^ I—i& *- > >v COMPENDIOUS SYSTEM OF MIDWIFERY, CHIEFLY DESIGNED TO FACILITATE THE INQUIRIES OF THOSE WHO MAY BE PURSUING THIS BRANCH OF STUDY. ILLUSTRATED BY OCCASIONAL CASES. WITH THIRTEEN ENGRAVINGS. SECOND EDITION, WITH ADDITIONS, &c. BY WM. P. DEWEES, M.JX- ****, —~-------------■ >'. .*v ADJUNCT PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA^*-■_A.: ,: * ' MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, fcc^Jkc, _> , £' ■". PHILADELPHIA; H. C. CAREY & I. LEA, CHESNUT STREET 1826. EASTERN DISTRICT OF PENNSYLVANIA, to wit : BE IT REMEMBERED, That on the thirteenth day of (L. S.) January, in the fiftieth year of the Independence of the United States of America, A. D. 1826, William P. Dewf.f.s, M. D. of the said Utetrict, hath deposited in this Office the Title of a Book, the right whereof he claims as Author, in the words following, to wit: "A Compendious System of Midwifery, chiefly designed to facilitate the In- ** 4njiries of those who may be pursuing this branch of study. Illustrated by "Occasional Cases. With thirteen Engravings. Second Edition, with Additions, " &c. By Wm. P. Dewees, M. D. Adjunct Professor of Midwifery in the Uni- versity of Pennsylvania, Member of the American Philosophical Society, &c. &lc." In conformity to the Act of the Congress of the United States, intituled, "An M0t for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times there- ia mentioned." And also to the Act, entitled, "An Act supplementary to an A«t, entitled, 'An Act for the encouragement of learning, by securing the copies rftnaps, charts, and books, to the authors and proprietors of such copies, during th# times therein mentioned,' and extending the benefits thereof to the arts of designing, engraving, and etching, historical and other prints." B. CALDWELL, Clerk of the Eastern District of Pennsylvania. I.ydia R. Uatley, Printer. r PHILIP S. PHYSICK, M. D. PROFESSOR OP ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. MY EARLY AND FAITHFUL FRIEND, THE SPLENDOUR OF WHOSE PROFESSIONAL REPUTATION IS ONLY EXCEEDED BY THE PURITY OF HIS PRIVATE CHARACTER, THIS WORK, THE RESULT OF MY INQUIRIES, OBSERVATIONS, AND REFLECTIONS, ON AN IMPORTANT SUBJECT, IS AFFECTIONATELY INSCRIBED, BY WM. P. DEWEES. Philadelphia, Sept. 20th, 1824. /VslNEX ChStefchs "J - •>; i ..i i CONTENTS. Page Introduction,...........11 CHAPTER I. Sect I. Of the Pelvis,.........17 II. Of the Sacrum,.........18 III. Of the Coccyx,.........19 IV. Of the Ossa Innominata,.......20 V. Of the Separation of the Bones of the Pelvis, ... 22 VI. Of the Deformity of the Pelvis, .'----- 25 VH. Examination of the Pelvis,......- - 34 CHAPTER H. Of the Child's Head,.....•.....27 CHAPTER HI. Of the Genital Organs,.........41 Sect. I. Of the Internal Organs,.......44 II. Of the Uterus and its Dependencies,.....45 CHAPTER IV. Of the Menses, -.........51 Sect. I. Lunar Influence,........55 II. General Plethora, ---.....ib. III. Topical Congestion,........58 [V. Final Cause,.........61 CHAPTER V. Of Conception,...........62 Sect. I. Of the Changes produced by Conception, ... 64 II. Of the Membranes,........68 m. Of the Placenta,........70 IV. Of the Foetal Circulation,.......71 V. Of the Changes in the Uterus by Impregnation, - - - 73 CHAPTER VI. Of the Action of the Uterus,........77 CHAPTER VH. Of the Displacements of the Uterus,.......81 Sect. I. Prolapsus from Pregnancy,......( - ib. S II. Of the Retroversion of the Uterus,.....82 N HI. Of the Obliquity of the Uterus,......91 IV. Of Prolapsus, when not impregnated,.....98 VI CONTENTS. CHAPTER VIII. Of the Signs which usually accompany Pregnancy, , - - - 107 Sect. I. Suppression of the Menses,..... *°|* II. Nausea and Vomiting,........f~ HI. F.nlargement of the Mammae, ------ ,D- TV. Areola:,..........J" V. Formation of M Ik,........"* VI. Enlargement of the Abdomen,......J*^ VII. Increased Size of the Uterus,......Jf ° VIII. Pouting out of the Navel,.......*™ IX. Spitting of frothy Saliva,.......,b- X. Sal:va«;on,.........118 XI. Quickening,.........J*' XII. Vomiting, .........1?* Xm. Heartburn, .........125 XIV. Salivation, .........12' XV. Fluor Albus,.........*29 XVI. Pruritus, - ......135 CHAPTER IX. Of Deranged Menstruation, ._.-.--- 136 Sect. I. Tardy Appearance,......-- >b. U. Suppression of the Menses,.....- 143 Cases,.....146 III. Immoderate Flow,........152 IV. Painful Menstruation,.......- 155 V. Decline of the Menses,......- 160 CHAPTER X. Of the Term of Utero-Gestetion,.......168 _ CHAPTER XI. Of Labour, *" -.........- 170 Sect. I.^Of Rigors, &c. -........171 ** II. Frequent Inclination to make water, Tenesmus, &c. - - 172 HI. Affections of the Uterine System in particular, ... 173 a. Subsiding of the Abdominal Tumour, ... 174 b. Secretion of Mucis, - - - - - - ib. c. Dilatation of the Os Uteri,.....- 176 a. Contraction of the Longitudinal Fibres, ... 177 b. Contraction of the Circular Fibres, .... ib. c. Of the S'mple Contraction, -, -.....178 d. Of the Compound Contraction, ----- 179 e. Effects of the Tonic Contraction, .... ib. /. Cause and Effects of the Alternate Contraction, - 180 g. Of the manner in which the Os Uteri becomes opened, 182 CHAPTER XII. Conduct during Labour,.........187 Sect. I. What may be necessary for the Child, ----- 192 H. Unassisted Delivery of the Placenta, ----- 196 III. Of Putting to Bed,........197 IV. Of After Pains,.........198 V. Regimen during the Month,......203 VI. Of the Lochia, -........267 Excessive Lochia, -------- 208 VU.. Attention necessary to the Child,.....912 GONTENTS. Sect. VIII. Dressing the Navel, -......212 IX. Purging off the MeconiKB,......213 X. Suppression of Urine, ------- 215 XL Of Food for the Child, '- - - - - - - 217 XII. Of Aphthae,........,220 XIII. Of Colic,........- 225 XIV. Ophthalmia,.........230 XV. Ulceration of the Mouth, - - - . - - - 232 CHAPTER Xin. ©f Natural or Unassisted Labour,.......234 CHAPTER XIV. Of the Presentation of the Head,.......237 Sect. I. First Presentation, and its Mechanism, .... 239 n. Character and Mechanism of the Second Position, - - 240 in.---------------------------Third Position, - - - 241 IV.---------------------------Fourth Position, - - 242 V.---------------------------Fifth Position, ... 245 VI.-----------------------------Sixth Position, - - - ib. Til Se PART II. JL Of Labours, in which the Child presents the Vertex, rendered difficult or preternatural, - - - '".......247 CHAPTER XV. Causes of Preternatural Labours,.......ib. Sect. I. Of Flooding,.........248 II. Of Convulsions, --------- 250 HI. Of Syncopes, ..."......251 IV. Of Hernia,........ 253 V. Of Obliquity of the Uterus,.....- 254 VI. Of Partial Contractions of the Uterus, - - - fc I 255 VII. Of Compound Pregnancy,.......^59 VIII. Of Prolapsus of the Cord, &c. ,- - - - - - "^So IX. Of too short a Cord, - - '......261 X. Of the Bad Position of the Head, though the Vertex present, ib. a. Of the Bad Position of the Vertex, .... 262 b. Of the Chin departing too early from the Breast, - y 263 c. Cases in which the Face presents, .... 268 d. Presentations of the Head and Hand, ... 272 XL Of Exhaustion,.........273 XII. Of Haemorrhage from other parts than the Uterus, - - 279 CHAPTER XVI. Rules for conducting a Preternatural Labour,.....ib. Position of the Woman for Turning,.....:*K.\ ^^ 280 CHAPTER XVII. The Mode of Operating in each Presentation of the Head, - - 287 Sect. I. First Presentation, ......... ib. U. Second do. - -......'"- 288 III. Third do..........ib. IV. Fourth and Fifth do. - ......289 V. Sixth do. - . -.....290 Vlil CONTENTS. PART III. Where it is necessary to use Instruments which do no Injury to the Mother or Child,.........- - - 292 CHAPTER XVIII. Of the Forceps,...........292 Sect. I. General Rules for the use of FcTcp-,.....~93 a. Of those which regard ti>e '.Vcnan, - ~-'* b. Of the Condition of the S>-tt Puts, - - - - ~95 c. Application and mode of Action of the Forceps, - 296 a. Of Compression,.......3'~ b. Compres-on and Tract on,.....308 c. »L»de of Acting after Appl.cation, .... ib. II. Recapitulation,.........310 HI. General Observations on the Forceps, ... - 311 CHAPTER XIX. Of the Specific Application of tile Foictp-., - - - - - 314 Sect. 1. a. Appl.ci.tion in the First of tnesc Positions, ... 315 II. b.----------------Second,......316 III. c.----------------Th id,......317 IV. d.----------------Foui til,......318 V. e.----------------Fifth,......ib. VI. /. ---+.----------Sixth,......319 VII. g. —tbt----------Seventh, ------ ib. ^* CHAPTER XX. General Remarks on the Forceps, when the Head is above the Superior Stra.t, ...........320 CHAPTER XXI. Of the Locked or Impacted lu ;.a,.......322 Sect. I. Of the Causes, Signs, and Accidents of the Locked Head, - 323 11. Indications in the Locked Head, ------ 324 III. Method of using the Forceps in the Locked Head, - - 325 CHAPTER XXII. U&y^ Use of the Forceps in Face Presentations, - 326 wfV CHAPTER XXIII. Of "Presentations of the Breech, -------- 330 Sect. I. Species of Breech Presentations,.....331 II. a. Mechanism of First Breecii Presentation, ... 332 111. b.------------Second ditto, .... jj3 IV. c.------------Third ditto, ... - ib. V. d.------------Fourth ditto, .... 334 CHAPTER XXIV. Causes which may render Presentations of the Breech preternatural, - 335 a. First Degree of Advancement, ..... 335 b. Second ditto, - 3^7 c. Tliird ditto, - m. Sect. II. Position of the Child,...... 34Q lift* Size of the Breech,........ 34^ IV. Mode of bringing down the Feet, in the First Breech Presentation 342 V Mode in Second Position of the Breech, - 343 VL ------- Third ditto, - jj, VII.-------Fourth ditto. - - - . jj, CHAPTER XXV. Of the Use of the Forceps, when the Body is delivered, and the Head reV tained,...........*344 ib^*^ CONTENTS. IX Page Sject. 1. Cases proper for the Forceps,......346 o. Mode of Operating in First Case, .... ib. b.----------------Second do. - - - 347 CHAPTER XXVI. Of the Presentations of the Feet,.......348 Sect. I. Species of Feet Presentations,......349 II. Preternatural Labours when Feet present, ... - 351 III. Mode of Acting in the First and Second Presentations, - - 352 IV.-------------------Third and Fourth ditto, - - 353 CHAPTER XXVII. Presentations of the Knees,........356 Sect. I. Causes which render Presentations of the Knees preternatural, 357 II. Mode of Operating in Presentations of the Knees, - - 358 CHAPTER XXVIII. Of Rigidity, &c of the Soft Parts, as the Cause of Preternatural Labour, 359 Sect. I. Species of Rigidity, -.......360 a. Rieridity of the First Kind,.....ib. 6 Var. 1, --- - 361 2, - - . - - 362 3, - - - - ib. b. Rigidity from Local Injuries, - - - .. - - 365 e. Relative Rigidity,.....__ - - 371 d. Tonic Rigidity, ... - "fln* 3^2 CHAPTER XXrX. Of Uterine Haemorrhage,.........273 Sect. 1. Connection of the Ovum with the Uterus, - - - - 374 11. Causes which may tend to destroy this Connection, - - 375 III. Mode of Action of certain of the Remote Causes, - - 376 IV. Periods of Pregnancy at which Flooding may take place, - 389 V. First Period, *.........393 VI. Second Period,.........405 VII. Dehvery considered as a Mode of arresting Hemorrhage, - 413 Vlll. Hemorrhage from Situation of the Placenta, - - - 422 IX. Where the Uterus is but little opened, and very rigid, - - 435 X. When but little opened, but disposed to dilate, - 438 XI. Opened to some extent, but very rigid, .... 440 XII. When opened to the same extent, but soft, ... - 441 X11I. Wiiere fully dilated,........442 XIV. Causes of Uterine Inertia,.......456 a. I. When there is a partial separation, but the Uterus enj;iving some tonic power, ... - 458 b. II. Wiiere there is a partial separation, but where the Uterus possesses very little or no tonic power, 459 c. HI. Where there is a partial separation, while the remain- ing portion is too adherent, and the Uterus contracts but feebly,.......464 d. IV. Where every thing is as at III., except that the Uterus enjoys its full powers, - - - - - 467 e. V. Where there is an entire or partial separation, but the Uterus in a state of Exhaustion or Syncope, - 468 /. VI. Where there is either a partial or complete separation, and where the Body and Fundus are in a state of Inertia, while the Neck enjoys its tonic power, 471 V. Flooding after the Expulsion of the Placenta, - - - 474 KVl. On the Means for preventing Flooding, .... 476 [2] "N X CONTENTS. Vagc CHAPTER XXX. Of Puerperal Convulsions,.........480 Cases,............485 CHAPTER XXXI. Of the Assisted Delivery of the Placenta,.....- 493 Sect. I. Retention from want of Tonic Power, ----- 495 II. Retention from too firm adherence, ----- ib. Mode of Acting in this Case,.....496 III. Of the Encysted Placenta,.......498 Mode of Operating in this Case, .... 500 IV. On the enclosed and partially protruded Placenta, - - 501 Mode of Acting in each Case, ----- 503 V. Of the Delivery of the Placenta, when the Cord is broken or very feeble,.........504 a. Signs by which the Placenta may be detected, - - 505 b. Mode of Acting in this Case,.....506 CHAPTER XXXn. On the Inversion of the Uterus,........507 Cases,............515 CHAPTER XXXIH. Of Twins, &c. - ......520 Management of the Placentae,........529 CHAPTER XXXIV. Of Preternatuo^B)abours,........ 531 CHAPTER XXXV. Of the Presentation of the Arm and Shoulder,.....533 Sect. I. Of the Condition of the Uterus,......536 II. Of the Situation of the Arm and Shoulder within the Pelvis, 539 III. The Manner of Acting, if the Child be living, ... ib. IV. Of Spontaneous Evolution,......541 V. Mode of Acting, if the Child be dead, - 542 CHAPTER XXXVI. Of the Rupture of the Uterus,........543 PART IV. On Deliveries performed by Cutting Instruments, applied either to the Child or Mother,...........556 CHAPTER XXXVII. Deformity of Pelvis,..........ib. Sect. I. Of Turning in a Deformed Pelvis, as a Means of saving the Child's Life,..........557 II. Of the Forceps in a Deformed Pelvis,.....558 HI. Of Cephalotomy,........561 Observations on Elizabeth Sherwood's Case, - 572 IV. Of the Caesarean Operation, ---.._ 578 a. Mode of performing it, - - , - . . 585 b. Treatment after the Operation,.....588 V. On Premature Dehvery, -.-.... 59^ VI. Section of the Pubes,...... . 596 VH. Regimen,..........ib. CHAPTER XXXVin. Monstrosity and Accidental Deformity,..... tff CHAPTER XXXIX. Uncertainty of the Child's Death, ... ~ys r INTRODUCTION. IT has often been declared, that labour, being a natural act, it does not require the interference of art for either its promo- tion or its accomplishment; and, consequently, that when this becomes necessary, it only forms an exception to the rule. This view of the subject has had many followers; and has, from its influence, retarded, more perhaps than any other circumstance, the progress of improvement in this most important branch of medical science. It so entirely comported with the theories of the fastidious admirers of nature; it so completely coincided with the feelings of those whose supineness made them averse from inquiry; so effectually apologized for ignorance ; and so plausibly extenuated the evils arising from neglect, or the want of the proper and judicious application of skill, as to secure in its favour by far the greater portion of the practitioners of Midwifery. An error in premises must almost necessarily lead to error in deduction j hence the too exclusive reliance on the powers of nature, to overcome every obstacle connected with parturition —hence the almost total disregard of the first and most import- ant principles in the art of midwifery. These errors orginated in ignorance, and were perhaps at first excusable from this cause; but how reprehensible do they become now, since the powers of nature are better calculated, and the resources of art better understood ! In what light, then, should we view writ- ers, who still inculcate such doctrines—teachers who make the whole art of midwifery consist, in doing nothing ? Were the constitutional powers of the system; the physical conformation of the pelvis; and the size of the child's head, al- ways and undeviatingly the same; were the most favourable presentation of the child; the best construction, and the most Xll INTRODUCTION. healthy play of the powers concerned in this operation, never to be assailed by accident, or complicated by disease,—the opinions of those who contend for the supremacy of unassisted nature, would deserve much, and perhaps exclusive attention. But, as it is too well known, that this never has, nor ever can be the case; I must insist, that the powers of nature have their limits; and that the interference of art sometimes becomes absolutely necessary. I am very far from wishing to be understood, that I advo- cate the indiscriminate interference of art, during the progress of a healthy labour—it is the verv reverse of my opinion, and of my practice; I wish merely to insist, that nature is not compe- tent to all exigencies; for in very many instances, when she is permitted to proceed without interruption, and is eventually able to effect her object, the sufferings of the patient might have been most probably very much abridged, by the judicious interposition of skill. Of this, from long experience, I am en- tirely convinced. If this be true in the most healthy or practicable labours, how much more important does the judicious and timely appli- cation of adventitious aid become, when it is well known, that the deviations from healthy power and structure, are almost constant in their occurrence, and almost infinite in their variety. It is the knowledge of these aberrations, and the mode of obvi- ating them when necessary, that emphatically declare midwife- ry to be a science—for it has, and must have, its principles; principles, that must not only be known in the abstract, but constantly employed ; and it is the happy application of the * fundamental rules of this science, that makes one practitioner superior to another. I trust my last assertion will not be considered gratuitous: for if there be a difference in the skill of practitioners, it can only arise from a more perfect acquaintance with the rules which should govern; the extent of experience ; and the justness of deduction. But does not this declare there is something more to be learnt, than the bare exercise of patience ? What prac-.^ titioner has ever been eminently successful, who has neglected the first principles of the art ? He may have been extensively INTRODUCTION. X11I employed, and tolerably lucky, (for it is nothing more,) with- out a correct notion of either the structure of the pelvis, the mechanism of labour, or the powers of the uterus ; but will he be qualified to act where the first is faulty; the second obstruct- ed ; or the third impaired ? would he not, in most instances, where either of these conditions obtained, wait in vain for the all-sufficient exertions of nature ? Experience, however necessary and important, is not alone sufficient; a correct foundation must be laid, by the study of first principles ; and, with even this the progress must be slow ; since variety in labour, is so multiplied. It is only by a happy and well balanced generalization, that the practitioner can arrive at principles; and it is but by judiciously acting upon these, that he can be extensively useful. I may safely appeal to the candour of almost every practitioner, whether he has not admitted to himself, that, had he been better acquainted with principles at a previous period of practice, he could not have procured, in certain cases, either a speedier termination, or a more fortunate issue—I am sure he will answer in the affirm- ative. Too much importance can easily be aftached to experience alone; and though I consider it a sine qua non to the success- ful exercise of the profession, yet it becomes only decidedly useful in difficult cases, when it is based upon the fundamental principles of obstetrics. Without an acquaintance with these, every practitioner must act empirically; and this, to the too frequent destruction of human life. If he be ignorant of all that is essential to be known of the well formed and diseased pelvis; or unacquainted with the various ways the head may pass through it, he will be totally incompetent to act, when there is any material deviation from the healthy economy of labour; he may rashly suppose there is no alternative but in the use of the crotchet, where a little address might have rec- tified the error in presentation. Or he may negligently and reprehensibly wait for the successful operation of nature, until his patient expire, where nothing but the judicious and prompt interference of art could have saved her from an untimely grave : in a word, there is no error into which the man of mere experience may not run, Xl\ INTRODUCTION. In making an estimate of the value of experience alone, I must admit that many pursue the safer plan in submitting the case to nature ; for I confess that, in many cases of desperate appearances, she successfully surmounts the difficulties that menace her; but this is only submitting to a choice of evils: while the well instructed practitioner would triumph over them, and spare nature the hazardous conflict. That in many instan- ces we should be the silent observers of nature, is unhesitating- ly acknowledged; but I must insist, and I am persuaded I shall be supported by every well-instructed accoucheur, that it re- quires no less judgment to determine when we should be so, than when it is proper to offer assistance, or to take the busi- ness entirely out of her hands. But the decisions of ignorance do not always result in an en- tire reliance upon the powers of nature; they sometimes, and this but too frequently, end in the contrary extreme—in this ease there is an overweening desire to aid her efforts; and their ill-directed endeavours, but too soon eventuate in a destructive subversion of her powers. To this we must attribute the very many instances of injury, which take place in the hands of ill- instructed practitioffcprs. Who has not witnessed a labour, which if let alone would have been but an ordinary one, as re- gards either duration or severity, converted into one of great hazard, and protracted duration ? Can such mischievous igno- rance be too severely reprehended, or could it be too severely punished ? What has not that man to answer for, who shall per- mit a fellow creature to die, when a little address or knowledge might have saved her; or, what is perhaps still worse, who shall absolutely destroy her, by ill-judged, and rude manoeuvres, under the specious pretence of relieving her? Besides, the peculiar situation of our country, imposes a ne- cessity upon every medical student, to become well acquainted with the theory of midwifery; for every one almost must prac- tice it, if he pursue the object for which he is educated. A change of manners, within a few years, has resulted in the al- most exclusive employment of the male practitioner. This was mainly effected by a conviction, that the well-instructed physician is best calculated to avert danger, and surmount dif- INTRODUCTION. XV hculties; but how ill is this confidence repaid! a confidence which costs females, so severe a struggle ! Should they sub- mit their future welfare, nay, their lives, to an ignorant pre- tender, what security can they have, that they shall escape, without having entailed on them a permanent derangement of organ, or the perpetuation of a harassing, and loathsome dis- ease ? In whatever point of view we regard this subject, it must be highly interesting to the philosopher and the philanthropist; shall it be less so, then, to the physician who should be both, and who is more immediately concerned in its influence ? Shall it be a matter of indifference to him, who has almost the control of the future comfort and happiness of perhaps an ex- tensive population, and who shall become, as it were, the arbiter of the lives of thousands of individuals ? A man of very loose morality, shudders at the idea of a single murder; yet an igno- rant practitioner of midwifery, may feel no "compunctious visitations of conscience" for a hundred! I hope to be credited, when I declare, that the present work was not undertaken, without due deliberation upon the respon- sibility attached to such an enterprise; amd that my aim most honestly was, to be useful—I have endeavoured to make my experience available to the interests of humanity; and, should I fail to instruct, I feel a confidence, I shall not dangerously mislead. .* In the arrangement of my materials, I have ventured to de- part from common usage, in treating of the various objects belonging to the subject; it is the method I have pursued for nearly thirty years in teaching; and to me it appears the most natural. That is, I bring under one view all that may belong to any particular labour, or class of labours—whether natural, and to be trusted to the powers concerned in the operation; or complicated, and requiring a departure from this rule; or when essentially bad. I make all the modes of treating it under the various circumstances which may affect it, follow each other without interruption. Generally speaking, I have followed Baudelocque's distribu- tion of subjects, but not rigorously; and to him I hold myself XVI INTRODUCTION. indebted for nearly all I know: or, at least, his masterly man- ner of treating every thing connected with this branch of me- dicine, has enabled me to comprehend at once, the seeming .intricacies of obstetrics, and to profit by bed-side experience. I cannot too earnestly recommend the study of his works to the practitioner, as well as the student of midwifery, who may not have profited already by his genius, and his long, and well- tried experience. I occasionally, in the course of the present work, differ from this great man; but when I do, it is doubtingly ; and only after an examination of my own experience has produced a convic- tion, that it is correct so to do; accompanied however, at the same time, by a regret, that I am forced to the alternative. I have added Plates, to represent the different positions of the head, that no embarrassment might follow from mere de- scription. These I hope will prove as acceptable, as I am persuaded they will be useful. And I have added a Chapter on "Arm and Shoulder Presentations," &c. % * A COMPENDIOUS SYSTE|T OF MIDWIFERY. ^ CHAPTER I. Section I.—Of the Pelvis. 1. THE complete knowledge of the pelvis, both in its healthy and diseased state, is essentially necessary to the successful practice of midwifery. Had more atten^ti been paid to ac- quiring an acquaintance with its natural, and its. deranged dimensions, by those who profess to practice this important branch of medicine, we should have had fewer instances of gross mistakes, and, of course, fewer victims. Without un- derstanding the pelvis well, it is impossible that any one can safely give assistance, where either the operation of turning, or the application of the forceps is required, to terminate the labour; nor can the mechanisms of the various presentations be understood in their most simple forms, without a thorough knowledge of it. We hope then we shall be excused when we say, that no man should be trusted to practice obstetrics, who is ignorant of this important assemblage of bones. 2. The pelvis is that structure which is situated below the last lumbar vertebra, with which it is by one of its surfaces articulated; and above the superior extremities of the thigh bones, with which it is connected, by means of the acetabula. It is composed, properlv, but of four bones, in the adult state, f3] 18 OF THE PELVIS. viz. on its posterior part, by the sacrum and coccyx; and dn the lateral and anterior parts, by the ossa innominata. But, in treating of this structure, it is useful and proper, to consider each of the constituent parts, as composed of several, to which appropriate divisions and names have been given; we shall therefore pursue this plan; as it has both propriety, and utili- ty, to recommend it; and first,, of Sect. II.—The Sacrum. 3. This bone has been sometimes called the false vertebrae^ because it is a kind of continuation of the true; and because, in the fastal state, it may be divided into five portions; the Union of these five pieces can readily be detected, in adult age, by four transverse seams. Its general figure is triangular or pyramidal; the base of which is upwards, and connected to the last lumbar vertebra by a cartilaginous intervention. The apex of the triangle or pyramid is below; and has united to its extremity, the coccyx, by means of cartilage. It may be divided into four surfaces; namely, an anterior, a posterior, and two lateral su^ices: its anterior surface is smooth and concave; while its posterior is very rough and convex; its an- terior face is smooth, that no obstacles may be offered, or abra- sions take place, by the passage of the child's head through the cavity of the pelvis; its posterior is studded with pro- cessess, or eminences, to give greater security, and surface, to the various muscles that originate, and that are inserted on it; as also, to afford greater firmness of connection to the many ligaments which aid in its union with the ossa innominata. Its lateral surfaces are rough or scabrous; and they are cover- ed in the recent subject with cartilage, by means of which they are united to corresponding surfaces, offered by the ilia. This bone is pierced on each side by four holes, which transmit the sacral nerves. There is also on its posterior portion a canal, along which the spinal marrow is continued. 4. The manner in which the sacrum is set into the ossa in- nominata, is well calculated to give firmness and security, to its position; as it acts in same measure, as a kev-stone does to • THE SACRUJH. 19 an arch; this arises from two peculiarities of form: the ante- rior part of the bone is broader than the posterior; conse- quently, enters like a wedge between the ossa innominata; this enables it to sustain without injury, any force that may operate from within, outwards: the superior portion is also broader than the inferior; and of course, is placed precisely analogous to the ke\T-stone of an arch, by which it is enabled to support without yielding, the superincumbent weight of the body, &c. We cannot fail to remark, how admirably this arrangement gives stability to the whole of the pelvic circle. 5. The union of the last lumbar vertebra with the base of the sacrum, is permitted to take place in such manner as to look over, and into the superior opening of the pelvis; so as to form a promontory; and hence, is called the projection or promontory of the sacrum. 6. The length of this bone is usually from four inches, to four and a half; its breadth is about four inches. Its thickness, if measured from the middle of its base anteriorly, to the ex- tremity of the superior spinous tubercle on its posterior face, is very constantly two inches and a half; and we are informed by Baudelocque,* that this measurememjUs so constant, that he did not find it vary a line in between thirty and forty pelves, the greater part of which were deformed. The concave form of this bone gives a hollowness to the greater part of its length; the depth of this in a well-formed bone is about half an inch. Sect. III.—The Coccyx. 7. This appendage to the sacrum is also of a pyramidal form, and is about an inch and a quarter in length; like the sacrum itself, it resembles an inverted pyramid; its base being united with this bone by intervening cartilage: it is formed of three bony portions, whose connection with each other is rea- dily observed by the transverse ridges which their union forms. Its connection is such, as to permit of a regressive motion; especially, in the earlier parts of life. Lateral motion * System, page 38, par. 35-. t to the coccyx. ia prevented by the insertion into the sides of this bone, of the coccygai muscles; of parts of the levatores ani; and portions of the sacro-sciatic ligaments. Sect. IV.— The Ossa Innominata. 8. The other portions of the pelvis are made up of the ossa innominata; they constitute the lateral, anterior, and inferior parts of this cavity. Each of these is divided into three dis- tinct bones, by all the writers upon midwifery or anatomy; and there seems to be propriety in this separation; since, they were originally, or in the foetal state, distinctly marked as indepen- dent bones, though not so clearly defined, in adult life; and, in the study of the pelvis it will contribute to a more precise notion of its form and combinations. The os innominatum is then composed of the ilium, ischium, and pubis. 9. The ilia form the highest lateral portions of the pelvis; and may with much propriety be considered, as belonging to, and constituting a part of the abdomen, as of the pelvis pro- perly so called; the ilium is the largest of the bones now under consideration—its superior edge is nearly semicircular; is al- most always tipped with cartilage; and is called the spine of the ilium. It reaches down, and, with certain portions of the ischium and pubis, forms the acetabulum. The external sur- face of this bone is a little convex, and has been named dor- sum ; while its internal face is concave; and is called costa, or fossa of the ilium. There are four processes usually de- scribed as belonging to the ilium ; namely, two anterior, and two posterior, spinal processes. 10. The broad spreading part of this bone is divided from the lower portions, by a ridge which commences at its connec- tion with the sacrum; runs forward, and joins with a similar ridge, sent by the os pubis—this sharp line, marks the upper, from the lower boundary of the pelvis ; and is called, the linea ilio pectinea. 11. The ischium is the lowest of the three bones; and, like the ilium, forms a part of the acetabulum. From the posterior part of this hone, a sharp process runs backward, yet inclining the ossa innominata, 31 towards the cavity of the pelvis, so as rather to diminish its capacity; to this is attached, the internal sacro-sciatic liga- ments ; it then runs downward, and terminates in the tuber; into the inside of which, the external sacro-sciatic ligament is affixed. From this tuber a bony process is reflected, which joins the os pubis. 12. The os pubis is the smallest of the three bones which constitute, the os innominatum—its largest portion is employ- ed in the formation of the acetabulum; it then diminishes in size; and stretches over, to meet a similar portion of the os pubis of the opposite side. It now becomes broader and thin- ner, and sends a branch downwards, to unite with the one re- flected from the os ischium. The mode of union of these bones is such, as to leave a considerable space between them, and is called, foramen ovale, or foramen magnum ischii; which in the recent subject, is covered by a dense ligamentous mem- brane, and gives origin to the obturator muscles. Nerves and blood vessels are transmitted through this membrane, by ap- propriate openings. 13. The ossa innominata are joined at their posterior, and central portions, to the sacrum, by rough.corresponding sur- faces ; these are spread over by thin cartilage; and the union secured, by strong appropriate ligaments. The anterior junc- tion of these bones is called the symphysis of the ossa pubis; but the mode of union is different from that which connects their posterior portions—agreeably to Baudelocque, nature has paid much more attention to it, than to the other parts of the pelvis, by sending out, in addition to a proper quantity of cartilage, a number of short, but very strong ligaments, which give great security to the symphysis. Dr. Wm. Hunter has also given a very particular description of the mode of union of this symphysis, in the second volume of the Medical Ob- servations and Inquiries. 14. As it is not in the power of every body to consult, and study the pelvis from the natural one, it is thought important to give a figure of a healthy, well constructed one, that an idea may be formed of its general form and connections; and though 22 ©F THE SEPARATION ©F THE BONKS OP THE PKLVIS- »ot equally satisfactory with a preparation, it will nevertheless give a pretty correct notion of it. (See Plates I. and II.) Sect. V.—Of the Separation of the Bones of the Pelvis. 15. It would seem, from what occasionally occurs in prac- tice, that the bones of the pelvis may separate, notwithstanding the especial care that nature appears to have bestowed upon their union. This separation may take place in various de- grees ; from a simple relaxation of the connecting media, to an absolute separation. This accident may happen gradually, commencing almost with gestation, but not manifesting itself with much severity until after delivery; or it may occur sud- denly, during labour; or just when it is about to be finished. Fortunately for the female, it is a disease of rare occurrence; Especially, in this country; for we have met with but one de- cided case of the kind in the course of our practice. 16. Were we to yield to popular belief, we should be obliged to grant, that nature had kindly studied the comfort and safety ef the female, by endowing the ligaments and cartilages which connect the different portions of the pelvis with a capacity to yield to the impulses of labour, that the operation might not •nly be less severe, but safer. This opinion is coeval with medical record; and it has been sustained, not only by inge- nious reasoning, but by an appeal to observation. The respect- able names of Pineau and Pare, are used in support of it among the more remote moderns; and Gardien in our own time, yields to a belief of its advantage. While Baudelocque, Denman, &c. see nothing in this supposed provision, but misery to the female who is the subject of it. 17. We may adduce the following reasons as conclusive against this relaxation being a natural provision—1. It is cer- tain, so far as can be determined by the dissection of women who had died during, or immediately after labour, that the symphyses were very rarely found to have yielded in the slightest degree.—Baudelocque tells us, he sought for it twenty times in well-constructed pelves after laborious labours as well OF THE SEPARATION OF THE' BONES OF THE PELVIS. %3 -as in distorted ones, without meeting with scarcely one, which could remove all doubts of its existence.* 2. That it is not more frequent in the distorted, than in the well formed pelvis ; were it an advantageous provision, it consequently, should have been more certainly observed. 3. Were it agreeably to an arrangement of nature, the means do not seem adequate to the end; as it would require that the extremities of the ossa pubis be separated one inch from each other, to gain two lines, or two twelfths of an inch, in the antero-posterior diameter of the superior strait; an increase but very rarely sufficient to do good in a contracted pelvis; and unnecessary in a well formed ©ne; as the latter is almost constantly larger than is absolute- ly necessary in ordinary labours. 4. That wherever it has been ascertained to have taken place even in a slight degree, it has never failed to create either temporary, or permanent inconvenience; and, where extensive, the most serious evils, and even death, have followed. 18. Various causes have been assigned for this relaxation or separation of the pelvic bones: 1. Serous depositions in the cellular meshes, or interstices of the connecting media. 2. Tumefaction of the cartilaginous extremities of the ossa pubis. 3. The child in transitu acting like a wedge on the bony circle which bounds the upper strait. 4. Mechanical violences, as foils, blows, instrumental delivery, &c. 19. When mere relaxation exists, the symptoms, though pretty permanent, are not violent, as when there is a separa- tion—a painful tottering walk, with a greater or less inability to stand, and more especially on both feet with equal firmness, mark very certainly this condition of the pelvis; and this is sometimes detected, even before labour. When it happens during labour, it is always attended with a painful sensation at the relaxed part, together with an inability to exercise the auxiliary powers concerned in this operation. This latter cir- cumstance is worthy of notice; as it would seem to decide at once, that this yielding is not intended to benefit parturient women. When the injury is greater, and a real separation ha* * System, Vol. T. par. 5.* 24 OF THE SEPARATION OF THE BONES OF THE PELVIS. taken place, it has been found, that it is by the destruction ol the ligamentous tissue which connects the bones; and thus per- mits them to retire further from each other than mere relaxa- tion would have done. When it is the symphysis of the pubes which suffers this accident, an entire separation of the cartila-* ginous epiphysis from the extremity of the os pubis takes place; for, agreeably to Baudelocque, no power is capable of breaking the ligamentous substance, which connects these two bones. 20. When this last condition obtains, it is usually followed by a melancholy train of evils—pain, inflammation, suppura- tion, caries, gangrene, and death. 21. The mode of treatment of these evils is reduced to great simplicity, though far from equal certainty—the indications are : 1. To reduce the parts'as nearly as possible to their na- tural position, and to secure them thus as effectually as possi- ble. 2. To obviate inflammation and its consequences, as far as may be practicable. 3. To relieve pain. 4. To give strength at a proper time to the syrstem generally. 22. The first indication must be attempted by the proper application of bandages; and we are of opinion, that the sim- ple calico roller is as effectual, as any of the more complicated machinery contrived for this purpose. It should be applied as high as the cristse of the ilia, and a little below the trochanters of the thighs—its length should be so ample, as to secure a number of turns round the parts; and it should be drawn suffi- ciently tight to fulfil the object for which it is applied. The patient must be confined to a horizontal position, and employ her lower extremities as little as possible, at least in the be- ginning of the plan. 23. The second indication must be answered by blood-let- ting, leeching, or cupping; a very abstemious vegetable diet must be insisted on; and the most perfect quiet observed; the bowels should be kept free, but the effects of brisk purging, must be doubtful—this plan should be persisted in, until fever is subdued; then the course may be changed as in any other case, to a more generous diet, or invigorating regimen. If it OF THE SEPARATION OF THE BONES OF THE PELVIS. 25 run on to suppuration, it must be treated throughout its con- sequences, as any other abscess should be. 24. The third indication must be fulfilled/*'' f^he proper exhibition of opium in its various forms. 25. The fourth must be complied with by the judicious ad- ministration of tonics; as bark, sulphate of quinine, &c. &c. and by the daily use of the cold bath, where there are no con- tra-indications to render its use improper. 26. I believe I am justified in saying, that women may very effectually recover, when the symphyses have suffered from mere relaxation of their ligaments; but I fear we have but little reason to hope for an effectual cure, when the bones have been denuded of their cartilages, though the situation of the woman, by proper treatment, may be made comparatively comfortable. Sect. VI.—Of Deformity of the Pelvis. 27. Every departure from the .healthy dimensions of a pel- vis, either by excess or diminution, is considered a deformity —I shall therefore first state the admeasurements of the dif- ferent portions of this cavity, as generally agreed upon by writers, before I proceed to the consideration of such altera- tions as may justly be considered as deformity. 28. The diameter which runs from the superior parfof the symphysis of the pubes to the projection of the sacrum, in a well formed pelvis, is rather more than four inches; while the one running from side to side, a little exceeds five inches; and the one traversing the pelvis diagonally, from behind one of the acetabula to the union of the os innominatum with the sa<- crum, is nearly the same. The first of these is called the an- tero-posterior diameter, or small diameter of the superior strait; the second, the transversal or great diameter; and the third the oblique, which is also properly considered, the great diameter. At the inferior part of the pelvis, or the lower strait, the measurements are nearly the same, but reversed— that is, the great diameter of this strait, runs from the inferior edge of the synvphvsis pubis, to the point of the coccv_\.; allow* '[4] " 26 OF DEFORMITY OF THE PELVIS. ing for the regressive power of this bone, and is usually rather more than four inches. The small diameter of the lower strait, is from the tuber of one ischium, to that of the other; and is about four inches. From this it will be seen, that the great diameter of the lower strait, traverses the great diameter of the superior strait, at right angles—this should be constant!) borne in mind. 29. The deviations from the standard measurement, are so numerous, that it would be almost impossible to enumerate them, were that enumeration even useful; I shall not there- fore descend to such detail, as it would fatigue the memory, without benefiting the understanding. I shall content myself with pointing out only such variations as shall be practically useful; or such as would require a difference in the mode oi terminating the labour. 30. Deformities of the pelvis consist, first, in an excess of size in the diameters of this cavity; and, secondly, in a defect of them. The first presents scarcely any obstacle that is not surmountable by common means; as a precipitation of the uterus within the pelvis during gestation is the chief evil; occasioning some inconvenience or embarrassment to the flow of urine, the alvine discharges, and the locomotion of the wo- man ; during parturition, a too rapid labour, threatening the escape of the uterus with its contents, from the os externum; and after the birth of the child, giving rise to a profuse and alarming haemorrhage, by the uterus being too suddenly emp- tied, by the hasty expulsion of its contents. 31. The first of these inconveniences may be remedied by the application of a proper sized pessary—the second may be in a great measure prevented by a judicious management of the case during labour: 1. By forbidding the woman to bear down during pain. 2. By opposing the too rapid escape of the child, by pressing firmly against it with the fingers within the vagina, so as in some measure to counteract the influence of the pains, if the uterus be but in part dilated; and if fully dilat- ed, by making a firm pressure against the perineum with the extended hand, so as to allow of the more gradual passage of the head. The third, may be at least very much diminished. OF DEFORMITY OF THE PELVIS. 27 by brisk frictions upon the abdomen, immediately over the uterus ; by a proper management of the placenta; and by the immediate exhibition of twenty grains of the powdered secale cornutum. 32. That departure from the standard pelvis, (28) which consists in a diminution of its principal diameters, is much more common, and much more serious in its consequences, than the one I have just considered: for the difficulties are increased in proportion almost to the departure from the healthy proportions, I have just enumerated. 33. The most common cause of the distortions of the pelvis, is rachitis, in infancy and childhood ; and of malacosteon, in , the more advanced periods of life. The former of these dis- eases hinders the proper consolidation of the bones; and thus exposes them to the influence of any pressure that they may be subject to, during its continuance. This being the case, it will be very readily understood how a pelvis shall receive in- jury while labouring under this disease; for on it is exerted, the weight of the body from above, when the child is either sitting or standing; this carries the projection of the sacrum still more forward; while the acetabula serve as fulcra to the lower extremities, when it is standing on its feet, and thus obliges the yielding bones, to retire towards the sacrum ; hence, in some extreme cases, the approximation of these parts is such, as to leave but a very few lines of opening between them. 34. It rarefy happens that every part of the pelvis is equally affected by rickets; and when it is not, the consequences will be different, both in degree, and in location. Sometimes, but one side will have suffered by this extraordinary disease; while the opposite, shall be free from all complaint, and pre- serve its original healthy conformation—at others, it is still more partial, and only affects one small part of this cavity— while again, every portion of it seems to participate in the de- rangement ; then the consequences become most lamentably serious. The upper strait is generally the most injured; and that almost constantly in the direction of its antero-posterior diameter; leaving the transversal one as large, and sometimes 28 OF DEFORMITY OF THE PELVIS. oven larger, than usual; and the inferior strait sometimes without blemish. 3J. When the inferior strait is defective, it is usually in the direction of its small diameter; this is effected by the approxi- mation of the tubers of the ischia. It may also be faulty in several other ways—1. By the spine or spines, of the ilia look- ing inward too much.' 2. By the symphysis pubis being too ^salient. 3. By this symphysis being too long. 4. Byr the pro- cesses of the ossa pubis running down in too perpendicular a direction. The healthy depth and form of the pelvis may be injured in various ways,—1. By the sacrum being too straight. , 2. By its having too great a curvature. 3. By the coccyx look- ing too much upwards. 4. By this bone losing its regressive motion, by being anchylosed with the sacrum. 36. But as every degree of deviation does not render labour impracticable by the natural agents of delivery at full time, it will be well to fix the boundary, which the practitioners of Europe of the greatest experience, have affixed for it. It seems to be pretty generally conceded, that a labour cannot be suc- cessfully terminated, when there is less than three inches in the antero-posterior diameter of the superior strait. When a pelvis has three inches, or even three inches and a half in this diameter, the labour is rendered for the most part tedious, painful, and uncertain. We hear of some remarkable cases, however, of children born alive, when there have been but two inches and three quarters from the pubes to the sacrum; but these must constantly be regarded as exceptions to the general rule; and require, that it may take place, an un- usual suppleness in the bones of the cranium. See Baude- locque, &c. 37. I have appealed above to the experience of the Euro- pean accoucheurs for the datum, that labour at full time is im- practicable, when there is less than three inches in the small diameter of the superior strait—I did this, because I believe, that the united experience of all the American practitioners, would not have led to a correct conclusion upon the subject; as the occurence of deformity of pelvis in this country is so very rare, as not to have been even encountered by some OF DEFORMITY OF THE PELVIS. 29 practitioners of pretty extensive experience; and as far as re- gards my own, I must declare, that, I have not met with extreme deformity in American women, three times in my life ; and when it has occurred to such an extent, as to render labour impracticable by the natural powers, it has uniformly been with European women.* 38. Rickets, among the children in this country, is so rare, that practitioners of considerable practice have declared to me, they have not witnessed a case,—nor is this to be much wondered at; since, the remote causes of this disease are rare- ly present. Our population, even in our largest cities, is not crowded as in many of those of Europe; that we have mam- poor must be confessed; but even the poor enjoy, compara- tively, a purity of air, and a wholesomeness of diet, unknown to many of the same class in Great Britain, or in many parts of the Continent. Very little, indeed, of our population, live under ground, or thickly crowded together. They are not im- pacted in confined manufactories, nor exposed to many of their deleterious operations. It is a rare occurrence, if even our beggars do not regale themselves daily, on more or less animal food; and certainly the population, which with us would cor- respond with the common manufacturers of Europe, are for the most part, sufficiently, nay, oftentimes, abundantly, suppli- ed with it; hence, our general exemption from rickets, and of course our freedom from its consequences. 39. I have said above, (34) that when a pelvis is injured in its proper proportions, it is almost always in the small di- ameter of the superior strait.—Dr. Denman, however, declares it to be always in this diameter when this strait is faulty; and never in the direction of the great one; but in this I must differ from this experienced, and respectable practitioner; for it was my chance to meet with two instances of this kind in practice, as well as to be in possession of a natural pelvis, where the diameters at the upper strait, are reversed. Besides, Baudelocque admits the fact, though he says it is very rare. * In this I am happy to find myself supported by the testimony of Professor James, in a note affixed to his edition of Bums' Midwifery. Note k. p. 35. 30 OF DEFORMITY OF THE PELVIS. 40. One of the cases alluded to above, occurred to me within a few days, and, as it is one of some interest from its rarity, I will relate it. On the 18th March, 1824, at 9 o'clock, A. M. I was called to Mrs.----, in labour with her seventh child. —She had been complaining during the whole of the previous night, but the pains did not become efficient in her estimation, until I was sent for—at this time the pains were very slow, but pretty forcing. Upon examining her per vaginam, the os uteri was found but little dilated, much tumefied, but not rigid. As there was no immediate necessity for my presence, I took my leave, desiring the nurse to send immediately, should any change take place before I intended to visit. I saw her several times during the day, although no alteration had taken place, in either the force or frequency of her pains. At about 10 o'clock, P. M. of the same day, I was again summoned, in con- sequence, as the nurse said, of her having had several pains nearer each other and "smarter."—Upon a second examination every thing was found pretty much as it was in the morning— in the course of two hours more the pains became more fre- quent and urgent, and the os uteri was found more dilated, but still tumid; the head of the child still very high up, indeed was scarcely to be felt.—Two hours more were unprofitably employ- ed, in the hope of the advancement of the head; thinking it probable that this did not take place because the membranes were entire, and apparently more than usually rigid, I ruptured them, and gave issue to a very moderate quantity of liquor am- nii—the head did not yet descend as was hoped, though more within reach; and as the pains were now rather brisker, without manifestly advancing it, I was induced to examine into the cause of the delay more particularly. Upon a careful search being made as regarded the pelvis, it was found, that the point of the coccyx looked very much up into the pelvis, but that the pro- jection of the sacrum could not be felt by the finger, but seem- ed to retire very much posteriorly; the sides of the pelvis could be easily traced at the upper strait; and on the anterior portion of the pelvis, immediately behind the symphysis of the pubes, two fingers could be introduced with their breadth be- tween it and the child's head. The head of the child, was OF DETORMITY OF THE PELVIS. 31 found to occupy completely the transversal diameter of the superior strait—it now occurred to me, that this was an instance of deiormity, in which the transversal diameter was injured, and had procured an increase in the antero-posterior diameter; and that the head being placed diagonally above, could not en- ter the strait in this direction. With this in view, I introduc- ed my hand, and placed the head in such manner as to make the posterior fontanelle answer to the pubes, and the anterior to the sacrum, and then withdrew it. Twenty grains of the ergot were now given, with a view to make the pains follow each other more quickly, as well as to render them more powerful— but the first pain after this, made the head descend to the lower strait, and four more delivered it—there was a little delay with the shoulders, but they followed the second or third pain. 41. This lady, though the mother of six children previoush . never had had any untoward accident from this peculiar con- formation—but her labours she represented as always having been very tedious and severe—four hours of extremely hard pains was the shortest period she had ever known, after she found herself what she called, " to be in earnest." 42. During the existence of rickets, the child is constantly exposed to doing itself mischief by almost any position it may take; if it be placed on its feet, two powers are acting to this end; the weight of the body from above, and the pressure of the heads of the thigh bones from below; producing either moderate or extreme deformity, as the disease may be more or less severe, or as the patient may be more or less disposed to exert its lower limbs. In sitting, the weight of the body is sus- tained by the tubers of the ischia, and the point of the sacrum ; hence, the latter may become too much curved, and the forme r be made to injure the length of the processes of these bones, as well as those of the pubes, and thus do mischief to the arch formed by these bones. If carried in the arms too constantly, the whole of the lateral portions of the pelvis may become in- jured hx the pressure of the nurse's arms. 43. To guard against these evils, Baudelocque* suggest'-, a * system, pai,'e 51, par. 92. 32 OF DEFORMITY OF THE PELVIS. very important practical direction; which is, to keep the pa- tient as much as possible in a horizontal posture, and permit him to exercise his little limbs freely bv sprawling upon a bed or mattress. 44. Injuries arising from malacosteon are more rare, but not less grievous than those from rickets—of the former I have never witnessed an instance. Mr. Burns* says the women of manufacturing towns are particularly obnoxious to it. It be- gins very soon after delivery, and very frequently during preg- nancy ; and is comparatively rare in women who do not bear children, and is always hurried in its progress by gestation. Hitherto, no remedy has been discovered capable of arresting its progress, or preventing its occurrence. He recommends to such women as are afflicted with it, to live u absque marito." 45. The pelvis may also be injured by exostoses and tu- mours, which may give to either very difficult, or even im- practicable labour—of the former I was witness to one case, which occasioned a rupture of the uterus ;f of the latter I have never had the misfortune to meet with a single instance. They are occasioned in some instances by enlargements of the ovaria or glands; or they may consist of some adventitious substance within the pelvic cavity. They are said to be often moveable when of the ovarian kind; and fixed generally when of the other. They are found to have but cellular attachments; and are of easy removal, by making an incision through the vagina, and evacuating the contents of the tumour. There is a kind, however, which either adheres by a pedicle ; or has a broad base; these can only be removed by deep cutting, and are for the most part, cartilaginous. 46. Mr. Burns has laid down the following practical rules for the government of those, whose ill luck may put them in possession of such cases: 1st. " Whenever the tumour is move- able it should be pushed above the brim of the pelvis at the commencement of labour, and prevented from again descend- ing before the head of the child." • Principles of Miduiluy. James's edition, p. 34. r See Kss;iys on Subjects connected with Midwifery, p. 75 OF DEFORMITY OF THE PELVIS. 33 47. 2d. " That we should never permit thejabour to be long protracted, but early resort to means of relief." 48. 3d. " As it is impossible to decide with certainty on the nature of the contents of many of these tumours, we should in all cases, where we cannot push them up, try the effects of puncturing with a trocar. If the contents be fluid, we evacu- ate them more or less completely; if solid, we find the canula, when withdrawn, empty, or filled with clotted blood; if fatty, or cheesy, the end of the tube retains a portion; and we are thus informed of its nature." 