessive
venery, either by bad habits acquired at school or by legitimate
means, too generally cause impotence and  sterility.  It would be
foreign to my purpose to expatiate upon  this subject, but I may
observe, that excess of amorous pleasures  produces nervousness,
hypochondriasis,  indigestion, disorder of the digestive functions,
melancholy, and great enervation of body and imbecility of mind,
the latter  often causing a great  propensity to suicide.   Those to
wnom  these observations apply  will find all their multitudinous
symptoms under the above heads, in any popular system of medi-
cine. 
TREATMENT OF IMPOTENCE.
265
  Dr. Parry speaks thus of immoderate and precocious  coition :
" Inde apud mares oritur cultus praecox eteffrenus, quo nihil men-
tern magis infirmat, nihil corporis  vires frangit, nihil  articulorum,
ventriculi, cordis, cerebri, morbis  virium magis obnoxium reddit."
(Pathology, 1825.)—Haec vero nimis culta," says Professor Gre-
gory, " valde nocet praesertim junioribus, quorum  animos pariter
ac corpora multum degenerat."   Conspectus  de Med.)—Every
persons feelings must convince him of the languor, lassitude, and
inertness which succeed the evacuation of the spermatic fluid.  This
was noticed by Aristotle, who said, " Tristiam autem multum sem-
iois emissionem censet, cur ex omnibus animantibus homo maxime
omnium, postquam concubit dissolvatur et languescat."
  Frequent seminal emissions, whether by coition, masturbation, or
pollution, greatly debilitate the mind, and enervate the body gen-
erally, and the reproductive organs in particular, which are render-
ed incapable  of performing their  natural functions.  Physiologists
hold that the semen must be retained for sometime in its recepta-
cles, where its thinner parts are absorbed, before it can be prolific.
Masturbation, manustrupation,  or onanism,  is  the  unnatural effu-
sion of the seminal fluid, and  is too commonly induced by young
persons by the force  of bad example.   It  is highly injurious to
health, is contrary to  morals, religion, and nature.  It is condemn-
ed in the sacred writings, Gen. c. xxxviii. v. 10; Deut. c. xxiii.
v. 10, 11; Lev. c. xv.  v. 16; John, c. iii. v. 9; Prov. c. xxii.
v. 11 ; Matt. c. vi. v. I ;  Cor. c. vi. v.  15;  Rom. c. i. v. 8.  It
is contrary to human  nature; because it is beastly, terrestial,  and
unworthy of man.  It is  sometimes commenced before puberty,
and at this period becomes inveterate, unless removed by the le-
gitimate  pleasures of love;  and if continued, excites an invincible
estrangement from natural pleasure.  When  young persons are ad-
dicted to this destructive habit,  they become inactive, dejected,
fond of solitude, the  appetite is diminished, there is great depres-
sion of spirits, and  a total disinclination to activity,  playfulness,
and vivacity.   These symptoms are greatly increased by the con-
stant and frequent repetition of their cause.  The forehead is par-
tially covered with crimson-coloured hard  pimples, called  acne.
There is great timidity and disrelish for society by such persons.
The memory is impaired, and  the power of comprehension con-
siderably diminished ; all the mental faculties  so much  injured,
that stupidity, idiocy, and lunacy, sooner or later appears.   The
         34 
266
GYN^CO-PATHOLOGY.
 digestion is much injured, and  flatulence  becomes a troublesome
 symptom, even before or after  puberty.   The senses of vision and
 hearing become imperfect;  and blindness from amaurosis, or deaf-
 ness  frequently occurs.  I was once consulted  by a young man
 who had  amaurosis of both eyes, whose spirits were as depressed
 as possible, and who finally confessed that excessive masturbation
 had produced  his disease.   We  can easily  understand how this
 and a variety of other formidable diseases may arise from too fre-
 quent coition, when it is recollected that it  produces the most vi-
 vid and repeated stimulation of the whole nervous system, and ex-
 cites an acute or chronic irritability, or total  loss of sensibility in
 organs which are naturally the  most irritable.  Mr. Hunter was of
 opinion,  that masturbation unless excessive, was  not  more injuri-
 ous than coition, (Work on Venereal, 1st edition) ; but he recant-
 ed in his future editions.  He forgot that  the solitary masturbator
 can repeat his crime as often as he pleases; but  the compliance
 of a female is not always to be obtained.   Few  escape the  evil
 results of onanism, which is much worse than coition, being more
 frequently repeated, and being more vivid  and  violent.   Hence
 we find it induces the worst forms of indigestion or  morbid sensi-
 bility of  the stomach, (Andral, Pathol,) the worst form of hypo-
 chondriasis, or lowness of spirits, (Martinet. Therapeutics,) aneu-
 rism, and other incurable diseases of the heart and  its  large ves-
 sels, (Diet, de Med. h Chir. Pratiques, art. Arteritis,) all the dis-
 eases of the brain and spinal marrow, (Diet. Abrege des Sc. Med.
 art. Onanisme,) feebleness of the whole muscular system, chronic
 inflammation of the viscera of the chest, abdomen, and pelvis, and
 consumption,  (Op. Cit.,) stricture of the urethra, suppression or
 incontinence of urine, piles, and nocturnal  emissions.   These are
 only a few of the evils induced by excessive venery, as will ap-
 pear by a reference to Tissot's  work upon Onanism, to Winchman
 de  Pollutione diurna,  Beddoes on  H)geia, and A. P. Buchan's
 production, intitled " Venus sine Concubitu."
  It has  been held, from time  immemorial, by  moralists,  physi-
cians, and divines, that  the mind, or imagination,  by dwelling  on
obscene subjects, excites the commission and repetition of mastur-
bation ;  and consequently, that the suppression and  prevention of
impure ideas is the chief indication for the prevention of this ha-
bit.  The cure is  certainly in  the mind rather than  in the body.
Hence it is, that breaking through  the association of such ideas, 
TREATMENT OF IMPOTENCE.
267
controls and prevents even the most inveterate habit.   Thus we
find constant occupation prevents obscene ideas, and therefore con-
stant attention to business, and exercise in the open air, are to be
strictly enjoined in the treatment of this miserable affection.  Soli-
tude, indolence, and sedentary pursuits are to be  carefully avoid-
ed.   All  causes  which excite amorous  ideas must be avoided ;
and the association of such ideas which  has been long cherished,
and influences the mind even  during sleep, by exciting dreams and
nocturnal  pollutions, is completely destroyed by the use of opium,
or other sedatives, at bed-time.   Dreaming is often  prevented by
sleeping with the head considerably raised, which accelerates the
return of blood from the brain.  The  best position upon which
the patient can compose  himself to sleep  is on either side ; for
sleeping upon the back should be avoided.
   The first and great rule to be impressed upon the sufferer is to
return to the paths of nature.  The next,  to remove his morbid
sensibility, or irritability, to all internal  and external  objects, by
advising him to avoid all impure ideas or  meditations,  and by im-
proving his general health.  The derangements  of the digestive
organs claim great attention, and  are to be improved by the ordi-
nary remedies for dyspepsia and hypochondriasis.   Cold sea bea-
thing,  and daily effusion of cold water on the genitals, are benefi-
cial.   Should there be an  excessive secretion of semen, the food
must not be too nutritious, as, of course, it increases all secretions.
All drink should be rather cold  and all  liquors avoided.  When
the patient is reduced to a state of impotence from excessive sem-
inal emissions, he too often supposes that these can be  arrested
by medicine.   I  have been often applied to under such circum-
stances after marriage ; but need scarcely mention there is no as-
tringent capable of arresting the  evacuation.   Such persons also
request some temporary excitant; being  ignorant that temporary
excitement will be followed by collapse, and perhaps an extinction
of the  venereal appetite.    The tincture of lytta has produced this
effect.   Of this and other aphrodisiac medicines hereafter.—The
health should be restored  so as to enable the sufferer to enter into
wedlock.   This is the natural cure of the malady.  As the mind
is greatly  depressed in those who have indulged in excessive  mas-
turbation, they  suppose  themselves  impotent  should they fail to
accomplish  their wishes with  a female  selected  at  random; but
this is an erroneous idea ;  for while the venereal desire  continues, 
268
GYNJECO-PATH0L0GY.
and the organs are natural, there may be moral, but not absolute
impotence.   In such  cases, some  physicians have recommended
concubinage; and if  it succeeds, then marriage.   This advice is
decidedly immoral; but is  so  often acted on in general without  a
medical counsellor, that the reader must not be  too ready to cen-
sure the faculty for occasionally proposing it.   In any case, should
the person marry, the rule laid down as to diet in a former para-
graph is not to be followed, as here  the most  nutritious aliment,
with a moderate use of vinous or  ardent liquors, will be requisite
to restore the general health  and strength which had been  im-
paired.
   In some cases, the seminal vesicles discharge their contents,
without any venereal  desire being  experienced, when  the  bowels
are evacuated.  This form of seminal effusion was called Diurnal
Pollution, by Celsus, (Book iv. c. 21,) and other ancient writers.
It is sometimes accompanied, by the usual sensation.  In other in-
stances the semen is effused on walking, without erection, but with
voluptuous sensations.  A case of this kind came under my care,
in 1825, the subject of which was a  gentleman aged  twenty-six,
of a sanguineous  temperament, spare habit, and tall stature.  He
was married about a  year, and was distressed  by  as many as ten
seminal emissions during the day,  which were excited by the  fric-
tion of his dress.   He  ascribed the original cause  of his condition
to the habit  acquired at school.   He  did  not  indulge in  natural
marital rights more than  once a  week.   He had  tine, opii every
night, a blister to the perineum, and a free use of sulph. quininae,
cold sea-bathing, he., which removed his complaint. He was also
advised to obviate the urgency of his infirmity by natural  resour-
ces.  Dr. Colles, the justly celebrated  professor, of Dublin, was
consulted in this case,  and concurred in this mode  of treatment.
In a subsequent case, I found, in  addition to the plan of treatment
advised in these pages, that the daily introduction  of a bougie was
productive of much benefit.   In cases of impotence  arising from
moral causes in which  nuptial duty cannot  be  accomplished after
marriage, the use of opium, with total abstinence from all attempts
at procreation for a few days, nutritious diet, excitant drinks, and
lytta, after  the effect of the sedative had  ceased,  are generally
efficacious.
   I need scarcely observe, that the practitioner should endeavour
to alleviate or cure all the diseases of the genital organs.  Besides 
TREATMENT OF IMPOTENCE.
269
manifest diseases of these organs, impotence may be produced by
other causes, as the previous excessive use of the organs.   Thus
we find young  persons, scarcely  of the  adult  age,  incapable  of
procreation ;  others equally so in  the prime of life;  and others in
this condition when approaching the climacteric period.  These un-
fortunate individuals seldom consult regular physicians ; and if they
do, they are treated  with levity  or  derision, and  therefore they
must commit themselves to rash and unprincipled  empirics.  Dr.
Cullen asserted there was no medicine or food capable of increas-
ing the  generative functions; and hence all British writers sub-
sequent to his time have implicitly adopted his opinion.   Therefore
medical practitioners in this  country, when applied  to in cases of
impotence, have no means of acquiring therapeutic information, or
of affording relief to their miserable patients : some will observe,
there is the tinctura lyttae, so loudly praised as an aphrodisiac in
many of our dispensatories ;  but we must recollect  that it is as ex-
tensively  condemned  in  others.   When this remedy fails, as it
generally  does, then we must commit our dejected patients  to the
distressing despondency of their  condition.   It  is therefore right
to describe the  remedies  proposed  in other countries; many  of
which are highly useful, others  inert.
   That some substances possess a power of exciting sexual desires
cannot be doubted, for they manifest their power on animals, which
cannot be supposed, like  man, to be under the influence of ima-
gination :  thus the hemp-seed,  buckwheat, will  excite birds to
copulate ;  and oysters, if eaten at the spawning time, will excite
man, according to Bloch, and even their effects  at times are very
generally  acknowledged.
   Among the substances which augment the action of the genera-
tive organs, we find some which act  by affording an  abundance of
chyle and general renovation, and these  are called  spermatopia;
and others that act on the genital organs as excitants, as aromatics
and stimulants, which first act as  the former, and  then are called
aphrodisiac remedies.
   Spermatopia.—All alimentary and highly nutritious  substances
are included in the first class, and these are evidently useful in all
cases of debility, from whatever cause, from  abuse of venereal plea-
sures, excessive fatigue, long  and intense  study,  copious evacua-
tion,  inanition of every kind, as  during convalescence after fevers
and  acute diseases;  and in all  these cases aphrodisiacs do more 
270
GYN.ffiC0-PATH0L0GY.
harm than good.   Then to all who have lost the power of erec-
tion  from such causes, we exhibit mild, light, and nutritious food,
which does not fatigue the stomach, which is easily converted into
chyle, which is slightly tonic and stimulant; for example, strong
chicken  or fowl  broth or jelly, slightly spiced, turtle, and other
soups, eggs, oysters, rice-milk, sago, arrow-root, salep, chocolate,
roast or broiled meats, a moderate quantity of white wine, air, and
exercise  of various  kinds, walking, riding, he., flesh brush, he.
   Aphrodisiacs.—We find  many vegetable substances produce
effects on  the reproductive  system.  Thus  the  genus of plants
called umbellifera, as the artichoke, celery, seeds and root of pars-
nip,  carrot, and fennel.   Crucifera, as radish, tunnip, water-cres-
ses,  and rockets,  which  were strewed  at the temple of Priapus.

                Et quae frugifero seritur vicina Priapo
                Excitetut Veneri tardos eruca maritos.

   In the  class  acotyledones,  the  orange,  mushrooms,  especially
the smaller kind, which with sweetbread were so lauded by Ovid.
The French also include  the leguminous plants—beans, especially
those called  French beans, which from their flatulent  properties
in distending the intestinal canal in  the  vicinity  of the  spermatic
cords, excite the circulation  in them, and thus  ultimately excite
the testicles, inducing artificial plethora, or  increased circulation of
blood in  these organs.  We  must not forget the  class gynandria-
diandria of Linnaeus, the orchis, ophiris, and satyrion.  The bul-
bous roots of these  plants resemble the testicles,  exhale a sper-
matic odour,  which has  long fixed the attention of men,  and in-
duced them  to think these excited love.  Linnaeus states that the
leaves of orchis bifolia render bulls more ardent and vigorous for
copulation.  This class is highly  nutritive; and hence the bulbs
may be given wi^h sugar, or in any other convenient manner.  We
find,  in  Genesis,  that  Rachel married Jacob ;  but had no family
until she ate a certain plant, when she conceived of Joseph.  This
plant  is  called dudaim in the Hebrew text, and is called cucumis
dudaim by Linnaeus, a species of or chides : of this family is also
the  salep, which is prepared as article of diet, in the proportion
of % ss to Oij of water.
   The sweet fruits, as peaches,  pine-apples, raspberries, &c. are
styled spermatopia.   Of all the foods, fresh eggs are the most
powerful aphrodisiacs.   Chaumenton praises a fresh egg and choc- 
TREATMENT OF IMPOTENCE.
271
olate, the yolk  especially, as highly nutritious and aphrodisiac;
and even we have a  proof afforded by analogy from the stallion,
whose generative functions are wonderfully increased by the use
of eggs and sweet milk.  We find it recorded, that Alcimenes, an
Athenian,  had  triumphantly  made fifty  women mothers  in  one
night!!!   But  perhaps  this demigod had  taken  a few poached
eggs to  supper.   It  is also stated, that crabs, lobsters, pigeons, al-
monds,  and hazel-nuts,  have wonderful influence on the  genital
functions, as also oysters,  ray-fish, and all cartilaginous fish.   It has
been long observed, that  the Japenese, and other  ichthyophagous
nations, are highly prolific.  There is no more prolific people than
the Irish, the lower orders of whom almost wholly subsist on potatoes
and fresh eggs; but we  should  recollect, that  the greater  part of
our arrow-root  is made from the potatoe, according to  Dr. Paris
(Pharmacologia.)   Of all the causes of impotence, excessive ve-
nery, and too much chastity, are the most common ; and to these
we may add a cold  and apathetic temperament, which arises from
infirm and  unhealthy parents.   The sexual organs of such persons
are badly developed.  The excessive use and abuse of narcotics
and refrigerants are  causes of impotence.   Phosphorus  is  a most
powerful aphrodisiac; but cannot  be exhibited, being a  violent
poison.   Animals, to  which it  has been exhibited,  died  of the
most violent and amorous convulsions.  Borax has been exhibited
to horses, and renders them most ardent; and  that produced from
sea-salt is best,  which perhaps  accounts  for the  salacity  of the
residents on the coasts.
   In the class oroides, we have  the arum colocasia of Linnaeus,
which is lauded by the Egyptians ; the flowers of pathos, or cala-
mus aromaticus, by  the Malays.   The saffron  of  the Juddaea? is
highly  praised  in the  Ency. Methodique.   The seeds and leaves
of the hemp are in  great reputation with  the Turks and Indians,
combined with  musk, ambergris, and sugar.  The species amom-
um are  remarkably  aphrodisiac ; galanga, ginger, cardamon,  ze-
doary, curcuma,  and the maranta galanga, of Linnaeus, which
is extolled by the Egyptians.  The myristica are also included, as
pimenta, mace, canella, myrtle.  The Jews caused newly-married
persons to  repose on the  flowers of sage and marjoram ; and also
used embrocations of oil of spike.   We should  not  forget the
ginseng, celebrated by the Chinese, the betel of the Indian, and
the pepper, lauded by Tourtelle and Peyrilhe, or the opium  and
aromatics used by the Turks.   The  juniper-beiries, savine,  and 
272
GYNJECO-PATHOLOGY.
turpentine, have been  long  considered  aphrodisiac,  all of which
irritate the urethra and vaginal canal, as in leucorrhoea and  gonor-
rhoea.   Many animal substances have been praised by the ancients,
as the celebrated hypomane, which was nothing but the mucus, of
the vagina of the mare, which excited the stallion.   (Olivier de
Serres,  Theatre d'Agriculture.)—Castor,  ambergris,  musk, and
civet, are  also said to be of undoubted efficacy.   Prosper Alpinus
informs  us, that the women in his time rubbed the genital fissure
with ambergris  and musk, to reconcile the good graces of their
husbands.   (Med. Egypt, lib. iii. c. 15.)—There is also a species
of lizard,  used by the Egyptians, called by the  French  scinque
Marin,  the yellow amber, the ^cricket,  the ant, the spider, and
lytta, which the women of Kamtschatka devour to promote fecunda-
tion.  The use ofcantharides ought to be banished from medicine,
as it is a most violent poison, and it only causes priapism without
desire, or  violent strangury and inflammation of the bladder.  Pare
relates the case of an Abbe, who intended to be chevalier of Ve-
nus, and who had taken a  dose of this drug, which produced a mor-
tal  haematuria.   A cautious use of  this  medicine may produce
aphrodisiac effects.   The following formulae are lauded in France
as aphrodisiacs:
              Essentia Regalis.
           R. Ambrae Griseae, 2 scruples,
              Moschi, 1  scruple.
              Zibethi, \  scruple.
              Olei Canellae,
 Canellae,           > .  ,
-eLigno Rhodii,    \A droPs'
Carbonatis Potassae, \ ounce,
Tincturae Rosarum,
turae Rosarum,  >    ..
-Flor:  Aurant.  \ aa ** ounces'
  Solidis prius commixtis, dein immitantur olea, et denique tinc-
turae, stent in lagena bene obturata per  triduum illico coletur li-
quor, et hujus sumantur minima pauca in syrupo.
          R. Panacis quinque folii pulv. 5 ounces,
              Vanillae aromaticae, 10 ounces,
              Succini essentiae, \ scruple,
              Tincturae Lyttae, 5 ounces,
              Olei Canellae, 50 drops,
              Sacchari purificat.  lbx,
              Mucilaginis, q. s. 
TREATMENT OF IMPOTENCE.
273
  M. et divide in pastillos granorum xxivex his sumantur quatuor
singulis horis.
  The tincture of Magnanimity  of Dr. Virey is loudly extolled;
but I am unable to stale its composition.
  It is curious that many  inert substances have an effect on some
individuals, and will excite them  to venery, though inert on others;
those are the various vinous and  ardent liquors.  Bousquet never
took rice and milk without  much amorous propensities.
  Independently of the various alimentary and medicinal substan-
ces  now enumerated, there are others afforded by art and  instinct
which are originally preferred to all the drugs, as cold baths, erotic
lectures, voluptuous music, amorous prints, female society, nudity,
&c.   " Eh !" says  Bousquet, " quel homme resista jamais a la
vue d'un jolie sein ?"  What passion and sensation arises at the
sight of a lovely woman, a voluptuous  marble or  print!  When
all  these means fail, it is necessary to resort  to other  measures,
which  are thus described by our Gallic contemporaries : " II faut
en venir aux frictions, aux  attouchemens a l'excitations du mame-
lon, et des testicles, au chatouillement de la  peau des lombes, ou
de la partie  interne des cuisses, aux lavemens  acres, au ligatures,
au massage a l'emploi  de l'electricite et meme  de l'urtication, et
de la flagellation."
  Flagellation causes  powerful  erection, and this has been  long
observed when soldiers  underwent  such punishment.   Rousseau
was thus affected at his eighth year, which  was  observed by his
governess who never after punish him.  (Confessions.)  He as well
as Swift was impotent from bad habits acquired at school. Strangu-
lation is also an  excitant, and men have lost their lives by urging
it too far to gratify their  desires.  Such is  the  treatment of the
physical causes of impotence.   We next proceed to consider that
of the moral causes.

       Treatment of Impotence induced by Moral Causes.
  All  the depressing  passions  have great influence on the organs
of the body, and their removal often claims the attention of  the
physician.   The most frequent of these causes which impede the
generative act are chagrin and inquietude.   In such cases  we pre-
scribe  the consolations of friendship and those occupations which
divert  the mind, and to these we add the use of tonics.  Again,
we  know that ambition and jealousy have great influence on the
        3o 
274
GYNiECO-PATHOLOGF.
cerebral system, and often produce great activity in these and other
organs, and hence we prescribe light, nourishing nutriment, acidu-
lated drinks, a milk and vegetable diet,  and recommend less exer-
tion  of the  imagination, exercise almost to fatigue, and on no ac-
count the use of aphrodisiac remedies.
  The effects of the strong passions if prolonged, such as ambi-
tion, hatred, jealousy, will suddenly prostrate the genital faculty
in man ;  so also will too ardent desires, excited imagination, excess
of love, fear of not being loved, excessive modesty, and numerous
other sudden emotions of the  mind, will  suddenly destroy erec-
tion.  These causes are to be ascribed to irritability,  and are best
relieved  by tonics and  antispasmodics.  But what can we pre-
scribe, if impotence  arise from disgust, or physical imperfection in
the female ?
  Sterility  in Man.—It must be admitted by the best informed
physicians, that in most cases  it  is absolutely impossible to deter-
mine, during life, what are the causes which render man or woman
sterile.   The most common causes in the  former are immaturity
of age, excessive venery, or senescence, together with  defect of
harmony between the moral and physical states of  his constitution,
the frigidity or the  inordinate ardour of temperament;  and per-
haps these likewise apply to the other sex.
  It is only on dissection  we can be able to discover the physical
causes of sterility.  Then can  we  discover the absence of sper-
matic arteries, of the seminal  receptacles and their  appendages,
the  vasa deferentia,  &c.   The spermatic cords are often exten-
sively diseased.   The testicles may  be atrophied  or hypertrophi-
ed.  If the secretion of the  seminal fluid  be slow and imperfect,
as in weak, delicate habits, there will be more chance of fecundi-
ty than in strong and vigorous habits.   Similar  to the other se-
cretions in the economy, that  of the testicles may be increased or
diminished; and nothing is so prejudicial  to  its power as  its too
frequent  expulsion.  Thus we seldom  find  a man who performs
the sexual act oftener than once or  twice a-week have family  ;
and  this  fact we can readily understand, if we recollect  the doc-
trines of physiology.
  The fluid must be first secreted and next collected in the semi-
nal vesicles for some time, where its thinner parts are absorbed, be-
fore it is fit  for  its functions.  Hence the sudden secretion  and
sudden expulsion of it are injurious  to  the laws of the economy. 
CAUSES  OF STERILITY.
275
This accounts for the sterility of strong and healthy young married
persons, many cases of which have fallen under my own observation.
But as soon as such persons become less affectionate, and avail
themselves of occasional enjoyment, fecundation will readily hap-
pen.
   Again, we know that the male fluid is mixed  with  that of the
seminal receptacles and prostate gland during ejaculation, if already
too thin, will be so diluted as to render it unprolific.
   It is  a strange but certain fact, as yet  inexplicable  by the illu-
mination of  science, that those eunuchs  who have  no testicles
have amorous desires, and will perform the generative act.   They
have power of intromission and ejaculation, but the fluid expelled
is  merely the prostatic.   Even  the perversity of humanity profit-
ed by this circumstance, and women have frequently indulged their
passions with such persons, in ancient Germany  and  Rome,  be-
cause there was no  fear of impregnation, or as Juvenal  has it,
" quod abortivo non est opus."   Cannot we reproach  the women
of the  present age with something analogous, when we recollect
the wholesome precautions proposed by the disciples of Malthus
and  the French,  to frustrate  the end of marriage.   The  brutal
proposition of the  enemies of population  in this country, which
was propagated by a wretch upon whom legal vengence  has justly
fallen, cannot defeat generation.
   Zacchias maintained that marriage ought to be permitted to eu-
nuchs, as its  whole end is  not for propagation but for mutual atten-
tion and comfort.   And may we not fcontend it is  as proper for
such persons as for those impotent old men who embrace it on the
brink of the  grave.
   Sir A. Cooper  removed the testicle from a man on  whom he
had performed  a similar operation sometime previously, and  this
man had erections and emissions, accompanied by  the usual sen-
sation, for some, months afterwards.   (Work on Diseases of the
Testis, 1830.)
   The sultans seem good  physiologists, for they  cause the whole
external male appendages to  be removed prior to the  admission
of eunuchs into their harems.   This cruel and odious  operation is
fatal to every fourth person.
   With respect to sterility in females, we  are told by  medical au-
thorities there are thirty women in this condition to one man, and
this  on account of the  complication of the sexual  organs of the 
276
UYNJECO-PATHOLOGY.
former.   1 have already endeavoured to prove that this is a false
theory.
   When the physical causes of impotence do not exist in the ex-
ternal organs of the male,  we should recollect the many internal
causes which may account for  this condition.  Thus the diseases
of the vasa deferentia, the pressure of tumours of other parts on
their ducts, on the vesiculae seminales, the diseases of these recep-
tacles, hydatids, tumours, scirrhus, cancer, he., the diseases of the
prostate gland, enlargement, calculus, fungus, he., the diseases
about the neck of the bladder  and seminal  ducts, the calculus of
the latter, tumours, &c,  presence of stricture at the neck of the
bladder and in  the urethra,  diseases that are described in many
systematic works on surgery, but much more minutely in mono-
graphs on the respective organs.   There are some physical and
many moral differences  between  prolific  and sterile  individuals.
We find the latter distinguished by effeminacy, paleness, flaccidity
of the flesh, deficiency of beard, the hairs thin and lank on every
part of  the body, especially about the genitals, and the virile mem-
ber is remarkable for its  exiguity or smallness; the voice is sharp
and feminine, and never develops, as in strong and vigorous indi-
viduals.   It is also said such persons are pusillanimous, deceitful t
and perfidious;  but this does not apply to persons emasculated af-
ter puberty.  I mentioned  how the  testicles may be retained in
the  abdomen,  but  not  produce  impotence.  Bayle mentions  a
strange case of  this kind, which occurred in 1600.  A female ob-
tained a divorce before the Chamber of  Deputies in Paris, but the
husband alleged he was  capable of discharging his nuptial  duties,
and as a  positive  proof he proposed to perform his  operations be-
fore the Chamber.  The lady's modesty was shocked at the pro-
posal, and she fascinatingly replied, " Messieurs,  vous savez tres-
bein, que  les testicules  sont necessaires  pour ejaculer."—" Gen-
tlemen, you well know that testicles are necessary for ejaculation."
 She  obtained a divorce.   Even in 1665 the law of France re-
 quired both testicles to be  in the scrotum for the validity  of mar-
 riage.
   Rolfink relates a case  of  a  man whose testicles had never de-
 scended into the scrotum, and  who was a great  votary to  Venus,
 and a great favourite with the  other sex, as they feared no unpleas-
 ant consequences from connexion with him.   After death the tes- 
CAUSES OF  STERILITr.
277
tides were found at the abdominal rings. (De Part. Genit., part
i, c. 5.)
  Sterility in Females.—We  should consider  the causes which
impede impregnation, those which destroy conception the first few
days after impregnation, the causes which prevent  some women
from ever having children, and  those  which induce abortion, or
the premature  expulsion of the offspring.  The  whole of these
causes  maybe referred  to  three: 1st.  those depending on the
organs which receive the male fluid, as the vagina and uterus;
2d. the diseases of the  organs which further transmit it to the
ovaries, as the fallopian tubes;  and 3d. the diseases of the ovaries.
We have already  considered  the absence  and diseases of these
parts, as well as their excess or defect of function.  In fact, all the
morbid growths of these organs are causes of sterility. Fluor  albus
is the most frequent cause of the disease under  consideration, as
the male fluid is  too  much diluted  after its  effusion, and also is
seldom retained,  the  retentive faculty  of the  vagina and uterus
being lost.   I have known this occur to the finest  young lady I
have ever beheld.  Gonorrhoea acts in  the same  manner, as also
hydatids, in fact, all  secretions which inundate the  genital organs
and render them unfit to receive the principle of life communicated
during the generative  act.  Too frequent coition is the common
cause of fluor albus, or rather of an  increased mucus vaginal dis-
charge ; and hence we seldom  observe  prostitutes have offspring.
All acute diseases of the genital organs render the other sex barren,
and most of the chronic maladies produce the same  effect. Again,
certain changes of the  position of the uterus impede conception,
as  hernia, inversion, antiversion, retroversion, lateral obliquity, and
renversement,  or turning inside  out of the organ.  In  all such
cases the os  uteri will not be  presented to  the  penis ; but I am
strongly disposed  to think that  this is  not the real cause of sterility,
but the disorder of function, the pain, and  often  the disorganiza-
tion going on in the genital parts, as the prevailing theory of con-
ception now obtains, that absorption of the semen from the vaginal
surface is the true cause of fecundation.   The slightest penetra-
tion or intromission is sufficient for generation.
   But there may be an inertness  and frigidity in the uterus, and a
total disrelish  for the procreative act, even by well-formed, inte-
resting, and  lovely women.  I have been consulted in four remar-
kable cases of this description, and in all the subjects were  exces- 
278
GYN.KCO-PATH0L0GY.
sively vain of their personal appearance, and fond of admiration,
and having the strongest passion for dress and shew, but a complete
frigidity to venereal enjoyments.  They would  talk most ardently
of dress  during the conjugal act, and suffered it without the smal-
lest enjoyment.
  Fine women are generally fond of admiration and dress, and sel-
dom possess that desire so natural and common  to the sex.   Cor-
pulent females have also this inertness of the uterus, and seldom
bear children.  Impuberty is a cause of sterility ; although impreg-
nation has happened prior to the appearance of menstruation.  This
is an exception, however, to the general rule.
  On the  other  hand,  too much activity in the uterus is a pre-
ventive  to generation.   Thus excessive irritability, too ardent for
enjoyment, will derange the uterine functions; and hence our Gal-
lican neighbours assure us that spasmodic contraction of the uterus
will prevent the reception of the semen.   But here I may remark,
that in most cases there are no particular  sensations experienced
by  the female at  the time of conception ; and thus we can readi-
ly understand why so many of them mistake their reckoning, that
is, the period of pregnancy, which they often do, to the extent of
one or two months.
  The absence or obliteration of the  uterine tubes, or the attach-
ment of their extremities to  the uterus, is said to be a complete
barrier to conception,  examples of which I have observed ; but
this is a mere assumption, and requires further observation to con-
firm  its stability.
  The ovaries secrete a fluid  necessary to conception, and there-
fore the old opinion that females produced semen, is not so absurd
as might  be  imagined.   These organs may be affected with en-
largement, scirrhus, cancer, and encysted dropsy, atrophied, orhy-
pertrophied, as already described, and become useless.
  Again, we are informed by  Skenckius, that a Greek, being irri-
tated at the  prostitution of his daughter,  removed the ovaries by
the operation of spaying, by cutting through the abdomen. Women
thus treated are said to lose all the moral and physical feelings of the
sex, and assume those of the male ; the  voice becomes hoarse, beard
appears, the  mammae become  effaced, and even they have desire
for their own sex.   It is  also  well known that  females of inferior
animals assume the character  of the male when the  ovaries have
been removed. 
        HYGIENIC AND MORBID EFFECTS OF MARRIAGE.     279

   Treatment of Sterility in  Women.—If sterility depends on
the internal  diseases of the genital organs of either sex, it cannot
be cured, because during life it is impossible  to ascertain the cause
or even apply proper remedies.  Thus the uterus, tubes, and ova-
ries may be  wanting, or so diseased that no remedy can be of use.
Again, if the seminal vesicles or their tubes  be diseased, the case
is hopeless.   When a  frigid temperament is the cause, we should
have recourse  to those means of exciting love  which nature and
instinct teach the sexes.
   The general health  must be first attended to, and then that diet
and medicine employed which have been already described.  If
the simple fluor albus is the cause, and it generally is, it is to be
treated as already mentioned.   When excess of irritability of the
uterus is the cause, the exhibition of saline refrigerants and the
injection of  narcotics, as poppy, opium, and decoction of mallows,
will be used with advantage.  If it depends on  inertness of the
uterus, we have many remedies to propose,  as the aphrodisiacs al-
ready  enumerated, opiates and aromatics, or injection of tinctures
of assafoetida, castor, and amber into the uterus ; irritating pessa-
ries are also of great efficacy, and clysters of gratiola (hedge hys-
sop) are so  powerful as to excite temporary  nymphomania.  Those
means are more useful than the waters of the Nile, so lauded by
the Mussulmans, and absolutely imported into Toulon, by a  Cap-
tain Roustan, who was assailed by numbers  of females, who wish-
ed to purchase bis  provisions, and among the rest " the waters of
the Nile."  (Diet, des Sc. Med.)

   Section 2.—Hygienic and Morbid Effects of Marriage.
   At the age of puberty, young persons of  both  sexes experience
a train of new sensations  wholly  indefinable which induce an im-
perious and irresistible desire  for coition; a desire much more un-
governable  in the male, so that if coition does not take place, the
excessive activity of the generative organs induces unsolicited  emis-
sions of semen, especially during sleep, or the youth is misled by in-
stinct to deliver himself up to solitary manoeuvres—to onanism or
pollution. This unnatural resource supplies the place of coition, and
is even resorted by some  of the inferior animals. Nocturnal pollu-
tions are the result of an excited imagination, and are not injurious
to health, unless of too frequent occurrence.   Diurnal pollutions
are highly  injurious to health from  the frequency of repetition.

                                 v. 
280
GYNJECO-PATHOLOGY.
The truth of this position is manifest, if we only reflect upon  the
phenomena which occur at  the instant of coition, when the sensi-
tive action of the brain is carried to the highest degree of intensity.
The collapse which instantly supervenes on seminal emission,  ex-
tinguishes all desire of coition, in the same  manner  that hunger
ceases after a repast.  When  coition is precocious, or too  often
repeated, it exalts excitability of the whole  nervous  system, and
consequently of the whole body.   In the midst of this excessive
activity,  the slightest morbific cause  acts upon any of the impor-
tant viscera, developes a morbid irritation, which may be followed
by  great prostration,  convulsions, and even death, from the exci-
ted action of the brain.   This is the reason why coition excites
the nervous system, the  organs of respiration, and circulation, ex-
pedites the  flow  of  blood,  and aggravates chronic  diseases.   It
produces nervous excitement and consequent collapse or debility;
and hence  induces the  diseases of debility, or as they are called
the ataxic, and hence the danger of this debilitating cause to del-
icate persons, invalids, or convalescents.  It has been followed by
all  these acccidents when too much abused in old age, nay, it has
caused sudden death.
  There is  no acute or chronic disease which the abuse of coition
or frequent  pollutions do not  provoke, aggravate, or  renew: the
viscera of the head, chest,  and abdomen are powerfully affected;
diseases  of the lungs  and heart are developed, then those of the
brain and nervous system ; and,  finally,  those of the digestive
organs, and articulations.   These pathological remarks  accord
with the  general  phenomena which  manifest themselves before,
during, and  after  coition ; the heart palpitates violently, its impulse
is left over the whole side of the chest, and even in  the abdomen,
and the  action  of the  arteries, or, in  other  words, the pulse is
quickened in every part  of  the body.   We cannot  conceive that
this tumultuous  action of the  heart can be frequently repeated,
without producing different  diseases  of its tissue, both acute and
chronic,  diseases  which are in general irremediable.   The brain is
also highly excited, and reflects its action  on the chest and digestive
organs, and  not unfrequently produces convulsive or tetanic spasms
in every  muscle of the body.   During this time the respiration is
quick,  difficult, and nearly  suspended at the moment  of seminal
ejaculation.   This violent condition in which every organ  partici-
pates, is   followed  by a  depression or collapse more or less pro- 
        HYGIENIC AND MORBID EFFECTS OF MARRIAGE.     281

longed, or by the greatest debility.  It must be manifest to every
one of common comprehension, that the frequent repetition of this
violent commotion must be highly injurious to the faculties of mind
and body, while the physician must consider it as the cause  of an
immense number  of formidable and  incurable  diseases.   It has
long been observed that the bad effects of copulation are not so
great on  the other sex.   We cannot explain  the causes of this
difference, perhaps it is that man contributes most to the perpetu-
ation of the species.   Irritation, inflammation, and excoriation of
the sexual organs may arise  from  excessive  venery, as also leu-
corrhoea and urethritis, accompanied by simple gonorrhoea.
   It is a physiological axiom, that when an organ is  irritated or
inflamed, it affects all parts which are connected with it by nerves ;
and hence we can readily explain how excessive action or disorder
of the genital organs must affect all parts of the  body,  as all parts
are  intimately  connected with each  other by the cerebro-spinal
system, or by nerves.  In further illustration of this point, we may
state, that irritation, discharges, or ulcerations of  the genital mu-
cous membrane, may be  produced  by diseases of remote organs,
as the brain, chest, and  abdomen, as described  in the article on
Female  Violation.  We observe  the throat, the eyes, and  the
joints most commonly affected by metastasis, or sudden suppression
of the genital disease.   Here we  must recollect  the  change of
voice at  puberty, and the  momentary abolition of  vision  during
coition.  Amaurosis is induced by excessive venery, as exempli-
fied  in a case already narrated.  Again, the sympathy of mucous
membranes is universally admitted. When the mucous membrane
of the rectum is irritated by worms, there is itching  of the  nose ;
and  when that  of the cheeks or  gums are affected by dentition,
there is irritation  in the  genital portion  of the  same  tissue.  In
cases of cynanche parotidea or mumps, when the  swelling suddenly
subsides, the testicles become inflamed, and hence the application
of irritants to these organs for the cure of the disease. It is need-
less  to illustrate the universal sympathy which  exist between all
organs in the body, there can be no dissent upon the point.  From
the  preceding  statements, the inference  is manifest that coition
must have  the most powerful influence over the whole body, and
if carried to excess is  a fertile cause of an immense  number of
diseases.   On the other hand its moderate use is necessary  to the
preservation of health.   This is not the place to discuss its  influ-
         30 
282
GYNJCCO-PATHOLOGY.
ence in a moral, religious, or philosophic point of view, but merely
as a medical topic, that is to say, as relates to hygiene and patho-
logy, or as a means of preserving health or inducing disease.
   Let us now consider the influence  of continence upon health
and disease.   A moderate use of coition regulates the functions of
the brain or nervous system, and consequently of the whole  body.
Absolute continence or abstinence from venery in a healthy sub-
ject much disposed to it, induces many dangerous diseases, and
even death.   The venereal appetite is seated in the brain,  or ra-
ther in the cerebellum, and is excited by the reproductive organs,
and if  not  indulged, becomes greater and greater, and finally un-
governable, producing satyriasis,  priapism, and nymphomania,
which  are often instinctively obviated by masturbation.   If  not so
obviated, or by  nocturnal  pollutions, the morbid condition of the
brain deranges the functions of the organs of sense, as vision, hea-
ring, he., and of thought and volition,  and  hence hypochondria-
sis, mania, monomania, apoplexy, epilepsy, convulsions, hysteria,
and catalepsy, low fevers, disorder of the chest and abdomen, may
be  the results.  But  such effects are  seldom seen, inasmuch as
absolute incontinence is seldom  if ever  observed.  It is,  however
the ornament of virtuous  women,  and  is well exemplified by the
train of nervous and hysterical symptoms, which  render their lives
distressing  and uncomfortable.   Hysteria, in nine cases out of ten,
arises  from continence.   (Louyer-Villermay.   Traite  de Mai.
Nerv.) ; epilepsy arises from the same cause, (Haller, Buffon, Es-
quirol, Maisonneux,) and is cured by marriage, (Lauzonius,) and
it is also the commonest cause of insanity.   (Marc.  Gall, he.)—
It has  been held, that on the continent are  the most frequent sui-
cides.   Chaste women are most subject to  diseases of the womb,
(Gardien,  Bayle, Marc, Diet, des Sc. Med.) and cancer of the
breast  and womb are most common after the climacteric period,
when  women become useless  to the reproduction of the species
(Richerand, Nosog, Chir. Beatty, in Dub. Hosp. Rep. 1830, vol.
v. see Cancer,  p.  302) ; dropsy and scirrhus of the ovary arise
from the same cause. (Gardien, Sur les Acch.)
   Chaste people seldom live to  old age, (Hufeland Art of prolong-
ing Life ;  Buffon, Supplement  to Nat. Hist. torn, iv.; Deparcieux
on  Duration of  Human Life;  Hay garth, Phil. Trans.  58; Sin-
clair's Code of Health ; Fodere, art. Marriage, Diet des Sc. Med.)
The fact may be accounted for by the following causes, by  the 
        HYGIENIC AND MORBID EFFECTS OF MARRIAGE.     283

weariness and monotony of life, by the hatred of paternity, a right
so pleasant to married persons, and  by the certainty  of leaving
property to greedy, thankless relations, or friends.   Such persons
are subject to scrofulous enlargements  when  young, " which are
cured by the general excitation that coition occasions," (Richerand,
Op. Cit.) ; a fact also attested  by Wharton, who says, " Juvenus
ccelibes strumosi fiunt:  postea vero matrimonio sponte  curantur."
   The  old writers  considered marriage as the best means of pre-
venting diseases which arise from suppressed perspiration, as differ-
ent fevers, congestions, erysipelas,  gout, rheumatism, and numer-
ous other maladies.   It has been stated by Van Swieten and many
others, and observed by every attentive physician, that gouty per-
sons are addicted to venereal pleasures,  and here it appears  that
nature  points out a remedy ;  and Hoffman informs  us,  that this
disease  is unknown  among the Persians who obey the law of Ma-
homet, and consequently  are  not models of continence. " The
natural  state of man after puberty is marriage," according to  Buf-
fon ; for it certainly possesses great influence on morals, on popu-
lation, on  health, and on disease.   But granting all this, puberty
is not the  proper period for conjugal union, the sexual organs are
not sufficiently developed, and consequently the productive fluids
cannot be properly  elaborated, nor  possess the character of vitali-
ty.  The sexes at  this age would be unfit  to perform the various
important  duties of parents ; and hence the laws of  this and  most
civilized countries  have wisely prescribed a  certain  age as the
most proper  for marriage, and the real interests of  population,
which is the age  of twenty-one  years  for  males, and  eighteen
for females.   It must be admitted, that the sooner marriage is con-
tracted  after  these respective periods the better both for the par-
ties and their offsprings.  It removes a vast number of diseases in-
cidental to both sexes.   It is the best cure  for hysteria, according
to Hippocrates, Forestus, Hoffman, Reid, Boerhaave, Louyer-Vil-
lemay,  Esquirol,   Elliotson,  and many  others.  It removes  ame-
norhoea and ehlorosis, when all  other remedies have failed.   Ano-
ther  of its good effects is pregnancy, which  produces the happi-
est changes on woman ; because the determination of blood to the
uterus suspends, as if  by enchantment, a great variety of diseases,
by the  concentration  of vasoular and nervous actions, which arrests
irritation and morbid action in remote organs.   It arrests consump-
tion and hypochondriasis ;  it exempts the woman from contagious 
284
GYNJECO-PATHOLOGY.
diseases; it cures chronic affections, as hysteria, chorea, epilepsy,
mania, melancholy, ague, he.;  affords the greatest probability of
life (Hufeland,  Op.  Cit.) ;  and according to Sir John Sinclair,
women, though  exposed  to the innumerable dangers of delivery,
live generally longer  than those who are unmarried.
   It has been urged on the other side, that pregnancy predisposes
to a vast number of diseases, induces a host of moral and physical
evils, exposes woman to much  danger  during, at, and after deliv-
ery. These objections can only apply to women in crowded cities,
to the affluent, the subjects of luxury and effeminacy, who cannot
supply their fictitious wants, controul their passions, their wander-
ings of imaginations, or excesses of various kinds, which conspire
to injure or destroy the best constitution.  How much more happy
and fortunate are the inhabitants of the country, the poorest peas-
ants,  who experience no  danger during  pregnancy, or no alarm
during delivery.  It is known to all physicians who are versed in
the records of  obstetricity, that little solicitude  is entertained by
women in a state of natural simplicity for parturition, and this has
been amply attested  in the  article on  Tocology or Parturition.
It therefore follows, that pregnancy must  be  considered as a state
highly conducive to the health and happiness of women.   Never-
theless, marriage is not a universal panacea ;  it cannot be advised
indiscriminately  in all diseases, as it aggravates nearly all the nu-
merous disorganizations of the  uterus and  ovaries.  It ought to be
interdicted when obstacles exist to its consummation  in either sex.
Both parties  should be healthy : " for how can two  individuals,"
says Mahon, u be united by a contract which  exposes one to great
danger, and renders the other excusable in violating its condition?"
(Med. Leg.)—Should either labour under any serious disease, or
bad constitution, such conditions will, in  general, be aggravated;
the union will be unfruitful, or the offspring will be delicate, or of
short existance.  It has  been  maintained, that  persons  afflicted
with scrofula, epilepsy, and  consumption ought not  to enter into
marriage;  but the last disease  is the only one that can be deemed
hereditary, and from the evidence already  adduced, the others may
be cured by  this change  of life.   Those who labor under mental
imbecility  or mania, or who may be descended from parents cured
of these diseases,  ought to be advised  against conjugal union.
Women who labour under spinal curvature affecting the pelvis, and
inducing such deformity as must endanger the lives of themselves 
        HYGIENIC AND  MORBID EFFECTS OF MARRIAGE.      285

or their offspring, should be cautioned against entering into nuptial
engagements.   In all unfavourable cases, we should pronounce our
opinions with great caution and reserve ; we should not only  pos-
sess a knowledge of our  science but also that of the human heart,
and recollect that we touch  a  delicate cord of affection and  pas-
sions, which  obliges us to forget a purely physical medicine, or
rather to combine it with moral medicine,  this medicine  of the
heart and brain,  so well known to  all enlightened and scientific
practitioners. We have to bear in mind, the  rights of nature, mor-
als, religion, and medicine.
   When we consider the influence of morals and vicious habits
upon youth after the age of puberty, it is manifest that  conjugal
union should be effected at the time allowed by the laws, and
thus the ruin of fortune and health would be frequently avoided.
Debauchery and dissipation affect the offspring, and render it  deli-
cate and unhealthy.  The ancient  nobles of France fell into the
opposite extreme, and for the  extinction of their families, married
their sons when children.  Precocious or late marriages are  inju-
rious to reproduction.
   Every disproportion in the age of the married is incompatible
with a good union,  old men espousing young women,  and young
men espousing  old  women.  Such unions are contrary to  the mo-
ral and physical states of mankind.  So also when  either party  is
unhealthy, and labours  under any  serious chronic disease.   It  is
admitted by physiologists, that the genital faculties  will vary ac-
cording to various circumstances, as age, temperament, habit, diet,
occupation, climate and  season.   A few words may be said  in il-
lustration of each of these points.
   When the  lymphatic system  predominates, the individual  is
pale, of a relaxed, flabby spare habit of body, with  white  hair,
pale round lips, large blue languishing eyes, the sanguineous ves-
sels are not developed,  the pulse is slow and feeble, the character
gentle, affable  bordering on silliness;  this is called the lymphatic
temperament.   With such  subjects, there is an inertness of the
genital apparatus, and they beget  feeble, delicate infants.
   The bilious  temperament is  characterized  by a predominance of
the vascular over the lymphatic system, a dry spare habit, brown
skin tinged with yellow, black curled hair, superficial veins full
and large. Such a  person is much given to love and jealousy, and
ought not to  marry an  individual of the same temperament,  as 
286
GYNJEC0-PATH0L0GY.
their physical and moral  happiness would be much  endangered;
but if he marries a woman of a sanguineous temperament, he will
enjoy with her happiness, and a numerous posterity.
   The melancholic temperament is said to depend on the abdomi-
nal viscera, and the modification of the  bilious  temperament.   It
is  characterized by sadness and melancholy.  Love is a means of
secondary ambition with  the subjects of it.
   When the  vascular system predominates, the individual is of the
sanguineous temperament, his health is good, his pulse strong, his
body symmetrical, his hair sandy, his mind and  body are vigorous,
he is much addicted to venereal pleasure.
   The nervous temperament is characterized by an increased sus-
ceptibility, a  great vivacity in sensation,  an extreme promtitude in
judgment, a  precipitate and inconstant determination, a vivid im-
agination, a fickle disposition.
   This predominance of the nervous system is often  united to the
sanguine temperament, and then the character is impetuous, has-
ty, violent; a person so constituted offers the greatest  persistance
in  his resolutions.   Such persons are capable of great amorous ex-
cesses.
   The muscular or athletic temperament may or may not be cha-
racterized as  that which  is just described.   These different tem-
peraments may be combined in various  degrees, so that it is diffi-
cult to trace them in a large majority of cases.  M. Halle describes
a  temperament,  which he  denominates the genital, which is
characterized by an excess of susceptibility of the sexual organs,
by a violence of  venereal  appetite which  constitutes  an innate,
imperious, and irresistible desire, associated with an intense colour
of the skin, of the  eyes  and  hair, and  a peculiar odour.   These
men are ardent, covered  with black hair, and  seem only to live for
the purpose of communicating their existence; the genital force
is  in excess, and may be, in some measure, abated by anaphrodisi-
ac remedies.
   From what has been said in the Physiological part of this work,
it appears that age, season,  and climate have great  influence on
reproduction  (see p. 61.)  It is true, that man in a state of health,
may propagate his species at all seasons and at  all times: but still
it  has been observed, from time immemorial, that with  the majori-
ty of individuals,  certain  seasons of the  year, and moments of the
day, are more favorable than others for sensual enjoyment.   Hip- 
         HYGIENIC AND MORBID EFFECTS OF MARRIAGE.     287

pocrates said, spring was the season most favorable for conception ;
Pliny called it the genital season.  The purity of the air, the fresh-
ness of aliment, the bracing effects of temperature, all conspire to
the improvement of the functions of the body, the maintenance of
health, and conservation of the species.   At this season animals
and vegetables reproduce, all animated nature is excited; and re-
peated observation has  demonstrated  that  there  are more infants
born in December and  January than in any of the other months.
Though  averse to the citation of the Sacred Writings in  support
of science, we may allude to the conception of the Virgin in March,
and the birth of the Saviour in  December.   Summer is not so fa-
vorable for the exercise of the genital functions; the  excessive
heat induces  perspiration and  debility, and enfeebles  the whole
body.   Persons of the lymphatic temperament are more disposed
to love in this than in any other season of the year.
   Autumn is  still more unfavorable to reproduction, as the func-
tions of the body are  readily deranged by  the sudden vicissitudes
of the atmosphere; cholera, dysentery, and ague, are suddenly
produced, and it is held this season is the most inimical to the ex-
ercise of conjugal rights.   Winter, from its coldness, is also unfa-
vorable to reproduction; we have  only to refer to the animal and
vegetable kingdoms for  attestion of the fact.
   " Morning," says M. Virey,  " is the spring of the journey;" it
is the matinal sleep, which causes voluptuous illusions;  it is  the
morning in  which  all the functions of the  body  are renovated.
" Behold the reasons,"  says he, " which ought to engage us to
chose this time to contribute to the conservation of the species, af-
ter having contributed to the  health of the  individual.  All  the
senses enjoy  the plenitude of their functions  during the day, and
this time offers moments favorable to love."   But it must not be
after a repast, as  nothing  deranges the  functions of the stomach
more than coition.  The  process  of digestion  must be  finished;
and this is  not completed for three  or four  hours after a meal.
However plausible and  forcible  these observations appear, it must
be admitted that night is as  favourable as the other times of the
day to amorous impulse.  Allusion has been made in the  course
of these remarks to the ill consequences of excess of venereal plea-
sure ; nothing, I repeat, is more injurious to the well-being of mind
and body, nothing so likely to produce  impotence and sterility,
and want of family.  Nothing more effectually preserves the  con- 
288
GYN.ffiC0-PATH0L0GY.
jugal union than the birth of an infant; the happiness of the pa-
rents is increased, when they see themselves revived in their in-
fants;  their mutual love receives a new impulse ; the cords which
bind their family  connections are strengthened; little else is want-
ed to complete domestic  happiness.   Those, on the contrary, who
are not blessed with children, experience daily a diminution of af-
fection ;  a vague  inquietude agitates  them ; they are sad, and anx-
iously  seek the cause of their infecundity ;  apply to medical  men
for advice and assistance, or too often violate conjugal fidelity.
  The first object of such persons should be to endeavour  to  dis-
cover the cause of infertility, among those of impotence and ster-
ility, many of which are curable by the remedies already described
in the course of this article.   They are to avoid those obstacles to
conception which have been  enumerated, such as long abstinence,
insufficient nutriment, excessive corporeal or mental  exertion, an
inactive, voluptuous  life, too frequent  repetition of the conjugal
act, and  they must use some  of those aphrodisiac remedies, an
account of which  is to be found in this article.
  They must refrain from copulation during the presence of men-
struation, and employ it moderately during pregnancy, as nothing
is more likely to induce abortion. They must also attend to those
circumstances which are favourable to conception, as for example,
1. the  use of abundant nourishment,  for years of prosperity always
augment the  number of births ; 2.  the  use of certain  aliments,
which  experience has led them  to discover as excitants  of love, as
certain foods  already enumerated ; certain  fishes, and buckwheat,
are said to render the inhabitants of Cologne prodigiously prolific;
3. change of habitation, when  practicable, as residence seems to
have great effect; for example, the inhabitants of Ireland have
twelve or fifteen  children, the Germans five or six, the French
four  or five, the Spaniards two  or three; 4. abstinence from  the
conjugal act for some days ; 5. and coition should take  place  im-
mediately after the cessation  of menstruation ; this was the advice
given by Fernel,  the physician  to Henry III., whose  queen, Ca-
therine de Medicis, had not conceived till  it was followed.  It is
said  that the equinoxes are more favorable to conception than the
solstices, and that the autumnal months are the most unfavorable
for propagation.   It is always to be  remembered,  that coition is
only to take place as often as the genital organs manifest their en-
ergy, which must depend upon  idiosyncrasy or peculiarity of habit, 
        HYGIENIC AND MORBID EFFECTS OF MARRIAGE.      289

mode of life, and locality, diet, habits, and  various circumstances
already detailed.   Finally, it cannot be prolific unless  employed
at the intervals of some days.   I cannot conclude this article with-
out inserting the valuable and  interesting remarks on this subject
by my distinguished correspondent, Professor Dewees, of Phila-
delphia, which deserve great attention.  His chapter on Marriage,
in his excellent Treatise on  the  Physical and Medical Treatment
of Children, is so replete with sound sense, and really scientific
views, that I cannot refrain from quoting it  in full, as it corrobo-
rates  the opinions I have recorded  in the preceding  pages.   He
considers the subject of marriage under  the following heads :  1.
the most proper period for its consummation ; 2. the constitution  •
3. the disposition  to disease ; 4.  the immediate state of health.
   Period of Life.—It is notorious, that the development of body
is successive, and requires a certain period for its completion ; con-
sequently that certain functions  cannot be performed in their best
manner until the body  has acquired its full development; this rule
applies as well to the  female as the male.   It is also  familiar to
observation, that when any function is prematurely urged, it leads
to the imperfection of the product  dependant upon that  function,
as well as entails upon the part  so  exercised, debility and prema-
ture decay.
   From this it will follow, that  too early marriage is never to be
advocated, since it will materially influence the health and well-
being of offspring.  This fact is no less conspicuous in  the inferi-
or animals, than  it is  certain in  its consequences  in man.  We
would therefore not only say that marriage  should not take place
until the  body is healthily and completely developed, but also that
there should have been, on the part of the male, the most scrupu-
lous continency, that  the great object of marriage (the propaga-
tion of health) children)  should not be defeated ; this cannot  be
too strongly insisted upon.  The  female is always supposed  to
be so.
   It  would be  difficult rigorously  to fix the period, by years, at
which the body becomes fully expanded, since original stamina,
physical and moral education, climate, mode of life, he. will have
their influence ; but we may with much certainty fix it in this  cli-
mate  at  between  the twenty-third and twenty-fifth years, for the
male, and from the nineteenth to the twenty-first years,  for the fe-
male.   We are  informed  by Tacitus, that the ancient Germans
        37 
290
GYNvECO-PATIIOLOGY.
never married until the twenty-fourth or twenty-fifth year of their
age, and were as continent  before that consummation as the fe-
males to whom they were united; in consequence of which they
acquired a size and strength that excited the astonishment of even
the Romans.
   It has frequently  excited the surprise, as well as provoked the
reproach of foreigners, that the  females  in this country lose their
beauty  so  early,  especially  when  compared with the females of
Europe, and particularly those of Great Britain.  The cause of
this hasty decay must be principally sought for in our very early,
or rather premature marriages, but we confess that climate has also
a limited agency ; and though we are far from discouraging early
marriages, yet we are decidedly against premature ones.  By early
marriage we would wish  to be understood such as may take place
so soon  as the body has received its first expansion ; and that time
we have just fixed, as a  general rule, at nineteen or a little more,
for the  female, and twenty-three and a little upwards, for the male.
By premature ones we mean those which happen before the system
has received its ultimate  development.
   It will readily be  seen that  no precise or absolute  rule, based
upon the lapse of  years, can be laid down, since  the bodies of both
males and females may be precociously expanded, or may be pre-
ternaturally retarded.  In the first instance, the period we have as-
signed  may be anticipated with  safety, but in the second it would
be wise to extend it.  Thus, in India, females become mothers of-
tentimes at ten, while in Lapland they rarely give evidence of wo-
manhood until eighteen ; consequently the women of India would
be on the wane did they wait  for the  limit at which it would be
proper  for a Lapland woman to marry ; and the Lapland woman
could not  support  the contingencies of marriage did she attempt
to regulate it by  the usage of India.
   The  examples of the evils resulting from precocious unions in
this country are familiar to every body ;  they are not limited to the
diminished vigour and shortened life  of  the male, nor to the faded
beauty, the blasted  health, and the  premature old age of the fe-
male ;  for they are  extended to their unhappy offspring, on whom
they have perhaps entailed a diminutive stature,  debility of body,
and imbecility of mind ;  or have handed down to them strong pre-
disposition to consumption,  rickets, scrofula, &.c.  It is therefore
of the utmost consequence that parents do not consign their chil- 
          HYGIENIC AND MORBID EFFECTS OF MARRIAGE.     291

 dren  to  inevitable  ill  health, by consenting, or sometimes by ur-
 ging them to too early marriages;  and on the part of the children
 themselves, that they do not yield themselves up to almost inevi-
 table destruction (especially the female), by anticipating the eligi-
 ble moment for marriage consummation.
    We are, however, strong advocates for early marriages (agreea-
 ble to our definition  of them) ; we are persuaded of the  impor-
 tance of both their moral and political tendency, and we think
 they  should . ever be  encouraged wherever there is a rational ex-
 pectation of both these great ends being answered.
    The consequences of ill-assorted marriages were well known to
 the ancients,  and were strictly forbidden by the  Greek legislators;
 and though things have not proceeded to such lengths in this coun-
 try, as to  require  the interference of the laws, it is nevertheless
 sufficiently  common,  to make  a  caution upon  the point proper.
 Should no attention be paid to compatibility, the obvious and most
 desirable objects of marriage will be defeated, and one great source
 of health and longevity destroyed; for it is a fact, no less impor-
 tant than well  established, that a well regulated marriage contri-
 butes largely to these two great ends.  It is declared by Hufeland,
 that all those  who have attained great age were married even more
 than once,  and generally at a late period of life, and that there is
 no instance of a  bachelor attaining a great age.  We may give
 two remarkable  instances of  longevity,  where marriage was often
 repeated ; one in Thomas Parr, of  England,  who attained to one
 hundred and fifty-two years, and was married several years; and the
 other  in De Longville, of France, who lived until he was one hun-
 dred and ten  years old, and married  ten wives; his last  he mar-
 ried in his ninety-ninth year, and she bore him a son when he was
 in his hundred and first.
   It would seem to be agreeable to all observation, that better con-
 stitutions  are  perpetuated to offspring by  men advanced in life,
 where the physical powers have been well preserved by moderate
 and proper use, than by young men who have been prodigal of them ;
 for it is oftentimes better to be old in years than in constitution.
   Though we have said  that  men advanced  in  life may have
 healthier offspring than the man who too early attests his prowess,
 or the  one  who has been too  prodigal of his  powers, we  are not
 advocates  for  the union of old age to blooming youth.  On the
contrary,  we are entirely convinced  that none so completely fulfil 
292
GYNiECO-PATHOLOGY.
their  duties to society as those who unite themselves so soon as
the proper development of body  and well-established health  will
justify their union.   Yet we are equally persuaded of the truth of
what we have just observed, namely, that a man advanced in years
may have every requisite firmness of constitution to  justify a un-
ion ; while  a  young  man, who may have a natural  feebleness of
constitution, a strong predisposition to disease, or its actual exis-
tence, or a debility  from overtaxed powers,  may be altogether
ineligible to it.
   Of Consumption.—It is not alone sufficient for the best  pur-
poses of marriage that the body has received its final development,
either on the part of the male or the female, since all  the functions
of the body may be  disturbed, by  either feeble organization,  dis-
ease, or accident.   When, then, the  male or  female, or  either,
has suffered in constitution,  it is not to be expected they  can
impart to offspring that which they themselves  do not possess.  It
should therefore always be a consideration in a marriage contract
that both parties be of sound health and constitution.
   We are  aware it  may be said, in  many  instances, that hale,
healthy-looking children  belong to people of feeble  constitution ;
but we must be cautious  how we admit this, as militating  against
our position, since such appearances are by no means conclusive
of the good health  or the soundness  of constitution.  We have
many times spen children of robust  appearance from parents of
feeble health;  but we do  not  recollect a single  instance  where
such children attained an age much beyond manhood, old age was
out of the  question.   Indeed it  would seem,  in many instances,
that children of such  parents  most  frequently give an early pro-
mise of future  health ; but it  is illusory, for it is never,  or  but
very rarely, realized.  In the early part of the lives of the chil-
dren of whom  we are now speaking, a rapid, but morbid, develop-
ment of the body takes  place, every function  is inordinately per-
formed ; and when  the  constitution is confirmed in  appearance
by such a display of  health, it is but hastening to decay.   Let us
not, then, be  deceived by such appearances; and  when  we are
making a choice for our children, let us choose such as  give a
rational reliance upon the soundness of their constitution.
   Predisposition to  Disease.—There  are numerous diseases, or
rather a disposition  to them, which do  not  show  themselves for
many years after birth, or until they are called  into action by some
exciting cause, suddenly or gradually applied,  such as gout,  mad- 
        HYGIENIC AND MORBID EFFECTS OF MARRIAGE.       293

ness, scrofula, consumption,  he.   Those who  may  inherit such
predispositions may  for many years enjoy good  health,  and may
not be led to suspect any cause to be lurking  in their systems,
which, when called  into action, shall  but too soon  destroy such
flattering expectations.   It therefore  becomes a point of  duty in
parents to investigate the tendency to hereditary complaints, be-
fore they connect their children with  those who can give but a
temporary security  against the most painful, afflicting, irremedia-
ble, or suddenly fatal diseases.
   We hold it selfish, at  least,  if not  dishonest, for either sex to
marry under such predispositions, when,  from the knowledge of
the diseases of their forefathers, there was  every reason to antici-
pate a perpetuation  of them.   Who  has not witnessed the most
deplorable consequences  of such unions ; and who, after witnessing
them, would not deprecate their continuance, or further propaga-
tion ?  This  subject is one of much importance, for  some of the
best interests of society are involved in it;  and  every one  is  con-
cerned in diminishing the evils spoken of, by preventing marriages
which can promise  nothing but the extension of the most dreadful
diseases.  We  have seen but too many  instances of the  perpetua-
tion of each of the diseases above enumerated, not to feel interest-
ed in arresting them, by  recommending  the two only means by
which they  can be  either prevented or mitigated, namely,  by judi-
cious and well-assorted marriages, and a well-conducted physical
education.
   By the first means we may stop, in a great measure, the heredi-
tary transmission of predisposition, by selecting such subjects as
shall  be free from constitutional taint; or at least we may dimin-
ish, by  this  plan, the risk of such  occurrence, if we cannot ensure
exemption from it.   We may also do much good  by preventing
the union altogether of such as may have these tendencies; or di-
minish  the evils in  a degree, when no better can be done, of not
admitting to this union more than  one of the party who may have
hereditary taints.
   Bv the second, much may be effected by invigorating the sys-
tem in  general, so  as to  render it less susceptible to exciting cau-
ses ;  by attention,  while conducting this education, to strengthen
the particular parts which may be predisposed to disease.   But of
this more by and by.
   Of the Immediate State of Health.—By the immediate or ac- 
294
GYNJECO-PATHOL0GY.
 tual state of health, we would wish to be  understood that condi.
 tion of the system  in which  either of the above-named diseases is
 absolutely developed.   It might at first sight  appear strange that
 we should notice this change of the system, as every one would
 seem to be apprized of it, and consequently the person labouring
 under it would not be considered eligible by any one for the mar-
 ried state.  But this is not exactly so, as we find that every kind
 of artifice is  resorted to, to hide their  condition from those the
 most interested in  the  knowledge of it, hence the frequency of
 marriages under such circumstances.
   Besides, it but too  frequently happens that this foreknowledge
 is entirely  disregarded  by the persons  most  concerned.  This
 may  arise from several  causes;  1st, to a want of proper feel-
 ing for the consequences of such diseases, when extented to off-
 spring ;  2d, to a hope of an escape  from their consequences, as
 sometimes happens;  3d, to an ignorance of their nature, and of
 the  risk of their propagation ; 4th, to a disgraceful selfishness,
 where fortune or beauty is concerned.
   In Europe they  have such dread of the  perpetuation of these
 diseases (with perhaps the exception of gout,) that the  inquiry is
 frequently made in the higher ranks of society whether either of
 these diseases is actually existing, or whether the parties are liable
 to them by  hereditary descent, before the  marriage contract is
 signed;  and we are informed that marriages have been  frequently
 broken off, and even at a late period, when it  was discovered, on
 the side of either  party, that scrofula, consumption, or madness
 had existed, or was actually existing, in any member of the family.
   It is not, however, predisposition to disease, or its actual exist-
 ence, that exclusively disqualifies the parties for marriage, or that
 may entail feebleness of body or mind  upon  offspring,  for there
 are others equally certain, though less notorious to common  ob-
 servation ;  such are the habits of general dissipation and habitual
 intoxication.   The first appears to have most effect upon the bo-
 dy, the latter upon the mind ; therefore a woman would not unite
 herself to a man who labours under either, if it be known ; and the
 laws should protect her by granting a divorce, if it occur after.
   In this country the vice of intoxication is more common than
 the other ;  but unfortunately for the poor woman it but too often
occurs only after marriage, and against this the law makes no pro-
vision ;  she is then  doomed, in her own person, to all the  horrors 
        HYGIENIC AND MORBID EFFECTS OF MARRIAGE.      295

which await the vice, and her children are to be the inheritors of
feeble constitutions, or what is perhaps worse, the  predisposition
to derangement of mind.
   On the part of the female, certain physical disabilities may ex-
ist, which would render her  ineligible for the married state;  these
should neither be concealed nor passed over slightly, since with a
knowledge of them,  it   would be dishonest  towards the  man
she  may marry, as well  as fatal  to herself.   We would there-
fore recommend to a woman who  may be deformed, to abstain
from marriage, as she may purchase the title of wife at too high a
price ;  and we would advise such  as may be disposed to cancerous
affections, or  such  as  may have one  in an active state, to refrain
from this state, as she can promise  herself nothing,  as regards  her
disease, from this ceremony ;  for with  it she must  linger  through
continued ill-health and pain, and inevitably become a source of
misery and expense to her husband, whose patience and resources
may be  but  too  easily exhausted, and  she fall an earlier victim
than from disease alone.
   We would also recommend the female not to put off this cere-
mony to too late  a  period of her  life,  when she can with propriety
do otherwise,  unless she   be content to  endure  more than ordinary
suffering from child-bearing,  as well  as become regardless of the
pleasure of seeing her children settled in life before she leaves the
world, by  even the common contingency of age.   Women who
have passed the thirty-fifth  year of life, might perhaps do best by
submitting to  farther procrastination, that the period of child-bear-
ing might be past.
   Upon the same  principle, in part, would we caution  the very
'young girl not to enter into this state, as she, like the woman who
has waited too long, is liable to severe suffering from labour.   In
the woman too far  advanced, the  parts concerned  in  parturition
seem to  have  forgotten, in a degree, their offices; while in the  too
young female, they have not entirely  or perfectly acquired the ca-
pacity.  These facts are too well known to be disputed; and  na-
ture seems to have contended for  prerogative in  both instances.
Shall  we then  become   voluntarily blind by  shutting our eyes
against her obvious intentions?   Do  not these facts emphatically
declare,  there is a  time  best  fitted for  marriage ?   This time  we
shall fix  at nineteen for the earliest,  and five-and-twenty  for   the
latest,  best periods. 
296
GYN^CO-PATHOLOGY.
   We do not, however, mean to say the period fixed  for the ear-
 liest may not without much risk be anticipated a little, or that the
 second may not safely be exceeded;  we  mean merely to insist,
 that the  periods just  designated are best as general rules, for it is
 but general rules we can lay  down upon this subject.