49. 4th. " When the size of the tumour cannot be sufficient- ly or considerably diminished by tapping, I am inclined, from the unfavourable result of cases where the perforator has been used, and from the severe and long-continued efforts which have been required to accomplish delivery, to recommend the extirpation of the tumour, rather than the use of the crotchet. There may, however, be situations where the incision ought to be made in the vagina; but these are rare. But extirpation cannot in any mode be proposed, if firm cohesions have been contracted between the tumours and vagina or rectum." 50. 5th. " If the extensive connections, extent, or nature of the tumour, or danger from haemorrhage, prohibit extirpation, or the patient will not submit to it, and it has been early ascer- tained that tapping is ineffectual, I deem it an imperative duty to urge the perforation of the head, or extraction of the child, as soon as the circumstances of the case will permit." 51. 6th. " Much and justly as the Csesarean operation is dreaded, it may with great propriety be made a question, whe- ther, in extreme cases, that would not be less painful and less hazardous to the mother, than those truly appalling sufferings which are sometimes inflicted by the practitioner for a great length of time, when the crotchet is employed; whilst it would save the child, if alive at the time of interference. I am aware that it may be objected to this opinion, that in those cases, the tumour being softer than bone, the same injury will not be sus- tained as if the soft parts had been pressed with equal force, and for the same time, against the bones of a contracted pelvis, and that, in point of fact, recovary has taken place, though the [5] 34 OF DEFORMITY OF THE PELVIS. strength of two able practitioners were exerted and exhausted during several hours ; but such an instance cannot establish the general safety of the practice.'" 52. 7th. " It is scarcely necessary for me to add, that there may be different degrees of encroachment, which admit of the safe and successful application of the forceps, and of this mat- ter we judge by the size of the tumour, and the capacity of the pelvis."* ' 53. This subject is highly interesting to the accoucheur; and I would refer, for farther information, to the chapter from which the above is derived; and where a number of important references are made, to various authorities for cases, illustra- tive of the views of the gentlemen into whose hands they fell. It is a matter of much moment, in the event of meeting with such a case, that we should be well acquainted with the best mode of treating it; for, however rare such instances may be in this country, they certainly may occur; and to be ignorant of the resources of the art upon such an occasion, would be a reprehensible want of information. Sect. VII.— The Examination of the Pelvis. 54. A variety of means have been proposed for measuring the pelvis, in order to ascertain the diameters of the various parts, concerned in the passage of the child; much ingenuity has been expended with a view to, and hope of, accuracy; but we have reason to fear that none hitherto projected, has at- tained this end. The pelvimeter of Monsieur Contouli is lia- ble to serious objections; especially, as it affects to ascertain the state of the pelvis by developing itself within its cavity; for first, it is very difficult, as well as uncertain, in its applica- tion; 2d. It cannot be applied but to the upper strait, not being calculated for the measurement of the inferior strait; 3d. Its results are not by any means certain; as they have been known to vary several lines from the true measurement; 4th. It al- * See Davis's Elements of Operative Midwifery, page 99, in which this sub- ject is treated at some length, and some interesting views, and cases, are fur- nished. THE EXAMINATION 'OF THE PELVIS. 35 ways excites pain, however skilfully applied, and excites action in the parts, so as to render the result very doubtful; 5th. It cannot be applied to young girls, to whom the knowledge of the state of their pelves may be highly important. We must not, therefore, permit ourselves to be seduced by its ingenuity, and its apparent simplicity. 55. Baudelocque relies with much confidence upon the cali- per ; and declares, that its results are so uniform, as scarcely to present a line of difference when taken before the body is opened, and what is found after it has been subjected to the knife. I may add, my own few experiments upon the dried pelvis are in entire conformity with the assertions of this most valuable author. The mode of applying it is ex- tremely simple : one of the lenticular extremities of the cali- pers is applied to the centre of the mons veneris, the other to the centre of the depression of the base of the sacrum, or a little under the spine of the last lumbar vertebra: having ascertained exactly the distance between these extremities, which is accurately done by means of the graduated scale attached to the instrument, you deduct from it three inches for the base of the sacrum, and the anterior extremities of the ossa pubis, if the woman be thin; and a little more, should the woman be fat. If this result be so uniformly accu- rate as Baudelocque declares, we need not want a more exact mode of ascertaining the opening of the upper strait. One fear, however, presents itself to us, that considerable error may. be committed, if the extremities of the instru- ment be not accurately placed upon the points indicated; for I found upon the prepared pelvis, that a half inch higher or lower than the spine of the last lumbar vertebra, would affect the result; now, on the living subject, especially, if that sub- ject be fat, it is not very easy to determine the precise spot. Again, I have seen dried pelves, so peculiarly distorted, as to have the superior portions of the ossa pubes pressed almost close together ; by which means, the symphysis pubis is thrown as much in advance, as these bones lost in their circu- lar direction. In such cases the whole of the anterior, supe- rior portion of the pelvis, not concerned in the extension of 36 THE EXAMINATION OF THE PELVIS. the symphysis pubis, is made almost to touch the posterior, internal portion of the pelvis; consequently, the distance be- tween the svmphysis pubis, and the projection of the sacrum is greater than natural; while the superior opening of the pel- vis, may not exceed half an inch; yet measuring by the calipers, would give several inches in the antero-posterior diameter. 56. We may also, with considerable accuracy, determine the antero-posterior diameter, by introducing the finger into the vagina, and placing its extremity against the most projecting part of the base of the sacrum, and allowing the radial edge of it to press against the arch of the pubes; marking the part of the finger which is immediately below the symphysis by the nail of the finger of the other hand; ascertain the distance be- tween it, and its extremity, and it will pretty faithfully give the width of the small diameter of the upper strait: it must, however, be recollected, that a little allowance must be made for the oblique manner in which the finger descends from the sacrum to the symphysis of the pubes. Or we may ascertain with great accuracy in time of labour, the degree of opening at the superior strait, by introducing the hand into the vagina, and placing some fingers edgewise between the posterior part of the symphysis pubis, and the projection of the sacrum—the width of the fingers so employed, can easily be measured after the hand is withdrawn from the vagina. 57. We may very ne'arly assure ourselves of the extent of the small diameter of the inferior strait, by placing the woman in such a situation, as will give extreme flexion to the thighs; that is, make her squat: the tubers of the ischia can very rea- dily be felt, if the woman be not very fat; ascertain the space between the finger placed on each tuber, and it will give you the width of the lower strait pretty accurately, especially if you deduct two or three lines for the thickness of the bones. OF THE CHILD'S HEAD. 37 CHAPTER II. OF THE CHILD'S HEAD. 58. It is highly important to the well understanding of the mechanism of labour, that the various dimensions of the child's head be accurately known, as the strictest relation must exist between it, and the cavity through which it is to pass, that la- bour may not be obstructed. We must consider four principal diameters as belonging to the head: 1st. The oblique: this diameter runs from the symphysis of the chin to the posterior and superior extremities of the parietal bones, or posterior ex- tremity of the sagittal suture; 2d. The longitudinal diameter: this runs from the centre of the forehead to the top of the occi- put; 3d. The perpendicular: or the diameter subtending from the summit of the head, to the base of the cranium; 4th. The transversal, or the diameter which extends from one parietal protuberance to the other. 59. The second of these diameters will be constantly called the large diameter of the child's head; though strictly speak- ing, as regards measurement, it is not so: but accidentally be- comes so when it shall present itself to the opening of the pel- vis, as it constantly renders the labour untoward and tedious; while the fourth will constantly be considered as the small diameter. 60. These diameters are very often altered from their natural measurement during the progress of labour, by the pressure the head sustains in its passage through the pelvis; but all at the same time cannot either be diminished or increased. If the head be so strongly pressed as to diminish one diameter, it is- sure to be increased in another; for instance, if the transverse diameter be diminished, the oblique is certain to be augment- ed ; and when the head becomes much elongated, as it some- times does, ;*. is almost always in the direction of this last diameter. ^ 61. The extent to which this elongation in one direction, and 38 OF THE CHILD'S HEAD. diminution in another, can be carried, must vary considerably in individual cases; owing to the degree of pliability of the bones; the extent of separation of the sutures, and the size of the fontanelles; the transverse diameter may be diminished, sometimes six or eight lines, while the same length may be gained by the oblique. This compression, however, must ne- cessarily have its limit; and this should constantly be borne in mind; especially in the application of the forceps. If carried too far, there is a risk of fracturing the bones, wounding, or too strongly pressing the brain, or producing extravasation within its substance, or in the cavity of the cranium. Owing to the variety of hardness to which the bones of the foetal head may arrive while in utero, there must necessarily be a variety in the risk the child runs from compression; one head suffer- ing with impunity a loss of six or eight lines in one of its dia- meters, while half this might be fatal to another. The perpen- dicular diameter suffers in general but little, by the efforts of labour, however long continued, or strongly urged. The lon- gitudinal diameter, when the head is well situated, is very little liable to compression, or alteration; but when it does, it must necessarily increase the head in the direction of its transverse diameter. 62. The child's head is composed, like that of the adult, of a number of bony pieces, but which are not united after the same manner: in the child's head the principal bones (and these, as regards our subject, are all we have to consider) are tied together by a firm ligamentous substance; the lines of union are called sutures, and are three in number; 1st. The sagittal suture, or the line of union from the anterior portion of the occipital bone to the root of the nose, passing between, and connecting the parietalia, and dividing, yet connecting the frontal bone,into two equal portions. 2d. The coronal suture; or the line which connects the anterior portions of the parieta- lia, and the posterior and semicircular portions of the frontal bone; and passes from near the superior portion of one ear to that of the other. 3d. The lambdoidal suture or the line serving to tie together the posterior portions of the parietalia and the anterior portion of the occipital bone. OF THE CHILD'S HEAD. 39 63. From this arrangement, it will be seen, that the sagittal suture traverses the coronal suture at nearly right angles; and leaves at the points of decussation an open space or fontanelle. This is not always of the same size, owing to the more or less perfect ossification of the bones—but we always remark in it the following circumstances, and which deserve to be well no- ticed, as they serve to distinguish it from the one next to be mentioned—there are always four bony angles, the edges of which are almost always tipped with cartilage, easily depress- ed and smooth; and very often, nay almost always, a space of considerable size, which is soft, smooth, and yielding; it can be distinctly felt by the point of the finger; this is called, the anterior fontanelle. The other fontanelle is formed by the ter- mination of the sagittal, in the centre of the lambdoidal su- ture ; and has but three bony angles; two by the posterior and superior points of the parietalia, and the central point of the occipital bone. The union of these sutures does not leave the same kind of opening as the one we have just considered; though sometimes it is considerable, but always much less than the anterior—for when the posterior is well marked, the anterior is constantly found to be larger. Besides the circum- stance last mentioned,-we frequently remark, that the edges of these bony angles are more complete in their ossification, and present to the point of the finger a serrated edge; and some- times these little bony projections are so strongly marked, as to resemble small tooth-like processes; a character, which the edges of the anterior fontanelle never present; and which serves very certainly to distinguish it. 64. It sometimes happens, however, that the sagittal suture is continued through the middle of the os occipitis to its base; in such case, four bony points are offered to the touch; but their size and general character are so different from the an- terior, as but very rarely to mislead. 65. We would earnestly recommend the study of the fonta- nelles and sutures, to the beginner of the practice of midwife- ry ; he should very early accustom himself to touch, and dis- tinguish them—it will lead him with certainty to the situation ©f the head as regards the pelvis; and constantly, and instantly 40 Or THE CHILD S HEAD. apprize him of any departure from the best position; and thus enable him, at a proper time, to effect any necessary change, with a view to render the labour safer, easier, and of more speedy termination. No man can with any certainty render assistance, where the head has departed from its proper route, who shall be incapable of distinguishing this aberration by the touch—he will either not distinguish the faulty position, and thus condemn the poor woman to protracted and unnecessary suffering; or he will blindly and rashly attempt relief, at the hazard of the lives of mother and child. 66. Many rely upon the position of the ear, for the know- ledge of the situation of the head; but we object to this test: 1st. Because it may be so high in the pelvis, as to be out of the reach of the finger, when the fontanelles can be command- ed; 2d. It may be so impacted in the pelvis, as to prevent the finger from passing to it; 3d. That, when felt, it may give, from some peculiarity of situation, a wrong impression of its position; 4th. When the head is still enclosed within the ute- rus, the finger cannot always be made to pass under the edge of it sufficiently far to reach the ear, though the os uteri be •sufficiently dilated for all the purposes of delivery. 67. It is important, that the connection of the head of the child with the trunk, should also be well understood; other- wise the child may sustain much injury, if not death, from an ignorance of it—it must be constantly recollected, that the head cannot with safety execute a motion beyond a quarter of a circle, when it is freed from the pelvis, and the body retain- ed within that cavity; nor can the cervical vertebrae more safe- ly perform a greater sweep, when the head is detained, and the body without. A want of attention to this fact, I have great reason to fear, has caused the death of more children than I would dare to mention; especially, when they have presented by the breech, feet, or knees. I well recollect one instance of footling presentation, where the child was deliver- ed, to the head—the midwife who had charge of the case, could not succeed in delivering this ; I was sent for and was obliged to give two entire turns of the body, before the twibt was removed from the neck; I need not mention OF THE CHILD'S HEAD. 41 the fate of the child. Fewer errors of this kind are committed when the head presents; not because the cases are not similar, under equal circumstances; but because, the shoulders are seldom long retained after the exit of the head; and conse- quently, there is less temptation to employ ill-directed force. CHAPTER III. OF THE GENITAL ORGANS. 68. Of the parts concerned in generation and delivery, some are detected without the use of the knife, while the others are only brought into view by dissection; hence, they have been divided into external, and internal. The external consist, of the mons veneris, the labia, the clitoris, the nymphse, the mea- tus urinarius, the hymen, the orifice of the vagina, the carun- culx myrtiformes, the framum labiorum or fourchette, and the fossa navicularis. The internal organs are, the uterus, the fallopian tubes, the ovaria, the ligaments, and the vagina. 69. Immediately over the symphysis of the pubis, and part of the insertion of the recti muscles, we find a prominence, which in the adult is covered with hair—this is the mons ve- neris ; it consists of an accumulation of cellular, and adipose membrane—we know of no decided use of this part; and more especially, for being covered with hair. Apparently taking rise from this part, we find two bodies of similar appearance and texture, running parallel to each other, in a course, down- ward and backward—these are the labia pudendi; their exter- nal faces are covered with the common skin, and are studded like the mons veneris with hair; their internal surfaces are supplied with a beautifully fine and sen: ibie membrane, of a florid colour in young subjects; and is abundantly supplied with glands, that constantly secrete a fluid for the especial protection of these parts against adhesion. [6] 42 01 I Hi* GEMIAI. ORGANS. 70. On the separation of the labia, several other parts arr immediately brought into vieW; the clitoris presents itself, di- rectly beneath the superior union of these bodies. It is made to consist of several parts; as two crura, which have their origin from the ossa. ischia, and running along the branches of the ossa pubi.,, unite upon the symphysis, and form the body of this organ; these are connected by ligament to these bones, somewhat after the manner of the penis in males; its external termination, from its supposed resemblance, has been called its glans; but it is without urethra; being imperforate; a duplication of the internal membrane of the labia, forms its preputium. It has, like the male organ, two corpora caver- nosa, and an intermediate septum; it has also the power of erection, through the agency of two erector muscles, which arise from the ossa ischia, and are inserted into the corpora cavernosa. It is supposed, but without sufficient proof, to contribute to sensual gratification. It is this part, when pre- ternaturally enlarged, which has given rise to the various re- ports of hermaphrodites. 71. It is furnished with bloodvessels from several sources; both arteries and veins are branches from the hypogastrics and vasa pudenda. Its nerves, which arise from the sacri, endow it with great sensibility. 72. Depending as it were from the clitoris, are two similar bodies called the nymphse—they separate more widely as they depart; and run downward towards the os externum; they are very vascular; and in virgins are, like the whole of the inter- nal face of the vulva, of a bright red colour, and are supposed to augment venereal gratification—they certainly are very dis- tensible, and unquestionably contribute by this property to diminish the risk of laceration during the passage of the child. 73. In the centre of, and between the inferior extremities of the nymphse, the orifice of the urethra is found; and though, strictly speaking, it does not belong to the organs of genera- tion, yet it is of such importance in many cases connected with gestation and labour, as to render a familiar acquaintance with it, absolutely necessary in the practice of midwifery. I shall have, upon another occasion, to revert to this part with more OF THE GENITAL ORGANS. 43 exactitude as regards location, &c. The canal, or urethra, of which this is the outlet, is from one inch and a half, to two inches in length; and terminates in the urinary bladder; it is more capacious, and more distensible, than the male urethra; permitting, in many instances, calculi of considerable size to pass along it, without much inconvenience, or distress; and if this tube be slit up to its origin, it will be found studded with numerous mucous lacuna?, two of which at its orifice are par- ticularly large—in the unimpregnated state of the uterus, its direction is nearly horizontal. 74. Below the orifice of the urethra, and almost immediate- ly under the symphysis of the pubes, the orifice of the vagina or os externum is found—it may be said to occupy, in its un- disturbed state, a considerable portion of the arch of the pubes, but its limits are very much increased during the passage of the head of the child at the end of labour; it then extends below the tubers of the ischia. It is surrounded by a sphinc- ter, which arises from the sphincter ani; and is accompa- nied by the plexus retiformis. This sphincter has various degrees of power; owing either, to original conformation, or the habit of exerting it, or both. A medical friend informed me, he had a patient who had such complete control over this constrictor, as to enable her to retain an injection per vaginam, as long as she pleased. 75. In the virgin state, this orifice is almost always partially occluded by a membranous expansion, called the hymen—-this partition is situated immediately within the orifice of the va- gina, and seems to spread itself over, and be the connecting medium, of the carunculse myrtiformes. It is almost constant- ly pierced by a hole, which gives issue to the menstruous se- cretion ; when it is not, it gives occasion to such an accumu- lation of this fluid, as to produce great pain, and require for the most part the interference of art. This membrane has been considered by many celebrated anatomists, as a creature of the imagination; but I am abundantly convinced by mul- tiplied observation, that it really exists; and in the museum of our Medical College, several beautiful specimens may be seen. Among the Jews, a discharge of blood, which was sup- u OF TKJ. ui:mtal ORGANS. posed to proceed from the rupture of this membrane in prim.-*- coitu, was considered as the test of virginity. 76. Immediately at the external extremity of the vagina, we may observe several small fleshy, very vascular bodies, which seem to serve as a kind of valve to this orifice-—these are the carunculae myrtiformes; and upon which, in the virgin state, the hymen appears to spread itself; and are considered even now by many, to be the fragments of this membrane—these bodies exist independently of each other; and are besides, very much too large to be the debris of the hymen—their use ap- pears to be, to hinder the urine, and even other foreign bodies, from passing into the vagina; to contribute towards the vene- real orgasm; and to provide, in the lasj; moments of labour, a supply of distensible materials, to diminish the risk of severe contusion, or of laceration. 77. In advance of the hymen, and a little below it, the semi- lunar fold, called the fourchette, may be seen; it almost as certainly belongs to the virgin as the hymen, as it is rarely found after delivery—between the hymen and the fourchette, the fossa navicularis is situated. 78. The space, directly behind the inferior terminations of the labia, and before the anus, is called the perineum—in its natural state it is about an inch and an half in width; is pretty- dense, though chiefly composed of cellular membrane; but is capable of prodigious extension. Sect. I.—Of the Internal Organs. 79. The internal organs of generation consist of the vagina, the uterus and its appendages, the fallopian tubes, and the ovaria.—The vagina is that canal which leads directly to the uterus. I have already stated, {75) that the hymen in virgins, and the carunculae myrtiformes in married, or used women, guard, as it were, the entrance of this canal. Its length may be stated to vary at different periods of life; it is wider at its upper extremity than below; and more especially, towards the sacro-iliac symphyses, as its central portion is occupied by the uterus, which hangs pendulous in it. It is not direct in OF THE INTERNAL ORGANS. 45 its course, dipping first a little downwards, and then passing upwards to meet the uterus; with which it is so united as to exhibit, in time of labour, no line or mark of union; but form- ing with it a continuous canal. It consists of a pretty dense cellular substance, which is very elastic, as is proved after delivery, by its quickly restoring itself. 80. It is lined by a continuation of the membrane which covers the internal faces of the labia; it folds itself up into wrinkles, called rugae—it it asserted by some, that these ruga; are peculiar to women; and to which several duties are as- signed: 1st. That they contribute to venereal gratification, (but if this were one of their offices, they are certainly ill situ- ated.) 2d. That they serve as a remora* to the ejected semen, and at the same time offer it a larger surface to be absorbed from. 3d. That these folds serve to give greater length and breadth to the vagina, by stretching out during labour, and thus preventing laceration. The vagina is extremely well sup- plied with blood vessels; and, when well injected, is found to be highly vascular—throughout its whole surface innumerable glandular follicles may be seen, which constantly secrete a mu- cous fluid. The vagina in its course forms several points of adhesion by means of cellular membrane : 1st. it adheres very strongly to the urethra before ; and 2d. Behind, it unites itself pretty firmly at its upper part, to the rectum. Sect. II.—Of the UteYus audits Dependencies. 81. The uterus is situated in the pelvic cavity, at the upper extremity of the vagina; it is so placed as to have the bladder before it, and the rectum behind; with both of which, there is more or less intimacy of connection, by intervening cellular membrane, and reflected peritoneum. It is of a pear-like shape, but a little flattened; with its small extremity hang- ing down in the vagina. It has been usual with writers, for the sake of convenience, to divide this organ into three parts; namely, fundus, body, and neck—the fundus is made to consist * Speculations on Impregnation 46 OF THE VTERUS AND ITS DEPENDENCIES. of all that part which is superior to the origin of the fallopian tubes; the body, of that portion which is inferior to them, and extending to the commencement of the neck; and the neck, of all that acuminated portion which distinctly dips into the vagi- na, and terminates in the os tincae. 82. The substance of which the uterus is composed, has long been a matter of dispute with anatomists, and physiologists— some declaring it to be muscular, while others insist it is in its structure sui generis. Mr. Bell* decides on the muscularity of this organ, because he has seen and dissected its fibres; so thought Vesalius, Malpighi, Ruysch, and Hunter. Dr. Rams- bothamf denies the fact; and says, " this notion appears to be rather an assumption derived from the contractile powers, which this viscus is known to possess, and which are supposed only to exist on muscularity, than to originate in obvious ap- pearances. However authors may write, and teachers may talk about the uterine muscles, no such structure is evident to my senses." To me, neither this declaration of Dr. R. nor his reasoning has in the slightest degree shaken my faith in the muscular structure of this organ—the whole phenomena of labour at full time, and the throwing off of the ovum in abort- ing, irresistibly force me to this opinion. It is not at present, and perhaps it never may be decided, in what manner the fi- bres of the uterus dispose of themselves in composing this organ; yet enough of its structure is known, I believe, to warrant the declaration, that its functions as regards labour, are performed by the power of muscular contraction. 83. There is no organ in the human body, from whose struc- ture so little can be inferred, as the unimpregnated uterus; in it, when laid open by the knife, we see no manifestation of capacity for distention; on the contrary, we observe nothing but dense unyielding walls, that would seem to bid defiance to any attempt for this purpose—in it we have no promise, of the immense force which it is destined to exert, to relieve it- self of the produce of conception—nor can we anticipate the immense distensibility of its vessels from pregnancy, in the * Eclec. Rep. Vol. V. p. 37. f Practical Obs. Am. ed. p. 19. OF THE UTERUS AND ITS DEPENDENCIES. 47 diminutive, nay, almost imperceptible ones in its empty state —so wonderful, and so varied are the changes which this or- gan undergoes from impregnation. * 84. The cavity of the uterus is small and somewhat of a tri- angular form ; it terminates below in the neck, and its opening is termed the os tincae. The uterus is lined through its whole extent, by a fine membrane, which, from near the os tincae to its fundus, as also through the windings of the fallopian tubes, is so completely identified with the proper substance of these parts, as to defy any attempt at a regular separation—the same may be said of its peritoneal covering; refusing to dis- solve its union with the external portions of the body and fun- dus, by any attempt that may be made for the purpose, unless it be after incipient putrefaction. 85. It has uniformly been declared, so far as I know, that the whole of the internal surface of the uterus, including the neck of this organ, and the fallopian tubes, are furnished with linings, from a continuation of the membrane which gives cov- ering to the vagina—I have strong reasons to call in ques- tion the truth of this arrangement; so far at least, as the ab- sence of identity of function, would declare the absence of identity of structure—it is now no longer a matter of dispute, that it is from the internal face of the uterus, that the menstru- ous secretion proceeds ; yet this fluid is neither furnished by the vagina, nor by the fallopian tubes ; consequently, the mem- branes lining these parts, cannot be one and the same. 86. The division of the uterus into different portions, was suggested for the convenience of demonstration ; and has been employed by all the writers upon anatomy and midwifery, for the last century at least—I adhere to this division, but from very different motives ; many years ago, I insisted on this divi- sion as essential, to the explanation of several of the phenomena, which this organ constantly presents; I shall therefore tran- scribe without apology, my sentiments, as expressed upon this subject, from my "Essay on the means of lessening Pain, and facilitating certain cases of Difficult Labour," p. 17. ed. 2d. 87. " I cannot help regarding the neck of the uterus as a dis- 48 OF THE UTERUS AND ITS DEPENDENCIES. tinct and independent part from the body and fundus, as ha\ - ing its own peculiar laws and actions; and that this separation of powers is absolutely necessary to the explanation of some of the phenomena exhibited in health and in disease, and the influence of certain agents upon this organ." 88. " My reasons for thinking so are, first, that we find the fundus and body may be distended to a great extent, without affecting the arrangement of the neck; thus, in every uterine pregnancy, we see these p:vts gradually yhld to the influence of the ovum, until about the sixth or seventh month; while the neck remains very much the same as before impregnation." 89. " Secondly, that after the sixth or seventh month, the neck undergoes its changes, while the fundus and body remain in a great measure stationary; so that two distinct processes, or rather the same process, is performed at two different pe- riods, and in different parts, in the order we have just men- tioned." 90. " Thirdly, that the neck may be affected by disease, while the fundus and body may remain free, and the reverse; and that the neck may contract and relax, while the other parts are in opposite states—thus with women who are in the habit of aborting from some peculiarity of the uterus, we find the body and fundus may be excited to action, while the neck for a long time remains passive; and also the neck may relax, and, after some time, the fundus and body may be excited to contraction. And in cases of atony of the uterus after a too sudden delivery, the body and fundus may contract, while the neck is the only part in fault, and vice versa." 91. "The different conditions that the parts of the uterus may be in at the same time, where atony partially prevails, would seem to demonstrate the truth of what is here advanced. For it is a fact well known to almost every practitioner of mid- wifery, that each of the parts into which we have divided this viscus, may separately and independently of each other, be in a state of relaxation or contraction, and thus exhibit different phenomena, and be productive of different results." From this it would appear that nature has really established a divi- OF THE UTERUS AND ITS DEPENDENCIES. 49 sion of the uterus, which has hitherto been considered as merely conventional. 92. The uterus may be farther divided into an anterior, and posterior surface, and into two sides. The anterior portion of the uterus is rather more convex and thinner, than the pos- terior; and is subject to a less degree of distention—the posterior yielding considerably more, during the progress of gestation; and for this purpose more substance is given to it. From each side of the uterus, and at a line which would divide the fundus from the body, a tortuous body takes its rise; and is named the fallopian tube—it is hollow; but its caliber is not of a uniform width; at its uterine extremity, the opening is very small; but as it proceeds, it acquires size, and eventu- ally terminates in an opening of some size, which is surround- ed by an uneven frill, called the fimbria. 93. It has been thought by some, that these tubes were composed of similar tissues with the uterus itself; it is de- nied by others; but all agree that they enjoy a vermicular motion. Their linings are also said to be continuations of the same membrane which lines the uterus; but I have already called this in question (85)—the internal membrane of each tube, is contracted into longitudinal plicae through its whole length; and furnishes, by means of many little glands, a fluid which constantly lubricates its surface. 94. Near to the abdominal extremities of the fallopian tubes, we find two small roundish bodies called the ovaria; these glands, if we may so term them, are of primary importance to the genital system of the female. By them is given, the first impulse for the menstruous secretion, and venereal indulgence; by them is furnished whatever may be contributed by the fe- male, towards the formation of a new being. They are about the size of a common nutmeg, if it were a little flattened; and when cut into, present a glandular appearance—they are not remarkably supplied with blood vessels, nor do they possess much sensibility—at puberty, we may remark upon their surface, and especially when favourably placed between the eye and the light, a number of little vesicular bodies, of un- certain number, which contain a fluid, capable, it is said, of [7] 50 OF THE UTERUS AND ITS DEPENDENCIES. being coagulated—these are the ova. When these are dis- placed bv either fecundation or otherwise, they leave evi- dences, that thev occupied certain portions of the surface of the ovaria. 95. We may also remark upon the face of an ovarium, a number of little spots, which, from their colour, are named corpora lutea; these until lately, were supposed to be the cica- trices of removed ova; but Sir Everard Home* has pretty sa- tisfactorily proved, that these marks exist previously to im- pregnation ; and that they have no less a destiny, than to fur- nish the ovum; and prepare it for impregnation. In the vir- gin state, he declares a corpus luteum to be a solid, compact, glandular body; and when the ovum is liberated, the cavity it leaves, is filled with blood; which, after a while is absorbed, and a small pit remains. 96. The whole of the abdominal portions of the uterus, namely, the fundus and body, are covered with peritoneum—* it passes from its sides, in a state of duplication towards the lateral portions of the pelvis, and forms what has been termed the broad ligaments—each of these ligaments has an anterior and a posterior portion or pinion—in the anterior pinions, the fallopian tubes are included; and in the posterior, the ovaria. 97. The round ligaments, two in number, originate from the superior lateral parts of the womb, run in the doublings of the broad ligaments, and, rising to the brim of the pelvis, pass over it, through the abdominal rings, and lose themselves as it were in the groins. These ligaments are very vascular; espe- cially, during pregnancy; and it is to this engorgement, that Baudelocque attributes the pains the woman sometimes feels in these parts, as gestation advances. These two sets of ligaments, have been supposed to give support, or perma- nency of situation to the uterus; if this were the design of them, it must be confessed they perform their duties, in a very inefficient manner—for it is well known to every accou- cheur, that nothing can be more uncertain, than the situation of this organ; every change in the abdominal viscera, every • See Phil. Trans., years 1817 and 1819. OF THE UTERUS AND ITS DEPENDENCIES. 51 alteration in the contents of the bladder, and rectum, imposes a new position upon it. Mr. Charles Bell has, however, made a new, and what he seems to think an important suggestion, as to the offices of the round ligaments; he supposes, they give 'rise to a number of muscular fibres, which perform a most important role in the economy of gestation and of labour; while they, at the same time, perform the offices of tendons rather than of ligaments. I shall refer the reader, for a confu- tation of Mr. B.'s opinions upon this subject, to " Essays upon various Subjects connected with Midwifery," p. 461 et seq. 98. The uterus is supplied with blood vessels from the sper- matics and hypogastrics ; the intercostal, the renal plexus, and sacral, furnish it with nerves—and is most abundantly pro- vided with lymphatics.* Having, in a cursory manner, given the anatomy of the ute- rus, it would seem proper that its functions should next be considered; and first of the CHAPTER IV. MENSES. 99. By menses, we mean, " a periodical discharge of a co- loured fluid, resembling blood, happening every lunar month; commencing at puberty, and continuing until about the forty- fifth or even fiftieth year, unless interrupted by pregnancy, suckling, or disease." 100. It was formerly a matter of much uncertainty from whence this discharge proceeded; some supposed it came from the uterus itself, and others from the vagina, or both. This question is now put to rest, by both Morgagni and Dr. William Hunter having seen it proceed from the os uteri, in cases of procidentia. It was also a matter of much uncertain- • Cruikshank on the Lymphatics. 52 MENSES. ty, which class of blood vessels furnished this fluid: Ruysch declared it to be from the arteries; Vesalius from the veins; and Simpson from certain appropriate sinuses. If the views 1 shall take of this interesting phenomenon be correct, namely, its being a secretion, it will be found to proceed, as Ruysch supposed, from the arteries, as all secretions, so far as we yet know, with the exception of the liver, are performed by arteries. 101. It is uncertain who first suggested the idea, that the menstruous discharge is a secretion—the credit of it has been given to Haller, Bordeu, Hunter, and Saunders—the latter un- questionably taught it publicly in 1784, and how long before, I cannot ascertain. 102. Independently of considerations derived from the structure and diseases of the uterus, of the menses being the result of a secretory process, we are to regard the appearances of the discharged fluid itself, as confirmatory of the sugges- tion. This discharge must be either a portion of the common mass of blood as it circulates in the system, or it must have undergone some change during its separation from the com- mon mass—if the former, it should exhibit the appearances of blood detracted from any other part of the body by opening a vessel for the purpose; but this is not so ; if the latter, it is probable that it has been eliminated by that process termed secretion. This opinion is farther strengthened by the follow- ing considerations of the physical properties of the fluid itself: 1st. Its colour is between the arterial and venal blood; being less brilliant than the former; and more florid than the latter: 2d. It never separates into parts; blood drawn, or evacuated from any other part of a healthy body, does separate, in a short time, into its principal component parts: 3d. It never coagulates, though kept for years; while other blood, when free from disease, quickly does, when exposed to the influence of the air: 4th. Its odour is remarkably distinct from that of the circulating mass; and it is less disposed to putrefaction. 103. It is thought by some, to differ materially from com- mon blood by not possessing fibrin; of this I cannot speak with certainty; but I am disposed to believe, that this part of the blood has only undergone a change, during elaboration; more MENSES. 53 especially, as the coagula*injv lymph is alwavs found to accom- pany the re I globules, either when blood ha.- been accidentally extravasated, or designedly drawn; rr.v reason for thinking so is, that in raanv instances nothing more is necessary to diis effect, than the establishment of some peculiar arterial action— thus we find in certain kinds of small-pox, fevers termed pu- trid, scurvy, &c. the blood loses the power of coagulation; the blood of those who die from lightning, blows upon the sto- mach, &c. it is said has also this capacity destroyed—there- fore, the mere absence of coagulability, is not sufficient to prove the absence of fibrin. 104. In this, nature has shown her beneficence; for to what wretchedness would the woman be doomed, at each menstrual period, did it retain its property of coagulation ? Mr. Hunter thought that this effect was produced by the blood losing its living principle during the secretion—but to this I cannot subscribe; as this fluid, as I have already noticed, is thought to resist putrefaction longer than common blood. 105. I have stated, in the definition of "menses," that it first takes place at puberty, or that period at which the ani- mal is capable of propagating its species—this period must vary as it may be influenced by climate, constitution, and modes of life ; always being earlier in hot, than in cold coun- tries ; sooner in cities, than in the country, &c. Before they make their appearance, they almost always announce them- selves, in the altered appearance of the female—the mammae increase in size; the voice undergoes a slight change: the pubes are covered with hair: and the best proportions the in- dividual is susceptible of, now suddenly and successfully de- velop themselves. The mind is also replete with changes; puerile amusements now yield to maturer enjoyments, and ra- tional inquiry; capricious attachments give place to sincere, unaffected, and permanent friendship; in a word, a new crea- ture almost seems to be formed suddenly. Besides the physi- cal and mental changes just spoken of, there are other circum- stances which mark the pubescent period very near at hand— such as, headache, dulness of the eyes, pains in the pelvic re- .54 MENSES. gion, lassitude, whimsical appetite, slight leucorrhoea, &c. and after these have continued a longer or shorter time, they sud- denly depart, and a discharge of a small quantity of fluid from the vagina, is found to have taken place; but this need not necessarily be coloured at first. The last named circumstance is worthy of attention; as it will serve to explain those cases of impregnation which are said to have taken place previously to-the eruption of the menses. 106. The menstrous period is usually from four to six days; and, during this time, from four to six ounces of fluid are dis- charged—in this, there must necessarily be some variety; de- pending upon constitution, &c. After it ceases, the woman is exempt from a repetition^ for twenty-eight days, or a lunar month ; at which time, however, it will return with most dis- tinguished regularity—so much so indeed with several women I have known, as to enable them, not only to indicate the day, but also the hour—during the flow, the appetite with some becomes capricious; they are languid, pale, or hectically florid; a dark stripe most frequently may be observed below the eyes; and with many, a painful dragging sensation about the hips and loins, is constantly experienced, during the whole periodf 107. In this manner are women subject to this flux, until between the fortieth and fiftieth years; at which time they cease, never to return. For the most part, as the period of cessation approaches, they fail in their wonted regularity— sometimes the period is protracted to six or seveja weeks, and then, instead of five or six ounces being evacuated, there may be a loss of twenty or thirty; or there may be merely a show, as it is termed—at other times, the period may be anticipated by as many days, as it had exceeded before; and the discharge may be as vague as I have just mentioned. ■ 108. I have known several instances, where the eruption of the menses was constantly preceded by strong hysterical pa- roxysm*, of greater or less permanency; the menses would now appear, and instantly the system would be tranquillized, and the woman return to her ordinary state of health. One case I knew where a severe pruritus accompanied this convulsive MENSES. S3 state, to the great annoyance of the poor young creature who was the subject of it.* 109. From the earliest records of medicine, to the present day, the ingenuitv of the philosopher has been exercised to point out the efficient cause of this peculiar habit of the hu- man female; I shall therefore cursorily pass in review the va- rious hypotheses which have been invented for this purpose, and first Sect. I.—Of Lunar Influence. 110. The influence of the moon was very early assigned as the efficient cause of menstruation; from either the real, or supposed effects of this luminary upon tides and diseases, it was easy to believe it might have a power or control over some of the healthy functions of the body; and, as the men- struous flux was periodical, and observed a lunar period, or interval, it was no great stretch of the imagination, to suppose its return connected with the movements of this body: this opinion is not entirely exploded at the present moment; though, to destroy this hypothesis, it is only necessary to state the fact, that there are women menstruating promiscuously every day of the year, and every hour of that day. Galen, at an early period, saw the weakness of this scheme, and accordingly in- vented another; namely, Sect. II.— The General Plethora Doctrine. 111. This hypothesis has higher claims to our attention, than the one we have just been considering; for it is both in- genious, and plausible. He began with stating, that women * This young woman was perfectly relieved from these disagreeable symptoms, by camphor in ten grain doses, f at the commencement of the menstruous period, and liberally washing the parts in the interval with a strong solution of borax. t The writer of the " Critical Analysis of Dr. Dewets on Midwifery," in the Loud. Med. &. Phys. Jour, for July, p. 72, says, " We should be unwilling to give ten grains at a dose (of camphor) without having first tried, by the exhibition of a smaller quantity, the power of the patient to bear lilt remedy." I can assure the gentleman, that I rarely, if ever give this medicine in smaller doses ; nor have 4 ever witnessed the smallest iucoim i.ience to follow, which wus attributable to the Iarg' ncss of the dose. Idiosyucrac) may wake any quantity im; rop-r. 55 THE GENERAL PLETHORA DOCTRINE. were more disposed to plethora than men; 2d. That to get rid of this superabundance of blood, some outlet was necessary, and that this outlet was the uterus; 3d. That this state of ful- ness was essential to the female system, as it must make pro- vision for the child, while in utero, as well as provide it sus- tenance after it is born; and that these objects were effected by the suppression of this discharge during pregnancy and suckling; 4th. That when the uterus failed in destroying this plethora, some other part performed a vicarious office, and gave issue to the blood : hence haemorrhages from the lungs, bowels, ulcers, &c; 5th. That when this evacuation failed to appear under ordinary circumstances, the quantity of blood was below the ordinary standard; and that it could only be recalled by such remedies as would increase the measure of this fluid. 112. To the first of his positions, it may safely be said, that strong doubt must be entertained of the fact; for, though wo- men may exercise less than men, they perspire more; and their ingesta is certainly less. 113. And if there be a plethora, it must be occasioned by five or six ounces of blood; yet it is well known, that if five times that quantity was drawn just before the period was ex- pected, or during its flow, that it would neither interrupt the eruption, nor diminish the quantity that would otherwise be expended. Of this I am certain, from the following facts: many years since, I witnessed a singular periodical haemorrhage from the ear of a young lady, which was of several months' duration; it would commence at about 11 o'clock A.M. every day, with the utmost regularity, and, after giving issue to an ounce or two of blood, it would spontaneously stop, and not recur until the same hour of the next day: yet this young lady menstruated with the utmost regularity, both as to period, and quantity. It may not be uninteresting to state, that this affec- tion was cured by the application of a blister near the part, after very many other remedies had fruitlessly been tried. Another case fell under my observation, which goes still far- ther to prove, that general plethora has no agency in the pro- duction of the catamenia. A young lady asked my advice for THE GENERAL PLETHORA DOCTRINE. 57 a daily discharge of blood from the anus, of several years' continuance: she would lose very frequently from a half pint to a pint at a time, and smaller quantities almost daily; she of course was feeble, and far removed from plethora; yet she menstruated regularly, and never employed less than a week for the discharge. 114. To the second it may be answered, that men, however plethoric, have no such compensating discharge. To the third it maybe declared, the means are not adequate to the end: for the embryo would not require, for a long time, any thing like five or six ounces of blood for its support; and, at a more ad- vanced period of gestation, it would be altogether insufficient. With respect to its subserviency to lactation, how totally in- sufficient would it be for a healthy, or even a very feeble in- fant ! The fourth, I must protest against, as a fact: for in all good faith, I avow, that in five and thirty years1 practice, I have never witnessed an unquestionable case of this kind. And, as regards the fifth, the daily experience of almost every practitioner, must be set in opposition to it: for, though we very frequently employ stimulants for the restoration of the menstruous secretion, yet they do not act by filling the blood vessels, but by increasing their activity; but are we not obliged almost always to employ depleting remedies before we can advantageously use tonics ? and do they not sometimes succeed without the agency of stimulants ? 115. The doctrine of fermentation of the chemists; the mechanical solution of Dr. Friend; the preposterously indeli- cate hypothesis of Le Cat and Brown, do not deserve an at- tempt at refutation; we shall consign them, with .ome others, to " the tomb of all the Capulets," from whence, as we trust, never to be recalled. 116. I cannot, however, dismiss this part of my subject, without noticing the highly ingenious explanation of Dr. Cul- len, by whom it was taught with all the force of eloquence, and all the charms of fancy; and, such was its plausibility, and speciousness, as to enlist in its defence, almost all the teachers in Europe, and not a few in America. Tt is called the theory of [81 58 TOPICAL CONGESTION. Sect. III.— Topical Congestion. 117. Dr. Cullen supposes that the body is developed pretty much in the order of necessity, and the size of the vessels belonging to the part: hence the head and superior extremities are first unfolded; then the lower extremities; and, lastly, the uterus. u But," says he, " as the vessels of every part, by their distention and grovvth, increase in density, and thus give greater resistance to further growth; at the same time, by the same resistance, they determine the blood in greater quantity into parts not yet equally developed. By this means the whole system must be successively and equally evolved. Upon these principles, there will be a period in the growth of the body, and when the vessels of the uterus will be in equilibrium with the other parts or the system; and their constitution may be such, that their distention may proceed so far as to open their extre- mities, terminating in the cavity of the uterus, so as to pour out blood there; or it may happen, that a certain degree of distention may be sufficient to irritate and increase the action of the vessels, and thereby produce an hemorrhagic effort, which may force the extremities of the vessels, with the same effect of pouring out blood." 118. In either way, he accounts for the first appearance of a flow of blood from the uterus of women. In order to this, he does not suppose any more of a general plethora in the sys- tem, than what is constantly necessary for the successive evolu- tion of the several parts of it; and proceeds upon the supposi- tion, that the evolution of each particular part must necessarily depend upon plethora, or increased congestion in its proper vessels. Thus he supposes it to happen with respect to the uterus; but as its plethoric state produces an evacuation of blood from its vessels—this evacuation must empty these ves- sels more especially, and put them again into a relaxed state with respect to the system. This empty and relaxed state of the vessels of the uterus, will give rise to a new congestion, till they are brought again to that degree of distention, that may either force their extremities, or produce a new hemorrhagic TOPICAL CONGESTION. 59 effort that may have the same effect. Thus, an evacuation of blood from the uterus, being once begun by the causes just mentioned, it must, by the operation of the same causes, return after a certain period, and must continue to do so till particu- lar circumstances occasion a considerable change in the con- stitution of the uterus. What determines the period to nearly a month, he cannot explain; but supposes it to depend upon a certain balance between the vessels of the uterus and those of other parts of the body. This must determine the first peri- ods ; and when it does so, it can be understood, that a consi- derable increase or diminution of the quantity of blood in the whole system will have but little effect in increasing or dimin- ishing the quantity distributed to the uterus. And when this evacuation has been repeated for some time at regular periods, it may be supposed that the power of habit, which so readily takes place in the animal system, may have a great share in determining the periodical motions of the uterus. 119. Upon this celebrated hypothesis I shall beg leave to observe, first, that he has admitted more causes than are neces- sary to account for the phenomena—thus at one moment, " their distention" is such " as to open their extremities, ter- minating in the cavity of the uterus, so as to pour out blood there;" in an instant after, he conjectures, " that a certain de- gree of distention may be sufficient to irritate and increase the action of the vessels, and thereby produce an hemorrhagic ef- fort, which may force the extremities of the vessels, with the same effect of pouring out blood." Here two distinct causes are assigned, for the same effect; namely, "distention," and an " hemorrhagic effort"—both of these could not possibly ope- rate at the same time, if they be distinct agents; and if they be not, we are certainly entitled to be informed, in what they dif- fer; for we cannot understand what is meant by an hemor- rhagic effort, if it be distinct from such a degree of distention, as shall force the vessels to yield blood. 2d. That if this scheme be true, the menstruous discharge is nothing but a common hemorrhage ; for here are vessels distended to such extent as to oblige " their extremities terminating in the ute- rus, to pour out blood there;" now, what are we to understand 60 fOl'ICAL CONGESTION. in this instance of pouring out blood into the cavity of the ute- rus, different from blood beinij poured out in the cells of the lungs, or the cavity of the stomach, when the sides or extre- mities of their vessels are so forced as to yield their contents ? We see none; yet the appearance of the menstruous blood is entirelv different from hemorrhagic blood. 120. Third, were this doctrine true, no woman could possi- bly preserve the fruit of her womb to the full period of utero- gestation ; for it is a fact as well ascertained, as any connected with our history, that, so soon as conception takes place, an in- creased flow of blood to the uterus takes place ; now, if upon common occasions, much less blood will produce such a " dis- tention, or hemorrhagic effort" in the vessels terminating in the cavity of the uterus, that they shall pour out blood there, what is there to prevent an increased quantity, the consequence of pregnancy, from doing the same, and thus deluging at once the delicate, and unsettled ovum ? 121. Fourth. It would seem in some measure essential to this hypothesis, that " habit" should exert a certain influence, to insure the periodical returns of the catamenia—it can, we think, in one moment be shown that, "habit" has not the smallest agency in the production of this discharge ; for it is notorious to every body, that this is constantly interrupted in married women for many months together—nine months of pregnancy, twelve, or even eighteen months of suckling; dur- ing the whole of which time, the menses do not make their appearance; yet, the child is no sooner taken from the breast, than this evacuation establishes itself, and with as much regu- larity as if it had never been interrupted—since then, in these instances, " habit" has had no influence upon the first return, it cannot possibly be necessary to any number of returns. 122. From what has just been said, it appears that hitherto nothing satisfactory has been advanced upon this curious sub- ject—it yet remains for some future Haller or Hunter to en- rich medical science with a rational explanation of it. FINAL CAUSE. 61 Sect. IV.—Final cause. 123. The final cause of the menses, is perhaps enveloped in some obscurity; but of this we know at least one incontrovert- ible fact; namely, that the healthy performance of this function is in some way or other connected with impregnation ; as no well-attested instance is yet upon record, where this has taken place in a female who never had had this discharge, or even when it was not eliminated of a healthy character, and with a greater or less degree of regularity. It perhaps may be said, that in those rare instances where women never menstruated, there was some imperfection in the genital organs ; this per- haps is the case pretty uniformly; I know it was so in one which fell under my own notice—a young lady of twenty-eight. years of age had never menstruated, or given any evidence-of the necessity of this evacuation, as she very uniformly enjoyed good health and spirits. She was, however, seized with an inflammation of her bowels, and soon became alarmingly ill; I was requested to visit her in consultation; and as she never had menstruated, and as she suffered severe periodical pains in the region of the uterus, it was supposed that some derangement of this organ might be the cause of her present suffering; I was accordingly requested to examine her per vaginam. The fin- ger passed into the vagina with some difficulty, but the uterus was readily touched. It presented to the finger a size not exceeding the thumb of a man; and its neck was as slender as a common writing quill, and about half an inch in length. The pubes were covered with the usual quantity of hair, and the mamme were pretty well developed—the imperfection in this case consisted, most probably, in the want of size of the uterus alone ; as it is more than probable, from the'state of the breasts, and covering of the pubes, that the ovaria were not in fault—moreover, she was fond of mixed society, and, I have reason to believe, she was ardently attached to a gentleman, but refused to marry, on account of the absence of the menses. She died two or three days after my examination; but leave could not be obtained to inspect the body. 02 FINAL CAUSE. 124. But cases like the one just related cannot invalidate the other part of our position; namely, that women must not only menstruate, but must menstruate healthily, and regularly, to ensure impregnation. Besides, a strong analogy is presented to us in the economy of brutes—the females of which have their periods of salacity ; at this time they have a copious discharge from the vagina, which without question, is of similar import, with the menses of the human female—it is not a mere in- creased flow of the natural vaginal discharge; for we see it instantly detected by the discriminating olfactories of the male. 125. It may be asked, why are the menses in the human fe- male coloured ? It may be difficult to answer this satisfactorily; but I am of opinion, that one of its uses is, to advertise the female when this discharge is arrested, that impregnation has most probably taken place; and thus she is enabled to make the necessary arrangements for the period of becoming a mo- ther. Were this discharge not coloured, it might readily be mistaken for an increase of the secretion, natural to the uterus and vagina—but being coloured, this error could not well take place. CHAPTER V. OF CONCEPTION. 126. The ingenuity of physiologists has invented hundreds of hypotheses by which impregnation is said to take place in the human subject. The supporters of these various notions may, however, all be reduced to a few general heads, under which they will naturally range themselves:—First, they may be divided into those who suppose the male semen to be di- rectly conveyed to the ovaries by being urged by the powers of the male apparatus through the neck of the uterus into its cavity; and from thence to be transported by some inherent power of the uterus to these bodies. 2d. Into those who sup- OF CONCEPTION. 63 posed this ground not tenable; and who declared the semen is first absorbed from the vagina, and carried eventually to the ovaries, through the medium of the circulation. 3d. Into those, who believe the semen makes an impression upon the labia, vagina, or the uterus; and that impregnation takes place by the ovaria sympathizing with this impression. 4th. Into those who believe in the direct conveyance of the semen, by its being taken up from the labia pudendi or vagina by a set of vessels, whose whole duty is to convey it to the ovaries. 127". Against the first opinion it may be urged, that many well attested instances have occurred, where it was impossible that the extremity of the male urethra could be placed in direct opposition to the os tince, so that it could receive the male semen from it by a vis a tergo, (a sine qua non to this hypo- thesis,) first, because of the entire occlusion of the os exter- num by a too dense hymen, cicatrices, or the vagina termi- nating in the rectum; consequently the penis could not enter it. 2d. By the male urethra not terminating at the extremity of the glans penis, but beneath it, at the posterior extremity of the frenum; by the urethra being obstructed by strictures; by that canal terminating at the junction of the scrotum with the body of the penis; consequently, destroying the impetus the semen derived from the ejaculatory powers of the male organs, &c. 128. To the second, it may be objected, that if the semen were absorbed by the lymphatics of the vagina, it would be, like every other substance subjected to their influence, so changed as to be no longer semen; consequently could not impregnate an ovum, as it is no longer pure semen. To this it is true it may be answered, that the very changes imposed upon the semen by the absorbents, may be essential to fecun- dation. But this would be flying in the face of the experiments of Spallanzani, who found that the semen itself was absolutely necessary to impregnation. 129. To the third, we may say, it makes no provision for the formation of mules; for the peculiarities of, and likeness to parents; and for the propagation of disease, from parent to child. H OF CONCEPTION. 130. The fourth we must leave to others to object to—I many years since promulgated this conjecture; and it has since been in part confirmed by the discovery of ducts leading from the ovary to the vagina, in the cow and sow, by Dr. Gart- ner of Copenhagen. I think this the most simple mode nature could have adopted for the completion of her favourite object; but, I confess, it wants farther confirmation; and this I sin- cerely hope, is reserved to reward the industry of some Ameri- can searcher into the minute anatomy of the human frame. I cannot but lament here the early death of the indefatigable, and amiable Lawrance, who had intended to have made the search for these vessels one of his early occupations; and from talents and industry like his, what might we not have hoped for? Sect. I.—On the changes produced by Conception. 131. However philosophers may differ in the mode of ap- plication of the male semen to the female ovary, they all agree that it is either directly or indirectly essential to impregnation. I shall now consider the changes produced upon the female organs after this event has taken place; and shall begin with those induced in the ovarium. After successful coition has taken place, an ovum is perceived to increase in size, and is seen to stand in more decided relief from the surface of the ovarium; and it is said that this body now becomes more vas- cular: arrangements are now making, by the good offices of the absorbents, for its liberation from its nidus; accordingly its peritoneal covering is destroyed by these vessels, and it is ready to be embraced by the fimbriated extremity of the fallo- pian tube, that it may be conveyed through its cavity to the uterus. 132. The tube is at this time, found in strict union with the ovarium; and is in a short time more, found possessed of this little sphere. How it is detached from its bed, is not precisely understood ; some say it falls into the cavity of the tube__ others that it is mechanically forced into it, by the firm grasp of the tubal extremity, &c: certain it is, it rarely fails getting into this canal, a.id is made to travel, by some power or other ON JTHE CHANGES PRODUCED BY CONCEPTION. 65 its whole length; it is probably arrested at the uterine extre- mity for a short time after it arrives there, before it can effect a lodgement within the cavity of the womb. 133. Physiologists have not settled the point of time, at which the ovum loses its connection with the ovarium; nor the period it employs in travelling to the uterus, or when it is admitted within its walls ; analogy has furnished almost the only data that even conjecture can rest upon; and, in summing up the evidence it affords, it would seem to be about twenty days. A difficulty however, has always presented itself, after the ovum has arrived at the extremity of the fallopian tube, to get it satisfactorily into the cavity of the uterus. For it would seem, from the acknowledgments of almost all who have investigated this point in the human subject, that the fallopian tube is sealed by the decidua passing over it; and that, conse- quently, the ovum must be placed behind it; the question then is, how does it overcome the difficulty that this production offers to its immediate entrance into the cavity of the uterus ? Before we attempt a solution of this question, it will be neces- sary to inquire, what this production is; how it is disposed of; and what are its uses. 134. It would appear from the observations of those, whose opportunities and talents have led them to the investigation of this obscure part of human physiology, that the following fact constantly presents itself; that, so soon as impregnation takes place, and is perceived, if it may be so expressed, by the ovarium, the internal surface of the uterus throws out through its whole extent, a vascular tissue, which, from its being after a time cast off, has received the name of membrana decidua: this was first accurately described by the late Dr. William Hunter. It is, I believe, well ascertained, that all that is ne- cessary to induce the uterus to set about secreting this coat, is, that a vesicle be impregnated. And whether this escapes from the ovarium or not; tarries in the fallopian tube; or loses itself in the cavity of the abdomen, it never fails to produce the decidua; and that very quickly. Some* have thought it to * Dr. Hunter, Scarpa, &c. [9] 66 ON THE CHANGES be a coagulable lymph, which soon became organized, by thou- sands of vessels shooting up through the whole extent of its surface; others* imagined it was a kind of continuation of the proper vessels of the uterus; and Mr. John Hunter believed it to be originally a coagulum of blood. Injections prove it to be highly vascular; and constant observation proves it to be deciduous; therefore, it must be a temporary product; and certainly subservient to the uses of the embryo. 135. It is spread over the whole of the internal surface of the body and fundus of the uterus, but does not dip into its neck—it forms as it were a bag within the uterus; sometimes, we are toldf it does not stretch across the aperture formed by the neck; and sometimes,^ it is said not to be continued over the mouths of the fallopian tubes. 136. The uses of this new product cannot be mistaken ; it certainly serves as the bond of union between the ovum, and the uterus; and has, moreover, an indirect agency in the cir- culation between the mother and child. 137\ It is described by Dr. Hunter, Dr. Hamilton, Mr. Burns, and others, as a double membrane ; but as Mr. Burns is the latest of these authors; as he is, extensively engaged in midwifery; and has, as he declares, had several opportunities of examining the uterus within a month after conception; and, above all, as he is the present authority for almos.t every thing relative to this subject; I shall give his account of the mode m which the ovum places itself behind the decidua, that it may finally descend into the cavity of the uterus. He says, " when the embryo passes down through the tube, it is stopped, when it reaches the uterus, by the inner layer (of the decidua) which goes across the aperture of the tube, and thus would be pre- vented from falling into the cavity of the uterus, even were it quite loose and unattached. By the growth of the embryo, and the enlargement of the membranes, this membrane is distend* ed, and made to encroach upon the cavity of the uterus, or, more correctly speaking, it grows with the ovum. This disr • Haller and others. ■(■ Burns, p. 193. 4 Sir E. Home, Phil. Trans. PRODUCED BY CONCEPTION. 67 tention or growth gradually increases, until at last the whole of the cavity of the uterus is filled up, and the protruded por- tion of the inner layer of the decidua comes in contact with that portion of itself which remains attached to the outer layer. We find then, that the inner layer is turned down and covers the chorion; from which circumstances, it has been called the decidua reflexa." 138. From this statement, it would appear: 1st. That the decidua is a double membrane and capable of separation. 2d. That in order that the ovum shall be placed behind the inner layer, it must pass through the outer layer; or, in other words, the outer layer must be pierced by two holes, one at each fal- lopian tube. 3d. That the inner coat of the decidua, when pressed upon by the ovum, must increase in proportion to the augmentation of that body, that it may come " in contact with that portion of itself, which remains attached to the outer layer," or, in other words, to become reflected. 139. These things being admitted, it must necessarily fol- low, that the ovum will possess three layers of decidua instead Of two; one more than ever has been detected, or even describ- ed. I have examined many ova, for the purpose of under- standing their mechanism ; and this with all the care, and all the little ability I have for minute dissection; and I can most safely add, without any previously conceived theory: yet I have never been able to find but two lamine of decidua. If Mr. Burns' account be true, where is the third layer ? and that it must have three agreeably to his scheme, is evident, viz. two original layers, and an acquired one by the growth of the ovum, as it pushes it forward to occupy the cavity of the ute- rus, and " which grows with it." 140. It will farther follow from these premises : (134, &c.) 1. That the account given by Mr. Burns, is not exactly as he has stated it to be ; or that, 2. The reflected portion must be absorbed, as quickly almost as formed ; since it has never been observed. As regards myself, I confess I have no confidence in the history of the ovum as given by Mr. B.; and for this plain and simple reason—it does not comport with anatomical 68 ON THE CHANGES, See. facts; a foundation upon which the whole must rest, to be satisfactory. 141. I have no faith in the statement that the decidua is a double membrane ; at least I have never seen it such ; and of course, until I do, I shall admit it with great caution ; espe- cially, as it does not appear necessary to the explanation of this subject: 1st. Because a work of supererogation would have been performed, in making two layers, when one would appear to be all that is necessary ; and, 2d. Because, if we believe it to be a single membrane, the explanation is easy; and in entire conformity with the anatomy of the ovum, as presented to us by dissection. My opinion upon this subject then, is easily expressed, by substituting a single membrane for a double one. To understand the union which now takes place between the ovum and this adventitious covering, it is necessarv to say a few words on the subject of the Sect. II.—Membranes. 142. From reasoning on the subject, I was always of opi- nion, that the ovum brought its membranes with it from the ovarium; but I am now abundantly convinced, from the late observations of Sir Everard Home, who detected them, at a very early period of conception, by the aid of powerful glasses, assisted in the use of them by the skill of Mr. Baur. These membranes, two in number, the inner one called amnion, and the outer one chorion, serve to enclose the embryon, and the water in which it floats, even while it sojourns in the ova- rium ; after its escape from thence, they serve two other im- portant ends; one is, to furnish by means of the amnion a quantity of fluid for the protection of the very tender mole- cule within; and second, through the intervention of the cho- rion, to connect itself with the internal surface of the uterus. 143. At first these membranes are not in immediate contact; having between them a jelly-like substance, which fills up the space that separates them; after a while, however, owing to the increase of growth of the amnion, and a diminution of the gluten, they approximate each other so nearly, that they may MEMBRAN1S. 69 be said to touch. The amnion is thin, transparent, smooth, and destitute, so far as the eye can discover, of vessels—it lines the chorion; spreads itself ovtr the placenta; and invests the umbilical cord to the umbilicus—here it stops. 144. The chorion is also a thin membrane; is pretty trans- parent ; and, at the full period of gestation, is oftentimes very- strong, and resists for a long time tke impulses of labour. It adheres very firmly to the placenta, giving a covering to all its superficial vessels; it also accompanies the amnion along the whole extent of the cord. Its outer surface, very quickly after its escape from the ovarium, is found to assume a cellular ap- pearance, and soon after a flocculent one—it is this coat which furnishes, from its external surface, the innumerable vessels by which it unites itself to the uterus by means of the decidua. An interchange of good offices takes place between them; they permit reciprocally each other's vessels to repose themselves throughout their respective extents, by interlocking in such manner, as to establish a firm union between them. The ex- tremities of the vessels of the chorion penetrate the intersti- ces offered by the vessels of the decidua; while, those of the latter seek refuge in the meshes of the chorion. The union of the chorion with the decidua is so strict, especially, after the second month, as always to bring it with it, in cases of abortion. 145. These membranes enclose, besides the embryo and placenta, a fluid named liquor amnii—it would seem to be the product of the amnion; in this the foetus securely floats from its earliest existence, until the last period of utero-gestation- It seems to be but little more than water; having a little glu- ten, and muriate of soda in it. It is sometimes transparent like water, at other times yellow, brown, green, &c. and of various consistencies. Sometimes it is much more abundant than at others ; from four ounces, to as many pints. The use of this fluid is to give the most uniform distention to the ute- rus__to protect the foetus against external injuries; and to afford it the most gentle, and secure medium to repose in. Dr. Denman* says, it also " procures the most gentle, yet effi- • Introduction, Francis's ed. p. 219. 70 MEMBRANES. cacious dilatation of the os uteri, and soft parts, at the time of parturition." This opinion I shall have occasion to advert to, in another place. (443, &c.) 146. The ovum, after its establishment within the uterus, or after it is expelled by violence from it, consists of the de- cidua, the decidua reflexa, chorion, and amnion; of the liquor amnii, the foetus, and umbilical cord—the latter has one extre- mity inserted into the umbilicus of the child; the other affixed to the membranes, which now constitute Sect. III.—The Placenta. 147. The placenta is that vascular mass, by which the cir- culation is maintained between mother and child; and by which the latter is nourished. Its size is various, owing to the con- stitution of either mother or child, or both—it resembles in shape a large cake; it is in general nearly circular, thicker in the middle than at the edges. It presents two surfaces; name- ly, the uterine, or maternal surface; and the foetal surface. The former presents rather a rough and spongy appearance, tra- versed by several sulci of very inconsiderable depth; it is not unaptly compared in its appearance to the infractuosities of the brain; it is covered by a very fine cellular coat, but of such great delicacy, as to break upon the slightest bending of this mass. The eminences and sulci observed upon its maternal face, have been supposed to arise from a kind of necessity, for the greater security of attachment, by corresponding risings and sinkings, on the internal face of the uterus—I do not be- lieve in this necessity; and suppose these sulci are the mere impressions of the maternal vessels, which are so much swell- ed beyond the plane of the common surface of the uterus, as to impress the placenta with furrows like the internal surface of the skull, by the vessels of the encephalon. 148. The internal surface is covered by the chorion and amnion, through whose coats may be perceived a beautiful display of vessels; sometimes they are found in fine regular order, like radii from a centre ; at others, running into fantas- tic irregularity; these vessels are both the arteries and veins, THE PLACENTA. 71 which tend to a common point, and unite in what is called the umbilical cord: in uniting to form this rope, they sometimes run parallel to each other for several inches; then twine round each other alternately until they arrive at the umbilicus of the child. They are connected through their whole extent by a fine cellular product, in the interstices of which we constantly find a quantity of a tenacious, ropy fluid. 149. This cord consists almost always of two arteries and a vein: the vein conveying the blood to the foetus, and the ar- teries from it; the veins of the placenta rarely have valves, while they are frequently found in the arteries. The arteries are continuations of the hypogastrics of the foetus; they pass out at the umbilicus, and run to lose themselves in the sub- stance of the placenta: they anastomose with each other with- in the meshes of this mass, as well as with some of the venal branches ; this kind of communication is sufficiently extensive, to enable us to fill the whole plexus, by injecting one of the umbilical arteries; so also may the arteries be filled by inject- ing the vein. The vein originates by many branches in the substance of the placenta, and, after a variety of unions, col- lects itself into one trunk, near where the arteries give off branches, the area of which is rather more than that of the two arteries. Sect. IV.—Foetal Circulation. 150. There are five striking peculiarities in the sanguiferous system of the fcetus : 1st. The vena umbilicalis. 2d. The duc- tus venosus. 3d. The foramen ovale. 4th. The ductus arteri- osus. 5th. The arteriae umbilicales. 151. 1. The vena umbilicalis arises by very fine branches in the placenta. These branches are collected into one trunk, near the placenta; which trunk, forming a considerable part of the volume of the cord, enters the abdomen through the navel, and, running along the anterior margin of the suspensory liga- ment of the liver, empties into the left branch of the sinus of the vena portarum. While it is engaged in the anterior section of the umbilical fissure of the liver, it gives off several small FQ5TAL CIRCULATION. branches to the substance of the liver. Nearly two-thirds of its blood is distributed to the liver, through the sinus of the vena portarum and these small branches. 152. 2. The ductus venosus arises from the left branch of the sinus of the vena portarum, and empties into the left hepa- tic vein, near the junction of the latter with the ascending vena cava abdominalis. The ductus venosus occupies the posterior section of the umbilical fissure, being much smaller than the vena umbilicalis, and arising from the sinus of the vena porta- rum, at its back part, directly in face of the entrance of the umbilical vein, so that a probe may be passed very readily from the one into the other. 153. 3. The foramen ovale is a large aperture between the two auricles of the heart, furnished with a valve on its left side, which is shut down the moment after respiration begins. 154. 4. The ductus arteriosus is a canal leading from the pulmonary artery into the aorta. It is so large as to appear like a continuation of the pulmonary artery, and discharges into the aorta at the lower part of its curvature, just after the origin of the left subclavian artery. The right and left pul- monary arteries, being, at this time, but very small branches, arise on each side of the ductus arteriosus. 155. 5. The arterie umbilicales are two in number, being continuations of the internal iliac arteries, which are here much larger than the external iliacs. The arterie umbilicales make a curve, running on the lateral parietes of the bladder, con- verge to the navel, and, passing through it, accompany the umbilical vein to the placenta. They twist spirally around it, and are distributed by very fine branches to the placenta, com- municating with the extreme branches of the umbilical vein. 156. The course of the foetal circulation is then, from the placenta through the umbilical vein and ductus venosus, into the ascending cava, whereby the blood is discharged into the right auricle of the heart. The position of the eustachian valve is such as to turn the greater part of this column of blood into the left auricle through -the foramen ovale. The left auricle may, therefore, be considered as distended with the blood of the ascending cava, while the right auricle is distended with FCETAL CIRCULATION. 73 the blood of the descending cava. The auricles contract at the same time, and fill the ventricles. The ventricles also contract together, and fill the pulmonary artery and the aorta. The size of the ductus arteriosus enables the right ventricle to discharge the greater part of its blood through it into the descending aorta. This blood is very impure. The blood passing through the foramen ovale to the left side of the heart, by being driven through the root of the aorta, is turned off to the head and upper extremities, through the arteria innominata, the left caro- tid and left subclavian; and what remains after this diversion joins the blood of the ductus arteriosus in the descending aorta. A small portion of the blood of the descending aorta goes to the lower extremities, and by much the greater part circulates through the umbilical arteries to the placenta, where, after be- ing vivified, it runs into the extreme branches of the umbilical vein, and then repeats the same round until respiration begins. For the most part, immediately on respiration occurring, the vena umbilicalis, the ductus venosus, the foramen ovale, the ductus arteriosus, and the arterie umbilicales are closed, not to be again opened unless in very extraordinary cases. Sect. V.—Of the Changes in the Uterus by Impregnation. 157. Hitherto I have been considering the changes induced upon the ovum by impregnation; it is now proper to notice those, which take place in the parietes of the uterus itself. These changes commence with those of the ovum, and its own internal surface; for no sooner is a vesicle fecundated, than the uterus has more blood sent to it, and the quantity increases with the progress of gestation. The vessels, which, as already noticed, are very small, and very much convoluted before fe- cundation, now quickly enlarge, and become straighter—and they continue to increase in diameter, as well as to unfold, until they arrive at a very considerable magnitude ; so much so indeed, that some of the largest are said to be capable of admitting the extremity of the little finger. [10] 74 OF THE CHANGES IN THE UTERUS 158. The fibres of which this organ is chiefly composed, begin to develop themselves, so as to be recognised as muscu- lar—they assume more distinct directions, and, though not susceptible perhaps of positive demonstration as to course, and form, are yet sufficiently palpable to deserve the name of mus- cular fibres. In consequence of this change, these fibres be- come longer and more lax; and admit, without restraint, the interposing, and much enlarged vessels that traverse them, in all directions, until the uterus itself is no longer capable of bearing further distention. 159. This increase of size is by no means without its laws— on the contrary, the most perfect regularity, and order are maintained, from the beginning to the end of gestation—so constant is the progress of development, that the period of pregnancy, can with great certainty be indicated by the expe- rienced accoucheur, so soon as he has ascertained the exact condition of the uterus. 160. The position as well as distention of the uterus, lead us to a knowledge of the advancement of pregnancy—for the first three, and sometimes at the fourth month, the uterus is found, in consequence of its weight, lower in the vagina than it usu- ally is when not impregnated—after the fourth month, or at the end of the fifth, the fundus can be felt at the pubic region —at the sixth, half way between it and the umbilicus—at the seventh, at the umbilicus—at the eighth, half way between the umbilicus and the scrobiculus cordis—at the ninth, not but very little higher, in a well formed pelvis; as, at this time, there is a subsiding of the uterus within the pelvis, owing to the more frequently repeated, and stronger contractions of the body and fundus, and the now almost complete development of the neck of the uterus. It is not, however, the fundus and body alone, that suffer changes during the periods just stated; the neck, after the sixth month, participates in these altera- tions—it gradually becomes shorter and shorter, until after the eighth month; and, at the ninth, it is entirely obliterated. 161. The body and fundus first yield to the influence of the ovum; and they continue to expand until about the seventh BY IMPREGNATION. 75 month, or perhaps a little earlier—after this time, they seem to refuse to yield any farther; the neck then is obliged to con- tribute its mite for the farther accommodation of the foetus, and its appurtenances, which it does, until the period of labour commences—at this time, no trace of the neck is to be found—■ nothing remains of this pendulous part, but its orifice, which now may be distinctly observed to be a little open. 162. The fundus and body of the uterus, not only yield be- fore the neck, but some one part contributes more than another to the desired room for the comfort of the foetus; and these are the posterior portions—hence they are found thicker, in the unimpregnated state; (92) and hence, the fallopian tubes are always found at the last period of pregnancy in advance of the uterus—a fact of much importance in performing the Cesarean section. 163. In proportion to the advancement of pregnancy, the uterus acquires a deeper tone of colour—this is owing solely to the augmented quantity of blood which it now possesses. 164. The power, by which the uterus is distended, has been disputed. Dr. Denman will not admit the agency of the ovum; he says, " it is evidently not mechanical from the increasing size of the ovum, but from the accession of a new principle; for the uterus is never fully upon the stretch, like a bladder inflated with air, but relaxed in such a manner as to be appa- rently capable of bearing the farther increase of the ovum without inconvenience." 165. We should be at a loss to comprehend this doctrine of Dr. Denman's were we even to admit his proof—to say the uterus has acquired a new principle, does not do away the difficulty of understanding how it acquires size, unless some- thing be positively added to this organ, at the time it gains the principle—for, he must admit, the uterus is enlarged ; yet it is not distended like a bladder filled with air!—In what does the difference consist? There must be an increase of mat- ter, as well as " an accession of a new principle," to prevent its being distended like " a bladder filled with air;" or it must be stretched like one.—If it be declared there is an increase of 76 OF THE CHANGES IN THE UTERUS matter, we would ask for the evidence; as well as inquire what becomes of it, immediately after delivery ?* 166. I am of opinion, that were the bladder circumstanced precisely like the uterus, or the uterus like the bladder, the same phenomena would present themselves—that is, let the uterus be deprived of its adventitious blood, as would happen after severe hemorrhage, and it would be found as thin nearly, or perhaps quite, as the bladder, all things being equal—or let the muscular fibres of the bladder be separated by as many, and as large vessels as the uterus, and it would be as thick as the uterus when in a state of distention; for, we must deny that the uterine parietes, when freed from all their blood, are as thick as they were when unimpregnated. 167. Dr. Denman denies, that the uterus ever is in a state of " full distention;" I do not know what he would wish us to understand by " full distention;" if he mean, that it is still ca- pable, under extreme pressure, of yielding farther, I should agree with him, that it is still capable of greater distention: but, if he mean, that it is never so much distended at the full period of utero-gestation, as might be compatible with either its eco- nomy, or comfort, I would certainly deny it, and would seek for no other proof, but the well-known fact, that, after the se- venth month, it is constantly found resisting farther encroach- ments, by its parietes being excited to regular, and constant contractions, as may be distinctly perceived by the introduc- tion of the finger into the os uteri. Besides, did we not admit * I am happy to avail myself of the opinion of the judicious and experienced Dr. Ramsbotham, upon this subject. lie says, " that there is no actual deposi- tion of new animal matter within the uterine structure during pregnancy, appears to me evident in the established fact, that the uterus, by a process of silent and gradual contraction, continued for some time after the expulsion of its contents, can and does possess the power of daily diminishing its volume, until it has ac- quired its smallest unimpregnated size ; when it is again able to resume its origi- nal and peculiar functions. But if the parietes of the gravid uterus be supposed to owe their size to bulk, acquired by the deposition of new animal matter, by what natural means is that matter so suddenly removed ? Can the effects of ab- sorption be thought equal to it > We see no such rapid diminution of aize from the powers of the absorbent system under diseased structure. Contraction alone explains it." Pract. Obs. Am. ed. p. 26. BY IMPREGNATION. 77 this resistance to farther distention on the part of the body and fundus, how shall we ever explain the unfolding of the neck of the uterus at the period just indicated ? Now, if it be distended at the ultimate period of pregnancy, to the point of resistance, would it not seem to be a rational, and natural de- duction, that it had proceeded to " full distention," or at least, as far as was compatible with its economy, if not with its mere organization ? 168. We may also urge, in favour of the ovum, having an agency by its growth in the distention of the uterus, that, if we discharge the liquor amnii, the uterus will collapse imme- diately, and accommodate its parietes to the form and size, of the remaining contents. Could this be, did the uterus acquire its additional bulk during pregnancy, from an increment of new animal matter ? If this additional matter really did exist, it would doubtless be of serious mischief in cases of flooding; as it must necessarily interrupt contraction. CHAPTER VI. OF THE ACTION OF THE UTERUS. 169. The uterus exerts two kinds of action; first, that ac- tion which tends to reduce itself to its original size after hav- ing been distended, and the distending cause is removed; this is called by Baudelocque and others, its tonic action: and is performed by all the fibres of this organ gathering themselves up towards a common centre; but more especially, by that class of fibres we shall denominate the " circular fibres;" the other fibres, or those we shall call the longitudinal, not acting with a force equal to the other: hence the lengthened form of the uterus. 170. The tonic action of the uterus can be exerted in vari- ous degrees, as it may possess its inherent powers in a greater or less state of perfection; it can exist under the following 78 OF THE ACTION OF THE UTERUS. conditions, and varieties ; 1st. It may act with the most per- fect uniformity and success for the purposes for which it was intended. 2d. It may be impaired so as to act transitorily and feebly. 3d. It may act with force at one moment, and cease the next. 4th. It may act partially; that is, the fundus may contract, and the body and neck be flaccid; the body may con- tract, and fundus and neck be relaxed; the neck may contract, and the body and fundus be in a state of atony ; the body and fundus may contract, and the mouth be relaxed: when these occur, different phenomena present themselves, as shall be no- ticed, when treating on the subject of uterine hemorrhage. 171. Secondly, the uterus possesses the power of alternate action; this action manifests itself only when attempting to expel something from its cavity: but can never do so, unless the tonic contraction is in a state of greater or less perfection. It never does take place, therefore, so long as the uterus is in a state of atony. This contraction has also been termed the spasmodic, or painful contraction of the uterus; as for the most part, it is accompanied by pain. It is always the effect of stimuli, or mechanical irritation; hence it appears during la- bour ; during abortion; or in the form of after-pains, to expel coagula, or other foreign substances. It is almost always at- tended by pain, but not necessarily; when pain attends, it is not because it is an inevitable consequence of this contraction, but by reason of some change, which the muscular fibre has undergone from civilization, refinement, or disease. We see it sometimes most efficiently excited without pain, as in the la- bours of the aboriginal women of this country: in the women of Calabria, and, among some, even in this, our artificial state of society. It tends, during its best action, to diminish the ca- vity of the uterus, and, consequently, to expel its contents; but its effects are but transitory, as the uterus returns to the con- dition it was in before this contraction took place. It is most successfully exerted when all the fibres composing the body and fundus of the uterus act simultaneously—when it acts partially, it is more painful than when the action is general, and never achieves the object it is intended to effect. 172. In the brute, this contraction is successfully exerted OF THE ACTION OF THE UTERUS. 79 without the intervention of pain; unless, the labour be compli- cated with disease, or accident. When either of these occur, the same consequences follow—namely, pain. It would be wrong, therefore, to suppose, that the labour of the female brute is performed upon a different principle from the human female, because she is for the most part, exempt from pain—for truly, the same general process occurs in both ; and in both, the uteri exert the same kinds of action: the only difference is, the one is performed with pain, and the other without. It has been sup- posed by some, from the mere absence of pain, that in the brute, the foetus is expelled by one uniform, but sufficiently long continued effort, without the intervention of the alternate contraction; but this is not so—as any one may at once con- vince himself, by observing the progress of a labour in almost any of our domestic animals. It will be distinctly, and easily perceived, that there is, from time to time, a suspension of uterine effort, and a repetition of it; marking, most conspicu- ously, the intervention of the alternate contraction. 173. In the brute the alternate contraction is attended with pain, when the uterus is provoked by accident, or disease,, to severer exertion, than ordinary—and when this happens, their sufferings are as great, ceteris paribus, as those of the human female. From this it would appear, that such a condition of fibre may be accidentally induced in them, as is, pretty perma- nently fixed in the other. The alternate contraction would appear to be nothing more than a sudden and an exalted de- gree of the tonic ; and the pain which so usually attends this action, arises from some morbid, or altered condition of the muscular fibres, composing the uterus. This would seem to be proved by the effects which have followed civilization and refinement—and the influence of domestication may be even traced in those animals, which participate with man in the departure from his original simplicity; for We are informed, that the artificial condition to which the cow especially is re- duced for domestic convenience in and near great cities, sub- jects her to more difficult and dangerous labours than those in the natural, or less artificial state. 174. So far as we can determine the point, it seems that 80 OF THE ACTION OF THE UTERUS. the longitudinal fibres of the body in general, and those of the uterus in particular, have more especially felt the influence of the causes just mentioned; for man is said to have lost muc li of his original vigour and strength ; and women, suffer from child-bearing ; while the circular muscles, and sphincters, appear to have lost nothing of their primitive power: thus the heart and intestines, have parted perhaps with none of the original vigour with which, from the beginning of the world, they were endowed; nor have the several sphincters, among which the orifice of the uterus may be justly reckoned, suffer- ed from constitutional abuses. 175. In the uterus in particular, we may observe pretty nearly the same thing—for I hold it more than probable, that the circular fibres of this organ have not deteriorated in the same degree as the longitudinal, nor are subject precisely to the same penalty, since they may contract with great force, with- out the production of pain. We see this well and satisfactorily illustrated in that condition of the body of the uterus, called the hour-glass contraction. This state may continue for hours, without being attended by pain. 176. The contractions of the uterus are entirely independent of the will; their intervals can neither be accelerated nor re- tarded by any exertion of it; nor can their force be either augmented, or diminished, by its influence ; but passions and emotions of the mind, when strong, oftentimes exert a powerful influence over uterine action—-they may call it into play, at a time the least expected ; or may suspend it, when strongly ex- cited. The first is proved by their being often followed by abortion; and the latter by the following fact; which fell un- der my own notice :—In 1792, I was called to attend a Mrs. C----, in consequence of her midwife being engaged—as I approached the house, I was most earnestly solicited to hasten in, as not a moment was to be lost. I was suddenly shown into Mrs. C.'s chamber, and my appearance explained, by stat- ing that her midwife was engaged. As I entered the room, Mrs. C. was just recovering from a pain—and it was the last she had at that time. After waiting an hour in the expectation of a return of labour, I took my leave, and was not again sum- OF THE ACTION OF THE UTERUS. 81 moned to her for precisely two weeks. Every accoucheur has experienced the temporary suspension of pain upon his first appearance in the sick chamber, but for the period of two weeks it is very rare. CHAPTER VII. OF DISPLACEMENTS OF THE UTERUS. 177. Notwithstanding the uterus has four ligaments, purporting to support and sustain it in situ, yet they so ill perform this office, as to render it very doubtful whether such was the express intention of nature in their formation—certain it is, the uterus is subject to the impulses of the abdominal viscera, to the pressure of the distended bladder, and to the influence of the loaded rectum and sigmoid flexion of the colon; and we may add, to the influence of its own internal weight after conception. Sect. I.—Of Prolapsus from Pregnancy. 178. The latter of the causes just enumerated, (177) very often sink the uterus so low in the pelvis, as to make it com- pletely occupy the vagina; and it sometimes, discovers even a disposition to escape from the os externum—this subjects the woman when excessive, to certain inconveniences; but to none when moderate; except perhaps, a sensation, as if something were desirous of escaping from the vagina, when she is in an erect posture; but this is almost instantly relieved, when she disposes herself in a horizontal position. When more exces- sive, it creates embarrassments to the flow of urine, and the discharge of faeces. These inconvenieaces rarely require me- dical interference ; as they are relieved after a short time, when the uterus acquires a sufficient bulk to rise out of the brim of the pelvis. When interference is recmlred, the appli- / cation of a proper pessary is ail that is necessary. [H] 82 OF PROLAPSUS FROM PREGNANCY. 179. I recollect distinctly but two instances, in which it was necessary to introduce the catheter—for the woman is easily instructed to lie upon her back with her hips a little elevated when she is importuned to pass her urine; or readily taught to press back the uterus with her finger, should this not succeed; or to go upon her knees, which has, in several in- stances, been all that was necessary. 180. It is, however, liable to other derangements, much more difficult to remove, and much more serious in their con- sequences ; these are the retroversion and anteversion, as well as the prolapsus, when pregnancy has no agency in it. Sect. II.—Retroversion of the Uterus. 181. The retroversion, is that displacement of the uterus, where the fundus is precipitated backwards, and places itself between the rectum and bladder, in such manner as to be rea- dily felt upon the introduction of the finger into the vagina, while the neck is mounted up, behind the symphysis pubes. 182. This situation of the uterus was not distinctly known, until Dr. W. Hunter,* in 1754, favoured the world with his account of it; this he accompanied, by accurate drawings of the parts. Since this period, this disease has claimed much attention, and is now perfectly understood. It is not, however, regarded of equal consequence by all; while Hunter, Baude- locque, Meygrier, Burns, &c. look upon it as an accident of serious moment; others, as Denman and Merriman, view it almost with careless indifference—as both cannot be right, I shall, in the prosecution of this subject, attempt to show which of the opinions has the strongest claims to public confidence. 183. This deranged situation of the uterus may take place in its unimpregnated, as well as in its impregnated state—the latter is, however, by far the more common. It usually takes place between the second, and the fourth month of pregnancy, as after this period the length and thickness of the uterus will exceed the opening of the superior strait, and prevent its fold- ing down upon itself. See (160.) • Med. Obs. Vols. IV. and V. RETROVERSION OF THE UTERUS. 83 184. The remote cause of this complaint is, whatever tends to depress the fundus ; and may be either external violence, such as blows, pressure, sudden exertion, &c. or violent efforts to vomit, violent coughing, an over distended bladder; or perhaps, an unusual accumulation of faeces in the rectum, or sigmoid flection of the colon. These causes may operate sud- denly, so as instantly to produce the disease; or slowly, re- quiring a long time for its completion. 185. The symptoms produced by this unnatural situation of the uterus, may be more or less violent; according to the size they may have acquired; as the displacement may have been suddenly or slowly produced. When suddenly induced, the symptoms are usually violent, and alarming—such as an im- mediate interruption to the flow of urine, or the passage of the faeces; alternate pains, accompanied by great forcing or bear- ing down; a disposition to fainting, &c. When considerable time is spent in completing this displacement, the evils arising from it are less urgent and severe. But in both cases, if the uterus be not restored, the symptoms will increase in intensity; instead of a difficulty, and frequent inclination to make water, there will be a total suppression of it, accompanied by a pain- fully intense desire to do so—for the foetus will go on to in- crease in size, and the uterus to developing itself; thus, giving additional pressure, to the parts with which it is in contact. 186. In the unimpregnated state of the uterus, the symptoms, so far as I have observed, are never so distressing; the reason for this will be easily comprehended ; but the parts never be- come entirely reconciled to their new situation. In the im- pregnated state, however, so much restraint is not imposed upon the uterus, as to prevent farther development, as we have already stated; but the effects of this increase can most readily be anticipated. Experience has abundantly shown that, if it be not restored, it will go on to augment, and at last com- pletely occupy, the cavity of the pelvis.* This distinctly points out the time for the restoration of the fundus uteri. 187. The symptoms I have enumerated may, however, pro- ' See Dr. Hunter's case, Med. Obs. and Inq. also, Winner's cases, p. 144. 84 RETROVERSION OF THE UTERUS. ceed from other causes; it will, therefore, be proper to ascer- tain by the touch, the situation of the uterus, so soon as symp- toms become urgent. If retroversion has taken place, a round- ish tumour will be felt at the posterior and inferior part of the lower strait, occupying more or less room, as the uterus may » be a longer or shorter time impregnated, or as it may have been a longer or shorter time displaced. The finger cannot touch the projection of the sacrum ; but may gain a passage to the upper strait, immediately behind the symphysis pubis, where, if the neck has not mounted up too high, the os tincae may be felt. 188. This disease may be mistaken for a prolapsus uteri; but can most easily be distinguished from it: 1st. In the re- troversion, by the vagina interposing between the finger and the tumour; and the neck of the uterus being mounted up be- hind the symphysis pubis. 2d. By the absence of the neck of the uterus, which is always found in advance of the body and fundus in a prolapsus. 3d. To the symptoms never being so extreme in the latter; and confined to those already noticed, when speaking of this complaint. 4th. By the prolapsed ute- rus always being moveable, the other obstinately fixed. It may also, according to Mr. Burns, be confounded with a diseased ovarium, when it may chance to occupy this place, or with an extra-uterine conception, when it may have been found be- tween the rectum and vagina. I believe it may serve to dis- tinguish between these two complaints, by noticing, that in both the diseased ovarium and the extra-uterine conception, the neck of the uterus is always within reach of the finger; and also that a long catheter may be readily passed in the na- tural ?>ds of the uterus; for I believe the fundus would not be carried down with either of these bodies. 189. I may, moreover, observe, that both ovarial tumours and extra-uterine conceptions, are of slow and regular pro- gress; especially, perhaps, the latter; therefore, should it pro- dur«' symptoms analogous to retroversion, they would be of very gradual increase; and would require a long time for the symptoms to become imperative. 190. Dr. Denman has well described the mechanism of this » * RETR0VERSI6N of the uterus. 85 acfident; but I cannot agree with him entirely as to the cause; he considers that a distended bladder is always the immediate cause of the retroversion, and that a suppression of urine is absolute only before, or during the act of retroverting; there- fore, a stoppage of the water is the cause, and not the conse- quence of this complaint, as we have just described it to be. , I cannot subscribe to this doctrine, for the following reasons: 1st. Because I am certain that it has been suddenly produced by violence, and without the intervention of a suppression of urine. Baudelocque also declares the same thing. 2tL Be- cause, Baudelocque demonstrated to his class a slow retrover- sion of the uterus, which lasted three or four weeks before it was complete; in this case, there is no mention of any diffi- culty in making water. 191. Dr. Denman declares, also, that "the uterus must be elevated before it can be retroverted." To disprove this, it is only necessary to recur to those cases which have been sud- denly induced, as I myself have witnessed, from external vio- lences : though, I admit, that the elevation of the uterus would render it more easy of retroversion, were the remote causes acting at the same time. 192. The diagnosis of this complaint, as given by Dr. Den- man, will readily lead to the explanation of his considering this as a trifling disease ; for, he says, " If a woman, about the third month of pregnancy, has a suppression of urine continu- ing a certain length of time, and producing a certain degree of distention of the bladder, we may be assured that the uterus is retroverted." Should a mere suppression of urine in a preg- nant woman, really indicate a retroversion, as is declared by this gentleman, we can readily account for his indifference to its consequences, and his trusting its cure to nature, or the oc- casional drawing off the water by the catheter. The young practitioner is forewarned against this uncertain plan; he is to look upon this complaint as one of eventual, if not of immedi- ate danger; especially, when the temporising plan we shall , now speak of, does not succeed. 193. As the most pressing symptom in retroversion is the stoppage of the urine, we should most sedulously endeavour to 86 retroversion of the uterus. prevent this being of too long continuance; the consequenxes should be candidly stated to the woman, should she permit her delicacy to interrupt an essential point of duty. The catheter should be employed pro re nata; and the bowels emptied daily, either bv medicine of a mild kind, or by injections; if this plan n should not succeed in restoring the fundus, we should then maturelv consider the propriety of mechanically replacing it. To aid our jiidgment, we should consider; first, the period of gestation; secondly, the degree of development of the uterus; thirdly, the nature or severity of existing symptoms. The period of gestation should almost always influence our con- duct in this complaint; and we may lay it down as a general rule; the nearer that period approaches four months, the great- er will be the necessity to act promptly, in procuring the re- storation of the fundus ; the reason for this is obvious; every day after this, will but increase the difficulty of restoration, from the continually augmenting size of the ovum. The de- gree of development should also be taken into consideration; as some uteri are as much expanded at three months, as others are at four; consequently, when this obtains, there is a decided reason for acting earlier, than may at other times be necessary; so also at the fourth month, if the development be less than is usual for that period; we may, every thing being equal, delay the attempt at reposition, if any reason present itself to make this eligible. The extent, or severity of symptoms must ever be kept in view; for instance; we must not temporise too long where the suppression of urine is complete, and is not to be relieved by the catheter, lest the bladder become inflamed* or gangrenous,! or burst.:}: For the bladder, from its very organi- zation, cannot bear distention beyond a certain degree ; or be- yond a certain time, without suffering serious mischief. 194. From this I conclude, that the uterus should in every instance be restored when practicable, at, or very little after, the fourth month: if left longer than this, the risk of not suc- ceeding is every day increased; and I am firmly of opinion, * Dr. BeH, Med. Facts, Vol. III. p. 32. f Mr. Lynn, Med. Obs. Vol. V. p. 388. - Dr. Squire, Med. Review for 1801. * retroversion of the uterus. 87 that nothing can justify longer delay at this time; more espe- cially, when it proceeds from the vain hope, that nature will relieve herself at the full period of gestation.* 195. The symptoms I have noticed above, should teach us the propriety, and necessity, of ascertaining the true situation of the woman, by an examination per vaginam ; and, until this be done, however we may hint our suspicions, we should never positively affirm her labouring under retroversion. For I have frequently prescribed a little sweet nitre and laudanum, for a difficulty of passing water in pregnant women, with the*most decided success; and, when more severe or obstinate than common, have examined per vaginam, sometimes without find- ing the uterus in a state of retroversion. 196. My experience has furnished me with few facts of which I am more certain, than that " a certain degree of dis- tention of the bladder" may exist, and for a considerable time; and even, where I have been under the necessity of using the catheter, without producing retroversion. And I am also cer- tain, in retroversion, that the mere removal of the urine will but rarely, nay, not once perhaps in ten times, be sufficient to ensure the spontaneous restoration of the fundus, wdiere the complaint is of long standing, or the pregnancy advanced beyond the third month. But let me be clearly understood to mean, that the precaution of drawing off the water where prac- ticable, and that as frequently as the exigencies of the case demand, is indispensable, either to the spontaneous, or artifi- cial reposition of the uterus. 197. I have great reason to believe, that an exclusive reli- ance upon drawing off the water, has been productive of the most serious evils, if not in some cases of death itself: it therefore should never be exclusively trusted, except at the early period of gestation. If the woman approach, or a little exceed the fourth month, the attempt at restoration should most unquestionably be made ; nor should it be abandoned, but for very strong reasons: nothing, indeed, but the impos- sibility of succeeding, should induce us to abandon the patient to her fate—I say, to her fate; for, what can we promise our- selves in her favour ? * Merriman 88 retroversion of the uterus. 198. The objections usually urged against the attempt to replace the fundus, are: 1st. The hazard of provoking abortion. 2d. That it does not always succeed, after strong and repeated efforts. 199. With respect to the first, there is abundant proof in my own experience, as well as that of others,* that abortion is not a necessary, though it may be a possible consequence of the at- tempt. I have never seen it follow; the fear of an imaginary evil, must not induce us to subject our patient to a more seri- ous wnd positive harm. The risk of abortion is but trifling; but the neglect of reposition at the proper time, is a very seri- ous piece of mismanagement. 200. As regards the second, if it fail, it must in general be attributed to our neglecting the proper moment for acting; or when it has not been properly performed. Having decided upon the propriety and necessity of giving aid to the suffering woman, I shall next give directions for the best mode of doing this. I must first consider what forces are operating to pre- vent the restoration of the fundus, before I describe how they are to be overcome; they will be found to be; 1st. A distend- ed bladder. 2d. An impacted rectum; and, most probably, a loaded colon at its sigmoid flexure. 3d. The counteracting efforts of the woman herself. 4th. The too great bulk of the uterus. 201. The first thing to be accomplished is, the evacuation of the urine by the catheter; in this, it is said, we cannot always succeed ; I have never met with such a case ; and Mr. Burns declares the same thing; nay, he even goes farther—he says he does not believe it can occur—it must, therefore, be very rare. Dr. Denman has some very useful remarks upon this subject, which I would recommend to be studied—he advises the employment of the flexible male catheter; in this I heartily concur; he also cautions against any attempt to display dex- terity, by the quick introduction of this instrument; and re- commends the slow and cautious use of it—he also proposes pressure upon the abdomen, to promote the discharge of the * See Baudelocque, Hunter, Wall, Meygrier, &c. RETROVERSION of the uterus. 89 urine ; I may, however, add, that not only the introduction of the catheter should be slow, but the drawing off the water also—I am certain I once saw serious mischief arise from inattention to this direction. 