 Article III.—Encyonosology—On Diseases of Pregnancy.
   Although pregnancy  is  a natural condition, it frequently ex-
 cites considerable derangement in the  functions and organs of the
 human female.  These sensations are  considered signs of concep-
 tion in the first weeks of gestation, but  soon  become so trouble-
 some,  as to be  actual disorders.   The new  action  which  takes
 place in  the womb, and its appendages, is a  cause of  irritation,
 which extends to all the organs that have much sympathy with the
 affected parts.  Thus we know from physiology, that the womb and
 stomach  have  a strong  sympathy ; and that  the latter strongly
 sympathizes with the brain  and  nervous system; and  thus with
 every  organ  in  the body.   The  cerebrospinal system  of nerves
 very clearly accounts  for this universal sympathy between all parts
 of the body.  The consent or sympathy between the womb and
 stomach  is great; and hence we often find nausea, vomiting, heart-
 burn, loss of appetite, indigestion, arise  after conception, and are
 considered symptomatic  of this  condition.  The  breasts are inti-
 mately connected by  sympathy with the womb, and therefore be-
 come irritable  and enlarged, after  pregnancy—states  strongly in-
 dicative of it.   The irritation of the stomach  will speedily affect
 the  brain;  hence  we  find  slight pain in  the  head,  dizziness,
 drowsiness, convulsions, palsy, palpitation of the heart, toothache,
 dimness of the sight, impaired hearing, and deranged condition of
 the tongue,  and often induced by pregnancy.  The  uterus will
also affect the  intestinal canal, cause diarrhoea or costiveness; will
affect the rectum and  bladder, and often  induce strangury, heat in
 passing water,  and  tenesmus.—These sympathetic actions occur
soon after conception, continue till quickening, and gradually abate
and disappear towards the  latter months of  pregnancy.  They
sometimes,  however,  continue to the end of  gestation.   It is a
popular observation,  confirmed by experience, that women  who
are most sick, are the most unlikely to miscarry.
  From what  has been already stated, it appears that conception
is followed by considerable changes in  both mind and body.  The 
DISEASES OF PREGNANCY.
297
pregnant woman is more easily excited, and  more susceptible  of
impressions.  The vascular and nervous systems become excited •
and consequently all stimulants should  be avoided.   The diseases
of the pregnant state may be referred to irritability of the nervous
and derangement of  the  vascular systems, or to pressure of the
impregnated womb on the contiguous organs.   Some women have
better  health during pregnancy  than  at any  other time ;  while
otherssufferseverely to the moment of their delivery.   The diseases
of pregnancy may be divided into those of the early, and those of the
latter months.  The first class comprehends affections of the stomach,
as nausea, vomiting, indigestion, heartburn,and water-brash. The dis-
eases of the latter months of pregnancy are a febrile state, costi veness,
collections of faeces in the bowels, piles, spasm of the stomach and
duodenum, jaundice, gripings, dysentery,  tenesmus, diarrhoea,  or
looseness, heat and pain in passing water,  incontinence  of urine,
various affections of the bladder,  spasm of the ureter and uterus,
cramps and numbness of the lower extremities, varices of the legs
thighs, and abdomen, oedema, or dropsical swelling of  the legs,
want of sleep, solicitude,  anxiety and dispondency,  headache,
toothache, drowsiness, vertigo or giddiness,  cough, difficult breath-
ing,  palpitation, spitting of blood, dropsy,  either anasarca or as-
cites, inflamed breast, flatulence,  distension of the abdomen, pen-
dulous abdomen,  venereal disease, pruritus, or intolerable itching,
fluor albus, prolapsion, retroversion, antiversion, and obliquities of
the womb, abortion, flooding or uterine haemorrhage,  and false
pains ;  of the greater number of  these diseases, I have  treated al-
ready  in  the  Chapter  Parthenosology, and  shall now consider
those which belong peculiarly to  the pregnant state.
   Digestion.—The appetite and taste  are altered by pregnancy,
and  the vulgar attach great importance to the  gratification of these
different tastes;  but they are only to be gratified when nutritious
food is desired, and not when resulting from caprice, or a depraved
palate.   A voracious appetite may be  gratified by a proper quan-
tity of food, not given to satiety ; a variable appetite may be sat-
isfied by frequent light repasts; and a  diminished appetite by that
food the woman may desire.  All strong liquors are to be avoided;
they excite the  vascular and  nervous systems.  The diet should
be nutritious, and easy of digestion, and not increased on account
of the infant.   All  powerful mental andi bodily exertions are to be
         38 
298
GYNiECO-I'ATHOLOGY.
  avoided ; but regular and  moderate exercise on foot may be used
  with advantage.
     Nausea and vomiting are the  first diseases of pregnancy, the
  appetite is vigorous; and the sickness is more troublesome in the
  morning, when the woman assumes the erect posture,  as the en-
  larged womb presses downwards, causes irritation, and sympathetic
  action.
     The  best treatment for  nausea and vomiting, is the effervescing
  draught with tincture of opium, in the proportion of  six  ounces
  of the first, and one drachm of the second.   The various sedative
  preparations of opium, as  morphine, sedative liquor, or solid opium
  are used with  advantage.   Opiate frictions  to the  stomach will
  succeed, when every other remedy fails.   I have also used  an opi-
  ate  plaster  with advantage.   The tincture  of soap and  opium,
  with an additional quantity of the latter, may be  rubbed  on the
  stomach frequently during the day.   Sometimes cold water alone
  will procure relief.  Dewees found twenty drops of  oil of turpen-
  tine in  a glass of water, two or  three times a-day, succeed, when
* every thing else had failed.   The turpentine might be  mixed  in
  the  form of emulsion, and sweetened with honey.   This vomiting
  seldom causes abortion, and yet artificial  vomiting  often  does.   It
  sometimes continues during the whole period of pregnancy, in de-
  spite of all remedies.   Sims and Lorenzt  used leeches  with suc-
  cess ; others recommend blisters.   " In some bad  cases," Con-
   quest states that" premature labour must be  effected artificially, as
  essential to the  safety of such  women."  Vegetable bitters, as in-
  fusion of calumba with soda, may be given in a state of efferves-
  cence ; but if the vomiting be unrelieved, it may be necessary to.
  support the strength, by  nutritious clysters.   Burns strongly re-
  commends blood-letting in preference to all other remedies in cases
  of vomiting, and  says all other remedies may fail without  it.
     Depraved  appetite, indigestion, waterbrash, or acidity of the
   stomach, are to be relieved in the usual manner.   Bitter infusions,
   with soda, potass, or liquor of pure ammonia; liquor calcis (six oun-
   ces) liquor of potass (two drachms); a table spoonful frequently in
   the day have been used with advantage. Duges informs us that chronic
   gastritis may arise during pregnancy, from the state of the stomach
   under consideration.   The bowels are to be regulated  by the form
   of medicine mentioned for costiveness.   Lime-water mixed with
   milk and calcined magnesia, a quartern of  each of the two first, 
DISEASES OF PREGNANCY.
299
and a tea-spoonful of the last, might be given in acidity, with the
greatest benefit.   Baillie found  the mineral acids of more use in
this complaint than the alkalies; while Dewees  prefers vegetable
acids, as lemon juice.   One lady took a dozen  of lemons  daily,
and no other food or drink.   He also advises clove tea, as almost
infallible: twenty cloves to be infused in half a pint of boiling
water.  These disorders may be more urgent during the first, than
in any subsequent pregnancy, and, vomiting has been more severe
when the woman carried a male than a female.   Although it may
continue the whole time to delivery, the infant is generally healthy.
   Cardialgia or heartburn, is often a troublesome affection. The
sensation of heat proceeds  from the stomach to  the throat,  and is
extremely unpleasant.   The alkalies, as soda, potass, effervescing
draughts, lime-water,  chalkr may  or  may not afford relief.   De-
wees had a  patient, who lived nearly on chalk during pregnancy.
She used three  pecks  and  a half.  She became as white as the
substance itself,  and prematurely sunk from her disease.   He re-
commends aperient pills, each or every  other night.  Sims and
Denman praise the following mixture:
           R. Aquae distillatae, five ounces.
              Liquoris Ammoniae. )        ,   ,
              ^.x       ~ . .      \ aa one drachm.
              Magnesias Calcin.    $
              Aq. Cinnamomi, one ounce.
   Misce, Sumat cochlearia duo ampla saepe in die.
   I have found  the following mixture of great service :
           R. Liquoris Calcis, six ounces.
              Tincturae Opii, one drachm.
              Liquoris Potassae, two drachms.
   Misce. Dosis  Cochleare  amplum ex poculo jusculi bovini vel
     lactis ter in die.
   In some cases leeches and a  blister to the epigastric region will
afford relief.
   Pyrosis,  or waterbrash,  will be  relieved or removed by the
second prescription, when the fluid is acid; but should it be alka-
line or insipid, the mineral acids must be employed.   These  con-
ditions often alternate, and will require a change of remedies.  We
are  indebted to  Dr. James Johnson for the discovery of this  fact,
which clearly explains why alkalies  succeed in some cases, and
acids in others.   (Essay on Morbid  Sensibility of  the  Stomach,
 1831.) 
300
GYN JECO-PATHOLOGY.
  Ptyalism,  or salivation, is often a troublesome disease during
pregnancy.   The  quantity of saliva discharged daily has amoun-
ted  to three or four pints, without any connexion with disorders of
the stomach.    I have seen a remarkable instance of this kind with
my friend Mr.  Woodhouse,  of Ilford, and it continued in despite
of all remedies  for four months.   Gargles of the chlorides of soda
and  lime produced no effect.  Dr. Fahnestock, of Pennsylvania,
recommends  an infusion  of  the  inner bark of the rhus glabrum
or sumach,  as  the best remedy,  and also in the ulceration of  the
tongue, mouth, and fauces. (Lond. Med. h Surg.  1830, vol. iv.)
—Dr.  Geddings,  of Charleston, has found the following remedy
generally efficacious.
              R. Mucilaginis Acaciae,  5 viij.
                  Olei Terebinthinae, 3'ij.
      Misce. Usurpetur pro  gargarismate frequenter in die.
  There  is sometimes a  febrile state which deprives the woman
of sleep,  causes debility, emaciation, and sharpening of the fea-
tures.  It is relieved by the usual  treatment, saline aperients, effer-
vescing daughts, and blood-letting.  We should procure sleep by
the  sedative  preparations  of  opium,  so often described, although
Burns is  opposed to  the practice.  He asserts, that a continued
use of opium injures the stomach and bowels, and likewise the in-
fant.  Few men  would  leave their patients without sleep for se-
veral nights,  without endeavouring to procure it in some measure.
   There is a remittent, fever consequent to pregnancy, which  ari-
ses  from irregularity of the bowels.   It is cured by relieving  the
cause.
   Spasm of the stomach or duodenum is often  very severe, and  if
allowed to continue for any time, may kill  the infant.  The warm
carminative tinctures, as those of  cardamoms, rhubarb, senna, with
free  doses of  opium  and ether, in general procure immediate re-
lief.   If the head is effected, convulsions may set in, unless blood-
letting be employed.   The bowels  are  to  be kept regular, and
blood-letting employed in bad  cases.
    Constipation.— Costiveness is one of the most common disea-
ses of pregnancy : it arises from torpor of the  bowels, or pressure
of the enlarged womb.   The bowels ought to  be kept regular by
mild subacid fruits or proper diet, and if these fail, manna, magne-
 sia, Epsom salts, castor-oil, confection of senna, or the old lenitive 
DISEASES  OF PREGNANCY.
301
electuary, are the best remedies.   Dr. Hamilton's formula for cos-
tiveness, is—
         R. Extract Colocynth. Comp. 2 Scruples.
            Extracti Hyosciami, 1 Scruple.
  In  pilulas xv divide, ex  his capiat aegra unam vel duas pro re
nata.
  A  few grains of calomel, or pil. hyd. may be added when the
liver is disordered.
  To this  formula I  add  four minims of oil of peppermint, or
some  other essential oil, and half a scruple of calomel or mercuri-
al  pill should the function of the liver be deranged.  The com-
pound rhubarb and aloetic pills are advised by Burns.
  The colon and rectum may become distended to an enormous
degree with indurated faeces.  There will be severe cutting pain or
tormina, very urgent desire to evacuate the bowels, or tenesmus, and
mucus or pure blood will be discharged.  Some mechanical means
must  be resorted to, to breakdown the faeces, as  recommended by
Denman and Scarpa.   There is a peculiar instrument for this pur-
pose.   Laxatives are  to be given, as the bowels  are relieved.  If
there is great pain, blood-letting  must be resorted to, lest inflam-
mation  of the bowels supervene.
   The  French obviate costiveness by a daily use of lavements or
clysters.
   Diarrhoea,  or  bowel complaint,  may arise from relaxation, or
accumulation  of faeces.  Astringents with opium, and flannel rol-
lers,  are to  be employed in the  first form ; and mild laxatives in
tho latter.  Tenesmus and dysentery are best relieved by opiates
alone, or combined with the acet. plumb.   I think purging,  as re-
commended by  Dr. G. Gregory,  and others, highly  injurious.
   Hemorrhois, or piles, arise from the pressure of the gravid womb.
The  best  cure for piles is  the regulation of the bowels by mild
laxatives, as small doses of neutral salts, castor oil, or the electua-
ry of sulphur, and cream of tartar.  When  the  bowels have been
regulated, the  astringent lotions, and ointments in common use,
may  be applied—as solutions of acetate  of lead, alum and oak
bark, and gall  ointment.   The gall  ointment with opium or bel-
ladonna generally affords  relief.  Should  this  fail, an  anodyne
enema  composed of  three  ounces of starch mucilage, and half a
drachm of laudanum,  will often  succeed.   The introduction of
simple  cerate,  or combined with a grain or two of the watery ex- 
302                 GYN^CO-PATHOLOGY.
tract of opium, mitigates the present suffering.  Fresh butter, lard,
or suet may be used in the same manner.  When piles are  stran-
gulated by the sphincter ani,  warm fomentations, hip-baths, and
poultices,  will facilitate  reduction.   The daily application of cold
water in slight cases of  this kind will be used with much benefit.
The introduction of a piece of common  candle into the rectum is
also a very valuable remedy, it lubricates and cools the part.  Each
pile may be squeezed between the finger and thumb, and returned
into the rectum.   Dr.  Hamilton has seen  them  excised during
pregnancy.   Mr. Kirby, the  distinguished  surgeon of  Dublin,
advocates the operation  ; while Sir Astley Cooper thinks it most
dangerous.  The irritation caused by piles has produced abortion.
The French  apply  leeches to the anus: but in this country fe-
males are  generally averse  to  them.   I have described the treat-
ment of irritation, and other affections of the bladder, pp.  189.
   Colic, is a common disease of pregnancy, yet  in our  day we
scarcely hear of this complaint, although at one time it was most
fashionable.   Colic is defined—" pain in the abdomen, with sense
of twisting round the navel, vomiting, costiveness, spasms of the
abdominal muscles, and sometimes  retraction of the navel."  It
arises from spasm, accumulation of faeces in the bowels, cold, flatu-
lence, and biliary calculi.   Mild aperients, laxative clysters, opiate
frictions to the abdomen, when spasm prevails, are the best  reme-
dies.  Blood-letting, warm bathing, fomentations, leeches and blis-
ters, must sometimes be employed.
   Jaundice sometimes occurs during  pregnancy.  Small  doses of
calomel, with saline  medicines, next  day, generally remove it.*
Emetics,  or violent purges, ought to be avoided.  When the dis-
ease occurs in the last months  of pregnancy, it proceeds from pres-
sure on the gall ducts, by the enlarged  womb, and will  not  disap-
pear until delivery.
   Other discolorations appear on the  face and surface of the body
and of various colours, dark brown, greenish, or yellow.   Aperi-
ents remove  them, and  they are of no consequence.
   Palpitation of the heart often occurs during pregnancy.   It is
very distressing to delicate women, but by no means dangerous,
unless  in occasionally producing abortion.  It sometimes comes on
  * Pills prescribed for costiveness, with calomel, are generally effectual. (See
p. 301.) 
DISEASES OF  PREGNANCY.
303
but every third day, and generally at night, the slightest agitation
causing it.   The  best remedies  for it are antispasmodics, as opi-
um, ether, and ammonia, or these  combined,  or proper doses of
prussic acid  and the sedative liquor of opium.   Rest is more re-
quisite to the cure.   Tonics have been given with success as the
muriated tincture of iron, and also  compound tincture of valerian
and assafoetida.  The bowels are to be carefully regulated.   This
disease is often induced by  disorder of the stomach, and hence we
are to inquire concerning that organ.
   Syncope.—Another distressing affection of the heart, connected
with pregnancy, is syncope  or fainting.   This disorder occurs be-
fore or at the  period of quickening.  It occurs daily to those who
are weakened by the want of sleep, or by diarrhoea ; it may also pro-
ceed from slight exertion, speedy motion, or exposure to heat, but
it may come on when the body is at perfect rest.   Sometimes the
paroxysm continues  for a long time, at  other  times it  is  of  short
duration, the patient being  conscious of what is going on.   During
the fit, the recumbent posture, the admission of cold air, applica-
tion of cold  water to the face, and ammonia to the nose, with a
cautious exhibition of cordials, constitute the treatment.   Should
the fit continue for a long time,  it may end in death.   Whenever
syncope is long continued,  it is a most alarming occurrence ;  heat
is to be applied to the extremities, in order to  induce  circulation,
if possible.  There is a species of syncope that proves fatal dur-
ing the first six months of  pregnancy, and depends on an organic
disease of the heart.  Those who are subject to fainting fits, ought
to avoid fatigue, crowded or warm rooms, long fasting, quick mo-
tion ; and the digestive organs and  bowels are always to be  at-
tended to.  During the last months of pregnancy, the descent of
the diaphragm and due expansion  of the lungs are prevented, and
dyspnoea takes place, which is sometimes relieved  by  antispasmo-
dics.  Most urgent cough is also excited from the same causes,
and may often, by agitation of the abdomen, induce abortion.   In
fact, it is always a dangerous occurrence during pregnancy. Blood-
letting must be frequently  employed, and opiates and other  seda-
tives, as  hyosciamus, coniurn, and  prussic acid, are used  with  ad-
vantage.
   Hemoptysis and  hamatemesis, spitting and vomiting blood, of-
ten happen in the last months of pregnancy, and are  highly dan-
gerous.  Should they come on during labour, or pains come on 
304
GYNJECO-PATHOLOGY.
prematurely, it will be prudent to accelerate delivery.  The treat-
ment consists of venesection, and sedatives to allay irritation.  A
combination of the acetate of lead and opium is often successful.
In describing the diseases of the chest during pregnancy, it is right
to mention that phthisis will  be retarded during utero-gestation,
and  will rapidly advance after  delivery.   The  determination of
blood to the womb accounts  for  this during pregnancy,  and the
determination of blood to the bosom  and  chest after delivery, ex-
plains the increase of irritation in the thoracic viscera.  The next
subjects that claim attention are the  consideration of the disorders
of the brain and organs of sense, as the eyes, ears, taste, teeth, he.
   Headache, when occurring in  a full .habit, towards  the end of
pregnancy, is attended  with suffused eyes, ringing of the  ears,
confused vision, as flashes of fire passing before  the  sight, which
indicate apoplexy, or epilepsy.  Copious  blood-letting from the
arm,  leeches, cupping, or arteriotomy  in the temple,  purgatives
and saline clysters, are the only  means  of relieving  this disease.
In apoplexy  the child is seldom  expelled, but it mostly is in epi-
lepsy.  Palsy  may succeed the apoplexy, and  continue to the
end of pregnancy, but in general gives way to ordinary treatment
after delivery.   The most common  head aches arise from disor-
der in the stomach and bowels, and  depend  on  costiveness,  ner-
vousness, or dyspepsia.   They are attended with acrid eructa-
tions, giddiness, slight sickness, and bitter taste in  the mouth.
Such headaches, which  are  common, are relieved by mercurial
medicines at night, and  saline  purgatives  the  next morning, by
the application  of ether to  the temples,  or ammonia to the nos-
trils.  The alkaline earths, already  described in my  observations
on affections  of the stomach, in the early months of pregnancy,
will be often used  with advantage in acidity, or water-brash.  (See
pp. 299, 300.)
   Hysterical convulsions are often troublesome in the early months
of pregnancy.   They mostly  occur in irritable  habits, in  those
disposed to syncope, or who  have been  subject to pain, want of
sleep, or whose bowels are  confined.  During  the fit the face is
pale, countenance not distorted,  no foam issues  from  the mouth,
the patient lies as  in a faint, and  then  has convulsive motions,
screams, or sobs, and the fit is usually terminated by shedding tears.
The treatment  consists in the use of opiates and antispasmodics, as
the  ammoniated  tincture of assafoetida,  castor,  and valerian  ; 
DISEASES OF PREGNANCY.
305
a drachm of these three tinctures, with twenty drops of sedative
liquor of opium or hyosciamus in an  ounce of camphor mixture,
forms an excellent draught during  the fit.   Some sugar or honey
ought to be added,  as such draught is very disagreeable.   The
bowels  are to be kept  regular, the mind soothed, gentle air and
exercise taken, and sleep is to be produced by opiates.  If there
be any determination of blood to the head, blood-letting and  topi-
cal  bleeding should be  employed.   Convulsions occur  during
pregnancy,  and  excite  labour.  Blood-letting,  to forty  or fifty
ounces, is to be employed as soon as possible, and delivery effect-
ed when labour has commenced. (See Dystocia Convulsiva.)
  The  functions of sight, taste, and  hearing are affected in  vari-
ous degrees by pregnancy, and  are generally relieved by attend-
ing to  the bowels.   Toothache is also often troublesome ; but the
tooth ought  not to be extracted,  as that operation  generally indu-
ces abortion.  II  the tooth is decayed, the application of spirits of
wine, oil of  turpentine, tincture of opium,  and oil of cloves, spir-
its of nitre and alum, will in general afford relief; the  latter is re-
commended by my friend,  Dr.  Blicke, and I can speak from per-
sonal experience of its efficacy.   The extraction or excision of a
tooth is a most painful  operation  during  pregnancy.   The  most
successful, I  might almost say  infallible  remedy for tooth ache,
when there is caries of the tooth, is the application of nitric  acid,
which gives instant relief, and produces no  pain whatever.   It is
to be cautiously introduced on lint, and the mouth washed with te-
pid water.  I have tried it on  myself with invariable success,  as
well as on numerous others.   I  am indebted to a diligent and as-
siduous pupil of mine, Mr.  Myers, of Newington  Causeway, for
the knowledge of this valuable fact, and he discovered it by  acci-
dent, having applied the acid instead of the sulphuric to his own
tooth,  when almost distracted  with pain.   (See my Essay on the
immediate cure of tooth-ache.   Lond. Med. and Surg. Journ. vol.
vii.)
  The mamma, or breasts, or, to  speak in vernacular language,
the bosom, is often irritated by  pregnancy.   A serous discharge
may take place, or  an abscess forms.   Frictions with warm oil, or
tepid fomentations,  frequently applied, together with leeches and
purgatives, will generally remove the  disease.*
  * Pain and inflammation of the breast will be treated of in the artiale on Puer.
peral Diseases. 
306
GYN.KC0-PATHOLOGY.
   Despondency of mind is common  to some  women during ges-
tation.  They  are quite fearful of the  consequences ; and this
fear is generally aggravated by the prodigious stories, sedulously
told by old women and nurses, and especially the influence of the
imagination, longings, he.  Well-informed  women are less  liable
to such depression, and  laugh  at the absurdities of these stories.
The obscene works, so largely  circulated in these times, keep up
the delusion, and terrify the female mind to the most extreme de-
gree.   It is a  melancholy reflection to consider  that such works
are in the greatest circulation among women, who have no popular
work  on midwifery to consult.
   With  regard to the  treatment  of despondency  peculiar to
pregnancy, we  can only  afford relief by kind  and consoling assu-
rances of the safety of both the mother and infant, for here med-
icine is useless.   The only remaining diseases incidental to preg-
nancy  are false pains, abortion,  and haemorrhage from the  uterus.
   False pains  may occur for one, two, or three months before the
termination of pregnancy, and may be so severe as to  be mistaken
for approaching labour.   I have known one female who had them
several times, and most  severely during  the last  three months of
utero-gestation.   As in reality they are not connected with labour,
they have been named " false  or spurious pains," to distinguish
them  from true ones.   They are most common at night, depriving
the woman of sleep.   They often attack  the region of the  liver,
causing acute pain ; the digestive organs are usually deranged, and
the infant also extremely restless, and its  motions are very trou-
blesome.
   They may attack the back, umbilical or hypogastric regions, and
even the thighs and legs.   Nervous, delicate,  and hysterical wo-
men, and those fond  of cordials, are most liable to them, although
they may occur to the most healthy females.   When severe, the
abdominal muscles are affected; the  bladder  may be  protruded,
and has been mistaken for the membranes, and punctured by mid-
wives, and the bearing down sensations in  the rectum induces a
violent tenesmus.  False  pains are occasioned by a variety  of cau-
ses, as exercise, or fatigue of any kind, by flatulence, spasms of the
bowels, as colic, costivenesss, or diarrhoea, nephritic affections, ac-
companied with strangury, or by frequent or excessive copulation
in the last months  of pregnancy.  If the patient get out of a warm
bed, and  stand on the cold floor, she will be often attacked  with 
DISEASES OF PREGNANCY.
307
 spurious pains.  Agitation of mind has also the same effect. These
 pains may be attended with a watery discharge  from the vagina,
 although the os uteri is seldom affected  by them, yet it  may be-
 come dilated, and no labour take place.   These pains,  however
 severe,  are never so regular in their recurrence as those of labour,
 and the history of any case will enable the practitioner to form a
 correct opinion.  If we examine the os uteri in such cases, we do
 not find it at all  dilated, although such pains may continue  even
 for four, five, or six days, during which time the  woman is said to
 be in  labour.  The best treatment is opening the bowels, confin-
 ing the  woman  to bed, or at least to absolute rest, and exhibiting
 an anodyne; and if fever prevails, by abstracting  blood. Frictions,
 with strong  anodyne liniments, are  also very beneficial.  If the
 term  of utero-gestation  is completed we must be extremely cau-
 tious in  pronouncing an opinion, as false pains may end in real la-
 bour; this is unlikely  in the first or middle months of pregnancy.
 Rigors,  or shiverings, often  accompany  or precede labour;  they
 are best relieved by warm gruel  and an opiate.   The treatment
 of all  diseases of pregnancy  is to be conducted on ordinary  prin-
 ciples, making an allowance for that peculiar state, and not exhib-
 iting any violent, remedies, as mercury,  foxglove,  narcotics, in
 long continued courses, as they might destroy the infant; but this
 is still doubtful.
    Separation of the pubic joint is happily a rare occurrence, be-
 fore or after delivery; when it does happen  it  is  a most painful
 and deplorable event, and must be treated  on the strict antiphlo-
 gistic  plan,  and the woman is to  be  confined to bed for weeks or
 months.   She cannot walk without aggravating the pain, by caus-
 ing the motion of the  affected part; the ligaments and cartilages
 become  inflamed, abscess then forms, the ends of the bones become
 denuded, and the woman cannot  assume the erect posture, or use
 the slightest motion, without the denuded surfaces rubbing against
 each other,  and causing violent pain.  A roller is  applied round
 the pelvis in this state  of the disease, and the most perfect rest is
 to be observed.
   Another distressing disease, incident to pregnancy, is a tender,
 irritable state of the vulva with itching and heat in making wTater.
 The application of a sponge dipped in cold water,  or in a weak
solution of acetate of lead, generally affords relief.  In some cases,
bleeding  from the arm  and  leeches must be employed. 
308
GYN^JCO-PATHOLOGY,
   Incontinence of urine is a common occurrence  towards the last
months of gestation, and is caused by pressure of the infant's head
on the bladder.   The urine comes off involuntarilv, whenever the
woman coughs or laughs,  and must be  voided  very often during
the day.  There is no relief to be  expected until  delivery; the
disorder is a favorable sign, as it proves  that the head of the child
rests on the os uteri.  It  must not  be  confounded  with hydror-
rhcea.
   The womb  may be attacked with spasm (eclampsy) before or
after delivery, which frequently ceases, or is soon succeeded by in-
flammation, frequent pulse, thirst, heat of skin, sickness, constipa-
tion, tenderness in the hypogastric region, the pain passing to one
or both groins, and to the  back.   Abortion generally happens in
this disease, and the patient usually sinks soon afterwards. Some-
times the  pulse remains tranquil, which  proves the nature of the
case.   It is daily  mistaken for inflammation, a remarkable case of
which  I lately witnessed.  Opening  the bowels,  and opiates are
sedatives,  as morphine, sedative  liquor of opium,  ether, and  cam-
phor, are alone to be depended on;  but  if the  spasm be violent,
blood letting from the arm  must be employed.  Anodyne clysters
are useful in this disease.   Spasm of the  stomach, called  gastro- .
dynia,  is best relieved by a large opiate.
  Rupture of the Uterus.—This dreadful  occurrence may happen
at any period  of  pregnancy,   It  is ushered  in with severe  pain,
vomiting,  and  tendency to syncope;  the  pain  resembles  labour,
but more generally colic, and its duration is  variable.  The pa-
tient always complains  of  " something  having given away within
her;"  blood may escape from the vagina, but in general it passes
into the cavity of the abdomen, causing  enteritis.  The motion of
the child is great  during the rupture;  and if the opening is large,
the infant  passess through  it into  the abdomen, and  can  be felt
through its parietes.   The motion of  the  foetus soon ceases, the
tumour of the abdomen becomes diminished,  milk is secreted, in-
dicating the death of the foetus.  The woman is generally destroy-
ed by peritoneal inflammation, or loss  of blood; but sometimes
she goes to the full time, when pains, like those of labour, are ex-
perienced  ; they frequently go off, and  the child is retained for
many years, being inclosed in a cyst,  as noticed by Dr. Percival,
who described a case where the foetus was retained for twenty-two
years, and then discharged by  the rectum; it has also  been dis- 
DISEASES OF PREGNANCY.
309
charged by the vagina and abdominal parietes, numerous instances
of which are on record.   Lieutaud mentions cases where the foe-
tus was retained from ten to forty years, and Dr. Burns  relates
many other similar cases.  Women  seldom recover after rupture
of the uterus; they sink from inflammation of the bowels or from
inflammation or suppuration of the uterus, parietes of the abdomen,
rectum, and vagina, or perineum, through some of which parts the
foetus escapes piecemeal.  Dr.  M'Keever, of the Dublin  Lying-
in-Hospital, published an interesting  work, in 1824, on Lacera-
tions of the Womb and Vagina, well worthy  the  attention  of me-
dical men.   He describes several well-marked  cases, yet the pa-
tients recovered.  His cases occurred before delivery, and not in
his own practice.  This dreadful disease generally occurs  in  arm
presentations, or in preternatural labours, as I shall point out here-
after, and is  mostly fatal.  When it  happens in the early  months
of utero-gestation, the ovum may escape through the laceration
into the abdomen, even  survive there, and increase in size.  When
the  foetus thus escapes  into the  abdomen, its  motions are felt
stronger than before.   If the woman survives, the womb decreases,
and returns to its former unimpregnated size ; the menses  will re-
turn, the woman  may become  pregnant, and she may even bear
children,  before the expulsion of the retained extra-uterine foetus.
(Journ. de Med. T.  V., p. 422;  Burns, p.  105.)*
   When  the case is about to end fatally, the pulse becomes quick
and small, the belly  painful, the strength declines, and sometimes
vomiting  ushers in  dissolution.  The  foetus  has been expelled
through  an  abscess  externally.  Med. Corns.,  vol.  ii. p. 317:
vol.  iv.  p. 401 ;  Med. Journ., vol. viii. p. 324.   Various other
cases could  be cited  from foreign  medical  works.
   The most common causes of rupture of  the uterus are  mental
emotion (Percival  and  Underwood, Med. Corns., vol. ii. p. 77),
exertion, or  violence.   It may  happen with  a noise, and be audi-
ble to the bystanders.  The great danger  of allowing a woman  to
continue  in active labour for more than  twenty-four hours, is rup-
ture of the  uterus.   If we find, on examination, that the os uteri
is  dilated, the  labour  has really  commenced ;  and if the process
   * Cases of ruptured uterus, in the early months of pregnancy from falls and
blows, are recorded in Phil. Trans, vol. xlv. p. 121 ; Mem.  Acad. Scien. 1709;
Jour. Med. 1780 ; Burns'  Mid., p. 640-1; Annals of Med. 412; Journ. Med., vols.
v. and vi.; Med. Corns., vol. ii.; Dublin Medical Trans., 1830, vol. i., New
 Series. 
310
GYN.ECO-PATHOLOGY.
is not over  in  twenty-four  hours,  there  is invariably something
wrong; but some women have severe, and even continued pains,
for one, two, or  three days, without being in labour.   Pressure on
the  womb,  by  the  infant's head, may render a part of the organ
thin, and liable to rupture.   Spasmodic action, or attempts to re-
turn  a limb of the infant, when presenting, external violence, use
of the forceps,  and  the operation of turning, are often causes of
this  laceration.
   Three modes of treatment have been rcommended  in ruptured
uterus; to deliver by turning, or the forceps, to perform gastroto-
my,  and to leave the  case to nature.   Dr. Burns loudly condemns
the  idea of forcibly  dilating  the os uteri.  "I question," says he,
" if  the woman  could live until the delivery were accomplished."
This is the general opinion, though I believe it liable to exception,
when gestation has exceeded the seventh month.  It must be ad-
mitted that parturient action may take place at any period of preg-
nancy, therefore the cautious  dilatation of the  uterine orifice, in
a case of rupture or of convulsions, would be infinitely less danger-
ous than cutting through the abdomen, and much more accordant
with science than allowing the mother and infant to perish without
any  aid.   I was forcibly struck with this opinion in a case of con-
vulsions in  the eighth month, which defied copious depletion, large
doses of camphor, and proved fatal; for, acting on the rule which
inculcates the danger of dilating theos uteri, nothing  remained but
the Caesarian operation, which would not be sanctioned.  Now, in
such  fatal  cases, and they are occasionally met with, the punctu-
ring  of the membranes, or the gradual dilatation of the uterus, can
scarcely  be objected to, when without it the  fate of  the woman
and child is inevitable.  Admitting  the possibility of laceration,
which need not happen in ordinary hands,  this, after all, is not so
formidable  as is generally imagined.   We have numerous cases of
extensive rupture of the womb recorded by M'Keever, and Col-
lins,  of Dublin, which terminated favourably, and we should bear
in mind the fact of the dilatability of the womb at any period of
pregnancy.   Experience  will determine whether this  proposal is
not more feasible and less dangerous than gastro-hysterotomy, or
gastrotomy, in the cases under consideration.   Other objections
obtain against the latter in cases of extra-uterine foetation.
   The operation of  gastrotomy, I apprehend, can only be resort-
ed to in one species of extra-uterine foetation, namely, in the ab- 
DISEASE OF PREGNANCY.
311
dominal  or  ventral,  and  after the seventh  month  of gestation,
when the viability of the infant is certain.   In tubal and ovarian
pregnancies the foetus generally dies  about the second or third
month, and  the mother  may  die  in consequence of haemorrhage
from the  ruptured sac, or from inflammation.   All obstetric writers
agree that it is impossible to distinguish which form  of extra-ute-
rine foetation  exists  at this early period.   Besides, the woman
may recover, in the majority of instances, without any operation.
This is generally the case in abdominal foetation.  After the death
of the foetus, the amniotic fluid is absorbed, the infant is indurated,
petrified, or transformed  into a substance  like adipocere, the cyst
becomes fibrous, cartilaginous, or osseous, and all form a solid tu-
mour, which may remain  to  an indefinite  period, perhaps half a
century,  in the  abdomen  without injury.   The sac  may be filled
with pus, the  foetus become putrid, the cyst adhere  to the vicinal
parts, and an opening may form in different portions of the intes-
tines, perineum, vaginal, or abdominal  parietes, through which the
foetus may be discharged.   This process is tedious,  and some-
times fatal to the mother; but the records of medicine afford the
most ample testimony of  the favourable termination of the great-
er proportion  of such cases.   Extra-uterine foetation is of very
rare occurrence, and its protraction to  the ninth month has been
seldom observed.   Instances are recorded, however, of its arrival
at the full period,  by Haller,  Baudelocque,  Leroux, and  Galli.
We can readily understand the reason of abdominal foetation being
more protracted  than tubal,  ovarian, or utero-interstitial  (Desor-
meaux), when we  recollect the extent of the abdominal cavity,
the mobility of the viscera, and the greater amplitude tliere is for
the development of the foetus than in the former cases.   The di-
agnosis  of extra-uterine fcetations is extremely difficult.  Many
cases of  this description have  been supposed to exist, where natu-
ral parturition finally  took  place.  M.  Capuron states, that about
twenty-five  years ago, some of the most  eminent obstetricians of
Paris made  this mistake at La Charitie, and on another occasion
extra uterine  foetation was only  discovered after death, and again
retroversion of the womb was mistaken for it.   These facts should
have due weight before recourse can be had to gastrotomy.  After
the most minute consideration of all the circumstances of ventral
foetation, MM. Capuron,  Desormeaux, Gardien, Velpau, and va-
rious French writers, are  advocates for gastrotomy,  after the sev- 
312               GYN.S2CO-PATH0L0GY.
enth month.   They argue that the woman must be lost either by
haemorrhage, from the bursting of the foetal sac, or by inflammation,
and that the infant is also sacrificed.   They hold the operation as
safe as hysterotomy, and Capuron asserts that it has been crowned
with success, but he has not recorded any instance in  which the
operation has been performed.  If he means that gastrotomy and
hysterotomy are synonymous  terms, I must differ from  him.  The
circumstances of cases which require these operations  are widely
different.   In ventral foetation,  the presence of the ovum irritates
the peritoneum, a membrane  is formed, and envelopes the foetus,
and also becomes attached to the different viscera, epiploon, me-
sentery, vertebral column, external surface of the uterus, and oth-
er parts.  Its inner surface is smooth, and highly vascular near the
placenta, and its colour is red, brown, or black.   The  placenta is
broader and thinner  than usual, and  its vessels are comparatively
fine (Turnbull  and  Desormeaux), and therefore  incapable of  af-
fording  the  proper supply of blood,  in  most cases after the  third
or fourth month, hence  the death of the foetus.   Now these cir-
cumstances are totally different from the natural  condition of the
uterine appendages,  in cases that require the Caesarian operation,
or gastrotomy.  They present strong objections to the  latter ope-
ration.   M. Capuron is of opinion, however, "that the abdomen
should be laid open,  in the direction of the linea alba, or accord-
ing to the position of the infant, and  the placenta detached, as
there  is no danger of haemorrhage, or it might be left behind and
allowed to separate  and present itself at the abdominal opening."
He agrees with M.  Gardien, that the  operation should be per-
formed several  days  before the  period at which uterine action oc-
curs, as the mother  and infant would  have a better chance,  for
when the membranes rupture,  both must be lost by haemorrhage.
On the other hand, M. Velpeau is of opinion, that immediately  af-
ter the  rupture of the sac, the operation  should be performed—
" with the operation death  is too  probable, without  it death is
nearly certain."  It  appears  to me that both these writers speak
too confidently on the propriety of an operation which, I believe,
has never been successfully performed.  They ought to have sta-
ted, whether the sac which surrounded the foetus is to be extract-
ed or left behind, and also what is to arrest haemorrhage after the
detachment of  the placenta.  What  is to close up the mouths of
the vessels from which it has been torn ?  If the sac and placenta 
DISEASES  OF PREGNANCY.
313
are left behind, they will induce irritation  and inflammation, and
how can the former be  separated from  its adhesions?  M. Co-
lomb  performed  gastrotomy in  a case  of extra-uterine foetation,
but it ended fatally.   (Recueil des Actes de la Societe de Ly-
ons.)—He regretted, as also did Baudelocque and Guerin, that
they had not made  an  incision  through the  vagina, as the head
was clearly felt pressing upon that part.   Sabatier mentions that *
Lauverjat extracted the infant by an incision through  the vagina,
and the woman recovered.   (Dela Med. tome i. p. 136.)—Now
this operation is evidently preferable to gastrotomy, because much
less important parts will be divided, less haemorrhage,  less inflam-
mation, and less suppuration will be induced.   Besides, the abdo-
minal muscles and diaphragm may expel the infant, and if expul-
sion be not  effected in  this  way, the  feet  of the  infant  can be
brought down, and turning  performed.   The placenta should be
left attached,  lest  fatal  haemorrhage ensue,  and  the operation
should  be performed even if the infant were dead, but had arrived
at the completion  of the ordinary  period of pregnancy,  to save
the woman from peritonitis.  The wound should be left open, to
allow the discharge of  liquor amnii, blood, membranes, placenta,
or  purulent matter; of course  the  after treatment ought to be
strictly antiphlogistic.
   If  the  infant's  head  can  be felt, in these unfortunate cases,
through the vagina, which is extremely probable, from the super-
incumbent weight of the foetus during the latter months of gesta-
 tion,  it must be admitted, from the preceding observaitons, that
 extraction  through the vagina is  much safer  than  gastrotomy.
 Happily, however, these cases are of extremely rare  occurrence;
 but when they do present themselves, as in  the example which
 gave rise to these remarks, they become subjects of grave consid-
 eration.
    Retroversion of the Uterus.—Dr.  Hunter first described  this
 disease in  1754.   It  happens in the third, fourth, or fifth month
 of pregnancy, by  the distended  bladder pressing upon the enlar-
 ged uterus, and forcing its fundus downwards and backwards, be-
 tween  the  vagina and  rectum.  This  position  of the organ pre-
 vents the discharge of  urine and farces, and consequently may de-
 stroy the patient.   Severe bearing-down pains are felt, but espe-
 cially when the bladder becomes distended.   The complaint may
 be confounded with enlarged ovarium, or extra-uterine conception:
         40 
314
GYNJECO-PATHOLOGY.
but this is of little consequence, as the indications of cure are
similar in these instances, namely, to draw off the urine and pro-
cure stools.   The greater danger is,  that the  bladder becomes
distended, may be inflamed, become  gangrenous and perforated,
or may adhere to the abdominal parietes.  Inflammation and gan-
grene of the vagina may also be produced.  Suppuration  may
happen, and  purulent matter be discharged with the urine.
   Treatment.—The grand object is to evacuate the bladder; and
in order to succeed in effecting this by the catheter  we must call
to mind the  position of the urethra, which is curved towards the
sacrum.   Hence we turn the  concavity of the catheter  towards
the sacrum, and then  generally succeed.  In some cases the fin-
ger is to be passed into the vagina, so as to press down the os uteri
and facilitate  the introduction of the instrument, and an elastic ca-
theter only will sometimes succeed.  We seldom fail in  drawing
off the urine ; but if it should  so happen that we cannot succeed,
puncturing the bladder is advised (Sabatier); an operation seldom,
indeed never necessary.  (Burns.)—Moderate  pressure is  to be
made on the  bladder while the urine is coming  off, as otherwise
a considerable quantity of it might remain behind.  The water is
to be drawn off, morning and evening,  and by this plan alone the
womb will regain its natural situation.   After the first use of the
catheter, a purgative or cathartic enema is to be given, and an ano-
dyne clyster, if there  be much bearing down pain.   If any signs
of inflammation appear, the usual depleting remedies are to be em-
ployed.  Burns strongly contends,  that in most cases the proper
evacuation of the  bladder will cure the retroversion;  but should
it  fail, which is most unlikely,  an  attempt is  to be made to replace
the uterus.   This is done by passing two fingers into the rectum
and two or more into  the vagina, and pressing up the uterine tu-
mour.  (Sabatier, Blundell.)—After reduction, the patient should
lie  on either side, and not on  the back.  (Capuron.)—Hamilton
recommends  this practice in  every instance, although Denman
thought the morbid position should be left to nature, and Burns is
of the same  opinion (1829.)   The os uteri faces upwards, and
presses on the neck of the bladder, so as to prevent the introduc-
tion of the  catheter.   When  the catheter cannot be employed,
Drs.  Hunter,  Jourel,  and Hamilton recommend puncturing the
membranes, to bring on miscarriage.   They deem retroversion  a
most dangerous disease. Merriman said it might happen at the full 
DISEASES OF PREGNANCY.
315
time ; but this appears impossible, the uterus being so much high-
er than the bladder.   Duges says it cannot occur after the fourth
month.   Dr. Hunter said the bladder has been so much thickened
that some bystanders thought it was the womb  itself.  If labour
happens  during retroversion, it will be  slow and tedious; but it
is very rare, and scarcely ever occurs under such circumstances.
The complaint  is said to arise from agitation and violent exertion,
or coughing but this opinion is  doubtful.  Dr.  Dewees seems  to
deny it.
   Anteversion  of the womb  is said to  exist when  the  fundus is
thrown forwards, between the vagina and bladder;  the  orifice  of
the womb being turned  to the  sacrum—a rare occurrence.   Dr.
Burns never saw an instance of this; the urine is to be drawn off
and the  fundus raised  up.   The bladder  is thrown forward  by
pregnancy,  distorted pelvis and pendulous belly ; so  that in pas-
sing the catheter, as soon as we clear the pubes, the handle of the
instrument is to be depressed; whereas  in retroversion,  inversion,
or prolapsion, it is to be elevated, as the bladder, in all these ca-
ses, is thrown backwards into the cavity of the pelvis.   It is very
important that  these observations be borne in mind, otherwise we
shall be foiled in  attempting to  pass the catheter.
   Another derangement of the impregnated uterus occurs, which
is named obliquity by authors.   The obliquities are, first, the lat-
eral obliquity ;  second, the anterior obliquity, or anteversion ; third,
the left  lateral  obliquity; and  fourth,  the  posterior obliquity,  or
retroversion. Two of these conditions I  have just described.  The
right lateral  obliquity  is caused by the  distension of the rectum,
which presses the uterus to the right side.   The distension of the
sigmoid flexure of the  colon, and promontory of the sacrum, as-
sist in effecting this position ; hence it is the most frequent by one
hundred to one, according to Baudelocque.   In fact, the os uteri
will not be always in a  line  with the fundus; and hence  the  se-
verity of labour, under such circumstances—a frequent occurence.
The anterior obliquity happens rarely in first pregnancies, owing
to the firmness  of the abdominal parietes; but it often  occurs  to
the  same woman, in future cases.  In the latter months, anteri-
or  obliquity  becomes  very  inconvenient, by  pressing forwards,
and inclining the woman to  make water and void  faeces;  it has
been so  urgent, as  to oblige  the patient to remain in bed.   It
is most common in  small short women.  (Dewees.)   The best 
316
GYNJECO-PATHOLOGY.
 and only remedy for this distressing state, is a pair of drawers and
 a half waistcoat, which are to be put on in bed ; the patient being
 in the recumbent posture.  She is to raise up the womb, by lock-
 ing her  hands together, then slip on her dress; while an attendant
 is to lace the waistcoat tightly, so as keep up the uterus.  This is
 to be done before the patient assumes the erect posture, otherwise
 it could not  be effected but with  difficulty.   Thus  the womb will
 be prevented from falling forward ; the half-waistcoat need not ex-
 tend higher  than the navel, and may be supported by suspenders,
 if necessary; and thus will anterior  obliquity or  antiversion be
 prevented and the woman be rendered  comparatively  happy and
 relieved. - The same treatment will also relieve lateral obliquity;
; but before applying the dress, the woman is  to lay on the  oppo-
| site side. These obliquities are to be relieved by manual exertions
 during labour; and the proper  relations between the axes  of the
 uterus and pelvis are to be maintained.
    If the os uteri is not brought to the  proper axis in  the  pelvis
 during labour, much suffering must be endured, and great risk in-
 curred,  by permitting the  head  to descend, covered by the uterus.
 The hand, after being lubricated with lard, pomatum, olive  oil, or
 fresh butter, must in some cases be passed into the  vagina in order
 to discover the orifice of the uterus ; a  finger is then to be  intro-
 duced into the orifice, if dilated,  or easily dilatable, so as to hook
 it down into the vagina, and it is  kept there until the regular pains
 force the uterus  to correspond  with the axis  of the pelvis. By
 pursuing this plan, the patient will be saved from suffering severe
 pain.  Until a recent period, this condition of the  uterus was un-
 known ; and we find  no mention of it  by Hamilton, Denman,
 Burns, and other British obstetric writers.  The malposition has
 been mistaken for occlusion of  the os  uteri,  and an incision has
 been made  to allow the exit of the infant, although the same wo-
 man had borne children afterwards by the natural  passage.  The
 French writers describe inclination of the womb, that is, where it
 has a tendency to be displaced.
    Nauche describes degrees of retroversion and anteversion under
 the denominations retroflexion and anteflexion ; elevation and de-
 scent, inclination or  lateral obliquity, hernia,  renversement  when
 the internal  surface descends through  the vagina, all of which oc-
 cur in vacuity of the organs during pregnancy, at the moment  o(
 delivery, or  after delivery. (1830.) 
DISEASES OF PREGNANCY.
317
   The British obstetricians have nearly described obliquity of the
womb, in speaking of this disease  under the name of pendulous
belly.   Sometimes  the  abdominal muscles  do not yield  in first
pregnancies; at other times they yield  readily,  allow the  uterus
to fall forwards,  and form  this disease.  The  drawers  and waist-
coat are  the only remedies for this state, as  already mentioned.
When the parietes of the  belly do not yield freely, the  patient
complains of pain and  tension ;  and irritation may be so great as
to cause  miscarriage.  This state will be relieved by blood-letting,
and  warm fomentations of poppies,  he.   Sometimes one part
yields more  than another, even one part of  a muscle, and causes
deformity; but it is attended with little inconvenience.   Hamilton
places a  woman  with pendulous belly on her back, during labour,
or for a few pains, when the position will be rectified, as the weight
of the infant will fall on the spine and back  of the  pelvis, and the
head will be forced  into the natural outlet.
   Leucorrhoea is often a troublesome attendant on  pregnancy, the
symptoms and treatment of which  have been already described,
p. 182.
  Hydrometra—Hydrorrhea.—False or Spurious Waters.—From
the third to the  ninth month  of uterogestation, there may be a
watery discharge from  the vagina, which may happen in gushes,
or escape slowly, and be continued for six months, without impe-
ding the  development  of the gravid uterus, or without inducing
abortion  or  miscarriage.  This disease  has  been described under
the  denominations  at the  commencement of these remarks.  It
was  first noticed by Mauriceau, and denied  by Baudelocque.  In
some cases  there is a sudden gush of fluid,  and afterwards a con-
tinued  draining, or  the quantity may amount to several pints.
The discharge may or may not be preceded or followed by uterine
contractions, or by dilatation of the os uteri, the woman going to
the full time, and always having the membranes distended  as in
natural labour.   The quantity of the fluid varies exceedingly, for
sometimes an incredible amount is  effused.  The  discharge may
appear once or oftener,  and at different  intervals, sometimes con-
tinuing for a long time,  increased by mental or corporeal  excite-
ment or depression, the  cause is  sometimes undiscoverable, and
the discharge is greater  in some cases at night, in others during the
day.  The fluid is generally yellowish, sanguinolent or perfectly
limpid, or filled with flakes of fibrine. 
318
GYNJECO-PATHOLOGY.
   A great diversity of opinion exists as to the source of this fluid.
Some think it is produced by the amnios, others that it is contain-
ed between  the amnios and chorion, others that it is caused by a
rupture of lymphatics or hydatids,  situated  between  the chorion
and  uterus ;  and by far the greatest number maintain that it is si-
tuated between the chorion and uterus.  The  first opinion cannot
be correct; because all admit that rupture of  the amnios is inva-
riably followed, in a few hours or days, by expulsion of the embryo
or foetus.  The next opinion is also untenable, as no fluid is found
between the chorion and amnios after the  third month; nor is it
easy to understand by what  cause there could be rupture of the
lymphatics;  and even admitting this for the sake of argument, it
would not account for the large quantity of fluid which  is  often ef-
fused.  The existence of hydatids  must be admitted ; but even
these cannot produce the quantity  of discharge.  The following
cases, I think, clearly prove  the  received pathology:  Puzos de-
scribes four  examples which occurred in the  last two months of
gestation, in which the fluid was situated between the membranes
and uterus, the pregnancies were completed, the membranous sac
in each case was perfect, and the labour natural. Hildanus relates
a case which occurred at the fifth month of pregnancy, attended by
labour pains, and followed by a discharge  often pints of fluid, the
pregnancy went on without any other accident.  Mercier describes
a case at the same period, the  patient was  attacked  with  fever,
accompanied  by pains  in the pubic and lumber regions, ardor
urinae, constipation, and  a slight  discharge from  the uterus.   On
the sixth day, a  dead and a living infant were expelled; and be-
tween the births an elongated  bladder  presented in  the vagina,
from  which ten  pints of a  lactescent fluid, in  which flocculi of
albumen floated, were discharged.  A membranous sac followed.
Burns has met with several cases, and does not consider  the fluid
amniotic.   Pentland, of Dublin, also met  with the disease (Dub-
lin Med. Essays, Nos.  I. and II.) ; and I have met with a case
which occurred at the third month, and  the pregnancy was unin-
terrupted.  Mr.  Burton  Brown, of Blackfriars' Road, related four
cases at the  London Medical Society this  year, in two of which
labour did not happen for a period 132 days—nor was  it  acceler-
ated.   Various other examples might be quoted; but enough has
been said in support of the opinion, that the discharge is not am-
niotic.  Should the reader wish for farther evidence, he may con- 
DISEASES OF PREGNANCY.               319
suit the London  Medical and Surgical Journal, 1830, vol. iv.,
where  he will find a  good account of the disease, translated from
an Essay by  Dr. Geil, of Heidelburg; and  he will  find much
information in the Diet. Abrege des Sc. Med. Art. Hydrometre.
(See p. 300.)
  Redundance  of the fluid of  the amnios—Distension of the
Abdomen.—This fluid  may be so  much increased, that  a woman,
at the seventh month, appears as  large as at the full time.   This
is a dropsy of the ovum, hydroamnios,  the health  of the woman
seldom suffers.  The foetus is expelled in general about the eighth
month  ; and the  labour is attended with haemorrhage.   The mo-
tion of the foetus is obscurely  felt in the fluid, and it is usually  in
the upper part of the womb ;  and water,  to the amount of some
pints, is towards the orifice.  This disease has been called a mon-
strous  conception.   It may  be  caused by  the  venereal  taint,
general or  uterine debility, or original disease, or imperfection
of the  ovum,  in the  ovarium.   The infant,  if born  alive,  is
weak  and  delicate, and  seldom  lives—it generally dies in the
womb; and  its  death  is marked by a shivering fit, cessation  of
motion in it, and flaccid breasts. This sort of pregnancy frequently
occurs  to the  same woman. Treatment.—Tonics, cold bath, laxa-
tives, blood-letting, and mercury, are the remedies to be employed,
which may or may not  be effectual.  A course of mercury before
conception  is the only remedy, when a  venereal taint is  suspected ;
and it must be used  by  both parents.  (Trans.  Dub. Col. of Phys.
1824, vol.  iv.)  Also Drs. Joseph Clarke and Hamilton.—I have
lately met  with two cases of this disease:  one woman miscarried
at the seventh month, with a copious discharge of amniotic  fluid,
and a putrid infant;  she had  lost  six  children in this way, and
three at the eighth month.  According  to Dr. Beatty,  of Dublin,
both parents must  use a full course of mercury ;  and unless a
large quantity be taken, a cure will not be effected.  His papers,
in the Transactions of  the Dublin College of Physicians, vol. iv.
p. 24,  are  worthy of serious  perusal.   He informs us, that the
Dublin physicians have held this opinion since 1792.  Dr. Ham-
ilton inculcated  it in 1819 and 1820.  After taking a proper quan-
tity of  mercury, healthy infants will in future be produced.   In
one of  my  cases, a quantity of sarsaparilla has  been  tried, after
mercury, without success;  the lady is  now pregnant, and has had
a dead  child,  her last, after the use of  sarsaparilla.   She is a del- 
320
GYN-ffiCO-PATHOLOGY.
icate woman, and is subject to herpes on the mons veneris.  When
the liquor amnii is copious, and  the uterus largely distended, the
os uteri was forced open by  the  older  practitioners,  in  order to
evacuate  the fluid; an  improper operation.   Sometimes the os
uteri dilates; and then Puzos and others recommended the lacer-
ation of the membranes; but although  this  causes expulsion of
the fluid and infant, it will not cure the disease.
   I have described the various  tumours that occur in the unim-
pregnated state, which may be attached  to the vagina and uterus,
and stated that conception may take place even when such tumours
are very large.  If they impede labour, as they often do,  endeav-
ours must be made to remove them.  Pregnancy has  taken place
in scirrhus and  cancer of these parts.
   Muscular pains  may arise in  the parietes of the abdomen, in
the loins, and small of the back, which are generally produced by
walking, riding, dancing, or some other  exertion.   They may be
so severe as to threaten abortion. Rest and anodyne fomentations
are the best remedies.
   Pain in the  side is a frequent occurrence in the last months of
pregnancy, owing to the weight of the  uterus, or to the violent
motion of the  infant.   Pain  is also experienced in the course of
the colon, from the enlargement  of the uterus. Anodyne  frictions,
and attention to the bowels, may give relief; blood-letting is sel-
dom useful, although often employed.   Miscarriage seldom hap-
pens under these  circumstances.  Hernia may also occur, as also
starting, or  distension of the navel, and can be  only  palliated.
Pain in the back, and region of the kidneys and uterus, sometimes
occurs,  causing severe  strangury  and  premature labour.  The
pulse is slow and soft in these cases, and flatulence is troublesome.
Saline  clysters, followed by injections  of starch, and  a  half a
drachm of tine, opii, to half a  pint of  the  former, are used with
advantage, and also a sinapism to the  back, as we ought never ap-
ply a blister to the region of the kidneys, as absorption of the lyt-
ta would take place, and cause violent strangury.   The ung. tart.
ant. is a useful remedy in such  cases.   Its  effects are promoted
by the addition of a few drops of croton oil, as recommended by
my friend Dr.  Shortt.  Leeches to the loins, and  drachm doses of
carbonate  of soda,  will be  tried with advantage.  I have given
 S vj daily.
   Spasms, cramps, and numbness of  the lower extremities, in the 
DISEASES OF PREGNANCY.
321
latter months, arise from the pressure of the enlarged uterus on
the nerves of the pelvis.  Frictions  of the legs, and  change of
posture are  the  best  remedies.   The  muscles of the thighs and
loins are also affected by such pressure.  These spasms may go
off after some time;  in some cases they will continue to the end
of pregnancy.
   Anasarcous and (edematous swellings of the lower extremities
are also caused by pressure  of the enlarged  womb on  the lym-
phatic  blood-vessels ; aperients and frictions are the best remedies.
   Ascites, or dropsy of the abdomen, may also occur during preg-
nancy.   It  has  been mistaken  for pregnancy,  and vice versa.
Tapping has been employed with success, although condemned
by Denman.  Few persons, now-a-days, mistake dropsy for preg-
nancy.  By attending to the history of the case, a correct diag-
nosis is generally formed; of course  there is scarcely one of the
signs of pregnancy attendant on  dropsy.   Dropsy may exist, and
conception also occur; the abdomen  will be greatly distended  in
such cases.   Burns recommends tapping in the early months, and
asserts it is  more successful  than towards the end of pregnancy.
Great  care must be taken,  lest the uterus should be punctured,
with the abdomen;  an occurrence that has often happened.   If
dropsy  depends on an enlarged  liver, the distension of the abdo-
men and pressure of the infant, after the seventh month, increase
the irritation, and death in general happens.  Mild purgatives and
diuretics, as  the  compound  powder of jalap,  or the electuary of'
sulphur and cream of tartar, are used with advantage until after
delivery.
   Varicose  Veins.—The legs, thighs, and abdomen, may be at-
tacked with a varicose state of the veins, or oedema, during preg-
nancy.   This condition is also induced by pressure  of the uterus
on the large veins in the pelvis, and thus interrupting the circula-
tion.   These varicose tumours, although painful, are not danger-
ous ; the recumbent posture and tight pressure generally give re-
lief; but tight bandaging is injurious,  and must be resorted to after
delivery.
   Syphilis  may be communicated to pregnant women.   Denman
recommended the use of mercury, so as to impede, but not cure
it completely.  He was of opinion, with other eminent men, that
mercury, if used freely  would  destroy the infant.  He  recom-
mended the farther use of the remedy after delivery.   He asserts,
        41 
324
GYN.SCO-PATHOLOGY.
be found in the section On Diseases of the Internal Genitals, p.
177, which are to be  treated in the manner therein described.
  Abortion, Miscarriage.—When the foetus  is expelled before
the sixth month, the  process is called abortion,  when after this
period, premature labour.   There is first a separation of a portion
of the membranes  from the uterus, which is followed  by haemor-
rhage, and next the expulsion of the foetus with its appendages.
  There is always more or less  pain with haemorrhage during ab-
ortion, and the process of expulsion is both tedious and imperfect
during the first three months, as  either the embryo or its appenda-
ges will  be  retained  for days or  weeks.  Abortion  is generally
over in two or three  days,  yet  it may not be  completed  for six
weeks.   WheA it occurs during  the first two months, we can only
distinguish it from  excessive menstruation  by the blood coagula-
ting, an appearance seldom witnessed in the menses.   The quan-
tity of blood lost will vary according  to the age of the foetus; it
may be  from one to eight  pints, again it may  be very trivial.
There is most nervousness during the first three months when ab-
ortion happens; such state succeeds  the  event at a later period.
When the infant is dead abortion  will  in general happen.   Pre-
mature expulsion of the foetus may be induced  by an innumerable
variety of causes; in fact,  by every motion  and  exertion of the
parent,  by general or uterine debility, disorders of the stomach,
bowels, rectum, bladder, excessive nuptial  enjoyment in full ha-
bits, external  injury,  or exertion  of any kind, violent exercise,
muscular fatigue, much  walking,  riding,  dancing, strong  mental
emotions, either exhilarating or  depressing,  irritable and debilita-
ted condition of the womb, or its not developing beyond  a certain
extent, and the various  diseases of the  internal organs of genera-
tion already described.   It is worthy of mention, that consumtive
women, who have a great aptitude to conceive, seldom miscarry.
those who marry  late  in  life are  most liable  to it.  Habit, too,
will effect it and we know that women  may  abort  successive-
ly at the third month so often as twenty-three  times.   Many dis-
eases impede  the developemtnt  of the foetus, as scirrhus, polypus,
moles, excessive menstruation.  Vigorous salacious women, new-
ly-married, often miscarry from  too  much nuptial indulgence, so
that when abortion successively  happens to well-looking, healthy,
young* married women,  we are to suspect this cause.   Diseases of
the infant, or its coverings, are  frequent causes;  it may die, and 
DISEASES OF PREGNANCY.
323
regulated by a saline clyster, a rubefacient embrocation is next to
be tried, and if this fail,  venesection  and leeches to the affected
part, with hip-bath, will become  necessary.
   Spasm of the uterus may be induced  by the last affection, or
may be idiopathic, and is soon followed by hysteritis.  The ovum
is generally expelled, and the woman  dies soon afterwards.   The
treatment necessary in this  formidable case is the antiphlogistic,
with anodyne clysters.  Leeches are  to  be applied to the  groins
or vulva, hip-bath and internal use of opium are to be used ;  and
should the  disease proceed, in  defiance of these remedies, the ra-
pid employment of mercury, both internally and externally, affords
the only  chance  of success.  The free  use  of opium, by the
mouth and rectum, is strongly advised by Bates and others, as will
appear in the article on Puerperal  Diseases.
   Violent motion of the foetus causes much sickness and uneasi-
ness, which are produced, perhaps,  by too much sensibility of the
uterus.  These symptoms are extremely urgent in cases of the
neuralgic pains, already mentioned.  Relief is obtained by regu-
lation of the bowels,  and anodynes at bed-time.  In  the latter
complications the  practice has been already detailed.
   Umbilical and ventral hernia may occur during pregnancy, and
are to be relieved by a proper bandage.
   In  first pregnancies the abdominal muscles are often unyielding,
or they distend unequally, and in either  case there may be much
irritation of the abdominal parietes.  This is best relieved by an-
odyne fomentations and liniments.
   Inodorous or foetid gas has escaped from the gravid uterus, and
also during parturition (Mauriceau, Larrey de Nismes, Baudeloc-
que), and  this physometra,  or  uterine  tympanites, may  not be
discovered before  parturition.
   Hydrometra, or uterine dropsy, has  been already alluded to,
p. 317.
   Moles, hydatids, and polypous tumours may exist  in the ute-
rus during pregnancy.  See pp. 202, 207.
   Tubal, abdominal,  and ovarian pregnancies  are described by
by authors under the term extra-uterine  gestation ;  but these are
of such rare occurrence that we need not allude to them further
in this compendium.   (See p. 310).
   Various other diseases may exist during pregnancy, which will 
324
GYNJEC0-PATH0L0GY.
be found in the section On Diseases of the Internal Genitals, p.
177, which are to be  treated in the manner therein described.
  Abortion, Miscarriage.—When the foetus  is expelled before
the sixth month,  the  process is called abortion,  when after this
period, premature labour.   There is first a separation of a portion
of the membranes  from the uterus, which is followed  by haemor-
rhage, and next the expulsion of the foetus with its appendages.
  There is always more or less  pain with haemorrhage during ab-
ortion, and the process of expulsion is both tedious and imperfect
during the first three months, as  either the embryo or its appenda-
ges will  be  retained  for days or  weeks.  Abortion  is generally
over in two or  three  days,  yet  it may not be  completed  for six
weeks.   When it occurs during the first two months, we  can only
distinguish it from excessive menstruation  by the blood coagula-
ting, an appearance seldom witnessed in the menses.   The quan-
tity of blood lost will vary according  to the age of the foetus; it
may be  from one  to eight  pints, again it may  be  very trivial.
There is most nervousness during the first three months when ab-
ortion happens;  such state succeeds  the  event at a later period.
When the infant  is dead abortion will  in general happen.   Pre-
mature expulsion of the foetus may be induced  by an innumerable
variety of causes;  in fact,  by every motion  and  exertion of the
parent, by general or uterine debility, disorders of the  stomach,
bowels,  rectum,  bladder, excessive nuptial  enjoyment in full ha-
bits, external  injury,  or exertion  of any kind, violent  exercise,
muscular fatigue, much walking, riding, dancing, strong  mental
emotions, either exhilarating or  depressing, irritable and debilita-
ted condition of  the womb, or its not developing beyond a certain
extent, and the various  diseases of the internal organs of genera-
tion already described.   It is worthy of mention, that  consumtive
women, who have a great aptitude  to conceive, seldom miscarry.
those who marry  late  in  life are  most liable  to it.   Habit, too,
will effect it and  we know that women may  abort  successive-
ly at the third month so often as twenty-three  times.  Many dis-
eases impede the developemtnt  ofihe foetus, as scirrhus, polypus,
moles, excessive  menstruation.   Vigorous salacious women, new-
ly-married, often miscarry from  too much nuptial indulgence, so
that when abortion successively  happens to well-looking, healthy,
young" married women,  we are to suspect this cause.   Diseases of
the infant, or its  coverings,  are  frequent  causes;  it may die, and 
ABORTION.--MISCARRIAGE.
325
be converted into a mole, or hydatid.   Emetics, purgatives, em-
menagogues, or mechanical interference may cause abortion.
   Many of the causes of abortion have been described, p.  145 ;
and here I should state,  that plethoric  women, who menstruate
freely, or the irritable, excessively sensible, nervous, hysterical,
lymphatic, delicate, who have  large blue eyes, or those tainted
with syphilis, scurvy, rickets, or labour under any chronic disease,
abort  most readily, so also those who reside  in marshy, malarious
situations.   Certain states of the weather render abortion epidem-
ic (see p. 146).  All chronic diseases of the uterus and all affec-
tions of the ovum will induce it.   Diseases  of the chorion, amni-
os, vesicula umbilicalis, and   vesicula  erythroides produce this
event.  Almost all  the diseases to which  infants are subject after
birth  may affect them in the uterus,  and cause abortion.  Falls,
blows, or external injuries of any kind on the abdomen, may sep-
arate  the placenta, and produce the expulsion of the uterine con-
tents.   Mechanical causes must be recollected, more especially in
a forensic point of view.   Pregnant women should avoid  long
walks, hastily running up stairs, lifting heavy weights, unpleasant
sights, heated rooms,  stimulating or warm drinks, which hurry the
circulation, much vegetable  food,  which causes  flatulence and  ir-
ritation in the  intestinal  canal, late suppers, much  bowel medi-
cines,  tight lacing,  immoderate use of tea, coffee,  opiates, and
narcotics, long repose in warm feather beds, severe study,  in  a
word, all causes that  debilitate mind or body.
   These are frequent  causes,  but  others might be enumerated,
perhaps to infinity.   With regard to the prognosis, or termination
of a threatened abortion, there  is no malady out  of the many " to
which flesh is heir," that requires so much caution in pronouncing
an opinion.  We can never be positive whether it may or may
not happen.   Besides, it may lay the foundation of many chronic
diseases, or at once destroy the female by haemorrhage.  " We
must  be also cautious," says M. Desormeaux, "as the disposition
to abortion becomes less, according to  successive  pregnancy."
The French law  makes  it a veritable homicide  to provoke  abor-
tion.   Spontaneous abortion,  however  imminent, is not always
inevitable, even though  blood  has escaped, and the labour  pains
have commenced, or even if the membranes give way.  (Pent-
land,  Burns, Desormeaux,  Morlanne, and the author.)—In  some
cases  the rupture of a hydatid  causes the effusion (see  p. 210). 
326
GYNJECO-PATHOLOGY.
Again, one foetus may be  expelled  and another remain,  and be
developed, or a dead  foetus may be converted into a mole.  The
prognosis in abortion is often  doubtful, but in general favorable.
  The  treatment may be divided into preservative, palliative, and
active.   In all cases, the cause is to be removed, the urgent symp-
toms alleviated, and the female confined to  the horizontal  posture
on a couch, or much better on a bed.   A mattress, or sacken bot-
tom, should be preferred, the apartment to be airy, the bed-clothes
to be as light as possible, no fire to be allowed unless in winter,
and the most perfect rest of body and mind to be observed.   All
offfciousness of nurses and their garrulity to be prevented, all mar-
vellous  stories  do mischief by depressing the patient's mind, and
one or  two persons only should be allowed  in the chamber;  they
are sufficient for every useful purpose.   The diet should consist of
the vegetable jellies, as sago,  arrow-root, tapioca, water-gruel, bar-
ley-water ; the drinks to be mild, as lemonade, barley-water, he.
and  are to be taken  in the recumbent posture, and  rather cool.
This plan will usually succeed in preserving the infant, unless the
uterine  pains be urgent, the discharge of blood copious, the orifice
of the womb gradually dilating, and the woman advanced in  preg-
nancy,  when  preservation, or  palliation, is of no  avail.  If the
pains be slight  and irregular,  and no discharge, this  plan will be
effectual, and may be  assisted by  the exhibition  of an opiate.
The horizontal  posture  is to be observed  for weeks or  months,
especailly if  the woman has  aborted frequently, and must be con-
tinued until the usual period of aborting has  elapsed.   The French
writers  lay great stress on  blood-letting, either  in the arm or  foot ;
a practice not depended on in this country.   Desormeaux recom-
mends  the application of  leeches to  the groins, vulva, and anus,
to relieve local plethora.   Duges asserts that bleeding is the best
means  of arresting febrile or  inflammatory labour, by giving the
uterus the contractility it wants.
   In this country, venesection is considered one of the best means
of promoting uterine contraction in tedious labour, when the pa-
tient is  plethoric, and has been for some time labouring under use-
less pains.   If the pains  cease in the case under consideration
and the abortion  be averted, the patient should take  a light, mo-
derate  diet,  live  abstemiously, avoid exertion and conjugal  inter-
course,  take gentle exercise in the open air, and regulate the bow-
els by mild laxatives. 
ABORTION.--MISCARRIAGE.
327
   If the symptoms  of abortion or miscarriage be urgent between
the third and sixth month, the pains constant, the womb dilating,
the discharge  of blood considerable,  then we mnst endeavour to
use  palliatives.   The treatment just described  must h& resorted
to ; a napkin,  wetted with cold water, or vinegar and water, in the
proportion  of half a pint  to  the quart, is to be appled to the na-
ked  abdomen and genital fissure; and the opium and  acetate of
lead, and the tampon or plug, together with the cold injections de-
scribed  under the treatment of excessive menstruation,  p.  233,
employed.   Blundell recommeds drachm doses of digitalis, to act
on the circulation; but Haighton found this a most dangerous and
unmanageable remedy.   The  plug  or  tampon recommended by
I lippocrates, Moschion, Paulus Eginetus, Hoffman, Desormeaux,
Lachapelle, Capuron, Velpeau, Duges, Smellie, Leroux, Den-
man, Hamilton,  Burns, Merriman, Dewees, he. is now generally
employed.   In this country,  old linen or calico is  preferred; the
French use chapie, Dewees, a sponge  squeezed out  of vinegar.
Any of these substances, after being wetted in a saturated solution
of alum, and smeared with some oleaginous matter, is to  be passed
into the vagina, in order to act as a nidus, on which the blood may
coagulate.   The vagina is to  be completely filled with  the plug,
otherwise the  haemorrhage may go on  to a  considerable extent.
A fold of linen is then to be applied  to  the  genital  fissure, and  a
T bandage is  to be put on.   Nothing is more easy than the ex-
traction of the plug,  with the fingers, and this, as well as its safety
and great utility, ought  to be explained to the patient.  It will
not prevent the  evacuation of the bladder, if properly applied:  if
it does, it is to be partially withdrawn, to allow the escape of the
urine.   In some cases the genital fissure is  so much  contracted,
and the vagina is dilated,  that much  pain will be produced in pas-
sing strips  of calico, or a sponge of sufficient  size, and in other ca-
ses the vagina,  though tightly plugged, may dilate, and haemor-
rhage return.   Under these circumstances an injection  of a weak
solution of alum and water will often arrest the bleeding.  De-
wees applies a bladder of cold water to the  pubes.   Blundell re-
commends  sprinkling the  abdomen by  means of a hearth-brush
dipped in cold water.
   Dewees, Conquest, and others recommend the injection of cold
water into the rectum, or a solution of acetate of lead and opium;
but this practice is generally very much  objected to by the woman. 
328
GYN.SEC0-PATHOLOGY.
If the patient be of full habit, venesection may be tried with ad-
vantage.  Dewees bled such a patient  seventeen times in seven
days, and prevented a  miscarriage.   Some of  the  older obstetri-
cians even yet depend  on infusion of roses and sulphuric acid, to
allay haemorrhage in abortion.  Would  they resort to this remedy,
if one of them cut  his  finger ?  It is just as useful in one case as
the other.  When regular uterine pain commences, I believe noth-
ing can prevent expulsion ; and our chief endeavour should be to
restrain the haemorrhage as much  as possible,  for this is the  real
cause of danger.  If regular pains become more violent, after a tri-
al of the remedial measures enumerated, we might accelerate the
expulsion of the infant  by the use of the secale cornutum, or ergot
of rye, in  the manner already described.  Tedious haemorrhage is
often caused and  may  continue for five or six weeks, in conse-
quence of the ovum, or a part of its appendages, being retained,
and when in the orifice of the womb, may be drawn down with  a
finger,  or a clean curved dressing forceps.   Levret, Leroux, Bur-
ton,  Dewees, and Blundell, recommend a wire forceps to be pas-
sed into the womb in such cases;  a practice strongly censured by
Puzos  and many  others,  and long  since discarded in practice.
There  would  be imminent  danger of tearing  and wounding  the
womb by  such an operation.   (Duges.)   If the pregnancy (says
Burns) be not beyond  the  fourth  month, it would be  better to
trust to smart clysters,  and restrain the  haemorrhage by  the plug.
Some writers recommend  the, introduction of  the hand into  the
uterus, to extract  the abortion, but this is a cruel, barbarous,  and
impracticable operation, at any period  before  the  sixth  month.
Such men seem to have forgotten the size of the uterus, and  the
progress of its development.  If any part of the ovum or secun-
dines is left  behind, we might expect haemorrhage and  putrefac-
tion, together with  severe nervous  and constitutional  irritation.
Happily the ergot of rye will obviate all these evils. The worst con-
sequence of abortion is debility, induced by  the haemorrhage,  and
hence tonics,  air, exercise,  and nourishing diet, are to be employ-
ed during convalescence.   Mauriceau, La Motte, Dewees, &.C. in-
form us that the orifice  of the womb may be dilated to a considera-
ble extent in the latter  months of pregnancy, and yet no expulsion
of the infant take  place; and yet it almost invariably happens, to
the danger of the  life of the female, when rude or artificial means
are attempted to procure it. 
UTERINE HAEMORRHAGE.
329
  The venereal disease, when imperfectly treated, and left uncur-
ed is a frequent cause of premature labour, after the seventh month
of pregnancy.  Several infants will be expelled in a putrid  state,
about the seventh or eighth month.  This cause of premature la-
bour was discovered  in Dublin, in the year 1792,  according  to
Dr. Beatty (Trans. Dub. Col. Physicians, 1824, vol.  iv.); and
has also been described by Dr. Hamilton, in his valuable Lectures
for some  years.  Both  male and female must undergo a complete
course of mercury, and then they will  have  healthy children.   I
lately had a lady under my care, who used a vast deal of sarsapa-
rilla after a slight mercurial course; but she and her husband re-
sumed the latter medicine by my advice, as they had had three
putrid children after they had taken the sarsaparilla.  The  liquor
amnii may become too redundant, and induce premature labour, in
the last months of pregnancy.  Improving the general health is
the only  cure for this disease.  Women  who  marry late in life,
are very  apt  to abort:  and in such case, I apprehend very little
can be done.  It may be worthy  of remark,  that all acrid  medi-
cines  exhibited to produce abortion generally destroy the female,
by causing inflammation of the stomach and bowels; a fact to be
borne in  mind by the medical witness.  The woman may also be
destroyed by haemorrhage and flooding.
  Premature Labour, or the expulsion of the foetus after the sixth
month, requires the same management as natural parturition. (See
p. 103.)
   Uterine Hamorrhage.—This formidable and dangerous disease
may occur at any period of pregnancy, before or after quickening,
during premature labour, during natural  labour, after the birth of
the infant, and after  the expulsion or delivery of  the placenta, in
consequence  of want of contraction in the womb.   The haemor-
rhage is slight in the early  months, owing to the smallness of the
ovum ; and  is most copious in the last months, when the vessels
of the maternal surface of the placenta are so enlarged, as in some
parts  to admit the point of the little  finger.   Of course a rupture
of such vessels,  by a partial separation of the placenta, must cause
very copious effusion of blood.  The  discharge may be sparing
or slow, or it may be copius and  sudden, when the  quantity may
vary from a  pint  to  a gallon in  a very short time.  The  pla-
centa or  decidua may be partially separated  by  the  most  gentle
exertion, in a carriage or  on foot, by blows,  falls, lifting  heavy
         49 
330               GYN.'Et O-PATIIOLOGY.

weights, he.   An uneven  step, or a  sudden start, has  caused
flooding;  and it is inevitable in those cases  in which the placenta
is attached over or near the orifice and  neck of the  womb.   It  is
always  to be looked  on as a  formidable occurrence ; and yet, on
the whole, it is, if judiciously managed, more alarming than dan-
gerous.  In every case it requires immediate and active  treatment,
which has been in a great measure detailed when treating of abor-
tion.   It is worthy of remark, that flooding is less  formidable, and
more easily controlled in the early than  in the last  months of preg-
nancy.  When the placenta is attached to the fundus uteri and is
partially separated, the blood  insinuates itself between the decidua
and uterus, and will suddenly  escape unless  coagulated, upon the
slightest exertion.  It is said  that two-thirds of the haemorrhagic
cases arise from  implantation of the placenta over the os  uteri; and
the majority of the remaining one-third depends upon placental ad-
hesion adjacent to the cervix uteri.   Nature  arrests the  disease by
syncope, or by the induction of labour.   There is no dependence
to be placed on the use of the ordinary  astringents, as kino, alum,
catechu, he.  To use the words of that eminent obstetrician, Dr.
Blundell, "they are of excellent service when the battle is won."
The acetate of lead with  opium is the best remedy.  If any pain
arise in the bowels from this medicine, a very unusual occurrence,
an injection of one ounce of castor oil and a drachm of  laudanum
should be  used as a clyster; injections of cold water, solution of
acetate  of lead  and opium, are to be thrown into the vagina and
rectum; plugging the vagina  in the early months,  and applying
cold to  the pubes and loins, as already  described,  are the best re-
medies  in  this species of abortion.   As  the strength  of the woman
always suffers from severe haemorrhage, we should administer nu-
tritious  diet,  in  order to  obviate debility, which  often  happens.
The  vegetable jellies, as  sago,  arrow-root,  pearl-barley, tapioca,
&c, strong animal broths, and jellies as soon as they can be pre-
pared;  eggs, milk, "fish,  flesh, or fowl," are to  be  employed in
proper proportion, according to the desire of the patient, or urgen-
cy  of the haemorrhage.   Dewees,  Burns,  Blundell, and  many
others, approve of this practice ;  while  Conquest advises " as lit-
tle food as possible to be given, and that neither warm nor  spi-
ced."
  If, these means fail, and expulsion  of the infant appears to be in-
evitable, the  flooding  continuing urgent, it has been proposed by 
I7TERINE HEMORRHAGE.
331
 Rigby and Merriman to pierce the  membranes,  evacuate the li-
 quor amnii, and thus  favour the contraction  of the womb.   This
 method was found effectual by the former in sixty, and by the lat-
 ter in thirty cases.  The  operation is performed by passing a fin-
 ger or two into the uterus, and then introducing  a sharp pointed
 wire, or female sound sharpened for the  purpose, through the
 membranes, thus allowing the escape of  the liquor amnii, or  wa-
 ters.   Others separate the membranes for an  inch round the ori-
 fice of the womb, while Dewees recommends the hand to be pas-
 sed  towards  the fundus uteri, in the last months, between the
 womb and  membranes, when the latter are  to be ruptured.   He
 recommends the passage of the hand thus high to prevent the es-
 cape of the  liquor amnii; but how can  this fluid escape, if the
 wrist or arm fills up the vagina?  Another extraordinary  assertion
 is that of Dr. Blundell where he recommends the introduction of
 the hand into the uterus, in  the early months; he says that there
 is danger attending it; but it is possible to introduce even a small
 hand into the  womb during the  first five months  of pregnancy ?
 Burns condemns this  proposal. Happily that invaluable medicine,
 the ergot of rye,  will wonderfully expedite uterine contraction,
 much more certainly than any other means.
   When the flooding is violent and  great prostration  of  strength
 produced, the womb incapable of contraction for want of vitality,
 the affusion of a basin or bucketful of water to rouse the uterine
 contraction, ought to  be  applied to the  abdomen.  If the  vital
 spark is all but extinct, I think, with Blundell, that such a prac-
 tice would be dangerous.   The practice might be used in the early
 months of pregnancy with less  danger.  Formerly women were
 recommended to ride  about in their coaches on rough roads, to
 separate the miscarriages; but the poor cannot have this advant-
 age.
   In  excessive flooding in the last  months of pregnancy, where
 asphyxia seems to be approaching, the  face pale ; countenance
 ghastly; pulse small, irregular, intermitting,  or absent altogether;
the respiration hurried and gasping, with jactitation of the arms and
legs ; a feeling of the most oppressive anguish ; a sense  of cold-
ness and insensibility ; the woman, on no  account, should  move or
sit up, as the slightest motion brings on a repetition of the flood-
ing and instant  death.  Blundell  bears  testimony to this point.
 Again, no man should remove the clots from the vagina in such a 
332                   GYN-flECO-PATHOLOGY.