202. To overcome the second difficulty, injections should be thrown up the rectum if practicable ; but which, it must be confessed, is sometimes impossible—we can succeed, how- ever, with the elastic gum catheter of a large size, when the common means have failed; the injection should consist sim- ply of salt and water, in the proportion of a table spoonful to a pint. A few hours before we attempt the reduction, small and repeated doses of the sulphate of magnesia may be given; provided the stomach is not distressed by vomiting, or severe nausea. 203. The third difficulty which may oppose us, is, the vio- lent and involuntary efforts to bear down, to which the woman is excited, by the presence of the hand within the vagina— this is decidedly the greatest trouble we meet with in ordinary cases—for we may be foiled in our attempts at reposition, though the emptying of the bladder and rectum should not have been found troublesome. To overcome this opposition, experience has repeatedly taught me the efficacy of bleeding to fainting, or near to it. 204. When we have determined upon the bleeding, we should be prepared beforehand, to take advantage of the de- liquium, as its effects are but transitory—the bed should be prepared in such manner, as will allow the patient to lie upon her back, with the perinaeum free over the edge of the bed- stead, and her shoulders a little depressed—some protection should be placed between the back of the woman and edge of the bedstead, that she may receive no injury from its hardness —the parts should be well lubricated with hog's lard or oil— a chair should be placed for each foot to rest upon, and these supported by two by-standers. 205. When every thing is in readiness, the arm should be tied up, and the patient made to stand near the bed; a large orifice must be made, and blood drawn until faintness is induc- ed—when this happens, the arm can be secured, and the woman [12] 90 retroversion of the uterus. placed as just directed—the hand, after being well lubricated, should be passed into the vagina, in a state of supination; the fingers retracted in such a manner, as to form a straight line at their extremities; they must then be gently pressed against the base as it were of the tumour found within the vagina, so as to move it backwards and upwards along the hollow of the sacrum, until the mass shall reach above the projection of this bone ; when thus far, the hand may be withdrawn; and a pessary be introduced of a proper size : the woman must re- main quiet in bed for three or four days ; the urine for this period should be drawn off as often as may be required; and the faeces evacuated by injections. 206. The last of our embarrassments arises from the size of the uterus being equal to, or greater than the opening of the superior strait; this will be confessed to be one of much mo- ment and interest—yet, I trust, is not beyond remedy—I be- lieve that the plan just suggested, might succeed even here: but I confess it wants the test of experience. It should upon everjfljflgsideration be tried, before severer means be adopted; should imfail, we lose nothing. But suppose it fail, what is to be done ? Three modes of operating present themselves in this dilemma. 207. First, to confide entirely in the resources of nature, as recommended by Dr. Merriman. 208. Second, to attempt provoking of abortion by rupturing the membranes through the os tincae. 209. Third, to puncture the uterus through the rectum, as advised by Dr. Hunter, or through the vagina, as practised by M. Jourel. 210. With respect to the first, there is, from all I can learn, but little temptation to trust to it. See strictures on Dr. Mer- riman's opinions, in " Essays on various Subjects connected with Midwifery," by the? author, p. 291. 211. The second, if practicable, would unquestionably.be the mildest and safest; but its success (so far as I can at pre- sent determine) must be very uncertain, or it may be always impracticable.* • See Essays on various Subjects, &,c. by W. P. Dewees, p. 287. RETROVERSION OF THE UTERUS. 91 212. The third alternative has been condemned by some of the British writers; but, as it would appear, without sufficient reason; since M. Jourel succeeded recently in a case, the de- tails of which are highly interesting and instructive, and should be carefully consulted by all who practise midwifery.* 213. In the anteversion, the fundus of the uterus is thrown forward, and downward; so that it presses immediately against the posterior and inferior portion of the bladder, while its neck is carried backward towards the projection of the sacrum. In this displacement, the symptoms are said to be less severe, than with the retroversion—the tumour being anterior, and the neck of the uterus posterior, will readily distinguish the one from the other—I have never seen a case of this kind so strongly marked, as to leave no doubts of its existence—I was once called to a patient in whom I suspected it had taken place; but it was in a partial degree, if at all—the symptoms were distressing, but eventually relieved by the use of the catheter, and anodyne injections. This disease has been mistaken for stone in the bladder, agreeably to Luret,f and the operation of lithotomy absolutely performed. 214. When the unimpregnated uterus is retroverted, it cre- ates fewer inconveniences than when impregnated—the indica- tions are precisely the same—the mode of reduction is also sF- milar. This can sometimes, however, be effected without the introduction of the hand, by the proper application of the fin- gers alone—I succeeded in this way, in two instances of this kind of retroversion; both of which, however, were very recent when the attempt was made. Sect. III.—Of the Obliquities of the Uterus. 215. The inconveniences arising from these species of dis- placement of the uterus, are sufficiently serious to merit an ex- position of their mechanism. When we consider the globe-like form the uterus constantly maintains during the whole progress of its development; when we recollect how feebly it is sup- * Dictionnaire des Sciences Medicales, Vol. IX. p. 31. f Jour, de Med. Vol. IV. 92 OF THE OBLIQUITIES OF THE UTERUS. ported by its ligaments; and bring to mind, the angle at which it must pass through the superior strait, we shall not be at all surprised to find it fail to maintain such a situation in the abdomen, as will enable the axis of its fundus, and that of the superior opening of the pelvis, to coincide. If we add to this, the peculiarity of conformation of several of the parts of the pelvis, and of its more immediate dependencies; and the in- fluence these have upon this organ during its ascent into the abdomen, we shall soon be convinced of almost the impossi- bility of its centre preserving a correspondence with that of the pelvis—hence, the constant presence of obliquity in one form or other, in almost everv pregnancy. 216. The obliquities of the uterus may be divided into three kinds:—1st. The right lateral obliquity; 2d. The anterior obliquity; 3d. The left lateral obliquity. In the first, the fun- dus of the uterus is found more or less inclined to the right portion of the abdomen, and its length, and departure from a vertical line, can readily be detected by the hand placed upon it—and when this inclination is excessive, as it sometimes is, it may be observed by the eye ; especially, if the woman be view- ed from behind. This species is by far the most frequent; owing to the constant presence, and influence of certain deter- mining causes : 1st. The manner in which the rectum descends in the hollow of the sacrum; the rectum, in passing into the pelvis, does not preserve the centre of this bone, but inclines rather to the left portion of it; of course, when filled with faxes, it will occupy a part of the lower strait; and consequently, will give an inclination to the uterus towards the right side; 2d. The sigmoid flexion of the colon, from its position, and almost constant distention, will aid by its impulses the already inclined fundus, in the same direction; and if we add, 3d. The round projection offered by the salient portion of the sacrum, we shall be at no loss to determine, why the right lateral obli- quity is, of all, the most frequent. It would not, however, be correct to suppose, that the os uteri would be found always in an exact line with the fundus—I have known a number of ex- ceptions to this. OF THE OBLIQUITIES OF THE UTERUS. 93 217. In the second, or anterior obliquity, the fundus of the uterus continues to advance in the direction it received when passing through the superior strait—when on the pelvis, I mentioned that this was at an angle of between thirty and forty- degrees ; consequently, the fundus would carry the abdominal parietes before it in all instances, were not a counteracting in- fluence found in the firmness, and elasticity of these parts— therefore, the anterior obliquity will be, in frequency and extent, in exact proportion to the want of resistance from these pari- etes—hence, it is rare in a first pregnancy ;* owing to the firm- ness of the abdominal integuments; and of very frequent oc- currence in subsequent ones. Sometimes, the extent of this obliquity is almost incredible; especially, in small women who are much upon their feet; and in those who have a deformity of pelvis. In this obliquity there will be a greater, or less cor- respondence of direction between the fundus and mouth of the uterus, as this deviation may be more or less excessive. 218. This obliquity is almost always a source of great in- convenience to the woman, even before labour: for after the seventh month, the fundus is so depending, and so much in advance, as to destroy the usual centre of gravity; and the woman is, when either walking or standing, obliged b)r con- stant exertion, to make herself a new one. This is accompa- nied often, and more especially towards the latter period of pregnancy, with severe pain in the back, loins, and hips ; to- gether, with a forcing and bearing down; urging the woman to make water, or to go to stool. I have frequently known these symptoms so severe, as to oblige the woman to keep her bed, that she might enjoy a moment's respite from their urgency— this especially happens, to short women who have had a num- ber of children, and who have always had severe labours. 219. I have been frequently consulted for this very unplea- sant situation of the uterus—but there is but one remedy for it, so far as I know; namely, to support the body and fundus, as much as can be, by a proper bandage, or dress—the most * It may be proper to observe, I have never seen it take place in a first prey- nancy. 94 OF THE OBLIQUITIES OF THE UTERUS. effectual I have employed is, a pair of drawers, with a waist- coat attached to it which will lace behind. The waistcoat need not reach but a little above the umbilicus ; but it must be maintained in its situation by a support from above by a pair of properly adjusted suspenders. This dress should be put on in the morning before the woman rises upon her feet; and when it is about to be applied, the fundus must be raised, by the hands of the patient being placed under it, and lifted as it were upwards; while the back part of the waistcoat is laced sufficiently tight to give support to the uterus, when left to itself. By this simple contrivance, I have seen women be- come active, and capable of attending to their domestic con- cerns, who, previously to its application, were confined to their beds. 220. The third, or left lateral obliquity, is so rare, as to scarcely merit a mention; and especially, as the inconvenien- ces arising from it, must be nearly the same as from the right lateral; and the mode of remedying it also the same, mutatis mutandis. , *■ 221. It is of much practical importance, that these different deviations be known; as they are for the most part, of easy re- medy; and when not, much suffering is experienced. Thus, in the right lateral obliquity, placing the woman upon her left side, will very frequently be all that is required ; but should this position not bring the os uteri to the axis of the pelvis, we must aid it by the introduction of a finger within it, when it is either well dilated, or easily dilatable; and, in the absence of pain, gently draw it towards the symphysis pubis, and retain- ing it there, until a pain ensue; should the contraction of the mouth of the uterus offer much opposition to the force which would retain it at the symphysis, as just mentioned, we should gradually yield to it; but need not withdraw the finger—when relaxation has taken place, we again conduct the os uteri to the place before indicated; and maintain its position there, unless again forced to relax our effort for the reason just stated —in this manner we alternately retract, and relax, until we es- tablish a correspondence between the axes of the fundus mouth of the uterus, and the pelvis; when this is accomplish- OF THE OBLIQUITIES OF THE UTERUS. 95 ed, we shall find the labour will advance with more rapidity, and with less pain. 222. In the second, or anterior obliquity, the same indica- tion presents itself; namely, to procure a proper relation be- tween the axes of the uterus and pelvis; but the mode of ful- filling it is different—in this case we place the woman upon her back; and, at the time, and under the circumstances pointed out above, (221) we, with, the point of the finger, search for the os uteri towards the projection of the sacrum. In cases of extreme obliquity, it is oftentimes difficult to reach the os uteri by the ordinary mode of examination; when this happens, the pendulous belly should be raised, and supported, by an assist- ant, with a view to depress the os uteri—should this not suc- ceed, and should the pains be brisk, the head will be found to sink lower and lower in the pelvis, covered by the stretched, anterior portion of the uterus. If advantage be not now taken to introduce the hand to restore the os uteri to the proper axis of the pelvis, much suffering must be endured; and much risk incurred by permitting the head to descend, covered by the uterus. 223. Whenever the os uteri cannot be reached by a well di- rected search in the ordinary way, we must introduce the hand well lubricated,* so that its palm may be next to the dis- * I have seen with much pleasure, in the July and August Nos. of the Lond. Med. and Chir. Review, a most liberal examination of this work. The author of the review seems not to have clearly understood this par. (223) as he cautions against the introduction of the hand for the purpose of rectifying the bad position of the os uteri; stating, it. would be a difficult or painful attempt to do so, with a first child. I agree, under such a circumstance, it might be inconvenient; but the obliquity now under consideration, I have never known to take place in a first pregnancy ; consequently, the objections cannot be constantly valid : yet were it even to happen in a first labour, I should unquestionably pursue the same conduct, from a conviction, that I should expose my patient to the lesser evil. Let me however be clearly understood to mean, that I would introduce the hand, if the labour, from its duration and force, gave me reason to believe, that the want of progress of the presenting part, was owing to the constrained position of the uterus ; and when the os uteri cannot be reached by the ordinary mode of examination; consequently, when it did not correspond with the axis of the pel- 96 OF THE •nLIQUlTIES OF THE UTERUS. tended uterus; a finger should then be made to reach up to the neighbourhood of the projection of the sacrum, where, on some one portion of the uterine globe, the os uteri will be detected— when discovered, we should hook it upon the point of the finger, (provided it is either dilated, or easily dilatable,) and draw it towards the centre of the inferior strait—when it has followed so far, the hand may be gently withdrawn, (but not the finger from the os uteri,) and the uterus detained there, until the proper direction of the forces, and the axis of the uterus, are in correspondence. By this simple proceeding, much time and suffering are saved; and in some instances, I am well persuad- ed that much risk is prevented. Baudelocque has most satis- factorily illustrated the advantage of judicious interference, and the consequences of the neglect of it, by the recital of two apposite cases, to which I would refer the reader with much advantage to himself. 224. Within my own knowledge, this case has been mistaken for an occlusion of the os uteri; and upon consultation, it was determined, that the uterus should be cut through to make an artificial opening for the foetus; they thought themselves justi- fied in this opinion, first, by no os uteri being discoverable by the most diligent search; and secondly, by the head being about to engage under the arch of the pubes, covered by the womb: accordingly, the labia were separated, and the uterine tumour brought into view; an incision was made by a scalpel through the whole length of the exposed tumour, down to the head of the child—the liquor anmii was evacuated, and, in due course of time, the artificial opening was stretched sufficiently to give passage to the child; the woman recovered, and to the disgrace of the accoucheurs who had attended her, was deli- vered, per vias naturales, of several children afterwards—a proof that the operation was most wantonly performed. vis. This I confess to be a situation of rare occurrence ; yet it is one to be met with, as I can testify, and should be provided for, if it occur : for if the os uteri be not within reach by a common search, and it shall give rise to an operation like the one related in par. 224, would it not then be more than fastidious, to withhold a proper examination, from a mere repugnance to introduce the hand into the vagina, if the labour were even a first one ? OF THE OBLIQUITIES OF THE UTERUS. 97 225. I have found more than once, in cases of extreme an- terior obliquity, that it is not sufficient for the restoration of the fundus, that the woman be merely placed upon the back: for we are also obliged to lift up, and by a properly adjusted towel or napkin, to support the pendulous belly, until the head shall occupy the inferior strait. To illustrate this, I will relate one of a number of similar cases, in which this plan was suc- cessfully employed. Mrs. O----, pregnant with her seventh child; after the seventh month, she Was much afflicted with pain, and the other inconveniences, vvhich almost always ac- company this hanging of the uterus; and was obliged to wear the jacket recommended above, from which she experienced much relief. She was taken with labour-pains on the morning of the 10th of October, 1820; I was not sent for until about noon—the pains were frequent and distressing, and, upon examination per vaginam, the mouth of the uterus was found n'ear the projection of the sacrum, and dilated to about the size of a quarter of a dollar; it was pliant and soft: during a pain, the membranes were found tense within the os uteri; but did not protrude beyond it. 226. As this was the first time I had been called to attend this patient; and the history she gave of her former labours, representing the abdomen to be equally pendulous in each, with the exception of the first; I waited several hours, (the patient being placed on her side,) for the accomplishment of the labour. During the whole of this period, the head did not advance a single line: nor could it; as the direction of the parturient ef- forts, carried it against the projection of the sacrum. I had several times taken occasion to recommend her being placed upon her back; but to this she constantly objected, until I urged its absolute necessity—she at length reluctantly consented : -when upon her back, it was found the os uteri was not suffi- ciently advanced towards the centre of the superior strait; the abdomen was therefore raised, and a long towel placed against it; and it was kept in this situation, by its extremities being firmly held by two assistants—at the same time, I introduced a finger, as directed above, (221) wiihin the edge of the os uteri, and drew it towards the symphysis pubis, and then wait- [13] 98 OF THE OBLIQUITIES OF THE UTERUS. ed for the effects of a pain—one soon followed, and, with such efficacv, as to push the head completely into the inferior strait; and by three more, it was delivered. In this case, I have every reason to believe, that many hours more might have passed without profit, had I not insisted upon the change of position; and, in my opinion, it most decidedly proves the importance of correct principles in the art of midwifery. See Baudelocque. 227. It might be considered as highly useful in such cases, that the woman lie as much as possible upon her back, even from the commencement of the labour, as it would certainly contribute to the restoration of the displaced uterus: it is moreover very important in such instances, that the bowels be opened either by some gentle medicine, or by an injection, that no accumulation of faeces may take place in the rectum. Sect. IV.—Of Prolapsus Uteri, -when not impregnated. 228. Of the casualties to which the uterus is liable, few are more frequent, or more troublesome, than a prolapsus of this organ ; this displacement may take place at almost any period of female life ; I have witnessed it in the aged matron, and I have prescribed for it, in the youthful virgin. 229. When we consider how imperfectly the ligaments at- tached to the uterus sustain it in situ ; and when we reflect up- on the debilitating discharges from the vagina, sapping as it were the very foundation of its support, we need not be sur- prised at the frequency, and sometimes the inveteracy of thil distressing complaint. Fluor albus maybe considered as one of the most frequent causes of prolapsus; it produces it by relaxing the vagina, and making it yield to the weight of the superincumbent uterus, and the impulses of the abdominal viscera. I have already remarked, when speaking of the fe- male organs, that neither the broad, nor the round ligaments, were calculated to sustain the uterus in its natural position; if this be so, we must look to some other part for the support of this organ—and this is the vagina itself; this office of the va- gina we may derive from the manner in which it is united to OF PROLAPSUS UTERI, WHEN NOT IMPREGNATED. 99 the uterus, and the mode in which that canal is joined to the rectum and bladder. (80) The whole of this arrangement gives at once the idea, that the vagina is the efficient support of the uterus—it then follows, that whatever is capable of weakening the foundation, will tend to injure the superstructure: hence, leucorrhoea ; frequent deliveries ; too early rising after delive- ry ; very large children; veiy large pelves ; habitual coughs; severe pukings, and ill conducted instrumental deliveries, may all tend to this end by destroying the natural tone of this part, cither by the debilitating effects of an immoderate discharge from this part, or by overstretching, preventing a return of its natural firmness, and resiliency; or by the frequently repeated concussions this part must suffer, from the abdominal viscera, by coughing and vomiting. 230. The degree of precipitation to which the uterus may be subject, will depend upon the extent of injury the vagina may have sustained from the causes above enumerated, (229) and will therefore vary, from a slight depression to an entire displacement; so that in some cases it will be but barely with- in the os externum. 231. The symptoms which characterize this complaint, will be modified by the greater or less descent of the uterus in the vagina—they will be intense in proportion (caeteris paribus) to the extent of the displacement; but in all there will be a sense of something sinking in the vagina, as if the perinaeum were sustaining an unusual weight; with a dragging sensation about the hips and loins; a desire to make water, sometimes with- out the ability, and, when it does pass, it is reluctantly; and oftentimes painfully hot—a sense of faintness, and oftentimes a number of nervous or hysterical feelings, alarm, and almost overwhelm the patient. A pressure, and feelings resembling tenesmus, sometimes importunately demand the patient's at- tention, which, if she obey, almost always end in unavailing efforts. The pain in the back is sometimes extremely dis- tressing while the patient is on her feet, and gives to her walk the appearance of great weakness in her lower extremities. A benumbing sensation shoots down the thighs; especially, when the woman first rises upon her feet; or when she changes 100 OF PROLAPSUS UTERI, WHEN NOT IMPREGNATED. this position for a horizontal one. In some few irstances, the woman is obliged to throw her body very much in ad- vance, or she is obliged to support herself by placing her hands upon her thighs, when she attempts to walk. But all these unpleasant symptoms subside almost immediatel}', by the woman placing herself in a recumbent posture. 232. Besides the inconveniences, we have just stated, there is always a discharge of more or less matter, of a purulent appearance, from the vagina; this, in severe cases, is fre- quently tinged with blood, and occasionally is offensive. In addition to this, we often find the menstrual discharge also suffers some derangement: it is almost always more abundant, and often more frequent, than it should be,—this, with the accompanying leucorrhoea, very soon reduces the woman's strength to a very low ebb, and, if not relieved, entails upon her permanent ill health. 233. In married women, this complaint is readily detected, from the severe pain that coition is sure almost always to in- flict; and this becomes oftentimes one of the most powerful in- ducements to apply for relief. 234. Notwithstanding the diagnostics of this complaint are so strongly and decidedly marked, yet they are not sufficiently so to warrant us in taking it for granted: we should never, but from a careful examination, pronounce this complaint posi- tively present, lest we may be in error, as once happened to mys.-if. I was consulted by a lady who had almost every symptom recorded above; I pronounced her disease to be a prolapsus of the uterus, and, without further examination, had a pessary made for its support—but, to my sad mortifica- tion, when I was about to apply it, a careful examination proved that no such condition existed, and that all the unplea- sant symptoms had arisen from a thickening of the neck of the bladder. 235. A pessary of proper construction, is the only efficient remedy for this complaint—it should be as well fitted to the parts as the nature of things will permit; for much depends upon its proper adjustment. The one I prefer I have given a drawing of; and it is to be considered a modification of the OF PROLAPSUS UTERI, WHEN NOT IMPREGNATES. 101 circular elastic gum pessary. I made the alteration many years ago, and I have every reason to be satisfied with its effects. It is made of silver, strongly gilt; it is hollow, and pierced with a hole, of only. sufficient size to permit the escape of the discharges incident to the parts. I have three different sizes; one larger than the one of which a drawing is given, and one smaller—the medium size is most frequently required. The difference in size, is only one eighth of an inch; either in ad- dition or in reduction. See Plate XI. 236. When this is to be placed, care should be taken that the woman's bowels shall have been freely opened, and her urine passed; and also that she should have kept her bed for an hour or two previously to the introduction of the pessary. She must be placed perfectly horizontally on the bed, and near its edge— the parts lubricated, as well as the instrument, with hog's lard; the labia must be separated by a couple of fingers, one placed on each labium,* and the pessary then pressed gently, but firmly against the os externum, directing the force downwards towards the internal face of the perinaeum, and backwards in the direction of the vagina; but in such manner, as shall make the introduced edge look towards one of the sacro-iliac junc- tions.! We continue to press the instrument forwards in the course just pointed out, until the whole is received into the vagina. Then the finger must give it a transverse direction; or, in other words, the breadth of the pessary must correspond with the small diameter of the inferior strait—this is easily effected; and we can judge whether it be well placed by feeling for the hole in its centre, which must always correspond with the axis of the os externum. 237. The next consideration is to ascertain whether the neck of the uterus is placed in the excavation in the instru- ment; (for it must be remembered it should be introduced, so as its hollow shall look upwards;) this may be known by passing the finger over the edge which is under the symphysis * It is generally best to use the left hand for this purpose. See note following. •j- It will generally be found most convenient for the operator, to have the right side of his patient next to him; as in this position, he will command the introduc- tion of the pessary with liis right hand. 102 OF PROLAPSUS UTERI, WHEN NOT IMPREGNATED. pubis, and depressing it a little; the finger will then readily detect the position of the neck; and, should it not be placed in the centre of the pessary, it can readily be drawn there by the extremity of the finger. When this is adjusted, we take care that the transverse position of the instrument be correct, before we withdraw the finger; the woman may now be permitted to get up. 238. A proper size of the instrument is a matter of consi- derable consequence; and we cannot always determine a priori which of the sizes will answer best—if it be too large it will give pain; and if too small, it will escape, perhaps, on the first effort to go to stool—we can ascertain when too large by its producing uneasiness in the parts; should this happen it must be removed, and one of smaller size introduced. And for fear the instrument be too small, we should direct the patient not to go to the privy, for a day or two, lest it escape from her, and be lost. 239. The relief, in many instances, is immediate; but if not, it is almost always secured, if the instrument be of a proper size, and well adjusted. It may be proper to remark, that the pessary will do no good, where the perinaeum has been de- stroyed by a laceration. 240. Before I employ the pessary, I always make use of astringent injections for two or three weeks, with very de- cided advantage—the best perhaps is a solution of alum in the proportion of a half ounce to a pint of water; and after the in- strument is adjusted, a few syringes full of fine soap and wa- ter should be thrown up daily—if the gilt pessary be employ- ed, it will need removal but very rarely; not oftener than once in two, or perhaps three months; this gives it a very decided advantage over every other. The period it must be worn, must necessarily depend upon, 1st. The inveteracy of the dis- ease ; 2d. The extent of the displacement; 3d. The employ- ment of the patient; 4th. The greater or less disposition to fluor albus. As a general rule with young women, where the complaint has not been of long standing, from three to four months will be sufficient—it will of course require a longer time, where the woman is aged, and where the complaint is of OF PROLAPSUS UTERI, WHEN NOT IMPREGNATED. 103 long standing—one of my patients wore the instrument a year; but this was the longest time, I have known it to be required. 241. Besides the inconveniences just related, this condition of the uterus gives rise to a fixed pain in one of the sides, but especially the left, which has bid defiance to all general, as well as local applications, that have hitherto been employed for its removal. 242. In the complaint now alluded to, no suspicion was en- tertained by any of the practitioners, who had previously had the care of the cases, that it depended upon the prolapsed con- dition of the womb; and it is but a few years, since I was my- self aware of it. But as this complaint is more common than is generally suspected; and as it cannot be removed, so far as I ' know, but by the use of the pessary; and especially, as I have, since the publication of the cases about to follow, received various communications, as well as thanks for their promul- gation ; I have thought it proper to detail them in this place. See Philadelphia Journal of the Medical and Physical Sciences, No. 17, p. 144. 243. Case I. Mrs. T. aged thirty-six years, applied for my advice for a severe pain in the left side, immediately under the margin of the false ribs, extending to the spine of the ileum of the same side. She informed me she had suffered from this pain several years with more or less severity, and for which she had undergone severe medical treatment; such as bleeding, purging, blistering, leeching, &c. without the slightest benefit. The pain was not increased by respiration, pressure, or motion, but some relief was constantly experienced upon lying down; and espe- cially, as the night advanced. She could lie in any position without any increase of inconvenience, but felt most comfort- able in a bent posture. 244. I prescribed for her a variety of medicines with no bet- ter success than those who preceded me, and began seriously to despair of being any way useful to her; when, thinking the leucorrhcea, with which she was severely afflicted, might have some agency in weakening her, and believing this, from 104 OF PROLAPSUS UTERI, WHEN NOT IMPREGNATED. the description of her feelings, to arise from a prolapsed ute- rus, I mentioned mv suspicions to her, and stated the propriety of an examination to ascertain the fact.—To this she submitted, and the uterus was found low in the vagina. 245. I now ordered her some astringent injections, as I al- wavs do at first in such cases, which were persevered in for three weeks, with as much advantage as I contemplated—for the only advantage I expected from them, was to give a temporary tone to the vagina, before I should introduce a pessary. 246. At the end of three weeks, I introduced a gilt peBsary, and desired my patient to place herself upon her feet-—this she did, and declared she felt much more comfortable than she was wont to do, when she arose from her bed, and observed, that for the first time for several years, she was free from the pain in her side. Believing this to be only accidental, I paid but little attention to the declaration at the moment—but upon my visiting her the next day, she assured me she had had no return of it whatever, nor has she had to this moment. 247. This case made a strong impression; especially* as I could call to mind several similar affections of the side, in which I had failed to give relief, and made me determine, should another case of painful side occur, to inquire immedi- ately into the state of the uterus. It was uot long before this opportunity presented itself in a lady from the West Indies. 248. Case II. Mrs. D. had for several-years, (five,) been much afflicted by a train of severe nervous affections—she would, frequently, from the slightest causes, be thrown into violent hysterical paroxysms, which required considerable time to calm. She had a fixed pain in the left side, which would occasionally appear to swell, and became extremely painful to the touch—when this took place, she was almost certain that hysteria would follow. Her appetite was good, but her stomach could only digest certain articles—her bowels were constipated, and she had a profuse leucorrhcea of a puru- lent appearance. She was considerably reduced in flesh, and much debilitated. 249. She had tried a variety of remedies in the West In- dies for the local affection of the side—she had been repeatedly OF PROLAPSUS UTERI, WHEN NOT IMPREGNATED. 105 bled and blistered, without the smallest advantage-—took mer- cury to a considerable extent—was freely purged and puked— but all to no purpose. When the pain was unusually severe, it was considered as spasm of the stomach. From the detail of her symptoms, I was led, however, to suspect a prolapsus of the uterus, and inquired whether this opinion had been given by her physicians at home—she said it never had been suggested; it was considered as an affection of the stomach altogether, and all remedies were addressed to it, either direct- ly or indirectly. 250. I proposed an examination per vaginam, to which she very reluctantly consented—-and that examination confirmed my first suspicion of her case. I ordered her the tincture of cantharides, and some astringent injections—also, small, but daily doses of rhubarb ; and continued this plan for nearly three weeks. At the end of this time I placed the pessary. She was almost instantly relieved from the usual symptoms attending a prolapsed uterus; and also, the afflicting pain in her left side. 251. Experiencing such immediate relief, and the almost total exemption from nervous feelings, she became careless, and allowed her bowels to become, as they were wont to be, excessively costive, and in an effort to relieve herself, she dis- charged the pessary. This accident she concealed from her friends, until a recurrence of all her former inconveniences and pain, forced her to a confession. I was immediately sent for; and the loss of the pessary made known to me. I replaced it, and she again was restored to comfort; and now, a period of twelve months, is in the most perfect health. She is no longer troubled with hysteria—palpitation of the heart—or any of her former nervous sensations. She can eat without selection, and her bowels are perfectly regular. 252. Case III. I was requested to visit Mrs. P. who was represented to be suffering very much from an habitual colic. Not being well, my friend, Dr. Knight, kindly visited her for me, and prescribed a dose of laudanum, Sec. which procured her a tolerably good night's rest. I saw her the next morning, and found her under the distressing after effects of the lauda- [14] 106 OF PROLAPSUS UTERI, WHEN' NOT IMPREGNATED- num; but comparatively easy. She gave the following history of her complaint. She was attacked about twelve years ago with a pain in her left side, which was occasionally so severe as to produce hysteria, and other disagreeable nervous affec- tions. The pain was not augmented by pressure, cough, or respiration. She would swell, sometimes very suddenly, and then the pain was increased. She was much incommoded by exercise, or long standing, and if either were continued too long, she would become faint, and much pained. When this took place, she would be obliged to go to bed, take laudanum, and be unable to rise for several days together. She had leu- corrhcea to a great extent—was much debilitated—and ex- tremely pale—her appetite feeble—and her digestion bad. 253. She was much afflicted with headach, and pain in her back—also with a severe numbness down the thighs, after standing awhile upon her feet. She had tried a great many remedies for the period above stated; but considered herself growing worse daily. 254. Suspecting a prolapsus of the uterus to be the cause of her complaints, I proposed to ascertain it; to which she rea- dily consented. The uterus was found very low; the os uteri could be felt just within the labia. I introduced a pessary immediately, without previous preparation, as she was obliged to go to New-York, her place of abode, the next day. She was instantly relieved by the pessary; and declared herself, in five minutes after its application, to be perfectly free from all pain and inconvenience. 255. 1 had the pleasure to learn this very day, (September the 25th, 1824,) that she remains perfectly well; a period of nearly four months. 256. Case IV. Mrs. L. a very delicate woman, aged twenty-eight, after a premature labour, attended with a great expenditure of blood, was attacked with a severe cough, which seemed to threaten phthisis. She was, however, relieved of her cough, by a persevering use of remedies, and change of air; but there remained a fixed pain in the left side, together with a sense of bearing down in the pelvis, and a strong de- sire to make water, whenever she stood upon her feet. I was OF PROLAPSUS UTERI, WHEN NOT IMPREGNATED. 107 convinced she laboured under a prolapsus, and mentioned this opinion to her friends. She would not, however, submit to having it tested by examination, but permitted an old nurse to prescribe leeching to her side, followed by blistering. She experienced no advantage from these remedies, and was at length prevailed upon to allow an examination per vaginam. 257. I was again requested to visit her, and to make the proposed search—this proved the uterus prolapsed. After due preparation, as above suggested, I applied the pessary; she was immediately relieved, and continues well to this moment. 258. These cases prove most satisfactorily that sometimes the consequences of a prolapsed uterus are more extensive and more severe than have hitherto been suspected; and also teach us, under circumstances like those above detailed, to make the necessary inquiries into the condition of the uterus. I will not pretend to account for the pain in the left side; nor decide that this is invariably the seat of this sympathetic affection, since my experience is not sufficiently ample to war- rant such a deduction; I can only say, at present, it has pre- vailed in four consecutive cases, which are by no means to be considered as sufficient to establish a rule. 259. The pessaries I employ, are of silver, well gilt, and are made for me by Mr. John Rorer, surgeon's instrument maker, Arch street, above Fifth. CHAPTER VIII. OF THE SIGNS WHICH USUALLY ACCOMPANY PREGNANCY. 260. We have already remarked, that so soon as fecunda- tion takes place, various parts sympathize either directly or indirectly with this condition of the ovarium—these sympa- thies or disturbances, are so uniform in their nature, and so 108 OF THE SIGNS, &C regular in their appearance, that they have been considered as evidences of pregnancy—the first, and most usual is the inter- ruption of the menstruous discharge; second, nausea and vo- miting; third, enlargement of the breasts; fourth, the areola round the nipples ; fifth, the secretion of milk; sixth, the en*. largement of the abdomen; seventh, the increased size of the uterus; eighth, pouting out of the navel; ninth, spitting of white frothy mucus ; tenth, salivation. 261. Although almost every pregnancy has nearly the whole, or a greater part of the signs we have just enumerated, yet their union may not, in an individual case, so positively declare pregnancy, as to render it free from all doubt; espe- cially, where the subject may become an object of judicial pro- ceeding; and where life, character, or property may be involved in the consideration. On this account chiefly, we will spend a few words on each of these signs of pregnancy. Sect. I.—1. Suppression of the Menses. 262. The suppression of the menses in a married woman, or in a woman who has had illicit commerce with a man, may justly give rise to the suspicion, that impregnation has taken place ; and as a general sign may safely be looked upon as one of the most unequivocal that present themselves—yet a variety of causes, independently of pregnancy, may produce the same effect both in the married, and in the unmarried woman: 1st. Exposure to cold and damp, at the time the menses are about to appear, or immediately after they have shown themselves. 2d. Certain chronic affections, as phthisis pulmonalis, scir- rhous liver, or other visceral obstructions. 3d. The operation of certain powerfully depressing passions, or emotions of the mind. And lastly, some imperfection in either the ovaries, or the uterus itself. 263. If then the absence of the menses do not positively declare pregnancy, will their presence prove that it does not exist? This question would unquestionably be answered in the affirmative by Dr. Denman, and perhaps many others; not because they have not seen coloured discharges from the va- SUPPRESSION OF THE MENSES. 109 gina during pregnancy; but because, from a preconceived no- tion of the functions of the uterus, they deny these discharges to be menstrual. 264. In declaring women may menstruate after impregna- tion, I have fto preconceived theory to support; nor am I influenced by any affectation or vanity, to differ from others; nor do I believe I am more than ordinarily prone to be capti- vated or misled by the marvellous; for I soberly and honestly believe in what I say, and pledge myself for the fidelity of the relation of the cases I adduce in support of my position —I am anxiously desirous of the advancement of our science; but would regret to see this attempted at the expense of truth. 265. Nothing can be more vague and unsatisfactory, than Dr. Denman's definition of menstruation ; namely, " from the uterus of every healthy woman, .who is not pregnant, or who does not give suck, there is a discharge of blood, at certain periods, from the time of puberty to the approach of old age." Now, from this definition it would necessarily follow, that if a woman menstruate, she must be in good health, but the ex- perience of every body is against this conclusion—again, if a woman has a discharge of blood, while she is suckling, she must, by the terms of this definition, be either no nurse, or this discharge is not menstruous blood. Dr. Denman would cer- tainly agree to this last deduction, but what proof has he to Urge in support of this belief? So far as my own, and the ex- perience of many others go, I should say, none. I would wish to be understood to mean, (whenever I use the terms, men- struous discharge, menstruous blood, menses, or any other de- signation,) that legitimate discharge from the uterus, which would, under the best circumstances of health in general, or condition of the uterus in particular, constitute this important function in its most perfect form—I do not mean to include discharges of blood, properly so called; and properly so being, as coming within my views and meaning;"in a word, I would employ my terms to express this action, and its product, with- out ambiguity or subterfuge. And farther, I would wish to be understood to mean, by my terms, precisely what Dr. Denman no SUPPRESSION OF THE MENSES. wishes to be understood to mean, when he speaks of " men- struation." 266. The only argument adduced by Dr. Denman in sup- port of his hypothesis, is, " that, if a woman menstruated while pregnant, she must very often miscarry, as a part of the ovum must necessarily be detached from the uterus at each period." I would ask, why must a part of the ovum be necessarily de- tached to give issue to this discharge ? I see no reason why this should be so; as I am persuaded, that this can happen without any such consequence. Dr. Hunter, Dr. Denman him- self, Mr. Burns, Baudelocque, &c. all declare, that for the first two or three months the inferior portion of the uterus; and more especially the neck, are not always occupied by the de- cidua, but are left as free, and as unembarrassed, as before im- pregnation; of this I have no doubt; and it is from this unoc- cupied portion, that the menstruous discharge takes place. 267. If it be said, that this surface is insufficient in extent to yield the quantity that is ordinarily discharged, I would an- swer: First. I am not contending for the quantity, but the quality of the evacuation. And I admit, that, when this eva- cuation takes place during pregnancy, it is not so abundant as it usually is, under other circumstances: Second. That the following fact will show, how capable a small healthy portion of the internal surface of the uterus, is of yielding a quantity of menstruous blood. My friend, Dr. Coxe, the present pro- fessor of Materia Medica, gave me a diseased uterus, in the cavity of which there was a healthy portion of surface, not ex- ceeding in size a common thumb-nail; and from this surface was yielded, every menstruous period, a quantity of fluid; and, as far as could be detected by its sensible properties, of a perfectly healthy quality. 268. Again, I well know a number of women, who habitually menstruate during pregnancy, until a certain period; but, when that time arrives, menstruation ceases—several have menstru- ated until the second, or third month ; others longer; and two until the seventh month—the two last were mother and daugh- ter. I am certain there was no mistake in the cases, to which I now refer. My interrogatories were numerous, and the an- SUPPRESSION OF THE MENSES. Ill swers, bore all the marks of candour:—1st. The menses were regular in their returns; not suffering the slightest derange- ment from the impregnated condition of the uterus ; second, from two to five days were employed for their completion; third, the evacuation differed in no respect from the discharge in ordinary; except, they thought it less abundant; fourth, there were no coagula in any one of these discharges; conse- quently, it could not be the common blood, or the blood of haemorrhagy ; fifth, in the two protracted cases, the quantity discharged regularly diminished after the fourth month, a cir- cumstance, not perhaps difficult of explanation. I may also cite, in favour of my position, the authority of Heberden, Hosack, and Francis.* 269. With regard to nurses menstruating, every accoucheur must be familiar with the fact, as it is of frequent occurrence; happening, ten times perhaps, to the other once—here the same difficulty does not exist; for the uterus is now unoccupi- ed; and the only matter of surprise is, that it does not more frequently occur. Though I have strenuously contended for the fact, and attempted an explanation of it, yet I am well persuaded, it is but an exception to the rule, and not an ordi- nary arrangement of nature. 270. In one extraordinary case, which fell under my notice in 1791, the contrary of suppression took place at pregnancy— a woman applied for advice for a long standing suppression of the menses; indeed she never had menstruated but twice ; she had been married a number of months, and complained of a good deal of derangement of stomach, &c.—I prescribed some rhubarb, and steel pills. About six months after this, she/ again called to say that the " medicine had brought down her courses, but she was more unwell than before ; her sickness and vomiting had increased, besides swelling very much in her belly;" I saw this was pretty much distended, and imme-* diately examined it, as I suspected dropsy—but from the feel of the abdomen; the want of fluctuation; and the solidity of the tumour; I began to think it might be pregnancy, and told • Francis's ed. of Denman, p. 231 112 SUPPRESSION OF THE MENSES. the woman my opinion. She now became anxious to understand her s.tuatlon herself; and submitted to an examination per va- ginam ; this proved her to be six months advanced in pregnan- cy; after this time, she had the regular returns of her catame- niai pci !od until the full time had expired. During the period of suckling, she was free from the discharge: she was a nurse for mor; than twelve months; she weaned her child, and short- ly aft*.'-, ohe was again surprised by an eruption of the menses, whivdi, as on the former occasion, proved to be a sign of preg- nanes. Whether this peculiarity pursued her still farther, I cannot say; as she removed from the neighbourhood, soon after the birth of her second child. 271. Whether there was a periodical discharge of a colour- less fluid in this case, as a compensation for the regular men- ses, i ^m unable to say, as I did not examine the woman on this point, not having, at that time, the same interest as now, in such minute inquiry. I merely state the main facts, though they bid defiance to calculation, and almost to example; Deventer* being the only author, so far as I know, who has furnished a similar example. Sect. II.—2. Nausea and Vomiting. 272. Nausea and vomiting, though a very usual concomi- tant, is very far from being a certain sign of pregnancy; it oc- curs sometimes where the menses have been delayed by other causes—it may, however, be considered as adding to the gene* ral testimony in proof of this condition. Sect. III.—3. Enlargement of the Mammas. 273. Enlargement of the mammae is a very common attend- ant upon genuine pregnancy, though it is not uniformly so—I have known a number of cases where they did not swell even at the huter periods of gestation; nor was it until after deli- very, that they gave evidence of capacity to perform their ordi- * Chap. XV. p. 65. I AREOLA. 113 nary functions; on the other hand, I have known them to en- large considerably, where the menses were interrupted from other causes than pregnancy. Sect. IV.—4. Areolse. 274: The areolae, which are sometimes formed round the nipples, must be considered as equivocal in any but a first preg- nancy—in this case did areolae form, I should place great de- pendence upon them ; for so far, I have not been deceived. They do not, however, always present themselves; and may not be easily detected even when formed, in very dark-skin- ned women—there is always, I believe, an enlargement of the little sebaceous glands which surround, the nipples, when areolae encircle them ; and they, as far as my observations go, serve to strengthen the suspicion of pregnancy. So far as I recollect, this blush is not mimicked by obstructed catamenia, or from any other cause than pregnancy. It is possible that they may attend on a false conception or mole; but of this, I have no experience. In a second, or other pregnancies, I do not place the same reliance upon this sign ; as a trifling irri- tation, or other causes, I believe, may produce them ; or they may, as I have often noticed, be absent altogether. The marks I have been speaking of, must not be confounded with the permanent stain left around the nipple after a woman has suckled a child; and great care should be taken to conduct this inquiry in such a manner as to give no false impressions. 275. For when the nipples are to be examined, the woman should open her bosom so as to expose the whole breast; she must not be suffered to draw it above the margin of her clothes by placing her hand beneath it—in doing this, the nipple of- tentimes is irritated by the pressure of the fingers, which gives a new character to the appearances. I have, in a number of instances, detected pregnancy by this examination, where the patients insisted their irregularity proceeded from cold or other causes. It must, however, be remembered, that the absence of these areolae does not prove the woman unimpreg- nated. [15] 114 FORMATION OF MILK. Sect. V.—J. Formation of Milk. 276. The formation of milk in the mamma, is coeval in some pregnant women, with their swelling; while in others it is not formed until after delivery. Wb n this secretion takes place, it is looked upon by the vulgar as a certain sign of pregnancy; but I have oftentimes known this fluid (or at least a fluhl bear- ing all the marks of the first formed milk) plentifully secreted without pregnancy, merely by the interruption of the menses. It has been produced in women past the period of child-bear- ing, and even, it is said, in men, by the repeated application of a child to the nipple. It has also been produced in a girl of 'eight years old, as we are informed by Baudelocque. (See his very interesting case, Vol. I. page 219.) 277. I once knew a considerable quantity of milk form in the breasts of a lady, who, though she had been married a number of years, had never been pregnant; but who at this time had been two years separated from her husband. She mentioned the fact to a female friend, who, from an impression that it augured pregnancy, told it to another friend as a great secret; who in her turn mentioned it to another friend, and thus, after having enlisted fifteen or twenty to help them to keep the secret, it got to the ears of the lady's brother. His surprise was only equalled by his rage ; and, in its paroxysm, he accused his sister in the most violent and indelicate terms, of incontinency, and menaced her with most direful ven- geance. 278. The lady, conscious of her innocence, desired that I should be sent for forthwith; and insisted her brother should not leave the room until I arrived; some time elapsed before this could be accomplished, as we were several miles from each other, during the yellow fever of 1798. During the whole of this time she bore his threats and revilings, with the most exemplary patience, and silence. I at length arrived ; and, in the presence of the brother and a female friend, she informed me of what I have just stated ; and said her object in sending for me was, to submit to such an examination as I might FORMATION OF MILK. 11.) judge proper to determine, whether she was pregnant or not —she would not permit her brother to leave the chamber; and I conducted the examination without his withdrawing. This thing turned out as I had anticipated, from the history given at the moment, of her previous health. I pronounced her not pregnant; and she died in about eight months after, of phthi- sis pulmonalis, in which disease the obstruction of the cata- menia is not an unfrequent occurrence. Sect. VI.—6. Enlargement of the Abdomen. 279. The enlargement of the abdomen, perhaps, is one of the most equivocal of the enumerated signs, since it may take place from a variety of causes ; as 1st. Dropsical affections, of either the abdomen, uterus, or ovaries. 2d. A chronic disease of the ovarium, or uterus itself. 3d. A retention of the menses, from some accidental cause preventing their flow.* 4th. En- largement of almost any of the abdominal viscera. 5th. The simple obstruction of the catamenia. For these reasons, but little reliance can be placed upon this circumstance alone, or even when combined with several others. For I have had the pleasure in several instances, of doing away an injurious and cruel suspicion, to which this enlargement had given rise. Within a few days past I relieved an anxious and tender mo- ther, from an almost heart-breaking apprehension for the con- dition of an only, and beautiful daughter, on whom suspicion had fallen, though not quite fifteen years of age. This case, it must be confessed, combined several circumstances which rendered it one of great doubt; and without having had re- course to the most careful, and minute examination, might readily embarrass a young practitioner. 280. This young lady's case was submitted to a medical gentleman, who, from its history, and the feel of the abdomen, pronounced it to be a case of pregnancy; and advised the sor- row-stricken mother, to send her daughter immediately to the • See Miss F.'s case, in Essays on various Subjects connected with Midwifery, page 337. 116 ENLARGEMENT OF THE ABDOMEN. countrv, as the best mode of concealing her shame. Not wil- lingly viel1 ing to the opinion of her physician, (a young man,) and moved by th assertions of her agonized child, the mother consulted me. The history of the case was thus briefly given: " Her daughter commenced, between twelve and thirteen, to menstruate regularly, and continued to do so until late last fall;* at which time she had a very smart attack of the prevail- ing epidemic ; of this she was, however, relieved by the usual remedies—since that time, she has never menstruated; she gradually swelled in the belly; her stomach was much affected; especially, in the morning; the breasts were a little enlarged." 281. I examined the mammae, and found them a little tu- mid, but without areolae ; the abdomen was much enlarged, tense, and hard, in consequence of a large tumour which was confined to the left side of this cavity, and which could be ea- sily traced throughout its right and inferior margin, and prov- ed (at least in my opinion) to be an enlarged spleen; no tu- mour was found in the pubic region; consequently, the uterus was not found enlarged; the navel was sunk ; and upon an at- tempt to pass the finger into the vagina, I found so much evi- dence of her continency, that I did not persevere, being per- fectly satisfied, from the condition of the parts, that she was a virgin. I unhesitatingly, and with no common degree of pleasure, declared the poor child to be free from the charge, so heedlessly, and cruelly preferred against her. Sect. VII.—7. Increased size of the Uterus. 282. An increased size of the uterus, especially in young women, either married, or single, will necessarily create a sus- picion that it may arise from pregnancy; particularly if its surface, as distinguished through the abdominal parietes, be uniformly round, smooth, and of an elastic feel; and if there be combined with this, several of the rational signs of preg- nancy—but it is far from being infallible. This distention of the uterus may arise, 1st. from a dropsical state of the uterus; 2d. from disease within its cavity, as tumours, or excrescences j • 1823. INCREASED SIZE OF THE UTERUS. 117 3d. from moles or false conceptions; 4th. from a retention of the menstruous discharge from the occlusion of the os tineas, Sec. The case referred to (279) of Miss F. is strictly in point; and was one among others, where injurious surmises were most cruelly entertained for a long time. Sect. VIII.—8. Pouting out of the Navel. 283. Pouting out of the navel, if it take place, only proves that there is something behind it, which makes it protrude; but it by no means follows, that it is the uterus distended by pregnancy: I believe it invariably takes place in pregnancy after the sixth month, or sometimes even earlier ; and I think the following conclusions may pretty safely be drawn from this condition of the navel: 1st. If the woman be pregnant, it will, by its projection, indicate the advancement to be at least six months; yet the woman may be advanced to the fifth or a little beyond it, without this part undergoing a change; 2d. If this part protrude, it will by no means follow, without the concur- rence of other signs, that the woman is pregnant; for this may happen, a, from any cause, independently of pregnancy, that is capable of distending the uterus to a size equal to the sixth or seventh month ; b, from ascites, when the abdomen is much stretched ; c, from chronic enlargements of the liver, and, per- haps of some other of the abdominal viscera. When this part does not protrude, we are not to conclude that the woman is not pregnant; as it requires the presence of the uterus behind it, to make it appear; and, therefore, whatever is capable of preventing its presence immediately behind the navel, as in- sufficient development, or its sinking unusually low in the pel- vis from the extraordinary size of this cavity, is capable of interrupting this protrusion. Sect. IX.—9. Spitting of Frothy Saliva. 284. Spitting of very white frothy mucus, is by no means a constant attendant upon pregnancy; but when it does occur, it very certainly points out this condition. This saliva is very 118 SPITTING OF FROTHY SALIVA. tenacious, and very difficult to deliver from the mouth; it is extremely white and a little frothy, and, when discharged upon the floor, assumes a round shape, and about the size of a shil- ling piece: hence the expression, that the person is spitting English shillings, or cotton; and, so far as I have remarked, it is almost a certain sign of pregnancy. Sect. X.—10. Salivation. 285. Salivation, like the sign just mentioned, is not a con- stant attendant, except in a Aery moderate degree, upon preg- nancy; indeed it is even more rare, and seldom exists in ex- cess : but when it does happen, it very decidedly points out this condition—I do not remember to have observed this symptom from any other state of the uterus. 286. From what has been said, it appears, that the rational signs (as they have been termed) of pregnancy may exist in stronger or weaker combination, without proving it unequivo- cally ; though they may leave little or no room for rational doubt of its existence. There is, then, but one certain mark, by which pregnancy can be absolutely determined—and that is, the movements of the foetus itself within the uterus. In judging of this, we are not to rely upon the ipsa dixit of the woman, as she may be deceived, or have motives to mislead; upon this point, therefore, we must determine for ourselves. 287. To do this, it is necessary to place the hand upon the bare abdomen, and wait for the motion of the child; or we may endeavour to provoke it, by having the hand either hot or cold according to the season, as recommended by Morgagni; and as has been often practised successfully by myself. Should the weather be hot, we should have the temperature of the hand reduced by cold water, or ice ; or, if the weather be cold, have the temperature raised, by placing the hand in warm water for a short time. By these means, we rarely fail to excite the foetus to action; and we may succeed in having it even pretty frequently repeated, by repeating the same means. Of this fact I am perfectly certain; but to account for it, is beyond my ingenuity. By touching per vaginam, we may ascertain, that BALIVATION. 119 the uterus contains a solid body within it; but we cannot by this method determine whether it be a living being, or an im- perfectly organized mass. 288. Will the absence of all motion within the uterus deter- mine the woman not to be pregnant, when a sufficient number of the rational signs combine to render it more than probable that she is ? I must answer this question in the negative ; as instances have occurred to others,* and one to mv^elf, where the motions of the child were never per^wrtj|^gring the whole period of utero-gestation. In such cases, an*examina- tion per vaginam will aid much; especially, at the latter period of pregnancy—the state of development of the uterus; the feel of the substance contained in it; the condition of the os tinea;; the height of the fundus, &c. will, when taken into considera- tion, and found perfectly to correspond with the woman's his- tory of herself, prevent any serious error, in my estimate. Sect. XI.—Of Quickening. 289. By quickening, we are to understand the first perception the woman has of the child's muscular action. It is presuma- ble, that it has in a very feeble manner exerted itself very often before it is or can be noticed by the mother; and the first mo- ment that this action becomes obvious to her, must be at very different periods of pregnancy, in different women, owing to the greater or less strength of the foetus ; the quantity of the liquor amnii; and the sensibility of the uterus itself. I once knew a lady of great nervous sensibility, who constantly per- ceived the motions of her children at twelve weeks; others are longer, and may be said to be at every period between the twelfth week and seventh month—the medium period is the most common; and when I declare the most usual to be at the fourth month, I am perhaps as near the truth as can well be ascertained. 290. An anonymous writer in the Medical and Physical Journal for June, 1812, under the name of ".Medicus," has * Levret, as quoted by Baudelocque, Vol. I. p. 24Q. 120 OF QUICKENING. puzzled himself, besides appearing willing to puzzle every body else, bv a learned attempt to explain the cause of quick- ening, bv physical and metaphysical reasoning upon the subject. He evidentlv confounds two circumstances totally distinct (if one of them really has an existence) in their natures, under one general term—namely, the first perceptible motion of the foetus, is confounded with an imaginary change in the uterus, at the period the fundus usually appears above the superior strait. The^jjisposition to syncope, which is sometimes felt by women at about the fourth month, he calls quickening; and declares it to be owing to the sudden escape of the uterus from restraint to liberty, by mounting above the brim of the pelvis, and their enjoying greater freedom, and repose. He will not admit that any motion of the child constitutes quickening; but that it essentially depends upon the change of position of the uterus itself. He rejects the common and "ancient" explana- tion of quickening, for the following reasons : 291. 1st. "The sensation of quickening (by which he does not wish to be understood to mean any muscular action of the foetus) is not constant and universal; some women never ex- perience it, others with some of their children only." 292. 2d. " It has a distinct character from any subsequent motion of the child; no'woman ever admits that it resembles, in the slightest degree, the struggles of the foetus." 293. 3d. " This sensation is never repeated in the same pregnancy, which must happen if it arose from the motion of the child." 294. 4th. " It is totally incomprehensible that any motion of which the foetus is capable, in the fourth month, should com- municate such a sensation to the mother as to produce deli- quium animi." 295. The whole of this argument goes to declare, that when the uterus, suddenly overcomes any restraint to its passing out of the brim of the pelvis, the woman is wont to feel faint; and he confounds this fed^fcg^if it exist) with the sensation which all women (as a general *iile) experience, after the foetus has acquired sufficient fe*ength to make itself felt; and which in- creases in forehand* is multiplied in frequency, as gestation OF QUICKENING. 121 advances; or, in other words, he calls the sensation created by the uterus suddenly rising above the superior strait, quicken- ing ; but declares it to be distinct from the motions of the foe- tus—in this 1 most fully agree; as I do not believe, that the uterus is ever so suddenly elevated into the abdomen, as to pro- duce the sensation of faintness—for I have never been con- vinced of it, by any inquiry I have made from women, who, I should suppose, were the best judges upon this subject—but these inquiries have resulted in the establishment of the fol- lowing facts:—1st. That all women experience (some sooner, others later) the sensation which they term quickening; 2d. In some, this feeling is accompanied uy a sensation of faintness, or rather of sinking, as they express it; and this is experienced, in some few instances, whenever the motion of the child is re- peated, until after the fifth month, sometimes; 3d. That those who " quicken" very early, are most obnoxious to this en- feebling sensation; 4th. That, when the feeling of faintness comes on, they are certain it is always produced by the motions of the child itself; 5th. That none have ever been sensible of any disposition to deliquium, but from the stirrings of the foetus. 296. These facts are conclusive, that the sensation in ques- tion, is the result of the muscular agitations of the child; and that the explanation of " Medicus," is at variance with this opinion; consequently, not calculated to explain the pheno- menon. Besides, the circumstance mentioned by " Medi- cus," of the sudden eruption of the uterus from the pelvic ca- vity, has no existence; and even if it were true, I do not see why this change of position is to be confounded with the ab- solute stirrings of the foetus. If he can make out his position, that the uterus suddenly surmounts certain difficulties in its attempt to rise higher in the pelvis; and that this is accompa- nied by deliquium animi, it is well; but, for the sake of pre- cision, and of logic, do not let him confound it with quick- ening. 297. Besides, there is a want of ingenuousness in the state- ment of facts by " Medicus ;" for we are yet to discover, that any one has explained the term "quickening," by saying it [16] 122 OF QUICKTMNC". was owing "to life being suddenly imparted to the embryo,"— this would in itself be absurd, and contrary to all belief upon the subject; for I do not hazard much, when I say, that there is no one at present, nor perhaps ever has beenf who supposed that the embryo did not possess life from the instant it obeyed the stimulus of the male semen for development; and for this plain and simple reason; that if it were not alive, it must be dead; and if dead, it must be cast off by the womb, as an ex- traneous substance. There must be a period when the embryo is not sufficiently developed, to move; another when this can be but feebly, and imperfectly performed ; and another when it can move with sufficient force to give evidence of this increase of power; and this moment, is instantly recognised by the mother; who then says she has "quickened;" and that this novel sensation should be accompanied by novel effects, and even sometimes by syncope, is no way surprising. The older writers, merely wished to be understood by the term quicken- ing, that moment at which the embryo gave the first physical proof of life; and not the moment it received it. 298. That an abatement of the severity of the*symptoms of pregnancy, takes place about the period of " quickening," I am well convinced; and that this takes place with greater certainty when the uterus can repose itself upon the anterior portion of the pelvis; yet I am unwilling to admit, that this change is owing to the sudden rising of the uterus above the brim of the pelvis, as is declared by "Medicus:" 1st. Because, I do not know that this has ever taken place as a natural arrangement; 2d. And because if it did, it might create the unpleasant sen- sations agreed upon by " Medicus." 299. To me, the melioration of symptoms at this period,-ap- pears to depend upon two circumstances mainly: 1st. Upon the uterus being enabled to repose upon the symphysis pubis and its neighbourhood; therefore, no longer liable to be de- pressed in the cavity of the pelvis, by the often repeated im- pulses of the abdominal viscera. 2d. To the sensibility, and irritability, of the uterus being diminished, by the frequent re- petitions of the child's motions; in this, obeying the law, which seems to govern every other portion of the system as regards OF QUICKENING. 123 the operation of stimuli, by becoming less and less sensible to them, in proportion to the frequency of their application: hence, parts pretty uniformly sympathizing with the uterus when impregnated, will cease to do so, or will do so in a more moderate degree, as that viscus shall be itself less affected. Sect. XII.—Of Vomiting. 300. The morning sickness, and vomiting of pregnant wo- men is one of the most common, and sometimes, one of the severest of their many distresses. It commonly occurs upon their leaving their beds, and frequently harasses them for two or three succeeding hours. The matter thrown up is usually a sour, tenacious mucus ; at other times, a thin, extremely acid water, which now and then even excoriates the fauces, and sets "the teeth on edge." At other times, bile accompanies the discharge, even in considerable quantities. For the most part, this vomiting is attended, with confined bowels; the appetite is either voracious, or nearly destroyed; and almost always, whimsical; and, what is oftentimes remarkable at such times, the most unpromising, and apparently preposterous article, will not only be most acceptable to it, but best suited to its way- ward humour. 301. The vomitings, however, rarely proceed to any very dangerous lengths; and as rarely, require strict medical treat- ment; a pro re nata plan is for the most part all that is required.. I have found a glass of warm water, or camomile tea, taken so soon as nausea is felt, very frequently abridge the sickness, by immediately inducing vomiting, or by composing the dis- turbed stomach. Should much acidity prevail at such times, a glass of soda water will have a very good effect. Should the bowels be in fault by their tardiness, small doses of cal- cined magnesia in a little milk, will be found highly useful. If nausea, and frequent vomitings occur during the day, and the food be thrown up, the patient should be confined to a table spoonful of milk every fifteen or twenty minutes, and no one thing beside; this rarely fails to tranquillize the stomach, 124 OF VOMITING. and enable it to take food with advantage—we may occasion- all v add a spoonful of lime water to the milk, until the stomach be relieved. 302. But such is the predominance of acid, that none of the antacids is capable of overcoming it, though administered with a liberal, or even a daring hand. I rarely persevere in the use of the alkaline remedies, when I find that considerable doses will scarcely have a temporary effect; when this is the case, I have recourse to acids themselves for the relief of this most distressing state of stomach. I have employed both ve- getable and mineral, with perhaps about equal success; but the vegetable will in general merit the preference, on account of the teeth. I have, in several instances, confined patients for days together upon lemon-juice and water, with the most de- cided advantage.* 303. In two instances I have witnessed the best effects from substituting a glass of iced water, for tea or coffee in the morn- ing, by which the patients were enabled to retain a cracker or two upon their stomach; which would not have been the case, had they taken either of the other substances. When the vomiting is so persevering as to discharge every thing from the stomach as fast as taken in, the bowels should be eva- cuated daily, by mild injections ; and permitting these to act rather by their bulk, than by their stimulus. Should the pulse be full, as it almost always is under these circumstances, a little blood should be taken from the arm; more especially,if head- ach attend. Should pain, and a sensation of burning about the region of the stomach be felt, much good is experienced by the application of a few leeches to the part, so as to abstract five or six ounces of blood. 304. I have repeatedly found much benefit from the use of the spirit of turpentine three or four times a day, in twenty- drop doses. This medicine is very easily taken if mixed in cold, sweetened water. When the system is not excited to febrile action, and where the stomach rejects eVery thing al- * One lady took the juice of a dozen of lemons daily, for many days together, with the most decided advantage, and nothing beside. OF VOMITING. 125 ■most as soon as swallowed, I have often known a1 table spoon- ful of clove tea* act most promptly and successfully. 305. With respect to the diet of patients so circumstanced, it would be in vain to point it out; as any plan we could devise would scarcely apply to any two patients—I generally direct the use of such articles, as their experience has proved best suited to their condition; and sometimes, it is truly astonish- ing to observe, the wavwardness of the stomach upon such oc- casions. I have lately had a patient who could retain no arti- cle, except Indian meal cakes, baked pretty hard upon a board —these uniformly kept down, and she literally lived upon them for weeks. Sect. XIII.—Of Heartburn. 306. This very distressing symptom is sometimes one of the first the woman experiences after impregnation—at other times it does not make its appearance until gestation is pretty well advanced; and sometimes is absent altogether. It is almost always very distressing, and very difficult to subdue. I have known large and repeated doses of the alkalies exhibited with scarcely a temporary truce, much less a permanent benefit; in consequence of which, I have for many years past ceased to urge them in large quantities, where I find smaller ones pro- ducing no effect. In such cases, I think it better to abandon the attempt to neutralize the acid, and begin with the use of the acids, so soon as the other class of remedies shall prove useless. 307. I have already, under the head of vomiting, mentioned the advantage of acids, (302) to counteract that of the sto- mach, and they well deserve a trial. The vitriolic, or the citric, may be used freely in such cases, but the latter, as I have al- ready observed, merits the preference. 308. Magnesia and chalk are in familiar use; and in mode- rate cases are every way competent to the exigency, especially the former. Magnesia should always be preferred to chalk, except (which very rarely happens) a looseness of bowels ac- * Clove tea is made by bruising about twenty of them, and then pouring a half pint of boiling water on them, and permitted to stand covered up until cool; 126 OF HEARTBURN. companies tKis complaint. The chalk is never so pure as mag- nesia, and is always sure to constipate the bowels—sometimes it is used in immoderate quantities, but always with manifest injury. I formerly attended a lady with several children, who was in the habit of eating chalk during her whole term of pregnancy; she used it in such excessive quantities, as to ren- der the bowels almost useless. I have often known her with- out an evacuation for ten or twelve days together, and then it was only procured by enemata; the stools were literally nothing but chalk. Her calculation, I well remember, was three half pecks for each pregnancy—she became as white nearly as chalk itself; and it eventually destroyed her, by so deranging her stomach, that it would retain nothing upon it. 309. When heartburn is moderate, it may be relieved by soda water, lime water and milk, and the occasional use of magnesia. The operation of these substances in the cure of an acid stomach is easily understood; but the action of a few blanched almonds, or a few roasted ground-nuts, is not so easily explained; yet both of these substances, I have known most successfully employed where the complaint was mild—they should be taken from time to time, as the acidity may prevail. 310. Confining the patient to any one article of diet of either the vegetable or animal kind, is sometimes productive of great advantage ; as simple boiled rice; oysters ; milk or cream: or very sweet butter, and stale bread, &c. 311. Costiveness is very common, and should be carefully guarded against; the diet should be made to conform to this end, whenever practicable; where the stomach will bear bread or biscuit, they should be made of unbolted flour. The ship- bread, as it is called, I have found answer occasionally a valu- able purpose—but where this is not sufficient, or it cannot be used, the following pills may be taken with great advantage, < if properly persevered in:— R Gum aloes, sue. 3ss. Pulv. Rhaei. 5'i. Ol. Caryoph. gut. iv. Sapo. Venet. gr. viij. Syr. Rhaei. q. s. M. f. pil, xxx. OF SALIVATION. 127 One of these every night if necessary ; or every other night, as may be most eligible or necessary. Sect. XIV.—Of Salivation. 312. The sympathy between the salivary glands and the im- pregnated uterus, is perhaps as remarkable as any that takes place. In a ver.y moderate degree (285) it maybe considered as a pretty general attendant upon gestation ; as almost all wo- men, at such times, have more than an ordinary quantity of saliva secreted. In this mild form it will scarcely require at- tention ; or it may even pass without notice. But it becomes very distressing, and enfeebling when excessive. It is almost always accompanied with acidity of stomach, and constipation of bowels; the fluid discharged from the mouth, for the most part, is perfectly colourless, and transparent; at other times it is more tenacious and frothy, and the quantity poured out is sometimes incredibly profuse. It almost always has an unplea- sant taste; though not attended with an offensive smell;—it keeps the stomach in a state of constant irritation, and not un- frequently provokes puking; especially, if the saliva be tena- cious, and require an effort to discharge it. At night it is ve- ry troublesome; interrupting sleep, from the necessity of fre- quently emptying the mouth. 313. If it continue long, the woman becomes weak, from the quantity of fluid poured from the mouth, as well as the inability it produces to take and retain sufficient food upon the stomach. I have never known this complaint prove fatal; though I have witnessed two cases in which the patients were in great jeopardy—one of which I will relate, as it is remark- able for the extent to which it ran. 314. I was called upon to prescribe for Mrs. I. who was advanced to the fifth month of her pregnancy. At the second month she was attacked by a profuse salivation; she discharg- ed daily from one, to three quarts of saliva; and was at the same time harassed, by incessant nausea, and frequent vomit- ings—so irritable was the stomach, that it rejected almost in- stantly any thing that was put into it; she now became ex- 128 ©f SALIVATION. tremely debilitated; so much so, as to be unable to keep out of bed; and, when she did attempt to sit up, would faint, if not quickly replaced. 315. From a belief that the affection might be local, astrin- gent gargles were freely employed ; but with marked disadvan- tage. A large blister was next applied to the back of the neck, with decided, but transient benefit—that is, the salivary dis- charge was less, the nausea diminished, and the vomiting less frequent; but this favourable impression was but of three or four days duration : for, after this time, all the unpleasant symptoms returned with their former severity. An emetic of ipecacuanha was now exhibited, followed by a cathartic of rhubarb and magnesia, without the smallest benefit;—soda ■water, lime water and milk, milk itself, &c. were, in turn un- availingly employed. I now put my patient upon a diet alto- gether of animal substances, and ordered ten drops of lauda- num morning and evening, and fifteen at bed-time: this plan succeeded most perfectly in the course of a few days; nausea and vomiting ceased, and the discharge was reduced to less than a pint per diem ; and, perhaps, the force of habit had no inconsiderable agency in the production of this quantity. The bowels, during this plan, were kept open by the extract of butter-nut and rhubarb, in the form of pills. This lady never had any return of this complaint in her subsequent pregnancies. 316. As a general plan of treatment in this complaint, either when moderate, or severe, I endeavour to destroy the acidity of the stomach, by the various antacids ; to keep the bowels free, by the frequent use of magnesia; rinsing the mouth fre- quently with lime water, and the use of solid animal food; to- gether with a strict injunction to the patient to resist the de- sire to discharge the saliva from the mouth, as much as pos- sible. 317. This complaint, when moderate, almost always abates, if it does not cease altogether, after the fifth or sixth month; but, when severe, its period is doubtful. A lady informed me, that this affection continued with considerable force, during the whole period of gestation in one of her pregnancies. OF FLUOR ALBUS. 129 Sect. XV.—Of Fluor Albus. 318. This complaint is a very frequent attendant upon preg- nancy, though the woman may not be subject to it at other times ; when connected with pregnancy, it seems to be owing to the increased flow of blood to these parts ; and almost always assumes a mild form. When this discharge, as an attendant upon pregnancy, is in excess, it merits the attention of the practitioner, though he must not expect, nay, must not attempt, a radical cure of it, unless it can be accomplished by mild local applications, and a strict attention to cleanliness. I am per- suaded that much mischief has arisen from the attempts to cure this complaint during gestation, when, for its accomplish- ment, the active remedy recommended by Mr. Robertson, has been employed: I therefore, during this period, confine my- self to a temporizing plan, from a conviction, a more active one would be injurious. For this reason, I simply direct wash- ing the parts three or four times a day with luke-warm water; and throwing into the vagina, by means of a syringe, a weak solution of the acetate of lead; that is, a scruple to eight ounces of water. Previously to using the injection, the parts should be well washed with a weak solution of fine soap in warm wa- ter, by throwing up the vagina a few syringes full of it in quick succession, and these followed by the saturnine solution. Much advantage is derived from this last plan ; for I am convinced it will afford relief, when the non-observance of it might not be followed by the smallest benefit. 319. I am aware that I differ from almost every practition- er, in recommending warm water as a common wash; but I think I am recommending the better plan; it is one I have pursued for the last thirty years; and I am abundantly convinc- ed of its superiority. 320. I rarely recommend constitutional remedies, in this kind of fluor albus; the pulse must be controlled by occasional blood-letting, when necessary; and the bowels carefully regu- lated—should much acidity of stomach attend, give magne- sia ; or magnesia and prepared oyster-shells, when the bowels are disposed to looseness. [17] 130 OF FLUOR ALBUS. 321. My plan is very different, when the patient is not preg- nant; I shall therefore say a few words upon this subject. 322. Leucorrhoea is one of the most common complaints to which the female is subject; and consists in an increased, and oftentimes altered secretion, from the vaginal vessels, and per- haps of the uterus itself. Most systematic writers locate this complaint in the uterus; but I am disposed to believe, this is comparatively rare. There are few women who bear children that escape this complaint, and who do not find it almost al- ways increased by pregnancy; now were this disease situated within the uterus, it would cease so soon as impregnation had taken place. It is in vain to say, that when the uterus is impreg- nated, the discharge does stop from this place, but is increased from the vagina; unless some good reason should be assigned, or some striking and apposite analogy be furnished, for this exchange of function—I can see no such good reason, or analogy. 323. I have never been perfectly satisfied, but in three or four cases, of the very many that have been under my care, that the discharge in question proceeded from the cavity of the uterus—in all these, the following peculiarities were present. 1st. During the night, there was no-discharge what- ever ; but upon rising, there would be a very abundant one of a glairy, tenacious substance, and sometimes mixed with some, of a purulent appearance. 2d. That during the day, when it did escape, it was always suddenly, and accompanied by a sensation of effort, within. 3d. That when a piece of sponge was introduced into the vagina at night, with a view to deter- mining the point, it was never found filled with the kind of matter, that very quickly issued, when this was removed. 4th. All these cases I found to be incurable, though capable of re- lief. 5th. All the women were barren. 324. These considerations make me believe, that fluor albus has its seat for the most part in the vagina. I believe farther, that it is almost always local; but by excess of quantity, or peculiarity of quality, the system frequently becomes involved. I am not prepared to decide on the nature of the irritation 'which keeps up this discharge; but I believe it to consist in an OF FLUOR ALBUS. 131 altered action of the vaginal lacunae, or glands, which, in a state of health furnish the moisture so important to this part. When speaking of this complaint, I would wish to be under- stood, not to include the discharge from this part, which is symptomatic of some derangement of the proper substance of the uterus, or that, which always accompanies a prolapsus of this organ. 325. The idiopathic forms of this disease, may be divided into three stages; each of which requires a little difference of management; in the first, or most simple form, the matter dis- charged is glairy and transparent, or resembling a thin starch; this very often accumulates in considerable quantity, from its tenacity, within the vagina, and is then suddenly discharged, either by its own weight, or from some sudden exertion of the woman; especially, upon stooping, or lifting a weight—this never becomes acrid; unless, there is the most reprehensible neglect of cleanliness; nor, so far as I have observed, is the system implicated, though it may take place in women consti- tutionally plethoric. 326. I always commence by directing, that the parts be regularly washed with warm water, three or four times a day— if the patient be plethoric, I cause her to be well purged; con- fine her to a milk and vegetable diet; and sometimes, order her to lose blood—when the pulse is sufficiently reduced by these means, or if the pulse be in a proper condition without these means, the tincture of cantharides is to be given; of this I direct thirty drops every morning, noon, and evening, in a little sugar and water; increasing the dose every third day, five drops at a time, until strangury* is produced, unless the dis- ease is arrested, which is not unfrequently the case, before this * I always direct my patient to desist from the use of the tincture, so soon as she feels the approach of strangury, and not to resume it until all uneasiness dis- appears. If the strangury be severe, direct the free use of flaxseed tea, barley water, or gum Arabic water—and five-and-thirty drops of laudanum. Should this not succeed, direct an enema of a gill of thin starch, a tea spoonful of lauda- num, and thirty grains of finely powdered camphor—as far as I recollect, this enema has never failed. It may be also proper to mention, that the tincture I employ, is fifty per cent, stronger, than the ordinary tincture of the shops; or to other words, where they use two drachms, I use three. 132 OF YLUOR ALBUS. symptom appears. Should the complaint not yield to the first' strangurv, I am not discouraged ; but re-commence the tinc- ture at the original dose of thirty drops, and increase it as be- fore, until a difficulty in making water is again experienced— it rarely, however, withstands the second irritation of the bladder. 327. Astringent injections are to be employed, so soon as a change is observed in the discharge, by its becoming thinner, and more abundant; but never until then; should this require three or four stranguries to effect it. The best kinds of astrin- gent injections, are the acetate of zinc, in the proportion, of five or six grains to the ounce of water; or the sulphate of copper in solution, in the proportion of a scruple to half a drachm, to eight ounces of water; either of these may be employed three times a day; taking care to wash out the vagina with soap and ( water, as above directed. (318) 328. This plan, when properly conducted, or sufficiently persevered in, rarely fails to effect a cure—and I must here declare, the high confidence I have in this medicine ; for it rarely has failed in my hands. There is reason to believe, that when this medicine is not successful, it is chiefly owing to not giving it in sufficient quantities, from an apprehension it may produce mischief—I can most honestly say, I have never wit- nessed any other than a temporary inconvenience from this article; and I have given it, in what might at first sight appear hazardous doses—in two instances, the dose was gradually raised to two hundred drops, three times a day, without pro- ducing strangury, until this quantity had been persevered in for several days successively. Injections aid the operation of this medicine much, if employed at the proper moment—this moment I have indicated above (327)—I never use them, it may be proper to observe, in young girls, for reasons suffi- ciently obvious. 329. In the second stage, the matter discharged has a white, or yellowish, purulent appearance—it is usually more abundant than the discharge of the first stage; and is constantly leaving the vagina, by a pretty uniform stillicidium. If proper atten- tion be not paid to cleanliness, it may become offensive, or may OF FLUOR ALBUk. 133 even excoriate—this state is almost always accompanied with pain in the back, hips, and in the region of the pubes; the wo- man's complexion is generally sallow; and when the discharge is excessive, she becomes subject to a train of nervous symp- toms, that are both troublesome to the patient, and difficult of management to the physician. 330. The system is almost always involved in this second stage; for if the pulse be carefully examined, it will be found hard, wiry, and irritated—in this stage, as in the former, the most scrupulous attention to cleanliness should be observed— I purge most commonly; confine the patient to a vegetable diet; and sometimes, bleed—I am sure, that in every stage of fluor albus, time is saved, as well as a material point gained, by a pretty brisk catharsis, in the commencement of the curative plan; it should therefore never be neglected. When the pulse is in a proper state to bear the tincture of cantharides, it must be exhibited as above directed; subject to the same restrictions and distinctions, (326) but with this difference; that we may com- mence advantageously in proper subjects, with injections; but they should be of the sedative kind; a weak solution of the acetate of lead is perhaps the best; this may be used several times a day, preceded by the soap and water, as just mention- ed. (318) 331. In the third stage, there is an aggravation of all the symptoms of the second; the discharge is of a greenish colour, and is frequently tinged with blood—I consider both the last- named forms, but exalted degrees of the first; that is, the in- flammation is greater in their numerical order; in the last, therefore, we have more to contend with, than in the second; and more in the second, than in the first—but the same general directions are applicable to all—for nothing can compensate for the neglect of cleanliness—this must, therefore, be insisted on; the bowels must be purged, and as the system is more frequent- ly and extensively implicated in this, than in the former stages, we are oftener obliged to bleed, and enforce a strict observance of a vegetable diet. We may, as in the second stage, where the subject will permit, commence with the injections of a weak so- lution of the acetate of lead; then perse veringly employ the can- 134 OF FLUOR ALBUS. tharides—in using this tincture in this stage, I depart from the method just recommended, if the disease be of long standing, bv more gradually increasing the dose, or making the intervals of increase two or three days longer. My reason for this is, that the system may not too suddenly be affected by it; for I have observed, that when strangury is hastily induced, the effects are neither so satisfactory, nor so permanent, as when more slowly brought on—It may, however, be remarked in general, that the more susceptible the system is of the influence of this medicine, the more easily the cure is accomplished. 332. As on former occasions, I do not use the astrin- gent injections until the sign for their employment shows it- self; (327) that is, an increase and thinning of the discharge; even the first injections of this kind should be rather more fee- ble than those formerly directed; but the strength must be in- creased, as the parts become more accustomed to them. I go on, iteriun iterumque, to renew the strangury, should the first not be sufficient. Nor am I to be discouraged, if the com- ' plaint does not yield to several; for I am very rarely disap* pointed in the operation of this medicine, when sufficiently persevered in. 333. I, however, confess, that I am occasionally not sucess- ful; but cannot this most truly be said, of every known reme- dy ? I have now and then succeeded with the balsam copaiva after the other has been fully tried without advantage; and I also have effected cures in some obstinate cases, by the use of alum and nitre—five grains of alum and ten of nitre, given three times a day, have proved very successful after other remedies have failed. 334. The discharge which attends the prolapsus uteri is owing altogether, or at least in great part, to the mechanical irritation the surface of the vagina suffers, from this displaced organ, and does not come under our present consideration"; I have adverted to this when speaking of the disorder which produces it; and the same may be said of the sympathetic production of fluor albus, from a diseased condition of the uterus itself. OF PRURITUS. 135 Sect. XVI.—0/" Pruritus. 'U 335. One of the most troublesome and distressing com- plaints to which .the female is subject, is the pruritus or itch- ing of the pudendum. Women who are not pregnant, are liable to this complaint; though not equally with those who are pregnant; in both, the desire to scratch is so indomitable, as sometimes to put decency at defiance. 336. Dr. Denman says, that those women who carry dead children are more subject to this disease, than those who carry living children. This remark is not confirmed by my own experience. I have known many instances, where dead children were carried, without this disease being present; and I have known a number of cases of pruritus, where the child was certainly alive. The precise nature of this affection, has not hitherto been pointed out; and accident furnished me with an opportunity of detecting the condition of the parts, where this complaint was in full force. 337. A lady, whose husband was more notorious for his gallantries, than his domestic virtues, was attacked in the inci- pient stage of pregnancy with an intolerable itching in the pudendum, and even within the os externum and vagina. Sus- pecting the affection to be venereal, I was sent for; and^ she giving such an account of her feelings as to make me think it might truly be the case, I proposed an examination of the parts; which was finally acceded to. Upon separating the labia, the whole face of the vulva, the os externum, and as much of the vagina as could be viewed, were covered with an incrustation of aphthae. I assured the patient, her disease was not what she suspected, but one, I hoped, that could quickly be removed. I accordingly ordered a strong solution of borax in water, and requested her to wash the parts with it four or five times a day, as well as throw it up the vagina. She did so; and was per- fectly well in twenty-four hours. 338. I was led to the employment of the borax in this case, from the analogy which the thrush in children furnished me with; and its success since, has led me to regard it as a certain 136 OF PRURITUS. remedy in this complaint—I have had nine cases within the last five or six years, in all of which it proved completely suc- cessful ; but not with equal speed. Two of the cases just men- tioned were pretty obstinate, and especially one; in both, I was obliged to bleed and purge liberally; and to confine the patients to a low diet; but in o^ie, I was also under the necessity of ap- plying leeches to the part, before the disease would yield—I thought that small doses of magnesia, with the daily use of lime water and milk, were useful in this case. But in the others, the disease yielded almost immediately, to the simple applica- tion of the borax and water. 339. Where this complaint proves at all obstinate, depletion adds very much to the influence of the borax; I therefore would advise attention to this circumstance. I am not certain, however, that in every case of pruritus there exists this aphth- ous efflorescence; but think it probable. I have had but two opportunities of examining the parts, under such circumstances; in both of which, this condition obtained. CHAPTER IX. OF DERANGED MENSTRUATION. 340. The derangements to which this discharge is liable, are as follows:— 1st. Its too tardy appearance. 2d. Its interruption after having been established, common* ly called the suppression of the menses. 3d. Its excess of quantity. 4th. Its painful production. 5th. Its irregularity towards the decline of life. Sect. I.—1. Tardy Appearance of the Menkes. . 341. The average period for the first appearance of the menses may be, between the fourteenth and the fifteenth year TARDY APPEARANCE OF THE MENSES. 137 in this country ; when they fail at this time, much anxiety is evinced on the part of friends, for the situation of the girl so circumstanced; and every indisposition with which she may be attacked, is sure to be attributed to this cause. In the hope of provoking the menses, now due as thev suppose, the patient is almost always condemned to medical discipline; and but too frequently injured by submitting to its rules. Nothing per- haps would be so difficult to overcome, as the vulgar prejudi- ces entertained upon the necessity of this discharge, at a cer- tain period of female life; (and this determined by the num- ber of years which have passed,) if we were so idle as to at- tempt a reformation. Women upon this subject, are but too often incorrigibly wrong-headed, and we are obliged to yield for the patient's sake, an appearance of acquiescence. In many instances, did we attempt to convince them of their error, (however egregious that error might be,) it would not only be labour lost, but, what is worse, would but too often be deliver- ing the patient over to the discipline of some rapacious quack, or some ignorant pretender to medicine. 342. Upon this subject, we are not bound to disclose our views of the case to the friends of the patient—we should prescribe agreeably to our own impressions ; for candour does not exact an avowal that we differ from them. The welfare of the patient, I must repeat, will very often depend upon the address with which we manage this tender and interesting sub- ject. My patience, oftentimes tried, suggests the cautions just urged; and my experience has but too often proved the neces- sity of them. 343. The lapse of a certain number of years is not all that is required, that the menses make their appearance ; the uterus, and ovaria, must be developed, and in good health, if I may so term it, before they will appear; and this condition of the genitals is always indicated by corresponding changes in cer- tain other portions of the system—there must, and will be evidences of womanhood, before this event shall happen; and when these are absent, the girl should never be tortured by the class of medicines called emmenagojrues. 344. There seem to be four conditions of the' female sys- [18] 138 TARDY APPEARANCE OF THE MENSES. tern, ill which the menses are' tardy in their appearance: a. Where there is little or no development of the genital organs; b, or where it is taking place very slowly; c, where this deve- lopment is interrupted by a chronic affection of some other part; d, where the most perfect development has taken place, but they do not make their appearance. The management of each of these conditions, is different—I shall therefore treat of them in order. 345. Condition a. This condition of the system is easily detected by the absence of all the signs which should charac- terize puberty—the breasts are not swelled, but remain dor- mant as it were; nor is hair always on the pubes. In a girl thus circumstanced, who otherwise is in good health, it would be more than idle, it would be cruel and dishonest, merely be- cause she had attained her fourteenth or fifteenth year, to sub- ject her to medical rule, or goad her system by stimulating emmenagogues. In such a case, if the mother or friends are rational, and to be trusted, we may honestly give our opinion of the entire insufficiency of medicine to produce the desired end. We should explain, so far as we can, the nature of the function of menstruation, and of the pre-requisites to this dis- charge ; and attempt to produce on their minds the important conviction, that time, under proper circumstances, is all that is required, to effect the anxiously hoped for change. 346. I have encountered many such cases—with some I have succeeded, to bring them to my opinion; in others I have not been so fortunate as to convince them of the justness of my views—the latter may be divided into two classes—the one, though not convinced, dare not openly bid defiance to our opinion; because, they fear the responsibility, and thus will yield a reluctant acquiescence. The second, confident in their own judgment, will sometimes act upon it, to the imminent risk, if not to the destruction of the poor girl, who may be the object of their solicitude. 347. With the latter, when importunate, we should use a temporizing plan; and, by the administration of some entirely inert medicine, gain time, and save the patient from permanent ill health, or an untimely grave. I but too often call to mind TARDY APPEARANCE OF THE MENSES. 139 with bitter recollection, the fate of a most amiable, and inter- esting young creature, for whom I was requested to prescribe for the expected menses, but who had not one mark which would justify an interference ; and was beside in perfectly good health—she was fifteen, it was true ; and this was all that could be urged by the mother in favour of an attempt to " bring down her courses." I relied too much upon the good sense of her anxious parent; and freely explained myself to her—she left me apparently satisfied: I heard nothing of the poor child for six months, when I was suddenly summoned to attend her, as she was said to be alarmingly ill. 348. When I saw her, she was throwing up blood in consi- derable quantities from the lungs; she died in a few days more, from the excess of this discharge. The distracted mother told me, that, though she appeared satisfied with what I had said when she left me, she was convinced I was wrong, and that her daughter's.health required the immediate establishment of the menstrual evacuation. With this in view, she determined upon the trial of a medicine of much celebrity, in similar cases, vended by a quack. She procured it; gave it according to directions; in a few days her daughter became feverish, lost her appetite, and frequently puked—-her strength rapidly fail- ed, and after a short time, she was confined to her bed—the mother called upon the " Doctor," and informed him of the condition of her daughter; he encouraged her to persevere: and told her, that the fever, &c. was an effort nature was mak- ing for the end proposed—she persevered, fatally persevered; for, in a few days more, she lost her only, and lovely daughter. I examined the medicine which had been exhibited; it proved to be the oil of savin. 349. Condition b. This condition is known by the partial alteration the mammae have undergone; by some expansion of body; and the protrusion of hair on the pubes. The general health sometimes suffers slightly; especially, if the girl has passed the fifteenth year, and grows tall rapidly—she is assail- ed by a train of nervous symptoms, as they are called; such as palpitation of the heart, ringing in the ears, headach, a tern- 140 TARDY APPEARANCE OF THE MENSES. porary loss of strength upon any sudden exertion; ;i diminish- ed, or a whimsical appetite. 350. This condition is not unfrequently accompanied by fluor albus; and when it is, it mote particularly deserves notice. I consider this case as meriting attention, when there is weaken- ed health; but I as certainly set my face against any interfe- rence, when there is not. 351. Our exertions in favour of such patients, should tend to the invigoration of the system in general, and the develop- ment of the uterine system in particular. The first should be attempted, 1st. by the establishment of a regular course of ex- ercise :—such as riding on horseback, where practicable; walk- ing in proper weather; skipping the rope within doors, when the weather will not permit exercise abroad; dancing mode- rately, and with strict attention not to become overheated, and cooling too suddenly; 2d. by proper attention to dress; wear- ing flannel next to the skin in cold weather, and properly pro- tecting the feet and legs against cold; carefully avoiding damp and wet places, and partial streams of cold air, especially when warm: 3d. by a diet of easily digested substances, both of the animal and vegetable kind; avoiding all stimulating drinks, such as wine, spirits, or beer, &c. under the specious pretext of strengthening. 352. The second must be accomplished by such medicines as appear to have a direct, or indirect action upon the uterus itself; of the direct^ the tincture of cantharides appears to be the most efficient, and should be preferred to all others when leucorrhcea attend—thirty drops should be given three times a day, until this discharge cease. We may gradually increase the dose, should the complaint be obstinate; for it is of prima- ry importance that it be removed; and we need scarcely look for the catamenia, while this remains in any force—for leucor- rhcea is a kind of local depletion; and will prevent that partial congestion so favourable to development, and the production of the catamenial discharge. The parts should be regularly bathed every day with warm water; especially, during the con- tinuance of the fluor albus. 353. Of the indirect kind, aloes seems to be the most certain TARDY APPEARANCE OF THE MENSES. 141 —the influence of this drug upon the uterus, has been very long acknowledged, and was much extolled for this purpose by Morgagni and his contemporaries—it should be given in very small doses, and perseveringly continued; this medicine is per- haps preferable to the tinct. canth. where leucorrhoea does not attend; the following is the formula I generally employ: R. Gum. aloe. sue. 3ss. Pulv. Rhaei. opt. 3j. Ol. Caryoph. gut. iv. Sapo Venet. gr. viij. Syr. Rhaei. q. s.—M. f. pil. lx. 354. One of these to be given every night, night and morn- ing, or every other night, as they may affect the bowels—the object is to keep the bowels free, but not purged. This pre- scription is a remarkable instance of the power of combination; for the very small dose just recommended, will sometimes act with great force upon the bowels—so much so, sometimes, as to oblige us to reduce the above quantity one half. The same regard must be paid to air, exercise, and diet, (351) as just re- commended. 355. Condition c. This condition is readily detected, by the presence of any such disease, as may be capable of interrupting this discharge, after it has been thoroughly well established; such as phthisis pulmonalis; chronic inflammation of the liver, or spleen; dropsy; &c. Under the existence of either of these diseases, the menses will almost slways be suspended; because, it will certainly interrupt the development of the organs, es- sential to the formation of this discharge, however favourably this expansion may have commenced. 356. This case will most completely expose the physician to the importunities of the friends of the patient, for something "to bring down the menses;" it is in this case, of all others, they are persuaded that nothing more is wanted to re-establish health—it is here we must conceal our real sentiments, (342) as above recommended—however convinced of the inefficacy of the trial, we must not say so, for the reason urged just now; we can easily say, we have taken the circumstance into con- sideration, and that we shall prescribe accordingly. By this 142 TARDY APPEARANCE OF THE MENSES. means we can retain the confidence reposed in us, and not ex- pose the patient to the risk of injury, by her being taken out of our hands, and placed into those, whose ignorance, or extremely limited views of the disease, might speedily prove fatal to her. To be useful in this case, is to remove the disease which inter- rupts the regular appearance of the menstruous discharge; if we cannot do this, we cannot effect the other. Of the diseases which may give rise to this interruption, it is not our province to speak. 357. Condition d. This condition is easily known, by the girl having all the outward signs of womanhood; the menses is all that is wanting to complete her title to it, and fit her for the duties she is destined to fill. This case is sometimes at- tended by fluor albus; when it is, it must be treated as I re- commended above ; (350, 351, 352) at other times, there is a manifestation of an attempt to produce the discharge, by the institution of pain in the back, hips, and loins, with a sensation of fulness in the pelvis, attended sometimes with a forcing or bearing down. This is periodical sometimes; and may be ac- companied even by a serous discharge from the vagina, resem- bling whites. The tinct. canthar. as recommended above, will rarely fail to produce the discharge, if given steadily for two or three weeks; or the madder may be given, if the period for the return of the pains just spoken of, be near at hand. 358. I have found that a strong decoction of this wood is of equal efficacy with the substance, and is much more easily taken —-\ direct a pint of boiling water to be poured upon an ounce of finely powdered madder, and a scruple of bruised cloves; these to be gently simmered for fifteen minutes; when cool, strain off, and give a wine glassful every three hours—I have lately had a case of this kind, where the madder succeeded most prompt- ly. This case rarely gives much trouble, unless the interruption has been occasioned by imprudent exposure to wet or cold—4H this instance, it must be treated as an obstruction. SUPPRESSION OF THE MENSES. 143 Sect. II.—2. Of the Suppression of the Menses. 359. However well established the menstrual discharge may be, it is liable to interruption, from a variety of causes indepen- dently of pregnancy, and suckling. The little regard which young females pay to this period, exposes them but too fre- quently to a derangement of it; nay, some I have known, so heedless of consequences, as to designedly interrupt them, by putting their feet in cold water, when engaged for a party of pleasure. Cold in some form or other may be considered as the most frequent remote cause of this suppression; and it may be applied either in the interval; just as they are making their appearance; or after they have flowed some time. 360. When cold is applied with sufficient force in the inter- val to arrest this discharge, the first notice the woman has of its influence is, the want of return of the menses, at the subsequent period; she for the most part neither suffers pain, or other in- convenience, until the menses may have failed in their return for several periods; she then may experience the approach of ill health; and is now an object of medical care. She may now become pale, emaciate, and be much enfeebled—a train of nervous symptoms may be superadded, such as palpitation of the heart, difficulty of breathing, a sense of suffocation, espe- ciallv, after any thing has hurried the circulation—she may also be attacked by fluor albus, which soon aggravates the pre- vious unpleasant symptoms. 361. When cold is applied as the menses are about to appeal-, or after they have flowed some time, the symptoms are gene- rally very different: in such cases, the patient is frequently attacked with violent pain in the head, back, or bowels, and this with such force, as to give great alarm for her safety. I have known temporary derangement, violent hysteria, and se- vere colics, result from this cause. For the relief of these, we are obliged to have recourse to blood-letting, purging, warm bath, camphor, opium, assafoetida, &c; and, for the time being, are necessitated to treat the complaints as if they were inde- pendent of such a cause ; for we very rarely can re-establish 144 SUPPRESSION OF THE MENSES. the discharge, at the moment when it has been thus interrupt- ed ; nor should it always be attempted, as sometimes much injury is done, by neglecting the consequences of this interrup- tion, and directing the whole force of our endeavours to the recall of the discharge. I admit, that after bleeding and purg- ing have been performed, advantage is sometimes derived from either the general or partial warm bath, or hot fomentations to the abdomen; especially, if pain be experienced in the region of the uterus. Should pain be severe, I have found nothing to answer so well as an injection composed of a gill of thin starch, a tea spoonful of laudanum, and thirty grains of finely powder- ed camphor. If it be complicated with hysteria, the addition of three tea spoonsfull of the tincture of assafoetida, instead of camphor may be useful; this may be repeated pro re nata. When colic supervenes upon the interruption of the mense9, after bleeding (should the pulse have indicated it,) I have found nothing so certainly to relieve, as half-ounce doses of the elix. proprietat. in warm sweetened milk, until the bowels be opened. 362. Having pointed out, in a cursory manner, the plan of treatment for the consequences of a sudden interruption of the menses, I shall now proceed to the consideration of such plans as will invite their return. In doing this, I must be considered as only speaking of the idiopathic suppressions, and the modes of treatment proper in them. I must here premise, that I do not look upon every deviation in regularity', as a legitimate cause for medical interference; for in many instances with young girls, and especially, those who began precociously to menstruate, there will be a want of precision in return, that must not be mistaken for disease. Did we subject the poor girl to medical treatment upon every aberration of this kind, we should be condemning her to most improper discipline. So also, it many times happens with hale robust young women, that a temporary suspension takes place from cold, or passions or emotions of the mind,* which after a certain duration, re- • A lady informed me, that while menstruating, she fell down stairs ; and from that moment, the discharge was suspended; nor did it re-appear, until the next period. SUPPRESSION OF THE MENSESi 145 turn without medical application, or even the slightest premo- nition. My rule is, never to interfere, unless there be some evidence that the health is suffering by the absence of this discharge. 