case, as such removal would produce fatal effects.   Dr. Blundell
would not suffer a woman,  after such flooding, to  be moved for
twenty-four hours; but she might be made as comfortable as pos-
sible, by dry  napkins. Diffusible stimulants, as the  ardent liquors,
brandy, rum, whisky, gin, he. with ammonia, opium, are now to
be given freely.   Haifa  glass of any ardent spirit is to be repeat-
ed every ten or fifteen minutes, carefully watching  the effects.
When the pulse rises or  returns, the lips redden, and the woman
is roused, the liquor has done good.  A pint  of pure brandy has
been given in such cases to a  female, who  never before took a
glass full in the whole course of her life.   But the stomach, to use
the words of an able teacher, like all other parts of the  body,  is
half dead ;  and this accounts for urging the spirit so far.  Any li-
quor will be preferred to  medicine, and little or no  reliance is to
be placed on large doses  of opium, as recommended  by Hamilton
and Stewart, according to Denman, Dewees, Blundell and  Bar-
low.  Hamilton gives five grains of opium, and three every hour,
until seventeen grains are given.  Steward exhibited a  hundred
drops of laudanum, and fifty or sixty every twenty minutes,  until
the 'desired effects were produced; two or three drachms of tinc-
ture of opium may be given in two or three hours.—(Med. Chir.
Trans, v. iv.)
   When the cervix uteri begins to develope,  and the placenta  is
adherent to it, tliere will be a separation of the connecting vessels,
and  consequently more  or less haemorrhage.  The quantity  of
sanguineous effusion will depend on  the  extent of separation ;  is
at first slight, but soon very copious.  It generally occurs between
the seventh and ninth months of gestation.  It ceases for a day or
two, and sometimes  for  a  week, and on its  recurrence  is much
more copious ;  and ultimately,  after  such alternations,  becomes
continued and fatal, unless  labour comes on, or art is employed.
I have been informed of an exception to this conclusion, by a sur-
geon  of great obstetric experience, who  assured me  that he  at-
tended  a lady between the seventh and  eighth month, and found
the placenta detached to the extent of two inches,  yet  she went
to the full  period.
   In these cases we institute a vaginal examination,  and  carefully
determine whether the placenta is directly over the os uteri, or an
edge of it adjacent to this orifice.  Care must be taken not to mis-
take the membrane for the placenta, or a clot of blood for the lat- 
UTERINE HEMORRHAGE.
333
ter.  The os uteri will  be dilated, and  a soft  fungous  mass will
be adherent to it, which is the placenta.  I have been called to a
fatal case, in which there was scarcely half an inch of the edge
of the  afterbirth detached.   This haemorrhage is much more fatal
than that caused by abortion, though pregnancy has gone  to  the
completion in such cases.   (Duges.)—But in these cases, the wo-
man will be enfeebled,  premature labour will be induced, and can-
not be  effected  by art without danger;  and finally the foetus will
be dead.
   When flooding cannot be controlled in the latter months, it has
been proposed to deliver the woman by turning the infant, that is
bringing down the feet  as soon as the os uteri is dilated to the size
of a crown piece, or by puncturing the membranes, as I have  al-
ready described.  The first method is applicable to these cases in
which  the orifice of the womb is sufficiently dilated, and no ute-
rine pains  present; and secondly,  when  the  pains are urgent.
Mauriceau,  Dionis, La  Motte,  Mesnard,  Heister, Puzos, Pasta,
Kok, Leroux,  Baudelocque and Dewees  recommend delivery ;
and Meygrier  and other moderns contend  it ought to be  effected
indiscriminately.  Puzos, La Motte, Smellie, Dewees, and others,
found it difficult to effect delivery at the sixth month and a half.
In bad cases of flooding, delivery will not always save the woman.
Some persons recommend indiscriminate delivery, at every period
of  pregnancy ;  these are few in number.   Others have forced the
uterus,  about the middle  period of pregnancy, and delivered by
the feet.   Some of this class bring the feet through the orifice of
the womb,  and leave  the rest  to  nature.  The  most numerous
class wait for dilatation of the womb, or rupture of the membranes ;
others trust to natural efforts, if  the pains are strong, or deliver at
once.
   Another cause of flooding is the adhesion of the placenta over
the neck of the womb, or partial attachment to it.   This was first
described by Levret.   Rigby asserted  that dilatation of the orifice
of  the  womb seldom  happened in those cases before the time of
natural labour,  in consequence of the uterine  vessels shooting into
the placenta ; but Denman, Burns, Dewees, Baudelocque, Leroux,
Kok, and others, relate cases in which it dilated much earlier.
The best practice in this case is, to pass the fingers at the edge of
the placenta, separate it from the  womb, rupture of  the membranes
and bring down the feet, that is, perform  the operation of turning. 
334
GYNJEC0-PATH0L0GY.
If the placenta was pierced through the centre, when it lies over
the os uteri, the root of the navel string most probably would be
ruptured, and  the infant destroyed ; besides, the opening might ad-
mit the  hand  and  arm of the practitioner, but not allow the pas-
sage  of  the infant.  " Boring the placenta," is therefore highly
objectionable, if it can be separated at a side.   Smellie, Delamotte,
and Pardigon, assert,  that the placenta may separate, the  mem-
branes present, and the  placenta be first expelled.   Leroux in-
forms us, that  clots  may  form and arrest the flooding.  Baudeloc-
que states, that the placenta may entirely separate, the membranes
present  at a side, burst,  and delivery happen.   All obstetric wri-
ters agree,  that delivery should be  effected as soon as the hand
can be passed with safety, that is, when the orifice of the  womb
is dilated to the size of a crown piece.   Dewees records the case
of a  lady, who was  sitting in the midst of her family, when she
suddenly lost half a gallon of blood, owing to a slight dilatation of
the os uteri.   I  have  known a  female lose nearly a wash-hand-
basin  full of blood  in about ten  minutes, and others who bled to
death when the os  uteri was not dilated more than the size of the
disc of a shilling.
  Our indications  of treatment  are  to  prevent the  flooding, to
promote  the natural dilatation  by  the ergot, when the presentation
is natural, and to deliver with  as much speed as is consistent with
the welfare of the woman and child.
  The plug will arrest the flooding,  and is  indispensable, upon it
the life of the woman  depends;  and  if the  pains  do not  cease,
the ergot promotes  the dilatation ; and as to delivery, the strength,
loss of blood,  and  extent of  contraction, are to determine  the
proper time for its accomplishment.   Such is the treatment, when
the os uteri is  rigid  and undilatable.
  When the uterus is but little opened, but  disposed to dilate, we
are to wait for some time, and never leave the patient, lest  flood-
ing come on suddenly and destroy her.   Sometimes the dilatation
will not exceed a certain extent, according to Mauriceau, Leroux,
and Rigby; and here there  will be a danger of laceration by
turning.   At other  times, the os uteri remains closed, but is  easily
dilated, and the woman  delivered, if necessary.  This condition
is not to  be confounded with rigidity, just  described.  If the os
uteri  is opened to the  extent of the size of half-a-crown, but yet
is unyielding,  we ought to delay the operation if possible;  for al- 
UTERINE
HEMORRHAGE.
335
though the hand may pass, yet the body of the child may cause
great laceration.  By hooking down  the  os  uteri on the finger,
we will find it rigid, or  soft; if the latter, we  may deliver.
   In some women the  uterus opens very suddenly, and here de-
livery is to be speedily effected, lest haemorrhage destroy the pa-
tient.    This proves the necessity of not leaving the chamber in
placental presentations.  The uterus may open suddenly, and the
infant's head may push the placenta before it, and so press on the
open vessels as to relieve haemorrhage, as Baudelocque, Leroux,
and others,  inform us.   Sometimes  the  hand  will not stop the
bleeding, so that we must still deliver as soon as possible.   Some
recommend the  puncturing  of the membranes; this cannot  be
done when the placenta lies over the os uteri without piercing it,
and increasing the bleeding;  and even, although we perforate it,
we cannot always reach  the membranes; and  if even pierced
and the waters evacuated, the  flooding will be rarely restrain-
ed, and the difficulties of turning be  greatly increased.  If even
the flooding cease, after the rupture of the membranes,   it re-
turns on the dilatation  of the womb.  The only exceptions to
these directions, is when the  membranes present.  Baudelocque
seldom saw the rupture of the membranes stop the haemorrhage.
All the difficulties attendant on  placental  presentations, are con-
siderably  increased where haemorrhage occurs at the sixth month.
Here we cannot pass  the hand  into  the uterus, in order to turn,
without danger, and there is  a great want of disposition in the or-
gan to  dilate.  Nature saves the woman in this case, as  Rigby
and Leroux inform us  ; and we should leave all such cases, during
the first six months, to nature, and only palliate by the plug and
cold applications, and the acet. plumbi.  (Dewees, Leroux, and
 Duges.)—The plug arrests the  flooding, saves the strength of the
 patient, and favours the relaxation by allowing nature time to ef-
 fect it.  The precept  of Denman and Rigby, to allow the  flood-
 in"- to cause relaxation, is dangerous.   When there is no pain in
 placental haemorrhage, but the  womb sufficiently dilated,  ought
 we to deliver in  the last three  months  of pregnancy, for  if the
 plug is used, internal flooding cannot destroy the patient.
    The uterus  is filled  by the product of conception ; it resists all
 distension; blood cannot be effused, if a proper plug is employed,
 and this remedy allows  the  labour to proceed, which is  the most
 certain means  for removing  the  evil.  When  labour has com- 
336
GYNJEC0-PATH0L0GY.
menced, and the  presentation of the  foetus is natural,  we should
puncture the membranes,  (Mauriceau,  De venter, Puzos,  he.)
and expedite the  process  by the ergot of rye, or in preternatural
cases by the forceps or operation  of turning.  In all  cases, the
placenta should be extracted  immediately after the birth of the
infant,  and  permanent contraction of the uterus ensured by the
ergot.
  In such cases,  puncturing  the  membranes  and evacuating the
amniotic fluid, might induce uterine contraction ;  but if the  foetus
and placenta were extracted  without pain, and no contraction  to
occur,  the flooding would  be  fatal.   In the  presentations under
consideration, some  advise us to perforate the placenta, to which
there are many valid objections :   1. the increase of the haemor-
rhage,  which occurs by making a hole in it, and also the pressure
used in making such aperture, will separate it from the uterus;  2.
although the  hand may pass through such opening, the body of
the infant cannot, without enlarging it;   3. the body of the child
drawn  down to the arm-pits,  will  be  arrested; and if force now is
employed, the whole placenta will be separated, and its bulk add-
ed to  that  of the arms  and head  (Baudelocque.)   Again,  in
piercing the afterbirth, we  may rupture  the umbilical vessels, and
kill the child by haemorrhage ;  4.  it  will be difficult, if not impos-
sible, to pierce the placenta, when its centre  lies exactly over the
os uteri (Rigby).—The  placenta should  be separated from the
uterus  at  one side, as I already stated ;   the hand and  arm of the
operator press on  the bleeding vessels, and thus restrain the bleed-
ing,  which saves  the mother and infant.
  Uterine haemorrhage may occur to a frightful extent during  la-
bour, although the patient  may beat the full  time,owing to a par-
tial or  total separation of the placenta,  or a  want of uterine con-
traction to  close  up the open vessels of the  mother.   The ergot
of rye should be  exhibited, and delivery effected by the forceps,
or other means, as soon as circumstances will permit.   Unless the
placenta is speedily  expelled after the infant, affusion of cold wa-
ter on  the naked  abdomen, from   an ewer or large vessel, should
be applied, and the hand  introduced into the womb, in order to
extract the placenta, and  make pressure on  the organ, so as to
excite  contraction.  Pressure is to be made on the abdomen with
the other hand at the same time.   If  the  uterus contract, the
hand will be pushed through  the vagina, and the womb will ap- 
UTERINE HEMORRHAGE.
337
pear a hard round tumour, above the pubis, about the size of an in-
fant's head, when no more haemorrhage can take place.  The woman
is never safe until such contraction occurs.  This latter treatment
is to be actively employed after the birth of the infant, if haemor-
rhage is urgent.  Hamilton  inculcated,  " that we should wait an
hour after the birth of the infant, for the expulsion of  the placen-
ta ; but not a moment if  haemorrhage set in."   With great defer-
ence to the justly celebrated professor, to whose valuable instruc-
tions I am greatly  indebted, I must  observe, that I fear this rule
has been much abused or mistaken, and  leads generally to an un-
necessary introduction of the hand.   Young  practitioners are
alarmed, if they observe  a slight effusion  of  blood at the expira-
tion of  an hour, and immediately proceed to extract the  placenta.
But, in referring to the report of Dr.  Clark, of the Dublin Ly-
ing-in Hospital, I find that in more than ten thousand cases, it was
only necessary to  extract the  placenta  twenty times.   The pla-
centa will be mostly found  in the vagina  within an hour, or cer-
tainly within two, and will come away without any haemorrhage.
I need scarcely remark, that the introduction of the hand into the
uterus after delivery is a  most  painful operation to the patient, and
one that ought not to be  resorted to  on  every occasion,  when the
placenta is not expelled  at the end of an  hour.  Dr. Blundell  is
of the same opinion.  There  can be  no danger  from retained
placenta when the uterus is contracted, even if it  should remain
an hour or two; but  in general  it is in  the vagina before the ex-
piration of an  hour.
  The last species of haemorrhage is when  it occurs after the birth
of an infant, or after the expulsion of the placenta, and arises from
want of contraction  in the fibres  of the uterus.  This is denomi-
nated after hamorrhage.  The ergot should be given,  and pres-
sure made on the abdomen, as recommended by Smellie fifty years
ago, by placing a pillow or large volume  under the common roller.
Clarke, of Dublin,  recommends constant pressure, by the nurse,
for  six hours, lest dilatation should return  after contraction, which
 is  a frequent occurrence.   Others recommend placing alarge vol-
ume, as  the family Bible, on the abdomen, and securing it with a
roller; while others have  proposed to  sit  on the patient's abdomen.
The man who made the last uncouth  and barbarous proposal, knew
as  much about  the science of medicine as about the knowledge  of
the world or society.   In the first place, respiration would be im-
         43 
338
GYN.KC0-PATHOLOGY.
mediately interrupted; and, in the second place, no educated fe-
male  would consent  to such an indecent and ridiculous proposal.
The ergot of rye is invaluable in these cases.
   If the patient has lost a large quantity of blood, a strong ten-
dency to fatal syncope, or asphyxia, is apparent;  the  face is pale,
the lips bloodless, the pulse rapid, tremulous, fluttering, occasion-
ally absent altogether; the extremities cold and clammy, the res-
piration gasping, the deglutition gone;  there is nothing to save
the patient  but that  godlike  operation of restoring the flickering
vital spark—transfusion.   Hamilton knew the pulse  to be absent
for twelve hours, and the patient recover, by the use of  diffusible
stimuli.  In these extreme cases,  the slightest motion of the fe-
male will extinguish life.  The  removal of the clots from the va-
gina, by introducing the  hand, will produce the same effect Cold
affusion, if freely applied,  would also destroy the patient.  De-
wees  recommends  a warm blanket to be wrapped round the legs
and arms,  and cold cloths  to the  abdomen, a nice and scientific
distinction.
   There  is no disease incidental to females which requires more
serious  reflection than that under consideration; the mind ought
to be  made up as to the treatment, before the  alarm of the case
could impede our judgment, for delay or precipitancy will seal the
fate of the patient.   A question has been discussed by the  theolo-
gians, whether it was ever  lawful  to extract the infant in cases of
flooding, or placental presentation, before the seventh month, as it
could not live sooner.  But if the loss of blood is great, the infant
cannot survive, and there is a greater chance of arresting the hae-
morrhage by such extraction.   Yet it is  not a certain mode of ar-
resting flooding, and therefore is a strong argument against produ-
cing indiscriminate  abortion in all cases of haemorrhage.
   When  the  placenta presents, flooding  is most common in the
last  three  months of pregnancy, and therefore is more easily ma-
naged, as  the hand  can be passed into the  womb,  if necessary,
which is seldom the case before the sixth month.   Again, delivery
is more easily accomplished at  this period in ordinary haemorrhages.
The membranes ought not to be ruptured in any case before the
sixth month, and until every other means had been tried in  vain.
We ought  not to force  the uterus if rigid and undilatable.  The
bowels ought  to be  regulated  by laxatives, as manna, castor-oil,
magnesia, Epsom salts,  according to Hamilton; while the late Sir 
UTERINE HEMORRHAGE.
339
R. Croft and Dewees were of opinion, that constipation ought to
be allowed for three or four days.  The diet should consist of ve-
getable and animal jellies, eggs, milk, ardent spirits, warm water
and sugar, in proper quantities; a form of diet that can be readily
procured.  The diet should be nourishing in the more severe floo-
dings, as those after labour, in which the prostration and inanition
are great asphyxia  approaching, for the best physiologists are of
opinion that four or five ounces of blood, and consequently nutrition
to that amount, will save the patient.  The stomach can bear no
more than half a pint of any of the jellies at once ;  but this quan-
tity may be frequently repeated.   In extreme cases of flooding,
where  every sign of death becomes apparent, the face blanched,
respiration  scarcely audible, gasping, hurried, pulse scarcely per-
ceptible or entirely absent, cold and clammy extremities, power of
deglutition  lost; tliere is nothing to save the female but the ope-
ration  of transfusion.   The name of the man  who employed  it
successfully in restoring  human life will live for ever : the name
of Blundell will be revered as long as the god-like science of me-
dicine is cultivated.
   The operation of transfusion, is not a recent  discovery;  it
had been tried by the French some centuries ago, but was revived
and applied by our countryman  in a manner  and  under circum-
stances never before  attempted.   The  operation was first  tried in
France, where it was proposed to reanimate the aged and infirm
by transfusing  the blood of healthy young persons into their veins.
The clergy objected to this  as irreligious,  and  derogatory to the
will of the Supreme Being; and  their opposition soon put an end to
the operation.   The discovery lay dormant for many  years, until
the rage for experiments on animals in France and this country
caused it to be revived by Dr. Blundell.  He was the first who
proved to demonstration, that human blood might be infused into
human veins with safety; nay, with the perfect success of restor-
ing human life, when it was all but become extinct, from loss of
blood,  as often happens in the worst cases of uterine haemorrhage.
He tried a  great number of experiments on dogs, drained them to
asphyxia and death,  and resuscitated  them afterwards by the sy-
ringe, and  the blood of their own species.   He found that when
he used human blood, or that of the other  animals, the dogs,  al-
though revived, died in a  short time afterwards ; and this fact was
suggested by Dr. Locock, in his Thesis,  published at  Edinburgh 
340
GYNECO-PATHOLOGY.
about twelve years ago.   The blood of one genus of animals can-
not be substituted in large quantities for that of another.  Dr. Blun-
dell also proved, that the passage  of blood  through the  syringe,
although of course deteriorated, yet would not be fatal to human
life.  For a full account of his experiments, see  Medico-Chir.
Trans., Physiological Researches,  and  Lectures  in  the Lancet;
all  of which are well worthy of attentive perusal  and reflection.
From a most attentive perusal of all the observation on transfusion,
I shall endeavor to sum up a succinct, although  perfect descrip-
tion of the operation, in as  plain a  manner as possible.
  The usual mode of  performing  the operation  is as  follows :—
We take a two-ounce brass syringe, tinned  internally, perfectly
air-tight; not clogged with oil, yet perfectly free and clean, with
the lateral tube affixed in the manner employed for injecting,  and
at the end of this tube is a small  ivory one, also perfectly clean,
with the extremity somewhat  bevelled.  The basilic or cephalic
vein in the patient's arm, is to be  cut  down upon with a  sharp
scalpel, and separated from the integuments, so that a  probe may
be passed under it.  It is then  to be opened, about one-eighth of
an inch with a lancet, perfectly clean and in  the  best order;  and
we  are now to ascertain whether the small ivory tube can be easily
and freely inserted into the opening.  We  are  next to heat  the
syringe by warm water, or by drawing up the piston several times,
so that when the blood is drawn into  it, coagulation will not take
place.   This done, we open  the vein  in the male  person,  by a
free incision, and receive the blood.
  The blood is  to be drawn into the syringe, the instrument be-
ing  held  in the vertical position, and a  small  quantity left  in  the
vessel, for if all  were taken,  air would also be taken into the in-
strument.  Now reversing the syringe  still vertically, the handle
of the piston being lowest, we force  out about a tea-spoonful of
blood, thus expelling all the air from the tube and end  of the syr-
inge ;  and this done we place our finger on the end  of the  ivory
canula, lest the air rush in, or  the weight of the  piston  press  it
down ; we now give the instrument a horizontal direction, and car-
ry the end of the tube to the vein  of the woman.  The assistant
is to press the vein with  the  probe, and  thus prevent the flow of
blood, and sponge all  off the  opened  vein,  if necessary;  when
done, we are now cautiously  and steadily to  introduce  the  ivory
tube, about half an inch  towards the heart;  we are then to inject 
UTERINE HEMORRHAGE.
341
the blood slowly and  gradually, for if suddenly, we should over-
power the heart, and  extinguish life.   We should slowly and cau-
tiously urge on the blood, and  watching the countenance of the
patient; if the lips quiver, or eyes flicker, we are to cease ; if the
countenance improve, then we  are to proceed.   If we are obliged
to delay for a minute  or two, we must  discharge the  instrument,
and refill  it with  blood, in  the same manner  as already stated.
We are to wait six or eight minutes between each injection, that
the injected blood may circulate through the system, even where
the operation  succeeds according to our wishes.   The syringe  is
to be washed  out with tepid and cold water  between each  injec-
tion ;  and  from four to sixteen  ounces of blood, although eight or
ten are generally sufficient, may be injected.   Dr. Blundell as-
sures us, that  four or  six turn the balance in  our favour; but that
the large  quantity may be  used, if we wish to  restore vigour.   If
the respiration stop, all is over ; if the respiration go on well or
improve we have every hope of success.  Such is the brilliant and
wonderful operation of transfusion.   There will be great difficulty
encountered in the  performance of this operation, unless  the vein
is fairly raised on the probe, and unless the  syringe is  in  perfect
order.  The former will be experienced when operating on the
dead  subject.
   All the objections that are raised against transfusion, are equally
applicable to any capital operation in surgery, which is also  likely to
prove fatal.   I think  there are thirteen successful  cases now on
medical record ; and  if even the operation were less successful, as
the Caesarian section  certainly is, yet it ought  to  be performed.
It is the only  chance  of life for  the patient; and I apprehend there
is none  of us  if equally reduced by haemorrhage, as a patient for
whom the operation is necessary;  nay, if even  friends,  more dear
to us  than ourselves were concerned, but would readily submit to
this only chance of existence.   The simple and golden  rule laid
down in the sacred volume, " do  unto  others as you would  wish
they should do unto  you," is here applicable,  and is to direct us
in the performance of this operation.   Ask  the question  in  your
mind  : would  you submit to the operation, if equally situated, or
would you perform it on  the  nearest  friend, the partner of your
heart, and an  inward  monitor will apprize you,  whether it is right
to resort to it or not.   No doubt  flooding of  the most alarming
kind will not prove fatal in nineteen out of twenty cases:  but then 
342
GYNJEC0-PATH0L0GY.
in the twentieth case, is the only chance  of life  to  be withheld
from the patient ?   I  answer, no; for if the operation fail, the pa-
tient can only die, and will die without it.  In  this, as  in  all ex-
treme  cases  of medicine  or surgery, it is  our  imperious duty to
give every chance, if even one chance out  of a hundred be in fa-
vour of the patient; such is the opinion of that Leviathan of the
profession, the late Dr. Gregory, of Edinburgh.   I cannot  state
precisely what are the chances in  this case; but  I rather think
that there are thirteen chances to one in favor of the  operation.
The great dangers of the operation are  immediate  death, if too
quickly performed, or inflammation of the vein,  afterwards extend-
ing to the heart, which hitherto has not happened.
   Before I conclude my remarks on this subject, I should observe
that reaction is to  be  expected after severe haemorrhage, with or
without transfusions;  and this should  prevent us from infusing
more blood than is absolutely necessary for  resuscitation.   Such
reaction is not to be subdued by antiphlogistic measures.  Haigh-
ton observed that bleeding, leeching, and blistering, did not  relieve
the vertigo, and  other symptoms consequent to uterine haemor-
rhage.   Who could think of bleeding a woman in extreme flood-
ing, or after transfusion, but an ignorant man,  and one who  for-
gets the loss of blood  already sustained.   A troublesome diarrhoea
occasionally succeeds  during the convalescence  after flooding, and
may withstand all  the  ordinary remedies, and will be found to
yield to change of air, when all else fail; this may appear incredi-
ble, but it is a certain fact;  of course, the  ordinary  remedies are
to be employed.
   Before I dismiss the subject of  flooding, it is to be  borne in
mind, that it may take place during labour, and this species  is of
the most alarming kind.   If the woman have arrived at the latter
months, or end of pregnancy, delivery is to  be effected by turning,
or the  forceps, as soon as  the os uteri will permit of it.   Another
species of flooding is  that which occurs when labour has been te-
dious, and then a  tremendous  haemorrhage will come on,  as the
placenta may have been separated  for some  time.  Pressure on
the uterus, and extraction of the placenta, are to be resorted  to in
the manner hereafter  to be described.   Affusion of cold water is
here really most valuable, before much blood has been lost.   We
should remain with a  patient, after bad flooding, four or six hours,
as the  flooding may return in  such time and  destroy her;  and in 
UTERINE HEMORRHAGE.
343
such cases, no matter how much the patient or nurse may entreat,
there should be no  " putting to bed," that  is, making the woman
comfortable by change of posture.  She is to  remain twelve or
twenty-four hours in a most quiescent state, as the slightest motion
would bring on the flooding, or haemorrhage;  and she is to be
made as comfortable with dry napkins as possible, but without any
motion.
   Flooding may occur after delivery,  or  there may be internal
flooding; the womb being filled with blood.   In all cases of te-
dious or lingering labours, the first thing we should do after deliv-
ery, is to press the hand on  the  abdomen; and  if we find  the
uterus contracted, hard, and like a full  grown infant's head, all is
right; there is no room  for internal  haemorrhage ; if the womb
cannot be thus felt, then it is  dilated, and  there is great  danger.
The introduction of the  hand  is a most unpleasant operation,  and
happily is seldom necessary. We should be ever averse to introdu-
cing the hand into the uterus ;  it is a most painful, cruel, and dan-
gerous operation, not only to the poor sufferer, in consequence of
the contraction of the passage after delivery, but it is abhorrent to
our own  feelings,  and injurious to our reputation.   By  grasp-
ing the womb through the abdomen,  rolling the hand on it, or
shampooing it, we  shall  succeed in causing it to  contract, as well
as if we introduced the  hand  into the cavity.   Bandaging  and
pressure, as already described, are here most useful and important
auxiliaries.  The womb may be contracted and again dilated, and
these states recur alternately for an hour or two after delivery;
here of course  there is  danger of haemorrhage.  I have  lately
seen a case of this kind with Mr. Wilson, of Northampton Square,
 which required pressure with the hand for three hours, ergot and
 cold affusion.   In  spite of strong pressure, the uterus dilated re-
 peatedly.   Another  frequent  cause  of flooding after delivery  is
 retention of the placenta,  and this I explained on a former occa-
 sion ; it prevents the full contraction of the uterus, and thus the
 open vessels may pour out  their contents, for they are only closed
 by uterine  contraction.   A portion  of the  placenta  may be re-
 tained, and hence  the rule  always to examine that substance after
 expulsion, in the presence of the nurse or some  of the females;
 for if we neglect it, this examination will be made in our absence,
 and  our knowledge a  good deal questioned by a jury of matrons.
 The uterus may be partially or completely inverted, and may be 
344
GYN.SC0-PATH0L0GY.
 in the vagina or beyond the external  parts, and cannot then be
 found above the pubis ;  it is to be reduced as soon as possible.
   A portion of the placenta may remain  in the utero, and hence
 it is a grand rule always to examine that mass, by spreading it on
 a napkin, and even  where it has  passed  before  our attendance.
 This examination satisfies our own mind, and the mind of the pa-
 tient and her friends.   We ought also to pass up a finger, to exa-
 mine whether the womb be  inverted, which may occur, if too
 much  force  be used in  pulling the umbilical cord.   The womb
 has been inverted and drawn down between the limbs by midwives,
 and  then cut off.  This  is called  renversement  by the French.
 If the womb is inverted  in the vagina, flooding will be kept up for
 a considerable time,  unless we shall discover the cause.  1 have
 observed cases of flooding produced by this cause, which continued
 for six weeks after delivery.  When there is  a  sanguineous dis-
 charge after  the ninth or tenth day subsequent  to  delivery, we
 ought to suspect this  cause.   Replacement of the uterus, plug-
 ging the vagina, acetate of lead with opium, and cautious stimula-
 tion  where prostration  occurs, are the  best remedies.   If a por-
 tion  of the  placenta,  not larger  than  a walnut, remain in the
 uterus, flooding will come on, and prove  very troublesome.  Such
 portion may  be  left by the operator,  when he is flurried by the
 alarm of uterine flooding.   The ergot  is  of great value in this
case.  In  such cases, or  where the whole  placenta remains in the
 uterus, friction on the abdomen, gentle pressure, grasping the ute-
rus, or shampooing,  will  frequently excite contraction.   Should
 these methods fail, the flooding be great,  and the strength of the
 woman allow it, the hand must be  gradually and cautiously in-
 troduced in a conical  form into the uterus, following the cord to
the placenta ; and as soon as the hand shall reach the placenta, it
is to  be separated at the  circumference  and drawn to the centre,
which readily detaches  it, and when loosened, we are to press the
knuckles on  the  uterus gently,  while the other  hand is to make
pressure on the abdomen, and  thus  will contraction  be induced;
in a word, the uterus ought to contract, lessen its cavity, and force
down the hand and the placenta.  The contraction of the womb
is most necessary in all cases of flooding,  and is the only certain
and infallible means of arresting  the  haemorrhage.   Dr. Hamil-
ton's rule is never to be  forgotten, which is, " if there be haemor-
rhage,  the placenta is to be extracted  as soon as possible," unless 
UTERINE HEMORRHAGE.
345
the woman be moribund, and then if we attempt  it,  the patient
will expire, as I have witnessed ; " wait an  hour after delivery, if
no haemorrhage—not a moment if haemorrhage," unless asphyxia
be present.   We shall  best  prevent flooding  and asphyxia by
keeping the woman in the horizontal posture, with the head low,
for by obstructing the circulation in the brain, and accumulating it
about the heart, by raising the lower limbs  with pillows, we shall
best prevent these, and fatal syncope.  When faintness is slight,
we need not interfere—if deep and grave, then we are to stimulate.
We are to depend  on ardent spirits, as brandy, rum, whiskey, gin,
he., with which most women are more satisfied than with medi-
cines.   The  vagina must not be plugged, lest internal haemorrhage
should occur.  We can always learn from  the patient, whether
she found any thing coming  away ;  care must be taken that hae-
morrhage does not  take place in the bed without her knowledge,
which  is obstetrically called hidden flooding.   The countenance,
respiration, pulse,  and state of the womb are to be closely exa-
mined, and their appearance taken  conjointly, which will enable
us to form a  proper prognosis of the danger, or unconsciousness
of uterine haemorrhage.  We are to  bear in mind,  that uterine
haemorrhage  is  more alarming than  dangerous; for  in nineteen
cases out of  twenty,  the woman will recover.   A  recollection of
that fact will tend  to allay too much  perturbation.  Our minds
should be always tranquil in these cases, and our reason and judg-
ment should  be clear and collected.   Again, if the  patient sur-
vive a bad flooding five or  six hours, she will in general do well.
Happily, copious flooding is a rare occurrence in ordinary practice;
and we may  be years in active practice and not meet half a dozen
cases of it, although it may happen that our first essay in obstet-
ric life will be  connected with  this  occurrence;  we  must recol-
lect that the  employment of the means already pointed  out, will
enable us to  treat  it with success.   Before  1 dismiss this subject,
there is one  other remark well worthy of consideration, which is
management or prevention of frequent  miscarriages.   Some wo-
men will abort four or five  times in twelve  or fifteen months, and
suffer great haemorrhage on  each occasion, so that their health and
strength will soon  be destroyed.  1  have known this  happen to a
fine young woman, during the first year of marriage ; and the con-
sequence was, that she died of phthisis in fifteen months from her
bridal day.   How  are we  to manage such  casts?  We cannot
         44 
346
GYN^CO-PATHOLOGY.
advise any unnatural preventives of procreation, without incurring
a weighty moral responsibility.
  If procreation  be impeded or prevented, the moral crime is as
great  as if the grosser, beastly, and unnatural means  were resort-
ed to.   Canonists,  divines,  and  lawyers,  hold the affirmative of
this opinion.   A separation  of the parties  can only be proposed,
a cessation of connubial  intercourse,  which will be seldom com-
plied  with, and will lead too often to infidelity and domestic mis-
ery.   Depraved and loose  as the  present  age is, L cannot bring
myself to imagine that a recommendation of performing the pro-
creative act imperfectly could be  safely inculcated, or  would be
generally  complied  with  by even  illiterate individuals.  A great
moral guilt, and an open violation of  the divine and  natural law,
would be  effected by any unnatural suggestion on this  point. The
frequent repetition of the conjugal act would be natural, but  yet
debilitate  the female ; this, however,  is still  less objectionable
than any of the artificial  methods proposed by the French, or by
the disciples of Malthus  in  this country.   The French proposal,
although partly unnatural, is effectual in preventing insemination ;
while the  modern plan proposed  in  this country is not a bar to
procreation.
  Article  XV.—Dystocia,  Difficult,  Preternatural
Labours, Mechanical, Manual, Artificial, he.
  These terms, with  the exception of the  first, are too arbitrary,
and have led to a great confusion  among authors.   The designa-
tion of dystocia employed by Hippocrates, Sauvages, Merriman,
Blake, Desormeaux, and others, expresses the whole  of the cases
of labour  which require the  aid of art, and is decidedly preferable
as a generic term.
  The subdivisions of this  class proposed  in  this work are more
explicit  and exact than those at the  head of these remarks;  for
example,  dystocia,  haemorrhagica  has been placed in the  classes
of difficult,  preternatural, laborious, mechanical, manual, and in-
strumental labours,  according to the pleasure of the different wri-
ters.  It is evidently better  to base upon nature the causes of dif-
ficult labour.   This plan offers real and incontestible  advantages ;
it allows us to reduce or  multiply  the genera or species without
injuring in any  way the general classification ;  and it combines all
the methods proposed by authors.   After all,  difficult labours  are 
MORBIB PARTURITION.
347
characterized  by the accident  that complicates them, and not by
the kind of succour  which they require.
   The causes which render labour difficult depend on the mother
and the infant.  Those of the  mother are the acute diseases, as
inflammations of the brain or its membranes, of the lungs or pleu-
ra, of the peritoneum, or of the uterus,  Sec. which  occur during
labour; a haemorrhage  which  endangers  the  life of the mother
and of the infant; convulsions, syncope, prolapsion of the uterus,
premature  expulsion of the placenta  or of the  umbilical  cord,
hernia, aneurism, asthma, deformities of the pelvis, and  the vari-
ous diseases of the  generative  organs, which  narrow the vagina,
as fibrous and other  tumours; transverse  presentations of the foe-
tus, its deformities and diseases.

   Section  I.— Obstacles dependent on   the Mother.—Dystocia
                         anenergica.
   1. Inertia of the  Uterus.—Inertia  of the  uterus depends on
two causes; 1.  torpor, or primitive feebleness;  2. exhaustion.  In
the first, there is want of power and flaccidity; in the second, fa-
tigue and  rigidity,  or permanent contraction  without  expulsive
efforts.
   Causes.—Organic lesions, lacerations,  over distention of the
uterus by an  excessive  quantity of water,  (hydramnios), or by
twins, fever, abuse of alcoholic liquors,  sometimes fright, shame,
drowsiness, distention of the bladder, and sudden  discharge of the
amniotic fluid,  produce the first  species of inertia; all the me-
chanical obstacles dependent on the mother or foetus produce the
second, which is most  common with  the primiparous, or in first
labours.  The premature rupture of the membranes allows the es-
cape of a small quantity of water  during  each  pain, and prevents
the uterine contractions from dilating the  orifice.   Labour is then
prolonged, and the multiplied  contractions it requires,  cause ex-
haustion.   In all cases of protracted labour, this exhaustion may
occur, and  expose the woman  and foetus to great danger.  This
fact must never  be forgotten by the obstetrician.
   Treatment.—Our first indication is to dissipate the  inertia, when
this is possible, which  may  be  effected by frictions  on the abdo-
men.    A moderate use of cordial and stimulant drinks, of clysters
and catheterism, may be highly efficacious.   In cases of distend-
ed bladder during labour, we must sometimes  use a gum  elastic 
348
GYNJECO-PATH0L0GY.
male catheter straightened, as the female instrument may be found
too short.  Rupture of the membranes  is  to  be effected when
there is over-distention of the uterus.   The ergot of rye is inval-
uable in these cases, in the doses already described, p.  141.
   Exhaustion will be removed  by repose, which is to be induced
by some  of the sedative preparations of opium,  as the acetous so-
lution  of the  Dublin  Pharmacopaeia,  Battley's sedative liquor,
morphine, &c, and  these are always to be preferred to common
laudanum when our  object is to allay  pain, and  produce  sleep.
The French writers  recommend warm baths or fomentations, fu-
migations, and blood-letting.  With respect to venesection, it has
been strongly recommended in  cases of rigidity of the  soft parts
of the  generative  organs, by my justly celebrated preceptor, Dr.
Hamilton, of Edinburgh.  This was his practice when the patient
was robust; and  the starch and opiate  clyster when she was  del-
icate.  I can add my testimony in  favour of the  great value of
these   remedies.   When the membranes are  very strong,  they
ought to  be  ruptured,  either with the finger,  or a female sound
sharpened.   When these means fail, Duges advises us to termi-
nate labour, by version, or turning, the forceps, he.  I do not think
it possible that the ergot of rye, when properly  preserved, can fail
to excite uterine  action;  and  if  the  delivery  be  accomplished
without the contraction of the  uterus,  there would  be  danger of
hour-glass contraction and haemorrhage  ; and if  the organ was not
excited on the extraction of the  placenta by  the obstetrician, which
might fairly be expected in a case of great  prostration of the vi-
tal powers in  consequence of exhaustion, death  must be the inev-
itable consequence.  But I am  very  confident that few  cases can
occur,  in which uterine action cannot be induced by the remedies
already mentioned.

        Mechanical  Obstacles offered  by the soft Parts.
   Dystocia  ectopia ;  Obliquities of the  Uterus.—These have
been already  described, p. 315; but I may observe, that right lat-
teral obliquity is most frequent,  in the proportion of one hundred
to one  of the left.  The effects of obliquity are displacement of
the os  uteri, so that the expulsive efforts cannot dilate this open-
ing, it. being carried to one side, or pushed backwards, so that one
of the  parietes of the  neck  presents in the centre of the pelvis;
pressed by the foetus, it is expanded and  thinned,  and descends 
MORBID PARTURITION.
349
into the vagina, or appears at the vulva (Morgagni, Slevogt, Bau-
delocque,) where it is lacerated, or becomes gangrenous, and gives
a passage to the infant, or it is incised  for this  object (Cathral.)
More frequently nature reduces the orifice  to the centre, and di-
lates it (Boer) ; above all, it is reduced by placing the woman on
the opposite side, and by bringing the  orifice to its  proper  place
with the  finger (Baudelocque, Dewees, see p. 317.)—The  inter-
nal orifice is sometimes rigid, tense  without our being able to de-
termine whether it be the  result of organic derangement, or a state
of spasm or cramp ;  its sides are thickened,  hard, rounded ;  it has
even, in  some instances, been  thought  advisable to make incisions
into them: an uncertain method, and which may cause lacerations
extending as far as the  body of the uterus.   More frequently, af-
ter a considerable lapse of time,  which weakens the womb, and
invariably produces pains in the kidneys, the orifice becomes sof-
tened, thinned,  and dilated.   Warm  baths, fumigations, blood-
letting, hasten this happy termination,  which often requires  much
time and patience.   In order to hasten it more, opium, in clysters,
have  been recommended  (Asdrubali) ;  the application of an oint-
ment made of the extract of belladonna  has proved successful
(see p. 135.)
   It is not unfrequent to find this orifice surrounded with scirrhus,
thick,  hardened, rounded with uneven edges.  The orifice resists
for several days all efforts at  expulsion, at last it becomes lacera-
ted in several parts, the scirrhus lobes separate, and allow the child
to  pass; but  the uterus, by being fatigued, requires1 frequently to
be aided  by making use of the hand or the forceps.  It is not im-
possible but that an extensive  scirrhus  may destroy the life of the
woman, instead of yielding to the usual remedies.  In similar cases
the neck of the uterus has been seen to break off above the scir-
rhus, the child tear the rectum, and pass out by lacerating the anus
(Archives de  Medicine).   This would probably be a case for ma-
king several slight incisions around the uterine orifice by the means
of a bistoury, covered with linen nearly to the point (Baudeloc-
que).  This  method has been used with success.   Probably the
scirrhus  may  be easily  removed, and this cancerous degeneration,
which brings on death in a few months, a year, two years, or even
more, prevented.
   Finally, the neck of the uterus being thinned as much as  possi-
ble without rigidity or scirrhosity, it may happen that its external 
350
GYNjECO-PATHOLOGY.
 orifice  will remain  closed, and almost obliterated.  It has some-
 times been thought that there was a complete adhesion of its edges,
 and  that  laceration was necessary for the passage of the child.
 The orifice may possibly be deformed by cicatrices, rendered less
 distensible, and may even require incisions ; it may be conceived,
 that  although  the examples are doubtful and of rare occurrence,
 that  the  adhesion of the lips of this orifice has  been complete
 (Portal,  Martin,  Amand, Sanson, Weis) ;  but in many cases it is
 only apparent; an  inequality, somewhat deep,  is felt at first near
 the centre of the  hemispherical projection,  formed  by the thinned
 neck of the os uteri,  distended, and forced out by the waters or
 the  head of the foetus ;  this point yields  to the pressure of the
 end of the finger, by which the lips of this orifice are separated,
 and which, if  we may be allowed the expression, are hidden, ob-
 structed, and agglutinated by those thick mucosities which are found
 usually at the  neck of the uterus.   When once the separation
 has  been  effected,  dilatation  follows spontaneously and  without
 difficulty, and this obstacle, which had for a long time resisted the
 uterine efforts,  gives no more obstruction to the progress of  labour.
 If art does not aid nature, the latter will at last effect the separa-
 tion and dilatation of the  opening.
   Tumours of a fibrous, hydatic, sarcomatous, osseous, and syphi-
 litic character,  may  offer an obstacle  to the passage of the child
 (Viardel,  Mauriceau,  Voigtel, Beclard, Moreau, Jackson. Med.
 Repos. 1826, Peleten.  Clin. Chir. torn, i., Park. Med. Chir. Trans.
 vol.  ii., Davis,  he,) either having taken root in the uterus itself,
 in the ovary, or in the vagina (Merriman, Lachapelle, and others),
 or they may be  produced  by  the walls of  the pelvis itself, (See
 p. 202, et seq., Thiery, Drew, Stark, and Ramsbotham.)   A cal-
 culus in the bladder, a considerable thrombus of the sides of the
 vagina,  may cause the same effect (Voigtel.) Sometimes, those
tumours will allow of  sufficient compression, so as to permit the
spontaneous passage of the infant, or by the aid of the forceps, or
by version if it  be alive, or craniotomy if dead.   At other times
we should try to remove those  tumours (polypi, calculi), to push
them above the superior strait (Beclard) ; tumours  filled with
matter may be opened  ; and finally, if  those tumours should be so
numerous  as to obstruct altogether the passages, and cannot be dis-
placed by  art, extracted, or destroyed, no other resource will re-
main, but  the Caesarian operation.  In a case of this kind,  nature 
MORBID PARTURITION.                351
may effect delivery (Beatty and  Crampton, Dublin Med. Trans.
1824, vol. iv. see p.258).
   Imperforation of the  vagina  by bands, membranes  either con-
genital or accidental, the hymen being rigid (Boehmer, Baudeloc-
que, Smellie, &c.,) may offer so  much  resistance to  the passage
of the infant, as to render labour difficult (see article on Impo-
tence, p. 248); but it  rarely happens  that nature alone cannot
overcome such   difficulties, either by dilatation or laceration, and
may be assisted by incisions.   The same thing is observed in co-
hesion or cicatrices of the  genital fissure.   But as the vulva and
perinaeum are gradually dilated, by the repeated pressure of the in-
fantine head during labour, we should  allow sufficient time, and
have sufficient  patience before we resort to incisions ; and it is on-
ly when the rigidity is such as to offer an invincible obstacle, that
an incision becomes  necessary to prevent laceration,  which may
extend even to the anus.  The necessity for such  operation is
however extremely rare, and has not  been met with during a long
life  of active practice.   In rare  instances  the  vagina has opened
into the  rectum (see article Impotence) ;  impregnation and par-
turition have taken place (Lois, Barbout) ; but this is still  a more
rare occurrence.
                     Dystocia Amorphica.
   Mechanical  Obstacles formed  by the Pelvis.—The deformities
of the pelvis have been partly described in the article of Gynaecot-
omy, p.  9.   The brim, or superior  strait, may  be deformed  in
every part, and its  dimensions  be diminished  so  much  that the
pubis may approach the sacrum,  and vice versa.   Exostosis may
form any part of the osseous canal of the  pelvis.  The  rami  of
the  ischium may approximate so closely as almost to touch each
other ; and the coccyx  may be within an inch of the pubis.  Every
imaginable degree of deformity between the  natural  dimensions
and these now  mentioned may take place.   The  causes  of these
malformations have been detailed in  the article already referred to
(p.  9.)  I have also described the dimensions which ought to dis-
qualify the other sex from  marriage, and these are to be ascertain-
ed  by the finger, or according  to the French,  by  pelvimeters.
(See pp. 9, 10, 246.)
   Prognosis.—The degree of deformity must determine our prog-
nosis.  We have to fear the prostration of the  vital powers by the
long protraction of labour,  fever,  inflammation,  rupture of the ute- 
352
GYN^CO-PATHOLOGY.
 rus, gangrene, and fistulae (vesico-vaginal,  or  recto-vaginal) from
 compression of the soft  parts.   We  must recollect  that delivery
 may  happen though there is considerable  impediment, either by
 relaxation of the pelvic joints, by putrefaction of the infant's head,
 or by premature labour.   The infant  is destroyed when subjected
 to much compression by fractures of its bones,  or when  born by
 apoplexy, convulsions, or asphyxia.
   Indications.—These are based upon the degree of contraction
 or deformity, upon the life or death of the foetus, its age, and the
 strength of the woman.  1. We should favour spontaneous labour,
 which may happen when the sacro-pubic diameter is three inches
 and a half in  extent.   2.  The long forceps will diminish the head
 and effect delivery in such a case ; but version or the operation of
 turning, will save most infants.   It has been found, at the Mater-
 nite of  Paris, that the  former saves less than  one-half, the latter
 fully two-thirds.  3. We should  favour  premature labour, when
 the infant is viable, which is after the  seventh month.  This  me-
 thod was proposed by Macauley, and  is adopted in Germany and
 Italy, as well as in  this country.   This operation, which is  per-
 formed for the preservation of the  infant's life as well as the  mo-
 ther's, is a felony, according to the law of this country.   (See
 Abortion.)—But the   humane and benevolent  intention  of our
 criminal  law  on  this,  and all  occasions, is highly commendable,
 though here erroneous.
   The French resort to symphyseotomy or division of the pubic
joint in these cases, when  the infant is alive;  but this is an opera-
 tion not performed in these countries.   (See pp. 7, 307.)
   4. Craniotomy is performed in this empire ; but not until the infant
 is dead in other countries.  In extreme cases of deformity,  the in-
 strument called terebellum, or cephalatrobe by the present Baude-
 locque,  of Paris, who is  nephew to the distinguished obstetrician
 of that name, or the instrument of Professor Davis, of the London
 University, will  be used with advantage in extreme cases  of de-
 formitv.
   5.  Gastro-hysterotomy, or the Caesarian operation, is performed
 in France when the infant is presumed to be alive, and when the
 sacro-pubic diameter measures only two inches  and  a half.   This
 operation is not performed  in  the British dominions under such
 circumstances;  Craniotomy  is prefered. 
MORBID PARTURITION.
353
        Section 2.— Obstacles dependent on the Infant.
  It has been long held by  women, that the death  of  the infant
impedes labour.  This dynamic obstacle is at present regarded as
no criterion;  it, however, is certain, that a dead  foetus  paralyses,
in some degree, the uterus, by depriving it of the sympathetic ac-
tivity which the living child keeps up  in  its circulation ; besides,
a putrified foetus is less under the influence of the movements and
mechanism of parturition ; it fills up the passages, and is often te-
diously  expelled.   But these difficulties are not in any  respect so
serious as those we are about to describe.

      Obstacles arising from Malpresentation of the Foetus.
  This  article treats of all those obliquities of the foetus, depend-
ent or independent of those of the uterus.  The obliquities of the
pelvis prevent  the proper position of the foetus, force it in a direc-
tion contrary to the axes of the pelvis,  pressing the  presenting
part against the walls of  that cavity, or against the border of the
superior strait.   These are to be remedied by the means pointed
out under the head of uterine obliquity, or by those recommended
in cases of preternatural presentations.
  The  posterior obliquity  of  the foetus occurs frequently,  and
more so in  first labours,  when the abdominal parietes  being but
slightly distensible force  back the fundus  of the  uterus, causing
those positions known by the names of super-pubic, and head re-
tained  above the superior strait, they are without any  known
cause, and  frequently embarrass the obstetrician.
  It is  to  be recognized, 1st, by that particular elevation, and  by
the position of the head of the child above the pubis, or sometimes
it is difficult to reach it;  2dly,  by the vacuum which remains be-
hind the head, at the opening of the strait, or as much as can  be
felt  in  consequence of  the sac of the membranes, or the wa-
ter  contained therein ; 3dly, by the elevation  of the uterus and
the flattening of the abdomen.
  It not unfrequently happens that the membranes burst, and the
foetus is precipitated into the cavity ; but sometimes it continues
elevated, and the labour  must be accomplished  by artificial  means.
  Instead of having recourse to version, as some  eminent practi-
tioners advise,  upon a misunderstanding  of the circumstances, we
have always succeeded in lowering the head of the foetus, by di-
recting the woman to walk about, or remain  standing up,  especi-
        al 
354
GYNJECO-PATHOLOGY.
ally at the moment the membranes burst.   It may even be of ser-
vice  to place her on  her knees and elbows, so that the body of the
foetus falling forwards, the elevation and depression  of the whole
womb may bring the head  backwards and towards  the centre of
the strait.  We have sometimes been able to reduce the head into
the same centre by pressure upon the hypograstric region, as re-
commended by Baudelocque, in certain false presentations of the
ear.   Version should always be a last resource.

Obstacles arising from an irregular Position of the Part pre-
                sented at the Superior Strait.
   Presentation of the  Vertex.—The occipito-posterior and the
transverse are frequently of such a mechanism as  to require the
aid of art, and particularly  the use of forceps.
   They may be all different from the obliquities of the uterus, by
slight irregularities of the pelvis, or some primitive arrangement of
the foetus, by  the  presence of twins, he.; the consequences are,
that  the head  cannot be bent so as to enter the  excavation, and
offers to the strait  the anterior part of the  head, or even the  fore-
head ; that one of the parietals may  be retained by the sacro-ver-
tebral angle (anterior obliquity, malformation of the pelvis), most
usually occurs, or by the pubis (posterior obliquity,) occurring sel-
dom, or by one of ilia (lateral  obliquity), which  is  still  less fre-
quent.  The other parietal then advances into the cavity, the ear
gets  near the superior strait, and can be felt.  Can the head form
an excessive flexture, and  present the occiput  too plainly ?   We
think not, although this has been made the subject of a particular
set of presentations.
   These alterations can be distinguished  by the displacement of
the sutures and fontanelles, which have been described as signs of
natural presentations.  These imperfections are often rectified by
the effect of uterine contractions; but sometimes they must be ob-
viated by art, either by adjusting the head, or by effecting version.
Others recommend the lever, or one branch of the forceps. When
the child is dead,  we should  perform the  operation of Cranioto-
my.

                       Dystocia glutealis.
   Pelvic presentation.—When the  breech presents, we should, by
the  aid of the fingers,  fillets, or blunt  hook,  applied  over the 
MORBID PARTURITION.
355
 groins, assist in extracting the  infant.   The forceps applied over
 each hip will often  materially assist delivery.   This  is the most
 common presentation next to the vertex.

                      Dystocia humeralis.
   Presentation of the Shoulders.—When the shoulder, arm, or
 any part of the trunk, from the base of the skull to the breech,
 presents, we must  perform  the operation  of version.  This  is a
 general rule, liable like all  such, to exceptions.  I  have  known
 two instances in which the arm presented;  the pains having ceas-
 ed, the arm was returned, the  head brought down  in the  proper
 relation of the  pelvis, and the rest of the labour was natural.  But
 this success is  not to be always expected,  as the greater part of
 obstetricians have observed  the immense  difficulty,  nay, imprac-
 ticability, of this operation, and hence recommend version in  per-
 formance.   When the uterine contraction is violent,  the arm or
 shoulder impracted in  the pelvis, and  version impossible, as soon
 as the infant is destroyed by compression,  we should decapitate it
 with a scalpel  or blunt hook, as recommended by Celsus, Smellie,
 and Vanhorne, and laying hold of  the arm for  the extraction of
 the trunk,  and by applying the forceps to the head, we can readi-
 ly extract  it; or should we find this difficult, pressure should be
 made  on the abdomen, the  bead fixed in the pelvis, and its  vol-
 ume reduced by craniotomy.   I fully agree with the eminent Vel-
 peau, that  all preternatural  presentations may be divided into, 1.
 those of the head, 2. those of the breech, and 3. those of the shoul-
 der.   The presentations of the feet, knees, and breech, are exam-
 ples of spontaneous version; and many anormal positions  of the
 head, including frontal, occipital, facial, and aural  presentations,
 are to be relieved by imitating this operation, by performing ver-
 sion.   When the arm  or leg  presents with head, we should, in the
 absence  of pain or uterine  action, return  either into the pelvis,
 and this  1  have repeatedly done without the woman having been
 aware  of it.
  Malformation of the Foetus.—When the infant is hydrocephalic,
or has dropsy of the chest, abdomen, or spine,  labour will  be im-
peded ; but these causes are  of rare occurrence, and are to be ob-
viated  by paracentesis  or  tapping, after the uterus had sufficient
time to effect  delivery.  When the fluid is evacuated, the uterus
may expel the foetus; and  should this not happen, we  should 
356
6YNEC0-PATH0L0GY.
 have recourse to the  forceps,  to version or cephalatomy.   Such
 tumours developed on different parts of the foetal  trunk  may im-
 pede parturition ; but these can scarcely be discovered during la-
 bour.   The simultaneous presence of many infants in the uterus,
 may  offer impediments  to delivery.   In twin cases, both infants
 may present in  the natural way, or one may  present the vertex
 and the other the feet.   Cases are recorded in which both heads
 presented through the genital  fissure at the same time, before and
 at the expiration of the full period of pregnancy.   This  fact was
 illustrated  by the  Siamese boys, and  the Hungarian  sisters,  al-
 ready  mentioned.  This union  of infants offers  great varieties,
 whether by a circumscribed junction on the trunk  or superior ex-
 tremities, or on the whole surface of the  back or abdomen, or even
 by  the heads.    Sometimes there are two heads on one trunk, or
 two trunks for one head; and  again, the lower extremities of two
 bodies to one trunk.   An infant may be expelled by the feet until
 its head is in the pelvis; and that  of another foetus may descend
 into the  same cavity, when both will be  immoveable.   In such
 case, the forceps or version is impracticable, and craniotomy must
 be performed.   But then a question arises, which head is  to be
 opened ?   Velpeau proposes detroncation, it is not stated of which
 foetus, as the only resource we possess to save  the mother and one
 infant.   Now, supposing that the protruded infant  is alive, which
 actually  occured in a case recorded by  Dr.  Fergusson in the
 Dublin Medical  Translations, 1830, is the  infant to be sacrificed ?
 The narrator intended to craniotomise the other;  but nature ex-
 pelled the second head first, accompanied by that of the first. The
 first infant was dead, the second  alive.   Perhaps it might be pos-
 sible, in the absence of uterine action, to push  up both heads, so
 as to raise that of the  second  above the pelvic entrance  or brim;
 while the other might be depressed into the cavity of the pelvis
 by traction on the body or  neck of the  infant  partially protruded.
 The positions of the head impede labour.

                Dystocia  Facialis et Frontalis.
  Facial and frontal presentations usually terminate without  as-
sistance ; but sometimes require operations which will be described
 hereafter. 
MORBID PARTURITION.
357
               Dystocia Occipitalis et Nuchalis.
   Occipital and nuchal presentations are exceedingly rare, and
are to be rectified with the fingers, the lever, or one blade of the
forceps.

                Dystocia Auralis et Temporalis.
   The aural, temporal, and lateral positions are to be reduced to
the vertical presentation by the means stated in the last paragraph,
and if the shoulder is low,  version ought to be performed.  There
is  a general rule applicable to  all  malpresentations of the head,
that they should be reduced to natural, if possible, by the means
just  stated; and if these fail, embryotomy  must be resorted to.
The various operations  under this head will be  described in the
article on Artificial Parturition.

          Section 3.—Accidents relative to the Mother.
   Various accidents occur  to women during parturition, and these
differ according  to their situation.
   A woman who makes violent efforts of expulsion, and suppres-
ses her voice, or " holds in her breath," may become affected with
emphysema of  the neck and chest.  This arises from rupture of
some part of the trachea.   The disease disappears spontaneously
in  a few days ; but in some cases punctures become necessary.
   The symphises, or joints of the pelvis, are more or less relaxed
during pregnancy  and natural labour, and in some cases the pubic
and sacro-coccygeal joints are lacerated and inflamed. The inflam-
mation may extend to  the peritoneum,  to  the glands  or vicinal
nerves, and cause phlegmasia dolens, according to Velpeau. These
abscesses  are  generally  fatal, and therefore ought to be  prevented
by local and general bleeding,  warm bath,  fomentations, calomel
and opium.   I have already described the treatment of  inflamma-
tion of the pubic and sacro-coccygeal joints,  (p.  6. 307.)
   The  ovary and  uterine  tube have burst  during labour, and
caused fatal haemorrhage.  The  distended bladder has burst, and
caused fatal  peritonitis  (Ramsbotham.)—There  may be  chronic
peritonitis and hysteritis, and gangrene of the uterus, before deliv-
ery ; cases of which I  have witnessed.   (See Lond. and Mod.
Surg. 1831, vol. v. vi.) 
358
GYNiECO-PATHOLOGY.
                    Dystocia Laceratoria.
   Rupture of the uterus may occur in all cases of preternatural or
dystocial labour, but more especially when there is some mechan-
ical obstruction to the passage of the infant.   It may occur in na-
tural  labour, and during pregnancy.  The symptoms  and treat-
ment have been,  in some measure, described.   (See p. 308.)   I
may, however,  remind the reader,  that rupture or laceration  may
take place in any part of the  uterus ; the haemorrhage  is seldom
fatal; but the escape  of blood,  amniotic fluid,  or  some  part  or
whole of the infant into the cavity  of the abdomen, will generally
induce fatal  peritonitis or enteritis, as the infant only can be remo-
ved.  Nevertheless, when the foetus is extracted, the patient  may
recover.   This fact is now well attested by recent writers. (M'Ke-
ver,  Labat, Collins, he.)
   Treatment.—When the rupture is slight, and situated near the
orifice, the application  of cold,  astringents, and the plug ;  and
carefully to  guard against abdominal inflammation.   Opium, and
wine  when  there is much  prostration, are highly  useful.   As a
fold of intestine descends through  the laceration, it has been  pro-
posed to cut through the linea alba to relieve the strangulated in-
testine (Pigrai, Labat.)—This operation can be seldom, if ever,
necessary ; as it is easy to return the bowel into the abdomen ;  at
least I have found it so.
   When the infant  has escaped into the  abdomen, with the ex-
ception of the  head,  which remains  in the  pelvis, the  forceps
should be applied to accomplish  extraction.   If the  foetus  has
passed entirely  through  the uterine laceration, the hand should be
passed after  it,  the feet  grasped and brought through the opening,
and the operation of version performed.   But  should the lacera-
tion be small or  diminished by uterine  contraction, so as to  pre-
vent the  performance of version, and the woman vigorous and the
infant alive,  it is generally recommended to have recourse to  gas-
trotomy.  This practice has succeeded (see p. 311, et seq.); but
it appears to me to be,  in general, unnecessary, for  many  valid
reasons.   It is  to be recollected, that the uterus can be dilated by
the gradual pressure of  the hand ;  and here we must bear in mind
the occurrence  after dilatation of the organ, and I  cannot under-
stand upon what grounds it is said  that the uterus cannot be dila-
ted, and that the  body of an infant cannot be brought through an
aperture, through which it has already passed.   Even admitting 
MORBID PARTURITION.
359
this conclusion, it is manifest that a further laceration of the organ,
by the extraction of the foetus, could scarcely be more dangerous
to the woman than cutting  through  the abdomen, and  exposing
her to the danger of an  operation generally fatal,  and doubly so
from the effects of the laceration.  Again, it is universally admit-
ted that  the uterine contraction almost always ceases on the oc-
currence of the rupture, and  therefore there can be no  difficulty
in passing the hand through the lacerated opening, and extracting
the infant by the feet.
  When the woman is moribund immediately after the rupture, it
is recommended to introduce the hand, and bring down the infant;
and if this be impracticable, which I cannot  think,  to perform gas-
trotomy to save the infant.   But how can  we  ascertain that the
infant is alive ?   Do we not generally find  it is usually destroyed
by compression long before rupture takes place?   If  these ques-
tions are answered in the  affirmative,  it is obvious that  we ought
to hesitate in laying open the abdomen of a woman in  the agonies
of death for the extraction  of a dead infant.   Neither can I agree
with the proposal of performing gastrotomy after death, as advised
by some writers.  If  there was reason to  believe that the child
was lately alive, the operation should be performed in a few min-
utes, for example, in a quarter of an hour after the mother expir-
ed, as the infant might be resuscitated.  Dr. Blundell succeeded
in saving  the infant, though extracted by gastro-hysterotoray fif-
teen minutes after the mother had expired.   (See p.  169.)
   Rupture of  the vagina  is followed by the same consequences
as described in the last  paragraph,  and requires  the  same treat-
ment.   This accident is not so dangerous as the former; it usual-
ly yields  to proper treatment.
   Rupture and sanguineous infiltration of the labium arise from
laceration  of the spongy tissue of the vagina by continued com-
pression of the head.
   The labium  becomes tumefied to such  a degree  as  to oppose
the passage of  the infant, the evacuation of the bladder and rectum,
and the tumour formed  by it is of a black colour.   The swelling
extends to the  bladder and rectum, and terminates in abscesses,
which may prove  fatal.
   The treatment consists in incision of the labium, evacuating the
coagulated blood, and plugging the vagina to prevent haemorrhage.
   Rupture, inflammation, and gangrene of the  vagina,  of the 
360
GYN^CO-PATHOLOGY.
bladder, and rectum, may occur from the long continued pressure
of the head upon those parts, the results of which will be perfo-
rations of the bladder and rectum, technically denominated vesico-
vaginal and  recto-vaginal fistulae.   The consequence of  these dis-
gusting and  distressing  fistulae are incontinence of urine and faeces.
These openings  appear about the second or third day, and when
small may heal spontaneously (Hildanus, Mauriceau), and when
large are treated with sponges,   pessaries, and the catheter (De-
sault).  These means  having proved ineffectual,  the actual caute-
ry has been  applied by Dupuytren, upon the principle that burns
contract, and he also employs the  catheter.   This plan  has be-
come general, (seep.  177;) but is not  invariably  successful.
Lallemand has cured a large  transverse  vesico-vaginal  fistula by
the repeated application of nitrate  of silver.  The sutures pro-
posed by Hobert (see p.  179, and  Naegele  have been used with
success by Malagodi; but may also fail.   Holmes and Earle have
proposed the introduction of a gum-elastic bottle.  While writing
these pages, and since  my description of the disease under notice
in a  former part of the work, (p. 178) was  printed, an interesting
case of this  kind was placed under my  care.  The sufferer was
twenty-one  years of age, of low stature, general  health  always
good, was delivered of her first child after a labour of three days'
duration.  The medical attendant said there was  no malformation.
On examination, it was discovered that she  had recto-vaginal and
vesico-vaginal fistulae.   She  was  visited by Dr. Conquest, who
was of opinion an operation was indispensable ; and  he  recom-
mended the  patient  to  Mr. Earle.  She however applied to  Mr.
Brodie for the purpose  of performing the operation  ; but that gen-
tleman declined to operate, and advised her to  place herself under
the care of Mr.  Earle, in St. Bartholomew's  Hospital.   On ap-
plication at that Institution, she was admitted under Mr. Lawrence
who, with Mr. Earle, considered an operation impracticable, as
there was no laceration of the perinaeum,  and as the genital fissure
was  so contracted as to preclude the possibility of applying sutures
to the vesico-vaginal aperture.   An ingenious and most industri-
ous pupil of mine, Mr. Hargreaves, of Burnley,  Lancashire, then
dresser to Mr. Vincent in  the hospital, proposed  my plan of treat-
ment to  Mr. Earle; but he  considered  it  not likely to succeed.
The patient remained in the hospital for a fortnight, and was then
dismissed, with the  declaration,  " that nothing could be done  for 
MORBID PARTURITION.
361
her."  My intelligent pupil  thought this an unwarrantable decis-
ion, and  therefore recommended the  patient to consult me, and
place herself under my care, should I  consider any treatment like-
ly to be of use to her.  She first consulted Mr.  Salmon, who
thought he might cure the rectal  aperture.  I saw her on  the 6th
of May last, two months after delivery.   On making a  vaginal
examination, I experienced  considerable difficulty in introducing
the finger.   This arose  from the contracted  state of the genital
fissure,  which was as small as  that of a person at puberty, but
more especially from  the existence of a strong ligamentous band,
which ran across the vagina, and occupied the situation of  the hy-
men.  It occupied the lower third of the vaginal orifice, and could
not have escaped laceration  during  the passage of the infant, had
it existed before delivery.   On passing the finger beyond it,  I dis-
covered, a transverse aperture in the neck of the bladder,  fully an
inch in  length,  and about three  lines in width ;  its edges were
smooth and  hard, and it was sufficiently capacious to admit the in-
troduction of two fingers.  There was  an opening in the rectum
an inch and  a half in length, and the vagina  was in  a high state
of irritation  from the  passage of the faeces and urine into that ca-
nal.   The vulva was slightly inflamed.   The urine was constant-
ly escaping  from the vagina.  The general health was excellent.
The treatment consisted in relaxing the  bowels, and keeping them
in that state, in introducing  as much oiled lint as was borne  with-
out pain, and strenuously advising the patient to lie on either side
or on the face, so that the urine might be collected  on the sound
surface of the bladder, and  the cause of the irritation in the vagi-
na in this way removed.  In three  days  the vagina was  filled
tightly with  oiled lint, which was removed every third day.  This
plan was pursued in until the  1st July, when the faeces no longer
escaped through the vagina, and the vesical opening was contract-
ed to the size of a sixpence.  The urine escaped  in  diminished
quantity.  The  fibro-membranous growth had gradually ascended
towards the pubis,  and formed  an excellent support for the tam-
pon  or plug.  The patient remained in bed during this treatment,
and  was allowed to sit up in the  middle of July, as scarcely any
urine passed through the opening  unless on  coughing or walking
much.  She suffered no inconvenience, and on the 1st of  August
considered herself well.  At this time the fistula was scarcely per-
ceptible ; but the orifice of the vagina is nearly closed by  the ad-
        46 
362
GYNJECO-PATHOLOGY.
ventitious membrane already mentioned.  This  production must
be incised, as it will effectually prevent  sexual  congress.   The
operation is deferred until exercise in the open air will remove the
effects of such long confinement.   The result of this case clear-
ly proves that fistulae of the description under  notice may be cu-
red without sutures, caustic, or cautery.   It shews the importance
of attending to the position of the patient during the treatment.
In all the cases I have hitherto heard of in the London and French
hospitals, the  patient was allowed to lie on her back, and conse-
quently the escape of the urine into  the vagina, or in other words
the cause of irritation was allowed to continue.   Under such cir-
cumstances, a cure could not be  reasonably expected.   It was un-
necessary to  employ catheterism in  this case,  as the urine  was
retained by the position of the patient as soon as the  vagina was
plugged, and it was regularly voided by the urethra.   In another
case of vesico-vaginal  fistula  an abscess formed, and pointed on
the tuberosity of the ischium, on  opening which a  pint of foetid
pus escaped;  the constitutional irritation and hectic continued, and
in despite of all remedies the woman sunk in a month afterwards.
The nymphae  may be inflamed  or lacerated;  but little inconven-
ience arises, and the treatment must be conducted upon antiphlo-
gistic principles.
   Rupture of the Perinaum.—When the genital fissure  is small
or rigid, as in  young girls or women advanced  in life, the head
large, instruments badly applied, the  perinaeum labiorum and peri-
naeum may be lacerated, and the passage of the shoulders enlarge
the laceration, unless the perinaeum  is properly supported.  The
laceration may occupy the superior  part of the perinaeum, or the
inferior  part near the sphincter ani.   In some cases the laceration
occurs in the centre, and as the  head advances through the supe-
rior part, it extends through the  inferior commissure.   My friend,
Mr. Matthews met  with a case of this kind,  in which there were
first, two perpendicular lacerations, one of which extended  through
the commissure.  I have seen a case in which there was an open-
ing in the centre of the perinaeum.   Merriman relates such cases,
as also  Duges.  In first cases  of labour there is a slight laceration
at the vaginal  edge of this part.   In such cases,  simple  dressing
to prevent the irritation of the lochia and urine,  and keeping the
limbs together by a bandage, effect  union by the first  intention.
But if the laceration is considerable, the  insertion of sutures be- 
MORBID PARTURITION.
363
comes necessary;  and should its edges cicatrize without cohesion,
their surfaces are to be excised and sutures applied.

                   Dystocia Hemorrhagica.
   Hamorrhage during Labour.—This may depend on laceration
of the vagina or neck of the uterus; but it most commonly arises
from separation of the placenta,  and it is distinguished from the
former by the abundance of blood which follows the labour pains.
The practice in this case has been partly  described in the section
on haemorrhage in the last months of pregnancy,  in speaking of
the plug, rupture of the membranes, he.   Sometimes natural la-
bour will arrest the haemorrhage ; but the rule is to deliver, as soon
as possible, in unmanageable cases, either by the forceps or by ver-
sion.   (See p. 336.)
   Dystocia Convulsiva—Labour with  Convulsions.—The con-
vulsions of parturient women may be local or general;  a single
member or part may be affected as the face, or all muscles, as the
pharynx,  oesophagus,  stomach, intestinal tube, bladder, uterus,
heart,  diaphragm,  and voluntary muscles.  The synonyms of
dystocia convulsiva are convulsio apoplectica, apoplexia hysterica,
a. lactusa, a. sympathetica and eclampsia.  The last term is gen-
erally employed in France.   The cause of this disease is conges-
tion in the brain.  The subjects most liable to it are nervous, irri-
table, and delicate women, and more especially those who are in
labour for the  first time,  and who are  illicitly in  this  condition.
   Some have gone so  far as to say  the disease was occasionally
epidemic.
   Symptoms.—The patient complains of intense pain in the head,
vertigo, confusion of ideas,  depraved vision or hearing, defective
speech, mental depression ;  the countenance is wild, or  she is at-
tacked with general convulsion without any premonitory symptom
Dr. Hamilton  was  wont  to  observe, that there was  generally in-
tense pain in the  forehead, which  was a premonitory sign.   When
the fit comes on, every muscular organ in the  body  may be con-
vulsed.  In some  cases  the contents of the stomach, intestines,
bladder, and even of the uterus, are expelled during the paroxysm.
The duration of the paroxysm  is  as variable as its intensity;  it  is
in some cases of ten, fifteen, or thirty minutes; in others it con-
tinues twenty-four hours.  Coma may supervene  and render the
patient insensible for some days, and terminate  in complete resto- 
364
GYNJEt O-PATHOLOGY.
 ration of health (Velpeau) ; but it may end in apoplexy and death.
 Certain functions may be depraved after recovery, as vision, hear-
 ing, smell, and even some of the intellectual functions, and these
 are  explained  by some degree of compression  on  the brain.
 When the woman recovers from the convulsive fit, she is  languid,
 and  generally unconscious of what  has happened.
   When consciousness returns in the interval between the fits, the
 convulsions are designated epileptiform; and  when  coma and
 stertor supervene, they are called apoplectic or eclampsic.  This
 division is useful, as the  epileptic  or hysteric convulsions  are less
 dangerous than the latter, and differently treated.
   The autopsy does not always account for the symptoms.  Some-
 times there is a small  quantity of serum in the ventricles, the  en-
 cephalic  veins and sinuses are more or less engorged ; the meninges
 and  cerebral  substance  are red  or natural, or there are  evident
 marks of congestion, or effusion of blood.   In many  instances no
 appreciable lesion exists.
   The prognosis is unfavourable, as a third of the affected is des-
 troyed.   The disease is of rare occurrence; but certainly not so
 rare  as  the French would lead us  to believe.   They say, that it
 only occurred in sixty-five out of forty thousand cases.   It is much
 more common in  these  countries,  and very often supervenes on
 transverse and other dystocial labours.   It occurs in the last three
 months of pregnancy, or  during labour, and is less  dangerous after
 delivery.
   The infant is usually destroyed in convulsions, from the extraor-
 dinary movements during the fits.
   Treatment.—In these kingdoms, copious depletion with camphor
 mixture,  ether, he. are chiefly employed.  When there is reason
 to suppose the  disease is of the epileptic or hysterical character,
 the most  powerful antispasmodics, as opium, ether, castor, camphor,
 he.  are  used by  the French.   Dr. Hamilton considered opium
 highly injurious, and copious depletion with camphor mixture the
 best  remedy.   Mauriceau,  De la Motte, and Puzos, were strong
 advocates for venesection ; and there can be no  doubt of the val-
 ue of this remedy, when  the signs of cerebral congestion are une-
 quivocal.  The venesection should be  repeated to the third or
 fourth time, according to the strength of the patient, and the blood
should be taken from a large orifice; should the pulse contra-indi-
cate repeated venesection, thirty or forty leeches should be applied to
the temples, behind the ears or to the neck. When coma supervenes, 
MORBID PARTURITION.
365
we should abstract blood by cupping from the neck, and apply si-
napisms  to  the  feet  and legs.   The temporal artery might be
opened with advantage.   I should prefer this operation to cupping
in a desperate case, as blood can be taken more rapidly.   Bau-
delocque, and others preferred opening the saphena vein in all ca-
ses ; but this practice is not followed at present.
   Tepid-baths are useful,  when  apoplectic symptoms  are absent,
and after blood-letting, if the patient is in a fit  state  to lose blood
without danger, otherwise they promote the afflux of blood to the
head ;  they are to be avoided when the convulsions  depend upon
loss of blood or inaction, as after  severe haemorrhage.
  The woman might remain in the bath about twenty minutes and
cold water or ice might be applied to the  head  at  the same time
(Denman, Baudelocque.)   Velpeau  thinks the  latter   practice
must be employed with great caution and circumspection.
   Irritating clysters are also advantageous as revulsives, and upon
this principle the French apply synapisms  to  the feet,  legs and
thighs, a blister to the neck, and  frictions along the spine.
   In all cases of convulsions, immediate delivery  is  to be accom-
plished as soon as possible, either by  the forceps, version, or cra-
niotomy.   Though  the disease  ceases in general on delivery, I
have known  it to continue for a day  after in despite of  all reme-
dies.  The young practitioner must be reminded that copious de-
pletion can be only employed with  safety in strong, young, pletho-
ric women, and that local bleeding is preferable in nervous, deli-
cate, and lymphatic persons, and also when the disease comes on
after haemorrhage.  In the  last, the narcotics  will be used with
success.   I am very  much  astonished  that  Dr. Burns, in  his last
edition,  1829, has not distinguished the forms of this disease, and
has indiscriminately recommended copious depletion and narcotics
in  no  instance  (see  p.  305,)   But it often happens that  the os
uteri does not dilate during the most violent convulsions, and con-
sequently delivery cannot be effected.   In such cases the French
apply  extract of belladonna to dilate the uterine orifice, and when
this fails, the woman and infant  being in danger, Boelin recom-
mends incisions  through the uterus,  and Simson and Lauverjat
think  the operation should  be called the vagino-caesarean.  In such
a case, I agree with Ashwell, that  it would be much  safer to  di-
late the os uteri  with the fingers: a proceeding which would give
 the mother and infant a much better chance of life.   I have held 
366
GYN.SCO-PATHOLOGY.
 this opinion, and taught it in my lectures long before Mr. AshwelPs
 work appeared, and it was forcibly impressed upon my mind  in a
 case where there was no  dilatation,  and the woman  died undeli-
 vered.   When we consider the dilatability of the os uteri in every
 stage of pregnancy, more especially in the last three months, the
 plan I propose is not so objectionable as it would  appear at  first
 sight.   Should the woman die undelivered, we ought to perform
 the  Caesarian operation  about ten minutes  after death, as the in-
 fant might  be resuscitated,  even after two  days, according to
 others.
   Dystocia syncopalis.—Labour  with syncope.—Delicate,  ner-
 vous, irritable women, sometimes faint from the slightest pains, or
 from severe pains, haemorrhage, and  inanition.   Syncope is, how-
 ever, a  rare occurrence.   If the life of the  woman is in danger, we
 must deliver as soon possible.  In slight cases, we exhibit  cordi-
 als, antispasmodics, and treat  them upon ordinary principles  (see
 p. 318.)
   Dystocia with Asthma, Hydrothorax, Ascites,  Ovarian Dis-
 ease, various Tumours in the Abdomen.—It is well known  that
 violent exertion accelerates the respiration, and induces a  sense of
 suffocation in diseases of the chest, or when the lungs cannot  ex-
 pand properly from incurvation of the spine, or from tumefaction
 of the abdomen (see p.  240.)  As the efforts of the most natural
 labour affect the respiration, it must be  obvious  that in the cases
 under notice, there must be considerable danger, and  therefore it
 is a rule to  effect artificial delivery as early as possible.   The ef-
 forts of the woman may induce asphyxia, or fatal collapse.  Nev-
 ertheless many hydropic women have the easiest labours (see p.
 321.)
   Dystocia with Hernia.—The practice in this case  is to reduce
 the hernia, if possible,  before  the  pains become  strong, and to
 make pressure on the opening through which it passes, during each
 pain.
   Dystocia vesicalis.—The bladder ma) be protruded in  the  ear-
 ly  stages of labour.  It  is  to be returned and retained in its  situa-
 tion; and when the head advances into the pelvis, it is, in the  ab-
sence of uterine action, to be kept in the natural  situation,  when
the next pain may push down the head.   This is  a  rare occur-
rence (see p. 437.)
   Dystocia placentalis.—Placental presentation has been descri-
bed in the section on  Abortion (see p. 324.) 
MORBID PARTURITION.                 367
          Section 4.—Accidents relative to the Infant.
   Dystocia Funicalis.—Dystocia caused by the premature escape
of the umbilical cord.   This accident causes the death of the in-
fant, which is induced  by the compression of the navel  string,
which interrupts the circulation of blood between the mother and
infant.
   The treatment in this case consists in preventing the cord  be-
ing compressed, and to perform the operation of version, should
the presentation admit of it, as when the abdomen is  over the os
uteri.  When the breech  presents, we must  facilitate  delivery in
the manner described for  the management of that presentation.
Various methods have been proposed for retaining the cord in  the
uterus.  Dudan proposed a sound for pushing up the cord ; Wel-
lemberg, a canula;  Duchamp, a ring ;  others retained  it with a
sponge ; and Sir Richard Croft recommended the hand to be passed
into the uterus, and the cord to be placed on the  inferior  extrmi-
ties.   All  these plans are useful when  the child  is alive ;  but as
soon  as pulsation  ceases  in  the  cord,  death has happened,  and
then they are unnecessary.   When the head presents it is advisa-
ble to push up the cord;  when the presentation is transverse,  the
plan proposed by Croft is advisable as  a preparatory step  to  the
operation of version.  It must be unnecessary to state, that wheth-
er we perform a manual or instrumental operation  in these cases,
we should  carefully avoid compressing the cord, or effecting that
mischief which we wish to prevent.
   Dystocia from shortness or excessive length of the Cord.—Bau-
delocque, De la Motte, and others, supposed that when the cord
was only six or  eight inches in length,  it impeded the descent of
the head, if the placenta was attached to the fundus uteri. It was
said that the recession of the head, after the cessation of the ute-
rine contractions, was  accounted  for by  this cause.   But every
one knows that such recession occurs in all cases, more especially
when the perineum is rigid.   Shortness of the cord, however, may
cause detachment of the placenta, expose the woman to  haemorr-
hage, and destroy the  infant; and the repeated extension or pul-
ling of the cord may diminish or  arrest uterine contraction, and
in  this way impede labour.  When the  cord is too long, it is like-
ly  to present, or to be twisted round the neck, body, and limbs of
the infant,  and produce  the same effects as in the preceding case.
It is therefore, more liable to pressure during the contractions, or 
368
GYNJECO-PATHOLOGY.
during the passage of the infant through  the vagina.   Neverthe-
less we see infants born alive with the cord twisted  round  the
neck, trunk and limbs,  and  even knotted  in three or more points.
But if we found the cord too short in a case in wbjch  the infant
was in danger,  and on the point of birth, it ought to be cut, and
delivery effected  by the hand or forceps  as  speedily as possible.
When we discover the cord  round the neck, after the expulsion of
the head,  we should rub the abdomen, and excite uterine action as
speedily as possible to effect delivery, for otherwise  the compres-
sion of the vulva will arrest  the circulation, and kill  the  infant.
Should contraction not come on,  we  ought to loosen the cord, by
pulling it gently, or slip it over the head in some cases.
  Artificial Parturition.—Operative  obstetricy  may  be divided
into three  parts—1.  The operations  which  preserve the integrity
of the organs of the  infant and  mother.—2dly, the  operations
which require some solution of continuity of the organs  of the foe-
tus.—3.  Operations which require some solution  of continuity of
the maternal organs.  Such it the division of M. Duges, which is
the best hitherto  proposed.   I have  divided  obstetric operations
into two classes—.1. Chiragotocia, manual labour.—2.  Organiko-
tocia, instrumental labour.
   Chiragotocia, manual extraction of the  foetus.   Version—Tur-
ning.
  There are two species of version,  one  in which the  head,  and
the other in which the feet are extracted first.
  Hippocrates  advised version by the head in  all presentations  ;
and Celsus maintained that by the feet, after the infant  was dead.
iEtius and Paulus Eginetus  followed the practice of Celsus when
the foetus  was living, as also did Wolf, Franco, Pare, and Mauri-
ceau.  Guillemeau proposed to perform version by the feet when
presentation of the head was accompanied with accidents.  Ver-
sion  by the feel is decidedly preferable.   The circumstances fa-
vorable to  the  performance of this operation are dilatation of the
cervix uteri, without rupture of the amniotic sac, or bag  of waters,
or immediately after rupture has happened.   The most  favorable
moment for the performance of  version, is while the amniotic sac
is entire, and  the  uterine orifice  dilatable.   The  best  position in
which to place the woman is on the side, according  to British and
American writers ; but the  back is preferred by the French,  and
the pelvis should rest on the edge or foot of the bed.   The ope- 
ARTIFICIAL PARTURITION.
369
rator may be seated, or  kneel upon  one knee; some advise  to
take off his coat-sleeve, others to turn  up his cuffs ;  and in former
times he  wore a napkin as an  apron.  The last appendage is sel-
dom employed at present.   The sleeve  of the coat should be ta-
ken off, as pulling it above the elbow causes so much pressure up-
on the arm,  as to impede its  free motion.  The object to be effect-
ed is to pass the hand into the uterus, to seize the feet, and bring
them through the  pelvis.  The operation is required in all trans-
verse presentations, when any part of  the infant, from the base to
the skull to the breech, presents.   Others advise us to push up  the
trunk with the palm of  the  hand, and  thus affect a rotation of
the foetus, so that the feet may be brought over the uterine orifice.
The former  practice is in general preferred.   The choice of  the
hand cannot be determined before the rupture of the membranes;
and when the hand is introduced, and cannot be employed conve-
niently, it is to be withdrawn, and the  other introduced.
   When the feet, knees, thights,  and posterior region of the foe-
tus are at the left side of the strait, the left hand should be pre-
ferred ;  and when the positions are inverse, we use the  right.
   When the  vertex presents in  the  occipito-pelvic position,  the
left hand must be used, and the  right in the inverse position ; in
the antero-posterior positions of the head, either hand may be em-
ployed.
   In shoulder presentations,  the  left requires the left hand, and
the right must be employed when the  right shoulder  descends.
The right hand is to be preferred  when the sternum or back pre-
sents,  the head being to  the left, and  in the opposite cases  the
the right hand is to be chosen.
   Some distinguished obstetricians recommend the introduction of
the  hand in a state of semi-pronation,  so that the palm may be
turned towards the abdomen and feet  of the foetus (Baudelocque,
Lachapelle, Duges, Desormeaux, Major de  Lusanne, he.) ;  but
this rule is liable to  exceptions;   it is  not perfectly applicable in
presentations of the pelvis,  back, or shoulder (Velpeau).
   Others recommend  the hand which is naturally turned to that
side of the  pelvis in which  the  feet  are  placed.  Dr.  Breen, of
Dublin,  prefers the left hand  in all cases, in  order that the right
may most commodiously aid the uterine  action by pressing on  the
hypogastrium.   The choice of the hand should be  determined ac-
cording to the former rule;  and this selection may be facilitated by
         47 
370
GYN^SCO-PATHOLOGY.
changing the  position of the woman on her  sides, abdomen, or
back.
   The hand being chosen, it is to be smeared with some oleagin-
ous or mucilaginous  substance, both to render its introduction less
painful, and to guard the practitioner against infection from conta-
gious diseases.  The back  of the  hand may be lubricated with
lard, pomatum, butter, oil,  mucilage, he., as this part only can
produce pain;  and the palm ought to be dry, as it is to be applied
to the surface of the infant, which is  moist  and slippery.  This
was the  precept  of  Roederer,  and  is generally followed.   The
forearm must be also lubricated.
   Introduction of the Hand.—The fingers are to be brought to-
gether in the form of a cone, and  gradually introduced into the
vulva and along the axes of the inferior and superior straits.  This
must be accomplished very slowly in the absence of pain, if pos-
sible, for unless this  caution is attended to, uterine action may be
excited, and the operator rendered incapable of proceeding.   The
palm of the hand is to be passed  along the shoulder, side, thighs,
legs, and to the feet, and both these brought down into the pelvis,
though sometimes one foot only can  be grasped.   In bringing down
the foot or feet, the body of the foetus  undergoes an evolution,
and hence the origin of the  term  turning.
   In effecting this evolution or mutation,  care must be taken to
bring down the inferior extremities  on the  anterior surface of the
foetus, by seizing the knees or ancles  in  preference  to the feet
(Burton, Delpech,Breen).
   Extraction.—When the  feet,  legs, and thighs  are  extracted
through the vagina, they are to be  enveloped in a napkin.  The
thighs and hips must be turned to the long diameter of the inferi-
rior strait or outlet; that is,  in the ischeo-pubic, or partly towards
the pubis and  coccyx,  and must be  elevated  and depressed until
the lower or posterior hip is first expelled ; the hands are  to be ap-
plied over the ilia or hips, but not on the abdomen, and the thumbs
upon the loins.  The lateral regions of the  trunk should be in the
long diameter  of the outlet, or nearly so, until the infant has de-
scended to  the axillae, when  its abdomen should be turned towards
the spine of the mother.  As soon as the umbilicus has passed the
genital fissure, the navel-string must be drawn down and liberated,
or the  pressure of the external  genitals will speedily interrupt its
circulation and kill the infant.   If it cannot be loosened,  it should 
ARTIFICIAL  PARTURITION.               371
         be cut, and the  labour finished (Hatin).  If uterine action com-
         mence, so much the better ; and  if it fail, it is to be induced by
         the ergot of rye.
            The Extraction of the Arms next claims attention.  The arms
         are on the  sides of  the bead,  and are situated differently in rela-
         tion to the pelvis, according to the position of the infant.  If the
         abdomen of the infant is turned  to the spine of the mother, the
         occiput will be to the pubis, the forehead towards the sacrum,  and
         the arms towards the iliac bones,  and sometimes on the neck (Du-
         ges.)  If, upon the other hand, the abdomen of the infant is turn-
         ed to the thigh of the parent, then one arm will be towards the
         pubis, the other towards  the sacrum.   The practice in either po-
         sition is  to  introduce the  index and middle fingers over the shoul-
         der and  on the elbow joint, and then gradually extract the arm,
         supporting the perinaeum at the same time.  The first position, in
         which the  limbs face the hips, is recommended in these countries,
         and renders the extraction much easier than in the last position,
         which is the ordinary one  according to Duges.  In it the  lower
         arm should be extracted  first,  and to accomplish this, the body of
         the infant must be elevated towards the maternal abdomen.
            The operation of extraction would be rendered exceedingly dif-
         ficult, if  the back of the infant  was towards that of the mother;
         and it would also be difficult to extract  the head in  that position.
            Disengagement of the Head.—When  the forehead rests on the
         promontory of the  sacrum, the long diameter of the head is to the
\         short of  the pelvis (seep.  11), and our  object is to adapt the long
         diameters of the head and brim, or superior strait of the pelvis to
         each other, which in  general can be easily accomplished by turn-
         ing the forehead to either sacro-iliac symphisis.  The head being
         thus brought into the cavity of the pelvis,  we have next to imitate
         nature,  by turning  the  face into the  concavity of the  sacrum.
         The body  of  the infant should now  be raised  towards the abdo-
         men of  the mother, by placing it on the left arm of the operator.
         Velpeau says it should be  first depressed  towards the perinaeum,
         to facilitate the escape of the occiput.   The index and middle fin-
         gers of the right hand are to be placed on  the neck, and the index
         of the left in  the mouth, to depress the chin, then place the fin-
         gers on each side of the  nose ; when in  general, gentle traction in
         the axis of the outlet, during uterine action, accomplishes delivery.
         If there  be no uterine pain, we should excite it by friction on the 
372
GYNJEC0-PATHOLOGY.
abdomen, or by the ergot, or the pressure on the navel string will
kill the infant.   The chin, face, forehead, vertex and occiput es-
cape in succession, so that the back of the infant must be gradu-
ally elevated until placed on the abdomen of the mother.  The
following cautions are to be attended to in performing the opera-
tion of version.  The hand should not be introduced during pain,
as it would be benumbed  and partially paralysed.  According to
British practice, it must be passed during the  interval of pain (also
Desormeaux and Velpeau.)   By observing this precaution, Mid-
dleton succeeded in version when all others had failed.  He boast-
ed of having had a secret, which he revealed in his old age; and
and this was a large opiate to  tranquilizethe uterine action.  The
sedative preparations of opium, as the sedative solution, morphine,
Sec. are to be preferred  in this case, as the common tincture often
excites instead  of allaying  uterine action,  and  sometimes fails to
produce either effect.  I have  known  a drachm of the  sedative
liquor of opium to be exhibited  in a case of cholera, in the space
of eight hours,  with the effect of arresting the vomiting and diar-
rhoea ; and yet well-marked uterine action commenced, which was
removed by a starch  clyster only.   The  patient was under the
care of my friend Mr. Holloway, of Leather-lane.
  The os uteri  ought to be  dilated to the size  of the disc of a
half-crown, and dilatable, to justify the operation  of version.
  The  general  plan is to bring down one or both feet; if only one
can be found, the other  will be bent on the abdomen or back, and
must of course come on when the breech  is propelled.  The prac-
tice of bringing  down one foot,  and re-introducing the  hand to
bring down the other, as advised by MM. Velpeau and  Hatin of
Paris, is not easily effected: but this is obviously unnecessary, ac-
cording to the opinion of British  obstetricians,  and of M. Duges
of Montpellier.
  Care must be taken to ascertain the position of the feet before
passing  the hand, as  otherwise we should be obliged to withdraw
and re-introduce it, which might excite uterine action, and defeat
our object.
  The bowels  and bladder should  be evacuated before we com-
mence this and  most  other obstetric  operations.
  We  must prevent  the descent of the  infant with its abdominal
surface-towards the pubis;  for in such  case the chin  would be 
ARTIFICIAL  PARTURITION.
373
hooked on the  pubis, and  could  not be brought down unless by
adapting  the head to the long admeasurement of the pelvis.
  In order to depress the face in this case, the body of the infant
should be lowered,  and the finger  placed in the mouth  (Portal,
Smellie,  Deventer,  he.), or the lever or forceps should be ap-
plied in the manner hereafter mentioned.  Asdrubali advised the
elevation of the body of the infant, to allow the escape of the oc-
ciput ; but all these manoeuvres  are difficult,  and ought to be
avoided,  by attending to the directions already detailed.
  The operation of  version is required in all transverse presenta-
tions, as  when the neck, back, abdomen, and superior extremities,
descend,  and according to the French,  in many presentations of
the head.  Dr. Burns thinks that in cases in which the  labour  is
rapid, and the membranes unbroken, it would be good practice af-
ter rupturing the membranes, to adapt the head to the proper di-
ameters  of the pelvis, though as a general rule turning is to be pre-
ferred.   We need not wait for the  complete dilatation of the os
uteri, as  in general  the waters are effused at this period of labour.
   After  the rupture of the membranes, and  when the uterus  acts
powerfully, we should exhibit from forty to eighty minims of com-
mon laudanum according  to the  received  axiom; but  I  prefer
twenty-five  or  thirty minims of the sedative solution  of opium.
In general we find,  that after two hours the uterus will be tranquil,
and the operation can be easily performed.
   When the anodyne fails, it has been proposed to employ vene-
section to  syncope, or to  the approach of that condition;  and
should this  fail, I  would certainly try the tartarized antimony to
produce  nausea,  as in  cases  of strangulated hernia.   When the
infant is  dead, and  version impracticable, which I can  scarcely
think possible after venesection and antimony, Dr. Burns recom-
mends perforation of the abdomen, and the application of a hook
on  the  pelvis, so as to pull it down.   This  practice may succeed
if the infant be small; but it must fail when  the infant is large.   I
am surprised  that  the able author I have quoted has not given  a
more  minute  account  of the management of cases in which  ver-
sion is impracticable ; that is, in cases in which the operation  can-
not be performed with safety in consequences of uterine  action.
It is  a  great oversight  to omit the mode of proceeding in trans-
verse cases, in which the operation of  version cannot be accom-
plished.   The woman is not to be deserted  in such circumstances; 
374
GYN-flSCO-PATHOLOGY.
and the young practitioner should be  informed  of  the practice
which ought to be employed.  In such cases, the infant being alive,
the Caesarean  operation was  formerly proposed and practised, as
Baudelocque states in the Recueil Period, xiv., cases five and fif-
teen.   When the child is  dead, as it soon is by pressure, it has
been  pulled down by the breech, by Peu,  Smellie,  Giffard, and
others ; and the vertebrae separated by Hamilton and Perfect, and
the thorax  eviscerated by J.  Clarke.   In cases of arm presenta-
tion, when turning cannot be accomplised, F. Ramsbothatm divides
one or two ribs, eviscerates  the chest and abdomen, having perfo-
rated  the diaphragm ; the body collapses, and  may be expelled by
the process of spontaneous evolution; or should the pains cease,
the crotchet  should be fastened on the spine or pelvis, so that the
breech may  sweep  the sacrum  and  perinaeum : he saw this prac-
tice successful five times.   Douglas, of  Dublin, recommends the
extraction  of the breech, in imitation of spontaneous evolution;
and Lee is  of the same opinion.  Edinburgh  Medical and Surgi-
cal Journal, April 1828.   Velpeau loudly condemns  this practice,
and proposes in its stead the Caesarean vaginal operation, whether
the infant is living or dead;  a  practice  which no man who wishes
to save the life of the mother, is justified  in adopting.  But spon-
taneous evolution is a rare occurrence, and out of thirty cases col-
lected by  Denman,  there was but one where  the infant was born
alive.  It can seldom happen at the  full period of pregnancy.   It
is most frequently observed in premature labours, before the seventh
month.
   With respect to the evisceration of the chest and abdomen, it
may be well to state that  it is a tedious  and  difficult operation,
and will require, at least, one hour for its  proper performance.  I
have  performed it in the following manner,  after the  death of the
infant:—The arm may or may not be removed ; the thorax is  to
be opened by means of a scalpel, with a long  handle, or with the
perforator; the ribs are to be broken by the  craniotomy forceps,
which will also readily enable us to extract the viscera of the thro-
rax;  the diaphragm is next to be torn with  the same instrument,
or  with the  sharp  hook, and the  abdominal viscera  extracted
through the chest.  The body then collapses,  and if  the pelvis be
capacious, it may be  extracted, by fixing a blunt hook on the pel-
vis or spine of the child, and cautiously using such traction as will
bring  down the breech.  But if the infant is of the full size, the 
ARTIFICIAL PARTURITION.
375
pelvis small or contracted, the breech cannot be extracted as now
described.  In such cases,  the  infant may be decapitated  in  the
manner about to be mentioned,  the arm and thorax being first de-
livered, and then the head.  But if the head is so high in the pel-
vis, that it cannot be reached with ease, even after the removal of
the arm, then I have succeeded by separating the dorsal vertebrae,
by the careful application of the blunt hook, and divided  the trunk
completely;  so that the upper  part,  arm, and head, can  be  ex-
tracted ; and next, the lower, by fastening the blunt hook on the
pelvis.   I have performed the  operation twice  in this  way,  and
with perfect safety to the woman.  This method is not mentioned
in any writer or teacher on Midwifery with whose work I am ac-
quainted.  The operation of  decapitation, when practicable,  is
more simple  ; but the introduction of a sharp sawing instrument,
as recommended by Ramsbotham, senior, and D.  Davis,  I think
very objectionable ;  for I apprehend that dividing the neck of the
infant, " when the instrument is to be used as a saw," must injure
the  soft parts of the mother.  There might be a curved saw con-
structed, so that its extremity might be blunt for an inch  or two,
and by this contrivance there would  be less danger of injuring the
uterus.  The instrument which I employ for this  purpose is the
 blunt hook, with one end roughly pointed, which when  fixed firm-
 ly on the cervical vertebrae, by a gradual steady pressure,  will di-
 vide the neck and soft parts.   The  arm is next to be drawn down,
 and the chest and body delivered;  and  the head is then to  be
 adapted to the proper axes of the  pelvis, and  extracted by the
 blunt hook,  forceps or perforator.  There seldom  can  be  any dif-
 ficulty in finding it in the cases under consideration.
   Decapitation is most  proper when  the  neck  is the  presenting
 part.
   The operation of turning is  applicable to all  the transverse pre-
 sentations, from the First to the Eighteenth Orders  of the Second
 Class (see p. 109,) except in  pedal presentations;  and if it can-
 not be performed with safety to the parent, the operation of em-
 bryotomy, in the manner now detailed, must be  resorted to. I have
 succeeded in finding one leg, by passing up the blunt hook, with-
 out introducing the hand, and have drawn it down into the vagina.
 If we cannot bring down the leg next the os uteri, the  infant must
 be turned in the womb, by bringing down the other.
    Baudelocque maintained, that every  part of the infant  might 
376
GYNECO-PATHOLOGY.
present, and divided the body into four regions ; but his classifica-
tion, though long received with enthusiasm in  France, was oppos-
ed  by Lauverjat,  Flammant, Meygrier, Gardien, Capuron, La-
chapelle, and recently by Velpeau.  The last author in his essay
(Remarques sur les Positions Vicieuses et la  Version  du  Foetus
1830,) with a copy of which he has favoured  me, contends that
" daily observation and reason demonstrate, that the infant pressed
by the uterus presents to the orifice the head,  pelvic  extremity, or
shoulder."   He alludes to the frequent transmutations of the foetus
when one part presents, and is  replaced  by another, and thinks
that the spontaneous evolution mentioned by  Denman  is not  so
rare as is generally considered.   He gives an  exact description of
the various transverse presentations, and endeavours to  prove by
experience, that all of them were primarily to  be  referred to one
of three already  mentioned.   He argues that  presentations of the
loins, groins, abdomen,  back, neck,  sternum,  he. are  rarely met
with, and are supposed to  exist though  never  observed  by the
most eminent practitioners.   He cites the works  of Bland, Merri-
man, Boivin, Lachapelle, Dewees,  de Deutsch, Naegele, to  prove
that in 100,000 cases there  was not one of the presentations un-
der consideration ; but all were to be referred  to the  head, breech,
or shoulder.   He concludes, " that every presentation of the foetus
which does not belong to the free or deviated positions, whether
of the head or of the feet, enter necessarily among the free or de-
viated positions of the  shoulders."  He thinks  that this position
will be found agreeable to truth  and science, and  therefore worthy
of adoption.   It certainly reduces all the anormal or preternatural
presentations of the head and trunk to a small number, and  brings
them into a small focus, thus simplifying the practice of obstetricy.
This reminds us of the opinions of Dionis, A.  Petit, Bounder, &c.
that the feet ought to be brought down even when the vertex pre-
sented.  The descent of the foetus  by  the feet is contrary to the
laws of the organism for the reasons already mentioned, and though
they with the legs and thighs escape in the form of a cone, we
must recollect that after the escape of the pelvis,  such pressure
is made on the abdomen by the uterine orifice, as to produce dan-
gerous consequences.   1. By  strong compression of the viscera,
and in particular of the liver, which by its size and  structure is
more liable than other organs to contusion or rupture by mechani-
cal injury.  2.  By obstacles opposed  to  circulation in  tbe abdo- 
ARTIFICIAL PARTURITION.
377
men.   In effect, the circular strangulation to which the abdomen
is subjected may be extended to the  aorta,  vena cava and vena
porta, so that the circulation of blood  in the  inferior parts of the
body must be interrupted.   3.  The pressure of the  funis umbili-
calis may destroy the foetus, as well as pressure on the  head in
the pelvis unless speedily extracted.  The former occurs when the
uterus ceases to act after the descent  of the  head into the pelvic
cavity;  and the latter when the head is too voluminous.   It is
therefore manifest that the passage of the foetus by its pelvic ex-
tremity, breech, knees, feet, or by the operation of version, is more
dangerous than the descent by  the vertex, and  cannot be classed
with it as natural labour.
   Version  in  Cephalic Presentations.—All the presentations of
the head may be reduced to two;  1. when  the occiput is to the
left side  of the pelvis, the left occipito-iliac position of the  French ;
2. when  the occiput is to the right side of the pelvis, or the  right
occipito-iliac position ; the object  in these cases is to raise  the head
into the  iliac fossa, press the hypogastrium  with the  other hand,
and incline the uterus to the side, and bring down the feet.   Wi-
gand and Velpeau have brought the head into the natural position
by mere pressure on the abdomen.   In some cases the head may
be adapted to the proper diameter of the pelvis;  but in general
this cannot be  accomplished.  After elevating the head,  the hand
is to traverse  the neck,  shoulder, side, thighs, and legs, until it
arrives at the feet.
   Face  Presentations.—The  chin should  be  bent on the neck,
and the  head adapted to the pelvis ;  but if this  cannot be  effected,
the feet must be brought as in the former cases.
   Shoulder Presentations.—When the  left  shoulder presents, the
operator should introduce his left hand,  and place the thumb on
the sternum, and the fingers on the  back;  he  is then to elevate
 the body, and facilitate  the descent  of the  lower extremities by
 pressing on the hypogastrium with the right hand.  He is next to
search for and bring down the feet.  When  the head  is turned to-
 wards the right side of the pelvis, the  right  hand must be em-
ployed.
   When the right shoulder presents, the  right hand  is to be em-
 ployed.    The operation of version is unique, and is  the  same for
 all the presentations of the head and shoulders.  Sternal, dorsal,
 and right  and left  lateral presentations,  are to be  managed al-
         48 
378
GYN^CO-PATHOLOGY.
most in the same manner as the former.  In the latter, the lower
shoulder is to be depressed, and the remainder of the operation is
the same as in shoulder presentations.
  Arm Presentations.—The arm is to be drawn to one side, the
hand introduced, the body elevated, the feet brought down, or the
hand may be pressed at once to the feet.   It is  bad practice to
amputate or twist off the arm, as neither proceeding can change
the transverse position of the infant, and no man would adopt such
an absurd  proceeding but an ignorant practitioner.  The only case
that warrants the removal of the arm, is when the infant has been
dead for some lime, and the arm so tumefied that the vagina is fill-
ed up, and there is no room to pass the hand.  When an arm and
leg presents,  the operation of version is partly performed ;  the leg
is to be drawn down,  and the body  pushed up with  the other
hand.  No one but an ignorant practitioner would pull down the
arm and leg at the same time.  When both arms or legs present,
we must ascertain whether  they belong to  the same infant.  Be-
fore dismissing  the subject of version, it is right to notice what is
termed spontaneous evolution.
   In transverse  presentations, it has happened that the breech of
the infant  has been gradually expelled, and  this has been called
spontaneous evolution by Denman  ; and  spontaneous version by
Murat.   It has also been observed by Gartshore, Martineau, La-
chapelle, Douglass of Dublin, Gooch,  he.; but is an exceedingly
rare occurrence at the full period, and in general should  not be ex-
pected.   Some  of the most experienced obstetricians have never
seen a case of it, and  others have observed it between the  sixth
and seventh month, when  the  infant is not fully developed.  I
have known  it occur at the full time in two cases of arm presenta-
tions, and in  both the infants were born dead.  Denman observed
thirty cases,  and in one only was the infant born alive.   The uni-
versal opinion of the profession now is, that the knowledge of the
possibility of spontaneous evolution should never prevent us from
performing version.   It would  be  bad practice  to leave a trans-
verse presentation to nature in expectation of such an occurrence.
Burns has not met with a single case of it; neither  has Clarke of
Dublin.   It  is sometimes possible in brachial presentations to push
up the limb  in the interval of pain, and bring down the head; an
operation performed twice successfully by my friend Mr. M'Nolt) ,
of Queen-street, Golden-square.  On the other hand, M. Deutsch; 
ARTIFICIAL PARTURITION.
379
a Russian professor, has  succeeded in pushing up the body with
the palm of the hand, and effecting a rotation which brought the
feet to the uterine orifice  ; and assures us that this operation is ex-
ceedingly advantageous in shoulder presentations (Duges).
   When  the  breech has approached the vulva, we must raise it
towards the abdomen, in order to disengage the hip, which is to-
wards the coccyx first.   Sometimes the  forceps, blunt hook, or
fillet, must be  employed to  assist  its extraction, as  will appear
hereafter.
  Sometimes the inferior extremities are  flexed upon the back, in
which case they are to be brought  down by the fingers or blunt
hook.   Velpeau states,  that in  breech cases, the limbs being on
the abdomen,  we must extract these first; but in this empire they
are allowed to  descend without any interference.  When only one
limb descends, he advises us to search  for the other;  but this prac-
tice is considered unnecessary by British obstetricians.
   In all presentations of the face or vertex, we commence by el-
evating the  head on the iliac fossa, press on the hypogastrium, and
push the uterus to one side, so as to bring the breech into the ca-
vity of the pelvis.   In shoulder,  sternal, and abdominal presenta-
tions, the same revolution or  version of the breech is to be accom-
plished.   In a  word, the same manoeuvre is required in all cases
which  require version by the feet.
   Here I must caution young  practitioners against  using violent
traction during the  operation of turning,  and especially when the
body is expelled, and the head is  in  the pelvis. The spinal marrow
in the neck  may be contused, or otherwise  injured as to destroy
the infant, and hence great care  is necessary to manage this part
of the operation as already mentioned.
   " All the positions of the head,"  says M.  Velpeau, " reduce
themselves to two, in the manoeuvre (version) ; all the positions of
the side belong to the second part of the manoeuvre of positions of
the head ; all the positions of the back and of the sternum should
be reduced  to  positions of the shoulder;  and all the positions of
the  shoulder  are at first  transformed into positions  of the feet.
There are,  in  reality, in version, but two essential positions, and
are comprized  in the rule laid down in speaking of version by the
feet in  presentations of the  vertex."  (Par. 1046.)—In conclu-
ding this article, I cannot but highly applaud the accuracy and re-
ally scientific views of M. Velpeau,  to whose admirable Treatise 
380
GYN-flECO-PATHOLOGY.
and Essay on Version, I am  much indebted for  many valuable
facts on this important subject.