363. The general health rarely suffers, until three succes- sive periods have passed over, unless this obstruction be ac- companied by fluor albus. When this attends, the health may be earlier affected; and when this happens, it should be imme- diately attended to. The remedies will vary, according to the state of the system ; and I cannot too earnestly recommend at- tention to it; as success in the treatment of these complaints almost exclusively depends upon this discrimination. Perhaps there is not in the whole range of medical practice, such a de- parture from principles, as in the treatment of certain female complaints—they seem to be prescribed for with determined epiricism, as if the laws which govern diseases in general, were not applicable to them. The want of success in many of the complaints of females, is owing almost altogether to the deter- mination to discover specifics for them; for the existing condi- tion of the system is too seldom taken into the calculation, when the prescription is made; hence, the almost uniform failure of certain remedies in the hands of some practitioners, which are as uniformly successful, in the hands of others. A practitioner acquires by long habit and correct observation, a control over certain diseases, that will not yield even to the same remedies, when indiscriminately used by others—this tact in the use of certain medicines, is but the result of accurate observations on the various conditions of the circulating system; and when this study is neglected, it is a moot point whether the remedy succeed or not. 364. In prescribing then for the disease, or rather, derange- ment under consideration, it were almost hopeless to employ remedies without the most strict attention to the existing state of the system; the remedy which shall relieve in one case may not only be used unavailingly, but perhaps injuriously, in an- other; it therefore behooves every one to become familiar with the various states of pulse, before he prescribe his remedies, if he expect to succeed by their employment. [191 146 SUPPRESSION OF THE MENSRS. 365. The word debility has occasioned the death of thou- sands ; and perhaps to the end of time, it will have its victims —every interruption of a natural action, which may involve the system at large, with nine-tenths of the writers upon dis- eases, originates in debility; hence, the whole class of diseases we are considering, is supposed to either originate in, or be perpetuated by, weakness: thus fluor albus, and the deranged conditions of the menses, are considered as diseases of rveak- ness ; than which, for the most part, nothing can be farther from the truth. The most opposite remedies will in their turn re- move the same diseases; and the person who cannot under- stand the reason of this simple fact, will never be able suc- cessfully to combat them. 366. Having stated some general notions on the manage- ment of the complaints under consideration, I shall now pro- ceed to detail the practice essential in each particular state of the system. When the suppression is of recent date, that is, not more than of three or four months' standing, it is almost always found, that the pulse, so far from betraying marks of debility^ manifests a tendency to an excess of action; when this is the case, we should commence the treatment with such remedies and regimen, as will reduce the pulse to a proper standard, be- fore we proceed to the exhibition of such medicines as shall have a direct tendency to produce the menstruous discharge— this is to be done, by blood-letting, by purging, and by a strict vegetable diet—this plan is so effective in some cases, as to require nothing more, for the re-establishment of health; and in others so indispensable, that success can only result from its employment as a preparative step. I will illustrate both of these cases by appropriate cases. V Case First. / 367. Miss----, after having stood a long time on a damp brick-paved cellar on a hot day, and at the warm employment of " preserving," found herself chilly, and her menses arrested: her feet were ordered to be put into warm water, and some hot pennyroyal tea was given her; this removed the chilliness \ but did not restore the discharge ; she was occasionally taking SUPPRESSION OF THE MENSES. 147 remedies without effect, until some time after the third month; at this time she became more indisposed, and I was requested to visit her—I found her labouring under severe headach, which was much increased by sitting up, or motion; her pulse full, and a little quickened ; her tongue slightly furred ; her ap- petite impaired, and her bowels costive. I directed her to lose twelve Ounces of blood; to be freely purged by senna ; and to confine herself to rennet-whey, barley water, or thin tapioca for nourishment. 368. Her symptoms were much less severe next day, but not entirely removed—I ordered another dose of senna tea to be taken, and the same diet to be observed: on my next visit she appeared perfectly relieved, but I insisted on her using a spare diet for some time longer, and to take an aloetic pill every night; this plan was pursued for several days, at the end of which time her menses made their appearance. Case Second. 369. Miss----, after a stoppage of her menses for four months, desired my advice; her health of late began to suffer considerably—she was pale and emaciated; had some fluor albus; headach ; loss of appetite ; and was readily agitated by slight causes ; much palpitation of the heart; especially, on going up stairs. Her pulse was tense and hurried; skin hot; and tongue furred considerably; especially, in the morning. I ordered her to lose ten ounces of blood ; to be purged by sen- na, and to be confined to a vegetable diet—she was relieved by these remedies ; but as the force of her pulse was not en- tirely subdued, I thought it best to keep the bowels loose, and confine her still to a vegetable diet. This plan, strictly persist- ed in for about ten days, reduced her pulse sufficiently to bear the tincture of cantharides, in doses, of five-and-thirty drops three times a day; in a few days the fluor albus stopped; and in a few more, the menses made their appearance. Upon these two cases, I shall merely remark, that had I given any emme- nagogue medicine in the commencement, I should not have had 148 SUPPRESSION OF THE MENSES. the pleasure of seeing my patients so quickly restored—or, in other words; had these cases been treated as cases of debility, I am certain the complaints would have been aggravated; yet, in the last, there were strong marks of debility, agreeably to the common notions upon this subj-ect* 370. The madder may be given more safely than any other remedy with which I am acquainted, without such particular attention to the pulse, as it excites no increased action in it. I am in the habit of using this drug without previous prepara- tion, should I be applied to, near the period at which the menses ought to appear; and succeed sometimes most promptly with it—indeed this is the only time at which it seems useful; for if it fail then, it is rarely more fortunate afterwards. 371. When the madder fails, I commence, in recent cases, with the cantharides, after having duly prepared the system for its reception. I rarely increase the dose more than ten or fifteen drops beyond the original dose ; as the moderate doses of thirty-five or forty, have always been found suffi- cient with me, when the medicine would succeed at all. Should the cantharides fail, I then order the volatile tincture of guaiacum; which, when exhibited in proper cases, has never yet failed in my hands—I give it with a confidence I attach to no other medicine for this purpose. This confidence is the result of very many years' experience of its efficacy. I have often succeeded with it, where almost all the other emmena- gogues have failed; nay, I have done more ; I have found it to answer completely, after it was said to have had a fair trial —»-but this fair trial was very far from being so. As it is much more stimulating than the madder, or cantharides, I am always more attentive to have the system properly prepared for its reception. Therefore, the pulse should be more reduced, than for the medicines just named : this is easily effected, by the loss of a little more blood than in the other cases; purging more freely; and insisting on a low diet, for a few days. 372. When speaking of the tact that is acquired in the ad- ministration of certain medicines in certain diseases, I had particular reference to the employment of the tincture of guai* SUPPRESSION OF THE MENSES. 149 acum as an emmenagogue. I have, for nearly five-and-thirty years, almost daily used this medicine, in suppressed catame- nia ; and more especially, in those of long standing, without its having failed in any case proper for its use*—more cannot be said of any remedy whatever. 373. I say this in the most perfect good faith, as I have learned that some of my brother practitioners have not been equally successful with it—but I think I can readily account for their failure: 1st. From their not placing the system in a proper situation for its use; and, 2d, by not properly persever- ing in it. Neglecting these important points, it can readily be imagined, that it may not succeed; for I deem an attention to them essential to its success, more especially in those cases, where many months of interruption have existed. I think one of its superiorities consists in its certainty in cases of very long standing; and I could readily furnish from my note book, a number of instances, where it succeeded to restore the men- ses after an interruption of from nine months, to nearly three years. 374. The mode of using it is, a tea spoonful every morning, noon, and evening, in a wine-glassful of sweetened milk, or, where not forbidden by some peculiarity or circumstance, as much white wine, as sherry, Teneriffe, or Madeira. The dose must be gradually increased in those cases, where a persever- ance beyond four or five weeks becomes necessary. Should this medicine di jjturb the bowels too much; a few drops of laudanum must be added to each dose; but if on the contrary they should not be sufficiently opened, the addition of a little of the resin of jalap, or of powdered rhubarb, will be an im- provement. 375. As the tincture I employ, is different from the tincture of the shops, I think it right to subjoin my formula. - • By a proper case, I mean, where the suppression is an idiopathic disease, and not one, where the uterus has its functions interrupted by disease, or preg- nancy—for, in the latter, I have in two or three instances been imposed upon, notwithstanding all my caution ; and where I dared not suppose this condition to exist. But by these few cases, 1 learned, so far as they could go, that it would not produce abortion. 150 SUPPRESSION OF THE MENSES. R. Pulv. G. Guaiac. opt. %\v. Carbon, sod. vel potas. 5iss- Pulv. Piment. - ^i. Alcohol, dilut. - - ifei. digt.—for a few days. The volatile spirit of sal ammoniac, to be added pro re nata, in the proportion of a drachm, or two, to every four ounces of tincture; or less, or more, agreeably to the state of the system.* 376. Analogous to suppression may be considered the very sparing quantity of the menstrual discharge—this may happen, 1st, to young women in the prime of life ; and, 2d, to women pretty far advanced towards the period at which the menses are about to cease. With the first, when the usual quantity fails to be discharged, it always excites alarm, and recourse is almost instantly had to the nostrums of old women, or regu- lar application is made to the physician—I have seen many of those cases; and they may be classed under two heads:— 1st. Where this takes place from some accidental irregularity in the secreting powers of the uterus; and 2d. Where there is too early a tendency to cessation. The first may be again di- vided into two s ates: 1st. When, after it has continued some time, the health seems to be impaired pretty much after the same manner, as if a decided suppression were present; for it has very much the same accompanying symptoms; and, when this happens, this complaint, for the most part, seems to be relieved by the same remedies, as for obstruction; especially, by the tincture of cantharides. In the second state, it seems to be an habitual condition of the uterus, in a number of in- stances which have fallen under my notice; and, though the quantity discharged is sometimes extremely small, yet all the natural, or prolific powers of the genital system seem to be preserved; for I have in several cases known pregnancy to fol- • It has recently been proposed to relieve amenorrhoea, by the injection of liquid ammonia into the vagina. Dr. Hosack (New-York Med. & Phys. Journ.) declares, he treated a case successfully, of ten years' standing, by means of this remedy, after many others had been unavailingly employed. He directed a drachm of the ammonia, and a pint of rain water, to be thrown up the vagina, three times a day. The cure was effected in five weeks. SUPPRESSION OF THE MENSES. 151 low. I have prescribed for these cases all the known usual re- medies, without effecting any change in the quantity discharg- ed ; yet after marriage, these women became mothers. I have, therefore, of late years, not interfered in cases, where there was no evidence of ill health accompanying them. But it must be confessed, though no ill health may have attended, they are not fruitful; but in these cases, so far as I have yet seen, it has been an anticipation of final cessation—I have met with three instances, where this evacuation has ceased altogether, before the twenty-fifth year ; and two before the thirtieth year —the health of these women appeared to be as perfect, as if they had this discharge, in the most regular manner. 377. When this scanty menstruation takes place in women in the decline of life, so far as I have observed, it is not so regular in its periods as in young women; yet, as it never has, so far as I know, been productive of any unpleasant conse- quence, therefore, I have never thought it proper to interfere; especially, in women, after their five-and-thirtieth year. This condition of the menses, is more apt to take place in unmarried women, and in widows, than in married women. 378. In some instances of young married women, I have had strong reason to believe, it was owing to some deranged condition of the ovaria; for they were not only barren, but had never discovered any desire for sexual intercourse; or at least, were perfectly indifferent to it. 379. It would seem to follow from these observations, that the cases of deficient menstruation in which the health appears to suffer in a greater or less degree, are those of the most easy management; but in the treatment of them, the same regard must be paid to the condition of the vascular system, as if an absolute obstruction existed—I shall relate a case, by way of illustrating the material points in question. Mrs.----, aged twenty, during a period of her catamenial flow, suddenly heard of the death of her absent husband—the menses were immediately suspended, and continued so, for five months; during this time she suffered much from a train of most un- toward nervous symptoms; at the end of five months there was a slight show, which was repeated at the end of another 152 SUPPRESSION OF THE MENSES. month, and so on, for two or three periods more—but her health did not improve by this slight discharge, as was fondly hoped; and I was now consulted. I found her, as stated above with a variety of nervous symptoms, which were easily exa- cerbated by the slightest mental distress; together, with con- siderable leucorrhoea—much headach, and hot skin towards evening, and costive bowels—she lost ten ounces of blood; was purged by aloes and rhubarb; kept upon a milk and vege- table diet, and took the tincture of cantharides; the next month she had an ample discharge. Sect. III.—3. Of the immoderate Flow of the Menses. 380. This complaint is vastly more rare, than we should be led to imagine, did we regard popular opinion; or even the writers of practical systems of either medicine, or midwifery. I have seen, comparatively, very few cases of superabundant menses—for in the consideration of this subject, I shall confine myself to what should strictly be called an inordinate men- strual secretion. This complaint has been constantly con- founded with uterine haemorrhage; because, it always com- menced with a genuine menstrual evacuation, which continued two or three days, and was then followed by a discharge of pure common blood; all of which, by careless observers, has been classed under an " immoderate flow of the menses." Should this confusion be admitted into descriptions of this complaint, we need not be much surprised at the avowed fre- quency of it. 381. There must necessarily be an almost endless variety in uterine constitution, if I may so term it; consequently, there will be a corresponding variety in the performance of its du- ties—hence, one woman will lose twice or three times as much of the menstruous fluid as another, without suffering from this appearance of excess. As respects this discharge, excess must be regarded as a relative term; and we should only be direct- ed to consider it so, by comparing, or rather observing the effects it has upon the general health of the individual so cir- cumstanced ; should it not appear to produce debility, we have IMMODERATE FLOW OF THE MENSES. 153 no right to call this discharge immoderate, or excessive—for it is only so, as compared with those who may evacuate less, and yet be in no better health. It must therefore be repeated, that this discharge, in an excessive degree, is of very rare occurrence ; and that so long as it does not impair the consti- tution, it should not be meddled with; especially, if it be not inimical to impregnation. 382. I am well acquainted with a lady, now forty years of age, who has more than once assured me, that f.om her earliest recollection after this discharge commenced, (which was at her twelfth year) she never enjoyed a longer exemption from it than ten days, unless she were pregnant, or suckling; yet, dur- ing the whole of that time, she had never suffered the slightest indisposition that could be attributed to this apparent excess; she was, therefore, two-thirds of her time, with the exceptions just mentioned, giving issue to this discharge—she also de- clared her belief, that from what she could learn from others, she evacuated daily, as much as women in general—conse- quently she must have parted with at least three times as much as is usually lost during a common period. 383. Should this complaint prove excessive, in my accepta- tion of the term, (381) it should be treated, perhaps, as an hae- morrhage, properly so called—I say perhaps; because, I have met with but one case, where, from the quantity of the dis- charge, debility, and other evils were induced; and this was treated after this manner. Miss----, aged seventeen, was seized with a severe tertian, which, before it could be arrested, required much depletion, and left her for some time in a state of great weakness. After she was considered to be recovered, her menstrual discharges became very abundant, and recurred as they were always wont to do, every three weeks. The quantity discharged was very great, as far as could be determined by the pulse, and the appearances upon the cloths. She became very feeble, much emaciated, and confined to her bed, before I visited her; and this was while the menstrual period was upon her. Her pulse was frequent and weak; her feet and hands cold; she was ejp- [20] 154 IMMODERATE H.OW OF THE MENSES. tremely pale, and distressed by palpitation of the heart; ring- ing in the ears, and great sickness of stomach. 384. Bottles of warm water were ordered to her feet; thirty drops of laudanum, with as much of Hoffman's anodyne liquor; and two grains of the sugar of lead, with a third of a grain of opium, every hour, until the discharge should be mode- rated. The character of the discharge I was particular to ascertain ; and, from the most cautious examination upon this point, I had no hesitation to believe, (contrary to my first impression,) that it was a genuine menstrual flux, but of unusual severity. By the plan just mentioned, the discharge appeared to be much moderated in the course of a few hours; but early the next morning, I was sent for in great haste, as the flow had increased very much. I now ordered twenty grains of the sugar of lead; a tea spoonful of laudanum; and a gill of lukewarm water, as an injection—this quickly arrested the discharge; and she had no return of it from that time, >if we except a very moderate stillicidium of three or four days continuance. In the interval, a nourishing diet was directed—- quiet, and a mattress to sleep upon; also twenty drops of the elixir of vitriol, in strong, sweetened rose-leaf tea, four times a day, and the bowels kept open by small, but repeated doses of the sulphate of magnesia. On the arrival of the next period she was again attacked with a flow as abundant as on the former occasion; the same remedies were again successfully employ- ed. During the succeeding interval, two grains of the sacch. sat. every morning, noon, and evening, were ordered in lieu of the vitriol; she was directed to drink freely of cold camomile, and orange-peel tea; a plaster of Burgundy pitch to be applied to the back; and the legs and feet to be kept very warmly clothed. 385. At the subsequent period, the discharge was consider* ably more moderate, but still too abundant; the sugar of lead pills, were now given every two hours, until the flow should cease. The interval was conducted as before; and, after this time, there was no further necessity of medicine. Exercise, and sea bathing, very soon confirmed her health ; nor did she afterwards suffer any return. IMMODERATE FLOW OF THE MENSES. 155 386. The plan, as just detailed, proved successful in the in- stance just mentioned; but whether it would be so in other cases, my limited experience in " excessive menstruation," will not permit me to declare—though I am disposed to think it might; and under similar circumstances I should certainly adopt it. 387. Menorrhagia, or haemorrhage properly so called, suc- ceeding, or happening at the menstrual period, is much more common ; and has been, as just noticed, but too often con- founded with it. This complaint is readily distinguished from the one now treated of, as it is always accompanied by dis- charges of coagula; and is almost always attended with pain in the region of the uterus. This sometimes goes to a great length; and is occasionally very menacing. It is more common with married women and widows, than with young girls. Its treatment is precisely the same as that of uterine haemorrhage; and which will be minutely detailed, when that subject is treat- ed of. Mr. Burns, when speaking of haemorrhage of the uterus, makes mention of the sugar of lead as a remedy; but declares it to be a dangerous one. Upon what ground this is said, I am at a loss to determine. I have used this substance most freely for more than twenty years, without observing the slight- est inconvenience from it. Sect. IV.—4. Dysmenorrhea, or Painful Menstruation. 388. This complaint is very common in our climate; and is one not only of great suffering, but also very frequently of great obstinacy. The woman is obnoxious to this complaint, during every part of the menstruating period. It would per- haps be very difficult to assign all its remote causes: the most common are, the application of cold during the flow of the menses; taking cold after abortion; and in several instances, I have known it to follow the consummation of marriage. This latter cause is perhaps the most difficult of explanation— for it would seem, it should have no such agency, reasoning a priori. In a number of instances, the causes appeared to be .• 156 DYSMENORRHEA, OR so hidden, as not to be cognizable. The married, and the sin- gle, woman, is alike subject to it. 389. The sufferings at the menstrual period are sometimes beyond description severe : they resemble, in point of inten- sity, the pains of labour, or an abortion properly so called; for to either, it may be said to have a strong analogy. It usually commences by a slight menstruous discharge, which is pretty suddenlv arrested; and then pain almost instantly commences; which is described by women as a forcing, bearing down pain, returning at longer or shorter intervals, until a membranous substance, or small coagula, are discharged. If it be a mem- brane-like substance, it will be found of unequal size; some- times small, at other times large, and resembling the cavity of the uterus in shape; at other times, it will be broken into many fragments. After the expulsion of this substance, the woman enjoys ease, unless there be a fresh production of it; and it require fresh contractile exertions of the uterus for its expulsion. 390. The quantity discharged is very various; I have seen a portion not much larger than my nail; and again, I have wit- nessed as much as would fill a small tumbler. The period employed for the expulsion of this substance, is various; some- times, requiring but a few hours; at other times, several days. The degree of suffering is not always in proportion to the quantity of substance expelled; indeed, the pain would rather appear to be less when much is discharged; which perhaps is not of difficult explanation. 391. There appear to be two distinct states of this affection: one, where the mammae sympathize with the uterus, by becom- ing tumid, and oftentimes extremely painful; the other is, where there is no such affection. These two conditions are not equally manageable; the one accompanied with painful breasts, so far as my observations have yet gone, is the most so of the two. 392. Besides the alternate or labour-like pains, I have just mentioned, there is almost always a permanent one in the back, hips, and loins, which continues until the alternate cease: in- •. PAINFUL MENSTRUATION. 157 deed, this aching pain sometimes precedes the others, and announces the discharge to be at hand. 393. I have in another place declared, that the menstruous fluid is the product of a secretory process; (102) and there given my reasons for this opinion; I shall, therefore, assume it here as a principle, and upon that principle attempt to ac- count for the formation of the membranous production so often yielded in dysmenorrhea. But before I attempt an explana- tion of the formation of this membrane, I must direct attention to a very remarkable circumstance in the character of the men- strual blood ;—namely, its not possessing the property of coa- gulation—drom this, it appears that the blood, or a part of it, has suffered some change by the action of the uterine vessels; and that this change, has been imposed upon the coagulating lymph by the process of secretion; I have assigned reasons for this change, when speaking of menstruation. (103) Now, it is rot difficult to suppose that the uterus, like every other organ, may have its functions impaired; and that, instead of the texture of the coagulating lymph being subdued as it is wont to be, when the uterine secretory action is perfect, it remains nearly the same, as when it entered this viscus ; except, that it may be at- tenuated, as in some inflammatory diseases; it will, from this imperfect elaboration, be thrown into the cavity of the uterus, without being dispossessed of the power of separation, and of coagulation. 394. It is poured into the uterus, in a most gradual manners and, from this circumstance, may tarry there, sufficiently- long to separate into its constituent parts; the coloured part, or red globules, from their greater weight, will leave the imperfectly subdued coagulating lymph, and fall to the bottom of the ute- rus, and sooner or later be discharged; while the coagulating lymph, either in part or altogether, will be left to spread itself over the internal face of the uterus, and there quickly assume, as is usual with it when in contact with living parts, the ap- pearance of a membrane. This membrane will be, to all in- tents and purposes, an extraneous substance to the uterus; and will sooner or later urge it to repeated contractions to throw 158 DYSMKNORRH/EA, OR it off; which contractions will be painful, like those of labour— hence, the pain in this kind of menstruation. 395. The treatment of this complaint consists of the tem- porary, and the radical; the first consists in the administration of remedies to relieve pain at the commencement of, and dur- ing the attack; and the most efficient, and uniformly certain that I have yet discovered, is camphor in sufficient doses; the following is the formula I generally use: B. Gum. Camph. 9"i. Sp. vin. rect. q. s. f. pulv.—Add Pulv. G. arab. 3i. Sacch. alb. q. s. Aq. Cinnam. simp. ^i. M. One half of this draught is to be given the instant pain is ex- perienced ; and if it be not relieved in an hour or two, the other half is to be given—this quantity, however, is not always sufficient to subdue pain; in this case let the mixture be re- peated—or the same quantity of camphor may be finely pow- dered and given in ten-grain doses every hour, entangled in a little syrup of any kind, until relief is procured. Sometimes the stomach is much deranged in this complaint, and will bear nothing—when this happens, thirty or forty grains of camphor are to be rubbed down with a few drops of the spirit of wine, to a very fine powder; one drachm of laudanum; and three ounces of thin starch or flaxseed tea; and given as an injection. Should this be too suddenly discharged, it may be repeated. 396. Opium in various shapes has also been administered; either alone, or in combination with camphor, or ipecacuanha. The ergot has also been recommended; but it has hitherto failed in my hands—warm bath, pediluvium, and bleeding, have also been prescribed; but nothing has succeeded with me so well as camphor. 397. The radical treatment consists in the exhibition of re- medies in the interval, with a view to prevent a recurrence of pain—the one which has proved most successful is the vola- tile tincture of guaiacum, given as already directed, (374) for suppressed menses. The same regard to the state of the sys- PAINFUL MENSTRUATION. 159 tern as is there recommended, is also here insisted on. Perse- verance for two or three months, is oftentimes necessary. I think I have observed that this medicine is most decidedly useful, where the first menstrual period after its use, is more than usually severe. This, has been pretty uniformly found a favourable sign. 398. Though the tincture of guaiacum has been generally successful, it has not been uniformly so—in two instances where it failed, the ext. cicuta?, succeeded ; and in one other, where it had not been successful, the tincture of cantharides gave perfect relief. 399. I have never met with a case of fruitfulness, where there was a discharge of membrane in a married woman; though Morgagni relates a very remarkable one, in which it was otherwise—I have seen a few instances where there was painful menstruation without this membranous production, but where a few small coagula were discharged, and the women were fruitful—but such cases are rare. 400. Does this disease reside in the ovaria, or in the secret- ing surface of the uterus ? I believe in the latter; and that its being unfavourable to impregnation, is not owing to any in- fluence it may exert upon the ovaria, (for I have reason to be- lieve that ova have been impregnated, but not finding the ute- rus in a condition to receive them, have perished,) but to ei- ther the non, or the imperfect formation of the decidua. I believe the same surface furnishes both the menstrual secre- tion and the efflorescence called the decidua; it would seem then to follow, if it performed the first of these offices imper- fectly, it would also the latter; and consequently, the ovum would perish for want of a proper nidus. 401. This opinion is strengthened by the facts, that so soon as this wrong action is changed, the woman is instantly capable of being impregnated ; or in other words, fecundation becomes successful; and also, by the influence of camphor, a temporary change is induced, in the secerning vessels of the uterus, and the formation of membrane is prevented. Were it necessary, I could illustrate both of these positions, by very many cases; 160 DYSMENORRHEA, OR PAINFUL MENSTRUATION. but I shall confine myself to one of the former, as it is the most remarkable I have met with. 402. In 1791, I was applied to by a lady, who had always suffered at her menstrual periods ; and who at such times, al- ways discharged a number of membranous portions ; and who had been married nineteen years, without being impregnated. After due preparation, for she was very plethoric, I put her upon the use of the tincture of guaiacum ; in this she persever- ed, for three months—the first period after she commenced the use of this medicine, was one of prodigious severity; so much so, as to make her resolve to abandon it. I however persuaded her to persevere; the next period was better, and the one after was without pain—she conceived immediately after, and was delivered in due time of a fine girl. She took twenty-four ounces of the tincture. Sect. V.—5. Of the Decline of the Menses. 403. The nearer a woman approaches her forty-fifth year, fianeris paribus, will be the chance of some irregularity in the menses; and as this period is more frequently the one at which any latent disease of the uterus shows itself, it is always looked forward to with much anxiety by women. Indeed, so replete is this time with horrors to some, that we may very justly sus- pect apprehension to be the cause of some of the distressing symptoms, which sometimes accompany this interesting pro- cess of the human uterus. 404. The reason of this discharge leaving the woman at this time of life, appears to be founded in the highest wisdom and beneficence—it is to prevent child-bearing beyond that period, at which the mother would be capable of extending her care to her offspring, from the common chances of human life i and consequently, submitting her child to the doubtful manage- ment of strangers, or subjecting it to the waywardness, and caprice of those, who could not feel a parent's affection; or would not yield a mother's devotion to its necessities, at a time when its helplessness would most require kind offices. 405. This change is sometimes so silently effected, that the DECLINE OF THE MENSES. 161 woman scarcely notices her altered condition; at others, its approach is so gradual, as not to attract observation, until the diminished quantity gives warning that it is about to take its leave for ever; while again, the irregularity, both in period and quantity, may be such, as justly to give alarm, as well as to produce the most serious danger. 406. It would seem, that the apprehensions of this period of life, have arisen mainly from the notions entertained of the final cause of the menses; namely, that it gives vent to peccant humours. Whenever this discharge is less abundant than usual, the most serious fears are entertained, lest there be a retention of a portion, which will cause disease, either in the uterus itself, or in some other part of the body—hence, a diminished menstruous secretion is always more alarming to the female, than an unusual flow. 407. The vulgar error, that u women at this period of life are always in danger," is replete with mischief to the suffering aex: and it is but a duty to declare, that they are not necessa- rily more obnoxious to disease at this, than at any other period of their existence. That they are sometimes liable to disease at this time; and that disease, one of the most terrible in the long list of human infirmities, must be admitted ; but I must in- sist, that cancer (the disease to which I allude, and the one so much dreaded) is more rare in the uterus, than in certain other portions of the body; for instance, the mammas; and perhaps I am within the truth, when I say, that there are three instances of the latter, for one of the former. If latent dispositions to disease, in the uterus and other parts, become active about this period of life, it is not because the declining menses ex- cite them ; but because the disease is slow in developing itself, and is perhaps kept in check for a longtime, by the menstrual discharge serving as an important evacuation; especially, when the uterus may be the seat of the complaint. In such instance, the foundation of the disease was laid, perhaps, at a time when the menses were the most perfect, as regards period, and quan- tity; consequently, they could have had no agency in its pro- duction; but, on the contrary, from its frequently relieving the engorgement of the vessels, kept it in subjection for a long [21] 162 DECLINE OF THE MENSES. time; not as a specific discharge, but as mere depletion; or in other words, that if an equal quantity of blood could have been by any other means as certainly abstracted from the uterus, the same favourable result would have followed. Coincidences in the human system are so common, that they are frequently mistaken for cause and effect; hence, the cessation of the men- strual discharge, and the appearance of schirri, and cancers, are considered as cause, and effect. 408. However, our present concern is with the derangement of the discharge at or about the period of cessation; this will consist, 1st. in a diminution of the usual quantity; and 2d. in an excess of it. As regards the first, I have already said enough when treating of the suppression of the menses; and, with respect to the second, it must be treated according to the rules prescribed for the management of haemorrhage from the uterus from any other cause; that is, first, to diminish the quantity discharging; second, to prevent an excessive return. 409. The first indication is best fulfilled by rest; by cool air, and drinks; by cold local applications; by the acetate of lead, and laudanum; and by the use of the tampon.* We should immediately confine a patient so circumstanced to a horizontal position; and strictly forbid motion of every kind, even turning in bed. We should admit with freedom cool air where practicable; and give neither nourishment, nor drinks, except they be cooled—the latter may even be iced. Cold applications to the abdomen are frequently useful in ex- cessive discharges of this kind; the best mode of applying them, is by large, bladders not quite filled with water, in which there is ice, if it be in summer, or during hot weather; cold water alone will be sufficient, if in winter ; during the use of this, care should be taken that the feet, and legs are kept warm. We should also give two or three grains of the acetate of lead, guarded with a sufficient quantity of opium, or laudanum, by the mouth, every hour or two; or a scruple of it with a drachm of laudanum, and two or three ounces of water, as an injec- tion—this to be repeated pro re nata. And should these not control the discharge upon fair trial, recourse must be had to • See Chapter on Uterine Haemorrhage. DECLINE OF THE MENSES. 163 the sponge tampon. I have repeatedly seen the discharge of blood, at this period of life, so enormous and so rapid, as to threaten almost instant exhaustion. When thus excessive, it can only be met by the most prompt application, of the rnqst efficient remedies. 410. Whether this disease shows itself in the rapid expen- diture of fluid blood, or in the repeated expulsion of large co- agula, it must be opposed by the same remedies—these two conditions present no difference of indication, nor any essential difference in the complaint itself; the former, however, gene- rally requires more prompt interference than the latter, as more blood is expended in a given time. 411. The second indication must be fulfilled by blood-let- ting ; by purgatives; by hemlock; and by tonics. Notwith- standing the immense loss of blood, which sometimes takes place suddenly at each period of return of this haemorrhage, it does not prevent the almost continual draining off of this fluid, even when its violence is much abated; hence, we sometimes find a greater or less discharge almost always present—this renders the woman not only feeble, but keeps her mind in a state of extreme apprehension, from one period to another. These two causes, namely, the excessive discharge, and men- tal anxiety, keep the system in a constant state of excitement; and if the pulse be examined it will be found quick, and cord- ed. We are, therefore, under the frequent necessity of ab- stracting a few ounces of blood during the interval of each period; especially, towards that period, the disease has as- sumed for its movements—this, however, varies in different individuals; and in even the same individual, if any error has been committed, in either diet or exercise. But when all things are equal, we find the period pretty certainly marked; and it may be every three, or four weeks; or sometimes even longer. I have known two o*r three violent cases, where the discharge returned every two weeks. 412. To aid the vessels to contract, we should confine the patient to a strictly vegetable diet; or to a diet of milk, if this should agree with her—all kinds of liquor, and spices should be forbidden; and exercise absolutely prohibited. The patient * I 164 DIXLIM. OF THE MENSES. should sleep upon a mattress ; and should be directed to repose herself upon it, or a sofa, as often as she may feel a little weak- ened, or fatigued by sitting up. The feet and legs should, how^ ever, be kept warm; and, if habitually cold, should be rubbed two or three times a week with spi.it or brandy, in which a quantity of the flour of mustard is mixed. 413. The bowels should be kept freely open, by the regular exhibition of some mild purgative; such as rhubarb, sulphur, magnesia, or any of the neutral salts. Against the use of aloes there is much clamour; but I have some reason to believe, not with justice. I do not wish by any means to decide this point at this time ; as my experience in its use is as yet rather limit- ed. I have thought it proper to direct attention to it, that I may be aided by the experience of others, in determining the powers of this medicine—but I will relate what I know upon the subject, and leave it to the farther employment of this drug, to either confirm, or destroy my present favourable im- pressions. 414. A lady, aged forty-two years, for whom I had prescribed almost all the known remedies for the haemorrhage under con- sideration, with very little benefit, was told by some old wo- man, that the hiera picra was a certain cure in her complaint; she mentioned this, and I very candidly stated my own, as well as the general prejudices against the principal ingredient in this compound; but, at the same time, observed, that as the old woman who had recommended it, cited the cases of two or three ladies who were known to her, it would be easy to make the inquiry; and, if it were as she stated, it would be well to give it a trial, as every thing else had failed—the medicine was warmly recommended by these ladies ; and she proceeded to make use of the old woman's prescription: which was hall an ounce of the hiera picra to a pint of gin ; of this a wine glass- full was directed at bed-time—it was taken, and the lady was completely intoxicated all night, and very sick next morning. Thinking the effects would next night be less severe, she again ventured to take it, and with similar results. 415. She was now determined to abandon it, unless some DECLINE OF THE MENSES. ,165 less objectionable mode could be adopted forits exhibition— I prescribed it for her in the manner following: R. Hiera Picra, ?ij. 01. Caryoph. gut. x. Sapo Venet. gr. xij. * Syr. Rhaei. q. s. M. f. pil. xxxx. One of these was directed every morning, noon, and evening, unless they should prove too purgative—this did not happen, as the patient was of an extremely costive habit. She soon perceived, after she began the use of this medicine, a diminu- tion Of the discharge; and by the time she had finished the pills prescribed above, it was so much reduced in quantity, as to give no farther uneasiness. 416. Two cases of a similar kind, but of less severity, were entirely relieved after the use of the same formula—here ends my experience:—from this it would appear, that in the only three cases in which it was prescribed, the patients got well; but the precise agency of the medicine, remains to be deter- mined by future observation. I am, however, convinced, of the importance of gentle purging, in this oftentimes tedious complaint. 417. One of the most successful general remedies I have employed, is the extract of cicuta; beginning with a minimum dose, and increasing it gradually; but at the same time as rapidly, as the system will well bear. When the decided marks of its influence, such as vertigo, headach, or sickness of stomach, begin to show themselves, I do not increase the dose until they go off—when this happens, I again give an increased dose, and so on, until the complaint has so far yielded, as to render its farther exhibition unnecessary, or until I am con- vinced that it will not succeed in arresting it. I have thought this medicine most useful in those cases where the discharge was chiefly by coagula. 418. No class of medicine has done so much mischief in the complaint I am now treating of as tonics—and this from a wrong view of the disease in question ; for it has too generally been treated, as one of debility; consequently, all the most 166 DECLINE OF THE MENSES. powerful tonics, have been put in requisition for its cure. Bark, steel, wine, and all the bitters, have again and again, been un- availinglv tried; and oftentimes the patient abandoned to the ravages of this disease, because it could not be conquered by tonics—the opposite mode of treatment, with such views, would necessarily be considered as death to the patient. 419. I well recollect a case, where three pounds of bark had been taken in less than two months, with a proportionate quantity of the elixir vitriol, to the manifest increase of the disease, and of risk to the patient—she was afterwards entire- ly cured, by an extremely low diet, gentle purging with neu- tral salts, quiet, and repeated blood-lettings. I must therefore caution the young practitioner against the use of tonics in such cases, because they may be attended by absolute weakness in the muscular system. The state of the vascular system alone is to be attended to; and here a chorded pulse must not be mistaken for a weak one, because it happens to be a small one. 420. With respect to the preparations of iron, I have per- fectly convinced myself they can never be usefully employed during the active state of any haemorrhagy—in my hands they have never failed to do mischief; I have not used them there- fore for many years, in the cases of which I am now speaking. The use of wine, I am also certain, has done mischief—it is port wine alone, however, that has any reputation in such cases; and this has arisen from its possessing a slight astringent pro- perty—it must also be strictly forbidden. The bitters will fall under a slighter censure than the bark; because, they are ge- nerally much less powerful—the same objections, howeverj attach to them ; but in a minor degree. 421. Tonics are only admissible, where there is nothing but debility to contend with ; they may then be advantageously employed in properly regulated doses. The diet may then consist of more generous living; and when well ordered, and properly pursued, may be looked upon as the best possible tonic. 422. Hitherto I have been considering the severer forms of this complaint—I shall now say a few words upon the occa- sional irregularities of the menses, both as to period and quan« DECLINE OF THE MENSES. 167 tity. The periods of return may be anticipated, or protracted; and the quantity may be very small, or more or less excessive; or it may employ a great many days for its evacuation, with- out the aggregate quantity being very great. I have constantly- advised against any interference at this period of life, for mere irregularity, or irregularity with a diminished discharge; and for this plain reason; that, no other inconvenience is experi- enced ; and this is so trifling, as not to merit consideration. But if with this irregularity, the discharge be too abundant, I treat it as directed for haemorrhage; and try to prevent the recurrence by bleeding, a little before the expected return; a low diet; and purging with the neutral salts; these rarely fail to give relief. 423. When a great many days are employed in the discharge, or, as the women term it, being almost constantly unwell; and where the aggregate quantity may not greatly exceed the com- mon monthly amount, I have frequently succeeded by the tincture of rhatany in two-drachm doses, three or four times a day—and frequently bathing the parts with cold water; ab- staining from too much exercise ; and refraining from stimu- lating diet, and drinks. The alum whey, has often been useful in similar cases, and deserves trial; the sugar of lead, in small doses with opium, given daily for some time, has many times answered every end. 424. In every form of the disease under consideration, it may be remarked, I have thought, that very decided advan- tage has constantly resulted from injections of the solution of the acetate* of lead thrown up the vagina several times a day; except, during so profuse a flow of blood, as would render the use of the tampon necessary.! It may also be proper to remark, tliat the sponge or tampon, should not be suffered to remain within the vagina, longer than ten or twelve hours at a time. When taken away, it should be carefully washed in soap • The injections should be made of two drachms of the sugtir of lead, to about a pint a/id a lialf of water. f I lately succeeded in arresting a constant and long-continued flow, by injec- tions of warm alum water. A half-ounce of ulv.m to a pint of water, was used. 168 DECLINE OF THE MENSES. suds; and before it is again returned, it should be imbued thoroughlv with vinegar, or, if it can be procured, v> ith the pyroligneous acid; on this account there should always be tw account is defective as regards the treatment, as it does not inform us how, we are to overcome the constriction, after the hand has passed it; for if we do not find means to relax it, or very much abate its force, the breech cannot be made to pass. I will point out the mode I have pursued in such cases, by relating a case extracted from my " Essay on the Means of lessening Pain, &c." p. 137. 649. "1798, December 18th: I was called to Mrs. Z—-, ii labour with her third child; she had been in pain for forty-eight hours; waters discharged thirty-six; the uterus well dilated; pains severe, but no advancement of the child; during the pain, the child's head, which was well situated, would be forced down, but as soon as it ceased it would again be retracted; this had been the case many hours before I saw her. In order to ascertain the cause of this delay, I introduced my hand into the uterus, and presently found the cause of the child not ad- vancing; a circle of the uterus had closed between the shoulders of the child and its head, which prevented their passing. I bled her to fainting,* pains soon came on, and she was quickly de- livered." 650. This case terminated without the necessity of turning, but I have not been always so fortunate; some cases to which I have been witness, required this operation, and others the forceps. The value of this case consists chiefly in showing the very decided efficacy of blood-letting, and has been quoted for this purpose principally, as it is the remedy which should always be employed in such cases, and should be carried to the extent mentioned. It is the only remedy with which I am acquainted, that has any decided control over the contracted uterus; it is one almost certain of rendering turning practica- ble under such circumstances, if carried to the extent it should be—a small bleeding in such cases is of no kind of advantage; for, unless the practitioner means to carry the bleeding to its • System, Vol. II. p. Ill, par. 1117, 1118. PARTIAL CONTRACTIONS OF THE UTERUS. 259 proper limit, which is a disposition to, or the actual state of syncope, he had better not employ it. 651. Turning must not be thought of in the first of these species, as the head is without, or escaped through the os uteri; the forceps are, in that case, the only proper remedy; but be- fore they are employed, the same precaution of an extensive bleeding should be premised, or otherwise the most serious mischief may follow—either the uterus would suffer a lace- ration at the stricture, or it would be dragged with the child's body through the external parts. 652. The cases in which I have the oftenest experienced the good effects of blood-letting, were of the second kind of my di- vision; but I am, from what I have seen, as certain it would be equally proper, and equally successful in the first—in reasoning upon the subject, I should, a priori, think it would be, if possi- ble, more so in the first than in the second species ; as there are fewer fibres concerned in that portion of the uterus which forms the stricture; and besides, we have the most ample ex- perience of its good effects, in the rigid state of the os uteri, before it has become dilated. 653. When bleeding is determined on, the blood should be drawn from a large orifice, and the woman placed upon her feet, if practicable—much less blood will answer, if the bleed- ing be conducted in this way. Sect. VII.—7. Compound Pregnancy. 654. When a woman is pregnant with twins, or more chil- dren ; it will be found that the uterus does not, nor indeed cannot, act as favourably for their expulsion, as if there were but one. The reason is obvious even with twins; since, in such cases, the uterus cannot close upon the whole surface of a child at once; its powers are therefore exerted in such man- ner as that both the children shall receive a part of their influ- ence ; and both of course, will be pressed equally, or nearly so, towards the opening of the pelvis, but in which, both cannot engage at one and the same time. This will create difficulty in some cases, from the very commencement of labour, and 260 COMPOUND PREGNANCY. which cannot even eventually be overcome, by the natural agents of delivery; the delivery will therefore be protracted, as well as painful; and no alternative will be left for finishing the labour, but by artificial means ; hence, the frequency of a necessity to interfere—this case will sometimes require turn- ing", at other times, merely bringing down the legs, &c. 655. This embarrassment may sometimes be created, even in the best positions that twins can take * it will, therefore, be increased when they should offer untowardly to the opening of the pelvis; when one or both may be hydrocephalic, or have the abdomen loaded with water; when there shall be more than two children ; when two may be joined together, creating a monster, &c. No distinct rules can be laid down for the management of such cases ; interference almost always be- comes indispensable—but the precise mode of acting, must be left very much to the good sense, and discretion of the accou- cheur. 656. Independently of obstacles arising from the compound nature of the pregnancy, or the awkward situation of the chil- dren which compose it, this labour, like every other, maybe complicated by many of the accidents already enumerated, or to be enumerated, and thus require immediate delivery. But should this plan be considered as indispensable for the relief of the woman, it yet must not be carried into execution, before the uterus is in a proper condition, as has been constantly in- sisted, in every other case. See Chapter on Twins, &c. 657. Should the nature of the case be such as to render turning either improper or impracticable ; that is, if the head of the child cannot be moved up, in consequence of its being wedged by another child, or so low, that it would be danger- ous, after the long escape of the waters, to attempt turning, or after it has escaped from the neck of the uterus, we must then terminate the labour by the forceps. Sect. VIII.—8. Prolapsus of the Umbilical Cord, tfc. 658. It is a matter of some surprise, that the case now under consideration, should not occur more frequently than it does; BAD POSITION OF THE HEAD. 261 since, we do not perceive that any part of the economy of la- bour, or the natural order, or disposition of the fcetus and its cord within the uterus, appear calculated to prevent it; yet, comparatively^, a prolapsus of the cord is an event of rare oc- currence. With respect to its becoming a cause of preternatu- ral labour, it is only to be considered as such, when there is circulation in the cord; and when there is evidently a risk of its being interrupted, before delivery can take place by the natural agents, in time to save the child. When this occurs, turning maybe had recourse to—1st. When the uterus is suffi- ciently dilated or dilatable; 2d. When the head is still enclosed in the uterus; and 3d. When there is no deformity of pelvis to defeat the object. Should the forceps, however, be at hand when the head is low, and the cord in danger of compression, or actually compressed; we should without hesitation employ them. Sect. IX.—9. Too Short a Cord. 659. It is said that too short a cord, either natural or artifi- cial, will interrupt a natural labour, and oblige us to finish it by turning. I shall not positively deny such a condition of labour; but I must say, I have never seen an instance; and also, that I entertain strong doubts of its possibility^. See Chapter on Prolapsus f the Cord. Sect. X—10. Of the Bad Position of the Head, though the Vertex present. 660. It is not simply because the vertex presents, that this labour is in general esteemed the best—it can only be consider- ed strictly so, when the great diameter of the child's head, cor- responds with that of the pelvis, and while this part maintains a certain position in its course, as well as describes a given route, in that course^s-therefore, the third and sixth presenta- tions must be essentially bad; since with them the reverse of a good presentation obtains; that is, the great diameter of the head offers to the small diameter of the superior strait, in both cases; besides the sixth having the disadvantage of the fore- head coming under the arch of the pubes. « 262 -JJAD POSITION OF THE HKAD. 661. But if the head present in the best possible manner at the superior strait, it gives no absolute security, it shall con- tinue so; since, it may depart from the route, which is essen- tial to an easy labour. Therefore, the labours in which the vertex presents, may require interference from four different causes: a. From the vertex presenting to the small diameter of the superior strait, as happens in the third and sixth pre- sensation, b. From the chin departing from the breast toa early'; though at first a proper relation existed between the head and pelvis, c. From the presence of the face; owing, to the excessive departure of the chin from the breast, or the re- tiring of the vertex, toward the back. d. From some part, as the hand, or arm, accompanying the head; though the latter was at first well situated. a. Bad Ppsition of the Vertex. 662. In the third presentation of the head, the vertex offers to the pubes, and the anterior fontanelle to the sacrum. Should the pelvis be ample, or the head not too large, which virtually amounts to the same thing, the natural powers concerned in la- bour will be every way competent to its accomplishment; but should the reverse obtain, great difficulty may be experienced; or the labour be impracticable, without extraneous assistance. When the difficulty to delivery depends exclusively upon posi- tion, we have nothing to do, but to change it, to remedy the evil; and then commit its farther charge to nature. 663. When we are about to rectify the position of the ver- tex, the woman must be placed, as will be directed by and by; the hand introduced into the vagina; the head grasped by in- sinuating the thumb and fingers within the orifice of the ute- rus, in such manner, as the fingers shall lie on one side of the head, and the thumb on the other; then raise the head a little, and turn the vertex towards one of the acetabula—if the right hand be used, turn it towards the right acetabulum; if the left, to the left acetabulum; and then trust the rest to nature. But should any of the accidents I have enumerated complicate the labour, and render delivery immediately necessary, we must BAD POSITION OP THE HEAD. 263 turn, and deliver by the feet; provided the os uteri be in a proper condition. 664. If it be the sixth presentation, we must proceed as above directed; (663) and reduce the situation of the head, to either the fourth, or fifth ; and then commit it to the natural powers for furtherance. It must be remembered, that in the changed sixth, to the fourth or fifth, we must not attempt a farther reduction, as recommended for both these presenta- tions, when they originally offer ; as this attempt, if successful, would necessarily destroy the child, by the excessive twiot the neck must receive in the operation. Should any of the acci- dents mentioned above complicate the labour, we must turn, and deliver by the feet; as directed for the third presentation. (662) Or, if the waters have long been expended, or the ute- rus in a state of inertia, we should apply the forceps. See Chap, on Forceps. b. Chin departing too early from the Breast. 665. When treating on the mechanism of labours of the vertex, I remarked that the chin rested upon the breast of the child (606) until the vertex or forehead were about to emerge from under the arch of the pubes; and that this position of the chin was essential to a natural, or easy labour ; when the chin does not confine itself to the breast, until the proper time for leaving it, the great diameter of the child's head must offer to the small diameter of the lower strait, at the last period of la- bour ; and thus present almost insuperable difficulties to deli- very. 666. This case is known by the anterior fontanelle being found in the centre of the pelvis, in the beginning of labour; and, at the last period, by this part being at the bottom, or rather the lowest part of the child's head, and resting on the internal face of the perineum; by one of the parietal protube- rances offering under the arch of the pubes; and by the fore- head being placed on one side of the pelvis; but on which,side , will depend, whether a first or fifth; a second or fourth pre- sentation, was deranged. If either of the two first, the fore- head will be to the right side ; if the two latter, to the left. 264 BAD POSITION OF THE HEAD. 667. Various causes have been assigned for the production of this very untoward situation of the head: Levret supposed, it was owing to the shoulders being arrested at the superior strait, in consequence of the oblique situation of the child's body; while Baudelocque, contends it arises from the direction of the expulsive forces of the uterus, and the manner in which they act upon the child's head. 668. The indication in this situation of the head is, to re- store the chin to the breast; this may be effected at two dis- tinct periods of the labour; first, where the head has not de- scended entirely into the lower strait; the second, where it occupies the lower strait. As regards both convenience, and certainty, the first situation of the head is the preferable to operate upon ; and, where practicable, should be chosen. But, to act with success, it is necessary that the os uteri be well di- lated, and the pains sufficiently brisk. The mode of acting in this case is very simple; first, rectify the obliquity of the ute- rus, by placing the woman upon the side opposite to the devia- tion, if it be either the right or left lateral that prevails; upon the back, if the anterior; second, in the absence of pain push up the forehead, and maintain it in tfiat position by making a fulcrum of the points of two or three fingers; when a pain comes on, maintain the resistance, by supporting the forehead with the fingers, until the vertex is found to descend, and the forehead to rise in the pelvis; when this is done, the delivery of the head may be trusted to nature. I believe it is seldom necessary to introduce the whole hand, in this case; though perhaps absolutely necessary in the second. 669. Baudelocque recommends acting upon the forehead in the time of pain; I am aware, that it is rarely safe to differ from this best of authorities; yet I am equally convinced, it is occasionally proper to do so—and the case we are considering, is one in point—first; because, did we act in time of pain, we should be under the necessity of overcoming its force, be- fore we could raise the forehead; this, of course, would be a work of supererogation; second; by acting in the absence of pain, we, by a very little force, can carry the forehead as high as we wish, and can maintain it in the position we desire it to BAD POSITION OF THE HEAD. 265 take, by an exertion scarcely more than the weight of the child's head; third, the vertex will descend as a matter of course, if the forehead be prevented from doing so ; fourth, by- acting during pain we are obliged to carry the forehead in di- rect opposition to the action of the uterine forces, which, when the uterus firmlv embraces the head, are so entirely in the di- rection in which the forehead would descend, that we should only raise the forehead, without giving an opportunity for the vertex to fall into the pelvis. 670. In the second situation of the head, we are to be go- verned by the same principles; but they are more difficult to put in execution; in this case, it is essential to success, that we raise the forehead in the absence of pain; and particularly, if the head has escaped the orifice of the uterus; when this is the. case, it requires the introduction of the hand to raise the whole head; this should always be done first, that we may be certain of keeping the forehead sufficiently high, to permit the vertex to descend. After we have raised the head sufficiently, towards the superior strait, we must place the extremities of the fingers against the posterior edge of the frontal bone, and make them serve as a fulcrum, as in the first instance. In doing this, we should carefully avoid pressure upon the anteri- or fontanelle itself. When the position is rectified, we must withdraw the hand, and let nature perform the rest. 671. I have dwelt upon this case; because, it is one of great consequence, to both mother and child—if it be improperly managed, the latter too often falls a sacrifice ; and the former, must incur the risk which always attends embryulcia. For it is one in which the forceps cannot relieve; since, the head can- not be made to leave the pelvis in the direction it has descend- ed to the lower strait; as its large diameter will be parallel to the small diameter of this strait. Turning will be rarely possi- ble, were it resolved upon; since, in the second situation, the person who has charge of the case, and svho must be supposed ignorant of the principles which should govern it,* will permit * The person who has charge of this case is supposed to be ignorant of its mechanism ; because, he proposes another remedy for its relief than the reduc- [34] 266 BAD POSITION OF THE lil.Al), a great deal of time to pass, after the escape of the waters, under the hope, that every pain will deliver the head, because of its nearness to the opening of the pelvis; he will at this time most probably find the head free from the mouth of the uterus; in which case, turning must ever be forbidden; or the uterus will be so firmly contracted upon the body of the child, as to render this operation impracticable: embryulcia is then the only resource of such a practitioner. 672. I will endeavour to illustrate this subject, by the rela- tion of a case. Mrs.----was under the care of a young prac- titioner of midwifery, with her fifth child. Her labours were ordinarily rapid, and her health and constitution excellent. She was attacked early in the morning, in the usual manner of her labours; and her accoucheur gave her a promise of speed} relief; her pains were strong, and frequent; the uterus was well dilated; and the membranes burst soon after his arrival. Every expectation was entertained, that the patient would soon be delivered; the head of the child had descended to the infe- rior strait; the pains were strong, and frequent; but after a short period, the head was found not to advance. Still sup- posing that nothing could prevent the delivery of a head so near to the world, he constantly gave encouragement to his pa- tient, until her patience, and that of her friends, was exhaust- ed—they now proposed a consultation. To this he did not absolutely object; but begged they would wait another hour, before they should resolve ; assuring them, at the same time, that it was impossible it should last beyond that time—the hour passed away, without his hopes being realized; and the consultation was again urged; to which he reluctantly consent- ed, from a firm persuasion that it was unnecessary. I was now sent for (six o'clock P. M.); I happened at the time to be some miles in the country; and did not return until after eleven o'clock; and, by the time I saw the patient, seventeen hours had elapsed since the commencement of her labour; which, until this time, had rarely occupied two. tion of the forehead ; or negligently waits, in the hope that the powers of the uterus will effect the delivery. BAD POSITION OF THE HEAD, 267 G73. The gentleman in attendance gave the very candid statement related above ; with the additional declaration, that he was " at his wit's end." He declared he could not possibly conceive the reason of this very unusual delay, and begged I would examine the patient. This I did; and found the case to be, the too early departure of the chin, from the breast, as represented in the second situation of this presentation. I gave my opinion to the Doctor; and tried to explain the mode of remedying, this mal-position. He undertook the operation, under the persuasion he understood it; and I was anxious he should, as he was a particular friend of the family7, and was j ust getting into obstetrical business. He however pretty quick- ly abandoned the side of his patient; and earnestly requested, I would do what was necessary. I had the patient properly placed, and introduced my hand under the'head of the child, and raised it up to a sufficient height, and then sustained the forehead until a pain came on ; the two first pains did not bring down the vertex as I had hoped; owing, to the very firm con- traction of the uterus upon the body of the; child; I now direct- ed the head more towards the right sacro-iliac junction, and had the satisfaction, upon the accession of the third pain, to have the vertex descend properly—I withdrew my hand; and the head was delivered the next pain, to the great joy of the mother; the safety of the child; and the astonishment of the Doctor. 674. This case was an important lesson to this gentleman; he called upon me next day, and begged me to represent the presentation upon the machine; this I did most cheerfully7, to his great delight and satisfaction; he now thoroughly compre- hended its mechanism. It may however happen, that after the reduction of the head, and before it has passed through the ex- ternal parts, some sudden accident may7 complicate the labour, and oblige us to terminate the delivery immediately; in such case, the forceps must be used. It is also possible, that accident may7 complicate the labour before the head is reduced; should this be so, it would be best to turn ; provided the circumstances we deem essential to its success be present. 268 BAD POSITION OF THK HEAD. c. Cases in which the Face presents. 675. The face may present at the superior strait in four dif- ferent manners—the most common is, where the forehead offers to the left, and the chin to the right side of the pelvis; 2d, is the reverse of this; 3d, the forehead answers to the symphysis of the pubis, and the chin to the sacrum ; the fourth, is the re- verse. In face presentations the woman always finds a difficul- ty in delivering herself; and delivery can only7 take place, when the head is in this position, in a well formed pelvis. They may7 therefore be considered, without many exceptions, as es- sentially bad, or preternatural presentations. Some authors have considered them so exclusively such, as to recommend turning wherever the face offers.* I would not be considered as constantly recommending this practice ; yet I am persuaded, that should the third and fourth of these presentations occur, it would be the best practice; especially, where we could have the choice of the time, and condition. Turning is always at- tended with more or less risk to the child, however favourable the situation of the uterus may be for the operation, or how- ever dexterously7 it may be performed; I may say the same however, of face presentation; especially, in the two last; and, above all, should the pelvis be rather contracted and the head large; therefore in such cases there is only a choice of evils. 676. It will be perceived, by the reader who may be familiar with the divisions of this presentation by Baudelocque, that I have reversed his order—I feel there is a propriety in this; as I hold it to be a good rule, to place the most frequent of a par- ticular presentation, first, in the numerical arrangement—and I am persuaded, as far as I dare trust my own experience, that the first and second of my arrangement, are by far the most common—nay7,1 may go farther, and declare, I have hitherto * Dr. Davis is the latest author that advocates the indiscriminate turning, in face presentations. He directs, " When the face is discovered to present at the brim of the pelvis at an early period of a labour, whether before, or very soon after the escape of the liquor amnii, there can, in my opinion, be no doubt of the preferableness of turning, to all other modes of treatment." (Elcm. Oper. Mid. p. 245.) BAD POSITION OF THE HEAD. 269 not met with either the third, or fourth; (the first and second of Baudelocque,) and indeed I entertain some doubt whether they have ever occurred—Baudelocque does not appear to speak from his own observation on this subject; or he would not have proposed the employment of the vectis for the reduc- tion of the vertex—a mode of acting that can never succeed; for it cannot be made to reduce the vertex, even upon the ma- chine; as I have frequently demonstrated to my pupils. 677. The face may readily be distinguished from any other part, by the eyes, the nose, the mouth, and the chin; and its particular situation may be determined by this last feature, and the nose. The indication in these labours, if it is determined to interfere with them, is to bring down the vertex, and place the chin upon the breast. Baudelocque* says, this is effected by operating upon the vertex, rather than pushing up the chin— so far as my experience will justify differing with him, I should declare, that pushing up the whole head before we attempt to bring down the vertex, though the head may still be at the su- perior strait, is essential to success. And farther, that we should always press the ball of the thumb against the forehead, and urge it upwards, at the moment that we are endeavouring to make the vertex descend. 678. When these labours are terminated by the natural agents of delivery, they are always very tedious and painful; the child's face comes out much swoln and frequently livid; the eyes tumid, and the child itself is often born in a state of asphvxia. 679. The proper moment.for acting can rarely be seized, in the cases under consideration; either as regards the condition of the uterus, or the situation of the head; for before the mem- branes are ruptured, the case is not easily distinguished ; and after they are, the uterus is not always sufficiently7 relaxed to act with facility, or advantage; and by the time it does dilate, the waters may have been so long drained off, as to render the ^ attempt fruitless. 680. In the first and second presentations, we must have the concurrence of the following circumstances, before we ;it- • System, par. 1337. 270 BAD POSITION OF THE HEAD. tempt the reduction; first, the uterus must be sufficientlv open to permit the hand to pass, with little or no difficulty ; secoml, the head must not have entirely passed the superior strait; third, the waters must have been recently expended. If these advantages combine, after having the woman properly placed, a hand must be passed into the uterus; and the choice of the hand is a matter of the first consequence, to the success of the operation; 'the governing rule is simple, and easily remem- bered ; namely, the hand which is to the side, on which the vertex is-placed; that is, in the first, the right hand must be used; because, when before the patient, it offers to the left side of the pelvis; if the second be the presentation, the left hand must be employed, for the same reason. 681. In the first presentation of the face, we pass the right hand into the uterus in such a manner as shall put the back of the fingers to the posterior part of the pelvis, or before the left sacro-iliac symphysis, and place them on the side of the head, while the thumb is pressed against the opposite side; the head is then to be firmly grasped, and raised to the entrance of the superior strait. When the head is thus poised, the extremities of the fingers are to be carried over the vertex, while the thumb is moved to the centre of the upper part of the forehead; the fingers are then made to draw the vertex downward, while the thumG tends, by its pressure, to carry the face upward, thus executing a compound action upon the head. All this, it should be remembered, must be executed in the absence of pain; if we find, when pain comes on, that the vertex moves suffi- ciently downwards, and the face upwards, to give assurance it will now descend, we may withdraw the hand, and trust the rest to the action of the uterus. But if, on the contrary, upon the accession of the pain, we find the face still has a tendency downwards, we must be certain that the reduction is incom- plete ; and we must again and again attempt it, in the absence of pain, if it be necessary—for, under the circumstances I have stated, we are pretty certain of success under a well-directed management.* * Whenever the waters have been evacuated some time, the operation here described will be embarrassed, by the uterus narrowing itself at that portion of BAD POSITION OF THE HEAD. 271 682. In the second presentation, under the conditions I have stated for the first, we employ the left hand; and act in every respect, as directed for that presentation. 683. Should however the above stated conditions of the ute- rus be present at the proper time ; or should the head have de- scended through (or nearly through) the superior strait, we cannot hope to succeed by any attempt made with the hand to reduce the vertex; the choice of remedy will then lie between turning, and the employment of the vectis. We should prefer turning, when the waters have not been too long drained off; when the pains are not either very frequent or severe ; and while the head is still enveloped in the lower part of the uterus. 684. The vectis may be tried under the contrary condition of things, by passing it up the side of the pelvis, until it pass over the vertex—when it is placed, we must endeavour to raise up the face with the other hand, and prevent the vertex rising at the same time, by a counteracting force exerted by the vec- tis ; this should be performed in the absence of pain, and until the face is found to ascend, and the vertex descend. If these manoeuvres succeed in getting the vertex down, we may com- mit the rest to nature. It may, however, agreeably to my own experience, be practicable to turn, after the vectis has failed.* 685. In the third and fourth species of face presentations, I am persuaded, it would be losing important time to depend upon any other mode of operating, than turning; provided; 1st, the uterus be sufficiently dilated; 2d, the waters but re- cently drained off; and 3d, the head still easily moveable, at the superior strait. Should these important conditions be absent, it .would be perhaps best (but this is purely speculative) to itself, which corresponds to the neck of the child; and will thus prevent the reduction of the head. This obstacle must not be attempted to be overcome by force—it must be submitted to by letting the head advance with the face fore- most. * Dr. Davis proposes, for the reduction of the vertex in face presentations, a kind of vectis, armed with teeth. The objections to such an instrument, he has % proposed himself; namely, the wounds inflicted on the scalp of the child, &c.; and are every way sufficient to prohibit its use. The common vectis, as I have observed, when properly managed, in proper casts, will succeed, as I ha\t experienced 272 BAD POSITION OF THE HEAD. employ the hand in such manner, as will guide the forehead tu the side of the pelvis; or in other words, convert it into a first or second presentation of my division of the face, and then at- tempt the reduction of the vertex by the vectis, or deliver by the forceps. d. Presentations of the Head, accompanied with the Hand. 686. The head may present perfectly well as regards its own position, yet may be accompanied by the hand—the presence of the hand can sometimes be detected, before the membranes give way; and when it is found in this situation, it is almost sure to proceed with the head. If the case be under manage- ment at this moment, the presence of the hand can rarely create any embarrassment to the well-instructed accoucheur; he knows, that by proper management, it may be easily pre- vented from descending, so as to occasion any great inconve- nience. When the hand accompanies the head, it should be prevented from proceeding—this for the most part is readily managed, by placing the point of the forefinger between the fingers of the child, and preventing its farther descent, by sup- porting it during a pain; and at the same time, directing the hand towards the face. When this is properly conducted, the head gets under the hand, and makes it retire within the cavity of the uterus. 687. When this case is neglected, by permitting the hand to descend, it may create great inconveniences, especially, in a narrow pelvis : 1st, by obliging the head to turn away from the axis of the superior strait, and making the shoulder pre- sent itself in its stead; 2d, by accompanying the head in its descent, and preventing the latter from making its proper turns, that it may escape from the pelvis. 688. The first of these difficulties will be considered under the head of " shoulder presentations," which see; and the other will require the aid of the forceps—it occasionally hap- pens, that this situation of the hand and arm creates consider- able embarrassment, from the fixed situation it gives to the head, as well as the strong, and perhaps dangerous compres- sion which the arm suffers; also, from the absolute necessity BAD POSITION OF THE HEAD. 273 there is to depart from one of the cardinal rules for the appli- cation of the forceps, by placing them upon the vertex and forehead; as the following case will show. I was called upon by Dr. Brown to visit a patient, who was under the care of a midwife, and who had been long in labour, in consequence of the arm being included between the symphysis pubis, and the head; the labour had been stationary several hours, as the head could not descend, though she had at first frequent and severe pains, but which were becoming more and more feeble, not- withstanding every possible exertion of the poor woman her- self—the arm was very much swollen, the scalp pushed down, while the head was completely transverse, as regarded the pelvis—the head, in consequence of the long absence of the waters, could not be pushed up, therefore turning was imprac- ticable. After having the woman properly placed, I applied the foreceps so as to embrace the vertex and forehead—a moderate force was sufficient to bring the head through the superior strait; this gave so much freedom to the arm, as to induce me to withdraw the instruments, and re-apply them comme il faut; the head was soon disengaged; and the mother and child did well. 689. It must be recollected, that the head is not the only part, which the hand may accompany; it may present with the breech, the knees, or the feet; when this happens, it rarely creates any obstacle to delivery per se, though it may embar- rass, if improperly acted upon, either accidentally or designed- ly, by an ignorant practitioner. Whenever the hand is perceived at the superior strait, it should be treated as above directed, though the attempt to retain it within the uterus may some- times be unavailing, as it frequently denotes the presence of the shoulder at the upper strait. Sect. XI.—11. Exhaustion. 690. The capacity to support the toil of labour, will differ in those who may be subject to it, either from original stamina, or the severity of the process itself. Hence, the most robust woman, as well as the most delicate, may become exhausted [35] 274 KXHAUSTION. from the force or the long continuance of labour—the exhaus- tion now alluded to, is not the mere loss of strength in the muscular system, but a state of inertia of the uterus itself. Both these conditions may combine ; or they may exist sepa- rately, and independently; when combined, they are almost al> ways accompanied with syncope; of this, I have already treat- ed; when they exist separately, our conduct must be regulated by the system which suffers. Should there be a mere loss of muscular strength, and the uterus preserve its powers, it will offer no indication as regards delivery; but should the powers of the uterus be upon the wane, or entirely suspended, though the woman possess great muscular vigour, it should warn us not to confide too long in this general appearance of strength, lest the uterus itself may be subjected to casualties, indepen- dently of temporary loss of vigour. 691. This situation of the uterus may arise from very differ- ent causes, and require very different modes of treatment; first, over distention from an excess of the liquor amnii; when this is the case, we find the pains returning at rather uncertain inter- vals ; and confined to the uterine globe; very little of that bear- ing down sensation, which accompanies the healthy protrusive effort; the membranous bag with the waters not very tense during pain; and a general restlessness, and anxiety, when pain has abated. In this case the loss of power is only rela- tive ; and though it may have all the appearance of absolute weakness, and is frequently mistaken for it, yet it is not truly so ; as Stimulants but increase the mischief, by exciting the arterial system, and goading the uterine fibres to more fre- quent, yet more feeble efforts. The remedy in this case, is to remove the cause; namely, the liquor amnii, as the following case will show. 1796, May 16th: Mrs.----, in labour with her first child, and of good constitution; was taken with feeble, but pretty frequent pains in the night, which she bore without disturbing her family until the morning, at which time she sent for her midwife. As the pains were feeble, and transitory at the time of the arrival of the midwife, she told her her labour was yet too weak to bring her child; but she would call again in the EXHAUSTION. 275 course of an hour—she did so; and found things pretty much in statu quo; she again took her leave, and did not return until towards the evening; and then in consequence of a summons from the patient, who had become verv uneasy and restless; enjoying no interval of comfort, though the pains had become slower. She now examined the patient; who had at this time what is called a plentiful show, and a relaxed os uteri; but as the pains made very little impression upon the membranes, she concluded this could only arise from weakness ; she accord- ingly prescribed strong cinnamon tea, and a stimulating injec- tion. The injection afforded a temporary relief by discharging a large quantity of hardened faeces ; but the pains were still weak, though recurring frequently. The patient became fever- ish, with much headach and thirst; the midwife, and the friends of the patient became alarmed, and I was requested to visit her. 692. On my arrival, I received the above account—I waited a few minutes to observe the nature of the pains, as well as to ascertain other particulars. I examined the uterine globe dur- ing pain, by placing my hand upon it, and found it to harden but little; the uterus was enormously distended; so much so, as to have the fundus at the scrobiculus cordis; the pulse was quick and full; there was also considerable headach. I exa- mined the state of the uterus per vaginam, and found, as the midwife had declared, a relaxed os uteri; or at least a yielding one, and very little pressure^upon the membranes during pain. It immediately occurred to me, that this appearance of uterine exhaustion was but relative; and during the next pain, I rup- tured the membranes; this gave issue to a prodigious quantity of water; frictions were instituted upon the abdomen; in the course of half an hour, the pains began to increase; and in half an hour more, the patient was safely delivered, after a labour of eighteen hours, which might have been terminated, by pro- per management, in six. 693. This appearance of exhaustion in the uterus, may also arise, from an engorgement of this organ; it will, like the one just mentioned, similate weakness, or want of power, as if there was positive inertia present—this condition may7 be known, by its having come on kindly; but the uterine powers are found 276 EXHAUSTION. to diminish gradually; the os uteri disposed to dilate; but the presenting part, is not protruded during pain; and the pain felt over the whole abdomen. The woman feels a sense of suffocation, or sinking; the pulse is hard, full, or depressed; and the pains irregular, both in force, and frequency. This case is only to be relieved by blood-letting; the following case, selected from a number of the kind, will illustrate this situation. 1792, August 17th, Mrs.----, aged twenty-eight years, in labour with her first child: pains commenced regularly and pretty severely, and continued to be so for some time; they then became desultory in frequency, and less in force—the midwife, before I saw her, gave her some stimulating drinks, which increased her unpleasant feelings; as a sense of suffocation, heat and pain over the whole of the abdomen, sickness at sto- mach, &c. without augmenting the force or frequency of the pains. When I saw her, she was labouring under all the dis- tressing symptoms just mentioned; together with a depressed pulse ; frequent sighing; great uneasiness, and very apprehen* sive; the mouth of the uterus but little dilated, though quite unresisting, when an attempt was made to stretch it; its edges were thickened, but not tense ; during pam, very little impres- sion was made upon the child; and the mouth of the uterus rather contracted than opened. As much oppression about the praecordia attended, together with great heat in the abdo- men, she was ordered to lose blood. About twenty ounces were taken before the oppression and heat were much dimin- ished ; but as these were relieved, but not removed; and as the pulse acquired vigour by the operation, I was induced to con- tinue the bleeding, until these unpleasant symptoms should subside; this happened upon the loss of about ten or twelve ounces more of blood. The pains now increased so much, that in about twenty minutes, she was safely delivered. 694. There is another variety of this exhausted, or rather passive state of the uterus, which if not well understood, may mislead—it is, where labour commences with the usual precur- sors, such as the subsiding of the abdominal tumour; the secre- tion of mucus; forcing, or bearing down pains; and thus giving promise of a speedy delivery. After these favourable appear- EXHAUSTION. 277 ances have continued a longer or shorter time, the pains cease altogether, or nearly so, without evident cause; and the whole labour seems to be at an entire stand. The pulse, in this case, is very little disturbed ; but a train of nervous symptoms su- pervenes; such as palpitation of the heart; great oppression about the praecordia, with a sense of suffocation, if the patient attempt to lie down, and a disposition to syncope, if she rise up. The os uteri is well dilated ; and the membranes remain entire. 695. This case excites much alarm ; and is not unfrequrently treated by stimulating medicines, or liquors, by ignorant prac- titioners, to the injury of the patient. This condition of the uterus is peculiar; and requires the administration of such remedies as may have a specific action upon its fibres; such as the secale cornutum; and is one of the happiest cases, to illus- trate its powers, as the following case proves. 1824, March 14th, I was called in haste to Mrs.----, whom I found perfectly free from pain, on my arrival. I was how- ever informed that her pains had been frequent, and strong, previously to sending for me; indeed so much so, that they feared I should not arrive in time. She experienced pain, par- ticularly while lying on the bed; to relieve which, previously to my coming, she arose; and from that moment, she was easy. She complained of a most distressing pain at the lower part of the sternum, with a sense of suffocation, and palpitation of heart. I waited half an hour, for the return of uterine contrac- tion; but it did not take place. She was requested to lie down, in hope it would produce their renewal, as they had been severe while she was in a horizontal posture—she complied; upon examination, the os uteri was found well dilated, and the head occupying the lower strait; and the membranes entire. I waited another half hour; but pain not returning, a scruple of the ergot was given; in fifteen minutes the pains were briskly renewed, and she was soon after safely delivered of a healthy child. 696. Exhaustion, however, may be positive; and may be occasioned by severe, and long-continued exertion. In this ease, the uterus ceases to contract, or contracts so feebly, as 278 EXHAUSTION. not to advance the labour. When this is so, the general strength of the patient fails also—she becomes listless, and in- disposed to exertion; she almost always sleeps between the slight pains, if they exist, or if they do not, she continues in an uneasy and disturbed slumber, until she may be aroused by the anxiety of her friends, or by officiousness in offering her some- thing to " refresh her." The skin is almost always damp, or even sweating; the pulse frequent and small; the countenance pale and haggard; and the stomach oftentimes much disturbed. 697. The original cause of inertia of the uterus, is very frequently owing to the rigidity of the os uteri, or external parts retarding the labour, until the uterine powers are expend- ed, in the attempt to overcome it—when this happens, the relaxation so much desired takes place, from both general and particular weakness ; but the woman derives no advantage from the kindly opening of the os uteri, or long looked for yielding of the external parts ; for she is now deprived of that energy, so necessary, to profit by these changes. It is in vain to give stimulants, or waste important time in waiting for the restoration of uterine power—we should, however, try the ergot; and, should this not renew the uterine forces, we must turn, provided the uterus is sufficiently relaxed; the mem- branes entire, or the waters but recently expended: and the head of the child still enveloped in the uterus. If the head has left the uterus; or occupies the lower strait, and is not easily moveable in the pelvis, we must use the forceps. 698. I have been obliged, under the head of "Exhaustion," to give examples that were not in strict conformity with the subject in question; namely, where " a natural labour was complicated, and required manual assistance." But they are of an important character, and could not perhaps be classed under any better head. Hitherto, so far at least as I know, every7 species of inertia has been treated in the same manner; the distinction I have made, I think, deserves attention. HEMORRHAGED kt. 279 Sect. XII.—12. Haemorrhage from other Parts than the Uterus. 699. It sometimes happens, though rarely, that a bleeding of an exhausting kind, as from the stomach, bowels, or lungs, may oblige us to finish a labour artificially, that might have terminated naturally. When a bleeding accompanies labour, which if too long continued would exhaust the patient, we should inquire, first, what agency the labour has, in either its production, or its continuance; and second, how far immediate delivery would contribute to arrest it. If we are satisfied up- on these heads, and conclude, that the only chance for the wo- man, is delivery7, we should proceed to it, without further loss, of time. We should turn, when the uterus is dilated or dilat- able ; when the membranes are entire, or they have but lately given way—use forceps when the uterUs is strongly contract- ing on the body of the child, and the waters long expended ; or when the head is low in the pelvis. CHAPTER XVI. RULES FOR CONDUCTING A PRETERNATURAL LABOUR. 700. Under this head, I shall only consider the rules pro- per for conducting a preternatural labour, where the hand is sufficient alone to terminate it, or will enable the woman to deliver herself. As preternatural labours, strictly so called, have nothing in themselves which declare their nature, we can- not possibly rely upon any symptoms to point them out; we must therefore depend solely upon an examination per vagi- nam, to satisfy7 ourselves of their nature: but we cannot always determine with sufficient certainty the exact position of the child, until the membranes have given way; it is therefore in general necessary to wait until this takes place, before we can decide on the nature of the presentation, , 280 PRETERNATURAL LABOUR. .701. In the accidental preternatural labour, we must deter- mine upon the necessity of interfering, according to the extent or severity of the accident which may complicate it; and not by the good or bad position of the child. We therefore, in such cases, have to regulate our conduct almost exclusively, as regards delivery, by the condition of the os uteri—should it be unfavourable to operating from the smallness of its opening, or its rigidity, we must, for the time being, abandon the idea of entering it to turn, or to effect any other important change; since, it would require a force that would be wholly incompa- tible with the safety of the woman, or the preservation of the child. In the meantime, we temporise in the best manner the nature of the accident which has complicated the case will per- mit, by prescribing such remedies as may be most proper, or adopting such means as may best suit the exigency. But on the contrary, if the os uteri offers no difficulty, we have only to consider the best moment to act, when we have the choice in our power. This choice must be governed by general, as well as particular rules; before however entering upon either of these, it will be necessary to point out the proper position of the woman, that both may be the better understood. Position of the Woman for Turning. 702. When necessity obliges us to terminate a labour, either well, Or ill begun, the woman should be placed so as to give the least possible hinderance to the operations of the accoucheur —this is agreed upon by all; but there exists a diversity of opinion, what that position is. Some recommend the side; others the knees, and others the back. I coincide with the lat- ter ; as it has always appeared to me as the best we can adopt, for either convenience or advantage; I therefore constandy direct the woman to be placed upon it, so as to give the greatest possible freedom for action. This position should be made as comfortable as the nature of things will permit; I therefore order the bed to be made in the following manner:— 703. 1st. A mattress, if at hand, must be placed so as to reach over the edge of the bedstead, to protect the woman from POSITION OF THE WOMAN FOR TURNING. 281 being injured by its hardness; 2d. The mattress itself must be covered with a folded blanket, or sheet, that it may receive no injury7 from the discharges: 3d. Two chairs should be placed to support the feet of the patient, at a proper distance apart: 4th. The feet and knees are to be steadied by an attendant sit- ting on each chair; 5th. An old rug, blanket, piece of carpet. or oil-cloth, should be spread upon the floor, immediately be- low where the patient will be placed, to secure the floor from injury; 6th. A pot, or basin should be at hand, that it may be placed upon the floor, below the patient, after she is fixed upon the bed for delivery, to receive whatever may drain from her; 7th. The patient must be placed upon the mattress in a hori- zontal posture, with her lower extremities over the edge of the bed; so as to leave the perineum and cocc\7x free of the mar- gin of the bedstead; 8th. She should be covered, to be protect- ed against cold, as well as to comply with the rules of decency— so much regards the patient. On the part of the operator; 1st. All parade should be specially avoided, as well as formidable preparation; the idea should never be given that the operation in question, is one of difficulty or hazard; 2d. If within com- mand, he should put on, after he has taken off his coat, a loose bed-gown with large sleeves, which must be slipped up, when on the point of operating; this will prevent the exposure of bare arms, which are always unsightly both to patient, and by-standers; especially, after operating; 4th. A folded sheet should be at hand, that it may be thrown over the lap, if the operator sit; but I have ever found it more convenient to kneel upon a pillow; which position I would recommend; es- pecially if the bedstead be low; 5th. The hand should be lu- bricated with lard or fresh butter, as well as the vagina, and external parts of the woman, before an attempt be made to pass the hand; 6th. The time of pain should be chosen to in- troduce the hand; which should be made into a conical form, that it may enter, and dilate the vagina the more certainly, and easily; 7th. After the hand is in the vagina, the absence of pain should be chosen, to pass it into the uterus; 8th. The hand should be passed in the most gentle and gradual manner, that as little pain mav be given, as circumstances will permit, rs6n 282 POSITION OF THE WOMAN FOR TURNING. as well as not to provoke untimelv contractions of the uterus: 9th. If the hand becomes much cramped or fatigued, it must be witlxlrawn, that it may recover; 10th. The operator will be much aided, while searching for the feet, and in bringing them down, by the other hand fixing the uterus by a gentle, yet suf- ficiently7 firm pressure, from time to time, externally upon the fundus; thus giving advantages to the hand within, that could not be procured without it; 11th. A proper selection of the operating hand must be made, either not being equally proper in all cases; 12th. The hand should be passed immediately to that part of the uterus, where the feet are expected to be; and this must be determined by the presentation, or situation of the child. 704. When the operator has gained the feet, he should, 1st, grasp them firmly with the hand, but should always, in doing this, place a finger between them, to prevent injury, frpm com- pression ; 2d, when practicable, both feet should be acted upon at the*same time ; 3d, though sometimes practicable, nay easy occasionally7, to deliver by one foot, it should never be done but from downright necessity7; and this can occur but rarely; 4th, in bringing down the feet, they should be conducted in such manner as will make the toes constantly look towards the abdomen of the child; or, in other words, make them pass as it were over the face; this rule is most important, and should never be neglected, if we have any regard for the safety of either mother or child; if infringed, the mother may suffers laceration of the uterus, and the child certain death, by an in- jur}- done the spinal marrow; 5th, should it only be practica- ble to bring one foot to the entrance of the vagina, let it be se- cured by a fillet; while search is made for the other; 6th, no attempt should be made to turn the child during a pain, lest the uterus suffer laceration; 7th, but after the feet are without, every advantage should be taken of pain, if it exist, to facilitate the delivery7; 8th, the whole act of turning should be consi- dered as one of necessity, rather than of choice; therefore, where it is proper to attempt it, it is, I believe, always proper to finish, and not trust the farther delivery of the child to the powers of nature, as some have recommended; 9th, the opera- POSITION OF THE WOMAN FOR TURNING. 2&3 tion of turning should be performed slowly, and steadily; es- ' pecially, if it be attempted in the uncontracted uter*us, or im- mediately after the evacuation of the waters ;* 10th, difficulty is frequently experienced in bringing down the breech, when the feet are in the vagina, owing to the head sinking in part, into the superior strait; when this is the case, the head should be raised, while the feet are drawn downward; this is easily managed, by applying the thumb against the forehead of the child, and forcing it upward, while the fingers which are grasp- ing the feet are made to draw them downwards;! 11th, when but one foot can be seized at a time, care should be taken that it belong to the side which the hand has passed over; other- wise, a severe twist will be given to the body of the child, and most probably defeat the attempt to bring it down ; 12th, the feet should be brought through the external parts in such man- ner, as will place the toes towards the anus of the mother; and when the legs are delivered as far as the knees, they should be wrapped in a piece of dry cloth, and the thighs taketa hold of with the same, and gently drawn downwards, until the nates are entirely without; the hips should then be taken hold of, and the abdomen drawn through, until the umbilicus appears; 13th, when the umbilicus is exposed, a loop of the cord should be drawn without the vulva, that it may not be injured by be- ing too severely put upon the stretch; to do this in the best manner, a couple of fingers should be slid along the cord two or three inches, and the part of the cord above the fingers should be gently pulled by the upper finger, while the portion of cord next to the child should be prevented from being- stretched, by pressing it and retaining it, or rather pulling it towards the umbilicus by7 the thumb, and lower finger; while the upper finger draws down a portion of it, if it be sufficiently loose, by stretching itself along the upper part of the cord: * This ride should never be violated, as the too sudden emptying of the uterus may occasion several accidents, of a serious kind; as, inversion of this org-an, ot severe haemorrhage. f Baudelocque, par. 1302, declares this double action to be impossible, at one and the same time; but I know the contrary, from frequent experience ; and have very often demonstrated it to my pupiN upon the machine. 284 POSITION OF THE WOMAN FOR TURNING. 14th, if the cord does not descend, or cannot be made to do so by gentle means; and if there be reason to fear it will suffer, if farther stretched, it is thought best to cut the cord; Baude- locque says without applying a ligature, but I should think it best to .apply one; 15th, when the child is freed from the re- straint occasioned by the cord, or if none exist, and it is deli- vered beyond the umbilicus, it should be made to pass through the arch of the pubes with its spine looking towards, or press- ing against, either the right or left leg of the pubes, that the head may enter the superior strait obliquely ; this must be done by a little turn of the body, if it does not place itself in this situation as we continue our tractions downward. Little difficulty is experienced in delivering the child thus far; but its progress is interrupted by the axillae appearing at the vulva; 16th, when the axillae appear at the os externum, the one next to the sacrum, should be first delivered by passing a finger or two upon the point of the shoulder, and pressing it pretty firm- ly downward, and then tracing the arm to the elbow; this I endeavour to bend, by pressing on its internal surface exactly opposite the joint, and at the same time, urging it downwards, and forward, to the face of the child, where it will almost al- ways disengage itself, and fall into the cavity of the vagina; from whence, it is easily delivered by hooking it forward, with the point of the finger—if the child be large, or the pelvis small, it is best to raise up the body of the child towards the abdo- men of the mother, before we attempt the delivery of the first arm; if the pelvis be large, or the child small, this is not ne- cessary ; 17th, the second arm is now to be delivered; this is almost always more difficult than the first, and sometimes ex- tremely so, if the head and arm are both engaged, in the small diameter of the superior strait; or when the arm has passed behind the neck of the child; this difficulty however is over- come by a very simple process, which I do not remember to have seen recommended by any one for this purpose; but which has always, in my hands, been successful—this is, when the head and arm are thus situated, to turn the shoulder of that arm, to that side of the pelvis, to which the face of the child looks, and it will instantly become disengaged; it must POSITION OF THE WOMAN FOR TURNING. 285 then be brought down as directed for the other; 18th, if the head should be too high to deliver the shoulders as directed, it should be made to descend lower in the pelvis, by pulling at the body, provided this can be done safely to the child; if this cannot be done, let the arms be brought down first; 19th, should the head be so low as to press the arms strongly against the margin of the inferior strait, it must be pushed backwards and upwards, that the arms may have more freedom. When the arms are delivered, there remains the head to be disengaged ; for the liberation of which, we must attend to the following rules : 705. 1st. Before any attempt be made to extract the head, its situation should be determined by a careful examination; if it be at the superior strait, the face should be at one side, that the great diameter of the superior strait, and that of the head, may correspond ; if it be not in this position, let it be so placed, by pressing the side of the face with a couple of fingers —when thus adjusted, it will readily descend by a small force applied to the body; but this must be in the direction of the axis of the superior strait; 2d. If the head be at the inferior strait, the face should be in the hollow of the sacrum; if not thus situated, rectify the bad position by pressing against the cheek, and carrying the face to that place; or rather, so that the face shall lie upon the perineum; when thus, the great diameter of the head, and that of the lower strait, will corres- pond; 3d. The body of the child must now be carefully sup- ported, by passing the arm beneath its body, and allowing the legs to straddle the arm ; while the fore, and middle fingers, are passed one on each side of the neck, which will not only give support, but permit a firm hold when tractive force is re- quired, to deliver the head; 4th. When the head is in this situation, it is almost always without the uterus; we cannot ex- pect, therefore, any aid at this time from the contractions of this organ—the woman must now be solicited to employ her voluntary powers of bearing down, that too much force need not be employed, by acting on the body of the child; 5th. To co-operate with the exertions of the mother, we must draw the bodv of the child nearly upward, while we press with two or 286 POSITION OF THE WOMAN FOR TURNING. three fingers upon the occipital bone, so as to carry it down- ward, and disengage it from behind the pubes; this last direc- tion I consider as one of great importance—by attending to it, I have secured safety to the child, which would have been lost without it; 6th. Advantage is sometimes gained by depressing the chin, but never by acting.upon it—the object in depressing the chin is, to prevent its hitching in the folds of the vagina, and thus creating delay and difficulty. 706. It will be readily seen, that in deliveries of this kind, the child must run a constant risk, whenever there is the least delay to the delivery of the head: this danger arises from, 1st. The compression of the umbilical cord ; 2d. The compression of the head and chest; and 3d. From a severe extension of the neck, doing mischief to the spinal marrow. With a view to remove these latter dangers as much as possible, we should never attempt to deliver the body of the child rapidly or by- main force; the whole of this difficult, but highly important process, should be conducted coolly, and deliberately; making all our endeavours co-operate with those of the uterus—pains should always be waited for, though they may be far apart; as much of the mischief which constantly threatens the child, is removed by their forwarding it, instead of its being the effects of force applied to its body. Should there be no pains, we are then obliged to act without them; but we should endeavour to imitate them, by permitting intervals of rest, and soliciting the efforts of the woman. 707. In the hurry, and confusion consequent upon a delive- ry7 of this kind, a young practitioner is apt to forget the useful caution of not turning the body of the child, upon the head, beyond what the spinal marrow will bear; but this important direction must not be lost sight of, in attempts to deliver the head by acting upon the body—I once saw, in the hands of a midwife, two complete turns of the body at the expense of the neck; I need not mention the result of such ignorance. TT FIRST PRESENTATION. 287 CHAPTER XVII. THE MODE OF OPERATING IN EACH PARTIC1 LAR CASE OF HEAD PRESENTATWX. 708. Having in the preceding pages pretty7 fully detailed the general modes of conducting the operation of turning, I shall now consider it, and the other methods to be pursued, in each particular presentation of the head, when rendered pre- ternatural, by some accident complicating the labour; or where the presentation itself, renders interference propter and useful. Sect. I.—First Presentation. 709. I have already given the characters of the different pre- sentations of the vertex; therefore I shall not repeat them. I must premise, that it is very often essential to the success of the operation of turning, that a proper choice be made of the hand. I would wish to impress this truth upon the recollection of the inexperienced practitioner; and, as the rule is extremely simple, there is no excuse for its neglect. That hand should be employed, the palm of which will look towards the face of the child; therefore, in the presentation under consideration, it will be the left hand. 710. A necessity7 for turning existing, the woman is to be placed, as already directed for preternatural labours; (702, ike.) and the left hand, properly prepared, must be introduced into the vagina, with the thumb looking towards the symphysis pubis; the hand must be placed, so as to grasp the head with the fingers on one side, and the thumb upon the other—it is then to be raised in the axis of the superior strait, and placed in the left iliac fossa, where it must be retained by the wrist 'and fore-arm, while the fingers are made to travel over the left side of the child, which will be towards the posterior part of the uterus, until they get possession of the feet—these are to be brought, as already directed, as far as the middle of the 288 URST PRESENTATION. vagina; when thus far,it frequently happens, that their farther progress is arrested by the breech not descending; and the breech is prevented from descending, by the head having slip. ped from the iliac fossa, where it had been placed in the com- mencement of the operation. When this is found to be the case, the head must be removed by the compound action of the hand already described; (704, 10th) when this is clone, the breech will pass into the superior cavity of the pelvis, without farther difficulty; and when the feet appear without the vulva, such direction should be given to the breech, as will place the breast of the child towards the left sacro-iliac symphysis; or, in other words, obliquely as regards the superior strait; this is effected by acting for an instant only upon the foot that is im- mediately under the pubes, and finish the delivery as directed. Sect. II.—Second Presentation. 711. In thte presentation the right is the proper hand, for the reason already7 assigned; (709) it must be passed up until the head is placed into the right iliac fossa, as before directed for the first presentation; the right side of the child must be passed over; the feet brought down, and the labour finished as above. Sect. III.— Third Presentation. 712. I have already remarked, that this presentation maybe bad in itself, and render a labour either difficult, or preterna- tural, where measurement of the pelvis is rather below the healthy standard; or the head excessively7 large; but that it might offer no more difficulty than the first, or second, where there obtained a proper relation between the head and pelvis. 713. Either hand is eligible in this presentation, as will be readily perceived, by recalling to mind the rule upon this sub- ject—should the circumstances accompanying the labour (be they original, or accidental) oblige us to have recourse to turn- ing, Ave may employ that hand, of which we have the greatest command. Should nothing but the position of the head, with a slight diminution of capacity in the antero-posterior dhr>' - THIRD PRESENTATION. 289 ter affect the labour, we may sometimes enable the woman to deliver herself, by two or three fingers applied to the side of the head, so as to carry the vertex towards one of tht acetabula —to the right, if we use the right hand, and to the left, if we use the left—when thus placed, we may commit the termination of the labour to the natural efforts, provided, no other circum- stance complicate the labour. 714. Should this mal-position of the head not be discovered in time; and the uterus be contracted firmly on the body of the child, the fingers, (as directed above,) will not be sufficient for the removal of the occiput from over the pubes ; we must, in this case, introduce either hand so that the palm will look up- wards in the pelvis, and then take hold of the head, as already directed it should be seized; raise it in the direction of the axis of the uterus, and when a little freed from the supe- rior strait, turn the face to the side, contrary to the name of the hand employed ; then trust to the powers of the woman, for the rest, provided these appear sufficiently efficient. 715. When, from the nature of the case, we are obliged to turn, we carry up the head, and give it the turn just mentioned ; and where practicable, make the shoulders take the same course ; the hand will point out the side to which the face must be turned; then finish the delivery, as if we had interfered with a first or second presentation. If we cannot change the shoul- ders bv acting immediately upon them, we may give the pro- per turn by pulling for a little while upon the right leg, if the face is turned to the left side, and upon the left, if turned to the right side. Sect. IV.—Fourth and Fifth Presentations. 716. These presentations, in consequence of the forehead coming under the arch of the pubes, are alwavs more painful and tedious, (caeteris paribus,) than where the vertex offers to this part; but in a well formed pelvis, unless some accident complicate the labour, we are seldom or never obliged to turn for position alone. Should, however, any circumstance render it necessary, we mav turn in these cases, with as much facility [37] " 290 FOURTH AND FIFTH PRESENTATIONS. as if they were the first and second vertex presentations; and we conduct the process precisely in the same manner; that is, in the fourth, the rules for turning are exactly the same as has been already directed for the second, presentation, and in the fifth it is conducted as if it were the first—it is important, in these cases, that the leg which offers under the pubes should be more acted upon than the other, that the breech may take a proper position in the superior strait. Sect. V.—Sixth Presentation. 