    Section 5.—Organikotocia—Instrumental Parturition.
   I find, on  referring  to the works of Hippocrates, De Morbis
Mulierum, that he recommended all the obstetric instruments now
in use, but, of course,  in an imperfect form.  He advised a small
sword to open the  head,  pincers or forceps  to extract the bones,
and also a blunt hook.   His forceps had teeth to extract the dead
infant.   Celsus recommends the hook in his Seventh Book. Avi-
cenna speaks of a forceps which did  not injure the infant,  (lib. iii.)
Albucasis describes many kinds of forceps  (Meth. Med.  lib. ii.) ;
and Rueff improved and brought them to perfection (De Concept.
et Gen. Hominis.)—The compendious form of this work precludes
me from following up  the history of the  forceps, and therefore I
must content myself with stating, that the Chamberlains of Lon-
don are admitted to have introduced the modern forceps in 1672.
   Smellie introduced a simple instrument, which, with slight modi-
fications, is employed at present.   If the reader is desirous of ob-
taining full information on  modifications of the  forceps,  I beg to
refer him  to the  Operative Midwifery  of Professor Davis, of  the
London University ; a work that evinces great research, acute  dis-
crimination, ample  observation, and high talent.
   Obstetric instruments are divided  into two classes; 1.  tractors,
as the  forceps,  lever,  blunt hook; 2. incisors, as the perforator,
crotchet, craniotomy, forceps with teeth, sharp hooks, and scalpel.
   1. Organikoticia tractativa.—The instruments comprised in  this
class are blunt tractors, and  are called  the forceps, the lever  and
blunt hooks.   The forceps is  composed of two  parts or blades,
which have been denominated male and  female, right and left,
but no two writers  agree  in the use of these terms.  Some  call
the blade  which is turned to the right side of the pelvis, the right
hand blade, and that to the other side the left  (Duges) ; but as the
blades eross at the joint, the handle of the right branch will be in
the left hand, and is called the left branch  by Hatin,  and the han-
dle of the left branch is the right branch of the same author.
   General Observations on the Forceps.—The forceps is to  be
applied,  1. When  the  head of the infant  is too large to pass
through the passages  without exposing the woman to danger, as
when the  pelvis is  small;  2. when the uterus is inert, from long 
INSTRUMENTAL PARTURITION.
381
continued exertion, after the dilatation of its orifice and the rup-
ture of the membranes ; 3. when some serious accident renders the
extraction of the foetus indispensable, as  in cases of haemorrhage,
eclampsy or convulsions, syncope  or extreme  prostration ;  and
when the head presents preternaturally, or is impacted or locked,
as the old writers had it.  According to some  writers, the head
may be considerably compressed, and according to others not more
than three or four lines.  In cases of simple inertness of the ute-
rus, and in which there is no enlargement of the head or narrow-
ness of the pelvis, and consequently no undue  pressure on the
head  or on the soft parts of the pelvis, the ergot of rye should be
administered before the use of the forceps.   This instrument has
been properly called an artificial  pair of hands, which enables us
to extract the infant without any danger to  it or to the parent.
 When  properly constructed  and applied, it will not  injure either
 parent or offspring; but when  improperly employed, and the ex-
 traction made too  quickly, it may lacerate  the  vagina or uterus,
 contuse the vulva, rupture the perinaeum, and expose the vagina
 to fistulous  openings; contuse or lacerate the scalp of the infant,
 or fracture its cranium.  When the head is  impacted, the pressure
 causes congestion and slow inflammation of the soft  parts, which
 generally terminate in sloughing  after delivery, or may extend to
 the uterus or peritoneum, and cause death.  There  may be rup-
 ture  of the uterus from spasmodic  pain ;  and tumefaction of the
 scalp of the infant with elongation of the head, and the  long con-
 tinued pressure will destroy the foetus.   General irritation and ex-
 haustion may destroy the woman.   Rigidity of the soft parts will
 also  require the forceps after a sufficient time is allowed for their
 dilatation. Protracted labours predispose to puerperal cases.  Less
 pain would be produced by the forceps  than by nature in some of
 these cases;  and the woman  would be more likely to recover.
 Mischief can only arise from the forceps,  by delaying its use too
 long,  or  by an  incautious  employment  of it.  Drs. Hamilton,
 Burns, and Osiander recommend  an early use of the  forceps, and
 oppose the  disciples of the  school of patience, who would leave
 all to nature.   Decided impaction oftener requires craniotomy than
 the forceps.   Hamilton held, that twenty-four hours of real labour
 should elapse before we interfere;  Burns is of the same opinion,
 when he says from twenty-four to thirty-six hours; while Denman
 thought we*should operate after six hours.   The time must be de- 
382
GYNJECO-PATHOLOGY.
    termined by the circumstances of the case, as the state of the con-
    stitution, and of the softer parts.
      It is right to mention  that Dr. Hamilton prefers the curved to
    the straight forceps, of which Dr.  Burns  is not satisfied of any
    material advantage, though he prefers the former.   I cannot help
    thinking that the straight instrument is  very objectionable; for I
    have found its application more difficult, besides it is liable to  in-
    jure the rectum when the handles are elevated.  The French for-
    ceps is slightly curved, though not so much so as our own.
      The forceps can be applied at the superior and inferior straits.
      Dr. Conquest observes, in his excellent work, that the long for-
    ceps answer the  purposes of the short,  and is  a most important
    substitute for the perforator and crotchet, in many of those cases
    in which children are doomed to be  destroyed.   It  is  applicable
    in all cases, when the head is above the brim of the pelvis, where
    the  head is beyond the reach of the short forceps, and where  de-
    livery is essential to the well-doing of the mother: as in cases  of
    convulsion, haemorrhage,  or in cases of distorted pelvis, where the
    deficiency of space  is from pubis to sacrum, and is so slight that a
    little power beyond  that  of the uterus will enable us  to extract
    living infants, that are too often doomed to sacrifice  by  the inci-
    sive instruments.  Dr. Burns is against the long forceps, until the
    practitioner is well acquainted with the application of the short or
    common one,  (Work, 1829.)
      The foreign obstetricians use the long forceps in all cases.
      The short forceps is a more favourite instrument in this country,
    and is useful in  cases where  the  head is in the cavity of the pel-
    vis.
      In some very rare cases of natural labour, that is when the ver-
    tex  presents,  as in cases of extreme debility, haemorrhage, or con-
s   vulsions,  states that may supervene, the  short forceps must  be
    applied to save both mother and infant.

          General Rules for the Application of the Forceps.
      1. The patient and her friends should be  apprized of the  ne-
    cessity, the intention and importance explained, and  the  parties
    assured of the safety of the operation.  This is most requisite, in
    order that other  advice may be had,  if desired; and in  all cases,
    it would be safer for the practitioner to have further  advice  before
    he resorts to  the use of instruments ;  it divides the responsibility ; 
INSTRUMENTAL PARTURITION.
383
satisfies the relations; and if any unfavourable issue occur, he will
avoid much blame and censure.   Females are greatly alarmed  at
the application of instruments ; and should the patient die of any
disease during the puerperal state, it will be ascribed to  their use
alone, or even if  she should die in months afterwards.
   2d.  The bladder and bowels should be evacuated by the cathe-
ter and clysters, before the use of any instruments.   It is almost
unnecessary to remark, that the os  uteri should be  fully dilated,
and the perinaeum be in a dilating condition.
   3d.  The patient should be in  the  usual  obstetric  position,  on
the left side,  or on the back, in order that the operator  may use
his right hand more efficiently.  The instrument should be applied
over the ear, and its convex edge should be turned to the cavity
of the sacrum  in all the direct positions of the head, and the ex-
ceptions in the diagonal positions at the superior and inferior strait
as will be stated hereafter.
   4th.  The  instrument should be brought to  the temperature of
the body by  being held near the fire, or immersed in warm water,
and then should be smeared with some oily  substance before  its
introduction.
   5th.  It should  be introduced during the interval of pain, slowly
and cautiously, the greatest care being taken  not to include any
part of the mother, two fingers of either hand being passed into
the vagina on the scalp, so as to serve as  a director, on which the
respective  blades of the forceps are to be passed.   According to
Velpeau, Hatin,  Duges, he., the  lefthand branch  of the forceps
should be first introduced.
   6th.  Each blade of the forceps  is  to be gently moved before
locking, in order  to ascertain that no part of the mother is included;
and care must also  be taken, that no part is included in  the lock,
by examining carefully with the fingers.
   7th.  Unless the  blades lock or meet accurately at the joint, the
instrument is improperly applied, and either  blade  must  be fre-
quently withdrawn  or elevated  and  depressed, until  the proper
adaptation of the locking parts  shall be  effected.   No traction
should be made until the blades are  locked, otherwise the instru-
ment will slip.
   8th.  The  instrument being properly locked, a ligature may  be
tied on the handles with a running  knot;  and it should be recol-
lected, that the handle of each blade will not be in close contact, 
384
GYNJECO-PATHOLOGY.
 and that if the lock or joint be even, the instrument is  properly
 applied.
   9th. The instrument  is to  be worked  from side to side, very
 gently, and always in the axes of the pelvis, and only during pain •
 if no pain is present, then it is to be worked at intervals,  in imita-
 tion of the natural efforts.   The time  necessary to effect delivery
 will depend on the difficulty to be overcome.
   10th. The infant's ear should be  felt distinctly, before the short
 forceps can be applied with safety.
   11th. Recollect that the forceps is very  rarely requisite, not
 more than once  in two hundred, and in private practice one in one
 thousand cases; and now more rarely since the use of the ergot
 of rye; and also, that the incisive instruments are  three times less
 in use than the former.
   Positions of  the  Vertex at the  Inferior Strait or Outlet.—
 There are six positions of the head at the inferior strait, namely,
 two direct and four diagonal; though in this country it is gener-
 ally said there are but four, namely, the occipito-anterior, or the
face  in the cavity of  the  sacrum;  the occipito-posterior,  or the
face  towards ths  pubis; and  the right and left occipito-ischiatic,
 or  the occiput to  either ischium.  I shall, however, describe the
 former as the more comprehensive and complete.
   Fiist direct Position  of the Vertex at  the Inferior Strait—
 Occipito—Anterior Position.—The  occiput  corresponds  to the
 pubis, and the forehead and face to the curve of the sacrum.
   Application of the  Forceps.—In these countries the woman  is
 placed on her left  side, and in continental Europe  and America on
 her back.  The obstetrician introduces two fingers  of the lefthand,
 and passes them  over the right ear; and then  the  right-hand
 branch of the forceps,  previously warmed and lubricated, is to be
 carefully insinuated between the fingers and the ear.  The fingers
 being withdrawn, the branch or blade  is to be held with the  right
 thumb.  If well applied, it will be parallel to the  axis of the infe-
 rior  strait, and the joint will be in the centre of the vagina.  An
 assistant may keep  it  steadily fixed.   Two  fingers  of the right
 hand are next to be  carried over the left ear of the infant, the for-
 mer blade being supported by the right thumb, or  by an assistant.
 The  left-hand branch  is  now  to  be introduced  along  the  fin-
 gers, and between  them and  the head.   The fingers  are  to be
 withdrawn, and both blades or branches articulated or locked, no 
INSTRUMENTAL PARTURITION.
385
part of the woman being included, and the handles being nearly in
opposition, they are secured by a tape, with a running knot.  The
handles are now seized with the right hand, they are to be work-
ed from side to side, during a pain, or at short intervals if there is
no pain, and with a very slight degree of traction  in the axis of the
outlet; the perinaeum being supported with the left hand.  If the
woman complains of cutting or laceration during  the movement of
the instrument, it is hardly applied, and some of the soft parts are
included.   In such case the instrument  must be removed, unless
the woman complains from fear, which is often the  case when the
forceps is  properly applied.
   The lateral motion of  the  forceps  being  continued until the
head approaches  the perinaeum, the  handles  are now  to be de-
pressed towards the  coccyx, to facilitate the escape of the  occi-
put under the  arch of the pubis; and  this being accomplished,
they are to be elevated  towards the  abdomen, or in other words,
in the axis of the outlet, so as to extract the head in the course in
which it is propelled in  natural labour.   We must push back the
head when on the perinaeum, from time to time,  in order not  to di-
late this part too  rapidly.   When the perinaeum is much distend-
ed, we support it with the left hand, while we elevate the handles
of the forceps on the abdomen of the mother.  Wh§n the head
is disengaged,  we  disarticulate  the  instrument, by removing one
blade after the other.
   When the head is extracted, we should excite uterine action if
none exists,  by friction  on the abdomen, or by the  ergot of rye ;
and when uterine action is excited, we facilitate the passage of the
shoulders, by adapting  them to  the  axis of the inferior strait, or
outlet.  The fingers or blunt hook must be sometimes applied on
the axillae;  but the latter  is scarcely  ever employed in these coun-
tries.  If the  head is voluminous, and requires compression, the
ligature on the handles of the forceps is to be tightly applied  ; and
it is held that the head may be compressed to the size of the space
between the blades of the forceps, without much danger to the in-
fant.   Compression,  however, to this  extent is very seldom ne-
cessary ; indeed I have been often astonished  at the slight degree
of lateral  motion of the head, which  often enables it to descend
on the perinaeum.   When this is the case, the forceps may be re-
moved, blade by blade, and if there is uterine action, it will com-
plete delivery.  But when there is no uterine action, and  convul-
        49 
386
GYN^CO-PATHOLOGY.
sions, haemorrhage, or syncope  present, we must extract the head
through  the  genital  fissure in the  manner  above mentioned.  In
cases of  first  labours, the external genitals are rigid, or undilata-
ble, and  hence great care must be taken not to dilate the perinaeum
suddenly, or it will be lacerated.  This  caution is also to be ob-
served when  the woman is very young or advanced in life.
   Second direct Position of the  Vertex at the Inferior Strait—
Occipito-posterior position.—The  occiput  corresponds  to the
curve of the  sacrum, the forehead to the symphisis pubis.
   Application of the Forceps.—The application of the forceps is
exactly the same as  in the preceding position, except the  handles
of the instrument  ought to be  held  less elevated, in order to em-
brace the head more completely, in  the  direction of its length.
The lateral motion of the forceps  and head is the same as in the
preceding case;  but we must first elevate the handles towards the
pubis, in order to allow  the occiput to escape first; and then
strongly  depress the instrument to allow the chin to escape under
the pubis.   The  perinaeum must be well supported, and gradually
expanded in  this case, or otherwise it will be lacerated.
   Right and left transverse  Positions of the Head at the outlet.
We  are  often able to rectify the positions in these cases with the
hand, that is, to turn the face into the hollow of the sacrum; but
should we fail, a blade of the forceps should be passed under the
pubis, with its convexity towards  the face; and after the  applica-
tion  of the lower blade, or that next the sacrum, the handles are
to be articulated, and the face  is to  be turned into the sacral con-
cavity ;  and the remainder of  the operation is the same as in the
first  position of the head.
   Diagonal Positions of the Vertex.—First Diagonal Position
at the Inferior Strait.—The occiput corresponds to the left coty-
loid  cavity or acetabulum,  and the forehead to the right sacroiliac
symphisis.
   Application of the Forceps.—The  occiput corresponding to
the left cotyloid cavity, the obstetrician will take the right branch
with the right hand, and after  having inclined the handle towards
the left groin, he will  make it glide  by the aid of the left  hand
placed in the parts, on the side of the  head which is forwards.
The thumb ought to be placed under the posterior cheek, or edge
of the blade, as soon as the  branch  begins to enter.   This branch
being firmly  held  by an assistant, the obstetrician,  without with- 
INSTRUMENTAL PARTURITION.
387
drawing his left  hand  from the  vagina,  will carry it backwards.
Then taking the left branch with the right hand, he  will make it
glide under the branch first introduced, and will conduct it by the
help of the left hand, on the side of the head which  is behind.
   The two branches being applied, the obstetrician will withdraw
his left hand from  the parts, and will attend  to  the articulation of
the instrument, behind  which he will  place himself.   Then seiz-
ing the forceps as  we have directed for the inferior strait, he will
rotate the head,  and once the occiput is brought under the pubis,
and the face in  the sacrum,  he will treat it exactly as  in the first
direct position.
   Second Diagonal Position—The  occiput corresponds  to the
right cotyloid cavity, and the  forehead to the left sacro-iliac sym-
phisis.
   Application of the  Forceps.—The occiput corresponding to
the right cotyloid  cavity, the obstetrician  will take the left branch
in the left  hand, and after  having inclined the handle towards the
right hip, he will  make it glide  by the aid of the  right hand pla-
ced in the  parts, on the side of  the bead which  is forwards, taking
care to place under the most posterior cheek as soon as the branch
begins to enter.    This branch being supported by an assistant, the
obstetrician, without withdrawing  his  right hand from the vagina,
will carry it  backwards.  Then taking the right branch with the
left hand, he will  make it glide  in front of that which was first ap-
plied, and conduct it  by means  of the hand left in the parts, on
the side of the head which is  behind.
   The two branches being introduced, the obstetrician will with-
draw his right hand from the  parts, and  after  having  articulated
the instrument,  he will place himself  behind it.  Then applying
his hands as at the inferior strait, he will rotate the head, and will
treat it afterwards  as in the first direct  position of the vertex.
   Third Diagonal Position.—The  occiput corresponds to the
right  sacro-iliac symphisis, and the forehead to the left cotyloid
cavity.
   Application of  the  Forceps.—The forehead corresponding to
the left cotyloid cavity, the application of the forceps is practised
according to the same rules as in the first diagonal, except that the
face being  above,  the  handle  of the instrument ought to be held
less elevated than  in the  proceeding  positions, in  order that the
head may be better seized according to its length. 
388
GYNJECO-PATHOLOGY.
   The instrument being applied, the obstetrician will place him-
self behind it, will rotate the head, and  after having brought the
occiput into the hollow of the sacrum, and the face under the arch
of the pubis, he will then treat it exactly as in  the second direct
position of the vertex.
   Fourth Diagonal  Position.—The  occiput corresponds to the
left sacro-iliac symphisis, and  the  forehead to the  right cotyloid
cavity.
   Application of the Forceps.—The forehead  corresponding to
the right cotyloid cavity, the application of the forceps ought to
be practised according to the same rules as in the second diagonal,
except that the handle of the instrument ought to be kept less el-
evated.   The obstetrician, standing behind the forceps, will  rotate
the head, and will then treat it as in the  second direct position.
   1.  If the occiput corresponds directly to the  left side of the
pelvis, and the forehead to the right, we treat it exactly as  in the
first and third diagonals, except that one of the branches is placed
under the pubis, and  the other in front of the sacrum.
   2.  If the occiput  corresponds directly to the  right side of the
pelvis, and the forehead  to  the  left side, we shall treat it exactly
as in the second and fourth  diagonals.
   Positions of the  Vertex at the Superior  Strait.—The head
will take the same positions  at the superior as at the inferior  strait.
Smellie,  Hamilton,  and  Osiander recommend  the  long forceps;
Baudelocque, Capuron, Flamant, and Gardien prefer version un-
less the pelvis is contracted; and in such  cases they use the in-
strument.
   First direct  Position.—The occiput  is  above the symphisis of
the pubis, and the forehead  in front of the sacro-vertebral  angle,
or promontory of the sacrum.
   Application  of the Forceps.—The branches of the forceps are
applied exactly the same as in the first direct of the inferior strait,
except that they penetrate  farther, and the hand  which serves as
a guide, ought to be placed between  the womb and the head of
the foetus.
   Once the forceps applied, the obstetrician seizes it, as has been
directed for the superior strait,  and according as he places himself
to the left or the  right, he reduces it to the first or the second di-
agonal of the superior strait.
   To change it thus, it is  frequently  useful  to return  it  a little 
INSTRUMENTAL PARTURITION.
389
above the superior strait.   Once the head is placed in a diagonal,
we draw it into the cavity of the  pelvis,  by making  it follow the
axis of  the superior strait, and inclining the handle to the opposite
thigh.   The position is thus reduced to the first diagonal of the in-
ferior strait.   The hands are then applied as for this strait, we ro-
tate the head, and treat it then as in the first direct of the inferior
strait.
   Second direct  Position.—The occiput corresponds to the sa-
cro-vertebral angle, or promontory of the sacrum, and the forehead
to the symphisis  of the pubis.
   Application of the Forceps.—Exactly the same as in the pro-
ceeding position, except that the handle of the instrument ought to
be held less elevated, in order that the head may be  better seized
in the direction of its length.
   Once the instrument applied, we place ourselves to the left or
to the right; we return it  a little above the superior strait; and
we change it into the third or fourth diagonal.   We draw then the
head into the cavity of the pelvis, making it follow the axis of the
superior strait, and carrying the blade  of the forceps to the side of
the opposite  thigh.  We treat it then  exactly as in  the diagonals
of the inferior strait.
   First Diagonal Position.—The same  as  at the inferior strait,
except  that the head is less engaged.
   Application of the  Forceps.—Exactly the same as at the infe-
rior strait, except that the branches, and the hand which conducts
them, ought  to be carried within the womb.   The instrument be-
ing applied, the obstetrician places himself behind it, he draws  the
head into the cavity of the pelvis, always following the axis of the
superior strait, and carrying the handle of the forceps towards  the
left thigh.   The position is thus reduced to the  first diagonal  of
the inferior strait, he replaces his hands as for this strait, and treats
it exactly as for this first diagonal.
   Second Diagonal.—The same as at the inferior  strait, except
that the head is less engaged.
   Application of the  Forceps.—The  same as at the  inferior strait,
except  that the branches, and the hand which cohducts them,  are
to be carried further.  We draw the  head into the second diago-
nal of the inferior strait, in  following the axis of the superior strait,
and carrying the  handle of the  forceps towards the  right  thigh; 
390
GYN .SCO-PATHOLOGY.
 changing then the positions  of  the  hand, we convert  it into  the
 first direct, and terminate the labour as in this position.
   Third Diagonal.—The same as  at the inferior strait.
   Application of the Forceps.—As at  the inferior strait, except
 that the instrument is to be  carried  within the  womb.   The  ob-
 stetrician places himself behind  it; and we draw the head into the
 third diagonal of the inferior strait; we rotate it, and then termi-
 nate it in the second  direct position  of that strait.
   Fourth Diagonal.—The same as at the inferior strait.
   Application of the Forceps.—The same as at the  correspond-
 ing position  of the inferior  strait.   Once the instrument applied,
 the operator places himself behind it; we draw the head into  the
 fourth diagonal of the inferior strait,  and treat it exactly as in that
 position.
   1.  If the occiput corresponds directly to the left  side of  the
 pelvis, and the forehead to the right, it  is treated as in the first and
 third diagonals, except that  the first branch  ought to be placed
under the pubis, and  the second in the  hollow of the  sacrum,  by
rotating the head,  we bring the occiput under the  pubis, and  the
face into the sacrum.
   2.  If the occiput corresponds directly to the  right side of  the
pelvis, and the forehead to the left, it is treated  as in the second
and fourth diagonals,  except  that the branches should  be applied
as in  the  preceding  position, one before  and the  other behind.
The occiput  is then brought  under the  pubis, and the  face in  the
hollow of the sacrum.
   Impaction of the Head at  the superior strait—Vertex present-
ing.—Authors admit generally two species of  impaction of  the
head at the superior strait of the pelvis.
   In the first  species.—The antero-posterior diameter of the  su-
perior strait has four  inches  in  extent, and the head of the foetus
is  impacted by its  occipito-frontal diameter.
   In the second species.—The  antero-posterior diameter of  the
superior strait has  less than three inches and a half in  extent, and
the head of the foetus is impacted by its bi-parietal diameter.
   First Species.   Impaction of the  head according to its length.
—/The head of the foetus, according to  its  length, may be im-
pacted in  two different positions.
   First Position.—The occiput corresponds to the pubis, and  the
forehead to the sacrum. 
INSTRUMENTAL PARTURITION.
391
  Second Position.—The occiput corresponds to the sacrum, and
the forehead to the pubis.
  Indications to fulfil.—We must  return the head which is  al-
always possible in  these positions, and place it in diagonal.  These
positions may  be rectified with the hand, forceps or lever, the fore-
head or occiput being turned towards either sacro-iliac symphisis.
   Application of the Forceps.—The forceps, in these  two posi-
tions, ought to be  applied exactly in the  same manner  as  in  the
first and  second direct of the vertex at  the superior strait, except
that the  branches  ought  to be passed a little less  deeply.  The
obstetrician, placed to the right  or to the left of  the instrument,
will return the head, giving it  slight lateral movements, and will
draw it into a diagonal of the superior  strait, to treat it exactly as
in that position.
   Second Species.  Impaction of the head according to its thick-
ness.__The head  may be impacted, according to  its thickness, in
two different  positions.
   First Position.—The occiput corresponds directly  to the left
side of the pelvis, and the forehead  to  the right side.
   Second Position.—The occiput corresponds with the right  side
of the pelvis, the forehead with the left side.  These are of very
rare occurrence.
   Indications to fulfil—I. If  the infant is dead, it is better to
open its cranium, in order to diminish its volume, and to extract it
 then by means of hooks.
   2.  If the child is living, we must extract it by means of the for-
 ceps.  But  on what  part of the head  are we to apply the bran-
 ches ?   In the occipito-iliac positions at the brim,  the sacro-verte-
 bral  angle, or promontory of the sacrum with the coccyx and pe-
 rinseumVill not  permit  the application of the instrument over the
 ears, and it would be almost impossible to use it in the  axis of the
 superior strait.
    M. Capuron,  convinced that we can  always return the head,
 rejects the application of the forceps on  the  face  and occiput,  as
 generally recommended, and advises in all cases to return it, and
 then to apply the branches on the lateral regions.   He thinks that
 the instrument adds very little  to the thickness of the head, which
 besides suffers a sufficient reduction for it to  be afterwards possible
 to draw it into the cavity of the pelvis.
    If we can  return the head above the  superior  strait, we think 
392
GYNECO-PATHOLOGY.
with M. Capuron, that we ought to'apply the branches of the for-
ceps on the lateral regions of the head, and we should attend for
their introduction to the relations of the occiput with the pelvis.
If it corresponds to the left we introduce the branches  as for the
first and third diagonals.  If to the right, it is to be treated as the
second and  fourth diagonals.  But if  it should happen  that we
cannot return the head above the superior strait, we think, with
the Professor Baudelocque,  that we ought to  place one of the
branches on the face, and the other on  the occiput.
   We follow, for the application of the forceps, the rules already
laid down, on the occasions of the direct positions.  We  draw the
head into the cavity of the pelvis, in following the axis of the su-
perior strait,  and we replace then the branches  on the  lateral  re-
gions of the head.
   In order to simplify as much as possible this second application
of the forceps it is necessary to withdraw from  the  parts  that
branch only, which according to the relations of the occiput, ought
to be applied  behind: it  being understood that  for the replacing
the branches, the rules laid down for the transverse  positions are
to be followed.
   Positions of the face.—The face of the foetus can take six prin-
cipal positions at the inferior and superior straits  of the pelvis.  Of
these six positions, two are direct, the  other four are diagonal.
   Indications to fulfil.—The positions of the face present two
indications to fulfil ;  the one  consists  in  returning  the  infant to
bring it down by the  feet; the other in rectifying the head.
   If the changing of the infant is possible,  we would treat it as in
the positions  of the vertex ; and in the  contrary case, we must en-
deavour to bring the  occiput, in  order  that  the head may present
by one extremity of its greatest diameter.   We can rectify the
occiput by the help of the  hand only, as I have described when
on the anterior region of the trunk.
   It can  be  rectified  by means of a  lever, as I shall shew when
treating of the application of that instrument.
   When we  have rectified the  head   by  one or  other  of these
means, we abandon the labour to nature, unless any accident should
oblige us to have recourse to the  forceps, which ought then to be
applied as in the positions of the vertex.   But it  may happen
that the occiput cannot be lowered either by the hand alone, or by 
INSTRUMENTAL PARTURITION.
393
the lever:  then we must have recourse to the forceps. In all these
cases the chin should be depressed on the chest if possible.
   Positions of the Face at the inferior strait.   First direct Posi-
tion.—The forehead corresponds to the symphisis pubis, and the
chin to the curve of the sacrum.
   Application of the Forceps.—We introduce the  branches, ob-
serving the rules prescribed for the direct positions ;  but here the
head can be seized only in its occipito-frontal diameter.   Once the
forceps applied, the handle is seized with one hand,  and the occi-
put lowered,  whilst with the other hand placed  beneath the bran-
ches,we return the face into the interior of the pelvis.  When we
have rectified the head, we separate the branches without disartic-
ulating them, and  we pass them into the direction of the occipito-
mental diameter, by raising the handle of the instrument r  we ter-
minate then as in the first direct of the vertex.
   Second direct Position.—The forehead corresponds to the curve
of the sacrum and the chin to  the symphisis of the  pubis.
   Application of the Forceps.—The  same as in the  preceding
position, except that, as it is possible to  seize at once the head in
its occipito-mental diameter, by keeping the handle  of the  instru-
ment much elevated, it would  be quite  useless to  endeavour to
bring down the occiput, since the chin can be first disengaged.
   The obstetrician will place himself to the right or to the left of
the forceps, disposing of his hands, as has  been already directed
for the inferior strait.   Then giving lateral movements to the head,
he will first lower the handle of the instrument  to  disengage the
chin from beneath the pubis; after which he will turn it back  on
the abdomen of the mother, in order to disengage the  occiput which
is behind.
   First Diagonal.—The forehead corresponds  to  the left coty-
loid cavity, and the chin to the right sacro-iliac  symphisis.
   Application of the Forceps.—The face  being placed in diago-
nal,  the two  branches of the forceps  ought  to be introduced ac-
cording to the rules established for such positions.   But here, as
in  the  first direct, the head can  be seized only in  its occipito-frontal
diameter:  then the obstetrician, after having brought the face into
the first direct, ought to treat it as such a position.
   Second Diagonal.—The forehead corresponds to the right coty-
loid cavity, and the chin to the left sacro-iliac symphisis.
   Application of the Forceps.—Exactly the same as in  the
        50 
394
GYNJECO-PATH0L0GY.
cond diagonal of the vertex ; except the head, as in the preceding
position, can be seized only in the occipito-frontal diameter.  The
obstetrician, placed behind the instrument, will bring the face into
the first direct, and will treat it as such a position.
   Third Diagonal.—The forehead corresponds with the right sa-
cro-iliac symphisis, and the chin to the left cotyloid cavity.
   Application of the Forceps.—The branches of the instruments
ought to be applied according to the rules for the first diagonal:
but here the head can be seized in the  occipito-mental diameter,
and to do this, it is sufficient to keep the handle well raised.   The
obstetrician, placed behind the instrument, will bring the face into
the second direct, and terminate as in that position.
   Fourth Diagonal.  Principal Relations.—The forehead is di-
rected towards the left sacro-iliac  symphisis, and the chin to the
right cotyloid cavity.
   Application of the Forceps.—The same as in the second diago-
nal : except that the head can be seized in its occipito-mental di-
ameter.
   The obstetrician, placed behind  the  instrument, will bring the
face into the second direct, and terminate as in that position.
   1. If the forehead corresponds directly to the  left  side of the
pelvis, and the chin to the  right, it is  treated as  in the first and
third diagonals.
   2. If the forehead corresponds directly to the right of the pelvis
and the chin to the left, it is treated as  in  the second and fourth
diagonals.
   Positions of the Face at the Superior Strait.—The face pre-
sents at the superior strait, in the same positions as in the inferior.
   The relations  of the  head  with  the pelvis being  exactly the
same as at the inferior strait, except that the parts are less enga-
ged, we do not think it necessary to repeat them at each position.
   First direct Position.  Application of the Forceps.—The same
exactly as in the corresponding position of the  vertex.   Here, as
at the inferior strait, the head can only be seized  in  its occipito-
frontal diameter.   The obstetrician, placed at the right or  left of
the instrument, will return  the head a little above the superior
strait, and change the position into the first or second diagonal of
this strait.   He will treat it then, as we shall  speedily indicate,
when speaking of these positions.
   Second direct  Position.   Application of the Forceps.—The 
INSTRUMENTAL PARTURITION.
395
same as in the corresponding  position of the vertex.   Here the
head can  perhaps be seized in its occipito-mental diameter.   We
return it a little above the superior strait, and change it into  the
third or fourth diagonal, to be treated  as such.
   First and Second Diagonals.  Application of the Forceps.—
The same as in the corresponding positions of the inferior strait;
except that the branches and the hand which conducts them, ought
to be passed deeper.   Once the instrument applied, we draw the
face into the first or second  diagonal of the inferior strait,  inclin-
ing the forceps towards the corresponding thigh, and it is treated
exactly as in that position.
   Third  and Fourth Diagonals.   Application of the Forceps.—
The same as in the corresponding positions of the inferior strait;
except that the branches are carried  further.   When the forceps
are applied, we draw the face in the inferior strait, and  terminate
exactly as in the positions of this strait.
   I. If the  forehead corresponds directly to  the right, or the left
of the pelvis, we  apply the forceps, and terminate exactly as in
the corresponding positions of the inferior strait, after having drawn
the head into the cavity.
   Application of the  Forceps, the trunk  being external.—The
head, after the birth of the trunk, may be stopped at the superior
or the inferior strait of the pelvis.   It may take at either strait, six
principal positions ;  namely, two direct,  and four diagonal.
   In all these positions the principal relations of the head of the
foetus with the pelvis of the mother, are the same as in the posi-
tions of the vertex; except that instead  of  the  occiput, it  is  the
chin which presents first.  The forceps  ought to be applied  ac-
cording to the same rules, since the  positions are alike.  These
positions can in general be rectified by the hands.
   Positions of the Head at the inferior Strait, the Body being
born.  First direct.—The occiput corresponds to the arch of the
pubis: the face is in the cavity  of the sacrum.
  Application of the Forceps.—An assistant  raises the body and
arms  of the  foetus.   During this time, the  obstetrician  introduces
the branches of the forceps beneath, in order to seize the head in
the direction  of its length.  When the instrument is articulated,
he gives it lateral movements, and  terminates the disengaging the
head, by turning back the handle of the forceps on the abdomen 
396
GYNJECO-PATH0L0GY.
 of the mother.   In this last part of labour one of the hands ought
 always to support the perinaeum.
   Second direct Position.—The occiput is in the cavity of the sa-
 crum, and the forehead under the arch of the pubis.
   Application of the Forceps.—In  this position, we must apply
 the  forceps above, in order  to seize the head in its occipito-mental
 diameter.   An assistant supports the body of the foetus.   When
 the  instrument is applied,  the  obstetrician supports strongly the
 perinaeum with one  hand, and with the other he lowers the handle
 of the forceps, to disengage the face from  beneath the pubis.
   First Diagonal.—The occiput corresponds to the left cotyloid
 cavity,  and  the forehead to  the right sacro-iliac symphisis.
   Application of the Forceps.—The branches ought to be placed
 below the foetus, which an assistant keeps  raised.  We then bring
 the head into the first direct, and terminate as  in that position.
   Second Diagonal.—The occiput corresponds to the right coty-
 loid  cavity,  and the  forehead to  the left sacro-iliac symphisis.
   Application of the Forceps.—We must introduce the branches
 beneath the foetus, and change it into the  first direct, and termin-
 ate as in that position.
   Third  Diagonal.—The  occiput corresponds to the right sacro-
 iliac symphisis, and  the forehead to the left cotyloid cavity.
   Application of the  Forceps.—In this  position we must intro-
 duce the branches above the foetus, in order to seize the head in
 the direction of its  length.  We then  rotate it, which brings  the
 face  under the pubis, and the occiput in the cavity of the sacrum,
 and  we  terminate as in  the  second direct.   If we  find too much
 difficulty in introducing the  branches above the foetus, we must in-
 troduce  them below, and treat it, as we  shall speedily direct, when
 speaking of the same positions at the  superior strait.
   Fourth Diagonal.—The occiput  corresponds to the left sacro-
 iliac  symphisis, and the forehead to the right cotyloid cavity.
   Application of the Forceps.—We ought here to  apply the for-
ceps above the foetus, in order to seize the  head in its occipito-
mental  diameter.   We then rotate it, and terminate it as in the
second direct.
   If we find too much difficulty in introducing the  forceps above
the foetus, we must introduce it beneath.
   1.  If the occiput corresponds  directly to the left  of the pelvis, 
INSTRUMENTAL PARTURITION.             397
and the forehead to the right, we would treat  it in  regard  to the
application of the forceps, as in the first and third diagonals.
   2. If the head is in an inverse position,  we should conduct it as
in the second and fourth diagonals.
   Positions at the Superior Strait.—The relations of the head
of  the foetus being the same as at the  inferior strait, except that it
is less engaged, we shall not repeat them at each position.
   First direct Position.   Application of the  Forceps.—The
branches ought to be introduced  below the foetus, which an assist-
ant  raises.   When  the  forceps  is  applied, we  return  the head
above the superior strait; we change it into the first or second di-
agonal, according as we  place ourselves to the right or left of the
instrument;  we draw the head to the  inferior strait, and terminate
as in the position of that strait.
   Second direct Position.   Application of the  Forceps.—Here,
although the face is forwards, we must apply the branches below
the  foetus.    In  this manner the head is seized  in its  occipito-fron-
tal  diameter.   We return it above the superior  brim, and change
position into the third or fourth diagonal.    We draw the head to
the  inferior strait;  we rotate it, and  bring it thus to  the second di-
rect. But  the  head is badly seized for it to pass the  inferior strait;
we must then, unless the pelvis  is very large, or the head small,
disarticulate the forceps, without  withdrawing them from the parts,
raise the right  branch, lower the left, and  make the body of the
foetus to pass between them.   We rearticulate the  instrument in
front of it,  and by this manoeuvre, the head is found seized in the
direction of its occipito-mental diameter.  We terminate the labour
then as in the second direct position.
   First and second Diagonals.   Application of the Forceps.—
The forceps ought to be applied in  the same manner as  in the
corresponding  positions  of  the  inferior strait;  except that the
branches, and the hand which conducts them, ought to be  carried
further.  The  obstetrician places himself  behind the instrument,
and draws the head to the  inferior strait, carrying the handle of
the forceps to the corresponding  thigh.  He then rotates the head,
and terminates the labour, as  in the first direct of the  inferior
strait.
   Third and fourth Diagonals.  Application of the Forceps.—
Here it is indispensable to place  the branches  beneath  the  foetus.
We  draw the head to the inferior strait, carrying the handle of the 
398
GYNJCCO-PATH0L0GY.
forceps towards the  corresponding thigh,  and we rotate, which
brings the face under the pubis, and the occiput to the cavity of
the sacrum.  We disarticulate the forceps then, without withdraw-
ing it from the parts, we pass the foetus between the branches, and
we rearticulate the instrument above.  The head is seized in  the
direction of the length, and we terminate the rest of the labour as
the second direct of the inferior strait.
   I.  If the occiput corresponds directly to the left or the right
side  of the pelvis, we apply the forceps, and terminate it exactly
as in the corresponding positions of the inferior strait, after having
drawn the head into the cavity.
   Review  of the different  Applications  of the   Forceps.—In
whatever manner the head  presents, whether it be by its vertex,
by its face, or by its base; whether it be stopped at the inferior or
superior strait, the application of the forceps is  always performed
according to the same rules.   To be properly placed, the instru-
ment ought to seize the head laterally, and in the direction of  its
length, so that the occiput and chin be extracted first.
   Positions  of the  inferior  Strait.  Direct  Positions.—In  all
the direct positions of the inferior strait, whatever part of the head
presents, we place first the left branch with the left hand, and then
the right branch with the right hand.  Dr. Hamilton recommends
the right hand blade, and  Professor Velpeau  and  other French
writers the left hand blade.   This  difference is accounted for,  by
some designating the blades right and left, according to the posi-
tion of the handles; and others  according to the positions of the
blades in the pelvis.  We  articulate the instrument, the joint of
which ought  to correspond  to the centre of the  vulva, and  we
place ourselves indifferently to the right or the left.   Then seiz-
ing the forceps with the two  hands, placed one below  the handle,
the other above the branches near the genitals, we move the head
laterally, and  disengage it by turning over the  instrument on the
abdomen of the mother, if the  face is beneath  ; and  in lowering
it  powerfully if it is above.   The hand which is near  the genitals
ought to be carried in front of the perinaeum, when  the head is on
the point of escaping.
   Diagonal  Positions.—In all  the diagonal positions of the  in-
ferior strait whatever part of the head presents, we are guided, for
the application of the forceps, by the  relation of  the occiput or
forehead with the cotyloid cavities of the pelvis. 
INSTRUMENTAL PARTURITION.
399
  Each time that the occiput or forehead corresponds to the left
cotyloid cavity, we introduce the two branches with the right hand,
beginning with the right branch.
  Each time, on the  contrary, that the  occiput  or the forehead
corresponds with the  right cotyloid  cavity, we introduce the two
branches with the left hand, beginning with the left branch.   We
articulate the instrument, and we place  ourselves constantly behind
it.   Seizing then the forceps with the  two hands,  placed one un-
der the handle, and the other above the branches, near the  geni-
tals, we rotate the head, and terminate as in the first or second di-
rect, according to whether the  occiput or the forehead is brought
under the arch of the pubis.
  1. If the occiput corresponds directly to the left side of the pel-
vis, we treat it as in the first diagonal.
  2. If to the right  side of the pelvis,  we treat  it as the second
diagonal.
  Positions of  the Superior Strait.   Direct  Position.—In all
the direct  positions of the superior strait,  whatever  part of the
head presents, we apply the forceps as  at  the inferior strait; ex-
cept that the branches, and the hand which  conducts them, are
passed deeper.   The instrument being applied,  we seize it with
the two hands, placed one above the handle, and  the other below
the branches, the index extended as far as the head; we return
this back, giving it slight lateral movements, and replace it in the
diagonal of the superior strait.   That being done, we draw it into
a diagonal  of the inferior strait, inclining the handle of the  forceps
towards the corresponding thigh, and we treat it then as in the po-
sitions  of this strait.
  Diagonal  Positions.—In all  the  diagonals of the superior
strait, whatever  part of the head  presents, we introduce the for-
ceps in the same manner as at the inferior strait,  except that the
branches, and the hand which conducts them, ought to be carried
farther.  The instrument being articulated,  we place ourselves be-
hind it, and we seize  it with the two hands,  applied one above the
handle, the other below the branches; the  index  extended in the
parts.   We draw the head into a  diagonal of the inferior strait,
and terminate them as in  the positions of this strait.
  1. If the occiput corresponds directly to the left side of the pel-
vis, we treat it as in the first diagonal. 
400
GYNECO-PATHOLOGY.
  2. If to the right of the pelvis, we treat it as in the second di-
agonal.
  If the head is separated from the trunk, it may be extracted by
the forceps-lever; or craniotomy may be  performed.   This oc-
currence seldom happens at present.   Velpeau is of opinion, that
the forceps should never be applied to the pelvis in breech cases,
as it must contuse the  abdominal  viscera, and kill  the infant.
British writers consider the practice safe and valuable, and I  think
very justly.   In France,  Germany, Italy, and America, the wo-
man is placed on the  back, the inferior extremities flexed, and sep-
arated, the soles of the feet being on the bed ; and therefore  there
is no necessity for a  joint  or screw in one of the  handles of the
forceps; there is neither in the  French, German, nor American
forceps.   In  this country it is said, that the back is an indelicate
position; but in my  own  practice I have never known a patient
for  whom the forceps was required, make the slightest objection
on this point.   When placed on the left side, the right limb must
be supported, and often is allowed  to approximate the other, to
the great annoyance  of the operator.   Again, the bed  may  be so
placed that if the woman is to  be placed on the side, it musf; be
on the right, so that the other blade should have a screw or joint;
but I repeat, if  the  woman is placed  on the back, near the edge
or foot of  the bed, neither is necessary.
   Of the Lever or  Vectis.—Obstetricians designate  by this
name, an instrument  intended by its inventors to act as a lever on
the head of the  foetus, and to oblige it to descend across the canal
of the pelvis  and genital  organs.  The origin of this  instrument
is yet very obscure.  Its invention is most commonly attributed to
Roonhuysen, Herbiniaux, Denman, and Bruyn, a Dutch  physi-
cian preferred it to the  forceps; but  at  present the latter is the
general favourite.   The  lever  at  present used resembles very
much a branch  of the forceps, not curved at the borders.
   One of the extremities, which is called the branch, is constitu-
ted as that of the forceps, by two cheeks separated from one an-
other by a long  opening.   These two cheeks are curved on their
surfaces, so as to present on one side a concavity to accommodate
the convexity of the head of the  foetus,  and on the other a con-
vexity to  accommodate  itself to  the concavity of the pelvis.  The
other extremity of the lever is furnished with a piece of wood, and
constitutes the handle of the instrument.  Dr. Davis, of the Uni- 
INSTRUMENTAL PARTURITION.
401
versity, who has modified obstetric instruments to a great degree,
has proposed a new lever; but that of Lowder is, I believe, gen-
erally employed.
   One of the branches of the forceps may very well replace the
lever; nevertheless, as M.  Desormeaux has judiciously observed,
the lever, properly so called, is preferable when it is necessary to
make direct traction on the occiput.
   If we use a branch of the forceps in the diagonal position, we
must use the right branch when the occiput is to the right of the
pelvis, and the left branch when to the left.  In the direct posi-
tions we may  use either: in all cases, that which is used ought to
be introduced by the  corresponding hand.
   Use of the Lever.—The use of the lever is employed chiefly
to rectify the occiput, and to exercise  direct traction on it to bring
it to the centre of the pelvis, when it is turned on the back of the
infant, as it happens in the positions of the  face.  The lever can
be applied at the superior and inferior straits. It may be applied
on the occiput,  temple,  forehead, mastoid process and chin.  Its
use is to depress the head  at the superior  strait, which is better
done by the forceps or hand; and  to extract  it from the cavity,
which it will frequently do better than the forceps.  It is a useless
instrument when there are no labour pains, and in the hands of the
inexperienced may do great injury to the parent and infant.  Dr.
Hamilton  says,  " it should  be only employed in certain  cases
where there is a slight  degree of narrowness at the brim  of the
 pelvis, or where the  face of the infant is foremost."  (Outlines of
Midwifery, 1826.)
   Positions of the Face  at the inferior  Strait.  First  direct
 Position.—The occiput, turned back, corresponds to the pubis.
   Application of the Lever.—One of the hands being introduced
 into the vagina we pass the lever on the side of the head, and then
 bring it  with the fingers on the occiput, lowering strongly the han-
 dle of the instrument.   Once the lever applied, we raise the han-
 dle, and seize it with one hand, whilst we place  the other above
 near the pubis.  With the first we draw to ourselves, in lowering:
 with the second, we press strongly the head  from before back-
 wards.
    If we do not succeed in this manner in  rectifying the occiput,
 we must, at the same time that we are acting on the lever, push
 the face backwards with some of the fingers of  the  hand  placed
         51 
402
GYN.3BC0-PATII0L0GY.
near the pubis.   Once this see-saw motion performed, the labour
will terminate commonly by itself,  or else we ma) have recourse
to the forceps, if circumstances require it.
  Second Direct.—The occiput corresponds to the sacrum.
  Application of the Lever.—In this position, we glide the lever
in front of the sacrum, and as far as above the occiput; and when
we are certain it is properly placed, we seize it near the perinaeum
with one of the hands, and with the  other we draw on its extrem-
ity, raising it by degrees.  If we find much difficulty in bringing
down the occiput, we ought to assist the see-saw motion by push-
ing back the face with some fingers of the  hand  placed near the
parts.
  In this position it is  preferable to employ the forceps, since we
can at once seize the head in  the direction of its length, and bring
out the  chin first.
  First and Second Diagonals.—In the first the reversed occiput
corresponds to the left cotyloid cavity ;  in the second to the right.
  Application of the Lever.—One of the hands being introduced
in the parts, we glide  the lever on the side of the  head, and bring
it then behind the occiput, which is  lowered as in the first direct.
Once the head rectified, we abandon the labour to nature, or else
we apply the forceps, if necessary.
  Third and Fourth Diagonals.—In the first case, the reversed
occiput corresponds to the right  sacro-iliac symphisis, and in the
second, to the left.
  Application of the Lever.—In these positions we introduce the
lever, and we treat it exactly as in the second direct.
  In these two last positions, the forceps is preferable to the lever,
since we can seize  the head  in its occipito-mental diameter, and
disengage the chin first.
  1. If the reversed  occiput corresponds directly to  the right or
the left of the pelvis, we treat it as in the third or fourth diagonals.
  Positions at the superior Strait.   First and Second Direct.—
The same relations  as at the inferior strait; but less engaged.
  Application of the  Lever.—Exactly as  at the inferior strait:
except  that, as we lower  the  occiput, we must endeavor to bring
the head to a diagonal.
  Diagonals.—Same relations as at the inferior strait, except that
the head is less engaged. 
INSTRUMENTAL PARTURITION.
403
   Application of the Lever.—To be treated exactly as at the in-
ferior strait.
   1.  If the occiput corresponds directly to the right or the left of
the pelvis, we treat it as in the third or fourth diagonals.
   The lever is less useful at the superior strait than at the inferior,
and many obstetricians prefer the forceps.
   Of the Blunt Hooks.—The  blunt hooks used for the extrac-
tion of the foetus have not all  the same shape; some  represent a
curve more or less open;  others  form with the principal branch
of the instrument almost a right angle.
   The handle is commonly made of wood.
   The two blunt  hooks  at the  end of  the French or American
forceps will serve instead  of these.
   Use of the Blunt Hooks.—The  hook, bent at an acute angle,
is  destined to be applied in the  hollow of the arm-pit, when the
shoulders being retained in the pelvis, and the fingers cannot ex-
tract it.   It will also  serve to extract the  knees  at the inferior
strait; and it may be applied in the mouth to finish the  extraction
of the head, after turning a dead  child.
   The rectangular hook is destined solely for the bend of the hip,
in  the breech positions at the inferior  strait.  M.  Desormeaux
thinks that the finger will frequently serve instead  of the  blunt
hook.
   Introduction of the Blunt  Hook.—There are not any deter-
mined rules for its introduction:  the  only precaution necessary is
to precede it with the finger, in order to know well the disposition
of the place we  intend to apply it  to.  Once introduced, if it
embraces a limb, it ought to be seized by the  hand corresponding
to that limb; and in extracting the foetus,  we ought to take care
to direct it in the different axes of the pelvis.
   Fillets.—Bands were used from the time of Hippocrates until
the invention  of the forceps to effect the extraction of the infant.
They were composed of silk, cotton, linen, leather, and strength-
ened  by the addition  of cane, whalebone,  wire, or thin plates of
iron, variously braided and worked together.   They were applied
over the head, chin and  hips of the infant in breech cases; but
are now completely superseded  by the forceps, blunt  hook, and
operation of version.   A ribbon or tape is sometimes applied on the
arm and leg when either presents, especially by the French ; but
seldom if ever in these kingdoms. 
404
GYNJECO-PATHOLOGY.
  Every part of the pelvis  may be attacked with exostosis, with
mollities ossium, or softening of the  bones, or  may be fractured.
Every part has been occasionally fractured, and driven  into the
cavity; and of course lessening its dimensions.  The deformities
may be slight, or so great, as to prevent the passage of the infant
in the natural manner.   This is called  impracticable, or instru-
mental labour; and  the question is, how is delivery to be effect-
ed?   If the deformity admit the passage of the body of the in-
fant, when divided into different parts,  it has been proposed and
adopted, especially in this country, to open the head of the infant,
evacuate the brain, break the skull to pieces, open and evacuate
the thorax and abdomen, and  bring  away  the body in  different
parts; and this operation is called craniotomy, cephalotomy and
embryotomy.   Others open the abdomen of the parent, cut through
the womb, and extract the infant;  and this is called the Caesarian
section, or gastro-hysterotomoky,gastro-hysterotomy.  Again, it
has been proposed to incise the symphisis  pubis, which  is called
the Sigaultian operation,  after  Sigault, who first practised it, or
more properly Symphyseotomy.
   It is an established obstetric rule, that no woman should die un-
delivered, and that attempts must be made to save her and her in-
fant, or to save the one at the destruction of the other.   The last
question, whether  it was lawful to destroy one life to save the oth-
er ?  was submitted to the doctors of theology at the Sorbonne at
Paris, in the year 1648, who answered, that in this case, neither
ought to be destroyed, nor assisted; and their decision was as fol-
lows :—
   "Nous sous signes, Docteurs, en theologie de la faculte de Pa-
ris, sommes d'avis que si  l'on  ne peut tirer l'enfant sans le tuer,
l'on ne peut sans peche mortel le tirer;  et qu'en ce cas la, il faut
tenir a la maxime  de St.  Ambroise,  ' si alteri subveniri non po-
test nisi alter loedatur,  commodius est neutrum juvare.'   Delibe-
re a Paris le 24 April, 1648."   This is the  doctrine of the Ro-
man  Catholic church at present.   Another great objection to em-
bryotomy was, that the infant would  be lost without baptism.  It
was contended by Thomas Aquinas, that the infant could not be bap-
tized in the womb, for, according to Scripture, it should be first born,
that is, it should be natus before it could be renatus, by baptism.
This difficulty was over-ruled by the Sorbonne doctors in 1773, who
declared that baptism was valid, if the water touched any part of the 
GASTR0-HYSTER0T0MY.
405
infant's coverings.  They said," dummodo infans sit vivus, et arte
seu industria medicorumpossit aqua ad ejus corpus immediate per-
venire"   It remains as yet undecided, whether the outer surface of
the membrane,  which encloses  the waters and  infant, belongs to
the uterus, as it is firmly attached to it, or the foetus.  The decis-
ion of the  Sorbonne  removed one objection to  embryotomy, but
admitted the former.   In this country, the obstetricians are gen-
erally in  favour of embryotomy, whether the child be alive or not,
as the more valuable life of the mother, they contend, ought to be
preserved.   It is said, " the tree should be preferred to the fruit."
The French, German and American accoucheurs are in favour of
the Caesarian operation.  It has been performed  nearly forty times
in the British dominions, and only two women recovered ; twelve
infants were extracted alive, four of whom lived.   Barlow's Es-
say, 1822; Conquest's Outlines, 1826.  The writer in the Lon-
don Encyclopaedia has fallen  into a mistake, when  he asserts that
the operation was performed only in twenty-two cases in this em-
pire.  Mr. Barlow's patient was a strong, healthy country woman,
whose pelvis had been crushed by a waggon rolling over it.   She
recovered, and became pregnant, and the Caesarean operation was
resorted  to with success, for the  woman was attending her usual
pursuits in three  weeks afterwards.   The only other successful
case on record in the United Kingdom is that performed by an il-
literate  Irish midwife, named Mary Dunnally, who operated with
a razor extracted the infant, and held the wound, while a messen-
ger was  dispatched a mile  distant for some silk  and  tailor's nee-
dles, with which  she  sewed  up the wound, and then smeared it
with whites of eggs.  The woman recovered in twenty-seven days.
This case  occurred at Charlemont,  near  Dungannon, county of
Tyrone, and was  seen by Dr. King and  Mr. Stewart, who gave
an account of it in the Edinburgh Medical  Essays, vol. 1.
   In all the British cases,  the operation has not been resorted to
until every other method  has been tried in vain—the strength of
the patients had been worn out,  and  hence the want of success.
On the  Continent of Europe, the  operation is performed at an
early period, before the exhaustion of the  constitution ; hence re-
covery is so common.  In this country, the operation has not been
performed, unless in cases of the greatest deformity of the pelvis;
in which, the embryotomy could not afford relief:  in France and
Germany,  it has been  performed on subjects who afterwards  bore 
406                 gynjEco-pathology.
living children by the vagina.  In this country, the women invaria-
bly laboured under mollities ossium, and  were bad constitutions,
except Mr. Barlow's case; whereas, those on the Continent were
healthy.  This accounts for the difference of success, together with
the early performance of the operation.
   Osborne maintained, that if  the brim of the pelvis was one inch
and a half at the superior strait,  as in Elizabeth Sherwood's case,
the operation of embryotomy was practicable.  The practicabili-
ty of the operation in this case  is  denied by Hamilton, Burns,
Dewees, and many others.  The patient died in the country, so
that  the exact dimensions of the  pelvis were  not ascertained.
Any man, who has  performed embryotomy must  admit, that he
could not do so, in a  pelvis of such contracted dimensions.   Os-
borne has not stated how he extracted the base of the skull or bo-
dy of the infant.   Dewees most truly observes that embryotomy,
even in a case less  deformed, is as fatal to the woman as the Cae-
sarean operation.   This must  appear obvious, when we consider
the pressure which is  made on  the soft parts in the pelvis, during
the operation.  The vagina, bladder, rectum, and muscles  lining
the pelvis, become inflamed  and gangrenous, in consequence of
the pressure of instruments; and these states have been often ob-
served after death.
   It is also a strong objection that we have no certain and positive
signs indicative of  the death of the  child; and hence the Euro-
pean and American authors hold  that the sacrifice of the infant is
murder;  and that in case of extreme deformity, its mutilation will
not save the mother.  On the whole,  the most respectable and
eminent of the foreign writers are unanimous in preferring gastro-
hysterotomy to  embryotomy.  They contend, that if the former
operation  was performed  at an  early  period, the  woman's  life
would not be so much endangered as by the latter.  Mr. Lizars,
the eminent surgeon of Edinburgh, has frequently performed gas-
trotomy with success, and the  wound in the  abdomen healed by
the first intention (see p. 339.)   Hull informs us, in a note  in his
translation of Baudelocque's work, that out  of two hundred and
thirty-one women,  operated on by gastro-hysterotomy in this and
foreign countries, one hundred and thirty-nine recovered ; and the
recent reports of the German practitioners are still more favoura-
ble.   Denman observed, that in cases where the infant should be
invariably destroyed, a question ought to arise, whether a woman 
GASTRO-HYSTEROTOMY.
407
who was warned of this, again becoming pregnant, ought to be re-
lieved by embryotomy.  He, as well as Burns, Hull, and Dewees,
are advocates for  gastro-hysterotomy,  while  others  despise the
" silly theological  discussions,  concerning  the  question of saving
the life of the mother or infant," and agree as to the destruction
of the latter.  Henry the  Eighth was asked this question before
the birth of his son Edward ; and with that barbarity and cruelty,
for which he was so  remarkably distinguished, he exclaimed in a
rage, " save the infant, for it is easier to get wives than children."
The operation was performed on the mother, to whom it proved
fatal. The same  question was put to Bonaparte, by Dubois, be-
fore the  birth of his son, and he answered the terrified accoucheur,
" treat the  Empress as you would a shopkeeper's wife, in the Rue
St. Martin; but if one life  must be lost, by all  means save the
mother."  Both were saved.—O'Meara's St. Helena.
   Four methods have been proposed to relieve the women under
such circumstances—Caesarean section, or gastro-hysterotomy, em-
bryotomy, symphyseotomy; the induction of premature labour af-
ter the seventh month, and preventing the growth of the infant, by
diminishing the food of the mother.   Hysterotomy, embryotomy,
and the  induction  of premature-labour, are those now employed.
Hamilton had performed the last operation twenty-seven times, to
the year 1819, and saved twenty-three infants.   The operation is
not to be performed until after the seventh month, and is a simple
one.  It is  performed as follows, and lest the directions be improp-
erly applied, I shall give them in one of the learned languages:—
Circa orificium uteri  seperantur membranas digitis ad pollicis spa-
tium, ac si  non  accideret partus post tres dies, dein aperiantur
more solito,  instrumento  aliquo acuto,  membranae.  The patient
is to be  managed as during natural parturition.

  Ccesarian   Operation,  hysterotomy, hysterotomotokie,  gastro-
                         hysterotomy.
   The injuries which arise from transverse, or unnatural presenta-
tions, or  from deformities, are  inflammation and its consequences.
Hippocrates seems to have been aware of the evil consequences,
and accordingly he advised the pelvis of the woman to be raised,
that  the child might fall back into the fundus uteri, where it would
have room  to turn itself.   De Morb.  Mulier.  L. I.  Since his
time, the women were taken out of bed and shaken in various di- 
408
GYN.KC0-PATHOLOGY.
rections, by two or more strong men ; or the presenting part was
pushed back,  and the operator  endeavoured to bring down  the
head, until Pare, in  the sixteenth century, introduced the opera-
tion of turning.   Moschion, an early writer, left us on account of
the practice in his time ; he says, " alii ad scalas ligabant, et sic
pendere jubebant, alii  infinitum deambulare et salire cogebant,
aliis scalas ascendere, alii autem, manibus subaxillis missis, a terra
sublcvabant et diutius exagitabant."  Some tied them to ladders,
and allowed them to hang thus; others obliged  them to walk and
dance incessantly; while they raised others off the ground by the
hands being placed under the axillae, and shook continually. Hip-
pocrates was perhaps only called to cases where the head had been
left in  the womb, and  hence he  compared it to an olive in  the
neck of a bottle; he speaks of instruments, however, for extract-
ing the foetus.  He speaks of opening the head with a small sword,
the bones to be broken with the  pincers or forceps, and a hook
passed under the clavicle, to extract the infant; here we perceive
the enumeration  of the pincers or forceps, and the blunt  hook.
Op. Om, a Faesio.  De Morb. Mulier, L. I. p. 618.  Celsus also
speaks of the  hook,  B. 7. c. 29.  But  let us advert to the more
immediate consequences of difficult or laborious labours.  First, of
these we are to expect exhaustion, which if too long  continued,
will end in death.   Secondly,  we are to expect inflammation and
its consequences, suppuration,  and sloughing.  These are not im-
aginary, but real evils;  or we may expect rupture of the womb or
vagina, transversely or longitudinally ;  the infant and its secundines
may pass through the laceration  into the abdomen, or the bowels
may pass through the opening into the womb.  When rupture of the
uterus is about to occur, the woman exclaims: " she feels something
giving away within her, or the cramp ! the cramp !"   The lacera-
tion may be accompanied by  a  noise audible to the bystanders.
The pain then usually diminishes, the uterine tumour becomes ir-
regular, and the feet can be  felt in the  abdomen.   Again,  if the
forehead be to the sacrum, and forced down in this  manner, the
bladder, the cervix uteri, the vagina, and the rectum will be press-
ed or inflamed, and  sloughing the consequence.   If the head is
in the short diameter, the bladder and  rectum  will be pressed on
and obstructed, and both may be ruptured, or considerably ob-
structed.   The bladder has  been ruptured at the fundus, opening
into the abdomen in front, posteriorly opening into the vagina at 
GASTRO-HYSTEROTOMY.
409
its neck; and the urethra has been inflamed from pressure.   The
bladder may be distended with urine to a large size, and here a dif-
ficulty will be experienced in passing the common catheter.   Dr,
Ramsbotham proposed the flat catheter in this case, a most impor-
tant suggestion.   The head  can  be passed up a little, when the
pain is off, so that the instrument can be applied ; if not, the de-
livery must be speedily effected.   We should allow little drink in
such cases; but promote perspiration.  I have known the bladder
lacerated, and a piece as large as a crown come  away; yet the
part healed without any treatment.   In this and  sloughing, the
constant use of a  catheter and sponge give relief, as  proved by
Cuming, of Glasgow, and Hobart, of Cork, and I also have used
them.  Mr. Holmes has proposed the introduction of a gum-elastic
bottle into the vagina; but  this cannot be always employed, as
appears by the relation of a case which recently fell  under my
care.   (See p. 178.)  Dr. Blundell thinks that when the bladder
opens into the  abdomen,  the cavity might be washed out, and  a
ligature applied on the organ; operations that succeed on animals.
It will be  perceived from  these remarks, that in  difficult labours,
both inflammation, suppuration, sloughing, and laceration of various
kinds, are to be  dreaded.   The  whole cavities of the body may
be seriously affected  by  difficult labours.   The constant  forcing
 down will interrupt the respiration, or  breathing and  circulation,
 so that apoplexy, convulsions, epilepsy, epistaxis,  emphysema of
 the neck and face, copious  haemoptysis and rupture of  the heart
 may occur;  cases of which  are  on record.   Thus the  patient  is
 exposed to most fatal diseases.  In full habits, bleeding from the
 arm will be often useful.   A few  words  may be devoted to the
 history of this formidable operation.
    It is impossible to determine the period  in which the  Caesarean
 operation was first performed. It will appear in the course of this
 section, that it was  performed among the Jews, A. M. 140.   It
 is of much earlier origin, according to fabulous historians.  It was
 said, that the son of Jupiter was extracted from  the abdomen  of
 Semele, by Mercury.  The ancient Romans held that ^sculapius
 was extracted  in this way by Apollo.  Virgil  states, that Lycus
 was born  in the same manner.   Pliny was, perhaps, the first wri-
 ter of authority upon this point.  He says, "Auspicatius, cnecta
 parente, gitrnuntur, sicut Scipio Africanus prior natus, primus-
 que casus, cxso mains utero, dictus qua de causa casones appel-
59 
410
GYNJECO-PATHOLOGY.
lati, simili modo natus est Manlius qui Carthaginum cum exercitu
intravit."   (lib. xxxiv.)   It  was  believed  that one  of these
persons took the name of  Julius Caesar, and hence the origin of
the term under consideration.   In fact, the history of this opera-
tion is  very obscure.  It appears certain, however, that it was per-
formed t'wenty-four times with success from 1750 to 1800, accord-
ing to Baudelocque.  It was  also successfully performed by Lau-
verjat,  twice on the same woman by Bacqua, once by Le Maistre
of Aix, once by Dariste at Martinique, once by  Vonderfushr, in
1823 at Daplen, in 1827  at Florence,  and once each by the  fol-
lowing persons, Bulk, Graafe, Leutcz, Buren, and twice by Skenck.
The operation has heen  frequently performed unsuccessfully in
these and other countries during the last few years.  Baudelocque
related sixty-three cases of this operation, in forty-two of  which
the women  perished.  Spregnel detailed two hundred and thirty-
one cases, forty-five of which proved fatal; Kellie and Hull narra-
ted one hundred and thirty-one cases,  one hundred  and twenty-
three of which terminated fatally,  The only successful cases in
these kingdoms are one by Barlow, and one by an illiterate mid-
wife, which  is well authenticated,  as already stated.   There is
now the strongest reason to think that  incision of the abdominal
parietes is by  no means so fatal as  hitherto supposed, as will ap-
pear by referring to diseases of the ovary, in a former page.   The
experiment of Dr. Blundell on  animals confirms this position.  The
operation is  necessary when the sacro-pubic diameter of the brim
is reduced to an inch and  a half, and even when  this strait is not
so much contracted, when we cannot succeed in extracting the in-
fant by any other mode of proceeding.  It should  also be perform-
ed soon after the death  of the woman in other cases, as  the infant
has been saved at the lapse of twelve, twenty-four, and forty-eight
hours after the mother had expired.
   The princess  of  Schwartzenberg died  at Paris of a burn,  and
next day the infant was found alive.  Gardien  relates  a similar
case, in which the operation was not performed  until  forty-eight
hours after death, and the child was living.   Cangiamila states in
his Embryologia Sacra, that twenty-one infants wTere saved  in this
way in forty-three years; and that the operation was performed
twenty times at Syracuse  in eighteen months.   Numa Pompilius
enacted a law which still exists, in a work entitled Lege ragia
Diget. lib. xx., which  commanded the medical men to open the 
GASTRO-HYSTEROTOMY.
411
bodies of pregnant women after death, with  the intention of pre-
serving the citizens of the state.  The same law prevailed in Ve-
nice in  1608 and 1721, which punished medical men severely
unless they used the same caution in operating on the dead as  on
the living woman.  In 1749, the king of Sicily punished medical
men with death who omitted the operation  on women soon after
they  expired.  The  modern  practice  is  to perform  version  if
possible ; and if  impracticable, to resort  to the  former.   I had
once  the  misfortune  to witness the death  of a  woman in the
eighth month of pregnancy.  I thought to deliver by  the feet, im-
mediately after death; but could not force the os uteri.   Exam-
ples are detailed by Van Swieten, Baudelocque, Peu, and  Rigau-
deaux,  in  which the abdomen was  slightly divided, after  it was
supposed death had happened, which roused vitality  and  the wo-
man recovered.  We  find mention  made in historical  works  of
persons who had been extracted from the womb after  the mother's
death.
   This operation was first recorded  at Venice, in  1491, by Nico-
lai de Falconiis. Obs. Cbirurg.  It was performed in 1424, accord-
ing to Velpeau.  Many  obstetric writers  allege  that it was per-
formed  by  Jacob  Niefer,  a  Swiss peasant, on his own wife.  K.
Spregnel asserts that it was not performed on the living subject
before the  year 1610.   Geschite der Chirurgie,  1  Theil.  Halle
1803.   Deleurye, Levert, Mauriceau, and  Mendel,  deny that  it
was known to the ancients; but Joseph Plenck, Dionis, and Gar-
dien, refer to the thirty-fourth Book of Pliny's Natural History,
already quoted.   Rousset,  physician to Catharine de  Medicis, and
contemporary of Pare, collected a history of many cases performed
on the   living, to the  year 1581 (Trate  de PHysterotomakie.)
Casper Bauhin translated this work into Latin in 1591, and added
several  other cases.  The operation  was strenuously opposed by
Pare, Dionis, and Sacombe, in France.  Dr. Mansfield, of Bruns-
wick has published  a  most learned  work, " On  the  Antiquity of
Gastrotomy and Hysterotomy on the Living.  Weber das Alter
des Bauch  and Gebarmutterschnitts an Lebenden zu Brunschweig,
1824," from which I shall make a few extracts.   This erudite au-
thor and learned Hebrew scholar informs us,  that in the Thalmud,
or account  of the laws of the ancient Jews, gastrotomy during life
is  mentioned, under the article on hereditary rights.   He  asserts
that, in an earlier  work called Mischnajoth,  published about the 
412
GYN-ffiCO-PATHOLOGY.
year 140, there is this passage:  " In a twin-birth, neither the first
child, which by the section of the belly is brought into the world,
nor the one coming after, can attain  the rights of heirship or the
priestly office." In the Nidda, an appendix to the Thalmud, writ-
ten in the fourth century, we have these words : " After the open-
ing of the side, it is not necessary for women  to observe the days
of purification."  Dr. M. has given several  other passages, equally
valuable which, confirm the performance of gastrotomy on the liv-
ing.   The operation has been performed in  four different ways:
1. the lateral incision; 2. the  incision in  the linea alba; 3. the
transverse ; and, 4. the diagonal incision.   Rousset first accurately
described the  lateral  incision, which was to commence under the
umbilicus, and continued downwards and outwards,  parallel to the
outer edge of the rectus, until the lower part of the incision is  at
the distance of three fingers breadth from the linea alba.   Levert,
Stein, and  Millet, recommend that the incision should be made on
the side on which the uterus projects,  midway  between  a line
drawn from the end  of the last rib, where it joins its cartillage  to
the anterior superior spinous process of the ilium  ; so that the in-
cision may be two inches in breadth from  the linea alba.  This
was  adopted  on the  Continent,  during the  greater part  of the
eighteenth  century.
   In 1721, Mauriceau recommended the linea alba to be divided,
and was  followed by Guenin and Platner; the former first per-
formed the operation in  France in 1750.  Deleurye further sup-
ported this mode of  operation in 1779.   Henkel, a German, cut
from the navel to  the pubis, in 1769; a plan adopted  at present.
Osiander recommends the lower two thirds of the uterus to be di-
vided.   In 1788,  Lauverjat cut transversely at either side, to-
wards the spine;  an  operation  also  performed by Mr. Wood,  of
Manchester.   (See London Medical and  Physical Journal, vol.
vi.)
   Stein, professor of Midwifery at  Morburg,  and now at Bonn,
made an incision, diagonally from the last false rib of one side,  to
the body of the pubis at the other; a plan which is not adopted
at present.  (See the account of it in his Geburtshulfe, Abtrond-
lung Moburg.  1803.)  The operation in the linea alba is  prefer-
red in this country and on the Continents of  Europe and Ameri-
ca.  It is a curious and unaccountable fact, that the operation was
more successful formerly than of late years ;  even during the pe- 
GASTRO-HYSTEROTOMY.
413
riod when it was performed laterally, having the disadvantage of
situation,  the danger of wounding the epigastric artery, and the
unskilfulness of the  operators.   Klein collected an account  of
eighty-two cases, performed from 1500 to 1769, when the lateral
operation was adopted, and six only proved fatal.   Dr. Kellie pub-
lished an account of the mortality of the operation in the  Edin-
burgh Medical and  Surgical Journal, 1809,  vol. v., when  out of
two hundred and thirty-one cases one hundred and thirty-nine re-
covered.   During 1825, it had been performed three times with
success  in  Germany, by Schenck, Graafe, and Mende;  and du-
ring the same year, three  unfavourable cases are recorded in Sie-
bold's Journal, and three  in Mende's Obstetric Journal.  A case
is recorded in which the operation was twice performed success-
fully on the patient, in the Russian Repertory of Natural Sciences
and the Healing  Art,  also in  Siebold's Journal; and another, in
which the operation  was performed  three times, by Osiander, in
the Commentations of the Royal Society of Sciences, at Gottin-
gen, 1813.   Lounius,  a French accoucheur, is said to have per-
formed it seven  times on  the same person,  and all  the children
lived.   This is scarcely credible.
  After all that  has been said against the continental surgeons for
performing the operation on women, who previously had  borne chil-
dren in the natural manner, there are but four such cases on record:
one' by Naegele, in  his Erfahrungen and  Abhandlungen  aus dem
Gebiete des Krankheiten des weiblichen Geschlechts ; another, by
Henderson, in the Edinburgh Medical and Surgical Journal, No.
66 ; a third, by  Meier, in Siebold's  Journal;  and the  fourth, in
the same Journal, by Berger.   Morand  says, that the abdomen
has been laid open by the Lydians.   Barbette, of Amsterdam, cut
through the abdomen, and disengaged a twisted intestine, in  a case
of volvulus.  Bonetus and Schacht record similar cases.   L'Au-
monier, the chief surgeon at the hospital at Rouen, extracted  a
diseased ovary,  about  the  year 1774.   Smith,  of Connecticut,
lately extirpated  another.  Dr.  Macdowal,  of Kentucky, opera-
ted in three such cases, from 1809 to 1816;  and Lizars, of Ed-
inburgh, in 1823: the  woman sat up fourteen days after the ope-
ration (Edinburgh  Medical and  Surgical Journal, 1824.)—"It
appears to me," says Mr. L. "that there is little danger to appre-
hend in laying open  the  abdominal  cavity, and  that in diseased
ovarium, extra-uterine  conceptions, foetus in utero, with deformity 
414
GYN.EC0-PATHOLOGY.
 of the pelvis, preventing embryulcia (embryotomy),  aneurism of
 the common  iliac arteries, or of the aorta,  volvulus, internal  her-
 nia, cancer of the uterus, and foreign bodies in the  stomach threa-
 tening death  ; we should have recourse early to gastrotomy.   The
 delay, in such cases, is more dangerous than the operation. "  (See
 p. 240.)—The most extraordinary case of Caesarean operation on
 record,  is one performed  by a young negress on  herself.   This
 person, a servant, aged fourteen, went some distance from her  resi-
 dence,  and was observed by her master covering something  with
 snow, which  proved to be a naked child ; on being discovered, she
 ran towards the house, with something hanging.from the abdomen.
 This was  the body of an infant, the head being  retained by  the
 contraction of the womb, and also a large portion of intestines.
 Drs. Basset and M'Clellan were  called on, and found a  diagonal
 wound,  as to  the abdomen, two inches above the navel,  and  ano-
 ther towards  the sternum.   The  lower  part of the  abdomen  was
 found filled with blood, which was removed by change of position,
 the wounds stitched, and a bandage applied.   The girl recovered.
 (New York Med. and Phys. Journ. March 1823.)—Dr. Mosely
 relates the case of a negro woman  at Jamaica, who opened  her
 side with a butcher's knife, and extracted a  child,  which  died of a
 lock jaw.   The  woman recovered.  Surely  the result  of these
cases proves the operation not so unsuccessful  or impracticable as
 the profession in this country have hitherto imagined.  Two other
successful cases, in which both women and children were saved,
 were operated on  at the  hospital at  Maestricht,  by  M.  Bosch.
 Both  women were young, or in the prime  of life.   (Biblioth.
Med. 1823.)
   The operation was performed at Saltzburgh, but delayed a day,
because it was doubtful whether the child was alive or not; a de-
cision which  made all  the difference  between  the Caesarean  sec-
tion and embryotomy.  The motions of the child were perceived
next day,  when the former  was determined on.  The child  was
 alive, but died after  half an hour,  and the  woman recovered.
 Dr. Johnson,  the  able  editor of  the Medico-Chirurgical  Review,
remarks on this case,  " we consider the above procedure on the
 part of the surgeon as well  deserving  of condign punishment,
whether the woman survived or not.  To perform  the Caesarean
operation, in preference to embryotomy (where the latter is prac-
ticable)  is most unwarrantable, and evinces a lamentable, not to 
GASTRO-HYSTEROTOMY.
415
say a culpable want of judgment, as to the proper estimate of the
value of human life."   The French are deserving  "of this con-
dign punishment," as well as the Germans;  for M. Duges, the
last writer in 1830, asserts that the crotchet  aigu, which is the
same as the perforator, should not be  employed  until after the
death of the infant, " nous avon dit, qu'on ne pouvait l'appliquer
qu'apres la mort  certaine du foetus;  neu peut etre applique que
sur un  enfant indubitablement mort."   He asserts that the Caesa-
rean section is the only resource in the excessive deformities of
the pelvis.   The  Americans, also, deserve this condign  punish-
ment.   Dewees observes, " from an attentive consideration of both
operations, the crotchet and Caesarean section, we are free to confess
ourselves in favour of the latter, and for the following reasons:—
First, because the child must be destroyed by the crotchet; sec-
ond, because the risks are very great to the woman ;  third, because
there are cases in which it is  impossible to deliver with the crotch-
et ; fourth, because where this instrument  is employed, there is a
great risk to the mother, without a chance  of benefit to the child.
These remarks refer to  cases where it is ascertained, or presumed
that the child is  living; if it.be dead,  then  the crotchet  may be
used under a sufficient diameter of the pelvis.  But if the child
be dead, and the delivery impossible by the crotchet, the Caesare-
an operation should be proposed."  Par.  1472, p. 594.   He fur-
ther observes, " for what reprehension, what punishment would be
sufficiently severe for that practitioner, who after having destroy-
ed the child, should find it impossible to deliver it; and then,  for
its accomplishment, subject the poor womanlo the Caesarean sec-
tion ?   He would scarcely merit the plea of quo animo in his fa-
vour."   Par. 1479.   As the  English  Law  now stands, the de-
struction of the infant is a felony, even  to save the life of the mo-
ther, (see  p. 204) ;  yet Dr. Johnson's opinion is the prevailing
one in this country.   " In this country and in France, however
painful it may be to desti iy the life of the child, the  mischief is
considered less serious  in its consequences, than  the  destruction
(or we ought, perhaps, rather to say) the probable destruction of
the mother."   Lancet, 1828, p. 328.   Dr.  Kind asserts, that in
Germany, the  expediency,  as in  this country, of destroying the
child, is always  left to the  judgment of the medical attendant.
Op. Cit. p. 415.  The report of the Saltz"burg case cited above,
is somewhat opposed to this assertion. 
416                 GYN^CO-PATHOLOGY.
                                                                      I
           Gastro-hysterotomy— Casarean Operation.
   Definition.—The Caesarean section is an incision made in the
parietes of the abdomen and uterus, to extract the infant.   Abdo-
minal gastro-hysterotomy is the proper Caesarean operation ;  va-
ginal hysterotomy has also been performed with success.
   The ancient obstetricians made the incision in the left side, and
divided the epigastric artery or its branches,  and the woman died
of haemorrhage.  Lauverjat preferred the right side, and made a
transverse  incision towards the spine, a plan as dangerous as the
other.  Ritzen  proposed to  make  an  incision above the crest of
the ilium, to separate the peritoneum, to incise the summit of the
uterus,  and extract the foetus.  The  proceeding was proposed in
order to avoid wounding the  peritoneum; but the operator forgot
that he divided the peritoneal coat  of the uterus.   Baudelocque,
the nephew, considers the great danger of the operation arises from
the double incision of  the peritoneum, and regards wounds of the
uterus essentially mortal; he therefore  proposes a new operation,
which consists in an  incision from the spine of the pubis,  parallel
to Poupart's ligament,  and extending  to the superior-anterior spi-
nous process of the ilium.   He selects the left side on account of
the  inclination of the  neck,  when the uterus is inclined to the
right; and the right side in the contrary case.   After making his
incision, he  detaches  the peritoneum  of the  iliac  fossa, opens
the superior part of the vagina,  and hooks down the uterine orifice
to the wound in the abdomen, he now leaves the labour to the con-
tractions of the womb, and extracts the foetus, if necessary, with
the hand or the forceps.   He calls this operation elytrotomy, and
has repeatedly  performed it  upon the  dead  subject.   It is very
doubtful if this operation  is less dangerous than abdominal hyste-
rotomy.   Even the author of it, on a recent occasion, after having
tried it, was obliged to have recourse to the ordinary operation
through the abdomen.   Dr. Physick  proposed to make an incis-
ion  above  the pubis,  as the peritoneum was easily separable from
the bladder;  but I am not aware whether he had operated in this
way.   The general mode of  operating is through the linea alba.
  Some say that it is an  advantage  to have the amniotic mem-
brane perforated or ruptured, as the effusion of the amniotic fluid
cannot take place in  the abdomen.   Others contend that when the
membrane  is entire, it is easier to extract  the  infant; that the
wound in the uterus will be less extended, and much more reduced 
GASTRO-HYSTEROTOMY.
417
by uterine contraction.  Such is the opinion of Desormeaux and
Velpeau; and  it seems to be  valid.  The  rectum and bladder
should be evacuated previous to the operation.
   Instruments and necessary Apparatus.—Two bistouries, a com-
mon convex one and a button-pointed one, an artery forceps, and
some needles threaded  are sufficient  for this operation.  The re-
maining apparatus that will be  required comprises  a fine sponge,
some lint, long and  square compresses,  the body  and scapulary
bandages, and basins of cold water, with a little vinegar.
   The linea alba is  the  situation  now selected for  the operation.
The selection of the side was liable to serious objections.   1. The
inconvenience of dividing three sets of muscles, whose different
directions would be a great obstacle to cicatrization.  2. The epi-
gastric and principal arteries  of the uterus would be divided.   3.
the fibres of the womb  being  divided obliquely or transversely,
they could not contract without rendering the wound gaping, and
consequently causing an effusion of lochia into the abdomen.
   The uterine orifice  must be  dilated to some extent before the
Caesarean operation is resorted to, in order to afford a passage to
the blood, to clots, and to the lochia.
   If the  woman  is at all plethoric, it would be advisable to take
away  some  blood ; and at all events to open the bowels by a clys-
ter, evacuate the bladder, and shave  the pubes.
   Position of the Woman.—The patient ought to be placed on
her back near  the edge of the  bed, the  head and chest slightly
raised ; the inferior extremities extended during the time of ma-
king   the incisions;  and half  bent  during  the extraction  of the
foetus.
   In order  to render the  abdomen  more prominent, a pillow is
placed under the loins.
   Position of the Assistants.—Two assistants are to  fix the ute-
rus by steady pressure with their hands, and others are  to keep the
patient in the proper position, and to prevent her flexing the limbs
during the incisions.
   Operation.—The obstetrician, with the convex bistoury, makes
an incision  in the direction of the linea alba, from  the umbilicus,
or even a little  above it, to within an inch and a half of the pubis,
according to Baudelocque, in order to avoid wounding  the bladder,
and also as  the abdominal  parietes are thick near  the pubes.  If
the incision is commenced above  the umbilicus,  it should  be car-
         53 
418
GYNJECO-PATHOLOGY.
ried at the left side of this  part, to avoid the umbilical vein, and
the anastomosis between it and the  epigastric vein, as recently de-
scribed by Mesniere,  Clement, and Martin.
   When the incision  is made high up, it is impossible to incise the
uterus in its most elevated part, and thus  to prevent the effusion
of the lochia into  the abdomen.  The first incision ought to be
made through the  skin and subcutaneous cellular tissue.  The lin-
ea alba is next to be divided, some say from below upwards. The
peritoneum should now be opened  with the sharp-pointed bistou-
ry, and the opening is to be enlarged with the blunt-pointed in-
strument.  The uterus  is next to  be depressed by an assistant,
and incised from the  superior to the inferior angle of the abdomi-
nal wound, which  is an extent of about six inches.   This incision
is commenced with the sharp, and terminated with the blunt-point-
ed bistoury, which is  used from within outwards, and from above
downwards.   We  then  pierce the  amniotic membrane with great
caution ;  though, according to  Planchon, we should rupture it in
the vagina, to prevent the escape of the liquor amnii into the ab-
domen.
   When the uterus is divided,  the foetus is to be  extracted by the
feet, head, or breech, as  each of these parts presents.
   It is said we ought to  avoid  wounding the placenta  in dividing
the uterus; but the  position of it can only  be  determined previ-
ously by the stethoscope.  The placenta is to be extracted through
the wound, the womb is  to be cleared of all clots, a finger is to be
passed through the vagina and neck to facilitate the  escape of any
that may be there; and  the finger   should  be  occasionally intro-
duced through the os  uteri for that purpose.  If any large vessels
are divided during  the operation, they are to be pressed on by the
assistants, and secured by ligatures.   When the  uterus does not
contract,  we should make gradual pressure, and exhibit the ergot
of rye in the manner  already mentioned.   Sutures are to be pass-
ed through the abdominal wound, except at the inferior part, which
must be left open to favour  the escape of fluids  from the uterus.
Before applying sutures we must remove all fluids from the abdo-
men, whether blood or amniotic liquor, by changing the  position
of the patient, using tepid injections, and pressing upon the sides
of the abdomen.   Capuron objects  to sutures, as  they may be dis-
placed by tension of the abdomen when peritonitis  occurs. The su-
tures are, however, in general preferred to agglutinating bandages. 
VAGINAL HY9TER0TMT.
419
The wound is to be covered with lint, and the body and scapula-
ry bandages applied.  Some prefer adhesive plaster.  The dress-
ing is to be changed frequently the  first twenty hours, then mor-
ning and evening, if we suspect effusion.   We should prevent
adhesion between the uterus and abdomen, according to Bacqua,
Capuron, Gardien, he., as it  would expose the woman to drag-
ging sensations, haemorrhage, he.
   The woman should be carefully watched, lest peritonitis super-
vene ; and  the antiphlogistic regimen  must be strictly employed,
if the symptoms of inflammation come  on.   In  cases of rupture
of the uterus, Dr. Collins of Dublin very judiciously prevents in-
flammation  by active  antiphlogistic  measures.   (Dublin  Med.
Trans. 1830,  v. i. New Series.)
   Immediately after the operation, the woman should  have an opi-
ate to tranquilize  nervous  agitation,  and the shock inflicted on the
system by the operation.
   Vaginal Hysterotomy.—Many cases, according to authors, re-
quire vaginal hysterotomy, as  a fibro-cartilaginous state of the os
uteri  (Simeon,  Van Swieten,  Hamilton); violent  convulsions,
without dilatation of the uterine orifice  (Dubosque and Lambron) ;
obliquity of the uterus (Hamilton, Dewees, he.) ; the head of the
infant pushing the uterus to  the vulva  (Lauverjat, Hamilton,
Monro,  and Farquharson;) and when the  uterus escapes through
the pelvis and its orifice cannot be  dilated  by the fingers (The-
nance, Jacomet) ; and  in  extra uterine foetation (see  p. 308—
313).   Some recommend several incisions in these cases; others,
a simple incision ;  and Duges  advises us to remove the scirrhous
parts.   This operation  is seldom performed, though it is evidently
less dangerous than gastro-hysterotomy (see  p. 313).
   Gastrotomy is  required in extra-uterine foetation, and rupture
of the uterus; and the circumstances which demand it, have been
already  related (see p.  310).   The  instruments and apparatus are
the same as  in gastro-hysterotomy, or the  Caesarean operation.
The situation of the foetus, in these  cases,  must determine  the
place for the incision.  The foetus is  often encysted in different
parts of the abdomen.   For an accurate account of this subject I
refer the reader to pages 308—313.
   Symphyseotomy—Division  of Symphisis  Pubis—Sigaultian
Operation.—This operation is performed by the French, though
never in these kingdoms,  when the  infant is alive, and the pelvii 
420
GYN^CO-PATHOLOGY.
contracted from two and a-half to three inches;  when the head of
the infant is large, and in cases of monstrosity.   The  pubes are
shaved, and the symphisis completely divided with a scalpel;  the
infant being extracted  by  version or by the forceps.   The unan-
swerable  objections to this highly dangerous and unwarrantable
operation are, 1. the pubic joint may be ossified, and must be di-
vided with a saw;  2.  In  cases of  deformity, the  pubis  may be
more to one side than  the other;  3.  the  separation  of the sym-
phisis to the extent of  two inches as advised, must inevitably sep-
arate and lacerate  the sacro-iliac joints,  produce incurable lame-
ness, or abscesses that  may prove fatal, or the unfortunate woman
may be confined to bed with horrible pain for one or two years, as
the separated  joints, if ever  restored, can  only be united by an-
chylosis, which is a slow and  tedious process (see pp. 7, 307).
  In forty-one operations  of this kind, says Baudelocque, fourteen
women died, and twenty eight infants were destroyed  by the vio-
lence of the proceeding, which is  farther evidence against the adop-
tion  of this fatal operation.  Gardien, Giraud, and Ansiaux assert
that  the pubic bones may  be separated to the extent of four inches,
without any lesion of the  sacro-iliac joints; but  any one who will
try the experiment on  the dead subject will at once  observe  the
falseness of this assertion.
  Pelvic Contraction.—Induction of Premature Labour.—When
the deformity of the pelvis is such as to  prevent the passage of
the infant at the full time, it is usual, in order to save the infant,
to induce labour after the  seventh  month, after which time all ad-
mit the foetus to be capable of living or to be viable.  This  hu-
mane operation, however, is homicide according to our  laws, as
will  appear by a reference to my Manual of Medical Jurisprudence,
and  also in the section  on  Prolicide, Foeticide, and Infanticide in
this  work, p.  153.  Medical  men, ever  conscious of rectitude,
have always interfered  in  the cause of humanity ; and we find that
the reputed father of obstetricy in  this empire, Dr. Hamilton of
Edinburgh, has saved twenty-three out of twenty-seven infants, by
the induction of premature labour.   This was the number he  sta-
ted in his invaluable Lectures in 1818.   It is necessary, in these
cases, that the obstetrician should  duly estimate the capacity of
the pelvis, and accurately  remember its axes and diameters as de-
scribed in p. 11.  In these malformations, it has been recommend-
ed to diminish the volume of the infant by keeping the  mother on 
INDUCTION OF PREMATURE LABOUR.
421
low diet; but this barbarous and unnatural plan has not succeeded.
About the middle  of the  last  century, our countryman Macauly
first proposed the induction of premature labour, to obviate the ne-
cessity of craniotomy, gastro-hysterotomy,  and symphyseotomy;
and since that time, Barlow,  Hamilton, Ramsbotham, D. Davis,
Wigand, Baring, Blundell, and many others,  have performed the
operation with  success.   Velpeau, with great candour and credit
to himself, prefers  this operation to the  more dangerous proceed-
ings, which  his countrymen still advocate,  and  very justly consi-
ders it  more safe for  the mother  and  infant.   He thinks that a
thousand social relations compel us to save  the  mother, so that in
cases of deformity, which render  delivery  impossible at the full
time, he would not hesitate to advise  abortion in  the first months
of gestation.  He says, however, that when  the sacro-pubic diame-
ter of the brim is  only two inches  and  a-half, a living foetus may
be expelled without the aid of art.  He thinks the induction of
premature labour warrantable in such cases  at the seventh month,
as the bi-parietal  diameter at  that time  is  generally three inches,
and of course capable of diminution by compression.  He argues,
however, that this resource is  not so advantageous as is generally
imagined ; because it may  be followed by haemorrhage, convulsions,
or peritonitis, the uterus may  be wounded,  the  infant may be fee-
ble, there may  be slight uterine contraction, and delivery may not
happen for  five days.   These objections are invalid, as they may
be urgent in  cases of natural  labour, and may  be obviated by ju-
dicious management and the use of the ergot of rye.   Besides the
usual success of the operation  is an answer  to all objections.

Section 6.— Operations which require  a Solution of Continuity
   of some part of the Infant.—Embryotomy, Craniotomy, Ce-
   phalotomy.
   When the brim or outlet of the pelvis is so deformed, that the
head of the  infant cannot  be extracted by the forceps or lever,  it
has been the practice, especially in this country, to  pass  a sharp
instrument, called  the perforator through the cranium  by a boring
motion, then open its  blades, next close them and  make a crucial
incision,  break  down the brain, extract it by the blunt hook or
crotchet, then fracture the bones of the  skull with the craniotomy
forceps, extract them  cautiously,  leaving  the  scalp to cover the
ragged edges; and next perforate  the thorax and abdomen, evis- 
422
GYNJECO-PATHOLOGY.
cerate these cavities, and extract the body by the blunt-hook or
crotchet.   Such is the  operation of embryotomy.  Most men feel
the greatest reluctance and horror at  performing this operation on
a living infant, and naturally wish to delay, until there are certain
signs  of its death.   The signs of its death are want of pulsation at
the fontanels, cessation  of its motion, its falling like an inanimate
mass  to the side on which the woman may lie ; shivering fits of the
mother, flaccidity of her breasts, fostor of the uterine discharges,
and looseness of the bones of the cranium.   There are no positive
and infallible signs as to the certainty of the infant's death.  Many
lamentable instances are recorded of infants, who  have  been cra-
niotomised, and yet born alive by the natural  passages.   This can
be easily accounted for, if we recollect that all the cerebral nerves
originate in the  base of the brain, and consequently may retain
their  functions, though the greater part of that organ  be broken
down, or extracted.  The records of  military surgery confirm this
fact, as they afford ample proof that a considerable portion of the
brain  may  be removed by a grape shot  and life continue, nay re-
covery happen.
  The instruments employed in this operation are the perforator,
to open the head and  break down its  contents;  the  crotchet  or
sharp hook, to extract the brain ; and the craniotomy forceps, the
latter invented by  Dr. D. Davis, is now generally preferred to the
crotchet.   Every  midwifery lecturer  has  a  peculiar craniotomy
forceps;  but it may be here worthy of notice,  that nearly all  of
them  now in use are both  too clumsy and ponderous.  Dr. Heigh-
ton used  a  modified lithotomy forceps, and with success.  Mr.
Holmes has  invented a forceps, which is decidedly the best hith-
erto produced.
  Operation.—The perforator is to be passed along two fingers
of the practitioner to the head, and the greatest care taken not to
wound the  mother.   Pressure should  be made by an assistant on
the abdomen, so as to keep  the  uterus fixed, and the head steady,
during the  perforation.   Some hours should be allowed to elapse
after the skull has  been  opened, as the labour pains may expel the
brain, and complete the delivery.  When  the  child is expelled
this way, the mutilated  head ought to be shaped as nearly the na-
tural form as possible.   Sometimes the entire bones of the  head
and body  must be  broken in fragments to  admit of extraction.
When the  lower extremities and body are  expelled, and the head 
EMBRYOTOMY.
423
retained, it should be extracted by the forceps or lever; but if
these fail, it is to  be  perforated behind the ear.   The cases which
require this operation are extremely rare, in the opinion of Duges,
who also contends that the operation should  never be performed
until after the death of the infant.  Tliere  can be  little  doubt,
from the recent histories of the success of gastrotomy and gastro-
hysterotomy, but the operation under consideration will  ere  long
be discarded ; by far the greatest majority of obstetricians,  taken
collectively in all  nations, are opposed to it.   The preference given
to craniotomy in this country, arose from the plausible essay of Os-
borne, elicited by  a single case, namely, Sherwood's ;  the  reality of
which is now denied  by Hamilton, Burns, Dewees,  and every well
educated  practitioner.  The metaphysical  reasoning and sophistical
deductions, that an infant in the womb possesses no feeling, and there-
fore the operation ought to be performed in every case  in which  the
dimensions of the pelvis were like that of Sherwood's, are exposed
and ridiculed by Dewees, whose reasoning and refutation of this ad-
vice prove its fallacy  and impracticability. The destruction of a living
infant is inhuman, unnatural, barbarous, and contrary to the laws of
God and man. Nor is craniotomy practicable in cases of extreme
deformity ; and from mature consideration  of the history of the Cae-
sarean section, it is obvious that  the extraction of the infant by
craniotomy is  as fatal an  operation to the mother, and there is often
much more injury inflicted on her, than  by  timely removing the
infant through the abdomen.   I  would  venture to  predict, that
embryotomy will be nearly discarded in a few years, in the majority
of cases  under  consideration; and I might add in the numerous
others in which it is now so frequently and unjustifiably performed
in this  country.   I know  these  are unpalatable assertions; but
truth is great  and will prevail.
   The absence of a religious  motive is a cause of  the  compara-
tively frequent performance of embryotomy in this empire  The
necessity of its too  frequent performance in all Protestant coun-
tries, is almost exclusively founded on the  impracticability of de-
livery, by the natural passages.
   Perforation of the  head and dismemberment of  the foetus are
generally preferred,  in  these kingdoms and in Germany, to the
Caesarean operation. In France, cephalotomy is never performed
until after the death of  the infant, or  at  least  until it is  probable,
or when delivery is altogether impossible b)  the natural  passages. 
424
GYNJECO-PATHOLOGY.
(Velpeau, Duges, &c)  When the pelvis is less than fifteen lines,
and the hand cannot  be introduced  into the womb, the French
prefer gastro-hysterotomy,  though the infant should be dead. It is
however, too cruel to perform the Caesarean operation to extract a
dead infant, or one so feeble as not to survive for more than a few
minutes or  hours ; but it  is  equally cruel to open the head of a
strong vigorous infant,  when the mother is of  a good  constitution,
and when there is every probability the abdominal section, how-
ever dangerous, would save both mother  and  infant.  The  Caesa-
rian operation is  too often  performed in  France to  the  exclusion
of craniotomy ; and  the latter is too indiscriminately performed to
almost complete exclusion  of the former in these countries.   The
rule in this kingdom  is, that if the sacro-pubic diameter is only two
inches and a half, and  the  transverse  or bis-iliac three inches, cra-
niotomy is justifiable.   It is indicated, 1.  when the foetus is dead,
and the passages so contracted as  not to permit  extraction with
the forceps,  or by version ;  2. when the foetus  has  probably ceased
to live, oris  on the  point of  death,  and to extract it entire, with-
out abdominal hysterotomy  ;  3. when  the  head remains  in the
pelvis, and the hand, forceps,  or blunt hook, is not sufficient for
its extraction.   It is to be considered useless and highly danger-
ous, when the sacro-pubic  or short diameter of the brim is only of
an extent of an inch and  a half.  This  operation was performed
only in three cases in  over twenty  thousand  in France, according
to La Chapelle,  though so very frequently employed in this em-
pire.
   Instruments to  be  employed.—The instruments employed in cra-
niotomy have varied at different periods, and are even now  dis-
similar.   Various perforators were proposed by Hippocrates, Avi-
cenna, Mauriceau, Levret, Freid,  Oulde, Simson, De la  Motte,
Smellie, and the  Hamiltons ; but the scissors perforator of  Smel-
lie improved by  Denman  is generally  preferred.   In  France a
scalpel, bistoury, or  trocar  is employed.
   Position  of the  Woman.—The  position  usually  selected by
British obstetricians  is  the  left  lateral, while  foreigners prefer the
dorsal, which I believe to  be  the  most  convenient.  When the
head presents, we should introduce two fingers into the vagina, and
place them  on the anterior fontanel, or in the course of the sagi-
tal suture ;  and then introduce the perforator along the palm of the
left hand and fingers, taking great care not to wound the  soft parts 
EMBRYOTOMY.
425
of the mother.  When the base of the skull presents after the ex-
pulsion of the body, we must pass the  perforator in the occipital
region, or  in  the  lambdoidal, or  coronal sutures if possible.   In
either case, the head should be fixed, as it often recedes when the
instrument is applied, more especially if we cannot pass it through
some of  the sutures.  We employ a rotary or boring motion, and
pass the  perforator to the " stops or rests," open it to the extent
of an  inch  or two, then close  it, next re-open it transversely, so
as to make  a  crucial incision.   The instrument should  now  be
pushed through the dura  mater and brain, and the cerebral mass
broken up,  and finally the perforator should be closed  and careful-
ly withdrawn  from the genitals.   The brain now generally escapes,
more especially should uterine  action be  present; the bulk of the
bead will be considerably reduced; all pressure on the soft parts of
the woman will be removed ; and nature in a longer or shorter peri-
od will complete delivery.  In this case the operation is called sim-
ple.
   Craniotomy is chiefly applicable  in cases of impacted head in
first labours, occurring  at an early  or  late period of life,  when
there is no pelvic contraction.   The labour is generally tedious in
these cases, and all uterine action ceases in the majority of instan-
ces, in consequence of  the fear  impressed on the patient by the
necessity or performance of the operation.
   When labour ceases after craniotomy, the usual practice in these
countries among scientific obstetricians is, to exhibit a cordial with
an opiate, and  leave the conclusion  of  the case to nature.   In a
few hours, uterine action re-commences  and effects delivery.   This
is much  safer  practice  than to extract the  infant by the crotchet in
the absence of uterine action, which exposes the woman to unne-
cessary suffering and to haemorrhage.   When  the pelvis is natu-
ral,  the passages tumefied, and the pressure of the foetal head re-
moved by the  escape  of  the brain  after  craniotomy, there is no
scientific reason to extract the  body of the infant  during the ab-
sence of pain.  After allaying agitation and fear by a mild cordial
and an opiate, and  allowing the patient to recruit her  strength by
rest and  sleep, uterine action in general returns and expels the in-
fant.   But should  this  not happen,  the ergot of rye must be ad-
ministered, and will, if genuine,  most unquestionably  induce ute
rine action.   It is  to be recollected, that  the presence of a dead
infant in  the womb for a few hours, can be productive of no bad
        54 
426
GYNjECO-PATHOLOGY.
consequences;  as dead and  putrid  infants  are often  retained in
utero for weeks without producing  any bad effect.   I throw out
these hints for the consideration of those, who advise the immedi-
ate extraction  of the  body after simple  craniotomy; a practice
that I have frequently  known destructive to the woman by the in-
duction of haemorrhage, and the utter impossibility to excite ute-
rine action  by  any means.  Many eminent  writers are against
delivery when  there is no  uterine  action after craniotomy, and
among these are, Simson, Osborne, Kelly, Denman, Boer, Asdru-
bali, Burns, Blundell, Velpeau, Duges, &c.
   Sometimes we cannot succeed with the common  perforator, as
when some of the ossified  parts of the skull present.  In such
cases M. Duges  has proposed a kind of screw perforator, which
he has designated a terebellum, and  the operation is  called by the
French craniotomie terebrante.  This instrument  may also fail,
and to obviate the use  of all perforators,  Baudelocque,  the ne-
phew, has introduced a strong forceps without any fenestra, exact-
ly similar to that used by Dr. Holmes, which is capable of redu-
cing the volume of the infant's  head to almost any size which the
operator may desire.   Professor Davis, of the London University,
has likewise invented many valuable instruments for extracting the
head and trunk, which are delineated in his valuable work on Op-
erative  Midwifery.
   These instruments are highly valuable when the brim of the
pelvis is much deformed, and when it is extremely difficult to ex-
tract the base of the skull or the trunk,  either by his craniotomy
forceps, or by the old crotchet  or blunt hook.   If there is much
deformity, it is  a great  matter to leave the body of the  infant un-
disturbed for some time after craniotomy, and after breaking down
the skull; as the heat and moisture to which it is exposed favours
putrefaction and facilitates extraction.  1 have lately witnessed an
excellent illustration of this  point, in a case with my friend Mr.
Appleton.   In  extracting the base of the skull through a contract-
ed brim, we should bring it down edgeways, and first reduce it to
the smallest extent with the craniotomy forceps.  The  perforator
is next to be driven through the thorax between the ribs, and the
viscera lacerated in different directions, the crotchet or craniotomy
forceps  applied, and the ribs and trunk  dismembered in the best
and easiest manner practicable.   The spine, extremities, and pel-
vis are also to be brought down with the crotchet or craniotomy
forceps, when the deformity  admits, or reduced to the smallest size 
EMBRYOTOMY.
427
as the case may require.   When the breech presents, the inferior
extremities are  to be separated;  as also the pelvis in bad cases of
deformity.
   When the trunk remains in the womb after cephalotomy which
is named decollement by the French, we can extract it by differ-
ent methods; 1. by applying the blunt hooks in the axillae or arm-
pits ; 2. by disengaging the arms and drawing them  down;  3. by
fixing the crotchet on the upper part of the spine, or between two
ribs.  Desormeaux  and Hamilton prefer the spinal column as the
ribs are apt to break, and the hook may  slip, and 4.  by turning  or
bringing down the feet.
   In whatever  way we operate, we  must take care to adapt the
greatest diameters of the foetus in relation with those of the mo-
ther, and extract in  the axis of  the pelvis.
   Hydrocephalus.—When a hydrocephalic head presents by the
vertex or base after  the body is  expelled, it is to be discovered by
a careful examination.   The perforator must be applied to permit
the escape of the fluid;  the head closes, and the labour is termi-
nated by uterine action, by the  forceps, or by  craniotomy.
   Hydrothorax and Ascites are discoverable by fluctuation alone,
and are seldom  recognized.   A trocar must  be introduced, the
fluid evacuated, and the labour terminated by nature, or by man-
ual or instrumental aid.
   Hydrorachitis, when large, must  be punctured in the same
manner, and the labour completed, according  to some of the me-
thods already described.
   Detruncation.—When the head only remains in the uterus,  we
must endeavor  to adapt it to the proper diameters of the pelvis
with the hand,  having pressed on the abdomen with the other.
If we cannot succeed by this manoeuvre, we  must apply the for-
ceps or craniotomical instruments.
   Extraction of Monsters.—Living twins maybe united, at some
parts, by simple integuments.   We must separate them by incis-
ion when this can be done  with safety, and deliver according to
the rules of  art.  Twins may be  united by the top  of the  head,
as mentioned by  Pare, and cited  by  Baudelocque and Capuron.
In such a case, we should bring one down by  the feet; the other
will necessarily  present  by the  head ; and if  it remains too long
in the pelvis, we extract it with the forceps.   Two heads belong-
in* to the same trunk may  present at once at the brim.  In this 
428
GYN.SC0-PATHOLOGY.
case, we must reduce the volume'bf one or both, and dismember
as much of the trunk as is  necessary to admit of the passage of
the remainder.  Two trunks with one head have presented at  the
superior strait.  Here we should separate them, and extract each
successively.  Voluminous tumours may exist on any part of  the
surface  of \he foetus.  The practice is  to  remove  them, if they
impede delivery.  I have already described the management of a
case in  which the body of one  infant is  expelled to the  neck, and
the head of another infant descends into the pelvis ; an example
of which was lately  described by Dr. Fergusson, of Dublin. (See
p. 135.)

   Section 7.—Retention of the Placenta or Afterbirth.—Arti-
ficial Deliverance.—Extraction of the  Placenta.
   The  natural expulsion of the placenta has  been already  de-
scribed, p. 129.   I may remind the  young practioner, however,
that the mechanism of deliverance, as our Gallic contemporaries
term the expulsion of the placenta, presents  three periods :  1.  the
detachment of the  placenta from the internal  surface of the ute-
rus ; 2. its passage into the vagina; and 3. its expulsion from  the
genitals.
   In natural cases,  as the  contractions of the uterus, or  " after-
pains,"  detach the   placenta,  it becomes rolled  upon itself,  and
presents the  extremity of the  cone  which it  represents  at  the
os uteri, and pressed by the uterine  contractions it passes in  the
axis of the  superior strait into the  vagina, and thence in  the axis of
the outlet through the genital  fissure or vulva.   The membranes
attached  to  its  edges in general,  but  not always,  escape last.
Sometimes  it presents an edge, and sometimes  the  maternal or
uterine surface, and often the foetal surface, which renders the  ex-
pulsion more difficult, and in general embarrasses young obstetri-
cians.   In the last  case  its  edge should be  hooked on  the finger,
and gradually brought through  the vulva, the  practitioner twirling
it round to extract the membranes,  which after he has the whole
placenta between his hands, will require traction with the index
finger and thumb.
   Artificial Extraction of the Placenta.—The cases which cause
a necessity for artificial  extraction or separation of the placenta
are, haemorrhage, convulsions,  syncope, inertness of the uterus,
spasmodic contraction of the  womb, hour-glass  contraction,  pre- 
EXTRACTION OF THE PLACENTA.
429
ternatural adhesion, adhesion of the organ to the neck of the ute-
rus, and abortion.   Some of these require  immediate extraction,
as haemorrhage,  convulsions,  and syncope;  others, as  inertness,
spasmodic contraction  of the  womb,  unless  haemorrhage is pres-
ent ; preternatural adhesion, and hour-glass contraction  do not al-
ways require immediate extraction of the placenta.
   Manner of Extractiom.—If we turn the navel-stringor  cord
round two fingers of the left hand,  as  recommended after natural
labour, p. 129, put the remainder of the cord on the stretch, and
then pass two fingers of the right hand along it, until we feel its
termination ; the placenta will, in  general, be  detached and pro-
truded into the vagina, and is to be  removed as described in  a for-
mer paragraph.   But if we cannot touch the placenta, or feel the
end of the cord, the placenta  is not detached ; and according to
Dr. Hamilton, should be removed after the expiration of an hour
subsequent  to the birth of the infant.   In a vast majority of cases,
the organ will be found in the vagina, after the lapse of that peri-
od.  I have often waited two hours,  when the uterus was  firmly
contracted,  as no hemorrhage  can occur when this is the  case. It is
very rarely necessary to extract the placenta,  that is, to separate it
from the  uterus;  according  to Clark, of Dublin, about twenty
times in  more than ten thousand cases.   The  mode of operating
consists in putting the cord upon the  stretch, and passing the right
hand in a conical form along it as a guide to the placenta.   When
the hand is in the  uterus, if part of the placenta  is detached, we
carefully glide the  hand between this part and  the internal surface
of the womb, until the separation is completed.   If the placenta
is entirely adherent, we begin  by detaching some point of its cir-
cumference, by insinuating the  fingers between this point and the
uterus, and then separate it as just mentioned.   When it is adhe-
rent  only by the  circumference,  its centre being detached, we
should pierce the  centre, according  to  Baudelocque and  Desor-
meaux, and pass the fingers through the aperture, to separate the
circumference more easily.   When a portion  or even the  whole
of the  placenta is  so adherent  as not to be easily detached, it is
better to remove as much as possible  in the former case, and leave
the whole in situ in the latter,  than forcibly endeavour to extract
it.  The latter  case is one of extremely rare occurrence.   It may
not be met  with in the course  of a long professional life.  All por-
tions of  it which are detached, with all  clots  of  blood, are to be 
430
GYNJECO-PATHOLOGY.
 extracted.  For further information on this  subject, I refer the
 reader  to pages 126—344.   I may observe, however, in  this
 place, that, in general, the placenta is partially protruded through
 the os uteri, or  lodged  in the vagina, and only requires removal,
 and not extraction.   I wish students and  young practitioners could
 recollect this fact, which would  prevent  them from calling for the
 aid of their seniors  unnecessarily.  How often  is  the obstetric
 lecturer called at an unseasonable hour, and in inclement weather,
 to remove the  placenta, or a harmless  piece of membrane, from
 the vagina.  When  the placenta is retained from inertness of the
 uterus,  Mojon and other Italian physicians have recently  injected
 about six  or eight ounces of cold water,  or vinegar and water, into
 the umbilical vein ; colic, uterine pains,  he. were excited, and by
 these means detachment of the  afterbirth was  effected.  This
 plan has not been tried  as yet in this country.   It is a received
 axiom in obstetricy,  that the  placenta should be removed or ex-
 tracted  previous to  the  departure of the  practitioner.   This is a
 general rule to which there is but one exception, and that is in  the
 very rare  case, in which the  placenta is  so firmly adherent as not
 to be removable.  The  bad  effects of leaving it in the uterus in
 ordinary cases, are the  danger of haemorrhage, uterine phlebitis,
 which  is  attended with  great  constitutional  irritation, the  worst
 symptoms of typhus, and, in general, death.   I cannot assent to
 the opinion of my distinguished  friend,  Dr. Blundell, that it is
 possible no bad consequence might result from the presence of the
 placenta in the uterus if left  unattended to.   No doubt,  when it
 is ossified, scirrhus,  or  hydatic, or immoveably adherent in part,
 some portion must be left undetached ; but this circumstance will
 not justify us in  ordinary cases to leave the woman without remo-
 ving or  extracting the placenta.   Dr. B. merely offered this as-
 sertion as  an exception  to the general opinion, which he  forcibly
 inculcated.
  Gentle  friction on  the abdomen with the hand, with proper doses
of the ergot of rye,  will, in general, succeed in effecting  the ex-
pulsion  of  the placenta.   Some mild cordial  often  produces  the
same effect.  Midwives  advise  the woman " to bear down," " to
cough," which can seldom be accomplished unless pressure is made
on the  abdomen with the hand, "to laugh," or " take snuff," to
induce sneezing, " to blow on the back  of the hand,  or  into an
empty bottle ;" all which efforts threw the abdominal muscles into 
HOUR-GLASS CONTRACTION.
431
action, and thereby cause pressure  on the  uterus, and induce  its
contraction.  Gentle traction of the cord may enable us to remove
the placenta from the vagina, and this should be made in the axis
of the inferior strait.   Excessive volume  or size  of the  placenta
will cause its retention in the vagina, and in this case we hook  an
edge of it on the finger.
   Spasmodic contraction of the cervix uteri  may prevent  its de-
scent.  The French advise depletion in this case; but such a plan
is seldom necessary.   The application of the finger as a  hook is
sufficient.
   Hour-glass Contraction of the  Uterus.   Chatonnement-encha-
tonnement of the French.—This affection consists in a spasmodic
contraction of the uterus, generally about the middle of the organ,
the superior portion containing the placenta, and  the part inferior
to the contraction near the os uteri, being dilated.    Various causes
have  been  assigned for this  condition; but it generally occurs in
consequence of  the male or female obstetrician pulling  down the
shoulders and body of the infant, in the absence of uterine action,
after the expulsion of the head.   The patient may also induce it,
by forcing  down the body under the  same circumstance,  by the
action of the abdominal muscles only.  The practice in this case
is, to  introduce the hand along the  cord,  and  gradually  pass the
fingers successively through the contracted portion  of the womb,
which may require the lapse of  an hour or two for the accomplish-
ment, and  the hand having passed into the upper cavity, the  pla-
centa  is to be  detached in the manner already mentioned, and
pressure is to be made on the uterus  with the knuckles to  excite
contraction, until the  action is such as to expel the hand  and  pla-
centa.  In some of these cases, the placenta may partially pass
through the contraction, and then there is reason to think it is en-
tirely detached, and that the introduction of the hand beyond the
stricture is unnecessary.   In some cases there are several contrac-
tions  of the uterus above the strictured part.   In all these  cases
we should  apply friction on  the hypogastrium, and make  moderate
traction on the cord before we have recourse to the introduction of
the hand.  Rupture of the cord is seldom seen at present; but
should such a case  occur,  it will  be  highly embarrassing to the
young practitioner, as it  requires a nice sense of touch to enable
him to distinguish the placenta  from  the  uterus.   Examples are
not wanting to shew that the uterus has been lacerated in such cases. 
432
GYN.3EC0-PATH0L0GY.
When there is strong adhesion of the placenta to the uterus, if we
persevere in forcible attempts to extract it, we may induce haemor-
rhage, convulsions, inflammation of the uterus  or uterine  veins
(phlebitis), and also peritonitis.  The uterus has been found infla-
med and gangrenous  after  such efforts.  The adherent  placenta
has remained for days, weeks, and months without  producing  any
bad effect; but when it becomes putrid we must use tepid injec-
tions, and thereby prevent  the danger of absorption.  M.  Dance
contends, that absorption of this substance when putrid, or of mor-
bid lochia, is the cause of phlebitis of that  portion of the uterus
to which the placenta is attached, and that  this disease is the real
cause of puerperal fever.   Tonnelle is of the same opinion.   Ne-
vertheless, it is the more general practice  to  leave an adherent
placenta than to extract it forcibly.   Should copious haemorrhage
occur during partial separation, we are to treat it as already men-
tioned, p. 343, and press the aorta above the sacro-vertebral angle
when the hand is in the uterus,  or  even by  compression of the
abdomen.  This  practice  is recommended by Boer, Lachapellej
Duges,he.; but I have not found it at all successful.  If  convul-
sions or syncope occur after the expulsion of the infant, the placenta
must be extracted in the manner above mentioned.

   Article VI.—Lochianosology—Puerperal Diseases.
   After the expulsion of the placenta, we should apply the hand
on the abdomen to ascertain the state of the uterus, which may
be contracted in the form of a round tumour, aptly compared to a
child's head, which is generally the case ; or it may be uncontrac-
ted and inert:  a frequent condition  after tedious  or instrumental
labour, and one that exposes the woman to haemorrhage.   (See p.
337.)—The uterus may be distended with blood, clots, pieces of
placenta or membranes, all which should be  removed,  and con-
traction of the organ excited by friction on the abdomen, or by the
ergot of rye.  A warm napkin is to be applied to the genital fis-
sure after the expulsion of  the placenta, if the uterus is properly
contracted ;  a cordial, such  as a glass of wine and water, or a table-
spoonful of brandy with some water, is  usually exhibited, and a
roller or bandage is placed round the abdomen, for the purpose of
making gentle pressure, and  of preventing syncope on  motion.
Some persons have the roller applied loosely during labour,  and
gradually tightened as the process advances ;  but this is an antiqua- 
PUERPERAL DISEASES.
433
ted and useless practice, as the greatest  majority of women are
delivered without it.  The bandage is  useful after  delivery, and
ought to be five or six yards in length, and a quarter of a yard  in
breadth; so that it  may be brought several times round the  lower
part of  the  abdomen, and  once between the limbs, so as to keep
properly applied over the hypogastrium.   Unless this  precaution
is observed, it usually slips above the uterus, and becomes a liga-
ture, serving no useful purpose, but the contrary.   It must not be
applied  too tightly, as cases are on record in which it produced
apoplexy.   When  the abdomen is flaccid  and prominent,  a soft
pad or cushion, or two folded napkins, will be placed with advan-
tage over the hypogastrium, and under the first turn of the roller.
   The soiled cloths are to be removed, and a dry napkin, if neces-
sary, applied under the patient's hips, and as she generally feels
cold, an additional quantity of bed-clothes is necessary.
   The patient  should not be "put to bed," as it is termed, sooner
than half an hour or an hour if much  debilitated ; and  should be
shifted on a sofa,  or raised between two females  in  the  horizontal
position, while  the bed is adjusting.  It is highly injurious to per-
mit a puerperal woman  to assume  the erect or sitting posture soon
after delivery, as she may be attacked  with syncope, followed by
flooding, or the enlarged uterus may descend into the pelvis, and
be partially or  totally prolapsed and protruded beyond the  exter-
nal genitals.  There is  nothing to prevent the descent  of the ute-
rus at this time, in  the erect or sitting positions ; and I have repea-
tedly known haemorrhage induced by this cause, and in some cases
continued  for  five  and six weeks before the practitioner in  atten-
dance became  acquainted with  its origin.   A woman  applied  to
me at the Central Infirmary, who was  delivered  six weeks  previ-
ously, and  was never free from haemorrhage during that period.  On
enquiry, I learned that she was turned out of one of the Lying-in
Hospitals the fourth day after delivery.  On examination, I found
the uterus enlarged, its orifice dilated, and it considerably prolap-
sed.  It was restored to its proper situation, a plug applied, ace-
tate of lead and opium administered, the recumbent posture adopted,
and in a few days a cure was effected.  I believe that  " sitting up
too soon" is, in general, the cause of prolapsus uteri of the  lower
classes; and hence the  necessity  of bearing this observation  in
recollection.  1 have taught this doctrine in my  Lectures for some
years ; and it is now confirmed by Professor Velpeau,  who  holds
        55 
434
GYNEC0-PATH0L0OY.
that those " who rise too soon in the puerperal state are liable to
complete prolapsus (renversement), to anteflexion and retroflexion?
to the descent of the uterus, and to a thousand other dangers."
   The chamber should  be kept  cool  and quiet, the bed-clothes
light, visitors excluded, and no cordials  exhibited, unless advised
by the obstetrician.  The visits of friends, neighbors, and acquain-
tances, to a recently delivered female, are productive of the worst
consequences, headache, agitation, peritonitis, he.   Velpeau at-
tests this fact, when he says, that  in numerous cases of peritonitis,
observed in the hospital under his care, there were few which did
not originate without connection with  moral commotion.   Every
observant practitioner  is aware of the  high degree of sensibility,
and  the  accelerated state  of the vascular  system of puerperal
females ; and hence the  judicious  practice  of tranquillizing these
states by an opiate.  A draught composed of Liq. opii  sed. mxx,
Aq. Puleg.  o iss,  is usually  given after delivery.   This allays
after-pains, procures sleep, and  calms the  excited  state  of the
system.  Some  practitioners order a draught composed of Tine.
opii mx.  Aq.  Menth.  P.  ^ j., liq. am. ac. gij. 4tis horis;  but
this practice is chiefly to increase the medicine bill.  I  have  known
three six-ounce mixtures of spermaceti emulsion, with a few drops
of laudanum, ordered a patient daily, for the  same purpose.    A
single sedative draught, as recommended above, is, in general,  suf-
ficient for every  useful purpose.   Great attention must be  paid to
diet and regimen ;  for it is well ascertained that by far the greatest
number of women are  destroyed after delivery, by diseases  caused
by the nurse, advisers, or female herself.  The fact is,  that many
fatal diseases may supervene some weeks after delivery ;  and hence
the great caution necessary  in the management  of puerperal  wo-
men.  I have known ephemera become violent, and  terminate in
typhus  phlegmasia, dolens, supervene, and prove  fatal, seven
week after delivery.
   In  a former part of  this  work, I have described  the diet regi-
men of mother and infant,  p. 131.
   The most common diseases incidental to women after delivery,
are those arising from  intestinal irritation, and which are con-
stantly mistaken for peritonitis.  This irritative disease is slightly
glanced at by Drs. Burns and Granville, under the term intestinal
fever; and was first noticed by Dr.  Marshall Hall,Junder the  title of
intestinal  irritation.  The diagnosis of this affection  from inflam- 
PUERPERAL DISEASES.
435
matory disease in the brain, chest, and abdomen, is ably delineated
by the author last named.
  The  second class of puerperal diseases in order of frequency,
is that of inflammations; and they may be divided into the more
diffuse inflammations of the  peritoneum, and the more  confined
inflammation of the substance and  veins  of the uterus, and its
appendages, and of their peritoneal covering.  These are followed
by all  the symptoms  of the  malignant or real  puerperal fever.
This was  placed beyond all doubt, by the report of the Maternate
of Paris, for 1829,  published with the  sanction of Desormeaux,
by his  pupil Tonnelle.   I published this able report in the London
Medical and Surgical Journal, 1830, vol. v.   A  third  class of di-
seases  is that arising from loss of blood, either by haemorrhage or
blood-letting, and entirely undescribed by authors until the work of
Dr. Hall appeared.   The  fourth class is that arising  from mixed
cases, and is one  highly embarrassing to the practitioner.  Lastly,
we have to consider the epidemic puerperal fever, or peritonitis as
it has been erroneously called;  and cases  of a sporadic and diffe-
rent nature may occur during such epidemic.
  All the symptoms of phrenitis may occur from intestinal  irrita-
tion, or from loss  of blood; and besides, there is the peculiar puer-
peral  delirium.   We  also may have  to treat  convulsions and
apoplexy, either arising from pressure of the gravid uterus or loaded
intestines, during the last months of pregnancy, or from the par-
turient efforts during delivery.
   From what has been already  stated in the course of this work
it is obvious that all the female organs of generation, both internal
and external, may be  attacked  with irritation  and inflammation,
abscess or sloughing, in consequence of difficult, tedious and dys-
tocial labours.   Such affections and diseases are  to be treated  on
the established principles of medical science.   I shall now pro-
ceed to consider  these diseases in detail.

               Lochia—Discharge after Delivery.
  In consequence of the further contraction of the womb, a serous
discharge takes place;  usually for one, or two, three or four weeks.
It gradually becomes browner, paler, greenish, and ultimately  of
a dirty colour, or sanguineous,  serous,  lacteous  or purulent.  It
may be too profuse,  or entirely suppressed.   It is  named the
" cleansings," by nurses.   If  profuse, we are to use equal parts of 
634
GYN^ECO-PATHOLOGY.
the saturated solution of alum and water, to be injected  into the
vagina three or four times daily, as already described.  We should
also employ the treatment recommended for menorrhagia, and ad-
minister tonics—such as sulphate of quinine, the mistura, and pi-
lula ferri.   The diet should be very nourishing, for the excessive
discharge  greatly debilitates the  woman.   The suppression of the
lochia is the effect and not  the cause of  disease ; it is usually the
precursor  of hysteritis, uterine phlebitis,  and peritonitis.  When
suddenly suppressed we should  use  tepid injections  of decoction
of poppies into the uterus.
   After Pains are best relieved by opiates—as a draught of twen-
ty-five drops of liq.  opii, in an ounce of any of the distilled waters.
The medicine should be given a short time after delivery, and re-
peated in  three hours if necessary. The preparations  of morphine,
acetous solution of opium, or black drop, should be used if common
opium cannot  be given.   I must take this opportunity of stating
that Battley's  sedative liquor of opium does not possess  the pro-
perties of black drop as to  strength, for 1 find it is not  four times
as strong as laudanum.   I  have used it  in  a variety of cases in
proper doses, presuming it to possess the strength and  properties
of black drop, but without  success.  I have been informed of the
same result by others; and I regret much that I have recommen-
ded it so often in these pages.   I have been greatly mortified and
disappointed with the failure of  this medicine in several instances.
The acetous solution of opium of the Dublin Pharmacopoeia is to
be preferred.
   Dewees decribes a peculiar kind of severe after pains, principal-
ly felt in the coccyx, for which  large doses of camphor  are the
best remedy.  His formula is  nearly as follows :—
            R. Camphorae  gij ;
                 Sp. Vini rect.  q.s. ut fiatpulvis;
                 Acaciae Pulveris,  3iij;
                 Aceti Opii, Pharm. Eblan.,  3j;
                 Olei Juniperi,  guttas xx ;
                 Sacchari purificati,  § j ;
   m sit. mistura ex  qua. sumatur semuncia omni quadrante horae.
   When pains are troublesome in a day  or  two after  delivery, and
do not yield to opiates or camphor, we should examine the pulse,
lest irritation or inflammation be about to commence.  If the pulse
be under one hundred  there is no danger;  if over  that  number, 
PUERPERAL DISEASES.                437
we are to dread disease.  Such is the excellent rule of Dr. Ham-
ilton.
  The womb may be inverted, partially or completely, and should
be cautiously restored to its natural situation.  This organ may
be inverted, its fundus passing through the orifice—in fact, turned
inside out, or as the French call it, renversement.  The os uteri
is at the most superior part of the  tumour; whereas in inversion,
it is at the most  dependent part.   This is caused by pulling the
cord, in order to extract the placenta, instead of allowing uterine
contraction to expel it.  The  fundus uteri may be pulled down a
little; and of course there is every variety between this and the
state under consideration.   Instances are on record, in which mid-
wives cut off the uterus when  protruded.  Violent pains, haemor-
rhage, and loss of vital  power, are the effects of renversion, and
consequently the woman seldom recovers.
   The organ is to be reduced like a strangulated  hernia, as soon
as possible, by gradually compressing the neck  of the  tumour,
and forcino- it up into the  vagina.   When the whole is returned,
cold water ought to be applied to the abdomen to induce contrac-
tion ; or if the hand can be easily introduced in the same manner
as to extract the  placenta,  it is to be passed, and such pressure
 made on the womb as  will  promote contraction.   If the disease
 has existed for a few hours, warm fomentations and pressure must
 be applied previous to attempting its reduction.  This disease may
 become  chronic, and continue for years, when the surface of the
 womb will become  partially covered with cuticle or skin,  or be
 ulcerated.  A case of this description was seen by Dr. Hamilton,
 in 1793.  I was  lately consulted  in a case  in which the uterus
 protruded be)ond the vulva,  and  had been  in this state for some
 years, by my ingenious pupil Mr. M'Donnell.  The tumour was
 reduced, and  a proper pessary applied.  The patient experienced
 great relief from the instrument.    The organ has been removed
 by  ligature in such cases, as already mentioned.
    The womb, vagina, ovary, and Fallopian lube may be ruptured,
 the labia infiltrated with  blood, the  perineum ruptured, and the
 uterus  attacked  with pain  or spasm; forming the  disease called
 hysteralgia by Burns, and eclampsie by the French. Haemorrhage
 is  a frequent occurrence to  puerperal women, and has been alrea-
 dy described.   (See p. 337.   Hysterical and irritable females are
 subject  to spasm of the stomach,  bowels, and uterus after deliv- 
438
GYNJECO-PATHOLOGY.
ery, attended with severe pain, and often confounded with inflam-
mation.  The pulse is generally regular in such cases, or if accel-
erated during the paroxysm, will soon become natural;  the pains
become slighter and soon disappear, and recurring during the fit.
These symptoms enable us readily to distinguish the disease from
inflammation.   In order more clearly to understand the difference
between irritation and  inflammation,  I  shall add  a few extracts
from Dr. M. Hall's  excellent  Commentaries, which are the best
I have seen on this subject:—
  Intestinal irritation  is represented by Dr. Hall  as  a disease
hitherto undescribed in  medical writings, and by no means  under-
stood in  practice, or distinguished from other morbid affections
of a very different  nature.   In many instances  it  appears with
symptoms of the most  acute phrenitis; in others, with those  of
intestinal or peritoneal inflammation ; occasionally it assumes the
symptoms of pleurisy ;  and accompanied with palpitation,  it may
suggest the  idea of disease or accute inflammation of the heart.
The general symptoms are said  to be,—shivering  more distinct
than in cases of inflammation; afterwards heat of surface, with
disorder of the head, chest, or belly, or of all together.   There is
headache, giddiness,  and some morbid  impression on the  mind;
panting and fluttering about the heart, with general hurry, irrita-
bility, and restlessness ;  the tongue is white and furred; the alvine
evacuations are dark coloured,  foetid, and scybalous, or yellow like
the yolk of egg, or of the appearance of yeast; and the urine is
said to be turbid, and frequently to deposit a copious sediment.
  The more particular  assemblage and distribution of symptoms
may be stated in the words of the author.
  " The affection  of the Head consists of the most  acute pain,
the greatest intolerance of light and sound, and the severest form
of vertigo, wakefullness, and  distress, and sometimes even delir-
ium, and the pupils of the eyes are often extremely contracted.
  "The affection of the Chest  is denoted  by severe and acute
pain of some part, which is apt to vary its situation, passing from
one side to the other, or  to  the back,  or occupying a situation
higher up or lower down ;  this pain checks a deep inspiration, and
even the ordinary breathing,  to  which it imparts  a character of
difficulty and anxiety.
   "When the abdomen is affected, there is acute pain, and great
tenderness  under pressure, in some part, or more or less generally 
PUERPERAL DISEASES.                  439
diffused.  The attack and situation of the pain is such, in some in-
stances,  that  the case is with difficulty distinguished from gall-
stones, though it more generally resembles enteritis.
   " When the heart is the seat of this  affection, there are violent
and terrific attacks of palpitation—and  the course of the carotids,
and even of the abdominal aorta, is sometimes the seat  of violent
pulsation or throbbing."
   The foregoing description is however insufficient to establish a
well-marked difference between the  symptons which arise from in-
flammation or congestion in the head, chest  or abdomen, and the
effects to which Dr. Hall alleges intestinal  irritation gives  rise in
these several regions  of the body; and it is manifest, that it would
be extremely  difficult to draw the line  of distinction in any given
case between an attack of phrensy, or pneumonic, pleuritic,  or car-
diac inflammation, and of peritoneal or enteric inflammation, and
this disorder, alleged to be of a very opposite nature, and ascribed
by the author to intestinal disorder.  With the view of  removing
this difficulty, he draws a  very elaborate  diagnosis, the following
extracts  from which  it is absolutely  necessary that the  reader
should study with attention.
   " The affection of  the head from intestinal irritation  conies on
suddenly, is formed all at  once, and is  attended  with great rest-
lessness, suffering, and distress.   In  phrenitis, the disease is usually
formed somewhat more gradually ; the  patient has been subject to
pain of the head perhaps for some days or even  longer;  he com-
plains less; or at  least there is less  urgent distress,—less distress
of a general kind; the pain may be very severe, although it is
more frequently rather obscure;  the intolerance of light and sound
are less urgent; the rigor, and  subsequent  heat, and the  attack
in general are less marked; the patient is not so soon relieved by
remedies, and the tongue and alvine evacuations  are less morbid.
[n the attack of affection of the  head from intestinal irritation, the
patient is relieved, perhaps completely, if the lancet be employed,
but the attack soon  recurs with equal or  greater  violence; in
phrenitis, the  relief is seldom so complete, the interval of ease so
long,  or the return so marked ; the  pain  is  diminished,  perhaps,
but gradually  resumes its former violence, unless active measures
be interposed.
   " When the chest is affected from intestinal irritation, the pain
is severe and acute, increased by a full  inspiration.   If  the inspi- 
440
GYNJECO-PATHOLOGY.
ration be repeated,  however, a second  and a third time, the in-
crease of the pain is less and less; the situation of the  pain va-
ries ; there is*no cough, and no crepitus on making a full expira-
tion.   In all these  respects  the  case differs from  inflammation.
The remarks already made respecting the relief from remedies, the
tendency to a sudden  recurrence of the pain, he. in cases of af-
fection of the head, apply equally here.
   " I had long remarked that there might be both acute pain and
tenderness under pressure of the abdomen, without inflammation.
This  state of things is frequently the result of intestinal irritation.
It is distinguished from inflammation by the general symptoms of
this affection—the  mode of  attack—the effects of remedies.  In
inflammation, the surface is usually cool, the head unaffected, the
patient remarkably quiet.  In  the case of intestinal irritation, on
the contrary,  there is generally much heat after rigor, the head is
much affected, and the  patient is restless, and generally  distress-
ed, the tongue is loaded and perhaps swollen, the alvine evacua-
tions are  extremely morbid,  and  great  relief  is  bbtained by the
free operation of medicine.
   This disorder is often confounded with arachnitis, pleuritis, and
peritonitis, and  may resemble each in succession, and  be treated
with copious  depletion, with only partial  benefit.  The  patient
has lost blood to an  incredible amount, without effect,  and was
only relieved  by improving the condition  of the  alvine  evacua-
tions.  A  singular illustration of this statement is given in Dr.
Hall's invaluable  work on the Morbid and Curative Effects of
Blood-letting.   Another feature in this disorder is, that depletion
to a few  ounces  causes  syncope ;  whereas  in  the inflammations
above specified,  forty or fifty ounces of blood  must be  abstracted
to produce such an effect.   The paroxysmal recurrence  of  pain,
and its urgency in despite of the lancet and its sympathetic effects
on othe organs,  enable us to distinguish  irritation  from  inflamma-
tion.   Dr. Hall  cites several authorities to prove that the expect-
ed traces of morbid  anatomy, the  effects of inflammation within
the head, chest  and abdomen,  have been absent altogether.   In-
testinal irritation is in general supposed to be peritonitis by a  great
majority  of practitioners.  In fact the slightest pain in the abdo-
men of a puerperal  woman  is  pronounced  peritonitis  by three-
fourths of the ordinary practitioners.  The  treatment, however,
is widely different.   The full and free evacuation  of the bowels, 
PUERPERAL DISEASES.
441
followed by anodynes, with light and fluid nutriment, will effect a
cure.   The local remedies are cold  to the head, a liniment to the
chest, and a fomentation and liniment to the abdomen when affect-
ed.  A combination of ol.  Ricin and ol. Terebinth, for example,
 Svi of the first, and 5iv of  the second, followed by a full dose
of the acetum opii of the Dublin Pharm., and fomentations, com-
pletely remove  the disease in many cases.   But as it occurs  in
constipated habits, and as the  alvine evacuations are depraved, we
must give mercury  until  these become  healthy ;  depletion is not
the remedy in this disorder.
   The next class of puerperal diseases is that of fever and inflam-
mations.
   Some of the fevers arise from the  general irritability of the whole
nervous system; and others from local affections of the bowels,
breasts, or uterus.   Sometimes  fevers are easily recognized,  at
other times they are extremely insidious.
   Ephemera, Intermittent Fever,  or  Weed.—This disease  pro-
ceeds from a susceptibility  of the nervous system, by which slight
exposure to cold, mental agitation, improper diet, or abuse of ar-
dent or fermented liquors, which excites a general disorder of the
system.   This fever consists of a cold,  hot, and sweating stage,
which may terminate in health, intermittent, or common fever.  It
mostly commences  during the first week after delivery; its symp-
toms are violent, and yet it may disappear after the first paroxysm,
or be continued for several weeks.   If there  be no local  disease,
and the fits slight, the  case is favourable; but if the  patient  be
delicate, the breasts are  likely to become  inflamed.  Those who
have suffered much during labour are most liable to it;  and  yet it
may follow the  most easy delivery.  If it depend on local causes,
these are to be  removed, when the disease will at once disappear.
 Speaking  generally, it  is  not dangerous; but if coma, or coffee-
coloured fluid be vomited, it  may  prove fatal.  When  violent, it
 produces great debility, and may end in typhus, and prove fatal.
   I have attended  a case of this kind with Mr. Drysdale of Ken-
 nington;  the disease terminated in the worst  form of typhus, was
 followed by phlegmasia dolens, and proved mortal.
   During the cold stage, heat is to  be applied to the stomach,
 back,  and parts which are coldest,  and this is to be increased dur-
 ing the hot fit, by putting on  more  clothes, so as  to induce perspi-
 ration. After the sweating n\ the patient is to be cautiously shifted,
         56 
442
GYNiECO-PATHOLOGY.
the clothes being previously warmed, and she may have if weak,
some warm wine and water.  We can often arrest the disease by
exhibiting a large opiate before the third stage.   The  bowels are
to be well regulated, the diet  nutricious, and sulphate of quinine
and other tonics are to be given, if the disease become protracted.
If any local disease  is  present, it is to be treated on the usual prin-
ciples.   Ephemera is to be treated as an intermittent fever.

                         Milk Fever.
   The  secretion of milk is usually ushered in with sharp fever,
and tumefaction of the breasts, which seldom continue for twenty-
four hours.   A smart purgative generally cures the disease.   The
breasts should be fomented with decoctions of poppy or camomile;
the nipple should be drawn  by a strong infant, or by an adult; or
artificial means may be employed.

                        Miliary Fever.
   Miliary fever is caused by crowding the patient with bed-clothes
and giving warm drinks.  It is never met with, if the patient be pro-
perly  treated after delivery.  An eruption of vesicles, aptly com-
pared to millet-seeds,  appears, and hence its name.  It may be an
idiopathic disease.    Gentle  purgatives soon  remove  it.   The
chamber should be  kept cool, and all  exciting causes removed.
Formerly mineral acids were given to arrest the profuse perspira-
tion, which discharge possesses a peculiar odour.   Musk, cordials,
he. were given  where  the eruption  receded,  lest convulsions
should supervene ; but this is a rare occurrence.  Dr. Burns never
saw it terminate in this manner.
   Typhus sometimes  attacks puerperal women, and is to be treated
in the usual manner.

         Inflammation incidental to Puerperal Women.
   Hysteritis, Metritis, or Inflammation of the Womb, generally
occurs from the second to the fifth  day  after delivery.   The pain
in the affected organ is continued and violent, and is subject to oc-
casional aggravation.   The  region of the uterus is very  painful on
pressure; but no pain  in  the abdomen, unless the inflammation
extend to the peritoneum.   The  milk and locia are suppressed at
an early period.  There is a severe fever present.   The disease
may terminate  by perspiration, diarrhoea, or haemorrhage; which 
PUERPERAL DISEASES.
443
last is the most frequent and complete crisis.   Sometimes the dis-
ease proves fatal at an early period, or pus is discharged from the
vagina or rectum.   Mortification is a rare occurrence.
   Blood-letting should be employed  vigorously during the first
three days ; but if throbbing set in, the lancet is injurious, as sup-
puration is about to occur.  Leeches should also be applied freely ;
laxatives, fomentations and blisters are also useful.
   Saline effervescing mixture, with antimonials and opiates, are of
great service.   The pain should be allayed by anodynes, both in-
ternally and externally.   When a discharge of pus takes place,
the  recovery  will soon follow; and the convalescence  should be
promoted by nutritious diet, tonics, country air, he.
   Sometimes  a slighter form of this disease occurs about the ninth
day  after delivery, and is generally mistaken by the nurse for weed,
or ephemeral  fever.  The pain is  very slight in the uterus, and
the  milk and  lochial discharge continue ; the disease may continue
for days or weeks,  when suppuration  and discharge of pus will
take place.   If pus is not  formed, the disease is more tedious, so
that on the woman rising from  bed, she experiences all the unplea-
sant symptoms of prolapsus of the womb.   These symptoms may
continue for weeks.  If they are slight in the commencement, sa-
line  purgatives,  sudorifics, and fomentations, give relief; but if
more violent,  blood-letting, and blisters must be employed.
   There is a  great diversity of opinion among writers  and teach-
ers, as to the  question, whether inflammation of the peritoneum,
and the disease called puerperal  fever, are  the  same.  From a
good deal of  consideration on the  subject, I agree with  those who
think puerperal fever a peculiar disease.  The morbid appearances
sound on dissection are widely  different, in many particulars, from
 those observed in peritonitis; and besides, puerperal fever will not
be arrested by the most timely and copious  blood-letting,  as the
works of Gordon, Hey, Campbell, Mackintosh, and the reports of
Velpeau,  Hamilton, Burns, Roux,  Matoscheck,  Hartman, and
Raimann, fully prove.  I shall  therefore describe the diseases sepa-
rately.
   Peritonitis, or Inflammation of the Peritoneum, usually comes
on in a day or two after delivery, though sometimes not before the
third week.   The  pain is confined to a single spot, but soon diffu-
sed  over the  abdomen, which  soon  becomes tense and swelled.
The pulse is  frequent, small and sharp, skin hot, and all symptom 
444
GYNJECO-PATHOLOGY.
 of fever are present.  These symptoms may come on slowly and
 insidiously ; a  fact that must never be  forgotten.   The pain be-
 comes so acute, that the weight of the bed-clothes cannot be en-
 dured ; and is much aggravated  when the  patient turns in bed.
 The disease usually proves fatal within five days, although it may
 go on for eight or  ten.   On dissection  the peritoneum is found
 highly inflamed, but rarely mortified.   A considerable effusion of
 the serous fluid, mixed  with  curdy substance, is sometimes found
 in the abdomen.
   Blood-letting is  our chief remedy ; if it lowers the pulse, it is
 to be repeated; but if the pulse becomes worse by it, then we are
 to suspect puerperal fever.   Leeches are to be applied in consid-
 erable number, according to the extent of the inflammation.  The
 bowels are to be opened by ten grain doses of calomel, which have
 more purgative effect than half drachm doses recommended by Dr.
 Armstrong; infusion of sena with  salts is to be given next morn-
 ing.   A blister should be applied  to the abdomen  after the leech-
 es.  If effusion takes place, blisters, sinapisms, and irritating oint-
 ments are to be resorted to.
   If colicy pains, or spasms of the bowels set in, independently of
 inflammation the state of the pulse, apyrexia, and intermission of
 the pain, enable us to distinguish them from inflammation.  Lax-
 atives, anti-spasmodics,  anodyne clysters, frictions with camphora-
 ted spirits and opium, in  general  afford relief; but if  these fail,
 we must resort to the lancet and blisters.
   Armstrong and Bates speak in the most laudatory terms of large
 doses of opium after venesection in enteritis, peritonitis and hysteri-
 tis.  The former exhibited three grains of opium after venesection
to tranquillize  the system, and arrest the action of the pulse, allay
 pain, produce sleep and perspiration ; and in six hours he repeated
 the bleeding if pain returned or was present, and gave two grains
 of the medicine;  and in other six  hours  he repeated the remedies
 if necessary,  giving one  grain of opium.   He went so far as to
state, that he  preferred  opium to  the lancet.  Bates advises one
 bleeding to the amount  of a pint, and a clyster of 5 xj of starch
 mucilage, and 3 ij tine. opii.  The instantaneous  good effect of
this remedy in relieving the  agonizing pain is said to be truly as-
 tonishing.  If there is no return of the pain  after twelve hours,
 the same enema with half the quantity of the opium is to be em-
ployed to prevent a recurrence of the disease.  But should the 
PUERPERAL DISEASES.
445
pain be violent after the first twelve hours, the former clyster must
be repeated.   Some tenderness of the abdomen will continue for
a day or two, but generally subsides.   The clysters may be used
without any depletion, and with equal success.   Warm fomenta-
tions and leeches  to the abdomen  are also to be employed, fol-
lowed by  opiate  frictions.  Our  author states confidently,  that
opium  alone will cure  the  inflammations of the abdominal  and
pelvic  viscera.   He orders a grain of opium and a grain of anti-
monial powder in a bolus, to be repeated to  the tenth or twelfth
time, and then if no relief is  obtained, the  employment of the
opiate clysters is necessary.   The patient awakes refreshed ; but
low diet, absolute rest with quietness, and an occasional laxative,
must be employed during the convalescence.    In an exceedingly
well marked  case of puerperal  hysteritis, to which I was called
by an industrious pupil of mine, Mr. Heath, the free use of opium
and calomel effected a cure, after antiphlogistic measures had been
tried in vain.  So acute was the patient's sufferings after depletion,
general and local, blisters, turpentine, he., that she was incessantly
screaming from agony ; when she was ordered ten grains of opium
and a scruple of calomel,  which she took in  one night with great
relief, but without producing  sleep.   The next day she was mer-
curialized, and her  symptoms  much abated;  she  continued  the
opium  in smaller doses,  and ultimately had  a  purulent discharge
from the vagina.   Though I am convinced of  the efficacy of opium
when preceded by depletion, I  cannot agree with the authors just
quoted, that it is  an infallible remedy alone.   It is also liable to
another serious objection,  that though  it narcotises the patient, and
renders her insensible to  pain, the inflammation may prove  fatal.
This was the  fact in a case I attended with my talented pupil,
Mr. Waterson.  The  patient was so  powerfully narcotised,  that
the usual remedies were tried in vain  for twenty-four  hours ; and
yet, on dissection, there  was the  most extensive inflammation  of
the  bowels, they being agglutinated  by a  layer of lymph, three
lines thick in  some parts, and the cavity of the peritoneum  con-
taining a large quantity of greenish yellow fluid, exactly like pus.

           Puerperal Fever—Fatal  Child-bed Fever.
   It has become fashionable of late years to  question the opinions
of our predecessors, and  in no  instance more remarkably  so  than
on the nature of the disease under consideration.  There is no dis- 
446
GYNJECO-PATH0L0GY.
ease about which there is so  much  dissonance  of sentiment  as
puerperal fever;  many of the most eminent obstetricians in Europe
and  America entertain discordant opinions as  to the pathology of
the disease.  Some contend that " it is excessively absurd to speak
of puerperal fever, except as a  symptom of a local disease. (Con-
quest, Blundell, Duges,) while others,  as Hamilton,  Burns,  Jo-
seph and John  Clarke, Roux, Velpeau, Mastoscheck, Raimann,
Hartman, Boer,  Schiffner,  Festi, Belletzky, and Editors of the
Edinburgh Medical and Surgical Journal,  1824, entertain a differ-
ent opinion.
  TTie  first accurate account of puerperal fever appeared in the
Mem. de I'Acad. Roy. de  Soc. 1746, for a full detail of which I
refer the reader to my Essay in the Lond. Med. and Surg. Journ.
1829, vol. iii. p. 18.
  Dr. Gooch has given an imperfect history of this disease, and abso-
lutely contradicts himself.  At one time he  strenuously maintains
that it is peritonitis, or as he unfortunately designated it, peritoneal
fever; and in future pages he  tells  us,  that depletion  is  not the
remedy  in some cases;  so that he  is and is not a monopathologist.
Subsequent experience has proved, beyond all doubt, that the dis-
ease under notice is not  peritonitis.  This  will  appear by a refer-
ence to  the essays of Dr.  Conquest  and M. Tonnelle, which I
have inserted in full in the London Med. and Surg. Journ.  1830,
vol.  v. No. 25.                        ,
  Dr. Conquest objects to the vague term puerperal fever, under
which is confounded the most opposite diseases, of the brain, chest,
abdomen, and pelvis.   He informs us  that in many cases  the mor-
bid  appearances are not sufficient to account for  death.  He has
only found a  fallopian  tube, or ovary inflamed.  In other cases
there are hysteritis, uterine  phlebitis, gangrene of the uterus, and
agglutination of all the pelvic viscera.  The type of the inflamma-
tion  will be so modified by  circumstances as scarcely to be recog-
nised as the same disease in different women, in different  districts,
and during peculiar constitutions of the  atmosphere.   He thinks
the disease communicable by medical men and nurses,  that gesta-
tion  and parturition produce a change in the physical condition of
the female, which so modifies disease as to give it a specific char-
acter.   This is decidedly the general  opinion  of medical practi-
tioners.   He is certain that the disease may commence during ges-
tation, from mental depression, impure air, bodily fatigue, low liv- 
PUERPERAL DISEASES.
447
ing, improper food, he.   It may commence as hysteritis, or peri-
tonitis.   The approach of the  disease is  often so obscure  as  to
elude detection.
   When  the  disease is inflammatory, copious depletion  is the
remedy: when  epidemic, it  defies all treatment.  The greatest
caution must be observed in using  the lancet.   Leeches and cup-
ping are often  valuable adjuvants; hot turpentine applied to the
abdomen is of great use, it should be used with flannel every six
hours for ten minutes at each time, until high  erythematous  efflo-
rescence takes  place.  In my own  practice I used it freely at  once,
until the erythema appears.  Oil of turpentine alone, or combined
with castor-oil  and laudanum, is a valuable purgative in all cases,
not admitting of much reduction of power.  Opium and mercuri-
als, in large doses, are invaluable after bleeding and purging.  The
reader will find further observations on the efficacy of these reme-
dies on referring to the article Peritonitis in a former page.   Cam-
phor in scruple doses, combined with opium, is a valuable anodyne
in cases of great restlessness.   Digitalis,  nitrate of potass, ipeca-
cuanha, and antimony, are valuable adjuvants, but must not be re-
lied on exclusively.   Such are the leading facts detailed by Dr.
Conquest in  his Observations  on  Puerperal  Inflammation, com-
monly called Puerperal Fever, read before the Hunterian Society
of London, Febuary 1830.  M. Tonnelle prefers the term  puer-
peral fever to  peritonitis  or  metro-peritonitis, because it is more
comprehensive  than the  others ;  it  expresses nothing by  itself,
and  does not prejudice the nature  of the disease.   He informs us,
that the disease raged at the Maternite during  the year 1829, with
more violence than at any period  since the establishment of that
hospital.  He gives the following account of the Pathology.  "It
is in the most violent cases that the integrity of the peritoneum is
most constantly preserved ; it is mostly inflamed in the hypogas-
tric  region.  The internal surface of the uterus is almost always
covered with a putrilaginous matter of  a red brown colour, and  of
an insupportable fetidity.  The proper  tissue of  the uterus  is
rarely  changed, except by ramollissement or putresence.   Sup-
puration of the veins and lymphatics of the uterus, is seen in three
out of five cases of puerperal  fever,  and is nearly as constant  as
peritonitis.   It may extend to the  ovarian, hypogastric, and abdo-
minal veins.   This phlebitis  exists generally  on  the  sides of the
uterus.   M.  Dance  held that it existed more  frequently near the 
448
GYN^ECO-PATHOLOGY.
 insertion  of the placenta.   The  lymphatics may take up  fetid
 fluids after delivery, and become inflamed.   The presence of pus
 in the vessels, and its necessary transmission through the circula-
 tion, causes rapidly a  palpable infection of the blood, and a cer-
 tain number of phenomena which impress on puerperal fever an
 especial character, a  characteristic physiognomy.  In  two  hun-
 dred and twenty-two cases, the uterus was affected in one hundred
 and ninety-seven, and the  peritoneum in one hundred and ninety-
 three ; there was pus in the uterine veins, and lymphatics in one
 hundred and thirty-four cases.  The  terms  peritonitis  or metro-
 peritonitis cannot be applied to many of the alterations described,
 but the term puerperal fever may be applied to all—it prejudices
 none of them."  (Des Fievres Puerperales observees a la Mater-
 nite de Paris,  pendant l'Annee  1829,  he.  Par M.  Tonnelle
 Arch. Gen. de Med.  Mars  et  Avril,  1830; Lond. Med.  and
 Surg. Journ., July 1830.)

                Symptoms of Puerperal Fever.
   This disease commences from  one to eight days after  delivery,
 the  patient complains loudly of the severity of the after-pains,
 and refers  all her suffering to the region  of the pubis and uterus.
 The disease is  ushered in with much shivering or rigors, the pulse
 varying from 120 to 160.   There is great prostration of mind and
 body, and  a sense  of undescribable oppression about the prascor-
 dia, and often an utter carelessness about  the infant.  There is al-
 ways intense  pain in the  head.   Sometimes the skin is hot and
 dry, face flushed, and  indicative of great distress  of mind.  Res-
 piration anxious and profound, as  if performed with a sigh.   Pain
 in the uterine region  aggravated  by pressure (metro-peritonitis,)
 which is first confined, but soon extends to the whole abdomen.
 There is much restlessness  and  jactitation, the abdomen rapidly
 becomes distended as large as before delivery, the pain sometimes
 diminishes or ceases.   Nausea, or vomiting, at first of bilious, and
 at length of a coffee-coloured matter occurs; sometimes there is
 diarrhoea or constipation,  the face  is  peculiarly ghastly, and be-
comes pale, circle  about the eyes livid, lips dry,  headache, tinni-
 tus aurium, tongue pallid or red, secretion of milk suppressed lo-
chia continued, but may be  suppressed, according to Dr. John
 Clarke; urine sparing  and  high coloured, bowels  confined.  The
eyes become dull, the  pupils dilated;  the  nose sharpened,  the 
PUERPERAL FEVER.
449
cheeks hectic or pale, the lips purple, or the face livid, as in the
last stage of typhus,  the forehead and chest  are covered  with
cold perspiration.  The patient  lies  on her back, with the lower
limbs drawn up, to relieve her respiration, which is much impeded
by the tumefaction  of the  abdomen  from  gas or effusion;  the
tongue becomes black, the  mouth aphthous,  teeth covered with
sordes, the breath cadaverous, vomiting of a  brown pitchy fetid
matter, involuntary alvine evacuations of black colour, with fetid
odour; the abdomen becomes less swelled, the countenance is in-
animate, the alae nasi are tremulous, the respiration becoming more
and  more panting.   The patient speaks incoherently,  mutters to
herself, or is delirious and attempts to get out of bed.   The pulse
is so rapid as not to be reckoned, the perspiration is cold and clam-
my ; there is subsultus tendinum, and  death soon closes the scene.
Dr.  W. Hunter stated in his Lectures, " treat the disease as you
will, three out of four will die."
  This disease attacks every temperament and  constitution, the
strong and  weak,  the young and  middle aged, the  poor  and
rich  ; but is more common  among the poor  and middle classes,
and  from the  age of puberty to thirty-five,  than at any  other peri-
od.   It occurs  most  frequently within the  first eight  days after
delivery.   It is one of the most fatal diseases.   Lowder consider-
ed the inflammation of the peritoneum was erysipelatous, and the
fever typhoid.   He  said that all  patients  who were bled, died ;
and  that two were cured by taking a gallon of decoction of bark
daily.   It is most rapid in its fatal career, often terminating in for-
ty-eight or thirty-six hours—nearly  as rapid  as  the plague.  It
attacks single women  after  delivery  as well as the married.   Dr.
John Clarke was of opinion,  that a succession of warm  damp sea-
sons and mild winters would induce the disease.  This is also the
opinion in Dublin  (Lawder  de Febre  Puerperal. Edin.  1821.) ;
yet why  does not the  disease prevail in private  life, which is not
always the case, if the constitution  of the season  be the cause
of it?
  During the autumn  of 1819, fifty-six women died  of puerperal
fever, at Vienna; the  patients were  mostly between twenty and
thirty, were of a full habit of body,  and three only were emacia-
ted.   Seven patients had the disease in the Hospice d'Perfection-
nement at Paris, during the autumn of 1824, and all of them  were
under thirty years of age.   (Rev. Med. Janvier, 1827.)  Three
        57 
450
GYNJECO-PATHOLOGY.
of these patients recovered by the use of mercurial frictions, the
rest died; and in all the uterus  was  inflamed, and gangrenous in
some parts.    Velpeau, Bourgon, and Roux, tried the mercury, as
recommended by the surgeon at the Hospital at Antwerp.   I shall
detail their  opinions in this most formidable disease, as soon as I
shall have described the report of the Vienna Professors of 1819.
These eminent men were  appointed as commissioners by the go-
vernment to inquire into  the  cause of the epidemic; and report
that  " the fever  was preceded  by marked changes in the whole
system, and particularly in the  uterus, indicating clearly an inflam-
matory  state.   The lochia  disappeared  immediately,  or in a few
hours.  The breasts were found empty of milk, loose and flabby.
The mouth  of the womb was found gangrenous, when  the inflam-
mation  was  most recent.  In the last stage of the disease, symp-
toms of effusion into the chest and  abdomen, extreme debility of
the powers of life, and gradual dissolution, were apparent.  Effu-
sions of a brownish serum,  mixed with  coagulable  lymph, were
found in these cavities.  The  rapid  putrefaction of the body in a
few hours after death—the dissolved state of the blood, the stri-
kingly soft state of the  whole  bowels, heart, lungs, liver, spleen,
kidneys, and  particularly of the womb,  indicated a colliquative
putrescent  condition of the whole  system induced  by disease.
The uterus  was gangrenous in  every  instance,  especially at its ori-
fice, and it appeared to spread from  this point as from a focus.
This was seen in all the bodies,  fifty-six in  number,  all the pa-
tients having died, from the 26th of July to the 31st of August.
The treatment of the disease had from the first been antiphlogis-
tic ; blood-letting, leeches  to the abdomen,  with emollient cata-
plasms and clysters, blisters, calomel, and emetics were used. On
the commencement of  the debility, they had recourse to diffusible
stimulants, but with the same  unfortunate results.  Most of the
women  experienced, previous  to admission, a burning heat in the
abdomen, near the  pubes ; slight shiverings and  distressing pains
in the shoulders; and  the  greater number had erythematic spots
on one of the hands and feet, and chiefly on the joints.   Forty
of them had laboured under privations before delivery."   During
the last puerperal  epidemic fever of Edinburgh, " the  disease
spared neither high nor low, rich nor poor, those delivered in the
Hospitals, in the  city,  nor  in  the environs, neither the gay and
dissipated, nor the most retired and domestic."   (Edin. Med. and 
PUERPERAL FEVER.
451
Surg. Journ.  July  1824.)—" But," continue the editors of the
last work, " shall not  disease, which  in  every individual seized
with it terminates in gangrene, and in the destruction of the whole
organization, whici'  appears as highly malignant, we may say, as
pestilential fever, not a ho at least generate contagious matter, since
it is  universally allowed,  that gangrenous and  putrid fever very
readily produce contagious  matter?  Has not the disease a striking
analogy to hospital gangrene, typhus,  and even the exotic pesti-
lential diseases ?"  For a more  detailed account of the subject, I
must refer the reader to the Edinburgh Med. and Surg. Journ.,
and to the Med. Chirur. Review,  1825, vol. ii.  The German
Reporters advise a separation of the  patient  from  the healthy,
though no contagious  property could be traced;  a recommenda-
tion  made by Clarke  of  Dublin, Clarke of London, Young, and
Hamilton of  Edinburgh,  and Velpeau, Bourgon,  and  Roux, of
Paris.  The  three last named practitioners, in their report above
alluded to, had tried the  various modes of treatment recommend-
ed by Denman,  Leake, Gordon, Hey, Butter, Manning, Walshe,
Hulme, Clarkes, Hull, Hamilton, Armstrong, Brenan, Sutton, and
Broussais, and all without success.
   From fifty  to  two hundred leeches were  applied to the abdo-
men, as  recommended by  Broussais and Labatt, with  all  othef
means  "to boot," in fifty cases;  and without  success.   Even
blood-letting  from the arm had been freely tried at the same time.
The reporters then had recourse to mercury, and ordered inunc-
tions on the abdomen, two drachms of th'e  ointment  every two
hours, which saved three patients out of seven; the disease  being
advanced and hopeless in the fatal cases.   Two grains of calomel
were given every two hours, at the same time.  They think them-
selves warranted to draw the  following conclusions  from the facts
they observed:—
   1st. That puerperal peritonitis once completely established, and
abandoned to itself, is almost invariably mortal.
   2d. That it remains yet to be  proved that  sanguineous deple-
tion  alone is adequate to  the cure of the disease.
   3d. That the writings  of Hamilton, Gordon and  Vandenzande,
incontestibly  prove that,  by means of  calomel  in  large doses, ma-
ny cases of puerperal  peritonitis of the  most severe  kind have
been saved.
   4th. That  mercurial frictions over the abdomen, made at short 
452
GYNiECO-PATHOLOGY.
 intervals,  promise considerable  success, and  that  this ought to
 draw the attention of the profession to the said point of practice.
   5th. That, by  means of mercurial frictions, patients have been
 rescued, as it were, from the brink of the grave; and consequent-
 ly that this remedy should be tried, however late in  the disease.
   6th. That the friction  should  be continued without  fear, until
 the mouth becomes affected—and in most cases, for some time af-
 ter all the symptoms have subsided.
   7th. That it would probably be advantageous to conjoin the in-
 ternal administration of calomel,  warm baths, and warm tempera-
 lure.
   8th. That the  facts observed  by the authors, without being
 sufficiently numerous or conclusive, are yet such as may encour-
 age, authorise, nay, compel practitioners to prosecute the enquiry.
   From much consideration on all the opinions on this subject, I
 think it is obvious that the disease under consideration is a pecu-
 liar one, and widely different from common inflammation of the
 peritoneum, that it commences in the uterus, and is best relieved,
 perhaps cured by  the free use of mercury.  Dr. Blundell  recom-
 mends copious blood-letting as early as possible, and  repeated  two
 or three times:  but  this  has failed with the majority of domestic
 and foreign practitioners.   It is rather surprising, that local bleed-
 ing has not been  more generally employed.   Thus  leeching  and
 cupping might be applied to the groins, hypogastric region,  and
 the former to the labia and vagina.   Again, why not apply cold
 to these parts, and also to the  vagina  and uterus.  Cold injection,
 or pounded ice might be introduced  into the vagina, and applied
 to the orifice of the uterus ;  to that part which  is  first affected.
 The only objection to the use of cold would  be  the presence of
 the lochia; but this should not prevail, for the application of cold,
 both externally and internally to the  uterine  region, would lessen
 vascular action, increase uterine contraction, and so far  from sup-
 pressing the lochial discharge,  most probably increase it.  General
 bleeding should precede the use of mercury, which will ensure its
 effects as on  all other occasions.
  1 conceive great improvement might be made in the application
 of the mercury.   It ought  to be given  in large doses, as  recom-
 mended by Boyle in syphilis; by Cartwright in the same disease,
 in fever, liver complaint, and acute and chronic  dysentery (Medico
Chir. Rev. 1826,  p. 339) ; and by Musgrave,  in the fevers of the 
PUERPERAL FEVER.
453
West-Indies.  (Edin. Med. and Surg. Journal,  1827, v. 28.)—
Musgrave's plan is most applicable to the rapidly fatal disease un-
der consideration, which is the exhibition of calomel, every three
or four hours in the following doses, until some effect is produced.
He divides two  scruples of calomel  and one scruple of camphor
into twelve papers, and he has exhibited from three to five hun-
dred grains of the former, in fevers of the West-Indies, with suc-
cess.   He informs us, that the camphor promotes the mercurial
action.
   Again, the mercurial ointment should not only be applied to the
abdomen, as recommended by the  French,  but also to the axillae,
a mode that will often suddenly produce its effects.
   Before concluding  this article, I should mention the use of the
oil of turpentine, as  recommended by Dr.  Brenan, of Dublin.
That gentleman published an Essay on the use of this medicine
in puerperal fever; and records  six  cases,  four  of which it com-
pletely cured, and relieved  the  others.  The work, from which
I quote, was published in 1814.   The four  successful cases occur-
red in the Dublin Lying-in  Hospital, and were  witnessed by the
assistant-physician of that period.   The cases occurred in 1812,
when the disease destroyed a great number in  the hospital.  The
patients on whom it was  tried, were despaired  of when the tur-
pentine was exhibited.  The  quantity of the remedy did not ex-
ceed  two ounces in any case,  and  was  given in  the proportion of
half an ounce, or a table spoonful.   It was applied to the surface
of the abdomen, and with the  effect of relieving  the tension of
that part.   The patients declared themselves suddenly relieved by
the medicine.  It was exhibited by Hamilton in a few cases, but
without success.   Blundell and Copland also tried it in this coun-
try, but without producing any marked benefit.   They tried it,
however, only in a few cases.  The profession in  Dublin  also have
ceased to employ it.  If an  ounce  or two  of  oil of turpentine
could cure the  real  puerperal fever,  the discovery would justly
entitle its author to the especial notice of the government, and to
the thanks of posterity.  The talented author has not explained
the mode of operation of the  remedy, nor  has he given that mi-
nute history of the symptoms of the  case which  he has related,
that is necessary to establish them  as real instances of the disease
under consideration.   It does  not  follow, that as puerperal fever
ravaged the  hospital  at the  period, every woman " who vom'ted 
454
GYN.ECO-P A THOLOGY.
green and yellow bile, and had pain and tension in the abdomen,"
laboured under the disease; for it has happened in the same hos-
pital, that a woman lying between the beds of two others, labour-
ing under the disease, was not affected.  This is  asserted by Lavv-
der and Raymond, in their inaugural dissertation on the disease
published at Edinburgh,  1821.   The  remedy,  however, has not
been tried fairly by the profession, for I have been unable to find
a single practitioner who has employed it in ten cases.   All who
used it assert it  does no  injury,  and therefore  it should be tried
with the other remedies,  as already described.
  Blundell has known the disease to prove fatal in twenty-four hours;
and Joseph Clarke was of opinion, it might set in before delivery;
a fact that was proved in  the German epidemic.   Haighton descri-
bed a case  that  occurred  ten  or  twelve  days after delivery, and
proved fatal.   It may commence  insidiously, and has been mista-
ken for ephemera, milk fever, after-pains, colic,  spasm of the sto-
mach,  bowels  and  uterus; in fact, most of these diseases are
styled puerperal fever, by the majority of practitioners.
   In milk fever, the abdomen is soft, and not pained on  pressure,
the rigors are slight, and the pulse seldom exceeds ninety.  The
countenance is natural, the breasts are  swelled, hot,  and tender,
and all these  symptoms disappear in  twenty-four or thirty six
hours.
   It can be distinguished  from  after-pains, they being always pe-
riodical, and rather relieved by pressure, and generally removed  in
twenty hours, the countenance is  natural, the pulse is only quick
during the severity of the pains, and the lochial discharge is natu-
ral ; but soon fetid in puerperal fever.   Again, in colic, spasm  of
the stomach, duodenum,  and uterus, the pains are periodical, and
the pulse scarcely  affected, except during the fit.
   Blundell asserts that the disease may be cured, if the  patient be
bled within six hours of the chill;  and that she will usually die  of
the disease, if continued  for twenty-four hours.   The efficacy  of
bleeding is  not confirmed by the reports of the French  and Ger-
man physicians, nor by the statements of many British practitioners.
Blundell recommended blood-letting from twenty-five,  to thirty-
five ounces, if  the pulse range from one hundred and twenty to
one hundred and sixty, and there  be pain on pressing  the abdo-
men ; the operation  to be repeated from four to  eight hours, if the
symptoms be unchanged.  If the  pulse is  lowered, and  the pain 
PUERPERAL FEVER.
455
less, then the operation should not be repeated.  He is rather in-
clined to recommend the bleeding a  third time in six hours after
the second, if  the pulse and  tenderness are as urgent as  before,
" though from the use of venesection, he fears much benefit is not
to be expected.  Beware of bleeding, if collapse has begun, or  if
the two first bleedings have exceeded fifty ounces or more."  An
average quantity for a third bleeding  is from ten to twelve ounces.
The rapidity of the pulse alone, or the tenderness of the abdomen,
will not justify the second or  third bleeding. The bleeding should
be performed in the first  twenty four hours after the chill, and not
exceed  fifty ounces.  Opium, to the  amount of ten grains,  may be
given after the  bleedings,  watching  the  effects.  Calomel was
given to the amount of two  scruples after the first bleeding, and
the mouth  was soon  affected, but the patient died.   Blisters are
objectionable in the worst forms of the disease,  as they render it
impossible to decide whether  the tenderness be relieved.  Leeches
in great number are objectionable after the second bleeding; the
oil of turpentine, as recommended by Brenan, is an excellent ru-
befacient, and may be applied to the abdomen, until redness is
produced.   There is great danger from too much  depletion, col-
lapse may be hastened by it.   Doulcet of  Paris,  in 1782,  recom-
mended ipecacuan emetics, which are now never tried.  The pres-
sure caused by the abdominal muscles during vomiting would ag-
gravate the disease.  For a full  account of  the  pathology and
treatment of this disease, from the earliest  period to the present, I
refer to my observations in  the  Lond. Med. and Surgical Journ.
   Tonnelle places most reliance on mercurial frictions, which saved
three patients.   Dr.  Isaac A. Johnson has published six cases, in
each of which he exhibited half  an ounce of  turpentine and the
same quantity of castor oil every hour, until the bowels were freely
purged, and then continued the medicine  at longer intervals, and
all terminated successfully.   (Philadelphia Med. Journal.)—Dr.
Payne of Nottingham, most  strongly recommends the oil  of tur-
pentine, and has always found  it successful.   (Edinb. Med. and
Surg. 1822. vol. xviii. p. 538.)  He never used depletion of late
years.   In a subsequent essay he informs us that the disease was
epidemic in the  winter of 1822.  " Not any of those who  were ill
of the disease, to whom  I was  called, were bled, either generally
or locally, and every one of  them recovered.   Augmenting the
intestinal secretion,  appeared very speedily to  put  a stop  to the 
456
GYNJEC0-PATHOLOGY.
complaint in every instance."   (Op. Cit. 1824, vol. xxii. p. 59.)
Dr. Dewees, the eminent  American  obstetric  writer, has lately
recorded a case of real puerperal fever which was observed by two
other practitioners.   The antiphlogistic  plan was strenuously pur-
sued  but  without success.   The  case  was considered hopeless,
when thirty minims of oil of turpentine were exhibited every hour,
sinapisms  applied to  the legs, and an ounce of mercurial ointment
rubbed on  the abdomen every night, with an  enema, containing
one drachm of laudanum.  This  practice was continued for three
successive da)s—the patient recovered.    (Amer. Journ. of Med.
Sciences,  August, 1828.)

              Phlegmasia Dolens.—Milk Leg.
   The pressure on the sciatic, crural, and pubic nerves during la-
bour,  induces inflammation along the injured nerves, and may give
rise to one or several phlegmonous inflammations, which may  ter-
minate in  gangrene, and prove fatal.   (Martinet and Duges ; Rev.
Med. Aout. 1824.) This is often the cause of phlegmasia dolens,
and is called neuralgia and neuritis by the French.
   The crural veins and inferior cava may be inflamed, called phle-
bitis (Rev. Med. Sep. 1824); and uterine and  ovarian veins may
be similarly affected accompanying neuritis (Wilson, Chaussier,
Schwilgue, Dance, he.) ; and this state is said  to be the cause of
phlegmasia dolens, by Conquest, Hull, D. Davis, Bouillaud, Meckel,
Sasse, Lee, he.   The majority of the  profession  think  phlebitis
and phlegmasia dolens distinct diseases.   See my essay on the lat-
ter.   (Lond. Med. and  Surg. Journ., 1830, vol. iv.)
   Alard, White and  Casper, think inflammation of the lymphatics
in the groin, the cause of phlegmasia dolens; the two last include
the nerves and veins.  This disease consists in  a white swelling of
the thigh  and  leg, the skin, white, tense excessivly sensible  and
shining; but the oedema is not anasarcous, and  will not retain the
impression of the  finger.   The disease may continue for weeks or
months, may end in suppuration, abscess, paralysis, or very rarely
in death.
   Mauriceau asserted, that the disease arose from a translation of
the lochia.  Puzos attributed it to a translation of milk; Mr. White,
to a disease of the lymphatics ; Dr. Hull, to an inflammation of all
the soft parts; and Drs.  Conquest  and  D. Davis, to inflamma-
tion in the crural  veins.   Schwilgue gives a most  interesting  ac- 
PHLEGMASIA DOLENS.
457
count of an inflammation of the crural veins and nerves, the veins
in parts being reduced to the consistence of an artery, and in some
places filled with pus and blood  in a woman after delivery, yet
there was  no  phlegmasia dolens  (Diet,  des  Sciences, Med.)—
Meckel has recorded a similar case  in  the  dissertation of  Sasse.
Dr.  Davis's cases were  different from  phlegmasia dolens,  as the
infiltration  in  the limb was declared anasarcous  by no  less  an au-
thority than Mr. Lawrence (Med.  Ch. Rev. 1824, p. 386.)  All
obstetric authors agree that the puerperal swelled leg does not pit
on pressure.   But  the  Americans assert that the disease may
commence in the calf of the leg, and proceed upwards, and even
appear in both sexes, and in the superior extremities.   (Francis's
Memoir, New York, Med. Jour., No 1.)
   Dr. Beck saw it attack a woman fifty-two years of age, op. cit.
No.  2.   Dr. Hossack arrives at the following conclusions on the
disease, which he calls cruritis;
   1st. That cruritis is an inflammatory disease, not only affecting
the limb, but the whole system.
   2d.  That it proceeds from a suppression of the natural  excre-
tions, the effect of cold  stimulating  drinks,  and  other means of
excitement.   It is a  peculiar disease.
   3d.  That it is not connected with  the lochia.
   4th. That the first  irritations frequently appear in the leg,  and
not in the groin or pelvis.
   5th. That it succeeds easy labours,  and cannot proceed from
pressure of the child's head on the edge of the pelvis, rupturing
the lymphatics, as maintained by Mr. White.
   6th. That it appears in every  part of the limb; nor is it con-
fined to females, as proved by  Hull, Ferriar, Thomas, Davis, De-
wees, Chapman, S. Cooper, Hossack, Heermans, Beck, Denmark,
Duncan, Graves, Stokes, and others,  who state  that it attacks
males.
   7th. That it sometimes appears  in both limbs at the  same time.
   8th. That the usual means of subduing inflammatory action, are
most effectual in removing the active stage of the disease.
   9th. That in the second stage, when it is chronic, in addition to
the use of general stimuli and tonics, stimulating spirituous liniments,
friction, and the roller, are most useful in restoring the circulation,
exciting the absorbents,  and in removing the  disease.
        58 
458
GYN.ffiC0-PATH0L0GY.
   10th.  That it may prove fatal by abscess, or by exhausting the
strength of the sufferer.
   The disease occurs from the second to the  seventh week after
delivery.  It is of rare occurrence,  Hamilton, Burns,  Blundell,
Clark, of Dublin, Dewees, &c. (see my essay ut supra, and Edinb.
Med. and Surg. Journ. 1829, v. 32) ; it  does not  retain the im-
pression of the finger, or pit on pressure  (Callisen and all obstetri-
cians). It seldom terminates in suppuration, if judiciously managed,
though abscesses, paralysis, and mortification may  supervene.   It
is  thus defined by  Callisen : " the oedema of  puerperal women,
called lacteous by  some, is an elastic white, shining, hot and pain-
ful swelling, not retaining the impression  of the finger on pressure,
not infrequently attacking puerperal, but rarely pregnant women."
It  proceeds from  above downwards,  though sometimes  from the
foot or calf of the leg upwards.   The whole  extremity  is exces-
sively swollen and painful, but not red, and hence the designation
phlegmasia alba dolens.   The  patient cannot  bear  the slightest
touch, and the extremity is double the usual size.  The lochia and
milk may, or may  not be suppressed.   The parts within the pelvis
are highly irritable, and pained on the slightest  pressure; there  is
difficulty in evacuating the bladder.  The swelling arrives at  its
full extent in twenty-four or forty-eight hours.    There is now great
constitutional disturbance with fever.  The disease may disappear
in  six or eight days, then recur,  disappear, and return.  It  may
attack each limb sucessively, and return to the first  effected.  It
occurs after easy as well as  difficult  labours,  and  attacks women
of all constitutions.  All agree that it is seldom fatal.  (Hamilton,
Burns, Blundell, Dewees, he.)   It becomes chronic when judi-
ciously treated, or may be entirely removed.   It  is supposed that
it  may attack the male sex and the superior  extremities (Good's
Study of Medicine, by  Professor S. Cooper).   Its  pathology is
undetermined.   The appearance of the disease several weeks after
delivery  in aged females, and in the male sex, is  inexplicable ac-
cording to the proposed etiology of writers.  Mason  Good, Ham-
ilton, Dewees, he. do not think it is  caused by  phlebitis  of the
uterine or crural veins.
   Dr. Dickson advises  the  application  of leeches freely, one  or
two dozen to the effected part of the groin or the thigh, evapora-
ting lotions, saline  and antimonial  medicines,  quietude, and the
horizontal posture, and the comp.  powder of ipecacuan, or some 
PHLEGMASIA DOLENS.
459
other opiate to allay pain, and bleeding in full habits, if  fever  be
present.   Warm anodyne fomentations of acetate of lead, or warm
vinegar, sometimes procure great relief.  Opium should  be  given
to allay pain and  procure rest; though Dewees thinks it injurious,
Burns and Blundell recommend it.
   The chronic form is often relieved by bandaging, stimulating
liniments, and moxas.  Tonics are often  extremely necessary in
this stage of the  disease.  Mercurial  frictions and blisters  have
been  resorted to with success, and acupuncturation might also  be
used  with advantage.
   The disease is most common  from the second to the fifth  week
after  delivery, and is usually  preceded by marks  of uterine  irrita-
tion  within the pelvis, ulceration of the vulva or intestinal tube.
   Uterine Phlebitis, says M. Dance, appears soon after parturition
and commences in the sinuses of the uterus, is propagated  along
the innumerable veins in the  parietes of the organ, and may be said
to be parenchymatous.   It is generally complicated with metritis,
or may be secondary to it; and though the veins may be affected,
it is not correct to say, that the  pus does not infiltrate itself into the
substance of the  uterus.  I have afforded many facts in  my inau-
gural thesis to justify this opinion.  In one  case  half the^uterus
was  infiltrated, and  contained many small abscesses.  Metrai^and
phlebitis often exist at the same time,  though one may precede
the other.  Phlebitis runs along the hypogastric veins to those of
the ovary, and hence to  the  vena cava and other veins of the ab-
domen :  the ovarian veins, round ligaments, and tubes may  be  af-
fected, and  inflammation and  suppuration of these parts  occur.
Phlebitis  is generally unilateral, or confined to  one  side  of the
uterus, especially near the attachment of  the placenta, as the veins
over  which that body was attached may become inflamed and>ex-
tend  the disease to the side of the uterus, but this isolation  of the
inflammation was not observed so  well marked in the veins  in the
parietes of the organ.   The right side of the uterus was most
commonly affected,  and  the narrator states, that he has discovered
by auscultation the placenta  most  commonly atached to this side.
In eight cases, the ovaric veins of  both sides were affected  at the
same time in three instances, the left ovaric in  one  case, and the
right in four.   The right hypogastrics were most frequently affec-
ted.    The  causes of phlebitis are said to be laborious labours,
acrid lochia, decomposed clots of  blood and  putrified  portions of
placenta: causes which bear a close resemblance to those that give 
460
GYNJECO-PATH0LOGY.
rise to phlebitis after amputation, when absorption of unhealthy mat-
ter takes place.   It may occur after the easiest labour or the most
innocent operation, as venesection.
   It is difficult,  if not impossible, to discover the commencement
of the disease immediately after parturition,  the symptoms are so
obscure.  Sometimes the  patient makes  no complaint, and the
pain on  pressure may be mistaken for the usual sensibility of the
uterus  after delivery.  The organ enlarges,  however, and can be
easily felt above the pubes.   The  lochia may be diminished or
suppressed; and very often a thick,  purulent,  white, or sanious
foetid matter, escapes from the genital fissure.  The os uteri is di-
lated, is  painful  and  hot; the urine is scalding and passed with dif-
ficulty, especially if the inflammation extend to the parietes  of the
vagina and urethra.  There is no vomiting, the fever is slight, and
the general  state presents  nothing  irregular.   But when the dis-
ease extends to  the ovarian  and abdominal veins, then the symp-
toms are violent  and indicate a terrible complication, change of
countenance, indicative of great feebleness, great prostration, de-
lirium or insensibility, respiration difficult, icterus or inflammation
of many articulations take place ; the pulse is rapid and compress-
ible,jj^'death soon closes  the  scene.   Mr.  Dance thinks Mr.
Whitk'was probably warranted in concluding that puerperal fever
was a putrid disease from the  constitutional irritation produced by
absorption of pus.
   Autopsy.—The uterus is enlarged, and contains a fatty substance
resembling the  remains  of decidua,  bathed  in  a foetid, ichorous
sanies ;  its  parieties are thickened  and  softened, and  are  of  a
brown or black colour.  The  softening is most remarkable over
the site of  the  placenta, and  readily allows  the  finger to pass
throuo-h it like hepatized lung.  The veins are filled  with a whi-
tish or  yellow pus, which  is  squeezed out by pressure, and it is
necessary to introduce a probe or sound to discover their tortuosity.
There  is purulent engorgement of the lungs with pleuritis, some-
times abscess in  the spleen, liver,  or brain;  the mucous coat of
the digestive tube is  red or softened, and extensive suppuration of
the joints  is more common in this than  in  any other species of
phlebitis.
   Diagnosis.—It is  difficult to distinguish phlebitis from metritis,
but the pain and engorgement of the ovarian veins, the oedema of
the lower extremities, and of the lower part of the abdomen, which
pits on pressure (empatement,) announce that the inflammation 
PHLEGMASIA DOLENS.
461
has penetrated into the vessels of the abdomen, and opposes itself
to the free circulation of the blood ;  but of all the local symptoms,
that which merits most attention, is  an  indolent abscess in  some
part of the subcutaneous  cellular tissue.  The delirium may be so
acute as to lead to the supposition that the  chief disease is in the
head, especially if the history of the case cannot be learned; the
redness  of  the tongue  would  indicate enteritis, and the rigors
might be mistaken for intermittent fever or ephemera.   The due
consideration of the various bearings of the  case can alone lead to
a just diagnosis.   The prognosis, is unfavourable ; the disease is
much more serious than  metritis, it occasions much more extensive
disorder, and is more inevitably fatal.  In all cases, with  one ex-
ception, the disease proved  fatal towards  the  end  of the third
week.  The treatment ought to be antiplogistic, leeches to the
course of the inflamed  vessels, warm  fomentations, and low diet.
He terminates his interesting memoir,  by  observing  that women
ought to be cautious in  assuming their ordinary avocations after
the ninth day, for a great deal depends on the contraction of the
uterus;  and if the organ  can be felt in  the hypogastrium, the least
imprudence may  be followed by the most unfortunate consequen-
ces.  In two preceding  essays  he  gives a luminous account  of
phlebitis in different parts of the body, from wounds ligatures and
injuries  of veins,  and concludes that  abscess in the lungs, liver,
spleen, brain, or articulations, is the most  common effect of the
disease.   He has described phlebitis of the left renal  vein, but no
oedema  of the lower extremities, and in the whole course of his
remarks on uterine phlebitis, he makes  no  mention of phlegmasia
dolens.   From what has been now stated, these  diseases are man-
ifestly different.   It is necessary to compare the conclusions of  a
writer of the same period with those now  detailed.   Dr. Robert
Lee published a paper in the Medico-Chir. Trans,  in  which he
concluded that phlebitis of the crural veins was the cause of phleg-
masia dolens; which opinion was denied  by  the majority of his
reviewers.   It appears  the  reviewers were justified  in  their ani-
madversions, for the author has  abandoned his hypothesis, and in
the succeeding volume of the same  work, just published, he  main-
tains that phlebitis of the spermatic veins of the uterus, extending
to the crural vessels, is not only the cause  of phlegmasia dolens,
but of many of  the fatal disorders  of the  puerperal state, which
have been  usually comprehended under the  vague designation of 
462
GYNECO-PATHOLOGY.
 puerperal fever or peritonitis, and according as the serous, muscu-
 lar, or venous tissue of the uterus is affected, the  fever will be in-
 flammatory, congestive, or typhoid. He is at issue with M. Dance,
 for we are informed that "generally the spermatic veins alone are
 affected, for the most part only of that side of the uterus to which
 the placenta has been attached ;  and the inflammation  being once
 induced, it  is  liable to spread continuously  to the veins of  the
*vhole uterine system, of the ovaria, fallopian tubes, and broad liga-
 ments.   The  vena cava  itself may become  affected, but this  oc-
 currence is not frequent, the  disease being usually arrested at the
 entrance of the spermatic into the vena cava  on the right side, and
 of the  emulgent into the same  vessel on the left.  If, as some-
 times happens, it pursues  the direction of the kidneys, the sub-
 stance of these organs as well as  their veins may be  involved in
 the mischief.   The hypogastric veins are seldom affected on both
 sides,  and  rarely inflamed in  comparison with the spermatics."
 He thinks  phlegmasia dolens must now be  considered as merely
 one of the remote consequences of uterine phlebitis.  The obvious
 meaning of Dr. Lee, is that uterine phlebitis is the cause of phleg-
 masia dolens.   Against this  conclusion we have the testimony of
 a host of writers, as well as the author whose account of the dis-
 ease is already detailed, among whom are Dr. John Clarke, Burns,
 Wilson, Arnott, Sasse, Meckel, Schwilgue, we have seen suppu-
 rative inflammation of the uterus  unaccompanied by  phlegmasia
 dolens.  Mr. Wilson described three cases of uterine phlebitis ex-
 tending to  the cava, but no  swelling of the inferior extremities.
 Schwilgue relates a case of phlebitis or of the crural vessels after
 delivery, in which  there  was no  phlegmasia dolens,  though  the
 vein was filled with pus, and in one part  reduced to  the consis-
 tence of an  artery.   Mr. Arnott has described two cases of uterine
 phlebitis, the veins full of pus, but no affection of the inferior ex-
 tremity.   How often have I seen purulent discharge from the  ute-
 rus, which the dissection had  shewn to  depend upon  destructive
 ulceration of that organ and the vicinal tissues, but no phlegmasia
 dolens was present.   Here then are the veins in contact with acrid
 fluid, but none of the effects of uterine phlebitis.  Again, phleg-
 masia dolens occurs several weeks after delivery, when the uterus
 is restored  to its ordinary condition ; and according to Dr. Dewees,
 most frequently occurs after uterine haemorrhage  which ought to
 be unfavorable to phlebitis.   In phlebitis of  the superior and infe- 
4
                    PHLEGMASIA DOLENS.                 463

rior extremities there is redness and  common  oedema, symptoms
always absent in  phlegmasia dolens.   In Dr. Davis's first  case,
Mr.  Lawrence pronounced the oedema  " the result  of ordinary
anasarcous effusion, the inguinal glands a little enlarged, as  they
usually are in a dropsical limb, but without any sign of inflamma-
tion.  The femoral, external iliac, and common iliac veins, firmly
plugged by a coagulum of blood."   The second case related by
Dr. Davis, cannot be called phlegmasia dolens.  A lady was sei-
zed with peritonitis the day after delivery, which was removed by
active measures.   Ten days afterwards she  complained of deep-
seated  pain in the groin and along the great  vessels;  the limb was
swelled and very painful; but by leeches and blisters it was  spee-
dily reduced, and  in a week the swelling had entirely subsided,
and the patient recovered the perfect use of her limb.   From this
time she  convalesced  rapidly and satisfactorily, but  died in the
midst of perfect health six weeks after her  confinement.  Surely
this woman cannot be  said to have died of a disease and no symp-
tom of it present.  The third and fourth  cases related by the  same
writer are good examples of phlebitis, but the ordinary symptoms
of phlegmasia dolens  were absent.   The fatality of these  cases
proves them to be different from the latter  disease.   Professor
Velpeau's cases, published about the same  time, 1S24, were not
the disease in question.  In one, the limb was oedematous; in the
other swollen and red, and in the third, "beginning to shew  oede-
ma."  Dr. Bouillaud's description of phlebitis of the inferior ex-
tremity is very different  from that of  the puerperal swelled leg.
He says,  " the symptoms of inflammation in the trunk of a super-
ficial vein are easily recognized.   The  member  swells, becomes
hot, painful, and is even the seat of phlegmonous erysipelas. The
vessel  itself is tense, hard, and  knotty like a cord.  (Edema of the
limb is a very common attendant on phlebitis of one or more of the
principal  veins, and evidently arises from the mechanical obstruc-
tion  to the return of the blood.   The fever is putrid, adynamic  or
typhoid."  M.  Ribes gives a similar description of phlebitis, and
pronounces it quickly  mortal.  From  a  due consideration of the
symptoms, termination of phlebitis and phlegmasia dolens, it  is ob-
vious that they  are different diseases, and this is  the opinion of a
large majority of the  profession in every country, at the  present
period.
   Abscesses may form in the pelvic  joints, and in different parts 
464
GYNJECO-PATHOLOGY.
of the body of puerperal women ;  in the superior or inferior ex-
tremities, in the psoae and iliac muscles, in the lumbar and ingui-
nal region  (Diet,  des Sc. Med.)  Sometimes  they open in the
groins, loins, uterus, bladder and  rectum.   They are to be treat-
ed on ordinary principles.  They are of rare occurrence.

                        Paralysis.
  Some  women, after the easiest, as well as instrumental delivery,
are attacked with paralysis of  the lower extremities,  which is gen-
erally attended with retention  of urine.  The disease usually dis-
appears  in a few weeks.  Frictions,  tonics,  and gentle exercise
are the means of cure.   The  water must be drawn off night and
morning  with the catheter;  and  this  I have known  necessary for
three months.
  Laceration  of the Perineum.—Sloughing  of the vagina  and
contiguous parts, effusion of blood into the labium, and retention
of urine, have already been  described.
  Puerperal Mania.—This disease may occur the third day after
delivery ; sometimes not for a  fortnight; and again, not for sever-
al weeks, after parturition.   It generally appears after the patient
awakes, when  she speaks rapidly and  incessantly, supposing some
mischief  has befallen her, but most generally to her child, which
she thinks  is lost, stolen, or killed.  The lochia and secretion of
milk are  not suppressed.  The disease usually disappears in a few
days, though it may continue  for weeks, but seldom proves fatal.
Leeches  should be  applied to  the head, the bowels regulated  by
calomel; camphor and hyosciamus, or the acetous tincture of opi-
um, given to allay  irritation.   Blisters are considered injurious in
puerperal insanity.   The strait-waistcoat  must  be resorted to in
some cases, though the  milder the patient is treated  the better.
If the disease  become protracted, change of air and scenery are
of  great  advantage.  The disease is not apt to recur  in subsequent
confinements, and may be prevented by attention to the mind, and
general state of the health.  It may continue for sixyears, and the
woman have children;  and  in one  case  it continued  for eleven
years with  lucid intervals twice a week.  In  such case gestation,
parturition, or  lactation, must have lost all effect.

           Phrenitis or Inflammation of the Brain.
  This  disease comes  on  about  the third  day after  delivery. 
PHRENITIS.
465
The patient complains of pain or throbbing within the head, or in
the temples, experiences intolerance of light and sound, and soon
becomes furiously delirious.   The  pulse is rapid,  the eye vivid,
the lochia continue, but the milk ceases.   Care must be taken to
distinguish the disease from mania.   General and local blood-let-
ting, shaving the head, and  applying  cold, and  a blister to the
scalp, and opening the bowels, are the best remedies.
   Puerperal convulsions are to be treated  as already described p.
305.   Another  disease,  which  is often met in obstetric practice,
and hitherto undescribed  minutely by authors,  is excessive reac-
tion consequent on profuse loss of blood, by uterine haemorrhage.
I. have briefly alluded to it in the article on abortion, p. 342;  but
shall now more  particularly describe this disease.
   Excessive Reaction from  the Loss of Blood.—The best de-
scription of this disease is given by Dr. Hall,  in his valuable es-
says, from which I shall extract its history.  He states:
   " The phenomena are very different, if instead of one full bleed-
in"' to syncope, or of a profuse haemorrhagy and even protracted
syncope, the person be subjected to repeated blood-lettings, or to
a continued drain.   In this case,  within certain limits, the pulse,
instead of being slow and feeble, acquires  a morbid frequency and
a throbbing beat, and there are,  in some instances, all the symp-
toms of excessive reaction of the system,  which it is my object
now to describe.
   " The state of excessive reaction is formed  gradually, and  con-
sists, at first, in forcible beating of the pulse, of the carotids, and
of the  heart, accompanied by a sense of throbbing in the head, of
palpitation  of the heart, and eventually  perhaps  of beating or
throbbing in the scrobiculus cordis, and in  the course of the aorta.
This state of reaction  is augmented  occasionally by a turbulent
dream, mental  agitation, or  bodily exertion ;   at other times it is
modified by a temporary faintness or syncope.
   " In the more exquisite cases of excessive reactiont he symptoms
are still more strongly marked, and demand  a fuller description.
   " The beating of the temples  is at length  accompanied  by  a
throbbing pain of the head, and the energies and sensibilities of the
brain are morbidly augmented;  sometimes there is intolerance of
light; but still  more frequently intolerance of noise and of distur-
bance of any kind,  requiring stillness to be strictly enjoined, the
knockers to be  tied, and straw to bestrewed along the pavement,
        59 
466
GYN^ECO-PATHOLOGY.
the sleep is agitated and disturbed by fearful dreams, and the pa-
tient is liable to awake  or  be awoke in a state of great hurry of
mind, sometimes almost approaching to delirium;  sometimes there
is slight delirium, and  occasionally even continued delirium; more
frequently there are great  noises in the  head,  as of singing—of
crackers—of a storm—or of a cataract; in  some instances there
are flashes of light; sometimes there is a sense of great pressure
tightness in  one part, or round  the  head, as if the skull were
pressed by an iron nail,  or bound  by an  iron hoop.
   " The action of  the heart and arteries is  morbidly increased,
and there is great palpitation, and visible throbbing of the caro-
toids, and sometimes even of the abdominal aorta—augmented  to
a still greater degree by every cause of hurry of mind or exertion
of the  body, by sudden  noises or  hurried dreams or wakings; the
patient is often greatly alarmed and impressed with the feeling  of
approaching dissolution; the state of palpitation and throbbing  is
apt to be changed, at  different times, to a feeling of syncope; the
effect of sleep  is in some instances very extraordinary—sometimes
palpitation, at other times  a degree of syncope,  or an overwhel-
ming feeling of dissolution; the pulse varies from one hundred to
one hundred and twenty or one hundred and thirty, and is attend-
ed with a forcible jerk or bounding  of the artery.
   " The respiration is apt to be frequent and hurried, and attend-
ed with alternate panting and sighing ;  the movement of expira-
tion is  sometimes obviously and  singularly blended with a move-
ment communicated by the beat of the heart;  the patient requires
the smelling bottle,  the  fan, and  fresh air.
   " The skin is sometimes  hot;  and there are frequently general
hurry and restlessness.
   " In  this state of  exhaustion, sudden  dissolution has sometimes
been the immediate consequence  of muscular effort on the part of
the patient."   pp. 30—31.
   This morbid condition is to be relieved by stimuli, and not by
depletion.  See p.  342 of  this work.
   Bronchocele.—Enlargement of the  thyroid  gland  is an occa-
sional  occurrence after delivery; the  tumour may inflame  and
suppurate, or become a chronic tumour.
   Leeching, purgatives, and cold applications, should be resorted
to in the inflammatory state ; and if these  fail,  suppuration is to
be promoted by warm fomentations and cataplasms.  Should the 
BRONCHOCELE.
467
disease assume a chronic form, it  is best treated by the internal
and external use of hydriodate of  potass.  Ten drops of the tinc-
ture  or the solution of the  Dublin Pharmacopoeia 1826, may be
given twice a day, and the  ointment applied externally.  I am in
the habit of adding a few grains of tartarized antimony to the lat-
ter, which considerably increases its effects.  The internal use of
iodine is not free of danger, and consequently the closest attention
should be paid to the patient.
   Mastoids, Inflammation of the  Breasts.—This  is  a frequent
disease at any time after delivery, and  may be  caused by cold,
sudden  secretion of milk, or by retention of that fluid, in  conse-
quence of excoriated nipples.   The great object is  to prevent
suppuration; but here we  have much prejudice  to contend with,
as most  women  prefer  that termination.   The  breast becomes
tense, and excessively sensible, so  that cold applications cannot be
borne.  Warm fomentations, as those of poppies and chamomile,
or warm solutions of  acetate  of lead, will often  prevent suppura-
tion, by inducing a free  perspiration on the part.   The  bowels
should be well opened,  and  sudorifics exhibited.   In France,
leeches are freely applied; but Burns thinks  them of little use,
and I am of the same opinion.  The milk should be extracted, if
no pain be produced, either by glasses, the syringe, a clean tobac-
co-pipe, or by the suction of a strong child or adult.  The disease
rapidly terminates in  suppuration.   When  throbbing is experien-
ced, warm poultices should be  applied, as bread and  milk, linseed-
meal, he.;  and the  abscess generally bursts, when  the  matter
should be evacuated, spermaceti ointment applied, and over this a
warm poultice.   In some instances the milk soon returns, or most
commonly it ceases:  the breast healing, and remaining swelled.
in this case gentle friction with camphorated spirit is to  be applied,
or camphorated mercurial  ointment.  The part should be kept
warm by means of flannel, as there is a great tendency to relapse,
or to an indolent scirrhus.   In irritable  subjects  the abscess may
slough, and become very troublesome  and dangerous.   It is to be
treated on the ordinary principles  of surgery.
   The breast is subject to  superficial inflammation, suppuration,
and ulceration about the nipple.   Various applications are made
in this case, as palm  oil, mucilage of gum  arabic, white of eggs,
olive oil, spermaceti  ointment, fresh butter, melted marrow,  or
suet, he. he.   To  these  may be  added  weak  solutions  of sul- 
468
GYNJECO-PATH0L0GY.
phates of zinc, alumine, copper; acetate of lead, or nitrate of sil-
ver ; care being taken to wash them off with milk and water be-
fore  the application  of the child.   The vulgar apply tobacco
ointment in these cases, which I have  observed in one instance
nearly to destroy the  child.   The infant should be taught to suck-
le through an artificial  nipple, otherwise severe inflammation of
the whole breast may be induced.   Dr. Sibergundi, of Derston,
has strongly advised the following remedy for excoriated nipples:
       R. Ext. Opii  gr. j,
          Liquor. Calcis, > an  3iij.
          Olei omygdal. 5
   Sometimes aphtha or venereal ulceration of the child's mouth,
will cause the disease.  If the latter, mercury must be exhibited
to the mother.   If the female is delicate and irritable, and  suffer
severe pain on  applying the infant, it is necessary she should no
longer nurse ; but this must be decided  by the history and circum-
stances of the case.   If she wean the infant, it will be necessary
to exhibit smart purgatives, to prevent the secretion of milk, or to
draw the breast if the secretion prove troublesome.

                      Diseases of Nurses.
   Agalacty.—This name is given to the absence or  suppression
of the secretion of milk.   In some cases it depends on vivid emo-
tion  and then disappears ; in others on a delicate state of the con-
stitution.  In the former  instances,  fomentations and  stimulating
liniments applied to the breasts,  cause  determination of blood to
these organs, and induce the  desired secretion.  Artificial or na-
tural suction  produces the same effect.  The  disease  is often
symptomatic of metritis, peritonitis, and  simple fever.  Menstrua-
tion  may occur during lactation, and diminishes and  deteriorates
the quality and  quantity of the milk.   All  chronic diseases, as
phthisis, hepatitis, he. produce the same effects ;  and hence the
infant should be  committed to another nurse in all these cases.
When the milk is secreted  sparingly, we should order  nutritious
aliments, and caution the woman against the use of crude fruits,
vegetables, or acids.   It is very evident that the diet of  the nurse
affects the infant.  In illustration of this point we must remember,
that mercury taken by the mother will  cure  an infant  who labours
under syphilis.   In some cases the milk is rich and creamy in one
breast and thin in the other, and this difference cannot be account- 
PUERPERAL FEVER.
469
ed for, or removed.  Among the other species of mammalia, we
find the diet affect the milk.  We observe that cows fed on brew-
er's grains produce thin and aqueous milk.
   It is supposed by many that nurses may communicate  syphilis,
scrofula, gout, rheumatism and  cancer; but  further evidence  is
wanting  to  confirm  the validity of this point.  We  know that
mental agitation, passions, ehagrin, he. of the mother, affect the
milk, and produce colic and convulsions in infants ; and  that salt
food,  spices, leguminous substances, render it clear and abundant;
while strong drinks, brandy, coffee, spirituous  liquors, long watch-
ing, and too much sleep, render it too thin and watery.  It is gen-
erally supposed in this country, that the use of fermented liquors,
more especially of porter, increases the quantity and improves the
quality of the milk: hence women of the middle and lower clas-
ses indulge  in the use of this beverage.   There is no objection to
the moderate use of porter or ale, but an excess  is highly injuri-
ous.  A pint of either  in the twenty-four hours is sufficient. From
the preceding statements, we must admit, the existence of sub-
stances which increase the human milk or galacto-poietics.  When
the secretion of milk is too abundant it is termedgalactirrhoea. Some
women have a profuse  secretion of milk for the first three or four
months, and have their dress wetted, and in this way are rendered
uncomfortable and liable to take dold.   This  condition is followed
by pains in the  back  and loins, dry cough,  and much debility.
When  the milk is too  copious the patient should  live upon a spare
vegetable diet, use purgatives and diaphoretics; she should cease
to apply the infant too frequently.   Astringents,  such as vinegar
 and water are applied to the breasts by nurses, and by some prac-
 titioners.   Dr.  Ranque, of Orleans,  recommends low  diet,  and
cloths moistened with the following mixture,  to be applied three
 or four times daily to  suppress  the lacteous  secretion,  which he
 says will prove effectual in three or four days:
             R. Aquae Lauri Ceras  g ij;
                  Spts. iEtheris Sulphur, ^j;
                  Extract Belladonnae, 3ij. m
   Nurses should  take  nutritious diet, and avoid  the abuse of ar-
 dent or fermented liquors, depressing and violent  passions which
 injure the quality of the milk;  and according to some they should
 not expose themselves to the development of a new pregnancy.
 Should conception happen, the child ought to be weaned, as the 
470
PAIDONOSOLOGY.
milk will be deteriorated.   When the period of ablactation or wea-
ning arrives, the woman should have some aperients and moderate
diet.
   Though the finest infants are those reared  solely on the mother's
milk, yet about the fourth month, if the nurse is feeble, it is neces-
sary to allow the infant arrow-root, sago, tapioca, gruel made with
milk, beef tea, soups, he.; a milk diet is also  valuable.   When
dentition commences, the food ought to  be  diminished,  irritation
allayed by mild purgatives with opiates, and the gums should  be
incised when tumefied.  Many children are  necessarily  brought
up on spoon diet, and thrive  very  well.  Beef tea, gravy with
bread, sago, he, should be exhibited, for unless  the  child is well
nourished, scrofula and rickets  will appear.
CHAPTER  IV.
   Management and Diseases of Infants and Children.

   Article 1.—Section 1.  Management of Infants.—The man-
agement of new-born infants, which is necessary immediately after
parturition, has been described in p. 126; we shall now consider
their treatment  during the first months of existence.
   It is a fact that not one young mother in a thousand knows how
to manage a new-born infant;  and few nurses are better informed.
The ignorance  and  opposition of nurses and  young mothers to
medical advice, are almost the whole cause of diseases and mor-
tality of infants.  The clothing of the infant should be  ready be-
fore delivery.   The infant  should be  washed  and  dressed in an
adjoining apartment, in order to avoid noise and bustle in the sick
chamber, as the woman  requires rest and quietness.  The infant
should be enveloped in flannel; its head washed with tepid water
and milk soap, care being taken not to allow the lather to get into
the eyes.   Nurses use  a piece of soft  flannel in performing the
ablution.  The head is to be wiped with a soft napkin, and  a flan-
nel cap is usually applied.  This is not necessary, and is mention- 
MANAGEMENT OF INFANTS.                471
cd as a useless custom.   The body should be washed thoroughly,
and dried perfectly.  In performing this task, all hasty and violent
motion or turning of the infant should  be avoided.   The navel-
#trjng is to be enveloped in  a piece of rag, and a flannel roller
applied over it and round the  abdomen,  which is now fastened
with tapes.   There is a  great  improvement made in the dress of
infants, by substituting tapes  and buttons for pins.  When dressed,
the infant should be placed on its left side, in a piece  of flannel,
in its own cot, or with  the mother.  If we place  it with the mo-
ther, she should be cautious not to have it too warm, as generally
happens, and gives rise to a susceptibility of cold.  The  exposure
of the eyes to a strong light  or the blaze of a fire is highly inju-
rious, and produces ophthalmia, strabismus, and convulsions.  The
infant should not be removed from the apartment, in cold weather,
sooner than a month.   Nurses generally  remove it while the mo-
ther is asleep, and by exposing it to cold, often cause its death.
   Food and medicine.—In a state of nature no medicine is neces-
sary for a new-born infant.   It is a general  practice, however, to
purge off the meconium, or contents of the  bowels, and for this
purpose various purgatives were  employed by  our  predecessors.
The best is half a  tea-spoonful  of castor oil.  The nurses give
syrup of buckthorn, syrup of rue, butter and sugar, almond oil,
and syrup of violets, &c.  &c.  I have  known a nurse apply  a
blister between  an infant's  shoulders,  to clear its complexion."
The  first  milk  of  the  mother purges the  infant.  When she has
none, castor oil  is  the  safest purgative.   The first milk is called
colostrum.   Of all things  we should  caution  women against the
dangerous practice  of overfeeding infants :  this is  the cause of
almost all the diseases of the first month,  more especially of those
of the digestive organs.  The stomach of a new-born infant does
not contain more than three table-spoonful of fluid, and long and
repeated suction of the nipple must be  made before this quantity
can  be obtained.  During  the first  month the infant  should  be
applied to the breast every two hours.  The longer it sleeps the
better.  It should be  kept clean, quiet, and  warm;  and should
have fresh air  without  exposure to cold.   Washing and dressing
are to be performed as mildly as possible, to prevent that continual
screaming which is caused by rough usage.   When the child cries
and screams while dressing, it is a sure sign of mismanagement  on
the part of the nurse.   If the ablution and dressing are properly 
472
PAIDONOSOLOGY.
and quietly performed, the infant will never scream.  It should be
spoken to kindly, and soothed, whenever it evinces signs of fear.
It should never have cordials or opiates, unless ordered by the
medical attendant.
   The derangements of the organs of infants produce a change of
temper, and consequently of the moral  powers.  Besides the in-
humanity and  cruelty of rendering infants prone to peevishness
and passion, they become more liable to disease and to a diminu-
tion of vital power, and consequently their growth is impeded, and
their lives shortened.  The infant should never be frightened nor
treated harshly.  Attention to  this  point will prevent the habitual
screaming during the time of washing and dressing, which is  dis-
tressing to every sensitive mind.  An infant who is roughly hand-
led, will shew every sign of fear when the operation commences;
but it  scarcely ever dislikes to  be dressed or washed when gently
and carefully handled ; indeed it generally enjoys the application
of water.   It is right to mention that tepid water is to be preferred
to cold in winter and spring, more especially if the infant is deli-
cate.   The shock of cold water on  a delicate infant is highly inju-
rious ;  I am certain  that I have  known infants destroyed by this
cause.   The shock given the nervous system, and the abstraction
of heat, will soon destroy  delicate  and  sickly infants or children;
hence  the indiscriminate use of sea-bathing is  now  very properly
condemned.  Mothers  should  be  cautioned against the  use of
soothing syrups, syrups for facilitating the appearance of the teeth,
in a word all quack nostrums advertised in the public papers.  It
is really surprising how much these useless nostrums are sanction-
ed  by  families as if their ignorant  and illiterate discoveries could
possibly have more knowledge  of human diseases than the regular
medical practitioners, who devote their lives to reflection upon the
subject.  All rocking in cots or cradles,  or jogging on the knee,
should be prevented.  The infant should not be spoken to or per-
mitted to look on a light during the night, or to be carried in arms
round  the  room, which  answers no useful purpose; but  on the
contrary, exposes it  and the nurse  to taking cold.  It  should not
be removed from bed at night,  unless for the purpose of feeding or
cleaning ; and it should not be  allowed to remain in a soiled dress,
even when asleep.   During the first two months it should be car-
ried in a horizontal  position, and be neither shaken nor  allowed to
sit up.  The bones of the back are not able to bear the weight of 
MANAGEMENT OF INFANTS.
473
the head, and hence the back will bend when the infant is placed
in  the  sitting  posture, and  " grow out;" the head falls on the
chest or back, just as the child is inclined forward or backward.
It should be placed on the back and on the  abdomen on  the mo-
ther's knees; and the best exercise for  it is gentle friction all over
the body twice or thrice  a day.   It is a most erroneous idea that
an infant cannot  have proper exercise unless  it is  tossed about.
High and violent " tossings" are injurious.   The infant should be
spoken to when awake.   It  throws its  limbs about, which is the
best exercise it can have.
   Early attention should be paid to cleanliness; soiled  napkins
irritate  the skin, and  produce cold.  If the  infant is  accustomed
to be "held out" at regular times, it will  soon learn to make  its
wants known, and will express uneasiness even in  its sleep.   Its
dress should be changed as often as soiled;  it should be  washed
with a sponge and warm water,  and afterwards "powdered," even
though  there is no sign of excoriation.  When  the mother  can-
not suckle or employ a wet-nurse, the food should be  as  like her
milk as possible.   One part of  fresh cream, with four or six of
water, with a little sugar, is the best substitute for the mother's milk.
The suckling bottle,  with a teat, is to be used in these cases.  The
superiority of cream  over  milk  arises  from its being  destitute of
coagulum or curd, which a young infant can  seldom digest.  The
mother's milk  at  first chiefly  consists of cream  and  water.  A
moderate tea-cupfull of  milk is  a  sufficient  meal for  a child  six
months old ; and it is of great importance that it should be admin-
istered  by  suction,  as in this  way  the salivary glands stimulated.
Pouring the food down the throat by means  of a boat or  spoon, is
a most unnatural and injurious proceeding.   It is a great  error to
suppose a  child derives nourishment from the quantity of  food that
is given, as the stomach can  only  act on a small  quantity.  It is
highly improper to give solid food to a  toothless child, as it will
disorder the stomach and bowels, induce acidity, colic, griping, and
bowel complaint.   Many mothers err on this point, in giving minced
animal food, which is not sufficiently comminuted  or  divided  for
the weak stomach of an infant or child.   Bread and milk given in
this way is also objectionable  Liquid food alone,  and  that by suc-
tion, should be given for the first eight  months.  The child should
be in the open air as much as possible when the weather  permits ;
but uo risk  is to be run under the idea of hardening it by exposure
        60 
474
PAIDONOSOLOGY.
to cold.   Fatal inflammation of the lungs frequently follows this
practice.   When  the child begins to  walk, it should be raised by
placing the hands on the sides under the arms.   It is injurious to
raise it by the arms, or  to  allow  it to stand to soon.   The rule
upon this point is,  to be guided by the natural efforts of the child.
During infancy, when the woman has no milk,  we may advise, in
addition to the articles of food already mentioned, veal or mutton
broth, beef tea deprived of fat, and slightly  thickened with oat-
meal ;  the preparation of wheat, called farinaceous powder, biscuit
powder,  rice,  sago,  he.   These must be changed according as
they affect the infant.   Sometimes every  form  of diet fails, the
child becomes weaker, and a wet-nurse must be provided.   The
rule as to the selection of a nurse is,  that the  woman should be
healthy, and the period of her delivery should be as near that of
the female whose child she is to nurse, as possible.  The milk 'of
a woman six months after delivery, is not fit for a new-born infant.
The quantity of food taken by nurses should be increased, and the
diet should be nutritious.
   Weaning.—The period  at which an infant should be  removed
from the breast must be determined by the strength and size of the
child ;  it will vary from fifteen to eighteen months.   Some women
in high life wean their children at the end of six months; but the
lower classes not before the second or third year.  The poor adopt
the latter plan upon the grounds of avoiding pregnancy ; a condi-
tion that seldom happens during suckling.   Weaning ought to be
a gradual process,  and should never be commenced until after the
first teeth have appeared.   The breast should be  gradually with-
drawn, and the artificial food already mentioned, given during the
day.   It is a bad plan to allow the breast and  food at the same
time.  The child should be weaned, if the pregnancy or menstru-
ation occur during  suckling.
   Dress of Children.—It is highly important that there should be
an equal distribution of heat over the whole body, and to  secure
this, the infant ought always to wear a long flannel  dress for the
first four or five months.  Short clothes are worn after the third
month, when the child shews an ability to exert its limbs.   Wool-
len socks or stockings are to be worn at this time,  and care must
be taken to remove them when wetted or  soiled.  There is no
greater error than  exposing children  to cold, in order to  harden
them, as  it is termed.   There is  no  doubt that a greater number 
EFFECTS OF MEDICINES ON INFANTS.         475^
of the children of the poor die under scsnen years of age than  of
the rich, and this arises  principally from exposure to cold.  At all
times, exposure of infants to sudden changes of temperature is dan-
gerous.   It therefore follows, that the child should be  kept suffi-
ciently warm at all times, and its dress increased even  in summer,
if the weather is  inclement.  The dress should be loose and wide,
and secured by tapes instead of pins.  The limbs must be left  as
free as possible.   The head must not be kept loo warm; while
the chest and abdomen  cannot  be kept too much so.
   Exercise.—Every encouragement should be given to the volun-
tary exertions of an infant; but  no  force  is  to  be employed  to
make it walk.   It should be allowed to roll on the bed or floor, and
in this way will make exertions adequate to its strength.   The ef-
fect of placing infants upon the feet too soon, is irremediable defor-
mity.  The child should be in the open air as much  as  possible,
provided the weather admits; as we  often  observe  sickly infants
restored to health by country air, after all medicines had been tried
in vain.

Section 2.—Rules  for the  Administration  of Therapeutics in
                          Early Life.
    Blood-letting.—The best rule as  to the use of this remedy is
that  laid down by Dr.  M. Hall, to watch  the appearance of the
countenance, and if signs of collapse appear, we must  arrest the
flow  of blood.   The abstraction of  blood in cases of infants and
children until fainting occurs is the worst practice that can be im-
agined, as convulsions or death may be  produced.  The greatest
 prostration, nay, death  itself, may follow the  application of a few
 leeches.   Sometimes the hemorrhage cannot be arrested, unless
 by pressure or caustic.  Hence  leeches should be applied over
 those parts under which bony  surfaces  exist, in order to admit of
 compression, which should be made with lint and bandages.   It is
 to be recollected, that the loss of blood  from a single  leech bite
 has caused the death of an infant. No discretionary power should
 be left  to  nurses.  We  are  always to bear in mind the  rapidity
 with which  infants or delicate  children  sink from exhaustion, and
 the difficulty of  restoring them.   Bleeding can only be effected in
 young  infants by leeching ; and we must carefully watch the coun-
 tenance, examine the temperature of the  extremities, and the state
 of the respiration.  Some writers are of  opinion, that blood may 
476
PAIDONOSOLOGY.
be taken in the  following proportions  from infants and  children;
but I am convinced we must be guided more by the  effects than
by the quantity.   During the first month,  it is said that an ounce
may be taken ; from the second to the fourth month, two ounces;
from the fourth to the eighth  month, from two  to  three ounces;
from the eighth to the twelfth month,  from three to four ounces;
from the twelfth to the eighteenth, from four to  five ounces;  from
the second to the third year, from eight to ten ounces; and about
the sixth year, from  eight to twelve  ounces.  The veins on the
back of the hand or instep are usually opened in young children,
and the limb immersed in a basin of warm water.
  Blisters and  Irritants.—It is well known that  the skin of an
infant is'peculiarly irritable, and therefore great caution must be
observed in the use of blisters, sinapisms,  stimulating  liniments, or
the antimonial ointment, now so much applied.   It often happens
that inflammation, mortification,  and  death, are induced by blisters
and external irritants.  The surface  of a blister should be covered
with thin muslin; and it need never be applied longer than three
hours; in fact, until  the skin is reddened.  It  is  unnecessary to
cause vesication.   Blistering ointments is  often  adulterated  with
various acrid substances, and  hence  its deleterious effects on in-
fants.  I have seen a blister on  the  chest  followed by sloughing,
and an  aperture  from over  the epigastrium, which exposed the
subjacent viscera.  A  mustard fomentation should  not be applied
longer than five or ten minutes, and  a sinapism  from  a quarter to
half an hour.  These remedies are applied in inflammations of the
brain, chest, and abdomen.   They should be removed as soon as
they produce  pain.
  Cathartics.—From  the natural  irritability of the stomach and
bowels of infants and  children,  great care must be taken in using
purgatives. Diarrhoea is much more easily excited than controlled;
and if it becomes excessive, may induce great exhaustion, stupor,
and hydrocephaloid affection.  In  such cases the  powers of life
must be supported with arrow-root and a few drops  of brandy, aro-
matic spirit of ammonia, beef tea, he.
  There is now  a most injurious practice prevailing in the profes-
sion, that of administering continual doses of calomel, or hydrargy-
rum cum creta to infants and children.  In diseases of young and
old, all the disciples of the intestinal school  employ mercury. Eve-
ry one knows that a person under the influence of mercury is more 
EFFECTS OF MEDICINE ON INFANTS.
477
susceptible of cold than at any other time, and hence the diseases
excited by cold are more readily induced.   Nevertheless, we ex-
hibit mercury to  infants, and thereby expose them to inflamma-
tions of the brain, chest, and abdomen.   It is therefore  evident
that this  practice  is injurious, and that we  should  combine some
aperient  with,calomel or other mercurial preparations, to  prevent
their specific action on the system.   Ptyalism of infants  is often
followed  by sloughing of the gums  and cheeks ; and this I have
known to occur after the use of mercury in hydrocephalus.  Mer-
cury is only useful when we wish to  excite the liver or mesenteric
glands, and even  then it should  be  given  in alterative doses, as
one-sixth or one-fourth of a grain, as we know that  the best effects
on  the alvine secretions are caused by alterative doses of  this me-
dicine.   Dr. Philip has ably proved, that  the smallest  doses of
pil. hydrarg. produce more improvement  in the alvine dejections,
than the large quantities  usually given.   I have  repeatedly ob-
served, that a grain of calomel given every other night to children,
whose intestinal  evacuations were depraved, produced discharges
of  various colours in  succession.  As soon  as the stools are of a
rhubarb  colour, the mercury may  be omitted.  Calomel should
not be given as a purgative ; magnesia, rhubarb, senna, compound
powder of jalap, or castor oil, are preferable.
   Emetics  are to be used with caution, from the  gastro-intestinal
irritation  usually present,  and the antimonial  medicines  may do
much  mischief.
    Opiates.—The preparations of opium should  be used  with the
greatest  caution in cases of  infants  and children.   I have known
one drop of the  liq.  opii  sedativ.  narcotise an infant.   Mothers
and nurses  should be informed of the dangerous properties of all
" soothing syrups," and cordials, such as Dalby's Carminative, the
Vegetable Soothing Syrup for Cutting the Teeth,  Godfrey's Cor-
dial, diacodium, syrup of poppies, &c.  These things should never
be administered,  except by medical practitioners: and if proper
attention is paid  to diet, and judicious treatment employed during
dentition, opiates will be rarely necessary.   There is  scarcely a
day in which I do not point  out to  my pupils, infants labouring
under the influence of opium ; and experience enables me to aver,
that thousands of them in this metropolis  are destroyed  annually
by the improper  use of this  medicine.  Where an infant  is narco-
tised it cannot take food ; absorption goes on, emaciation and death 
478
PAIDONOSOLOGY.
soon follow.  During the first month, two drops of tincture of opi-
um, or half a drachm of genuine syrup of poppies, is the largest
dose that can be given with safety.

                Section 3.—Diseases of Infants.
   It is much  to be regretted, that there is no complete treatise in
our language on diseases of infants and  children.  Every writer
since the  days of  Underwood has implicitly followed the arrange-
ment of that writer;  and hence it is that we have not a standard
work in this country; one  that is not a century behind those of
other nations.   The truth  of this position  will  appear after the
perusal of the succeeding pages, which merely contain a catalogue
of the diseases  under  consideration ; but suggest an outline for a
perfect work.
   The diseases of infants  may be divided into,  1.  Intra-uterine;
2. Extra-uterine.   The first class comprises hereditary diseases,
as syphilis,  scrofula,  rachitis,  mollities  ossium, pertussis, variola,
and according to  some, gout and phthisis ; lesions of continuity,
of situation, of volume, of number, of coloration, and of func-
tions.   The second class comprises diseases dependent on parturi-
tion ;  1.  internal, as  asphyxia,  apoplexy, cerebral  congestion,
debility ;  2. external, as elongation of the head, livid tumours on
the scalp, contusions, luxations,  fractures,  and wounds; 3.  con-
genital, as occlusions of natural openings ;  of the eyes, ears, nose,
lips, anus, vulva,  vagina, prepuce, and urethra ;  4. union of cer-
tain organs;  of the tongue to the gums or lips, tongue-tie, of the
fingers and toes,  penis and scrotum;   5.  disunion  of organs,
hare-lip, cleft palate,  cleft  uvula; epispasdias, or opening of the
urethra on the dorsum penis ;  and hypospasdias, or opening of the
urethra on the inferior surface of the penis, between the natural
orifice and the scrotum ;  6. excess, or redundancy of parts,  as of
fingers, toes, excrescences,  he.;   7. defect of organs, of fingers,
toes, head, eyes, ears, arms, he.; 8. dropsies, as hydrocephalus,
hydrorachitis or spina bifida, ascites, hydrocele, infiltration of the
genitals;  9. hernia, encephalocele, omphalocele, bubonocele, os-
cheocele, he.;   10.  irregularity  of parts, as  obliquity of the
head, high shoulders, claudication, club feet, vari, valgi, pes equi-
nus, distortion of  the extremities, strabismus,  cataract;  11. vari-
ous marks on  the skin, secondary syphilis,  discoloration of the
skin, desquamation of the cuticle, various diseases of  the skin, in- 
DISEASES OF INFANTS  AND CHILDREN.
489
eluding inflammation and  absence of that tissue.   The whole of
the diseases assigned to both classes are further divided into medi-
cal and surgical.
   The medical  diseases should be considered in the natural order
of functions.
   Digestive Organs.—The diseases of this system are retention
of the meconium, constipation, colic, flatus, acidity of  the gastro-
intestinal tube,  hiccup,  diarrhoea, lienteria, prolapsus  ani, vomit-
ing, tormina, dentition  and its accidents, worms, malformations,
congestion or inflammation of the mucous membrane of  the cheeks,
stomatitis, aphthae, glossitis, diseases of the salivary glands, throat,
oesophagus and  stomach,  indigestion, erythema, follicular disease
and softening of the stomach ; malformation, inflammation, ulcer-
ation, gangrene, haemorrhage,  invagination of the  intestinal tube,
enteritis, spasm of the  colon, ramollissement, excoriation of the
anus, cholera, peritonitis,  and  tabes, diseases of the liver and uri-
nary organs; calculus, incontinence, and retention of urine.
   Diseases of  the Heart and Blood Vessels.—Pericarditis.
   Diseases of  the  Respiratory  Organs, are of the  nose, nasal
fossae,  coryza,  laryngits,  tracheitis, croup, oedema of the glottis,
bronchitis, pulmonary apoplexy, pneumonia, chronic catarrh, pleu-
ritis, oedema of the  lungs, pertussis, intra-uterine and extra-ute-
rine asphyxia.
   Diseases  of the  Cerebro-Spinal  System, are  malformations,
hydrocephalus, hernia  cerebri,  acephalous  cases, congestion of
 the brain  and medulla spinalis, arachnitis, convulsions, chorea, te-
tanus, epilepsy, spasmodic constriction of the  chest  and larynx,
cerebro-bronchitis or pertussis, typhus,  risus sardonicus, agrypnia
or insomnolence, panaphobia, or night-fear.
   Diseases of the Skin, are Icterus, erysipelas,  cutaneous  efflo-
rescence,  redness of genitals, excoriations, suppuration behind the
ears, haemorrhage,  inflammation or fungus of the navel, pernio,
 pediculi, porrigo, crusta lactea, tinea, strophulus, lichen, psoriasis,
ichthyosis, and the numerous other  cutaneous diseases described
by authors.
   Diseases  of the Senses, are blindness, cataract,  amaurosis, stra-
bismus, dumbness, and  deafness.   Many other diseases of infants
might be enumerated, especially  those included in the class loca-
 les by Dr. Cullen.
   It would be  impossible  to describe  the  treatment  of infantine 
480
PAIDONOSOLOGY.
diseases in a work of this kind;  and 1 am therefore restrained to
a few comments upon those of frequent occurrence.  We shall
consider them in the physiological order of functions.
  Lesions of Circulation.  Intra-uterine asphyxia.—The treat-
ment of asphyxiated infants has  been described in the article on
the Management of  New-born Infants, p. 172
  Anemia.—Infants may be born anemic from separation of the
placenta or rupture of the umbilical cord, or from the ligature ha-
ving slipped off the  cord.   The  pallidity of the infant, the cold-
ness of its body, and the presence of syncope, shew the existence
of this condition.  The  treatment consists  in the  application of
warmth,  by baths, blankets, he., by friction  of the spine, limbs,
and trunk, with ammoniated liniments; and  in extreme cases, of
insufflation or artificial respiration, at the same time administering
brandy, arrow-root, beef-tea, he.  When every thing fails, trans-
fusion has been proposed by Heroldt.  The syrup of sulphate of
quinine, with brandy in arrow-root, nutrient clysters and baths, are
advised by foreign writers.
   Cynopathy,  or  Blue  Disease, is a bluish  colour  of the skin,
which may continue to  the adult age.   There is no remedy for
this singular malady.
  Fever.—New-born infants are  liable to symptomatic fever from
a variety of diseases, which is to  be cured  by removing  the pri-
mary complaint.
  Phlegmasia—Inflammations.—The capillary circulation may
be accelerated, and inflammation  in the  various tissues produced.
The treatment  in all inflammations is that usually employed, with
the exception  of general bleeding.  The remedies must not be
urged too  far.   Under this head we are to include the various cu-
taneous diseases.   These may be divided into the exanthematous
(measles,  scarlatina,  small-pox), such as are attended with fever;
and into the chronic, including all the classes of writers on  diseases
of the skin.  In treating the exanthemata, we are to reduce fever
by purgation and diaphoretics, which are generally successful; but
should there be  signs of cerebral congestion or  pulmonic inflam-
mation, either from  the  non-appearance of the eruption at the
usual period, or from  its repression, we must apply  leeches to the
head or chest, then sinapisms to  the feet and  warm bathing, with
cold to the head at the same time.  The eruption will in general
appear under this treatment.   In a case of small-pox, which I at- 
INFLAMMATIONS AND FEVERS.
481
tended with  Mr. Appleton, in Baldwin's Gardens,  the child ap-
peared to be comatose.  The  parents objected to leeches to the
head, cold lotion to the scalp, a blister to the neck, and sinapisms
to the feet.   After  much  reasoning, they consented.  In a  few
hours the little  patient was  perfectly relieved,  and was covered
with variolous eruption.  Another child in  the family  had  the
same disease without proper maturation.  It  had suppuration of
the elbow, wrist, knee, and ancle joints, without the slightest mark
of antecedent inflammation.   It was kept alive for a fortnight by
quinine and  nutriment.  Cerebral congestion  will appear  when
the eruption  of  scarlatina is suppressed.  Two children died so
suddenly from this cause near White-Conduit  Fields, that a coro-
ner's inquest  was held to  determine whether they  had not been
poisoned.  Mr. Whitmore and myself examined the bodies.  Scar-
latina anginosa,  or maligna, is a most dangerous and fatal disease.
This is contrary to what is stated in books; but any physician of
observation will  confirm my statement.  We often see the simple,
cynanchical,  and malignant species in the same family, some hav-
ing it very slightly,  and scarcely indisposed,  and two or  more
destroyed  very  suddenly.  I  have seen numerous  cases of this
kind.  It is astonishing how  suddenly anasarca  supervenes after
scarlatina.   I was  called to a case in Gray's-Inn Road, the  pa-
tient having  been convalescent for more than  a month, who after
a hearty dinner,  went out to walk on  a cold spring day, at two
o'clock;  he returned in a short  time, and was completely anasar-
cotss; convulsions set in, and in  despite of copious depletion, local
and general,  abrasion of the scalp, cold  applications, blister to the
head, sinapisms  to the feet, and free purgation,  he was dead at
two o'clock next morning.  His brother, also an adult, became
anasarcous and ascitic under similar circumstances; but the follow-
ing remedies cured him in a few days:
     R. Pulv. Jalap. Comp.,  3vj;
       Pulveris  Digitalis,       ^
       -------Scillae,          > sing, gr xij ;
       Hydrargyri Subm.,     J
       Pulveris  Antimonialis, gr. vj ;
       -------Aromatici, 3j :
  in chartulas xij. divide, ex quibus capiat unam mane nocteque
nisi alvus nimis soluta sit.
        61 
482
PAIDONOSOLOGY.
 Friceter superficies abdominis Ung.   Antim. Tart drachma, mane
 vespereque, donee erumpant pustulae.
   Imperial should be  the ordinary drink,  and some mild diuretic
 mixture employed, unless the urinary secretion be sufficiently co-
 pious.   I have found  this  combination of the greatest  benefit in
 all forms of dropsy, which are  generally removed  by  it,  unless
 there is some extensive disorganization in the system.  It acts up-
 on the bowels, kidneys, and  skin,  increases  the functions of all
 these parts, diverts the circulation from  cellular and serous mem-
 branes, and thus enables the absorbents to remove the effused fluid.
 In old persons, tonics will be used at the same time with benefit,
 and the diet should be nutritious.   When children are the subjects
 of anasarca, the same combination in proper doses will in general
 remove the disease.   During convalescence after the eruptive fe-
 vers,  the alvine  secretions  should  be  carefully attended to, and
 mild purgatives with mercurials employed.  In scarlatina angino-
 sa there is intense inflammation of the fauces often extending into
 the trachea, which in addition to antiphlogistic treatment, imperi-
 ously requires leeches  to the throat, followed by blisters, ammoni-
 ated oil, or a light sinapism,  according  to the urgency  of symp-
 toms.   When  there is cerebral  congestion,  it is to be treated on
 ordinary principles.  As soon  as ulceration of the throat, with
 difficult deglutition and respiration appears, some recommend gar-
 gles with muriatic acid and myrrh  as the best.   I  have  found
 chloride  of soda in solution, properly sweetened, produce the best
 effects, when the foetor of the  breath was intolerable to the by-
 standers.  It can be applied in infants by securing a piece of lint
 on the shank of a spoon, or on a  piece of wood, and if any  of the
 gargle is swallowed it can do  no injury.  When typhoid symp-
 toms appear, the  sulphate of quinine, ammonia, diffusible stimuli,
 in a word, the usual  treatment must be employed.
   In eruptive diseases  unaccompanied  by fever, I have found a
mild purgative, with alternate  doses of calomel and antimonial,
powder,  remove nine-tenths of the cases which came before me.
Proper attention  to the digestive  organs is of  the utmost impor-
tance  in  treating  chronic diseases of the skin.  My pupils have
been often surprised at the disappearance of cutaneous  eruptions
which had resisted a host of external remedies, by the plan I have
mentioned.  The hydragyrum c. creta  with  rhubarb, is strongly
recommended in disorders of the digestive organs in children ;  but 
INFLAMMATIONS.                       483
I have seen much  better effects from  alternate doses of calomel
with rhubarb, antimonial, and aromatic powders.   This combina-
tion is generally efficacious,  in correcting depraved secretions, as
when the alvine dejections are of a green, brown, white, or black
colour.  The following formula may be given to a child between
a year and a half and three years old, the quantities increased ac-
cording to the strength and constitution.
        R.  Hydragyri Subm., gr. vj ;
          Pulveris Rhei, 3j;
          ---------Aromat., 3ss;
          Sacchari Pur., (51;
in chartulas vj. divide, quarum sumatur  una,  singulis vel alternis
noctibus.
   Syphilitic Eruptions, of  various kinds, appear on new born in-
fants  of a copper colour, and especially about the  nates and geni-
tals.   The  infant  is emaciated, and its skin shrivelled, as in the
last stage of tabes mesenterica.   The exhibition  of mercury  to
the mother will remove the disease, and in a short time the erup-
tion declines, and  the  infant improves  in health and strength.   It
is seldom necessary to administer mercury to the latter.   It is as-
tonishing how rapidly improvement  takes  place  in these cases.
The  milk of a nurse affected with syphilis will not infect a healthy
 infant.  A  case in  point  is related by Mr.  Lawrence in his lec-
tures.   The nurse was infected with syphilis  by the mouth of  an
 infant which was committed to her care.   She kept one breast for
 this infant,  and the other for  her own ; but though  she had well-
 marked secondary symptoms,  her own  child remained free from
 the disease.
   It  is  scarcely necessary to mention, that  the  lips of an infant
 may  be exposed to the matter of chancre in passing the portal of
 life, and may consequently  infect  every woman to  whose  breast
 they are applied.
   Erythema and  Erysipelas may appear on different  parts of  in-
 fants.   The latter is highly dangerous where it attacks the geni-
 tals,  as stated  in a former  article,  p.  78.   It appears about the
 umbilicus genitals and head.   It  is highly dangerous in the latter
 cases, and  often proves fatal.  The treatment should  consist of
 aperients, diaphoretics, fomentations, he. as in ordinary cases.
   Coryza—Inflammation of the mucous membrane of the nose
 is exceedingly  frequent from exposure  to cold.   The infant is said 
484
PAIDONOSOLOGY.
to have taken cold, and has frequent fits of sneezing.   It  cannot
breathe through the nose, and has been suffoeated.  It is obliged
to respire through  the  mouth.   The nose and  throat are often
inflamed.
   Leeches have been applied to the nostrils, and even slight scari-
fications  made as in cases of adults.  In general, however, an equal
moderate temperature, with the  application of oil  of  almonds to
the inside of the nostrils, removes the disease.   Nurses call  this
disease  the  " snuffles," and perform the disgusting operation of
suction of the nose to clear the nostrils.
   Ophthalmia neonatorum.—Infants are generally seized  with
slight inflammation of one or both eyes, which usually disappears
in two or three days by ablution with tepid milk and water. When
the inflammation is severe,  and does not yield to this plan, and there
is a muco-purulent discharge, a leech should be  applied to each
temple, and an aperient administered.   The best lotion for wash-
ing the eye  is composed of one  grain of oxymuriate  of mercury
and eight ounces of water,  and after removing the discharge,  the
conjunctiva should be touched with a camel-hair pencil, moistened
in a solution of four grains of nitras argenti, or six grains  of  sul-
phas cupri dissolved in an ounce of distilled water.   The ointment
of red precipitate  is to be applied to  the eye-lids at night  to pre-
vent them from  adhering to each  other.   Such is the mode of
cure proposed by Mr. Mackenzie  of  Glasgow.   This  plan effects
a cure in a few days, and is assisted  by a  blister to the  neck in
bad cases ;  but sometimes  the disease  continues for weeks in de-
spite of all remedies. When the disease is diminished, and becom-
ing chronic, a lotion of alum and rose-water will  remove it.  The
following formula  is very effectual—six grains of  alum and  two
ounces of rose-water.  The vinum opii is an excellent remedy.
   When the inflammation is  intense, with  tumefaction of the lid
and purulent discharge from the eye we have purulent ophthalmia
of  authors.   This form  of disease arises from the  application of
gonorrhoea! or leucorrhceal matter to the eyes, and is often destruc-
tive of  vision, unless properly managed.   The  eyelids are enor-
mously  enlarged,  and spasmodically closed; and if separated, a
jet of greenish-yellow purulent  fluid takes  place.  The cornea is
muddy and  the conjunctiva is highly vascular.   The mischief ex-
tends to  the globe of the eye, and causes an effusion of pus (hy-
popion,) softening or ulceration  of the  cornea, escape  of the hu- 
INFLAMMATIONS.
485
mours and crystalline  lens, or  the latter becomes opaque, and the
infant is deprived of vision, especially when both the eyes are af-
fected, or deprived of life  by  the  excessive pain and marasmus.
The treatment recommended by Mr. Guthrie in purulent ophthal-
mia, is the application of the ung. argent,  nitrat., or black oint-
ment.   His formula is as follows:
              R. Argenti  Nitratis, gr. x;
                Cerati Cetacei, 1 drachm ;
                tere intime et adde gradatim,
                 Liquoris  Plumbi Acet. m. xv.
   The mode of application requires  attention.  The eye is to be
washed and wiped ;  the  eyelids  everted,  and the ointment ap-
plied with  a camel-hair  pencil to the conjunctiva.   It is  said
that the greatest improvement takes  place next day, and that the
disease  is cured in a very short time.   Mr. Mackenzie has found
the former plan succeed, and  thinks this  remedy unnecessary  in
most cases.   I have been  informed  by several of Mr. Guthrie's
pupils who  attend  my lectures, that  the nitrate of silver ointment
is in general a most efficacious remedy.   I have found it so in  a
few cases;  it does not produce so much pain as I expected.
   Leucorrhoza.—Purulent discharge from the genitals of female
infants has been already described in the article on Female Viola-
tion, and  is analogous to the  disease last described as arising from
the same cause (Duges,) and  in the  same tissue.   When the dis-
charge  is white, it  disappears  spontaneously in a few days;  but
when greenish or yellow,  the inflammation is more intense.   Ac-
cording to Sir Astley Cooper, the preputium clitoridis  is the seat
of the  malady; and black wash  (calomel and lime water,)  with
cleanliness,  is the best remedy.  I have  repeatedly  seen  it on
young infants, and sometimes on two or more children in the same
family.   It is interesting in a medico-legal point of view to deter-
mine whether it is contagious.   It appears  in  healthy as well  as
diseased infants and  children.   According  to  the French writers
it may be expedient to  know  that purulent leucorrhoea produces
simple gonorrhoea in the male; but it is difficult to suppose a fe-
male infant  can come in contact with  another, and communicate
the disease.  Dr.  Darwall has seen three  children, who he thinks
had taken the disease from each other.  The oldest was only five
years of age, the second was  three,  and the last was an infant at
the breast.   He, therefore, advises that the affected child should 
486
PAIDONOSOLOGY.
lie alone.  (On Diseases of Children, he. 1830.)   Much more
evidence is required, in my opinion to confirm the infectious nature
of the disease.
   Aphtha, Thrush; Muguet, or White Millet of the French.—
This  disease consists of small  white  spots, or vesicles upon  the
tongue, cheeks, and throat,  which may ulcerate and assume a red
or black colour.  It is said to arise from difficulty experienced by
the infant on taking the breast, from the milk of an old nurse, from
derangement of the digestive organs ; and lastly, from syphilis.  It
may be accompanied with fever  or diarrhoea, or ulceration  about
the anus.  According to Mr. Cooke and others, there is erythema
in some portion of the gastro-intestinal mucous membrane.  Du-
ges asserts that the disease is not observed below the cardiac ori-
fice of the stomach,  while  others contend it extends from  the
mouth to the anus.   Experience has convinced me that both par-
ties are right.   The examples of the disease  in  the stomach and
intestines are rare (Billard, Lelut, Duges.)   With respect to  the
treatment, a good nurse, plain food, and good  air, are of  primary
importance.  The mel boracis,. Armenian bole and honey, applied
to the mouth with moderate  purgation, constitute the treatment.
The hydrargyrum c. creta with rhubarb, is lauded  by some;  but
I am  convinced that calomel, rhubarb, and  magnesia, with pure
sugar are better remedies.  When there is much debility, the  syrup
of quinine is of the utmost value.  The chloride of soda in solution
sweetened, is highly beneficial.  In general the disease  is mild
and may arise without any evident cause.  All remedies may fail
and then change of air and a proper diet may effect a cure.   Dr.
Darwell thinks  the diet  of the nurse should be attended to.  Oth-
ers advise leeches, and afterwards stimulating liniments to  the sur-
face of the abdomen.   The  diet of the child should consist of  the
vegetable or animal jellies.
   Gastritis,  Enteritis, Peritonitis.—These  inflammations may
exist  with  or without  aphthae.  There will  be  redness of  the
tongue, fever, vomiting  and  diarrhoea,  and sometimes tympanites.
These diseases  are  found to  exist in some degree in  the  infantile
remittent fever of children.   The autopsy will shew erythema, in-
flammation, or ulceration in some part  of the  intestinal  tube.   It
is, therefore, manifest,  that leeching and counter-irritation on  the
abdominal  surface  are  requisite, with  warm-bath, barley-water,
weak broths,  beef-tea, &c.   When diarrhoea  is urgent, the  chalk 
INFLAMMATIONS.                   487
mixture, with  proper doses of the  sedative preparations of opi-
um  are  of infinite service;  and when great  prostration  of the
vital powers appears, we must support the strength with  arrow-
root,  and a few drops  of  brandy, or aromatic spirit of ammonia,
beef-tea, he.   When  the disease becomes chronic, a nutricious
and mild diet,  with alterative doses of mercury, rhubarb, and anti-
mony, are of essential service.
   Bronchitis, Pleuro-pneumonia.—The application of cold to the
mucous membrane of  the lungs and  air passages, induces catarrh,
which is sometimes epidemic; this is called " common cold." The
first symptom  is frequent sneezing, followed  by a discharge of mu-
cous from the  nose.  The infant sleeps with its mouth open, and
cannot suck from  the obstructed state of the nostrils.  The respi-
ration is sonorous, and there is strong wheezing during sleep, and
at all times if  we  apply the ear to  the chest.   The  difficulty of
breathing is increased in proportion  as the inflammation extends
into  the mucous membrane of  the lungs.   A young  infant or a
child of a few months old, cannot  expectorate.   It coughs, and
gets up the mucous into the pharynx, and  then swallows it.  The
mucous accumulates in the stomach, and is  discharged by vomit-
ing or by diarrhoea.  Hence the practice of exhibiting emetics and
aperients.  The child dies  of exhaustion,  from  inability to take
the breast.  A fatal termination may occur in three days; the re-
spiration becomes  impeded; signs of cerebral congestion appear.
There is a lividity in  the countenance, which led Underwood to
style  the disease " the malignant snuffles."  The danger of this
complaint arises from the infant not taking  sufficient food, the blood
not being properly vivified in the lungs, or coma  with  effusion in
the brain, and  convulsions taking place.
   In  the treatment of this disease, we must commence by opening
the bowels with castor oil, magnesia,  he.;  then applying two or
three leeches to the chest, under the clavicles, which produce the
best effects; and should the case be  urgent, a blister is necessary.
The following mixture is also of great use  :
              R.  Syrupi  Simplicis, 10 drachms—12;
                  Oxymellis Scilla:, | drachm—1;
                 Mucilag. Acaciae, 2 drachms;
                Acid. Hydrocyanic, m 1 ;
in sit  mistura.  Dosis coch. min. 2da-  vel 3a- q. q. bora. 
488
PAIDONOSOLOGY.
   A few drops of vin. antim. may be substituted for the hydrocy-
 anic acid, in mild cases.
   Pneumonia, and  Pleuro-pneumonia,  are  analogous in their
 symptoms and treatment with  catarrh.  Pneumonia attacks new-
 born infants more freqently than children;  is generally considered
 "a cold," is neglected, and hence it is so often fatal.  Auscultation
 affords the only certain diagnosis, the crepitating rale, whereas the
 mucous rale, is characteristic of  catarrh.  The respiration is more
 difficult, the cough less troublesome, the fever more intense, and
 the face more  livid, in  the disease under  notice.  The child cries
 when  it coughs, the countenance becomes livid, the nostrils dilated
 during inspiration, the  head becomes  affected,  and death  takes
 place from the third to the seventh  day.   In general the posterior
 part of one lung is affected.  On dissection the lung will be found
 hepatised, and the pleura covered by a false membrane.
   The treatment  consists of leeches to the chest, purgatives, dia-
 phoretics, blisters, and  mustard  pediluvia.   Infants and children
 do not bear large  doses of tartarized antimony, in consequence of
 gastro-intestinal irritation, which  is generally present;  and also,
 from the frequency of softening of the coats of the stomach. Warm
 bathing is sometimes used to equalize the circulation.
   Extra-uterine  Asphyxia.—Infants have  been destroyed by
 strangulation,  suffocation,  and  submersion, as fully appears in a
 preceding article on  Infanticide,  p. 160.   In all these cases we
 should free the air passages, expose the infant to fresh air, employ
 baths,  friction, errhines, and all  means as in anemia, see p. 480;
 sinapisms, ammoniacal  frictions, vinegar clysters, he.  I have ful-
 ly described the  morbid  appearances in  my Manual of Medical
Jurisprudence.
   Cynanche Trachealis-Croup.—This is the tracheitis  of foreign
 writers, and comes on like catarrh; but is soon followed by a crow-
 ing or croupy  respiration, something similar to the crowing of a
 young cock.   The respiration is difficult, the face  becomes livid
cerebral  congestion appears and destroys  life, or death happens
from suffocation.   On dissection, we find inflammation of the mu-
cous membranes of the trachea  and sometimes of the bronchi, or
a false membrane  is formed of considerable thickness.   The dis-
ease comes on suddenly, and  often proves fatal in twenty-four
hours.
  The  indications of treatment  are, to arrest inflammation, and 
            DISEASES OF THE RESPIRATORY ORGANS.       469

thus prevent the formation of the false membrane.  To effect this
purpose, we should apply  three or four leeches along the trachea,
open a vein in the back of the hand, or on the  instep, and im-
merse the limb in a basin of warm water, or open the jugular vein.
We next exhibit an emetic of antimonial wine, and put the pa-
tient in  a warm bath, and  after his removal apply a blister in the
course of the trachea.   Depletion is only useful in the first stage
of the disease.   When this  has  passed, our chief dependence is
to be placed on  large doses of calomel, as recommended by Dr.
Hamilton.   He  states  that forty cases were cured by it, and that
it is effectual  if  given  before  lividity of the  face  appears.   It
should be continued in the dose of a grain  and a half  every hour
to a child six months old, and four-grain doses every  hour may be
given to a child  two years old,  until vomiting, purging, or green
dejections  are produced.   It was given to the amount of one hun-
dred and eighty grains in one case with success.  Its mode of in-
fluence on croup is not determined ;  some say it stops the effusion
of  lymph, as in  iritis; and others,  that  it  promotes  absorption.
Perhaps its excitation of the liver, and other digestive organs, di-
verts the circulation from  the trachea.  I have  known it succeed
when every other had failed.  It  sometimes  causes salivation.   I
would not, however, trust  to it solely, but employ the other rem-
edies at the same time.    I know  a  practitioner  who  never uses
any remedy in croup but  repeated doses of calomel and antimoni-
al powder, and  seldom loses a patient.  Mackenzie recommends
the application  of a solution of nitrate  of silver to  the internal
fauces,  as  he says fibrin is  first deposited  there, and then descends
into the trachea.   This practice is not followed.   Bretonneau ad-
 vises a  solution  of alum, which is much safer.   When suffocation
is threatened, bronchotomy is to be performed.  The last named
writer advises us  to pass   a piece of nitrate  of silver through the
opening, and  apply it to  the  false  membrane in  those  cases in
 which the latter cannot be  extracted.  Vomiting may cause the
 expulsion of the membrane, and hence the exhibition of antimo-
 nial wine by many practitioners.
    Pertussis—Hooping Cough, Cerebro-bronchitis.,—This disease
 is so well  known,  that I  need not give  its symptoms.   It is im-
 portant to mention, that it may induce cerebral or pulmonary con-
gestion, and these dangerous states require active treatment.   In
general the patient suffers little;  the disease  continues for weeks
         62 
490
PAIDONOSOLOGY .
 or months, in despite of all remedies, and then disappears.  This
 disease arises from spasm, or is purely nervous, according to the ma-
 jority of writers.  Others maintain that some tissue in the chest is
 diseased.   The first opinion is wortho of confidence, the other is
 mistaking the effect for the cause.
   The treatment consists in regulating the  bowels, applying seda-
 tive or stimulating embrocations to the spine and chest, exhibiting
 antispasmodic  cough mixtures, and leeching the chest and head
 when congestion or inflammation appears in either part.  As vo-
 miting very often occurs, and as the expectorated mucus is swal-
 lowed, repeated emetics are advised by some writers.   A combi-
 nation of camphorated  oil, soap liniment,  oils  of turpentine and
 amber, rubbed on the spinal  vertebrae, produce good effects.  In
 severe cases, the antimonial ointment to the chest will  be benefi-
 cial   The application of the pitch plaster with a few grains of tar-
 tarised antimony, between the scapulae, often affords relief. The an-
 tispasmodics  and narcotics are very strongly  recommended  by
 some practitioners.   Great care must  be observed  in  the use of
 them.   I have known  a  practitioner who boasted  of  a  specific
 for pertussis, which was a combination of camphor  and opium in
 powder.  I have found hydrocyanic  acid a  valuable remedy, and
 combine it with other sedatives in the following manner, carefully
 watching the effects :
     R. Syrupi Simplicis, 2 j ounces ;
        Oxymellis Scillae, j drachm ;
        Mucilaginis Acaciae, 4 drachms;
        Extract. Conii,      ^
        -----Hyosciami      \  a^ gr' j;—ij ;
        Tine. Carnph.  C,  3i—ij ;
        Acid. Hydrocyan, mj—ij ;
 m fiat mistura, de qua, sumatur coch! min. phiala  prius agitata, bis
 vel ter in die, nisi supervenerit somnolentia, vel nausea.
   The dose must be regulated according to the age of the infant.
The bowels should be well regulated.  When cerebral symptoms
appear, leeches are to be  applied to the temples, an evaporating
lotion to the  head,  and  mustard pediluvia; in a word, the same
practice as in  hydrocephalus.   This last  complication is often
present in consequence of dentition,  and unless well  managed,
proves fatal.   The child dies in convulsions ; and we find conges- 
DISEASES OF THE CEREBRAL SYSTEM.         491
tion, or effusion, in the  brain.  This  leads me to describe the le-
sions of the Cerebral Functions.
   Apoplexy.—Infants are born  apoplectic from  compression of
the head during parturition.  There is a violet colour of the face
and whole body, injection of the conjunctival  vessels, dilated pu-
pil, stertorous respiration ;  asphyxia more or  less  complete, and
flaccidity of the  extremities,  with immobility,  insensibility,  and
suspension of the pulse.   At other times  there are convulsions,
or more properly eclampsy.
   The chief object in the treatment of this disease is to dissipate
cerebral congestion, and this is best effected by allowing the navel-
string to bleed to the amount of an ounce or  two,  according to
the size of the infant.   The  warm bath is useful; but cold should
be applied to  the  head during the immersion  of the  body.  A
leech to each  temple, and  a blister to  the  neck, are powerful re-
medies.
   If asphyxia supervenes, we  should resort to artificial insuffla-
tion, stimulating frictions on  the spine and chest, soles of the feet,
and palms of the hands; and according  to Dr. Hamilton on the
face.   He advised the application of brandy or hartshorn  to the
 face and chest, as the best means of resuscitating still-born infants,
long  before  the discovery of Mr. C. Bell or M. Magendie.  I
 have found the practice successful in numerous cases.
   Convulsions, Eclampsy.—This  disease may  arise from a varie-
ty of causes ;  but in new-born infants it generally accompanies the
 malady just described.  The treatment in both is the same.   It
 sometimes arises from dentition, worms, or the non-appearance of
the eruption in measles, small-pox, or scarlatina.   During the at-
tack, all  the muscles are  thrown into involuntary action, there is
foaming at the mouth,  protrusion of the  tongue, the countenance
distorted, squinting, lividity of the face, and laborious respiration.
The fits may  continue a few minutes, and recur frequently.
   The general practice in treating this disease, is to immerse the
infant in a warm bath,  and to apply cold to the head at the same
time.   The  water must not be  too hot,  or it  acts as a stimulant.
Temporary relief is generally obtained by this remedy ; but we
should cover  the head with a piece of muslin,  and keep this con-
stantly wetted with cold water, or some of the evaporating lotions.
This is to be  accomplished   by the dropping  the water from a
 sponge, or in bad cases allowing the water to  fall on the bare scalp, 
193
PAIDONOSOLOGY.
from twelve to twenty inches in height.  The application of ice,
in folds of muslin, or a bladder of cold water, has produced the
best effects.   The  bowels should  be opened by some medicine
suitable to the age of the patient.
   Opiates must be carefully avoided.  If there are well-marked
signs of cerebral congestion, we must treat the case as one of ap-
oplexy, in the  manner  described in the last article.  If dentition
is  present, scarification  of the gums will  often  afford  immediate
relief.   It is to be recollected that convulsions will arise from ex-
haustion,  as well as  from plethora, or congestion, and then the
treatment  must be stimulant.   We can easily diagnosticate by
learning the history of  the case; and  whether any cause of ex-
haustion has existed.   Bleeding or purging would destroy the pa-
tient.  Aromatic spirit  of ammonia, or a few  drops of brandy in
arrow root or milk, with beef-tea, chicken-broth, he. are the best
remedies.
   Tetanus, trismus nascentium.—This is  a  rare disease in tem-
perate climates, and only seen in  warm countries.   Warm  baths,
with opiate liniments are the best remedies. The bowels, of course,
should be duly regulated.
   Lesions of the Senses.—Infants are  born with cataract, strabis-
mus, and  deafness; and here we can  do little for  sometime.   I
once operated ion a boy seven years old who had congenital catar-
acts, and succeeded in affording him vision.  The use of gogglers,
the apertures  placed so as to bring  the  eye in  the proper position,
are said to relieve, and often remove, strabismus.
   Lesions of Digestion.  Difficult Dentition.—Dentition usually
commences between the fifth and eighth months, but some deli-
cate or rickety children have no teeth sooner than a year  and  a
half, or two years of  age.  The  child  while  teething  is peevish
and  fretful, has its fingers continually  in its mouth, starts from  its
sleep, cries, moans, or screams suddenly, and  again dozes.   The
pain arises from the pressure of the teeth on the gums,  and the ir-
ritation extends to the brain and digestive organs, inducing convul-
sions, deranged appetite, or diarrhoea.   These effects can be easily
explained by calling to mind the connection between the cerebral
and  spinal nerves. The gums become swollen and inflamed ; fever,
thirst, diarrhoea, erythema of the skin, ulceration behind  the ears,
cerebral congestion, convulsions, and coma supervene, and  these
may terminate in hydrocephalus.   The warm-bath is the panacea 
DISEASES OF THE DIGESTIVE ORGANS.          493
in all  infantile diseases with many practitioners, and is generally
recommended in difficult dentition.
  The best and most efficacious remedy is lancing or scarifying the
gums.   It often happens, after this operation, that the convulsed
infant falls into a tranquil  sleep, and awakes lively, and in perfect
health.   Lancing the gums is by no means a painful operation ;  I
have repeatedly performed it without the infant making the slight-
est  moan.  We should always use a clean gum-lancet, and  take
care to have  it well sharpened, as in cutting  down on  the tooth,
and fairly dividing the gum, the edge will be  blunted.  Wherever
the gum is swollen  or inflamed, it  must be  divided  freely  by a
simple incision ; and I find this  generally  successful without the
crucial division, advised  by some writers.   In nine cases out of
ten immediate relief is afforded.  The  practitioner who neglects
this operation, does  not  act  honestly towards  those parents who
employ him.   The  bowels should be properly regulated; and di-
arrhoea, when  excessive, arrested by chalk mixture, catechu and
sedative liquor of opium.   The diet should  be mild and nutricious ;
and as the appetite is sometimes  voracious, it must not be gratified
to satiety.
  Should cerebral symptoms be  urgent,  leeches, warm baths, cold
to the head  must be employed.   Blistering is generally injurious,
as increasing the constitutional irritation.   It  is bad practice to en-
deavour to heal ulcers behind the ears.  If the bowels are proper-
ly  managed these  will soon disappear without any local treatment,
except the application of fine flour.
    Vomiting, Hiccup and Colic usually arise from repletion.  Mo-
thers and nurses, in general, give too much food.   If  we regulate
the diet, attend to the bowels, and give  some mild antacid, such
as  the following combination we afford  relief.   Let us suppose the
little  sufferer under  six months old.
               R. Aquae Menth. Virid.  2 ounces;
                 Magnesiae Calcin.  1 scruple;
                 Sacchari Puri,  1 drachm ;
                 Olei Anisi, m.  iv ;
                 Liq. Opii Sed. m. ij;
                 Confect. Aromat, \ drachm ;
        M. Dosis coch. min. bis, ter quaterve de die.
    If  griping is urgent, the warm bath should be employed.
   Diarrhoea.—When bowel complaint does not proceed  from 
494
PAIDONOSOLOGY.
dentition we may take it for granted it arises from improper food,
either in  quality or in  quantity; hence we must ascertain this
point.  In such cases we find after death, erythema, inflammation,
or ulceration, of some portion of the  intestinal canal.
   In treating this complaint, our  first object is  to  regulate the
diet of  the infant, and to  direct our attention  to the food of the
mother, if a nurse, or to  that of the infant, if nourished artificially.
The chalk mixture, with mucilage,  and liq.  opii  sedativus will
generally arrest the disease, after the diet has been  regulated.
   The infant's strength should be supported with beef tea, chick-
en and mutton broths,  arrow root, he. lest collapse or depression
of the vital powers set in, or that comatose  affection so accurately
designated  hydrocephaloid by Dr. M. Hall.  The  following mix-
ture is highly beneficial in diarrhoea.
               R. Misturae Cretae, 3  ounces;
                 Confect. Aromat..        > __ ,  ,   ,
                                X        > aa 1  drachm ;
                 Syrupi Papavens,        >
                 Sacchari puri, 2 drachms ;
                 Olei Anisi, mv;
M. Dosis coch. parv. post singulas sedes liquidas, nisi  supervene-
rit somnolentia.
   In some cases tincture of catechu must be added.
   Vitiation  of Secretions.—Icterus  neophytorum, Jaundice, Yel-
low  Gum.—Infants  often become jaundiced  the  third or fourth
day  after birth.  They  are drowsy and constipated.   It is stated
in books that this is a slight disease which can be readily removed
by a dose or two of castor oil.  I  have,  however, frequently seen it
prove fatal.   In obstinate cases, half a grain of calomel with mag-
nesia should be given twice or thrice  daily.
   Constipation.—This is best  relieved by calomel  in  repeated
doses, castor oil, and in obstinate cases by infusion  of senna with
a few grains  of aloes.   Dr.  Hamilton  mentioned  cases in which
large doses of compound tincture of aloes were  required.
   Colic and  Flatulence are often attendants on constipation.  The
infant screams and draws up its legs, the abdomen  feels hard, and
there is often retention of urine.  Warm bath, fomentations or fric-
tion  on  the abdomen, give relief, and should the pain continue, a
few drops of laudanum,  or  sedative solution of opium with  oil of
aniseed are highly efficacious;  clysters, with a  few drops of  tine- 
HYDROCEPHALUS.
495
ture of  assafoetida, and  suppositories, often afford  relief.  If the
pain is obstinate we must guard against inflammation.
   Hydropsies. Dropsies.—Hydrocephalus, hydrothorax, ascites,
anasarca, hydrocele and hydrorachitis, hydrocephalo-rachy, or ce-
rebrospinal dropsy, are  often  congenital.
   Hydrocephalus is the most common and fatal of these diseases.
The only effectual remedy is tapping, as proposed by Vose,  Hol-
brook, Callaway, Conquest, he.  Dr. Conquest has cured four
cases  out  of six by tapping.   In performing the operation, care
must be taken to avoid the arteries and sinuses  of the  head.  In
all these cases the subjects were children.   Compression has been
proposed by Riverius,  Blane,  Barnard,  and  others.  Mercurial
frictions to the head, especially at the angles of the jaws,  have
also been employed.
   Hydrocephalus is divided into acute  and chronic; the former
into acute inflammatory, and  acute asthenic, and consists of  effu-
sion of  serum, improperly called water,  into the ventricles of the
brain.   This is called " water in the head."   This effusion is the
effect, and  not the cause  of  the  disease.  The real cause  is in-
flammation of the brain  or its membranes, meningocephalitis.  Ac-
cording to the testimony of Abercrombie and others, different parts
of the brain and its membranes may be inflamed.  The remote
causes of  this disease are, dentition and irritation in the digestive
organs.   Charpentier thinks  two-thirds  of the  cases  arise  from
gastro-intestinal irritation.  Cheyne and A.  T. Thomson  main-
tain that the malady arises from sympathy with disease of the  liver.
Golis  and  Itard have found the abdominal viscera generally healthy.
All the symptoms of hydrocephalus may exist and on dissection
no fluid will be found in the brain (Quin, Cheyne, Warren, Golis,
Callaway, Gooch, he.)—In such cases, may we not fairly suspect
that the disease was hydrocephaloid ?
   The treatment, when the infant is young, should  consist of the
application of leeches  to  the  temples, cold lotions to  the  scalp,
mustard  pediluvia,  and  mercurial  purgatives.   Great attention
should be  paid to the state of the alvine secretions.   The warm
bath,  with cold to the head at the same time, is a valuable remedy.
When the symptoms do not yield to this treatment, a blister should
be placed  on  the neck, but, according  to  the French, upon the
lower extremities. According  to Beddoes, Withering, Mills, Max-
well, Rush, and Golis, copious depletion is necessary.   Maxwell 
496
PAIDONOSOLOGY.
cured sixty out of ninety cases by this remedy.   Golis performed
arteriotomy with  benefit.  Percival, Mills, Cheyne, Dobson, Fish-
er, Itard, and Jadelot, have given repeated doses of calomel daily,
and the  last writer has  used mercurial inunction on the head.
Fisher cured a case which  withstood  all remedies,  by mercurial
salivation  (Edinb.  Med.  and Surg.  Journ. 1825.)   Carmichael
Smith  had   emplo)ed  calomel  and  squills,  and  Itard  squills
with digitalis.  Dr. H. Davies used mercurial inunction, calomel
and digitalis  with success.   (Medical Repository, 1825.)—The
constant application of ice to the head and blisters to the legs and
abdomen (Golis), have proved successful with the former remedies.
(Lond. Med. and Surg. Journ, 1830).
  When depletion  and purgation, with counter-irritation,  fail to
arrest the disease, and the signs  of effusion  advance,  the patient
being weaker, the pulse more frequent or extremely slow, we should
endeavour to produce powerful revulsion by  a seton in the  neck,
by applying a moxa, an issue, or the cautery to some  part  of the
head, rubbing antimonial ointment behind the ears, and mercurial
frictions to the angles of the jaws or to the scalp, so  as to excite
profuse salivation.  It is at  this stage of the  disease that the diges-
tive organs are free from irritation, that calomel may  be given in
large and repeated doses; for example, four  grains three or  four
times a day, as it is extremely difficult to produce salivation.  James's
powder or antimonial  powder is lauded by many practitioners, and
nauseating doses of tartarised antimony by  others.  It is  at  this
time that nutriment may be given.   A warm bath may produce
copious perspiration ;  and is often used with advantage.   When
hydrocephalus follows scarlatina or measles, M. Martinet has found
frictions of the limbs and trunk with squills and  digitalis,  vapour-
baths, highly beneficial.   In the first stage of the disease,  a  long
continued stream  of cold water applied to the head after venesec-
tion is highly useful, and often succeeds in allaying head-ache in
fever, when every other remedy  fails  (Abercrombie, Southwood
Smith, he.)—Mills bled to the approach of  syncope, purged free-
ly, and next  exhibited calomel and opium to increase  the secre-
tions, and allay the  irritation of the nervous  system, and also ad-
vised the tepid bath twice or thrice daily.   He also used tartarised
antimony freely, and ordered blisters (Dublin Hospital Reports).
—When the disease becomes chronic,  Martinet  advises frictions,
with tinctures of squills, digitalis  and cinchona over the trunk, to 
DISEASES OF CHILDREN.
497
excite the functions of the skin and kidneys.  Recamier and An-
drieux used a bath composed of a pail full of water and an ounce
of tartarised  antimony, with  decided success.   The antimonial
ointment rubbed on the scalp and neck has been tried with bene-
fit.   P. Frank  ascribed the  frequency of the  disease to washing
children's heads with cold water.   When all remedies fail, tapping
may be effectual.
  Acute asthenic hydrocephalus,  hydrocephaloid disease.   Drs.
Marshall Hall,  and Gooch describe a disease of delicate infants and
children indicated by heaviness of the head, the child  unable  or
unwilling to raise its head, appears half asleep, one moment open-
ing its eyes, and next closing them, countenance expressive of
languor, absence of fever, the pupils  dilated.   The cause  of this
affection is debility, produced by too  much  purgation, diarrhoea,
or a want of sufficient nutriment.   It often follows  weaning and
diarrhoea.   It is usually mistaken  for congestion in the head or hy-
drocephalus ; but if treated by depletion, death will certainly fol-
low.   The best treatment is nutritious aliment, cow's  or ass's milk
with sugar, and a few drops of brandy, given as often as possible,
with five drops of aromatic  spirit of  ammonia, every  two hours.
The arms and lower extremities should be kept warm with  flan-
nel.  By this plan the child will be restored to health in twenty-
four hours.
   Dr. Darwall describes another species of acute asthenic hydro-
cephalus, in  which the child complained of pain in the head, and
restlessness,  the symptoms milder than in the acute  inflammatory
disease.  He has cured these cases  with five  grains of Dover's
powder every three hours, or until sleep is produced.   The medi-
cine may be required twice a day for a week.
   Lienteria.—When there is violent diarrhoea, with much griping
and spasm of the abdominal muscles, with  copious  alvine dejec-
tions and expulsion of flatus,  the disease is called lienteria, and by
nurses "watery gripes."  The treatment should consist of that laid
down for diarrhoea, due attention being paid to the condition of the
alvine evacuation*.   If the  alvine discharges  are depraved, the
hyd. c. creta, in doses of three grains with one grain of the  pulv.
ipecac, comp. three times a day, should be given.  The  pain or
griping will be relieved by this combination, or  by the astringent
mixture prescribed for diarrhoea in a  former article.   It  may be
necessary to apply fomentations or the  warm  bath.   Exhaustion 
498
PAIDONOSOLOGY.
 must be obviated by the remedies mentioned for anemia,  and the
 hydrocephaloid disease described in the preceding paragraph. The
 starch and opium clyster is also a valuable remedy ; the  quantity
 of opium must depend upon the age of the child,  and upon the
 quantity already  taken.   An ounce of starch  and two drops of
 laudanum are sufficient for infants and children  under two years of
 age.   These may be repeated three or four times in  twenty-four
 hours, according to their effects.   I can bear my testimony to the
 fact stated by Baron Dupuytren, that much smaller doses of laud-
 anum than those usually prescribed, will act powerfully when used
 in clysters.   The following plaster applied  to  the  abdomen  has
 been found serviceable by Dr. Darwall.
            R. Emplast.  Opii, 1^ drachms ;
               ----------Plumbi, 2 ounces ;
                Pulveris Opii, 1 drachm;
               Olei Menth. P., 1 drachm.
       M. et super alutam extende.
   Dysentery, or bloody stools, are rarely observed in  infants or
 children, and may be removed by the  remedies recommended in
 the last article.  *
   Worms.—In the whole practice of medicine  there is no disease
 in which such a variety of remedies is prescribed, as in that under
 consideration.  This  appears by reference to   Good's  Study of
 Medicine, by Professor S. Cooper.   The only rational  mode of
 treatment however is, to improve the morbid condition  of the di-
 gestive organs which  invariably exists  in  cases of worms.  This
 is to be effected by mild mercurial aperients,  with tonics.  The
 hydrarg. c. creta, or small doses of calomel with rhubarb, qu'nine,
 carbonate of  iron, powder of columbo, he. are  the best remedies.
 Little, if any, reliance is to be placed on the various anthelmintics
  Marasmus.—Infants and children are liable to a remitten: fever
 from disorder of the digestive organs, which continues for  days or
weeks, and is attended with emaciation.   There is a total loss of
appetite, or it is voracious, the alvine dejections are depraved and
offensive, are  of a clayey, greenish, brownish, or blackish colour.
The face is often flushed, then pale; the skin is very hot, as also
the hands and abdomen ; at other times there is no fever  present
for a few hours.   The abdomen enlarges,  the lips are covered with
a brownish sordes, there is great thirst,  and the  little sufferer often
urvives on barley water, or cold water, for several days, and con- 
SCROFULA.
499
sequently great emaciation and  exhaustion  ensue.   This is the
Infantile Remittent Fever of Children.  It generally arises  from
improper diet, or from imperfect  mastication ; and is  the  sequela
of exantheniatous diseases, of dentition, of diseased mesenteric
glands, and of scrofulous and rachitic complaints.  It may be pro-
duced by worms, and hence called Worm Fever; and when atten-
dant on dentition, it is denominated u fever from the teeth,"   It is
symptomatic of visceral inflammation in  the head, chest, or abdo-
men, and of  scrofulous disease  in the neck or joints.
   The chief indication of treatment is to regulate the bowels by
mild purgatives, such as  calomel  and rhubarb, or jalap, infusion of
senna with some aromatic, and next improve the alvine secretions.
The disease  is readily cured by this plan when it is early employed.
The disease  will remain  until the alvine  dejections are restored to
a healthy appearance.   As there is  generally erythema, muco-en-
teritis, or ulceration, in some portion of the intestinal  tube, leeches
should be applied to  the abdomen, though no pain exist on  pres-
sure.  When the abdomen is tumid, frictions with camphorated oil
and laudanum are very useful, and a flannel roller should be applied.
Mucilaginous drinks, with weak  broths and  farinaceous aliments,
such as thin arrow-root,  sago, tapioca, milk, he.  may be given.
No wine should be allowed, unless when exhaustion threatens life,
and  then stimulation only can  save  it.
   Scrofula.—This  disease arises from debility of constitution.  It
is common  to children whose skin is thin, and only slightly covers
the  minute  blood vessels, and hence the cause of the rosy  blush
of such persons.  The  hair is light-coloured  and fine, the eye-
lashes are long, the  pupils are  dilated, the fingers are long with
the  nails arched and curved, and the upper lip is thick.  This dis-
 ease most  commonly attacks the  absorbent  glands and joints,
 though it may attack almost all  parts of the body.   The glands
 of the neck and mesentery are most commonly affected.  Sudden
 changes of temperature excite the disease.   The change of sea-
 son has great influence upon  it,  which is proved by  the fact, that
 scrofulous ulceration will continue in despite of all remedies during
 winter and  spring, disappear spontaneously  in summer, and reap-
 pear the following winter.
   The  predisposing cause is debility ; the exciting causes  are
 those which produce or increase debility, as fevers, measles,  small-
 pox, scarlatina.  Scrofula after small-pox  is  now  prevented by 
500
PAIDONOSOLOGY.
vaccination, and this advantage  alone is a strong recommendation
of the Jennerian discovery.   Every part of the body is debilita-
ted in scrofulous or strumous habits, the lymphatic  temperament
predominates, the  circulation is languid, the blood is deteriorated,
the crassamentum  is loosely formed and coagulates slowly, the se-
rum is abundant, and the solids are imperfectly formed.   The mus-
cles are attenuated,  the fibres are delicate, the structure of the
blood vessels is defective, the  stomach and intestinal canal are thin
and  pellucid, the absorbent glands  are  enlarged, and the  nervous
system is irritable.   From this  pathology it is  manifest that the
chief indications of treatment are, 1. to make better blood ; 2. to
strengthen  the solids;  and 3.  to  invigorate the circulation.   To
fulfil the first indication, we should exhibit the most nutritious ali-
ments, and such as are easily digested.  These are animal  sub-
stances.  Animal food should be given  in small  quantities at least
three times a day ; and vegetable matters should be avoided.  The
child may have some wine and water,  ale or porter, at dinner, to
promote  digestion.  Eggs and  milk are highly nutritious.  Air
and  exercise are indispensable.  It is well known, that boys  who
exercise  in the open air are much  less affected by scrofula than
girls, who are more confined,  and  kept sitting all day in schools.
Exercise may be taken in wet or inclement  weather in a spacious
apartment.  Sea air has been long preferred ;  but sea-bathing is
now acknowledged to be injurious when children are very delicate.
The disease is absolutely most common on the sea-coasts.   Coun-
try air is the best remedy.   Flannel should be worn next the skin
in winter, and calico or cotton  in summer.  It is stated by  able
writers, that two-ninths of the children  born in London and Paris
die scrofulous under the age of fifteen years.  The general health
must also  be improved by medicine.   The  remedies most gener-
ally  employed are  hydrarg. c. creta and rhubarb, calomel in al-
ternative doses, rhubarb, magnesia with sugar, rhubarb and steel,
as two grains of one and three of the  carb. ferri once a week;
and  Sir Astley Cooper recommends the following formula :
       R.  Tinct. Cinchona?, >5 j ;
         Hydrarg. oxymur, gr. j;
     M. Dosis drachma bis de die. 
SCROFULA.
501
  It is extremely difficult to get children  to  take  this medicine,
and hence I usually substitute the following:
       R. Pulveris Rhei, sj— gss;
       Hydrarg. c. creta, 3ss—3j ;
       Ferri carbon., gr. xv.—xx;
       Quininae Sulph.,  gr. iv—vj ;
       Sacchari puri,  £ j ;
       Pulveris aromat.  2j;
in chartulas vj—x divide, ex quibus sumat unam singulis vel alter-
nis  noctibus.
  The dose must be increased or diminished according to the con-
stitution, age, and  delicacy of the  patient,  and according  to the
condition of the alvine secretions.  A bath at 94° should be used
every other morning.

       Scrofulous Inflammation of the Glands in the Neck.
   When the glands in the neck  are  swollen and painful though
 not inflamed, we should apply leeches  and a lotion composed of
 spirit of wine and  water.   The  bowels should be  opened with
 calomel and rhubarb.   If suppuration takes place, as soon as the
 skin is bluish or reddish we should make  an opening with a lancet
 transversely in the natural creases of the neck, and by this plan the
 deformity of a scar will be avoided.   We should not wait for intense
 redness, for when this occurs, it is better to apply poultices than
 make an incision, as less deformity will be induced.   It is a matter of
 some moment to recollect this advice in cases of females, as deformi-
 ty  from scars on the neck are great blemishes.  The whole fluid
 should be pressed out, and the sac injected with a lotion compos-
 ed of a scruple of S. Zinc and a Oj of water.   The best dressing
 is  a dram  of the  ointment of hydriodate of  potass,  and  an ounce
 of cetaceous cerate.  In cases of adults we should exhibit the so-
 lution of the hydriodate of potass of the Dublin Pharmacopoeia,
 and apply  the  ointment of the same remedy.   I have seen  the
 best results from these  medicines in cases of ulcerated  neck,  the
 sufferers from which had been dismissed from St. Bartholomew's,
 and St. Thomas's  Hospitals.   The  practice formerly was to  ad-
 vise the patient to take the compound decoction of sarsaparilla
 very  freely, and to dress the ulcers with resinous ointment and red
 precipitate.  I have known two empirics to obtain a livelihood by
 these remedies.  They compelled  the  patients to take no other 
502
PAIDONOSOLOGY.
drink but the decoction, and continued this plan for several months.
  Enlargement of the  Mesenteric Glands.—About the eighth
month the enlargement of the mesenteric  glands commences, the
abdomen becomes tumefied, the lower extremities emaciate, and
all the symptoms of marasmus, as already described, appear. This
arises from improper food which  irritates the mouths of the ab-
sorbents in the  duodenum, the irritation extends along these ves-
sels to the glands, and enlargement follows.  The chyle cannot
pass through glands when disorganized, the  supply to the blood is
cut off, the circulation  goes  on,  the different parts  of the body
want  nourishment,  absorption proceeds, and  general emaciation
ensues.  The  prognosis  is  unfavourable, though recovery may
happen very rapidly.   The  treatment is that laid  down for scrofu-
la and marasmus.  Friction  of the abdomen with the hand for a
quarter of an hour, twice or thrice  daily, is a powerful means of
promoting absorption of the  enlarged glands.   Some liniment may
be used at the same time as the amrnoniated or camphorated. A
flannel roller round the  abdomen,  warm clothing and nourishing
diet, must be employed.
  Scrofulous affections of the Joints.—When children are taken
out for the benefit of air by nurses, they are often compelled to
walk and keep  pace with the woman.   The child takes two steps
for her one, and dues not feel fatigued, as  its attention is so keenly
fixed  on surrounding objects.  Next day,  however, it  is ill and fe-
verish, and cries when  it is moved.  On examination  of its lower
extremities, it will be discovered that the knee or hip joint is pained
on motion.  If the attendant overlook this point,  he may suppose
there is some derangement of the digestive organs, and content
himself by ordering febrifuge remedies ; inflammation and suppu-
ration of the joint will speedily occur;  the suffering will be great,
and the recovery extremely  tedious.
   Treatment.—Cold lotions, such as  Sp. vini 1  ounce Aq. Oij,
or the liq. acet. plumbi dilut. should be applied the  bowels regu-
lated, the joint  kept in a state of  perfect rest; and if these reme-
dies fail, leeches  and blisters must be employed.
   When the knee is affected,  and  the  disease  proceeds, a splint
should be applied from the hip to the  heel, to prevent curvature
of the joint during the process of anchylosis;  no  surgeon of scie-
ence could allow the  leg to be permanently fixed at a right angle
with the thigh.   Ulceration  of the knee joint in adults is a tedious 
RACHITIS--RICKETS.
503
painful disease ; and  may be removed by time, even after the most
severe constitutional  irritation.
  When the hip-joint is  inflamed  from too much exercise, the
same plan of treatment is to be adopted; and should an abscess
form, it ought not to  be opened with a lancet, but allowed to open
by ulceration, which it does at a considerable  distance from the
joint:  whereas if opened early the joint would  be exposed, and
great constitutional and local irritation produced.   When suppura-
tion  is established, the strength should be supported by nutriment,
quinine, &c, and the child might be allowed to walk with a crutch.
Repeated or perpetual blistering over the  joint  is  advantageous;
but a very small blister should be applied as otherwise  too much
irritation would  be produced.  The antimonial ointment is also a
valuable counter-irritant.
   Curvature of the Spine.—The first symptom of this disease is
inability to  use the lower extremities.  The mother observes the
child unable to stand,  and that it screams when moved.   After a
short time, some of  the  lower dorsal or lumbar  vertebrae project
and  form excurvation, and the back is said  " to grow out."  If the
curvature is slight the child waddles or  stumbles.   This disease is
common among poor,  from bad nursing, filth, impure air, improper
diet, and allowing infants  to remain too  long in the sitting posture.
   Sir Astley Cooper recommends an  instrument invented by Cal-
low, which  supports  the spine, and is fixed  to the shoulders and
pelvis.  He holds deformity to be inevitable, and that rest in the
recumbent posture, with attention  the  general health, is  the best
remedy.   He thinks that blisters, issues, and setons, do more harm
than good.   His observations apply to  spinal curvature in young
persons about the age of puberty.  It appears, however, by the
reports of the Orthopedic Institutions of foreign  countries, that
the  worst  forms  of  curvature may be  remedied.  The works of
Dr.  Harrison, Mr. Beale, and Mr. Amesbury, leave  no doubt of
the  fact.   Every observant practitioner  must have met with spinal
curvature, and deformities of the  legs  of  infants and young chil-
dren which may be remedied by art, and even by nature.  This is
often the case in the disease called rickets.
   Rachitis—Rickets.—This disease  arises  from want  of proper
ossification.  The habit  is scrofulous,  digestion and  nutrition are
imperfect, the blood is defective, and is  deprived of solid materials,
and  hence all parts of the body are badly nourished, and of course 
504
PAIDONOSOLOGY.
 the osseous system is included.   There is not a sufficient  deposi-
 tion of phosphate of lime, which affords the  hard part of bone.
 Hence we find all  the bones are  soft  and yielding, and those
 which sustain much weight, as the spine  and the inferior extremi-
 ties are bent or curved.  The head  is enlarged because the bones
 of the skull are unable to oppose the action  of  the arteries of the
 brain ;  and  hence the enlargement, which is often  a precursor
 of hydrocephalus.   The weight of the  body  causes a  double
 curvature  of the  spine, and  the curvatures  are  in  opposite di-
 rections ; because when one  commences,  nature  endeavours to
 preserve the perpendicular line of the body by producing  the se-
 cond, and the equilibrium is maintained in this manner. The cur-
 vatures make the  spine  resemble an  italic S.  The scapula is
 thrown outwards, the ribs are flattened, the  sternum projects, and
 the child is said to be " chicken-breasted."   During  the progress
 of this disease the ancles become deformed, or " grow out," and
 the child  cannot assume the erect position without support.  The
 disease is produced by  mismanagement of children during the first
 three years of  their existence.   Bad food, bad  air, insufficient
 clothing, want of cleanliness, and  all  causes  of debility, excite this
 disease.   Hence it is so common  among  the lower classes.  All
 children  who have large joints and who are  late in their dentition,
 are predisposed  to this complaint.  It occurs from  the first to the
 eighth year.   We invariably observe that the digestive organs are
 deranged  in the  commencement of rickets, the appetite is depraved,
 is voracious, and yet emaciation advances, and the limbs become
 flabby.   The alvine  secretions  are  always  unnatural.  There is
 constipation in  general, though  sometimes  diarrhoea.  No teeth
 appear during the first year or even later.   The functions  of the
 whole digestive and nutritive systems are defective, and healthy
 blood is not  formed.   There  is generally enlarged  mesenteric
 glands, and the irritation of teething adds  to  the debility.
   The treatment of this disease is that laid down for scrofula; the
 diet should be most nutricious, the alvine secretions should be im-
 proved ;—air and  exercise  are of the  utmost importance.   The
 child should be as much in  the open  air as possible, and it should
 not be  allowed to stand or walk while the bones are soft.  Friction
of every part of the body should be  made for at least three hours
daily.  A little  flour to  prevent  chafing  is  all that is necessary.
 Friction will improve the tone of  the muscles, increase the circu- 
RACHITIS--RICKETS.
505
lation and produce  as  good effects as active exercise, which of
course is impracticable.  In most cases the child not  only regains
the natural appearance of its  limbs  and spine, but becomes as
healthy as if no disease had  ever  existed.  Perfect ossification
takes place in every part of the body, and often after all treatment
had been tried in vain.   I have seen the most astonishing recove-
ries from rickets and numerous writers attest the fact.  Some re-
commend mechanical means in spinal curvature  and deformities of
infants, but these do more harm than good.   Long confinement in
the recumbent  posture  destroys the  general health, and conse-
quently can never relieve deformity.
   Deformities of  the Legs.—These arise  from placing delicate
rickety children too soon upon their feet, before their own  feeling
and instinct dictate their ability to assume this position.  The con-
sequence is deformity of the knees and ancles,  which occurs from
the first to  the  third  year, and  generally disappears without the
aid of any instrument.   This information will afford great consola-
tion to parents.   Mothers are usually importunate in  their request
to apply some instrument or remedy in these cases.   The restora-
tion of general health by proper attention to diet, air, and exercise,
are the only remedies.   We find that errors in  diet and clothing,
weaning, dentition, and debilitating diseases, and  placing children
too soon in the erect position, are the exciting causes  of deformi-
ties.   Fat children are also subject to deformity from their weight.
The best rule with regard to teaching children to walk is to place
them on the floor, and  allow them  to assume  whatever  position
they please.  Delicate children placed  in the horizontal  position
on the floor, will turn  themselves about in different directions, and
soon assume the erect position. I have only to state in conclusion,
that deformities of the legs of new-born infants are easily remedied
by bandaging, and  the sooner attention is paid to this remedy the
better.  The bones, ligaments, and cartilages are soft, and can be
readily moulded to  almost any shape.   The bandage should be
assisted by pieces  of strong pasteboard, and loosened every third
day.  Club-feet may be cured by  this plan  within the  first or
second month, but the period will depend upon  the  development
of the infant.   I have treated some cases with  perfect success in
this way ;  no deformity whatever remained.   Should the case be
neglected until  the third or  fourth year, we must employ some
powerful mechanical contrivance, such  as  the  shoe  with  an iron
         61 
506
PAIDONOSOLOGY.
plate proposed by Dr. Colles  of Dublin.  Such cases sometimes
happen, as the generality of mothers consider the deformity incu-
rable, and therefore make no application  to medical practitioners
for relief.   Such cases occur only among  the poor and ignorant.

          Section 4.—Surgical Diseases of Infants.
   Tumefaction of the scalp is generally removed by friction with
the hand, and usually disappears in a few days.   Nurses  apply
ardent sprits.  Cold lotions are seldom necessary.
   Tumefaction and Lividity of the  face will be removed by na-
ture, or simple friction.
   Separation of coherent Labia may be affected by simple pres-
sure or a slight incision;  but as there is generally an aperture suf-
ficient to admit the escape of the urine, no operation is necessary.
Should separation be affected, some mild  dressing must be placed
to prevent re-union of the parts.
   Impervious Urethra and Anus often arise from a thin membrane
placed over these orifices, which may be divided  with  a lancet.
This disease is discovered by the infant not evacuating the bowels
or bladder  within  twenty-four hours.  Sometimes  the  rectum is
impervious by a solid growth, and then no operation can preserve
life. The rectum may open into the bladder, vagina, and urethra;
and then no operation is likely to succeed.
   Dysury.—The infant  may have  difficulty in passing water with-
out occlusion.   Warm fomentations to the pubes generally afford
relief.
   Incontinence  of urine is often a disease of children.  It generally
remains incurable until after puberty.
   Club-feet, vari, valgi, and pes equinus, have been described in
a former article  on deformity of the legs.
   Spina  bifida, dropsy of the Spine, Hydro-rachitis.—In this
case Sir Astley  Cooper  has punctured  the  part with  a cataract
needle as often as fifty times, and finally with success. He applied
a truss afterwards.   This operation has failed in later cases.  The
disease may continue until the adult age, though in general  infants
so affected seldom survive.
   Hydrocephalus, when congenital, can only be cured  by para-
centesis, as already described.
   Hydrocele may be removed by the application  of cold water
poured from a height, or by cold lotions. The operation of par- 
SURGICAL DISEASES OF INFANTS.
507
acentesis is seldom necessary.   If all remedies fail, a slight punc-
ture should be made with a lancet.
   Hydrocephalorachy, or dropsy of the brain and spine is incura-
ble.
   Fractures, Contusions, Dislocations, and Wounds  are  to be
treated on ordinary principles.
   The  (Esophagus and small Intestines have been found imper-
vious.   Infants have survived for sixteen days under such circum-
stances.
   Intussusception, or Intestinal Invagination, admits of no remedy.
   Lingua Ligata,  or  Tongue-tie, is obviated  by dividing the
froenum with a pair of scissors.  This operation  is necessary, as
the infant cannot suck.   The index finger of the left hand should
be passed under  the tongue, and care must be taken not to wound
the lingual  veins.
   Harelip.—The  operation should  not  be performed until after
the appearance of the teeth.
    Cleft Palate—cannot be remedied in infancy.
    Hypospadias, or opening of the urethra between the natural
 orifice and scrotum, and epispasdias,  or  urethra, opening on the
 dorsum, penis, or in the corona glandis or pubes, requires no ope-
 ration during infancy.
    Occlusions of the  Eyes and  Ears may be remedied when a
 slight membrane only exists.
    Supernumerary Fingers and  Toes may be  removed when at-
 tached by a pedicle, but not if there  is a  regular joint.
    Navi Materni, or mother's  marks, may be removed by vaccin-
 ation on the affected part, or by the application of nitric acid.  I
 lately applied the last remedy to a naevus on the root of the nose
 with success.  Others pass a needle  armed with a double thread
 under the part, and tie the threads in opposite  directions.
    Hemorrhage from  the Navel-string  may  occur from a loose
 ligature, or from the umbilical vein bursting between the ligature
 and the abdomen.  Exhaustion will  come on,  and is to be treated
 as already mentioned in the articles  on  anaemia and hydrocepha-
 loid affection.   Sometimes the cord  will bleed, however  tightly
 the ligature is applied.   Another should  be put on nearer the ab-
 domen, and care must be taken not to divide the cord by too
 much compression.                                     .
    Fungus  of the navel  is to be treated with calomel, sprinkled 
508
PAIDONOSOLOGY.
over it, with alum powder, moderate pressure, a ligature or nitrate
of silver.
   Umbilical Hernia  requires compression with  strips  of soap
plaister—a truss may be required.
   Inguinal Hernia will require a truss in  some cases, but is in
general cured by affusion of cold  water.
   Prolapsus Ani.—The bowel is to be replaced and kept in situ
by a compress  and bandage.  A  weak alum injection,  or five
grains  of acet.  plumbi to ^j aqua, may be used  in troublesome
cases.   The finger should be oiled when applied.
   Inflammation of the  Mamma of new-born infants.   Mastoitis.
Nurses make pressure  on the tumefied breasts, and aggravate the
disease.   No remedy is necessary.  The disease  disappears in a
few days.   Friction with olive oil, a cold  lotion,  and rarely the
application of a leech, are  necessary.
  Aures excoriatia.—Ulceration behind the ears may be caused
by chafing.   Simple ablution with milk and water, and the oxide
of zinc ointment effect a cure.   The bowels should be regulated.
The application of flour or calamine  powder is also useful.  An
ointment of acet.  plumbi  or  citrine  ointment generally effect a
cure.   If the parts become livid  or slough, camphorated spirit,
fermenting  poultice, and chloride of lime  must be used.  The
strength must be supported.  The  vernacular name for this form
of disease is " burnt-holes."
  Intertrigo-Chafings occur in the groins and axillae, and are best
cured  by ablution with cold water and  the  application of flour or
hair powder.  It  is sometimes necessary to  use an ointment com-
posed of an ounce of cetaceous cerate  and a scruple of sulphate
of zinc.
  Erosion of the cheek.—The best remedies for this  disease are
chloride  of lime, nitrate of silver,  camphorated spirit of wine,
tincture of opium, and fermenting poultice.
  Noma is a disease that destroys by gangrene, and thus differs
from erosion which proceeds by ulceration.   The cheeks and labia
pudendi are the parts affected.  It begins with a livid  spot with-
out inflammation.   The remedies are saturnine lotion,  and when
sloughing sets in, nitric  acid, chloride of lime  in solution, carrot
poultice, and opium; wine  and quinine, internally.
  Sloughing of the female genitals has been noticed in the  ar-
ticle on female  violation, p. 73.  It  should be  treated with port 
SURGICAL DISEASES OF INFANTS.
509
wine poultice, and when sloughing takes place, pure nitric acid,
chloride of lime,  while nutriment, wine, quinine, must be given
fully.  The disease is mostly fatal.
   Burns and Scalds.—The best  remedy is the constant applica-
tion of flour, or the immersion  of  the part in cold water.   These
diseases are in general fatal to children.
   Vaccinatiqn.—The  benefits conferred on  humanity by  the
splendid discovery of vaccination are now universally admitted.
No medical  man  should innoculate  for the small-pox.   Infants
should be vaccinated  after the age of six  weeks.  We should in-
variably advise vaccination.  The health of the infant should be
good, and the arm free from eruption.  See p. 499.
   Strophulus intertinctus " red gum,"  is a papular  eruption of
a vivid  red colour, which appears on  the face, neck, and chest of
young infants.   It disappears in a few days, by attention  to  the
bowels.   All rashes of infants  are cured by purgatives.
   The  reader will find a simple classification of cutaneous diseases
at p. 482, which, if  adopted, would enable us to practice  less in-
juriously and empirically.   There are  some diseases of the skin
which  defy all internal and external  remedies, and others which
are greatly aggravated  by ointments; but I  have  already so far
exceeded my limits, that I cannot describe them in this work. 
 
INDEX.
                A.
Abdomen, binding the, 127, 433,
  distention of, 319, 366.
  pain in, after delivery,  107, 436.
  section of, 407, 416.
Ablactation, 474.
Abortion, symptoms of, 324.
  causes of, 145, 325.
  treatment of, 326.
  felony to  advise, 144, 147.
  legal questions on,  144, 145.
  frequent prevention of, 345.
Abscess of  pelvic joints, 6, 307.
  in inferior limbs, 464,
  in superior, 464.
  in different  viscera, 464.
  from absorption of pus, 464.
  in articulation, 6, 307.
  in brain, 464.
  in liver, 464.
  in lungs, 464.
  in spleen, 464.
Age, when  a  cause of rigidity of the
  genitals, 2,  134.
  proper for marriage, 289.
 Acidity  of stomach, 298.
Agrypnia, 299, 472, 477.
 Ague, puerperal, 441,
Amenorrhoea, 265.
 Amaurosis  from masturbation, 265,
Amnii liquor,  redundance of,  319.
 Amnios, 50.
Anasarca, 321.
  after scarltina,  481.
   best treatment of, 481.
 Anaemia of infants, 280.
 Animation suspended, 128, 161.
 Anthelmintics, 498.
 Antiversion of uterus, 315.
 Anus imperforate, 506.
  prolapsus of, 508.
 Aphrodisiac remedies, 270.
 Aphtha?, 486.
 Appetite depraved, of infants, 298.
 Apoplexy 304, 363.
   of infants, 491.
 Arachnitis, 494.
 Areola of the  eyes and nipples, 29,84.
 Argent, nit. ung. 285.
 Arm presentation, 378.
I Arrest of the head, 390.
 Articulations, pelvic, 6.
 Ascarides in bladder, 192.
    hydatids in, 332.
 Ascites, 321, 481.
    congenital, dystocia from, 427.
 Aphixy of infants, 87, 161, 479, 488.
 Atrophy of infants ,498.
 Aures excoriatae, 506.
 Auscultation in pregnancy, 85, 87.
 Autopsy, mode of on infanticide, 16b.
 Axes of the pelvis, 12.

                  B.
  Ballotement, 86.
  Bandaging abdomen after delivery,
    127, 433.
  Barrenness—see  impotence and ste-
   rility.
  Belladonna, 13.
  Bladder, diseases of, 180, 192.
    stone in, 193.
    worms in, 192.
    spasm of 192.
  Black ointment, 485.
  Bleeding infants, 475.
    in convulsions, 305.
    women in labour, J 32.
  Blisters to  infants, 476.
  Blue-skin, 480.
  Bones of ihe pelvis, 2.
  Brain,  inflammation of, in infants, 494.
    women,  464.
  Breasts, flaccidity of, 150.
    inflammation of, 467.
    tumefaction of, 84.
  Bronchitis of  infants, 487.
    children, 487.
    women,  303.
  Burns and  scalds,  509.
  Burnt holes,  508.

                   C.
  Ceesarean operation, 416.
    history of, 407, 409.
    how far  preferable to  craniotomy,
    405.
    operation, success of, 404, 406.
  Calculus in bladder,  193.
    in the uterus, 216. 
512
INDEX.
 Camphor, good effects of, 452.
 Cancer of the uterus, 211.
 Cardialgia, 299.
 Carminatives, 493.
 Carunculae myrtiformes, 19.
 Catamenia, 26.
 Cataract, congenital cure of, 493.
 Catarrh in infants, 487.
 Cathartics for infants, 476.
 Catheter, introduction of, 189.
 Catheterism, 189.
 Cephalitis, 494.
 Cephalotomy, 421.
 Cerebro-bronchitis of infants, 489.
 Cerebro-spinal, irritation of infants,
   493.
   of women, 245.
 Chafings, 508.
 Chastity,  influence of on health
   and disease, 282.
 Cheek,  erosion of, 508.
 Chest dropsy, 527.
 Child's head, structure of, 13.
   progress of, in labour, 14.
 Child, life of, before quickening 144.
   absence of motion of,  85.
   dead, signs of,  150.
   equivocal, 150.
   causes of death of, 157.
   evolution of, 377.
   method of turning, 368.
 Child-bed, management of women in,
   432.
   fever, 445.
 Child, murder of, 149, 169.
 Children,  diseases of, 478.
   management of, 474.
   purulent discharges of, 77.
 Chiragotocia, manual labour, 368.
 Chirapsy,  67.
 Chlorosis, 224, 226.
 Chorion, 50.
 Circulation of fetus, 58.
 Cleanliness of infants, 473.
 Climate, influence of, on reproduction,
   63.
 Climacteric  period,  32.
 Clitoris, 18.
   diseases of, 174.
 Coccyx os, 4.
 Coition, bad effects of, 265, 280.
   influence of passions on, 253.
Cold-bathing of infants, 472.
 Colic in infants, 494.
   in women, 302.
Colostrum, 107, 470.
Conception, signs of, 83.
   effects of  climate on,  63.
   imagination on, 64.
   season on, 70.
   volition on, 62.
  phenomena of new being, 46.
   is  it possible  to  determine the sex,
   61.
 Congestion, cerebral, 304, 364.
 Conjunctivitis, 484,  463.
 Constipation of infants, 494.
   of women, 300.
 Consumption prejudicial to marriage,
   292, 304.
 Consumptive women, aptitude of for
   conception, 324.
 Contraction, hour-glass, 431.
 Convulsions species of, 363.
   of children, 491.
   of gravid women, 304.
   of puerperal, 363-
 Cord, umbilical, 54.
   impediment to labour, 367.
   haemorrhage of, 158,507.
   fungus of, 507.
   rupture of, 156.
 Corpora lutea, 45.
 Coryza of infants, 484.
 Costiveness of infants, 494.
   of  women, 300.
 Cough, danger of, on pregnancy, 303.
   hooping, 489.
 Coxalia ossa, 5.
 Cramp—see spasm.
 Craniotomy, 421.
 Cream, best food for infants next
   mother's  milk, 473.
 Cross-births, 373, 375.
 Crotchet or sharp hook, 422.
 Croup, 488.
 Cutaneous diseases, 482.
   classification of, 482.
 Cynopathy,  480.
 Cynanche, trachealis, 488.

                 D.
 Decidua, 60.
 Defloration, legal questions on, 73.
   signs of,  73.
 Deformities and marks, causes of, 64.
   of infants, 355, 428, 502,505.
   of  pelvis, 9, 246, 351.
 Delirium, puerperal, 466.
 Delivery, legal question on, 148.
   signs of, 148.
   during uterine haemorrhage, 336.
   management after, 432.
 Dentition, 493.
   fever of, 499.
 Despondency of pregnant women, 306.
 Detruncation, head left in pelvis, 427.
Diameters of the pelvis, 11.
 Diarrhoea of infants and  children, 493.
  of pregnant women, 301.
 Diet of children, 473, 500.
 Dietetics of new-born infants, 473.
   of pregnant women, 297.
   of puerperal, 122,130,434. 
EX.
513
                                IND

Difficult labours, 346.
Discharge after delivery, 435.
Diseases of infants, 478.
  children, 480.
  unfavorable to  reproduction, 252,
   255, 292.
Dissection, mode of, in child-murder,
   166.
Distortion of the limbs, 391, 428.
  of the pelvis, 9, 351.
Divorce, 260.
Dress of infants, 474.
  of children, 474, 500.
Dropsy, 321,  495.
  of abdomen, 321.
  cellular, 324.
  chest, 366, 426.
  of the head acute, 495.
  chronic,  495.
  treatment 482.
  fallopian tube, 243.
  ovary, 366.
  scrotum, 507.
  spine, 427.
  uterus, 317.
Drowning, death from, 161.
Dysentery, 301.
  of infants, 498.
Dysmennorrhoea, 230.
Dyspepsia, 298.
Dyspnoea, 303.
Dystocia, difficult  labour, 315.
  classification of, 108, 109.
  abdominalis, 373.
  amorphica, 351.
  ascitica infantilis,  427.
  auralis, 357.
  brachialis,  377.
  convulsiva, 305, 363.
  cruralis, 357.
  decidualis, 133.
  dorsalis, 373.
  ectopia, 348.
  embryonosologica, 355.
  epileptica,  363.
  facialis, 356.
  femoralis, 369.
  frontalis, 356.
  funicalis, 367.
  genualis, 369.
  glutealis, 354.
  gynseconosologia, 348, 351.
  hemorrhagica, 331,  334, 363.
  hernialis, 366.
  humeralis, 355.
  hydrocephalica,  427.
  hydrorachitica, 427.
  laceratoria, 358, 359, 360.
  manualis, 355.
  nuchalis, 357.
  occipitalis, 357.
  ovariaca, 340,  366.
  pedalis, 368.
        65
Dystocia, placentalis, 366.
  pluralis, 135, 427.
  retentiva, 428.
  syncopalis, 366.
  temporalis, 357.
  transversa, 373.
  verticalis, 353.
  vesicalis, 360.
Dysuria, of infants, 506.
                E,
Ears, excoration of, 508,
  occlusion of, 507.
Ecchymosis and cadaverous  lividity,
   159.
Eclampsy of infants, 491.
  of the uterus, 308.
  of women, 304.
Edematous inflammations, 424.
Emansio mensium, 265.
Embryo, developement of 47, 55, 56.
  functions of, 57.
  circulation of, 58.
Embryotomy, 421.
  when version impracticable, 373.
Emetics for infants, 477.
Emphysema, 357.
Encyonosology, diseases of pregnan-
   cy, 296.
Enteritis, 443.
  of infants, 486.
Ephemera, 441.
Epilepsy, 364.
Epichorion, 50.
Ergot of rye, 136.
  mode of administration, 140.
Erosion of the cheek, 508.
Eruptive fevers, 480, 482.
Eruptions cutaneous, 480.
  syphilitic, 483.
Erysipelas of infants, 483.
Erythema of infants, 483.
  the intestinal tube, 494.
  of the skin, 483.
Eunuchs' amorous propensities, 259.
Evisceration of foetus, 374.
Evolution, spontaneous, 378.
Examination per vaginum, 120.
Exanthemata, 480,
Excoriations and  chafnigs, 508.
  of nipples, 467.
Excresences on infants, 378.
  labia,  172.
  of the os uteri,  349.
Exercise of infants, 475.
Exsanguinity,
Exfcetation, 310.
Extirpation of the uterus, 214.
Exhaustion, 338, 465.
Extraction of the placenta, 428.
Extra-uterine foetation, 311.
Extremities of infants, deformities of,
   505.
  inferior, spasms of, 320. 
514
INDEX.
Eye, inflammation of, in infants, 484.
  occlusion of, 507.
                 F.
Face, lividity of, 506.
Face, presentations of, 392.
Fainting, 303.
Fallopian tubes, diseases of, 243.
Febrile state in pregnancy, 300.
Fecundation, conception, 44.
Fecundity, establishment of, 26.
Feeding infants, 473.
Female violation, 73.
Fever, ephemeral, 441.
  intermittent, 441.
  intestinal, 438.
  miliary, 442.
  milk, 442.
  puerperal real, 445.
  pathology of, 447.
  symptoms of, 448.
  treatment, 450.
  remittent infantile,
  of pregnant women, 300.
  typhus, 441.
Fillets, 403.
Fingers supernumerary, operation for,
   507.
Fistula; of the rectum, 177, 360.
  vesico vaginal, 178, 360.
Flatulency  of infants, 494,
Flooding, account of, 329.
Flooding, internal, 343.
Fluids, sexual, diseases affecting, 223,
   274.
Fluor albus, 182,
Fcetation, extra-uterine, 311.
Fcetati on-super, 18.
Foeticide, 151.
Foetus, turbulent motion of, 323.
  circulation of, 58.
  development of, 47, 55, 56, 143.
  evisceration of, 374.
  extra-uterine, account of, 310.
  signs of life  of, in utero, 150.
Food of infants, remarks on, 471.
Forceps.
  common, 380.
  application of, 382.
    to first position of vertex at infe-
      rior  strait, 384.
    to second, 386.
    to  first diagonal of vertex, 386.
    to second, 387.
    to vertex at the superior strait, 388.
    to impacted head at the superior
      strait, 390.
    to face presentations 392,
    to head when body born, 396.
  review of different applications of,
    398.
  application to pelvis, of infants, 400.
  craniotomy, 423.
   Fourchette, 19.
   Frcenum labiorum, description of, 19.
     lingua?, shortening of, 507.
   Fungus hrematodes of the ovary, 243.
     of the uterus, 202.
   Funis umbilicalis, 54.
     dimensions of, impediments  to  la-
      bour, 367.
   Fungus of umbilicus, 507.
     rupture of, 163.
   Furor, lascivious, 246.
                   G.
   Galactia, depraved milk, 468.
     defecta, 468.
     depravata, 469.
     prematura, 469.
   Galactirrhoea, superfluous milk, 469.
   Gastritis, 298.
     of infants,  486.
   Gastrotomy,  419.
     in ruptured uterus, 310*
   Gastro-hysterotomy, history of, 404'
     description of, 416.
   Generation, organs of, 17.
   Geneseology, generation of, 35.
   Genitals, external diseases of, 179
     internal diseases of, 177.
     sloughing of,  181.
      in infants, 508.
   Gestation, duration of, 91.
   Gonorrhoea of pregnant women, 322.
   Gum  red, 509.
     yellow, of infants, 494.
   Gynaecology, treatise on women, 1.
   Gynsecopathology, diseases of women,
      170.
   Gynoecotomy, anatomy  of  sexual or-
      gans, 2.
                   H.
   Haematemesis, 303.
   Haemoptysis, 303.
   Haemorrhage uterine, in abortion, 329.
     in advanced pregnancy, 331.
     from separation of the placenta, 332.
     from adhesions of placenta, near oa
      uteri, 333.
     management of, 333.
     during labour, 336.
     from retained placenta, 337, 344.
     internal after delivery, 337.
     of the navel string, 507.
  Haemorrhids, 301.
  Harelip congenital, 507.
.  Head, dimensions of, 13.
    natural presentations  of, 14.
    presentations of which, r.41 ire for-
      ceps, 384.
     compression of by the forceps, 386.
     and arms presenting,  4.
     impaction of,  391.
     on  lessening the, 421.
     on  perforation of,  craniotomy, 424. 
INDEX.
515
  separation of from the body, 400.
  left in utero, how extracted, 400.
  in utero after expulsion of the trunk,
     395.
Headache, treatment of, 304.
  after haemorrhage, 465.
Health and diseases, influence of, of
     coitus on, 280.
  effects of chastity on, 282.
  proper state of, for marriage, 293.
Heart-burn, 299.
Helminthia, worms, 498.
Hermaphrodites, 258.
  power of, to propagate  the species,
     258.
Hernia, of infants, 508.
  umbilical, 508.
  ventral of women, 323.
Hooks, blunt, description  of, 403.
Hiccup of infants, 508.
Hip-joint, disease, 503.
Hooping cough, treatment of, 489.
Hour-glass contraction, 481.
Hydatids in bladder, 192.
  in the uterus, 208.
Hydorrhce, spinous water, 3J7.
Hydragogues, 481.
Hydro-amnios, 319.
Hydrocele in infants, 506.
Hydrocephaloid affection, 497.
Hydrocephalorachy, 507.
Hydrocephalus, congenital,  506.
Hydrocephalus,  various kinds of, 495.
  dystocia from, 427.
Hydrometra, 211,317, 323.
Hydrops, abdominis, 321, 482.
  cellularis, 482.
  capitis, 427.
  ovarii, 366.
  scroti, 507.
  spina;, 427.
  thoracis, 366, 427.
  tubalis, 243.
  uteri, 316.
Hydrorachitis, dystocia from, 427.
Hydrothorax, 366.
Hymen, description of,  19.
  no proof of virginity, 19.
  diseases of, 175.
Hypochondriasis, 306.
Hypospasdias of infants, 507.
  effects on generation, 249.
Hysteralgia, 195.
Hysteria, 243.
  best  cure for, 283.
Hysteritis, puerperal, 442.
Hysterotomy, vaginal, 416.
Hysterotomotoky, 407.
                 I.
Icterus neophytorum, 494.
  of women, 302.
Ilium os, description of, 5.
Imagination, influence of, 64.
Impaction of the head, 390.
Impotence, 248.
  moral causes of, 253, 257.
  physical causes of, 264.
  treatment of, 261.
Impregnation, diseases affecting, 274,
    275, 277.
  physiology of, 35.
Infancy,  state of sexual organs in, 25.
Infanticide, account of, 149, 151.
  causes involuntary of, 156.
    voluntary of, 157.
  death of infants in utero, 150.
  mode of making autopsy, 149.
  ablution of, 472.
  constipation, 494.
Infantile remittent, 499.
Infants new-born, management of, 126,
    470.
  food of, 471.
  deformities of, 502, 504.
  and children, diseases of, 478.
  medicines for, 471, 475.
  rashes of, 509.
Infants, living, extraction ot", after pa-
    rent's death, 410.
Indigestion  of pregnant women, 298.
  of infants and children, 472, 493.
Inflammation of the bowels, 444.
  of the  mammae, 467.
  of the peritoneum, 443.
  of the uterus, 442.
  from dystocial labour, 357.
Insanity, puerperal, account of, 464,
Instruments, general reflections on,379.
  rules for the application of, 382.
Intermittent puerperal fever, 441.
Intertrigo, or chafing, treatment of, 508.
Intestinal irritation, 438.
Intussusception of infants, 507.
Invagination, intestinal, 507.
Invermination. 498-
Inversion of the uterus, 217,
Idoine, efficacy  of, 237, 502.
Irritation uterine, 196.
  intestinal, 438.
  spinal, 320.
Ischium os, 6.
Itching, intolerable, of thegenitals,172.
Jaundice of infants, 494.
  of gravid women, 302-
Joints of infants, diseases of, 502.
  of the pelvis, account of, 6.
  scrofula, 499.
  inflammation of, from labour, 357.
  separation of during pregnancy, 307.
                K.
Knee-joint diseases of, 502.

Labia pudendi cohesion of 506.
  diseases of,  171.
  majora, 17.
  minora. 18. 
516
INDEX.
Labia* erysipelas of, 3.
   excrescence of, 172.
   infiltration of, 359.
   inflammation of, 171.
   sloughing of, 79.
   tumours of, 172.
   ulcers of, 173.
Labour in a state  of nature, 95.
   signs of, 103.
   proportion of natural and preternat-
     ural, 109,  112.
   causes of at ninth month, 98.
Labour,whether attended with pain,99.
Labours premature, abortion, 100,118,
     145.
   causes of, 145.
   homicide to induce, 145.
   remote causes of, 100.
   natural mechanism of, 15,  115.
   divided into periods or stages, 102.
   first stage, description of, 103.
     duties of obstetrician in, 118.
     examination  in, 120.
   second stage, 105.
     duties, 123.
   third stage, duties in, 129.
   natural, remarks on, 130.
   classification of, 108.
Class I. Eutocia, natural labour, 111.
     II. Dystocia,  preternatural  la-
          bour, 332.
    III. Chiragotocia, manual, 368.
     IV. Organikotocia, instrumental,
          380.
      I.  Eutocia,  109.
          anenergica,  want of power,
            133.
          gemina,   twins,  multipar-
            ous,  135.
          phrenalgica,  mental affec-
            tions, 132.
          protracta, 133.
          quadruplex, quadruple, 132.
          quintuplex, quintuple, 134.
          sextuplex, sextuple,
          triplex, triple,  135,
Class II. Dystocia.  Vide Dystocia,
            315.
     III. Chiragotocia, Vide Version,
            368.
     IV. Organikotocia.
        instrumental parturition, 380.
Labours, dystocial, difficult, 315.
   classification, 108, 109.
   abdominal 373.
Labours amorphic from distorted pel-
     vis, 351.
   ascitic, from  ascites of infants, 427.
   aural, 357.
   brachial, 37T.
   convulsive, with convulsions, 363.
   crural, 357.
   decidual, 133.
Labours,  from rigidity or  rupture of
        membranes, 133.
     dorsal, 373.
     ectopfal,  from  displaced uterus,
      348.
     embryonosologic, from diseases,
       of  the fetus,  355.
     epileptical, 363.
     facial, 356.
     femoral, 369.
     frontal, 356.
     funical, from  descent, length, or
       shortening  of cord, 367.
     genitalis, knee presentation, 369.
     glutealis, breech, 354.
     gynaeconosologic diseases of the
       mother, 348, 351.
     haemorrhagic, 331, 334, 363.
     hernial, 366.
     humeral, 355.
     hydrocephalic, 427.
     hydrorachitic, 427.
     laceratoria, with rupture of uterua
       or  vagina, 358, 359, 360.
     manual, 355.
     nucal, 357.
     occipital, 357.
     ovaric, with enlarged ovary, 240,
       3b6.
     pedal, 368.
     placental,  366.
     pluralis multiparous, 135, 427.
     retentive,  retained placenta, 428.
     syncopal, 366.
     temporal, 367.
     transverse, 367.
     vertical, 416.
     vesical, 359.
Leg, puerperal swelled, 456.
  varicose veins of 321.
Leucorrhoea, 146,  198.
  of infants and children, 77, 485.
Lever application of, 401.
Legitimacy, legal  questions on, 91.
Lienteria  of infants, 497.
Ligaments of the uterus, 24,
Linea alba, incision of, 416.
Lingua iigata, 507.
Lives of  mother and infant, when to
  be sacrificed, 405.
Lividity cadaverous, and ecchymoses,
    159.
Liquor amnii, premature discharge of,
    133.
Lochia, or puerperal discharge, 435.
Lochionosology, or puerperal diseases,
    432.
Locked head, 390.
Longings, remarks on, 68.
Lungs, floating of, in water, 154.
  remarks on, 155, 164.
                 M.
Madness, puerperal, 464. 
INDEX.
517
Mammae, pain of after conception, 84.
  inflammation of, 467,
  in infants, 508.
Management of new-born infants, 91,
    470.
  of children, 473.
  of puerperal women, 432.
Mania, puerperal 464.
Marasmus 498.
Marks on bodies of children, 64.
  influence of imagination on, 64.
Marriage,  age proper for, 283.
  disqualifications for, 246, 284.
  early, injurious effects of, 247, 290.
  hygienic effects of, 279.
   influence of temperament on, 285.
Masturbation, effects of, 247, 265.
Measles, 482.
Meatus urinarius, 18.
Meconium, 471.
Medicines for infants, 471.
Membrana decidua, 50.
   protusion of, 104.
   rigidity of, 133.
 Menses, absence of, 223.
   absurdities concerning, 30.
   chemical properties of, 8.
   cessation of, 32, 248.
   commencement of, 27.
   derangement of, 224.
   effects of on health, and diseases, 27,
       33.
   eruption of, 27.
   establishment of, 26.
   excessive, menorrhagia, 232.
   hygienic precautions, relating to, 34.
   irregular, 196.
   management of women at this  pe-
       riod, 33
   laborious or painful, 230.
   physical properties of, 31.
   physiology of, 27.
   superfluous, 232.
    suppression of, 228.
    vicarious, 33.
    menorrhagia, 232.
    lochialis, 435.
 Menstruation, See Menses, 223.
 Mercury, bad effects on infants, 476.
    large doses of, 452.
 Mesenteric  glands, diseases of, 502.
 Metritis, 442.
 Miliary fever, 442.
 Milk fever,  442.
 Milk-flow absent, 468.
    deficient 468.
    depraved,  469.
    superfluous, 469.
    moral and physical influence on, 470.
 Milks of different animals, 469.
 Mind, despondency of, 306.
    influence  of, on fetus, 64.
    labour, 122.
Misdentition, 493.
Miscarriage, 324.
Mislactation, 468.
Moles, nature of, 207.
Mollities ossium, 10.
Mons-veneris, 17.
Monstrosity, causes of, 72.
Monsters, extraction of, 427.
   law relating to, 260.
Motions, violent of fetus, 323.
   absence of,
Muguet, 486.
Muscles, painful state of, 320.
Myrtiformes carunculae, description of
    19.
                N.
Naevus maturnus, 507,
Navel string, origin of, 54.
   haemorrhage from, 156, 507.
   mode  of tying, 128,507.
   ulceration of, 507.
   rupture of,  156.
Nausea, 298.
Neck scrofula of, 501.
Neuralgia of side, 243, 320.
   crural. 456.
Neuritis crural, 406.
Nipple,  excoration of, 467.
 Noma, account of, 508.
Nurses, disqualification of, 473.
   qualification of, 474.
 Nymphae, description of, 18.
   diseases of, 174.
   elongation of, 19.
 Nymphomania, 246.
                 O.
 Obliquities of uterus impede  labour,
     315, 347,
 Obstipation, 300.
 Odontia dentitionis, 493.
   dolorosa, 493.
 Onanism,  bad effects of, 265.
 Ophthalmia purulenta, 484.
   neonatorum, 484.
 Opiates, for infants, 441.
   large doses of,  444.
 Organikotocia, 380.
 Organs sexual, discription of,  62.
   external diseases of, 170.
   internal diseases of, 177.
 Operation, Caesarean. description of,
     416.
 Os coccyx, description of, 4.
   ilium, 5.
   ischium 6.
   pubis, 6.
   sacrum, 3.
 Ossa coxalia, 5.
   innominata, 5.
 Ova, 23, 44, 46.
 Ovaria, diseases of,  235.
                  P.
 Pains, false, 306. 
518
INDEX.
    in muscles, 320.
  Palate, cleft, 507.
  Palpitation, 302.
  Paracentesis abdominis, 321.
    cranii, 427.
    rachitis, 427.
    scroti,
    thorcis, 366, 427.
  Paralysis of infants, 503.
    after delivery, 464.
    of inferior extremities, 464.
  Parthenosology, 170.
  Parts,  sexual  dilatation of, in labour,
     104.
 Parturition,comparative of animals, 91.
    natural, 95.
    physiology of, 100.
    premature, 100, 118, 335.
    stages of, 102.
    dystocial, 315.
    eutocial, 109.
    instrumental, 380.
   manual, 368.
 Passions, influence  of,  on fetus in
     utero, 64.
   on coition, 253.
   influence of, on labour, 122.
 Pelvis, bones of, 2,
   articulations and separation of, 6.
   difference  of,  relative to age, sex,
     and species, 7.
   deformities of, 9.
   causes of, 9.
   dimensions, diameters, and axes of,
     11.
   obstetricial divisions of, 11.
 Pelvis,  contraction, and excess of am-
     plitude, 51.
 Penis, diseases of which cause impo-
     tence, 250.
 Perforation of the head—vide Craniot-
     omy, 421.
 Perforator, application of, 422.
   description of, 424.
 Perineum, laceration of, 176, 464.
   support of, 124.
 Peritonitis, 443.
   of infants, 486,
 Pessaries, 219. 222.
 Phlebitis crural, 456.
   uterine, 449.
Phlegmasia dolens, 456.
Phrentis, 464.
Phthisis, 292, 304.
Physiology gynaeco, 25.
Physometra, 211, 323.
Pica, 224, 229.
Piles, 301.
Placenta, development of, 51.
   extraction of from vagina, 129.
   from uterus, 428.
   removal of,  129.
   detention of, 428.
    symptoms arising from, 443.
  Planes of the pelvis, 11.
  Pleuralgia, 319, 322.
  Pleurisy in pregnant women, 322.
    in children, 486.
  Pleurodinia, 322.
  Pleuro-pneumonia, 487.
  Plurality of infants,  135, 427.
  Pneumonia of infants, 488.
  Pollution diurnal,  268.
    bad effects of, 265, 280.
 Polypus vaginae, 180.
   uteri, 202.
 Position obstetric, of different countries,
    124.
 Pregnancy, signs of, 83.
   diseases of, 296.
   detection of, 85, 86.
   different stages of, 86.
   duration of, 90.
   extra uterine, 311,
   ovarian  account of, 223.
 Pregnancy, tubal, 323.
   ventral," 323.
   signs  of quickening,  85, 149.
   salutary effects of, 283.
   supposed bad effects of, 286.
 Premature delivery, 390.
 Presentations, 16, 115.
 Procidentia uteri, 218.
 Prolapsus ani in infants, 508.
   uteri, 217.
   vaginae, 180.
   vesicae, 359.
 Prolicide, 159.
 Pruritus, account of, 172.
 Ptyalism, 300.
 Puberty, changes produced by, 27.
   diseases cured by,  27.
 Pubis, incision of, 419.
   os, description of, 5.
 Puerperal diseases, 432.
   convulsions, 363.
   fever,  history of,  445.
   pathology of, 446.
   symptoms of, 448.
   treatment of, 450
   inflammations, 442.
   mania, 464.
Purulent discharges, of children, 77.
  ophthalmia, 493.
Pyrosis, account of, 298.

Quickening, 85, 144, 150.
  legal questions on,  144.
Quinsy, 488
                R.
Rachialgia, 320.
Rachitis, 503.
Ramollissement of stomach, 499.
Rape, 73.
Rashes of infants, 509.
 Rectar fistula, 177. 
INDEX.
519
Red gum, 509.
Redundance of amniotic funid, 319.
Remedies aprodisiac, 270.
Remittent fever of children, 498.
  of pregnant women, 300.
  of puerperal, 445.
Reproduction physiology  of, 35.
  influence of season on, 287.
Respiration of infants, 126.
Ritching, 298. '
Retroversion of the uterus, 313.
Rickets,  503.
Rigidity  of the genitals, 134.
Rocking  infants, 472.
Rupture, premature, of  membranes,
    133.
  when required, 134.
  of the uterus, 308.
Rye, ergot, real properties of. 136.
  doses of, 141.
  use of in haemorrhage  143.
                S.
Scalds, 509.
Scalp tumefaction of, 506.
Scarlatina of adults, 411.
  infants, 481.
Scrofula 411.
  of hip and knee joints, 502.
  of mesenteric  glands, 502.
  of neck, 430.
Season, influence of on reproduction,
    287.
Secale cornutum, 136.
Secundines, retention of, 428.
Seminal  fluid, flux of, 265, 268.
  bad effects of 265.
  influence of on economy, 280.
Sex, ambiguity of, 258.
Sexual fluids, diseases of, <it% «*"•
  organs description of, 17.
  diseases of, 170.
Singultus of infants, 493.
Sinking after delivery, 338, 481.
Skin diseases of, 482, 473, 477.
Sleeplessness of infants, 493.
  of women, 300.
Sloughing of genitals, 79, 181.
  of infants 508.
Small-pox, 480.
Snuffles, malignant, 487,
Soda clorida in scarlatina, 482.
Spasm after delivery, 437.
  of lower limb?, 320.
  of stomach, 300.
  of the  uterus, 323.
Spermatopia, 269.
Spina bifida, 427.
Spinal irritation, 506.
Spine, curvature, 503.
  causes of impotence, 251.
  diseases of, 320.
  dropsy of, 427.
Spitting of blood, 303.
Spurious waters, 317.
Stays, tight, bad effects of, 247.
Steatomatous, 202.
Sterility female, 277.
  male, 274.
Stethoscope, use of in doubtful
     pregnancy, 85, 87
Stone in the bladder, 193.
Strangury, 308.
Strophulus intertrinctus, 509,
Stuprum violentum, 73.
Suffocation from asphxia, 161.
            drowning, 161.
            hanging,  160.
            memphitic, 160.
  pressure on head, 160.
Sugillation, 159.
Superfoetation, 88.
Support of perineum, 124, 180.
Suppression of menses, 228.
  urine, 188.
Survivorship, 149.
Suspended  animation, 161.
Swelled leg, 456.
Swelling of breasts of infants, 508.
Sympathies in gravid state, 296.
Symphyseotomy, 419.
Symphisis division of, 419.
Syncope,  303.
Syphilis of fetus in utero, 321.
  in gravid state, 322.
  of new-born infants, 483.
  ill cured, effects of, 319, 321, 329.
                T.
Tabes, mesenterica. 498.
Tapping—See Paracentesis, 321.
Teething, 493.
Temperaments,  influence of on gene-
     ration, 285.
Test, hydrostatic, value  of,  153,
Testes, removal of, no bar to one pro-
     lific coition, 249.
  diseases of, 263.
Tetanus of infants, 433.
Thrush, 486.
Toes,supernunaerary,operation for, 507.
Tokology parturition, 95.
Tongue-tie, 507.
Tooth-ache, effectual cure for, 305.
Terrefaction or burning, 160.
Tossings  of infants, 473.
Transfusion, operation of, 339.
Treatment after delivery, 432.
Trismus nascentium, 493.
Tubes uterine, 23.
  diseases of, 173.
  generation in, 88.
Tumours of various kinds, 202, 349.
Turning, description of,  363.
  operation described, 369.
  when impracticable, 373. 
520                               INDEX.
Turning, cases in which it is usefu-I, 375.
  in presentations of head, face, shoul-
      der, arm, &c. 377.
  spontaneous, 378.
  classification of, cases for, 379.
Twins, generation of, 88.
  manner of delivery, 135, 427.
Tympanities, 302.
Typhus, puerperal, 443.
                 U.
Ureter, spasm  of,322.
Urethra, excrescences of, 193.
  impervious, 506.
  irritability of, 188.
Urine, incontinence of, 308.
  in children, 506.
  suppression of, 188.
Uteri os dilitation, 103.
Uterine irritation, 196.
  haemorrhage, 329.
  various forms  of,—See  Haemor.
      rhage, 329.
Utero-gestation, signs of, 83.
  signs of different epochs of, 86.
  duration of, 91.
  diseases of*296.
Uterus, absence of, 278.
  anatomy of, 20.
  antiversion of, 315.
  cancer of, 211.
  cartilaginous  state of, 223.
  natural discharge of, 211.
  diseases of, 194, 255.
  difc^L^c.^cut  of, 216.
  distension of, gravid, 133.
  eclampsy impregnancy, 308, 322.
  extirpation of, 214.
  functions of, 22.
  gravid contents of, 47.
  haemorrhage  of, 329.
  hydatids of, 168.
  inflammation of, 442.
  inversion of after delivery, 437.
  irritable, 194,
  irritation of, 196.
  malformation  of, 194.
  obliquities  of,  315.
       impede  labour, 348.
  diseases of, impede labour, 350.
  ossification  of, 216.
  scirrhus, 211.
  various tumours of, 350.
  retroversion of, 313.
  rupture of,  in pregnancy, 308.
  tumours of, 202.
  ulceration of. 201.
Uterine tubes, 23.
  ligaments, 24, 25.
                V.
Vaccination, 509.
   Vagina, anatomy of, 22.
     diseases of, 177, 255.
     tumours of, 182.
   Vaginal examination, 120.
   Varicose veins of the legs, 321.
   Variola, 480.
   Vectis, description of, 400.
     use of, 401.
   Veins, varicose, 321.
   Veneris mons, description of, 17.
     diseases of, 174.
  Vermes, 498.
  Version, description of, 368.
     operation described, 369.
     when impracticable, 373.
    cases in which useful, 375.IJ
    in cephalic presentation,  377.
    in face, shoulder, and arms, 378.
    spontaneous, 378.
    classification of cases for, 379.
  Vesicula allantoids, 51.
    seminalis irritability of, 262.
    umbilicalis of, 50.
             dropsy of, 50.
  Vestibulum, description of,  18.
  Violation signs of, 73.
    legal questions on, 74.
  Virginity no proof of, 74.
  Violation, influence on conception, 62.
  Vomiting of infants, 493,
    pregnancy,  298.
  Vulva, irritability of, 22,  308.
                  VV.
  Wakefulness of infants, 477.
    women, 300.
  Walking, defect in, 503.
  Washing infants  and children, 472.
  Waterbrash, 298.
  Watery discharge from uterus, 211,317.
       323.
  Water in the head, 495.
    bag of, rupture of, 104.
  Weakness of constitution, 338,465.
  Weaning, 474.
  Weed, 441.
  Wheezing, 487.
 Whites description of, 182.
 Windpipe, 488.
 Women, management of in childbed,
      432.
 Women consumptive aptitude for con-
       ception of, 325.
 Womb,—See Uterus.
 Worms in bowels, 498.
   fever. 499.
   uterus, 217.
                  Y.
-Yellow Gum of infants, 494-
 Y^ow  jaundice  of gravid women,
    302.
 
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  " We have spoken in high terms of it because it possesses real and desirable excellencies."—Phila.
Med. Exam.

  " We can strongly recommend his ' Elements of Pathological Anatomy' to the  attention of the
pathological inquirer."—Amer. Med. Lib. and Intel.

  " It is not, indeed, of a character to be easily forgotten."—Boston Med. and Surg. Journ.
?S3= 
                  BARRINGTON  8c  HASWELL'S
      -t--------■———■-------------------------------------___________



               PHYSIOLOGY  AND  HYGIENE.



                         PHYSICAL AGENTS:


                             W. F. Edwards.

                                ON  THE

INFLUENCE   OF  PHYSICAL  AGENTS   ON  LIFE.


                By  W. F.  EDWARDS, M.D., F.R.S., Etc.


         TRANSLATED FROM THE FRENCH, BY DRS. HODGK1N AND FISHER.


To -which are added some Observations on Electricity, and Notes to the work.


                             1 vol. 8vo. sheep.

   This is a work of standard authority in Medicine ;  and, in a physiological point of view,
is pre-eminently the most valuable publication of the present century ;  the experimental inves-
tigation instituted by the author, having done much towards solving many problems hitherto
hut partially understood. The work was originally presented in parts to the Royal Academy of
Science of Paris, and so highly did they estimate the labours of the author, and so fully appre-
ciate the services by him thus rendered to science and to humanity, that they awarded hira,
though a foreigner, the prize founded for  the promotion of experimental physiology."





                           Thomas Lawson, M.D.


       METEOROLOGICAL  REGISTER

                         FOR THE YEARS 1826-30.


From Observations made by Surgeons of the Army and othert at the Military

                         Posts of the United States.


       Prepared under the direction of THOMAS LAWSON, M.D.,

                           Surgeon-General U.S.A.






                         ANIMAL  CECONOittY.


                               John Hunter.

        OBSERVATIONS  ON CERTAIN  PARTS  OF THE ANIMAL (ECONOMY.


INCLUSIVE OF several papers  from the philosophical transactions, btc.


                     By JOHN HUNTER,  F.R.S., Etc


              With  Notes, by  RICHARD  OWEN, F.R.S.


                              1 vol. 8vo. sheep. 
MEDICAL  PUBLICATIONS.
                              CLIMATE.


                             Sir James Clark


ON  THE  SANATIVE  INFLUENCE  OF  CLIMATE.


                            1 vol. 8vo. sheep.


 " It Is unnecessary to say anything of this work, as its value is too well known to the profession to
require any fostering at this period. The present edition is greatly superior to its predecessors."
— Western Lancet.
  " For amount of information, variety of details, and important instruction relative to the Interest-
ing subject to which it is devoted, we believe this work is unequalled.  It has been reprinted in an
elegant cheap form."—Gazette.
 ESSAYS  ON  PHYSIOLOGY AND  H YG I EN E, VIZ.:

I. Reid's Experimental  Investigation into  the Functions of the Eighth Pair
                               of Nerves.

II.  Ehrenberg's Microscopical Observations on the Brain  and Nerves  (with
                         numerous engravings).

III. On  the Combination of Motor and  Sensitive Nervous Activity;  by
                     Professor  Stroheyer, Hanover.

IV. Vegetable Physiology.
V.  Experiments on the Brain, Spinal Marrow, and Nerves.  By Prof. Maykr,
                        of Bonn (with wood cuts).

VI. Public Hygiene.
VII. Progress of the Anatomy and Physiology of the Nervous System, during
                      1836.  By Professor Muller.

VIII. Vital Statistics.  1 vol. 8vo.
                      PATHOLOGY.


                        Geo. Freckleton, M.D.

     OUTLINES  OF  GENERAL  PATHOLOGY.

                   By GEO. FRECKLETON, M.D.,
              Fellow of the Royal College of Physicians, &c.




                             John Hunter.

A TREATISE  ON  THE  BLOOD. INFLAMMATION,  AND  GUN  SHOT WOUNDS,


                     By JOHN  HUNTER, F.RS.


                   With Notes, by James F. Palmer,
    Senior Surgeon to the St. George's and St. James's Dispensary, &c, &c.


                           1 vol. 8vo. sheep. 
Il=-
BARRINGTON  &  HASWELL'S
n-
                          Wm. Thomson, M.D.


                      HISTORICAL NOTICES  05 THE


OCCURRENCE  OF  INFLAMMATORY  AFFECTIONS  OF  THE  INTERNAL ORGANS


              AFTER EXTERNAL  INJURIES AND SURGICAL OPERATIONS.


                     By WM. THOMSON, M.D., Etc.
                         James Macartney.

A  TREATISE   ON    INFLAMMATION.

          By JAMES MACARTNEY, F.R.S., F.L.S., Etc.



                        F. Magendie, M.D.

             LECTURES  ON THE  BLOOD,

    AND  ON THE CHANGES WHICH IT UNDERGOES  DURING DISEASE.

                     By F. MAGENDIE, M.D.
                                M. Gibert.


     CHANGES  OF  THE  BLOOD   IN  DISEASE.

              TRANSLATED FROM THE FRENCH OF M. GIBERT,

                    By JOHN H. DIX, M.D., M.M.S.S.


                           1 vol. 8vo. half sheep.

  "The treatise of M. Gibert is elaborate, and exhibits a very good view of the relations of the blood
to the morbid conditions of the system."—Western Lancet.
  u This is one of the best treatises on the changes of the blood in disease. It has been elegantly
translated from the French by Dr. Dix, of Boston, and is published for a mere trifle, by the enter-
 firising firm of Barrington & Haswell, of Philadelphia. It is a most valuable addition to a medical
 ibrary."— W. Gazette.
                        CONSTIPATION.


                             John Burne, M.D.         ,


A TREATISE ON THE CAUSES AND CONSEQUENCE OF HABITUAL CONSTIPATION.


                        By JOHN  BURNE,  M.D.,

Fellow of the Royal College of Physicians, Physician to the Westminster Hospital, etc.


                            1 vol. 8vo. muslin.


 " For some interesting cases illustrative of this work, the author is indebted to Dr. Williams, Dr.
Stroud, Dr. Callaway, Mr. Morgan,  Mr. Taunton, Dr. Roots, Sir Astley Cooper, Sir Benjamin
Brodie, Mr. Tupper, Mr. Bailer, Dr. Paris,Mr. Dendy, Dr. Hen. U. Thomson,"kc—Preface.
 
MEDICAL  PUBLICATIONS.                      T|
                            HYSTERIA.

                       Thomas Laycock.

              AN  ESSAY  ON   HYSTERIA.

BEING  AN  ANALYSIS  OF  ITS  IRREGULAR  AND  AGGRAVATED  FORMS.

     INCLUDING HYSTERICAL HEMORRHAGE AND HYSTERICAL ISCHURIA.

             With numerous Illustrative and Curious Cases.

                     By THOMAS LAYCOCK,
              House Surgeon to the York County Hospital.

                          1 vol. 8vo. muslin.
                              ETIOLOGY.

                                  Aretseus

       ON  THE  CAUSES AND SIGNS  OF ACUTE AND CHRONIC DISEASE.

                             FROM THE GREEK,

                By T. F. REYNOLDS,  M.B., F.L.S.,  Etc.

                              1 vol.  8vo. sheep.
  " The correct detail of symptoms, the nervous style, the graphic delineation of disease, displayed
in this author's work, the poetic and quaint fancies scattered throughout, give a certain Talue and
interest, that may fairly excuse an attempt to reinvest part of them in a vernacular garb."
  " We certainly have  no hesitation in recommending this curious volume to the  notice of our
readers.  Its price is a mere trifle."—New York Lancet.



                          SEMEIOLOGY.

                               Professor Schill.

 OUTLINES  OF   PATHOLOGICAL  SEMEIOLOGY.

            TRANSLATED FROM THE GERMAN OF PROFESSOR SCHILL,

                             With Copious Notes,

                     By D. SPILLAN, M.D, A.M., Etc.

                               1 vol. 8vo. sheep.

  " The sians of disease exhibited by the principal tissues and organs, are treated of
in a succinct  and comprehensive manner,  by Dr. Schill,  and as a work of daily
reference to assist in distinguishing diseases, it cannot be  too highly commended. -

  « a „ „i„,T»n» and accurate translation of a very ingenious and instructive work. We donot know



equivocal merit."—A«» York Lancet. 

BARRINGTON  8c  HASWELL'S
T
  MATERIA   MEDICA  AND  THERAPEUTICS.



                              John Bell, M.D.


   A   PRACTICAL   DICTIONARY  OF   MATERIA

                              MEDICA :


  Including the Composition, Preparation and Uses of Medicines ; and a large

        number of Extemporaneous Formulx: together with important

                         Toxicological  Observations.


ON THE BASIS OP BHANDE's DICTIONARY OF  MATERIA MEDICA  AND PRACTICAL

                                PHARMACY.


                         By JOHN BELL, M.D.,

            Lecturer on Materia Medica  and Therapeutics, &c, &c.


                             1 vol. 8vo. sheep.


 " Mr. Brande's is an excellent work, and with the retrenchments, additions, and alterations of
Dr. Bell, may be regarded as one of the most  valuable works on the Materia Medica we now
possess. It has an important advantage over many of the treatises on this subject, in giving a large
number of prescriptions for the administration of the principal articles. This renders it especially
valuable to the young practitioner." —Bait. Jour.
                           James Johnstone, M.D.


    A THERAPEUTIC ARRANGEMENT AND  SYLLABUS OF  MATERIA  MEDICA.

                     By JAMES JOHNSTONE, M.D.,

Fellow of the College of Physicians, and Physician to General Hospital, Birmingham.


                              Small vol. 8vo.

 " This book cannot but be particularly useful  to those who intend to lecture or write upon
the Materia Medica; as well as to the students for whose particular use it is prepared."—Brit.
and For. Med. Rev.
                  Henry Clutterbuck, M.D.

LECTURES   ON   BLOODLETTING.

           By HENRY  CLUTTERBUCK,  M.D.

                    1 vol. 8vo. half sheep.
                           A. Turnbull, M.D.

THE  MEDICAL  PROPERTIES  OF THE NATURAL  ORDER  RANUNCULACE*. ETC.


                       Br A. TURNBULL, M.D.
8
 
—=T5SI
MEDICAL  PUBLICATIONS.
If
     THEORY AND  PRACTICE  OF  MEDICINE.

                                 Stokes and Bell.

                             LECTURES

ON THE  THEORY   AND   PRACTICE  OF   PHYSIC.

                            By JOHN BELL, M.D.,

Lecturer on Materia Medica and Therapeutics; Member of the College of Physicians,
      Philadelphia, and of the American Philosophical Society, etc., etc.; and

                              WM.  STOKES, M.D.,

   Lecturer at the Medical School, Park Street, Dublin ; Physician to the Meath
                             County  Hospital, etc., etc.

   Third American  Edition, much enlarged and improved.  2 vols. 8vo. sheep.

  " With such additions and improvements, we consider  the work one of the best of its kind with
 which we are acquainted."—Maryland Med. 6r Surg. Journ.
  "The work has now assumed the form of a quite complete system of medicine, equally valuable
as a  text-book to the student, and a book of reference to  the practitioner."   We know of no book
of the kind which we would more readily place in the hands of a student, or to which we would
more readily refer the practitioner, for a hasiy investigation of a subject. "-NewEng. Quart. Jour.
of Med. and Surg.
  " Stakes and Bell's Practice being among the best works extant on practical medicine, will at
once commend itself to the practitioners of our country.  It is not going too far to declare, that no
nhvsician. whether his experience be large or small, should be without this work in nis library;
and, having it there, he should study its various parts with care and attention."— Western Lancet.
  "This work, of established reputation, is sent out from the press of Messrs. Barrington and
Haswell, Philadelphia.  No change in the mind of the medical public, touching the worth of this
very celebrated series  of medical lectures, has been wrought by the advent of later publications
on the same subjects.  It  is just as  popular as ever, and we believe, at this moment, is exerting a
far more extensive influence than was ever predicted by the warmest personal friends ol the two
learned authors."—Boston Med. and Surg. Jour.

The following is  from  the pen  of a distinguished Professor in  one  of the Medical
      Schools in the West.
  "We cordially recommend the joint labours of two  such distinguished physicians as Drs.
Stokes and Bell  to the notice of the medical profession.  They will be found to embody the prin-
ciples and practice of medical science down to the present moment."—Louisville Journal.
                              John Armstrong, M.D.

          LECTURES ON THE  MORBID ANATOMY, NATURE, AND TREATMENT OF.

                  ACUTE  AND  CHRONIC  DISEASES.

                          Bv  JOHN ARMSTRONG, M.D.,

      Author of " Practical Illustrations of Typhous and Scarlet Fever," etc.


                             EDITED BY JOSEPH RIX,

                   Member of the Royal College of Surgeons.

                                 1 vol.  8vo. sheep.

  •• Wo admire, in  almost every page, the precise and "««»»■ I™**"!*1^
ing  allusions  to instructive cases;  the urgent recommendations of_the P"^' '0*ethc*™
lobe diligent in observation, to avoid hurry and heedlessness, to be attentive <to the poor.
Nothing  can  be more excellent than the rules laid down for all the parts of the de cate
ma  iffemen  of fever patients: nothing more judicious than  the general .nstrucUons arising

imr the employment of some of the heroic remedies, as mercury, a.rsen'ci«n^°'^"i"ne"enSd
hs  powers of observation  and his  practical merits."  "The p.ous office of Paving and
pubMsliing his Lectures has been performed by Mr. Rix, with singular ability."-Bnt. and For.
Med. Rev.
 
A
                  BARRINGTON  8c  HASWELL'S

      -,__---------------------------------------------------------------------------------------------------------------------------------■----------------------*~


                            Alex. D. Gait. M.D.


                   PRACTICAL   MEDICINE.


       Illustrated by Cases of  the  Most Important  Diseases.


                     Edited by JOHN  M. GALT, M.D.,

                             From the Papers of

                 ALEXANDER  D.  GALT,  M.D.

         For many years an extensive practitioner in Williamsburg, Va.


                          1 handsome vol. 8vo. sheep.





                         Charles  J. B. Williams, M.D.


                PRINCIPLES  OF  MEDICINE:


Comprehending  General  Pathology and  Therapeutics*


              Br CHARLES J.  B. WILLIAMS, M.D..F.R.S.


With numerous additional Notes, Explanatory and  Critical, by the  Editor of the

             Select Medical Library and Bulletin of Medical Science.


                               1 vol. 8vo. sheep.

 "We consider, in fact, that in producing it, Dr. Williams has still further enhanced his
already high character with the profession and the public."—Med. Chir. Rev.
 " It is without a competitor in our language, and fills most successfully a decided gap in our
medical literature."—Philad. Med. Exam.
 " We would advise no one to  set  himself down in practice unprovided with a copy.  Even
among the old and experienced practitioners, we venture to say that there are few who will
not benefit by a perusal of this work."—Brit, and For. Med. Rev.
 " The reader will derive greater  pleasure, and more useful practical knowledge from this
book than from any other treatise on the  subject that we are acquainted with."—Dub. Jour.
of Med. Scien.
 "We would gladly see Dr. Williams's valuable book in the hands of every practitioner, satisfied
as we are, that  the cultivation of these  branches, in addition to those more commonly studied,
is the only method by which practical medicine can be severed from empiricism."—Western
Lancet.
 "In consideration of the advances made in recent years in the multitudinous subjects com-
prised in this branch of medicine, a  special treatise  must surely be quite acceptable; and this
one, including  the  notes, more copious  than usual, of the annotator, cannot fail to reward the
reader both with pleasure and profit."—N. Y Jour, of Med. and the Uollat. Sciences.
                            Henry Holland, M.D.

       MEDICAL  NOTES   AND   REFLECTIONS.

                  Br HENRY  HOLLAND,  M.D., F.R.S.,

Fellow of the Royal College of  Physicians, and Physician Extraordinary to the
Queen.
SS3=-
k 
MEDICAL  PUBLICATIONS.
                            Davidson and Hudson's


                       ESSAYS   ON   THE


SOURCES  AND   MODE  OF  ACTION   OF   FEVER.


 " The volume before us abounds in details of a highly instructive kind, and manifests a vigorous
and healthy tone of invesiigation, which, even in its indirect effects, cannot but be beneficially felt
by the American reader."—Bulletin of Med. Science.
 " Dr. Davidson evinces an intimate acquaintance with the subject which he treats, and embodies
in his essay a lar"e amount of valuable matter. The subject is one of intrinsic interest, and will
well repay the student for the time and labour devoted to its examination."— Western Lancet.
                                  Bouillaud


ON   ACUTE   ARTICULAR    RHEUMATISM   IN    GENERAL,


                       TRANSLATED  FROM THE  FRENCH,


               By JAMES  KITCHEN, M.D., Philadelphia.


                            1 small vol. 8vo. muslin.






                             S. H. Dickson, M.D.


                        ON   DENGUE:




                     By S. HENRY DICKSON, M.D.,

  Professor of the Institutes and Practice of Medicine in the Medical College of S.C.


                            1  small vol. 8vo.  muslin.






                             John Macrobin, M.D.


  INTRODUCTION TO THE  STUDY  OF  PRACTICAL

                               MEDICINE :


       Being an  Outline of the Leading Facts and Principles  of the Science.


                           1 small vol. 8vo. half sheep.


   .m, M,rrAhin'q work is lareely made up of the principles or medicine, embracing the patho-
  ^X^'f^sT^^S^L^Te be eSeemed  a nucleus around which the student
  mly, with Stage, gather a more extended system."-^*™ Lancet.
 
^___........._____--------------------—*=aa
BARFUNGTON  8c HASWELL'S
A
                            INDIGESTION.


                              Robert Dick, M.D.


     DERANGEMENTS, PRIMARY  AND   REFLEX,


                 ©if  sas ®m®.M$rs  ©if  educsjis©ini©3ES,o

                          By ROBERT DICK, M.D.,
                 Author of" A Treatise on Diet and Regimen."


                               1 vol. 8vo. sheep.

  "Tt is the fullest, most comprehensive, and decidedly the best account  of derangements of the
digestive organs that we have encountered.  While it embraces all that is important or interesting
to be found in the writings of other authors, it contains much original  information, which the
physician will find of great practical usefulness."— Western and Southern Medical Recorder.
  " We recommend this volume most warmly to the attention of our readers." — London Lancet,
No. 937.
   "  This volume may, in fact, be denominated with no small degree of propriety, an
encyclopedia of dyspeptic disorders, and we unhesitatingly commend it, as the most
useful and comprehensive treatise on  this  class  of diseases with which we  are  ac-
quainted."—N. Y. Lancet.
   " We have perused this work with  pleasure and instruction.  It is decidedly the
best  compilation iu the English language on the extensive class of disorders and dis-
eases comprehended under the term dyspepsia, united with a very large  proportion
of original  matter, both in the form of able  comments on other writers, and practical
information derived from the author's own experience."—Med,-Chir. Rev.
                 EPIDEMICS OF THE  MIDDLE AGES.



                             I. F. C. Hecker, M.D.


          EPIDEMICS  OF  THE  MIDDLE  AGES.


                             From  the German of

                     I. F.  C. HECKER, M.D., Etc, Etc


             Translated  by R.  G. BABINGTON, M.D., F.R.S.


      NO  I.--THE BLACK DEATH  IN  THE FOURTEENTH CENTURY.

  " Hecker'saccount of the ' Black Death,'which ravaged so large a portion of the globe in the
fourteenth century, may be  mentioned as a work worthy of our  notice, both  as containing
many interestingdetails of this tremendous pestilence, and as exhibiting a curious specimen
of medical hypothesis."—Cyclopedia of Practical Medicine.


                      NO.  II.---THE DANCING  MANIA.

  " Medical History has long been in need of the chapter which this book supplies; and the
deficiency could not have been  remedied at a better season.  On the whole, the volume ought
to be popular; to the profession it must prove highly acceptable, as conveying  so much infor-
mation, touching an  important subject which had almost been suffered to be buried in obli-
vion, and we think that to Dr. Babington especial thanks are due for having  naturalised so
i n teresti ng a production. The style of the  translation, we may add, is free from foreign idioms:
it reads like an English original."—Lond. Med. Oaz.
I
13 
MEDICAL PUBLICATIONS.
                              TETANUS.
                         Thomas Blizard Curling.
               A  TREATISE  ON  TETANUS.
     BEING THE ESSAY FOR WHICH THE JACKSONIAN PRIZE WAS  AWARDED.
                  By THOMAS  BLIZARD  CURLING,
              Assistant Surgeon to the London Hospital, etc., etc.
                            1 vol. 8vo. muslin.
 " This book should be in the library of every surgeon and physician.  It is a valuable work
of reference. It does not pretend to originality, for originality on such a subject was  not
wanted   But a compendium of facts was wanted, and such a compendium is this volume.  We
cannot part from Mr. Curling without thanking him for the information we have recetved."-
Mcd. Cliir. Rev.
                         INSANITY.
                     James Cowles Prichard.
              A  TREATISE  ON  INSANITY,
amb  ©mmaia  ronsBAflisB AiFiriso^nsr®  irmm  mtjihib.
       By JAMES COWLES PRICHARD, F.R.S., M.D.,
            Corg. Member of the Institute of France, etc.
                             1 vrjl. 8vo. sheep.
 '♦ The author is entitled to "reat respect for his opinions, not only because he is well known
as aT^nUo?°eX"[veeerudifioen, but also on account of W-.P'"^"^^^ ^ lhe
subject on which he writes.  The work, we may safely say, is the best, as well a,
on mental derangement, in the English iangaaSe."-Medico-Chv. Rev.
 with  the
the latest,
                             I. G. Millingen.
                        APHORISMS  ON THE
TREATMENT   AND   MANAGEMENT  OF  THE   INSANE.
               WITH  CONSIDERATIONS ON PUBLIC AND PRIVATE
                         LUNATIC  ASYLUMS,
        POINTING OUT  THE  ERRORS  IN  THE PRESENT SYSTEM.
                      By I. G. MILLINGEN,  M.D.,
    Late Medical Superintendent of Lunatic Asylum, Hanwell, Middlesex, etc.
                             1 vol. 8vo. sheep.

[he best thingof the kind we ever perused."-!*. Johnson's Review.
                       M.  Esquirol.
A  TREATISE  ON   MENTAL  DISEASES.
                    By M.  ESQUIROL 
If                      BARRINGTON  8c  HASWELL'S                      W
                                   CHEST.

                         Charles J. B. Williams, M.D.

                               LECTURES ON  THE

 PHYSIOLOGY  AND  DISEASES   OF  THE  CHEST.

      INCLUDING THE PRINCIPLES OF  PHYSICAL AND GENERAL  DIAGNOSIS,

              Illustrated by an Exposition of their Physical Signs.

                                     WITH

    NEW  RESEARCHES  ON THE SOUNDS  OF THE HEART.

                   By CHARLES J. B. WILLIAMS, M.D.

                        Third edition.   1 vol. 8vo. sheep.

  "Evidently written by a man thoroughly acquainted with his subject."—Lancet.
  " We strongly  recommend this work to the attention of  auscultatois.''— Med. Chir. Rev.
  " I gladly avail myself of this opportunity of strongly recommending this very valuable work."—
Dr. Forbes's Translation of Laennec.
  " Of all the  works on this subject, we are much inclined to prefer that of Dr. Williams."—Med.
 Gazette.



                             W. W. Gerhard, M.D.

     LECTURES   ON  THE   DIAGNOSIS,  PATHOLOGY, AND  TREATMENT  OF

                 DISEASES  OF   THE   CHEST.

                        By W. W. GERHARD, M.D.,
       Lecturer on  Clinical  Medicine in the University of Pennsylvania, etc.

                               1 vol. 8vo. sheep.

  " A series of clinical lectures—concise, lucid, and eminently instructive.  We have
no more able expositors of diseases of the chest than Dr. Gerhard, and any work of
his  on these important subjects is oertain of grateful acceptance by his  professional
brethren."—New York Lancet.
  " To our readers, therefore, we recommend the book of Dr. Gerhard  as the fullest and most judi-
cious  manual, in relation to the  disea.es of the chest, which they can procure."— Western and
Southern Recorder.
  "These lectures constitute a useful and practical digest of the existing knowledge of the diseases
of the  chest (lungs and heart)."—Bulletin of Medical Science.
                         G. Hume Weatherhead, M.D.

    A PRACTICAL TREATISE ON THE  PRINCIPAL DISEASES  OF THE LUNGS.

 CONSIDERED ESPECIALLY IN RELATION TO  THE  PARTICULAR TISSUES AFFECTED,
                 ILLUSTRATING  THE DIFFERENT KINDS OF COUGH.

                   By G. HUME WEATHERHEAD, M.D.,
Member of the Royal College of Physicians, Lecturer on the Principles and Practice
         of Medicine, and on Materia Medica and Therapeutics, etc., etc.

                               1 vol. 8vo. muslin.
14 
MEDICAL  PUBLICATIONS.
                               Wm. Stokes, M.D.

A TREATISE ON THE DIAGNOSIS AND  TREATMENT  OF DISEASES OF THE CHEST.

                  By WM.  STOKES, M.D., M.R.I.A., Etc.

           Second Edition, with an Introduction and Numerous Notes,

                          BY THE AMERICAN EDITOR.

                               1 vol. 8vo. sheep.

 " Altogether this is one of the  most useful of the publications that have recently issued
from the press,—one thatshould be studied by every man who presumes to treat the
class of diseases on which it is written.  It is delightful, indeed, to contemplate the
sound  pathology and rational  therapeutics which it inculcates; — so dilFerent from
the swelling egotism, the groundless assertions, the illogical conclusions, and often
empirical treatment, recommended in some of the modern works on these and other
important medical subjects."—Med. Examiner.
  " The present edition has been much enriched  both by the author and editor.  No
inconsiderable pait of the book is made  up of Dr. Bell's notes, and it now constitutes
one of our most useful treatises on the diseases of the chest, characterized by sound
pathology and  rational therapeutics."—New York  Journal of Medicine.
  " So well-known are the writings of Dr. Stokes, that no effort of the medical press
in this  country is necessary to increase their circulation.  Young practitioners would
find this volume a pathological  guide, which they would be unwilling  to part with,
when made familiar with its intrinsic value."  Boston Med. and Surg. Journ.
                            THE   HEART.

                                  T. A. Aran.

                              A PRACTICAL MANUAL

 ON   DISEASES  OF  THE  HEART  AND  GREAT   VESSELS.

                         Translated from the French,

                     By  WILLIAM  A.  HARRIS,  M.D.

  " This is an excellent, epitome of a large and important class of diseases—especially
as to diagnosis."—.Med. Chir. Rev.
  "The Treatises of Senac, of Corvisart, of Laennec, of Bertin, of M. Bouillaud, of
M. Gendrin, and especially the excellent work of an observer whom death has pre-
maturely removed from the field of science (Dr. Hope), have been our principal
guides."—Extract from the Preface.
  " This work, though issued under the  modest  title of a manual, is yet so comprehen-
sive as to afford minute instruction on every point of which it treats."—Philad. Med.
Examiner.
  " We do not know of any production in which so much positive knowledge has been compressed
within moderate limits, and yet clearness of description presented, as in this manual.''—Bulletinof
Med. Science.
  " We hope this manual, comprising, as it does, n summary of what has been published in more
elaborate works, will be extensively read, and that the study of it may lead to a more correct
appreciation of the character of these diseases."—West. Jocr. of Med. and Sirg.
  " The present treatise will prove of great value, as it really contains all that is well known
on this most difficult yet important branch of pathology and therapeutics."—West. Lancet. 
Ml-,
—4i
BARRINGTON  &  HASWELL'S
                            John Marshall, M.D.

                      PRACTICAL OBSERVATIONS

     ON  DISEASES  OF  THE  HEART,  LUNGS,  STOMACH,  LIVER,  ETC.

                   OCCASIONED BY SPINAL IRRITATION:

AND ON THE NERVOUS SYSTEM IN GENERAL, AS A SOURCE OF ORGANIC DISEASE.

                            Illustrated by Cases.

                       By JOHN MARSHALL,  M.D.

                             1 vol. 8vo. muslin.
                       CUTANEOUS DISEASES.


                              Samuel  Plumbe.


A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  SKIN.

            Their Constitutional Causes and Local Character, etc.

                         By SAMUEL PLUMBE,

    Late Senior Surgeon to the Royal Metropolitan Infirmary for Children, &c.


Illustrated with Splendid Coloured Copper-plate and Lithographic Engravings. New
                            edition in preparation.


  Plumbe on Diseases of the Skin.—"This excellent Treatise upon an order of diseases, the
pathology of which is, in general, as obscure as the treatment is empirical, has just been repub-
lished, edited by Dr. John Bell, of this city. We hail with pleasure the appearanee of any new
work calculated to elucidate the intricate and ill-understood subject ofskin-diseases. The late
Dr. Mackintosh, in his Practice of Physic, recommends it as the 'best pathological and prac-
tical treatise on this class of diseases, which is to be found in any language.'"—Phil. Med. Exam.
  "This work is one of the most excellent on  the Diseases of the Skin in the English language."
— West. Jour, of Med. and Phys. Sciences.
                             Thomas Nunneley.


                         A  TREATISE ON THE

NATURE,  CAUSES,  AND   TREATMENT  OF   ERYSIPELAS.

                        By THOMAS NUNNELEY,
Lecturer on Anatomy, Physiology, and Pathology in the  Leeds School of Medicine,
            Surgeon to the General Eye and Ear Infirmary, &c, &c.

                             1 vol. Svo. sheep.

  "The work in its entireness is one which will be accounted necessary to  every
physician's library."—Western Journ. of Medicine  and Surgery.
  "Nothing short of a perusal of the entire book will  do justice to the author or reader."—
Western Lancet.

  " Did our space allow, it would be both interesting  and profitable to enter  into a
fulKanalysis of this work;  but we would advise our readers, one and all, to purchase
it, and thus judge of its value from a personal examination of its pages."—N. Y. Jour.
Med. and Collat. Sciences.
m=—
16
•=3S 
MEDICAL  PUBLICATIONS.
                           CLINICAL  MEDICINE.

                              P. M. Latham, M.D.

                     LECTURES   ON  SUBJECTS

   CONNECTED   WITH   CLINICAL   MEDICINE.


                          By P. M. LATHAM, M.D.,

  Fellow of the Royal College of Physicians, and Physician to St.  Bartholomew's
                                    Hospital.

                                ] vol. 8vo. muslin.

  " We strongly recommend them [Latham's Lectures] to our readers; particularly to pupils
attending the practice of our hospitals."—Lond. Med. Gaz.
                              Graves and Gerhard.


             CLINICAL   LECTURES.


                  By ROBERT  J. GRAVES, M.D., M.R.I.A.,

Professor of the Institutes of Medicine in the School of Physic, Trinity College, Dublin.


                   WITH  ADDITIONAL LECTURES AND NOTES,

                         By W.  W.  GERHARD, M.D.,

Lecturer on Clinical Medicine to the University of Pennsylvania, Physician to the

                       Philadelphia Hospital, Blockley,  &c.

                                 1 vol. 8vo. sheep.

  " In the volume before us, a series of clinical lectures by Dr. Gerhard is given, and forms a most
appropriate and acceptable  addition to those of Dr. Graves.  Between these two distinguished
physicians we can trace many points of resemblance.  AVe find in both the same professional zeal,
— the same powers of close and correct observation,-the same discriminating tact,-the same
disresard of idle theory,-and the same decision in the application of right principles. No stu-
dent or  practitioner should be without this volume.  It is m itself a library of practical medicine.
—AT. Y. Lancet.
G.  Andral's
CLINIC  ON  DISEASES   OF  THE
ENCEPHALON.
ABDOMEN.
CHEST.
  Either  of the  works can be had separate,-each forming a distinct

                                    volume.

                              Three vols. 8vo. sheep.

 « The ' Clinigue Medicale' is the great work of its  distinguished author  J^^^j^f^X
house of invaluable information in pathology and therapeutics. No ™f*'«l ^'^^"^X IS
without it; and every physician, with  the smallest Pf^ensions to scent .fie au a^m«« ' °™b'«
desirous of discriminating disease accurately, and of treating it skilfully, should stuay   pages uy

^A^dr^s^tensive researches in pathology entitle  all his work..to.the careful conridera.
tionoftheorofession; and all  must agree  that this great philosopher has enritheaine science
vl°th many^nportant'truths, derived from that fruitful source, cluneal observation and indue-
lion." —Western Lancet.
A
17
2* 
»=-
BARRINGTON  8c  HASWELL'S
                           URINARY  DISEASES.


                               Robert Willis, M.D.


URINARY  DISEASES  AND  THEIR  TREATMENT.

                        By  ROBERT  WILLIS,  M.D.,

              Physician to the Royal Infirmary for Children, etc., etc.

  " We do not know that a more competent author than Dr. Willis could have  been  found
to undertake the task ;  possessing, as it is evident from his work that  he docs possess, an
accurate acquaintance with the subject in all  its details, considerable personal experience in
the diseases of which he treats, capacity for lucid arrangement, and a style of communication
commendable in every respect."
  "Our notice of Dr. Willis's work must here terminate.  It is one which we have read and
trust again  to read with profit.  The history of discovery is successfully given ; cases curious
and important, illustrative of the various subjects, have been selected from many new sources,
as well as detailed from the author's own experience, chemical analyses, not too elaborate,
have been afforded, which will be most convenient to those who wish to investigate the qualities
of the urine in disease ;  the importance of attending to this secretion in order to  a proper un-
derstanding of disease is strongly insisted upon: in short, a book has been composed,  which
was much required, and which we can conscientiously and confidently recommend as likely to
be useful to all classes of practitioners."—Brit. $■ For.  Med.  Rev.
                            S XT R. G  E R. TT.

                                 John Hunter,

 LECTURES  ON  THE  PRINCIPLES OF  SURGERY.

                         By JOHN  HUNTER, F.R.S.

                    With Notes, by JAMES  F. PALMER,
    Senior Surgeon to the St. George's and St. James's Dispensaries, etc., etc.

                          With Plates, 1 vol. 8vo. sheep.

  " We cannot bring our notice of the present volume  toa close without offering our testimony
to the admirable manner in which the editor and annotator has fulfilled his part of the under-
taking.  The advancements and improvements that have been effected, up to our own day, not
only in practical surgery, but in all the collateral departments, are constantly brought before
the reader's attention in clear and concise terms."—Brit. § For. Med. Rev.
                            Samuel D. Gross, M.D.



                                   INTO THE

NATURE   AND   TREATMENT   OF  WOUNDS   OF

                        THE   INTESTINES.

                      By  SAMUEL  D.  GROSS, M.D.,
             Professor of Surgery in  the Louisville Medical Institute.

                  Illustrated by Engravings.   1 vol. 8vo. muslin.

.1' Wf .K°nsid.ir '*,? v£,uab,e contribution to our literature, and as worthy of the high reputa-
tion of the author."—Philad. Med. Exam.

  "We  dismiss  the 'Experimental  Inquiries,'fully persuaded  that  the valuable
truths with which they abound, will  be the best  recommendation to the  medical
public."—A^.  0. Med. Jour. 
w=—
MEDICAL  PUBLICATIONS.
                                   Robert Liston.


                   ELEMENTS   OF  SURGERY,


                              By ROBERT LISTON,

Fellow of the Royal College of Surgeons in  London  and Edinburgh, Surgeon to
       the Royal Infirmary, Senior Surgeon to the Royal Dispensary for the
              City and County of Edinburgh,  Professor of Surgery in
                          the London University, etc., et..


                    Edited by  SAMUEL D. GROSS,  M.D.,

Professor of Surgery, Louisville Medical Institute.   Author  of Elements of Patho-

                             logical Anatomy, etc., etc.


 Third American, from the Second London Edition, with upwards of one hundred

                and sixty illustrative Engraving3.   1 vol. 8vo. sheep.


  " We must not forget to mention that the volume is rendered still more attractive by the addition
 of numerous wood engravings (some of them introduced by Dr. Gross), all finely executed. These
will be found of very considerable advantage to the  student, materially assisting him in compre-
hending the  explanation of morbid structure.  Another admirable feature, is the printing of the
notes in type of the same size as that of the text. This obviates almost entirely whatever objec-
tions can be alleged against foot-notes."— Western Jour, of Med. and Surg.
  "We are here presented with a republication of Mr. Liston's admirable  and much praised work
on Surgery,  which has been  subject to the alembic of a critical and learned friend, Dr. Gross.  He
has added ' copious  notes and additions,' such as the progress of surgery in the United States
demands in order to meet the wants of the surgeon. Professor Gross has also given an entire article
on Strabismus, and another on Club Feet, which were wholly omitted in the English copies.  They
may be regarded important, inasmuch as they give  a completeness  to  an otherwise unfinished
treatise.  The execution of the book is good; the paper firm, and well secured in the binding.  The
 plates are uniformly well executed, and the impressions distinct."—Boston Med. and Surg. Jour.
   "In another essential feature this edition is  greatly improved.  With the principles is taught
 also with it the practice of surgery; and both morbid structure and operations are doubly described;
 first by the author and editor, and next by the graver of the artist."—Bull. Med. Scien.
   " Mr. Liston's reputation as a clear, accurate, and scientific surgical writer, is so widely known
 and admitted, that formal panegyric is quite unnecessary.  Dr. Gross has discharged his duties as
 editor, with all the sound sense, accurate discrimination, and experienced judgment, which all who
 knew him expected.  The additions and notes are indeed profitable and interesting ; and our only
 regret is, that they are not still more numerous than they are.  The volume is inscribed to Profes-
 sor Parker, of the College of Physicians and Surgeons in this city,—the beauty of its typography,
 and • getting up,' will be readily taken for  granted by all who know the publishers—and the illus-
 trative engravings are executed in a style very creditable to American art."—JV. Y. Lancet.
   " Mr. Liston has seen much, thinks accurately, and speaks independently. From a volume
 written by  such a man, more really  valuable practical instruction is to  be derived than from
 all the books that were ever compiled."— Western and Southern Med. Recorder.
   "This is  a work of established reputation. It has gone through two editions in Great Britain,
 and the same number in this country. The additions of the American edition are copious, and
 add materially to the  value of the work.*'—Mmer.  Jour. Med. Sciences.
   "The author is bold and original  in his conceptions, accurate in deductions, plain and con-
 cise in style ; a combination of good qualities not often found united in a single volume.  The
 notes and additions by Prof. Gross, are well  arranged and judicious, supplying some evident
 deficiencies in the original work."— Western Lancet.
                          Sir Astley  Cooper, Bart.

    LECTURES   ON   THE   PRINCIPLES  AND  PRACTICE  OF  SURGERY.

                   By FREDERICK TYRRELL, Esq.,
Surgeou to St. Thomas's Hospital, and to the London Ophthalmic Infirmary.

      Fifth American, from the last London Edition.   1 vol. 8vo. sheep.
19 
V
BART.INGTON  8c  HASWELL'S
Sir Charles Bell.
          INSTITUTES   OF   SURGERY.

Arranged in the order of the Lectures delivered in the University of Edinburgh.


                 By SIR CHARLES  BELL, K.G.H., Etc,

         Professor of Surgery in the University of Edinburgh, etc., etc.


                               1 vol. 8vo. sheep.

  "In a work on Sursery, of 443 pages, by Sir Charles Bell, we would expect every line to contain
important matter; and this is really'the case."— Western Lancet.
  "Respecting the high merit of the present performance, there is an equal unanimity of judgment
among all who have examined it."—Maryland Med. and Surg. Journ.
                                Amussat.

                              LECTURES  ON

THE  RETENTION  OF  URINE,  CAUSED  BY  STRICTURES  OF THE  URETHRA,

           AND ON  THE  DISEASES  OF  THE PROSTATE.

                        Translated from the French,

                    By JAMES  P. JERVEY,  M.D.

                            I vol. 8vo. muslin.
                               VENEREAL.

                            John  Hunter, F.R.S.


     TREATISE  ON   THE  VENEREAL  DISEASE.

                    With  Notes, by Dr. BABINGTON.

                           With Plates.   1 vol. 8vo.

  "Under the hands of Mr. Babington, who has performed his task as editorin a very exemplary
manner, the work has assumed quite a new value, and may now be as advantageously placed
in the library of the student as in that of the experienced surgeon."—Brit.Q- For. Med. Rev.

  " The notes, in illustration of the  text, contain a  summary of our present know-
ledge on the subject; the  manner in which these notes are constructed is  at once
clever and perspicuous;  and the mode> of treatment prescribed, spring from a ri"ht
apprehension of the disease.   We would recommend  to the reader the note on The
primary venereal sore; the note  itself is an  essay in every word of which we fully
concur."—Med.  Gai.
concur.
20
 
J—
MEDICAL PUBLICATIONS.
Philippe Ricord, M.D.
A  PRACTICAL  TREATISE  ON  VENEREAL  DISORDERS,


                      AND MOKE ESPECIALLY OH THE


         eizc2,®isii  Aisns sim&.'ffssiEii'iF  ©if ©ieiai^sirieo


                     By PHILIPPE  RICORD, M.D.,
                  Surgeon to the Venereal Hospital at Paris.


                                 1 vol. 8vo.
TH E   EAR.
                              George Pilcher.


A  TREATISE  ON  THE  STRUCTURE, ECONOMY,

               AND  DISEASES  OF  THE  EAR.


BEINO  THE ESSAY FOR WHICH THE FOTHERGILLIAN  GOLD MEDAL WAS AWARDED
                   BY THE MEDICAL SOCIETY OF  LONDON.


                        By GEORGE  PILCHER,

Late Lecturer on Anatomy, Lecturer on Surgery at the Theatre of Anatomy and Medi-
    cine, Webb St., Borough, and Senior Surgeon to the  Surrey Dispensatory.


    First American, from the Second London edition, with Notes and numerous
                     Illustrative Plates.  1 vol. 8vo. sheep.


  " The perusal of this work has afforded us much pleasure — A work was wanted
to place the whole subject within the grasp of all persons who chose to devote some
nttleexclusive or particular  study to the diseases of  the ear, and this has fairly and
well supplied the place."—Med.  Chir. Rev.
  «TUr  Pilrher is an experienced, well-informed, and able practitioner, and his treatise on the ear
de ervcs o£rank"Urnonestthe best which have appeared upon the interesting .buttoogenerally
5Sdepartment of surgery to which it relate.."-MARYLAND Med- and Sui.o. Jottrn.
  "This is a most valuable treatise, illustrated with elegant plates, is a standard work, and must
have a great sale in Us present form.   It tells all about the  anatomy and diseases of the ear. '-
N. Y. Herald.
 
BARRINGTON  8c  HASWELL'S
                                    GUMS.

                                 George  Waite.

                           THE    GUMS:

                      WITH LATE DISCOVERIES OX THEIR

     STRUCTURE,  GROWTH,  CONNECTIONS,  DISEASES, AND  SYMPATHIES.

                              By GEORGE WAITE,

               Member of the London Royal  College of Physicians.




                                   TEETH.

                                 John  Hunter.

        A  TREATISE   ON  THE   TEETH.

                            By  JOHN  HUNTER.

                  With  Notks,  by THOMAS  BELL,  F.R.S.

                        With  Plates.  1 vol. 8vo. muslin.
  " The treatise on the teeth is edited by Mr. Bell, a gentleman accomplished in his art.  Mr.
Bell has studied his subject with the greatest minuteness and care; and in appropri.ite notes at
the foot of the page  corrects the  author with the air of a gentleman, and the accuracy of a
man of science.  The matter contained in  these  short notes forms an ample  scholum to the
text; and without aiming at the slightest display of learning, they at the same time exhibit a
ready knowledge on every point, and  an extensive information both of comparative anatomy
and pathology."—Med. Oazctte.
                         MINOR   SURGERY.


                             Henry H. Smith, M.D.

                  MINOR    SURGERY:

©IS, EmOTffl ©m  SISIl  Il'^"Em"S'QIE)A'S■ IDOTJIIES  ©IF SIBI31 ®WHL®I£©lSro

                        By HENRY  H. SMITH, M.D.,

     Lecturer on Minor Surgery, Fellow of the College of Physicians, etc., etc

            Illustrated by numerous Engravings.  1  vol.  18mo.  muslin.

  " And a capital little book it is.....Minor Surgery,  we repeat, is really Major Sur-
gery, and any thing which  teaches it  is worth having.  So we cordially recommend
this little book of Dr. Smith's."—Med. Chir. Rev.
  " This beautiful little work has been  compiled with  a view to the wants of the  pro-
fession in the matter of Bandaging, &c, and well and ably has the author performed
his labours."—Med. Examiner.
  " To students we would particularly  recommend Dr. Smith's work ;  and  with  it in
their possession, they would be  able to carry out to great advantage  the  advice of
an eminent  professor of a  neighbouring city— ' Provide yourselves each  with half
a dozen rollers,  and  after your  day's study  is over, just before  going to bed, amuse
yourselves by bandaging each other.   It is the only way to acquire an art, ignorantly
underrated, but of immense importance.' "—Boston Med. and Surg- Journ.
  "This is an excellent Treatise on Bandaging,and will prove of <rreat assistance to the student
and to the country practitioner."  " The book is very handsomely illustrated with a great number
of excellent wood-cuts.  The paper and type  are good.  We repeat, in conclusion, our very favour-
able estimation of its merits."—Med. Exam.
  "We venture to predict for  this  little volume a successful, career,  for we have here a means
adapted to an end." " Here are  furnished to  the student all the various inventions and modifica-
tions of bandages  and apparatus, more especially  by the American Surgeons, Fhysick, Dorsey,
Gibson, Barton, Coates, Hartshorne, and N. R. Smith."—A7. Y. Jour, of Med.
  '■ We have no hesitation in asserting, that  it is an excellent, we were going to say indispensable,
aid to all those who wish to qualify themselves for the practice  of surgery."—Bull, of Med. Science. 
MEDICAL PUBLICATIONS.
  MIDWIFERY  AND  DISEASES  OF  WOMEN,

                                  Robert Lee.

                             LECTURES  ON   THE

   THEORY  AND   PRACTICE  OF  MIDWIFERY.

           DELIVERED  IN THE  THEATRE OF  ST.  GEORGE'S  HOSPITAL.

                      By ROBERT LEE, W.D., F.R.S.,
Fellow of the Royal College of Physicians, London; Physician to the British Lying-in
          Hospital; and Lecturer on Midwifery at St. George's Hospital.
            Illustrated with numerous Wood Engravings.  1 vol. 8vo.

  " Dr. Lee's former  reputation for large practical knowledge of obstetrics is fully
sustained in the present work."  "The style is plain arid clear, and the facts and cases
are presented with due succinctness.  One  important feature is the introduction of
tables of the results of certain operations, as of craniotomy, aud of certain diseases of
the puerperal state, as puerperal fever; which constitute a statistical basis for future
observations and a present support for active and available practice."— Bulletin of
Medical Science.
  " Dr. Lee is too good and sensible an author  to be reviewed.  He should be read.
He has already, though but a young man, become  illustrious  by his earlier works.'
—Pltilad. .Mai. Exam.                                         . .
  " We can cheerfully commend it to the notice of students of medicine. — llestern
Lancet.                                             .      .                 ,
  " It  is the production of a highly cultivated and practical mind, and has  been ela-
borated with a degree of judgment and care which  must render the Lectures a valu-
able record of professional  learning and experience."— Western Journal of Med.
 Sciences.                                                       .....    il
  " While they are well adapted for the instruction of the student of midwifery, the
Lectures of Dr. Lee  may be consulted by the young practitioner with much satisfac-
tion and profit.  The wood engravings, by which the  text is  accompanied, are well
executed, and communicate a very accurate idea of the subjects they are intended to
illustrate."—Amer. Jour. Med. Science.
  " I .very passage  will indicate  in  the author a discriminating, practical  mind, en-
lightened  by learning, and extensive observation."  " It is  a  store-house of facts
from which  the student may enrich his  mind, and to which the  practitioner may
apply  to refresh his memory."— Western Jour.
  "The aim  of the publishers  was  to give to the profession one  of the very best
systems of midwiferv in the language for the  least money —to  place a volume of
unquestionable excellence within the reach of every  medical man  in the country.
They  have been successful."—Ibid.


                         James  Blundell,  M. D.

                              LECTURES  ON  THE

  PRINCIPLES   AND   PRACTICE  OF   MIDWIFERY.

                        By JAMES BLUNDELL, M.D.

                     Edited  by  Charles  Severn, M.D.

                                 1 vol. 8vo. sheep.
   « The eminently fluent and aereeable style-the  large and accurate information-the great
  exoeriencT, and original mind oT Dr. Blundell, have secured for him a very env.ablereputa ion as
  Public lecturer.  It is impossible to r, ad these lectures without being delighted - it is equall* im.
  ™ssible to "void being instructed.  Were these discourses more generally diflused and stud.ed here
  ^wereth^eir sound and judicious directions recollected, and their salutary cautions observed, we
  wouldI hear offewer cases of malpractice.  This work forms a complete system of midwifery, with
  the diseases of the puerperal state and ol the infant. ''-A. V Lancet. 
'                     BARRINGTON 8c  HASWELL'S
                          Robert Collins, M.D.

A   PRACTICAL   TREATISE   ON   MIDWIFERY.
\     LONTAINING THE RESULTS OF SIXTEEN THOUSAND SIX HUNDRED AND  F1FTY-FOUB
                 BIRTHS, OCCURRING  IN THE DUBLIN LYING-IN HOSPITAL.

|            By ROBERT COLLINS, M.D., Late Master of the Institution.

/                                   1 vol. 8vo. sheep.

i     " The author of this work has employed the numerical method of M. Louis ; and by accurata
if    tables of classification, enables his readers  to perceive, at  a glance, the consequences of the    ;
)    diversified conditions, in  which  he saw his patients.  A vast amount of information is thus    }
'>    obtained, which is invaluable  to those who duly appreciate precision in the examination of  •£
i    cases."—Bait. Chron.                                                                 t


\                                        -----                                        |

|                                  Robert Gooch, M.D.                                  >


\    A   PRACTICAL   COMPENDIUM   OF   MIDWIFERY,    j

\      Being the Course of Lectures on Midwifery, and on the Diseases  of  Women

<                 and Infants  delivered at St. Bartholomew's Hospital.

I                        By the  late ROBERT GOOCH, M.D.

I                            PREPARED BY GEORGE SKINNER,

(\                  Member of the Royal College of Surgeons, London.

J                                  1 vol. 8vo. sheep.
                             PUERPERAL  FEVER.

                     Gordon, Hey, Armstrong, Lee, and C. D. Meigs.

                THE  HISTORY,   PATHOLOGY,   AND  TREATMENT  OF

|    PUERPERAL   FEVER  AND  CRURAL  PHLEBITIS.

I                   By Drs. Gordon, Hey, Aiimstrong, and Lee.

                            WITH AN  INTRODUCTORY ESSAY

I                        by CHARLES  D.  MEIGS,   M.D.,

I    Professor of Obstetrics and the Diseases of Women and Children in the Jefferson
{                            Medical College, Philadelphia.

\                                   1 vol. 8vo. sheep.
i
  " We have peculiar satisfaction, in announcing the publication of this very judiciously arranged
series of treatises, on one of the most important and interesting diseases, which demand the atten-
tion of the physician."  " Dr. Meies's Introductory Kfsay is concise and judicious, and will be read
with profit.  He speaks in the highest terms of commendation of Dr. Gordon's invaluable treatise —
a treatise which cannot be too generally diffused and studied.  Altogether this volume presents the
most acceptable and useful compend  of the doctrines and practice of the  best authorities, with
regard to 'Puerperal Fever,' with which we have ever met."—N. Y. Lancet.

  " We are pleased to see the republication of these valuable monographs upon Puer-
peral Fever.  As they are all of them Essays founded upon an extensive observation,
and contain a very large number of recorded  cases, they must always be valuable."
— New England  Journal of Medical Science.
  " Taken in connexion, the treatise it comprises present an invaluable mass of facts
in relation to Child-bed  Fever, without an acquaintance with which no one can, with
propriety, be considered fully qualified to undertake  its  management."—Journal of
Medical Science.


                                                                   24 
MEDICAL  PUBLICATIONS.
|                                   UTERUS.

                           Waller, Lisfranc, and Ingleby.

         LECTURES  ON  THE  FUNCTIONS  AND  DISEASES OF  THE  WOMB.

|                By  CHAS. WALLER, M.D., Bartholomew's Hospital.

|    ON   DISEASES  OF   THE  UTERUS   AND   ITS  APPENDAGES.

                      By M. LISFRANC,  La Pitie Hospital.


      ON   DISEASES  OF  THE   PUERPERAL   STATE.

                         By  J. T. INGLEBY,  Edinburgh.

\                                  1 vol. 8vo. sheep.
''■     " We can very cordially recommend them as affording a concise and practical exposition nf the
'    pathology and treatment of a most important class of diseases, and which cannot be too attentively

    8l"lTlic'in~e^enTVoiumcf'contains a short and succinct practical account of the principal morbid
     lairs either of the functions or the structure ol the  womb, the best methods of distinguishing them,
              s which experience has shown to be the most etfeclual in removing them. The reader
               he obtains, in a small compass, a distinct view of the nature and treatment of each
stall's either ol tne lunctions or me ouumnc vi >uc ™uun,, ...£. «-..*..-------- -■--•-■> —w = „";,„'
and the means >--U!-1----••i.n»ii.i .hnwntn h« ih<> most effectual in removing them,  ihe reader
will find that  h.
disorder."—Edinb. Med. and Surg. Journ.
                DISEASES  OF  CSXILDREOT.

                          Evanson and Maunsell.

A PRACTICAL TREATISE ON  THE DISEASES AND MANAGEMEttT  OF CHILDREN.
                  By  RICHARD T.  EVANSON, M.D.,
                        Professor of Medicine,— and
                       HENRY MAUNSELL, M.D.,
          Professor of Midwifery in the College of Surgeons, Ireland.
                     Edited  by. D. r.CONDIK.M.D.
             From the Fourth Dublin Edition.  1 vol. 8vo. sheep.
  " The second chapter embraces the Management and  Physical Education of Cb.il-   >
dren  This chapter ought to be printed in gold letters, and hung up in the nnrsery of
every family.   It would save many lives, and pre\ent  much suffering.' — Medico-

  "Xfthis Practical Treatise on the Diseases of Childreu has before been made known   j
to the medical public, we dare not suppose it a new thing to any intelligent practi-
 inner iii this country ;  still, there may be those who do not own a copy—and to such
there  is nutbiii" ungenerous in saying we wish that they may always have it in their
no'wer to consult such authority."—Boston Med. and Sur«. Journ.
  ''The nresent edition is enlarged, and in its present lorm constitutes one of the best
works on the subject in our language. We do not intend to say that it is by no means
^nexcop.ionablo.but that at this time we know of no English production on the same
Subject which is superior, or perhaps, on the whole, as good.*—Pkdad. Med. Exam.   I


                          Michael Underwood, M.D.

 A  TREATISE  ON  THE  DISEASES OF  CHILDREN.
           WITH  DIRECTIONS FOR THE MANAGEMENT  OF INFANTS.
              Bt the late MICHAEL  UNDERWOOD,  M.D.
                 From  the Ninth English Edition, xeith Notes,
     By S. Meuriman, M.D., am. Marshall Hall,  M.D., F.R.S., Ere.
            witu notes, by joiin bell, md., etc, of Philadelphia.             1
                               1 vol. 8vo. sheep.                                ^4,

                                                                   —=m 

BARRINGTON  8c HASWELL'S
                       MISCELLANEOUS.  '

                            J. L. Ludlow, M.D.

            A  MANUAL  OF   EXAMINATIONS

  UPON  ANATOMY  AND  PHYSIOLOGY,  SURGERY, PRACTICE  OF MEDICINE,
            CHEMISTRY. MATERIA  MEDICA,  OBSTETRICS, ETC.

Designed for  the Use of Students of .Medicine throughout the United States.

                        By J. L. LUDLOW, M.D.
                               1 vol. 12mo.
 " We have no hesitation in sayimr, that Pr. Ludlow's Manual is decidedW the best, both in rela-
tion to comprehensiveness and general accuracy, that has yet been published inlhi country."—
West. Lancet.
  "In this ' Manual  of Examinations' the questions ore clearly put, and, with few
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                     Thomas Henderson, M D., U.S.A.,                        j

HINTS  ON   THE  MEDICAL  EXAMINATION  OF  RECRUITS  FOR  THE  ARMYi    !
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       AMD ON THE DIPCHAKGK OF  SOLDIERS FliOM  THE SKRVICK ON THE           j
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              Assistant Surgeon L'nited States' Army, etc., etc.


                       Prof.  \V.  E.  Horner, M.D.

  NECROLQGICAL   NOTICE    OF   DR.  P.   S.   PHYSIC*.

     Delivered before  the American Philosophical Society, May \, 1838.
                    By PROF. W. E. HORNER, M.D.
                                Pamphlet.
                              D re wry Oltley.

         THE  LIFE  OF JOHN   HUNTER, F.R.S.
                        By DREWRY OTTLEY.
                              1 small vol. 8vo.
  '•In the summing up of Mr. Hunters character, Mr. Ottley exhibits equal judg-
ment and candour."—British and Foreign Medical Rctieic.
SM=-
jjtqnnnnnrinrm'n-"**" m*mmm**A*u%*0v+*** * . ■■,
26
 
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        OBSERVATIONS ON  THE  PRINCIPAL  MEDICAL  INSTITUTIONS
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IS  MEDICAL  SCIENCE  FAVOURABLE  TO   SCEPTICISM1
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27 
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                       LIVER  AND   SPLEEN.

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|                                    DISEASES   OF

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\                            By WILLIAM  THOMSON,

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\                                  AND CLINICAL

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(                                  1 vol. 8vo. sheep.
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I    iKo in/i.lr nn , k « t.nn. in * U ~ rn»li.k 1 .. ...*.... ~<* n w. . U a ■ w. ■-...».. r. n t anti.a.4. f\f mV\if\n it I FPU t.fl.' '«—
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      CLINICAL  REMARKS  ON  SOME  CASES  OF

   LIVER   ABSCESS   PRESENTING   EXTERNALLY.

                     By JOHN G. MALCOLMSON,  M.D.,

    Surgeon Hon. E. I. C.  Service, Fellow of the  Royal  Asiatic Society, and  the
                           Geological Society,  London.

                                   1 vol. 8vo.



                 JOHN  HUNTER'S  WORKS.

  Comprising  his  Lectures on the Principles  of  Surgery; A Treatise on  the
      Teeth ;  Treatise on  the  Venereal Diseases ;  Treatise on  Inflammation
          and Gunshot Wounds ; Observations on Certain Parts of the
            Animal (Economy; and a full and comprehensive Memoir.

 Each of the Works is edited by men of celebrity in the Medical Science, and  the
                       whole  under the superintendence of

                            JAMES F. PALMER,

                 Of the St. George's and St. James's Dispensary.

                                  4 vols. 8vo.

   This is the only complete edition of the works of the  distinguished  physiologist
 ever published in this country.

   " One distinctive feature of the present edition of Hu nter's works has been already mentioned,
 viz.: in the addition of illustrative  notes, which are not thrown in at hazard, but are written by
' men who are already eminent lor their skill and attainments on  the particular subjects which
 they have thus illustrated.  By this means, whilst we have the views entire ol John Hunter in
 the text, we are enabled by reterence to the accompanying notes, to see wherein  the author is
 borne out by the positive knowledge  of the present day, or  lo what extent his views require
 modification and correction.  The names of the gentlemen who have in this manner assisted
 Mr. Palmer, are guarantees of the successful performance of their task."— Med. Gaz.
38 

   Any person ordering Books to the value  of Ten Dollars from the following
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      of Medical Science for one year, gratis.

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Principles and Practice of Medical Jurisprudence.  By John Bell, M.D.

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Blundell  on  Diseases of Females, a new and  improved edition.

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The  Diagnosis, Pathological Indications, and Treatment  of  Urinary
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Spasm, Languor, Palsy, and other disorders, termed Nervous, of the
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Practical Remarks on Gout, Rheumatic Fever, and Chronic Inflamma-
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32
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if
        THEOLOGICAL  AND  SCHOOL  BOOKS.




                      BARKINGTON & HASWELL

                   ALSO PUBLISH A VERY POPULAR EDITION OF

         THE  OLD   AND   NEW   TESTAMENT

               Without Note or Comment, in large type, 1 vol. 8vo.

  This edition is put up and may be had either with or without the Apocrypha, Con-
cordance, Psalms, or Plates.
  Their fine edition is ofsuperior workmanship, and the paper on  which it is printed
has all of the firmness, consistency, and colour of the best European.  They are in all
styles of binding.




                      AN  EXPOSITION
           OLD  AND-  NEW   TESTAMENT.

  Wherein each chapter is summed  up in its contents ; the sacred text inserted at
large, in distinct paragraphs; each passage reduced to its proper heads;  the sense
given, and largely illustrated.

              WITH PRACTICAL KKMARKS ANU  OBSERVATIONS,


                     By  MATTHEW  HENRY.

Edited by the Rev. Geo. Burder, and the Rev. Joseph  Hughes, A.M.; with the Life
                   of the author by the Rev. Samuel Palmer.

            TO WHICH   IS   PREFIXED  A  PREFACE,

                  By ARCHIBALD ALEXANDER, D.D.,
       Professor of Theology  in the Seminary at  Princeton, New Jersey.

                   First American edition, 6 vols, super 8vo.

  This work has elicited s^decidedly the approbation of the  most judicious men of
the  principal denomination of Christians in the United States, that the  publishers
deem it unnecessary to offer now many of the numerous recommendations they have
received from various quarters.
  The following  will serve to show the universal opinion with regard to this work :


  From the Rev. S. H. Cone, Pastor of the Oliver Street Baptist Church, New York.

  " I have examined  the stereotype edition of Matthew Henry's Exposition of the
Old aud New Testament, and take pleasure in bearing testimony to  its typographical 
ST
V
gj=----:-----
                      THE0LOGICAL  J'L BLICATIONS.
neatness and accuracy, and the comparative cheapness of price at which it is now
offered lo the American public.
  " With reference to the intrinsic excellence of the work itself, it needs not my feeble
commendation.  The wisi' and good unite in saying, that  it is  calculated to render
those who read it wiser and better; and having frequently  derived from it edification
and comfort myself, I do sincerely hope you may succeed in circulating it extensively
among my  fellow-citizens."


  The following  vivid delineation of its characteristic qualities is from the pen of the
Rev..Dr. Alexander, of Princeton :

  " A characteristic of this  Exposition of a more important kind than any that  have
been mentioned, is, the fertility and turned of good sentiment manifest throughout the
work.   The mind of the author seems not only to have been imbued wilh excellent
spiritual ideas, but to have teemed  with  them.   It is comparable to a perennial foun-
tain, which continually sends forth  streams of living water.   In deriving rich instruc-
tion and consolation from th • sacred oracles,  adapted to all the various conditions and
characters of men, the author displays a fecundity of thought, and  an ingenuity in
making the application of divine  truth, which  strikes us  with  admiration.   The
resources of most men would  have been  exhausted  in  expounding  a few  books
of the Bible; after which little more could have been expected  than common-place
matter, or a continual recurrence of the same ideas ; but the riches of our Expositor's
mind seem to have been inexhaustible.  He comes to every successive portion of the
sacred Scriptures with a fulness and freshness  of matter, and  with a variety in his
remarks, which,  while it instructs, at the same time refreshes us.   Even in his  Expo-
sition of those  books which are very similar in  their contents, as the gospels for ex-
ample, we still fine a  pleasing v.uiety  in the  notes of the commentator.  It is difficult
to conceive how  one man should have been able to accomplish such a work, without
any falling off in the style of execution."

  The  Rev. Edward Bickersteth says,—"There is  in Matthew Henry  a glow of
love, a full exhibition of the sense, a happy reference to the passage expounded, and
a lively cheerfulness, which  will  ever make his work popular,  useful, and  indis-
pensable."                                                                       \
                                                                                )
  Dr. Doddridge says,—  " Henry is, perhaps, the only commentator so large that
deserves to be entirely and attentively read through.   The  remarkable passages, I
think, should be  remarked. There is much  to be learned from this work in a specu-   j
lative,  and  still more in a practical  way."                                           j

  Dr.  Edward Williams says, — " It  is an  incomparable work, and too well known   J
   ueed a discriminating character "                                               \
                                                                                i
  " The Rev. Dr. Thomas Hartwell Home, in his valuable Introduction to the Study   <
of the Scriptures, says, that its high and generally known  value is so just and  exten-   ■
sive, that it needs no recommendation.                                             i

  The  Rev. Adam Clarke, the Commentator, says, — " The Rev. Matthew Henry,   5
a very eminent dissenting minister, is author of a very extensive Commentary  on the   j
Old and New Testaments, and one of ttie most popular v*orksof  the kind ever pub-   )
lished.   It is always orthodox, generally judicious, and truly pious and practical."     \
  Extract of a letter from the Rev. Francis Wayland, President of Brown University.

  " I am gratified to hear of  your intention to present the religious public with an
American edition of Henry's Commentary.  I  know of no work of  the kind in any
language which combines more  sound good sense with  fervent  and deep-toned
piety."
34 
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EEWHT'S   MAXIMS.  "
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      DJWOOT  Al'B  HOLY   H3FH.

ADAPTED TO THE STATE AND CONDITION OF AU. OUDERS OF CHRISTIANS,

                    By WM. LAW, A.M.

          Nineteenth edition, with some account of the Author.
                     Confession of Faith.

               THE  CONSTITUTION.

OF THE PRESBYTERIAN  CHURCn IN THE UNITED STATES OF AMERICA,

                       Etc., Etc., Etc.

     As ratified by the General Assembly, at their Session in May, 1321,
                     und amended in IS'.Vo.
       DOVE*  SELECTION"  CF  EYM2TS

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THE  PSALMS OF  DAVID.
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Translated and diligently compared with the Original Text, and former transla-
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