717. I believe it best in this presentation to turn, if the head and pelvis have but their ordinary relation; and most certainly so, if the latter is a little contracted, or the head of more than ordinary size, provided we are called early, that we may take advantage of the opening of the membranes; or if they have been recently discharged. If the head be small, it will come along without much difficulty; and if but very little smaller than the pelvis, advantages might be derived from turning the occiput from the projection of the sacrum, as recommenced by Bau- delocque, and as once practised by myself (see 620) ; but this presentation so rarely occurs, that almost all I can say upon the best mode of treating it, is derived from analogy, and rea- soning. After the head has passed the superior strait, it can offer no greater difficulties than the fourth or fifth presentation; but, like these, it may require the application of the forceps; for, if the waters be long drained off, and the uterus strongly contracted on the child, turning would be extremely difficult, if not impracticable ; as happened in the case I mentioned hav- ing succeeded, by turning away the occiput. 718. When turning is attempted in this case, either hand may be employed, at the option of the operator; the head must be seized as directed for the third presentation, and converted into the fourth or fifth. Baudelocque recommends it being re- duced to the first or second; I sincerely believe this to be im- practicable ; I am certain it cannot be done if the waters have been long evacuated; and if it have succeeded, it must be at the moment they have expended themselves, and wh'de the head SIXTH PRESENTATION. 291 yet enjoyed freedom, at the superior strait. The turning must be finished, as if the head originally presented in either of these positions. 719. Having spoken of the modes of terminating preternatu- ral labours where the hand alone was sufficient, I shall now proceed to the consideration of the forceps as a means, where the hand is not capable of performing it, or where it is not proper to employ it—for this purpose, I shall commence with a general consideration of these instruments; and afterwards point out the modes of application, in each particular case; this will bring me to the third part of the work. PART III. WHERE IT IS NECESSARY TO USE INSTRUMENTS WHICH DO NO INJURY TO MOTHER OR CHILI). CHAPTER XVIII. OF THE FORCEPS. 720. I shall consume no time in tracing the history of these important, but too frequently abused instruments; nor point out the alterations which caprice, or the affectation of improve- ment, have imposed upon them—I shall merely declare my preference for the long French, or the Baudelocque forceps. An experience of many years, I think, justifies my choice; my election was not either hastily or heedlessly made; I think 1 duly weighed the merits of each of the instruments; and the preponderance, was in favour of the long. I had no theory to support; and had, therefore, no prejudices to overcome; my sole desire was to determine which of the two, would best answer the ends for which they were designed—trials, often repeated, have led to the conclusion, that there is no situation of the head which can be delivered by the short forceps, that cannot, with at least equal certainty, be relieved by the long; but that there are situations of the head, which the long for- ceps can deliver, where it is entirely impossible to relieve, by the short—this, in my estimation, is conclusive. See Plate XIII. 721. I shall briefly state the objections, which experience has suggested, against the short forceps ; for a number of years they were the only forceps I employed; and were only aban- doned from a conviction of their inferiority to the long. First, Or THE FORCEPS. 29^ they can only be employed with advantage, when the head oc- cupies the lower strait. Second, when it is required to deliver from the superior strait, or above it, neither their length, nor their form, will permit their application; we are then obliged to use the long; but the converse of this never happens.* Third, from the shape, and shortness of their handles, they be- come very inconvenient to the operator; forbidding, from these causes, the application of a sufficient force, to overcome the re- sistance. Fourth, their mode of union is such, as to render. them extremely inconvenient to the operator, and oftentimes very painful to the patient, by including while locking, either a portion of the soft parts, or of the hair of the pudendum; thus creating a great deal of pain. 722. In favour of the long, I may state, that no one of these objections, attaches to them; they can be used in any position, or distance of the head within the pelvis; that the form and length of their handles, give great and decided advantage to the operator; rendering his exertions more effective, and much less fatiguing; their mode of union obviates the very serious objection urged against the short; for they lock without the vulva when the head is high; and remote from it, in lower po- sitions—besides, they unite in themselves, the forceps, the lever, and the blunt hook. Sect. I.—General Rules for the use of the Forceps. 723. We may divide the general rules for the use of forceps, into, a. Those which regard the woman herself, b. Those which respect the uterus and soft parts, c. Those which refer to the application of the instruments, and their action on the child's head; and d. The mode of acting, after they are applied. • Dr. Davis seems to entertain similar notions of the utility of the short forceps in certain cases, and I shall avail myself of his observations on this point. He says, " What I wish at present to insist on, is the absolute unsuitabl-mess of the initrument known in this country by the name of the short or common forceps, fur the relief of cases of impaction, from disproportipnate size of the foetal head within the pelvis, on account of a general deficiency of spue? within its cavity." I'Klern, Oper. Mid. p. 141.) 294 USE OP THE FORCEPS. a. Those which regard the Woman. 724. Position is important to the application of the forceps; but, as regards the particular situation of the woman for de- livery, there is a diversity of opinion, between the British, and Continental practitioners—and the same may be said of the different accoucheurs in our Own country; depending very much upon the school in which they have been educated, or the authority, they are in the habit of following. The British practitioner almost invariably directs his patient to be placed upon her side, with her hips near the edge of the bed :* while the Continental accoucheur, has her placed upon her back.f It is, perhaps, not very difficult to explain the cause of this differ- ence—the British practitioner never, or but very rarely since the days of the well-instructed, and judicious Smellie, attempts to deliver the head from the superior strait; while many of the Continental accoucheurs do—in the first, the lateral position of the woman is perhaps, as proper as any; but in the second, it would be impossible to deliver from the superior strait; now, as the position of the back enables the practitioner to deliver from any part of the pelvis, it should always, I think, be prefer- red ; especially, as the relative situations of the head, and pel- vis, will be better understood by the young practitioner; for he will have the symphysis pubis as a mark, by which he can determine every other part of the pelvis; this he cannot so ex- actly do, when the patient is on her side. 725. Therefore, when practicable, I would recommend she should be placed upon her back, as directed for turning (702, &c.) both for convenience and safety. I say when practicable; for it is not always so; since, in cases of extreme exhaustion, of flooding, of convulsions, &c, we sometimes cannot move the patient, to be thus placed; but we can always turn her upon her side; or if the head be very low, and the patient is on her back when interference is necessary, she may remain so; but, when we can command position, I repeat, I prefer placing the woman upon her back, with her perina;um free over the edge of the bed. * Denman, &c. f See Baudelocque, &c. USE OF THE FORCEPS. 295 726. Before we proceed to the use of these instruments, we should apprize the friends and the patient, of their necessity— it rarely happens, that the patient is alarmed at this alternative; a very short explanation of the mode of action of the forceps, always satisfies her; we have only to say, that the natural powers are insufficient; that the situation of the child requires immediate relief, as its longer continuance in the passage might be fatal. But at the same time, we must not give any positive assurance of its safety by the operation; though its chance should be represented as increased. Cause her to think the instruments an artificial pair of hands, whose use is to clasp the head of the child, and thus promote its delivery; and she becomes at once reconciled to their employment. 727. We should take care, before we employ the forceps, that the bladder be discharged of its urine, either by the ca- theter, or by a voluntary effort of the patient; and that the rectum be unloaded, byr a simple injection, if it has not been emptied a short time before ; also that the vagina, external parts, and instruments, be well lubricated by hog's lard, or soft pomatum; and the latter warmed by being placed in warm water.* b. The Condition of the Uterus and soft Parts. 728. The forceps should never be employed, whatever may be the emergency7, before the os uteri is sufficiently dilated, or readily dilatable, and the membranes ruptured. Were we to attempt their application before this period, we should cause much mischief, if not altogether be foiled in our enterprise. We must, therefore, wait until this has taken place; but we should endeavour to promote this condition by every means, which may be compatible with the existing situation of the wo- man. This may sometimes be by blood-letting, as in convul- sions, &c. or bv laudanum, as in certain kinds of exhaustion, kc. but never by force. We are told, that the application of * In warming the forceps, care should be taken, that the water is not too hot: it will be sufficiently warm, if the hund can just be borne in it. It is proper, even in warm weather, to observe the precaution of warming- the forceps. 296 USE OF THE FORCEPS. the belladonna to the os uteri has been useful for this purpose; but of this I have no experience.* 729. Should the membranes be entire at the time we are about to operate, we may very readily effect their rupture by artificial means; but this should not be done until the os uteri is in proper condition for the operation. It would be desirable, that the external parts should also be disposed to yield readily before we commence; hut this is of much less importance, than the relaxation of the os uteri; for these may be dilated gradu- ally by the instruments, or made to yield by the application of laro, or soft pomatum. c. Application, and Mode of Action of the Forceps. 730. The proper application of the forceps, in each situation of the head, has ever been considered as an achievement of difficulty. It requires, a complete knowledge of the various divisions of the pelvis; an acquaintance with the construction of the child's head; and the mode of detecting its precise situ- ation, in the cavity which contains it. It will also be necessary to the success of the operation, that the practitioner shall well understand the construction and mode of action of his instru- ments, and have by practice acquired a facility in placing them. It has been considered by Dr. Denman, as uncertain, whether the art of midwifery has been benefited, or injured, by the in- troduction of instruments into its practice.! That much mis- * Chaussier recommends the extract of the belladonna, with great confidence, in cases of rigidity of the os uteri. He causes it to be incorporated with some soft ointment, and applied by means of a particular syringe to the circle of the uterine orifice. In half an hour, or in forty minutes at farthest, after its applica- tion, he declares, the orifice of the uterus becomes so much relaxed, as to offer no farther resistance to the efforts of the body and fundus. (Considerations sur les Convulsions qui Attaquent, les Femmes Encientes, p. 22.) ■j-1 am convinced, that if the forceps be judiciously employed, the lives of very many children may be saved ; and that the death of the mother is a rare occurrence. Dr. Davis declares, "In my own practice, as one of the physicians to the Maternity Charity of London, which is, beyond comparison, the most ex- tensive obstetric institution in Europe, I have the satisfaction of being able to assert, that I have never incurred the misfortune of losing a mother in conse- quence of a forceps operation." (F.leni. Ope v. Mid '). 274.) USE OF THE FORCEPS. 297 chief has been done by the ill-judged, and worse conducted application of the forceps, I have had reason to know; but the abuse, or wrong use of a thing, by no means furnishes a logical conclusion against its use. Indeed, were we to admit this rea- soning, in almost any concern of human life, we should have a most reduced catalogue of real benefits; and, were it legiti- mate to urge it in the practice of physic, or surgery, we should scarcely dare to prescribe an article of the materia medica, or venture to employ a single instrument, of the very many we now consider essential, to the exercise of this branch of medi- cal science. Yet who would willingly give up, in the practice of medicine, opium, camphor, mercury, bark, and a hundred other articles, because quacks, and ill-instructed people, have abused them, or even destroyed with them? or who, in the practice of surgery, would throw aside the trephine, the scalpel, the gorget, or the amputating knife, because each, in the hands of the unskilful, mayr be mischievous ? 731. Let those who are to practise midwifery, become well acquainted with the elementary' parts of their profession, be- fore they commence it; then gradually proceed to the exercise of the more difficult operations connected with it, and the cla- mour against the use of forceps will in great measure cease; because, there will necessarily be less reason for complaint. A severe probation awaits an upright, and conscientious man, upon his introduction to the practice of midwifery; for, if he be such, it will be a long time before he will dare to flatter him- self, that he can do the best for his patient; and, until he can, he will not be satisfied with himself—but this very distrust would, very probably lead him to a practice, I would earnestly recommend; namely, to cultivate his talents by constant read- ing, to keep pace with the improvements in his profession, and to seek the aid of those better skilled, or qualified than himself, when difficulty presents itself. 732. Much of the embarrassment, and I may safely add, the risk, in the application of the forceps, might be obviated, if every gentleman, during his medical studies, were to pre- pare himself by the frequent application of them upon the ma- chine, under all the various conditions the head may offer it- [38] 29a USE OF THE FORCLPS. self within the pelvis—but I am sorry to say, this mode of acquiring knowledge, is not sufficiently appreciated by those, to whom it would be of the most direct, and essential service. There is a tact in every operation, which is indispensable to its well performance, and success; but this can only be ac- quired, by its frequent repetition—for what should be said of the surgeon, who expected to acquire a knowledge of the anato- my of the part upon which he was about to operate, by dissect- ing the living fibre, for the first time in his life ? or, who could expect a man to apply the forceps with skill, the first time he attempted it, upon the living machine; and this without a pre- vious exercise of the manner, upon the artificial one ? The same observations will apply to turning. 733. But it would be unfair to charge all the mischief which has followed the use of the forceps, to the ignorance of those who employed them; or to the action of the instrument itself— much is justly attributable to the views which many celebrated men have taken of their necessity, and utility; as well as to the rules they have laid down, for their employment. In many instances, the evils which appeared to follow their application really existed before they were employed; and might, I am ' persuaded, have bee;n certainly prevented, had a timely, and judicious use been made of them. 734. Dr. Denman, more perhaps than any other man, is chargeable with perpetuating errors in the use of the forceps; because, he is considered the highest authority upon the sub- ject. In his attempt at precision, he has created confusion; and, in his desire to generalize, he has so many exceptions, that his Aphorisms are no longer rules. The necessity for using the forceps is taken principally from the time the head has tarried at the lower strait or passage, and the condition of the woman; without the slightest regard to circumstances, which may com- plicate the labour, or make a departure from the rule necessa- ry to both mother and child. His aversion' to instruments made him restrict their powers to such narrow limits, as to render them scarcely subservient to the art; and he reduced the cases proper for their application to so few, and so pecu- USE OF THE FORCEPS. 299 liar, that they are scarcely to be met with, that they may be employed. 735. Thus we find that Dr. Denman's fourth Aphorism de- clares that " the intention in the use of the forceps is, to pre- serve the lives of both mother and child;" thus far good; but in the very next sentence he says, " but the necessity of using them must be decided by the circumstances of the mother only;" that is, as I understand it, and as I believe every body else, means, we are not to deliver with a view to save the child, unless something threaten the mother. Is not this sadly and improperly limiting the utility of the forceps ? for what secu- rity have we, when danger assails the mother, that the child shall not have perished before we are, agreeably to Dr. D., justified in delivering it ? Let us again suppose that the body of the child is delivered, and that the head cannot be made to pass, either from the want of ordinary power on the part of the mother, or from the extraordinary size of the child's head as regards the pelvis; are we to permit the child to perish be- cause there is no "circumstance," that is, as I understand it, no danger, threatening the mother, to authorize immediate de- livery by the forceps, though he has just expressly declared their "intention" is to save the lives of both? 736. His fifth Aphorism declares, "it is meant when the forceps are used to supply with them the insufficiency, or the want of pains ;" here is a plain and positive direction, one that the common sense of mankind would at once agree to be sound and proper; one that would justify' in the absence of sufficient, or efficient pains, the employment of forceps to supply the de- ficiency of the natural powers; but all this prudent and well- tested direction, is destroyed by the next member of the apho- rism ; namely, " but so long as the pains continue, we have reason to hope they will produce their effect, and shall be justi- fied in waiting." 737. In the Lond. Med. & Phys. Jour. Aug. 1825, p. 157, there is an indirect charge of a misquotation of Dr. D.'s fifth Aphorism, which I take this opportunity to disclaim. I quoted from an American republication of the Aphorisms, and I find I am correct agreeably to that. My observations on these 300 USE OF THE FORCEPS. i Aphorisms were made twenty years ago; and if there be a discrepancy in the two texts, it may have arisen from a subse- quent change in Dr. D.'s opinion on this subject; since, the reviewer quotes from the sixth edition. The additional sen- tence, " without any degree of vigour,'1'' alters the matter little or none, in my opinion—" with any degree of vigour," is ex- tremely indefinite ; for the degree of suffering may lead to the belief that force is always commensurate with pain; than which, there can be but few greater mistakes; especially, in cases like those under consideration. Had the sentence read, " so long as the natural pains continue with vigour," the meaning would have been clear; and it would have authorized the alternative of the forceps, when this was not the case. As it stands, even in the reviewer's quotation, I am persuaded, every inexperi- enced practitioner would feel himself justified in waiting too long. 738. I must still insist, that if this Aphorism has any mean- ing collectively, it forbids the use of the forceps so long as there are any pains, however feeble, transitory, and insufficient they may be for the end proposed—the value of pains must be esti- mated by their power upon the body to be moved, and not by the suffering the woman herself may endure. But let it be recollected, that, beside the risk the child runs by long delay in the passage, the soft parts of the mother are suffering from the long pressure of the child's head ; subjecting them to con- tusion, inflammation, sloughing, &c. and this to comply with a prejudice against the proper employment of the forceps., 739. Dr. Davis relates a case completely illustrative of the point I have attempted to enforce ; namely, that the soft parts of the mother may, by the long delay of the child's head in the passage, suffer extensive, and irremediable mischief. In the case alluded to, the patient was eighteen hours in labour; and " during no sjtage of this labour, could it be truly asserted, that there was not some progress made." The child " effected its transit through the pelvis, certainly in the midst of such a tempest of struggles, as I think I have never witnessed upon any other occasion." 740. " The patient died on the tenth day after her delivery." * USE OF THE FORCEPS. * 301 'On inspecting the body after death," "the cause of it was discovered to have been a large abscess, which seemed to have implicated all the structures at the superior part of the cavity, and towards the left side of the pelvis, and of which the left ovarium, probably dangerously contused during labour, had all the appearance of being the nucleus." (Elem. Oper. Mid. p. 149.) 741. I may also add, that the head of the child also suffers very severely from a long-continued pressure upon it; produc- ing extensive extravasations under the scalp, as well as some- times abscess of this part, as is related to have happened to a child that was delivered at the Royal Maternity Charity, after an unusually tedious and painful labour. Baudelocque gives an instance of the scalp sloughing, &c. Vol. III. p. 161. 742. In a word, experience completely proves, that much risk, both to mother and child, is constantly incurred, by^ the head remaining to press too long upon the lining of the pelvis. Dr. Davis mentions a case (p. 156.) where, after a labour of this kind, " the parietes of the vagina" were much swelled, and required blood-letting and leeching to subdue it. 743. It is merely intended, by what is just said, to justify the assertions I have made against Dr. Denman's reluctance to employ the forceps, and not a critique upon his Aphorisms— I have offered this elsewhere. See "Essays on various Sub- jects connected with Midwifery." 744. Dr. Osborn* carries this reluctance still farther; to a degree indeed I think reprehensible, as it seems to militate against the interests of society at large, and of the sex in par- ticular—but he has not done equal mischief with Dr. Denman; because, his authority was not equal. He requires, before the forceps are applied, " the powers of life to be exhausted; all capacity for farther exertion to be at an end ; and that the mind be as much depressed as the body; and would at length both sink together under the influence of such continued but un- availing struggles, unless rescued from it by means of art." 745. I would ask, with what prospect of success would art interfere under such a complication of evils ? the woman might be delivered, but what would be her after condition, or that of ■" Essays, p. 45. & .302 USE OF THE FORCEPS. the child?—the one would be subjected to all the evils which a too long delay of delivery would produce, if not death; and the other, to almost inevitable destruction: a court of justice should hold such conduct criminal; for it would merit a severe punishment. 746. Besides, the objections against the forceps are founded upon an erroneous estimate of their tendency—that they have been misused I admit; and so has almost every thing else; but that,they have been productive of more good than evil, I am every way persuaded. As regards the child, there can be no hesitation; and as they may have affected the mother, I am certain they have been highly beneficial. It is entirely within my recollection, when cases similar to those, now treated by the forceps, were relieved by the crotchet—the child a certain victim, and the mother a probable one.* 747. However stronely I may be impressed with the utility of the forceps, I should not feel myself warranted to use them as often as they appear to be used in Great Britain, and on the continent of Europe. The frequency with which they have been employed, in some instances is really alarming; and * In the year 1794, I was sent for by a midwife, to a woman who had been six- and-thirty hours(in severe labour with her first child; and she nearly forty years of age. Upon examination, the posterior fontanelle was found at the left foramen ovale ; the pains had been violent and frequent, but were now feeble and transi- tory, making no impression upon the child. I introduced the catheter, and dis- charged a large quantity of water; then applied the forceps, and soon delivered the child. So soon as it was born, it began to cry; and when liberated from the . placenta, I handed it to the midwife, who received it with averted face, and streaming eyes. I inquired of her what had so affected her; she answered by pointing to the child, and saying, " who with any feeling could help it ? a poor child to be alive with its head open!" As I did not understand her, I desired she would explain herself; this she did, by saying, "she would not have cared so much, had jt been killed outright; but to be wounded and live, was truly shocking!" I still insisted upon farther explanation, as I yet did not understand her, a»d at the same time uncovering the child, asked if she supposed it was hurt, and if she did she was much mistaken. She now examined the child ; and to her utter astonishment, found it without blemish. She then told me, she would have sent for me long before, but for the horror she had of having the child's head opened; which she assured me, had been the uniform practice upon such occasions, whenever she had sent for a physician. The influence of this case upon many of the midwives of this city, procured mc many opportunities of ap- plying the forceps. USE OF THE FORCEPS. 303 I had like to have said, must have been often unnecessary* In my own proper practice, I am persuaded I have not employ- ed them oftener than once in three hundred and fifty cases ; though I have been under the necessity of using them very frequently in the practice of others. 748. I must not, however, be understood as reflecting upon any individual, by the last remark—my meaning will be pro- perly understood, when I state, that some years ago, the practice of midwifery was very much in the hands of females. These females were not competent to the use of instruments; consequently, when they were necessary, others had to perform this duty for them: it fell to my lot to do much of this business. Bv this means, I have seen very many forcep cases; but the greater part of these did not belong to me, as original cases. 749. But let me ask, what is to be feared from a proper ap- plication of the forceps ? is their mode of action, when well directed, such as to do injury to either mother or child? cer- * The following statements upon the subject in question, I extract from Dr. Davis's " Elements of Operative Midwifery." " It has been stated by Prof. Boer, (see Medicina Obstetrica, p. 443.) that the forceps have been used in the practice of an individual or of individuals, whom, however, he has not chosen to name, in nearly one case out of every three labours. Prof. Hagen, of Berlin, delivered 39 women out of 350, or 1 in 9, with forceps. Prof. Nagcle, of Heidelburg, reports, that in the practice of the lying-in insti- tution of that city, for the years 1817 and 1818, he used the forceps once in 53 cases. Mr. Burns gives the proportions of Prof. Nagele, as " very much corres- ponding with those of his own list." In a statement of presentations at Le Maison d'Accouchemens, between December 1799, and May 1809, furnished by the late M. Baudelocque, we have the proportion of forcep to the whole number of la- bours, as 1 in 353. Madame Boivin, once in 212. Madame Lachafulle, 1 in 166. At the Obstetric School of Gottingen, 1 to between 18 and 19. At the University of «tockholm, 1 in every 100. Dr. Luders, 1 in 109. M. Lobstein, 20 times in 712 cases. Prof. Boer, of Vienna, once in 238 labours. In Dr. Clarke's Abstract of the Dublin Lying-in Hospital registry, it is stated, diat the forceps were used 14 ti,nes in 10,387 cases." Dr. Davis considers the proportion of 1 in 53, which is approved by Prof. Bums, at least 400 per cent, too great; and is of opinion, that the forceps are not required more than once in 300, or at most, 250 cases. From the above statements, it evidently appears, that the forceps, in the hands rf some practitioners, have been most wantonly used; and in those of some- others, as improperly withheld, .:•(>»■ USE OF THE FORCEPS. tainly not—then there is nothing to be apprehended from theii structure, application, and mode of action, since necessarily, they neither cut nor contuse, mother nor child; neither do they create unnecessary pain, nor inordinately augment that which may b:; present; but are truly calculated, in the language of Dr. Denman, to supply the insufficiency, Or want of labour pnins; if this be so, and it is so admitted by Dr. D. himself, should they- be condemned, because they may, like every sub- lunary good, be abused ? 730. Let me then endeavour to strengthen my case, by con- sidering, 1st. their structure; 2d. their application; and, 3d. their mode of action. Their structure is such as to offer the greatest possible security to the child—the breadth of their clams is so great,* as to prevent any^ partial or injurious pressure; and the excavated diameter between the blades, even when the handles are pressed pretty closely, will permit the. transversal diameter of the head of a child of ordinary size to lie between them, without any, or with very little inconve- nience ; the length and strength of their handles are such, as to permit compression wherever that compression may be neces- sary. 751. The proper application of the forceps consists in their complete adaptation to tire sides of the head of the child, or as nearly as may be over its ears—when fixed upon any other part of the head, it is but an exception. When placed as just sug- gested, the head is embraced in the direction of its oblique di- ameter; (58) the small diameter presents itself between the blades of the instrument. The advantages of this position of the forceps, are : 1st. That the head is seized in its smallest diameter; and this diameter is so little increased by the thick- ness of the instrument, as to offer no additional difficulty to the delivery. 2d. When the head requires to be compressed, that compression will be in the direction of the short diameter of the head, and will oblige the vertex to extend itself (however * Dr. Davis thinks the breadth of the blades of the French forceps, is too narrow, and proposes those of much greater breadth. I have never found any irfconvenience in the use of these instruments, which was exclusively chargeable ti> ♦his circumstance. (Elem. Oper. Mid.) USE OF THE FORCEPS. 305 little) in the direction of the oblique diameter; as its construc- tion gives a tendency to that direction. 752. The proper application of the forceps farther consists, in such a direction of its blades, as will permit their concave edges to come under the arch of the pubes, at the last period of labour—this rule is never to be violated. They must be plac- ed exactly parallel, upon the sides of the head, that they may lock; and it is ascertained that they are well placed, by their locking without the necessity of force being employed for this purpose. Should they not lock spontaneously, if we may use the expression, force must not be used to make them—for if force be employed for this purpose, it must necessarily be at the expense of the bones of the head, and, perhaps, the destruc- tion of the child. If the handles do not readily join upon the introduction of the second blade, we may be certain one of them has a wrong direction ; it must be ascertained which, and, by a judicious management of the one in fault, make it join, without force, its fellow. 753. When the handles join kindly, we may be certain the blades are properly applied; and one of the greatest difficulties of the forceps is overcome. The degree of compression to be applied must be determined by the size of the child's head; its suppleness; and the capacity of the pelvis—the less com- pression the head requires, the easier, and the more successful will be the operation. 754. The forceps have two modes of action: a. That of compression, in the first instance; b. and that of traction and compression, in the second. a. Of Compression. 755. I have already stated, that when the forceps are well applied, they traverse the head in the direction of its oblique diameter, or nearly so; and that the compression which it may suffer, is in the direction of its small diameter; now, as we can- not determine a priori, the size of the head ; the firmness of its bones; nor the resistance it will meet with in its passage, we cannot possibly calculate the force that will be necessary to re duce the head sufficiently, to permit it to pass through the [39] 306 USE OF THE FORCEPS. pelvis. I can, therefore, only say, the less force it is necessan to exert, the less the head will suffer; and consequently, so far as this operation is directly concerned, the greater the chance will be of preserving the life of the child—and also, that the converse of this is equally true. An inattention to this latter fact, or a want of knowledge of it, has given rise to many of the objections which are urged against the forceps—for it has occasioned their application upon any portions of the head; and the handles forced to lock, at the expense of the fracture of the skull ;* it has occasioned them to be employed, where there was so much disparity between the diameters of the head of the child and the pelvis, that it could only be delivered, af- ter the forceps had nearly broken down its texture ; need I say, what mischief would follow such displays of ignorance? the child dies by a species of murder; and the mother, especially, in the latter instance, is subjected to inflammation, gangrene, sloughing, or even death. 756. It has been imagined, from the elongation which the head sometimes permits in long protracted labours, that it would bear with impunity any compressing force, which might be applied; but this is an error; and an error of great magni- tude ; for by acting upon it, the benefits of the forceps have not only been undervalued, but really called in question. I must then, to prevent the perpetuation of this error, as far as may be in my power, declare, that the head will bear with safe- ty but a moderate diminution of its bulk, by the compressing * I was once called upon to determine whether any thing could be done for a newly-b»rn child, which had been most unskilfully delivered by the forceps— The frontal bone was severely indented by the edge of the forceps; and one eye entirely destroyed, by the extremity of the blade having been fixed upon it: yet was it born alive. The case of course was a hopeless one; and the child fortu- nately died, in a few hours after its birth. And I was once shown a blade of the forceps, which had beefl severely bent, by an endeavour to make it lock. In this case, the forceps were exhibited in triumph, and as a proof of the great dif- ficulty die operator had to encounter, in effecting tho delivery; and as additional evidence of this, he declared, that no strength was sufficient to deliver the head, as both his (and he was a powerful man) and that of an eqnally ignorant practi- tioner, were unavailingly exerted, alternately and collectively—he at last deliver- ed with the .crotchet, after having experienced very great difficulty in withdraw ing the bent blade of the forceps. USE OF THE FORCEPS. 307 force of the forceps; and oftentimes, much less than is some- times observed to take place, when the child has been deliver- ed solely by the exertion of the natural powers: the reason of this is obvious ; we cannot, by any contrivance of art, imitate this gradual (though not always safe) modification of the head; consequently, when it becomes reduced by a suddenly applied force, like that exerted by the forceps, it must be at the risk of much injury, or it may be even fatal to the child.* 757. This fact, limits the powers of the forceps, more than is commonly supposed, even by those who employ them with. the laudable hope of saving the lives of both mother and child; but who frequently experience disappointment, because not aware of it. The forceps, therefore, in the hands of one who considers them as a means by which a difficult labour may be terminated; but who applies them without rule, or without a knowledge of their mode of action, are nearly as fatal as the crotchet itself; because, they are regardless of the degree of compression they impose upon the head, during its extraction.] It would seem, then, from all experience, to follow, that from a pelvis with less than three inches, or even three inches and a half in its small diameter, a child's head, at full time, cannot be made to pass with safety, by means of the forceps, unless there be an unusual degree of suppleness in the bones of the cranium; or the head itself unusually small. If these facts were more generally known, or more constantly kept in view, we should have fewer complaints against the forceps; because, there would be fewer victims to their ill-directed power upon the head of the child, and fewer evils following their applica- tion, upon the soft parts of the mother. . * Dr. Davis, however, asks, " Whether in some peculiar circumstances, it might not be found more eligible to apply to the foetal head a certain required amount uf compressing force, within a short time, artificially by means of the forceps, than to await the result of a more gradual and protracted application of an ulti- mately equal degree of force by the natural agents of parturition ?" (Elem. Oper. Mid. p. 139.) f I have more than once witnessed the truth advanced here. I have seen the whole length, or nearly the whole length of the frontal bone cut through, by one of the sharp edges of the forceps, by an effort to compress it; and at another, I saw the parietal bone in the same wretched plight, from the same cause. 308 USE OF THE FORCEPS. b. Compression and Traction. 758. We can avoid but in very few cases, in which it is proper to use the forceps, a prettv constant compression, from the. moment of their application, until the final deliverv of the head. With a view to diminish the permanency of this pressure as much as possible, I am in the habit of not tying the extremities of the handles, as is usually recommended, that I may, after each tractive effort, permit the instruments to ex- pand, as much as the elasticity of the head, and the restricted capacity of the pelvis, will permit. In this, I think there is decidedly an advantage to the child; and there can no possible injury happen from it, to the mother. d. Mode of Acting after Application. 759. Each effort made to advance the head after the forceps ' are applied, must be considered as a renewed compression; though the lateral pressure upon it, may be but very little in- creased ; for that the head may advance, the curved extremi- ties of the instruments, must necessarily act at nearly right angles with their sides; consequently, the transverse diameter must be a little increased, or rather less diminished; which, to a certain extent, must increase the difficulty of delivery; or in other words, increase the necessity of a stronger tractive force. This however is in some measure, if not altogether obviated, by making each blade of the forceps act as a lever in conduct- ing the delivery; and this is the usual direction given for their employment, without expressing the reason for it—hence, when the instruments are fixed, we act with much greater effect, by drawing from blade to blade, than if we continued the force in a direct line ; for by making the handles describe a portion of a circle, by passing them from right to left, and the reverse, during the traction, we each time (when the head is moveable) make a part of its side sink lower in the pelvis, and advance towards the external opening of the pelvis. 760. The extent of the circular motion which the handle! should be made to perform each time, must, at first, and espe- USE OF THE FORCEPS. 309 eially if the head be high in the pelvis, be very small; or we shall be making fulcra of the soft, and bony parts of the mo- ther, at each effort; which must ever be carefully avoided. As the head advances, we may enlarge the space, through which the handles are to move; but it is never to be made so exten- sive, as to make the instruments press with much force against the bones, forming the arch of the pubes, and the external parts of the mother. 761. The motion just spoken of, is at first horizontal, or very nearly so; but as the head advances, we are obliged to elevate the extremities of the instruments, and this in propor- tion, as it approaches the vulva, or as it is about to escape the external machinery; so that, at the last moments, the extremi- ties of the handles are laid nearly upon the abdomen of the mother. During the operation, our tractive efforts should co- incide witK the action of the uterus, whenever that remains; when the uterus has ceased to act, we should permit as much time to elapse between each exertion, as generally takes place between the pains at this period of labour, that we may not ex- haust the woman; that we may secure the tonic contraction of the uterus, and that we may not make too sudden, and too long continued compression, on the child's head. 762. It is by no means unusual for the pains to cease after the application of the forceps ; and be obliged to perform the delivery without their aid—I am at a loss to account for this; for it is contrary to what might reasonably be expected. When, however, they continue with even moderate force, I have been in the habit of disengaging the instruments, when the head is about to pass through the external parts, that these may be the better supported, and the risk of laceration diminished. Should there be no pain, we are then constrained to continue our efforts, until the head is without. 763. In removing the forceps before the head is delivered, I am aware I am departing from high authority; for Dr. Den- man lays it down as a rule, that " in every case in which the forceps have been applied, they are not to be removed be- fore the head is extracted, even though we might have little or no occasion for them." But notwithstanding this positive in- 310 USE OF THE FORCEPS. junction, I am entirely persuaded, from experience, it is the safer practice, if we regard the integrity of the soft parts of the mother, worth the preserving. Sect. II.—Recapitulation. 764. As I have dwelt upon the use of the forceps longer than I anticipated, I shall sum up in a few words the prin- cipal points intended to be insisted on, or illustrated: 1st, that the long French forceps are the preferable, even for the unskilful; 2d, the best position for the woman is that recom- mended for turning; 3d, the bladder and rectum are to be emptied before the forceps are introduced; the former by the catheter, when the woman cannot command the discharge; and the latter by an injection, if it has not been done spontaneous- ly, a short time before ; 4th, the patient and friends are always to be apprized of the necessity and propriety of the operation before it is resorted to; 5th, the vagina, external parts, and the instruments, are to be coated, by fresh hog's lard, or soft pomatum ; and the latter warmed; 6th, the forceps are never to be employed before the os uteri, and external parts are re- laxed; and the membranes ruptured; 7th, this relaxation to be promoted by the best adapted means; 8th, should the uterus be in a proper condition for the operation, and the membranes at the same time entire, the latter must be ruptured, that the application of the forceps need not be delayed, when the case requires immediate interference; 9th, when the circumstances of the case require the use of these instruments, the applica-' tion should not be too long delayed, from an imaginary fear, that the woman might suffer from their use, or from an ill- grounded hope that the woman may deliver herself—we should, therefore, not permit her to be exhausted, or the child to perish, because feeble or inefficient pains attend, or because the head of the child has not been six hours in the passage; 10th, the » blades of the forceps are always to be applied to the sides of the head—that is, over the ears of the child—when necessity (which is very rare) obliges us to depart from this rule, it is but an exception to the rule; 11th, they must be applied, so that USE OF THE FORCEPS. 311 their upper, or concave edges, will come under the arch of the* pubes, at the last period of labour; 12th, should the handles of the instruments not join with ease, we may be certain they are ill applied; the cause of their not locking must be ascertained; and they are never to be joined by force; 13th, the head will not permit with safety, but a moderate approximation of its sides ; therefore, when compression is carried beyond this point, the destruction of the child is sure; 14th, with a view to lessen all unnecessary, and too long continued pressure upon the head, the handles of the forceps should not be tied; but after each tractive effort, they must be permitted to expand themselves, by ceasing to press upon them ; 15th, each traction should be made from blade to blade ; that each may act as a lever upon the head; 16th, the extent of the motion of the handles for this last purpose, must be regulated by the distance the head is from the external parts; for the less the head is advanced, the more circumscribed should be the motion; and the reverse— this motion is at first nearly horizontal;* 17th, the external extremities of the instruments must be raised towards the ab- domen of the mother, in proportion as the head advances through the external parts; 18th, should pains continue until the head has nearly passed through the external parts, the for- ceps may be removed; but if none attend, the delivery must be completed by the forceps. Sect. III.—General Observations upon the Forceps. 765. In delivering by means of the forceps, every attention should be paid to delicacy; and every care should be exerted that the patient be not subjected to unnecessary pain; to fulfil the first, the patient should not be exposed; this cannot be ne- cessary, even for the drawing off of the urine, should that be an essential previous step. The operator must become fami- liar with the introduction of the instruments without the aid of sight; more especially as this cannot serve him, and must, if employed, be highly offensive to the patient. He must per- form his duty under cover; and the guide for his instrument * That is, from one thigh of the mother to the other. 312 GENERAL OBSERVATIONS UPON THE FORCEPS. must be the hand in which the instrument is not held—this, of course, will sometimes be the right, and at others the left— two or three fingers must be introduced so as to touch the child's head when at the lower strait, and the extremities of them must be insinuated under the edge of the os uteri if that is still down; and upon the plane thus formed by the fingers, the instruments must be conducted; with this precaution he shall give no unnecessary pain; since it will prevent the edge of the uterus from being included between the blade of the forceps, and the head of the child. 766. Should the head of the child have escaped from the os uteri, he must pass the instruments in such manner as shall conduct their extremities under its edges; this is done by keep- ing the point of the blade pretty firmly against the scalp of the child as it passes into the pelvis—should it, however, meet with any obstruction in its passage, the difficulty must be overcome by address, and not by force—it may be a fold in the scalp, or it may be the ear, against which the point of the instrument is projected; gently depressing the handle of the instrument, or varying its direction a little, will almost always surmount this difficulty. 767. Should much pain be experienced by an attempt to lock the blades when well applied, as regards their position, we may be pretty certain, a portion of the neck of the uterus is included in the grasp of the instruments—we must inquire in which side of the pelvis the pain is felt, and withdraw the blade from that side, and introduce it anew. Should cramps be induced, we may sometimes relieve them by elevating or depressing the handles of the forceps. 768. The greatest care must be taken before we begin our traction, that no portion of the mother is included in the lock- ing of the blades—t'us must be done by passing a finger en- tirely round the place of union. This accident very rarely oc- curs in the use'of the long forceps, unless the head is high in the pelvis—with the short it is frequent, even under the direc- tion of the most careful operator; this forms, in my estimation, a very serious objection to their employment. I was once call- ed to a poor woman, who had a considerable portion of the in- GENERAL OBSERVATIONS UPON THE FORCEPS. 313 ternal face of the right labium removed, byr having been in- cluded in the joint of the short forceps. 769. When the instruments are properly adjusted, we should seize the hooked extremities with the right hand, and make them approach each other in the most gradual manner: and we should make no more compression than is absolutely necessary to secure a certain hold, or to enable the head to pass.* The left hand must be applied over the joint of the instruments, and in a manner that will permit the point of the index finger to touch the head of the child, which will enable him to deter- mine the progress it makes. We commence the traction by the smallest force, and gradually augment it, to the extent we may judge necessary—we should finish the effort by gently di- minishing the force, until it comes to a state of rest; taking care however, to maintain the advantage we have gained, by removing the pressure from the handles, and hooking two fin- gers in their curved extremities; and thus prevent the reced- ing of the head. When we have indulged the uterus in a suf- ficient interval; or upon the accession of a pain, we are to apply our hands as just directed, and act as before. 770. As the head is about to pass through the external parts, the left hand must forsake the instruments, and apply itself firmly against the now distended perinxum; and if there be sufficient power in the uterus to carry the head through the os externum without farther aid from the forceps, they should be removed, as advised; but if not, they must be suffered to finish the delivery. 771. When the head is without, the same care should be exercised as was recommended in a natural labour; that is, not to hurry the shoulders through the pelvis ; that the tonic con- traction may certainly follow their expulsion. 772. It is frequently more convenient to stand to perform this operation than to sit; but a chair should be at hand, that • When the pelvis is deformed, and the relation between it and the head of the child is very strict, we are obliged to depart from this rule, and apply a much stronger compressing force ; as the diameter of the head must be a little dimi- nished, that it may pass—in this instance, tb • handles arc to be brought together. *n<\ secured by a garter or ribbon. [40] 314 GENERAL OBSERVATIONS UPON THE FORCEPS. we may use it after the head is delivered; we should order a sheet sufficiently folded, to be spread over our lap, that we may receive the child upon it, when the body is expelled. The funis must be cut at a proper time; and the rest of the delive- ry finished, as on ordinary occasions. CHAPTER XIX. OF THE SPECIFIC APPLICATION OF THE FOR- CEPS. 773. Generally speaking, the difficulty of applying these in- struments is in proportion to the remoteness of the head from the inferior strait; and the facility of application, as the vertex, or forehead, may be near the arch of the pubes. It would be well, were it always practicable, or subject to choice, that the young practitioner should commence with the most simple cases, and gradually advance to the more difficult positions of the head—but as this is impossible under the circumstances of or- dinary'practice, he should, while in his power, become in some measure familiar with the application of the forceps, by dili- gently practising upon the machine—indeed it would be highly advantageous to all who may be about to engage in obstetrical practice, to order a machine, as a proper appendage to their instruments. By the use of this contrivance, he can make him- self well acquainted with every important presentation, and at the same time make himself master of their respective me- chanisms ; he can familiarize himself to the application of in- struments, and readily teach himself the routine of turning, &c. 774. I shall lay down the rules for the application of the forceps, in every presentation, as succinctly as the subject will permit; knowing, from long observation, that nothing but a careful experience with the living subject, can ever make a man adroit in their use. I shall therefore commence with the SPECIFIC APPLICATION OF THE FORCEPS. 315 most simple cases; and gradually advance to the more compli- cated, and difficult. 775. The various ways which the head of the child may offer to the pelvis, when it may be necessary to terminate the labour by the forceps, are, 776. a. 1st. Where the vertex answers to the arch of the pubes, and the forehead to the sacrum. 777. b. 2d. The reverse of this, the forehead to the pubes, and vertex to the sacrum. 778. c. 3d. Where the vertex is behind the left foramen ovale, and the forehead to the right sacro-iliac symphysis. 779. d. 4th. Where the forehead is behind the left foramen ovale, and the vertex to the right sacro-iliac symphysis. 780. e. 5th. Where the vertex is behind the right foramen ovale, and the forehead to the left sacro-iliac* symphysis. 781. f. 6th. Where the forehead is behind the right foramen ovale, and the vertex to the left sacro-iliac symphysis. 782. g. 7th. Where the position of the head is directly trans- versal: 1st, where the vertex answers to the left side of the pelvis; and 2d, where it answers to the right. Sect. I.—a. 1st. Application of the Forceps in the First of these Positions. 783. The woman about to be delivered with the forceps is constantly supposed to be placed upon her back, and every other circumstance, as already directed. 784. The first position in which we are to apply the forceps, Dr. Denman thinks can very rarely require them—this bv no means comports with my experience; for I have very often been under the necessity of using them in this situation of the child's head; for any of the causes which I have considered as complicating the labour, may happen at this period, as well as any other. What is there in this position which shall pro- tect the woman against flooding, convulsions, exhaustion, &c. and render immediate interference unnecessary? I can see nothing; for, though the labour is near its completion, it is not completed; and I am convinced, that in many cases both mo- 316 SPECIFIC APPLICATION OF THE FORCEPS. ther and child have suffered, from the delayr which Dr. Den- man's repugnance to the emplovment of these instruments has created, with the practitioners, who consider him the best autho- ritv. Were it necessary, it would be easy to give examples to prove what I have just said. (See 744.) 785. In this case, after duly preparing the forceps as already directed, we take hold of the male branch of the forceps with the left hand, and hold it as we would a pen when writing, while we introduce two or three fingers into the vagina against the child's head, and under the edge of the uterus if practicable; we then hold the handle or blade nearly perpendicular, but in- clining to the right side of the mother; then insinuate the ex- tremity of the blade between the labia, and slide it along the fingers intended as a guide, until it reaches four or five inches within the pelvis* gradually depress the handle as it advances, and embraces the head. It rarely happens that any difficulty is experienced in the introduction of this blade; its position, if properlv applied, is strictly lateral; its concave edge being under the arch of the pubes, the pivot will have a vertical po- sition, while the handle will be sustained by the edge of the perinseum. The instrument must be retained in its position either by an assistant, or by placing it on the knee, while you prepare for the introduction of the other blade—this must be taken in the right hand, as directed for the other blade; and must, like it, be conducted to its proper situation by two or three fingers of the left hand; when advanced as high as the first blade, the handle must be lowered and inclined towards the left thigh of the mother, until it crosses the first blade, and locks with it—if the instruments are properly applied, this will readily happen—the pivot must then be turned, that the blades may be secure of their position with each other—the handles are then to be seized, and the delivery conducted as already directed. Sect. II.—b. 2d. Application in the Second of these Position*,, 786. This position (777) is by no means as favourable for delivery as the first, though not more difficult for the use of the forceps; the presence of the forehead under the pubes, as SPECIFIC APPLICATION OF THE FORCEPS. 317 I have already stated, always renders it more difficult for the woman to deliver herself; and sometimes is of itself a suffi- cient reason for the use of the forceps. The application of the forceps, is, however, precisely the same as in the one just de- scribed ; we are only to observe, in finishing the labour, to permit the vertex to turn backward, as it is described to do when speaking of its mechanism. Sect. III.—c. 3d. Application of the Forceps in the third oj these Positions. 787. The application of the forceps in this situation (778) of the head is more difficult than in the two preceding; owing to the oblique manner in which it offers at the lower strait. It must assume this position before it can offer its vertex to the opening of the pelvis, but it may fail to make this necessary change, and thus render the labour difficult; or the causes which may complicate any labours may operate at the moment the head has arrived at the place designated, and thus render the use of the forceps indispensable. 788. When the forceps are to be used, the male blade must be passed to the left side of the pelvis at about the same dis- tance as before directed; it will almost always pass along easily, after describing a change of position, which carries the handle a little toward the left thigh of the mother, and gives to the pivot an oblique position, instead of the vertical one before spoken of—after the first blade is adjusted, the other must be passed nearly opposite to it, but a little higher, and immedi- ately against the right leg of the pubes, and behind the right foramen ovale; the handle must be made to incline like its fel- low to the left thigh; and, if properly conducted, the blades will lock; but in a manner that will enable the pivot to preserve its look towards the left groin of the mother. 789. When the instruments are joined, we are directed by Baudelocque and others, to turn the vertex towards the arch of the pubes; but this is certainly not always necessary; for I have usually found, that this took place spontaneously as I continued the traction. I have no doubts but this is occasion- 318 SPECIFIC APPLICATION OF THE FORCEPS. ally.necessary ;* especially, where the pelvis is a little narrow, or the head large, and when we find, after successive efforts, the head does not follow the proper direction, we may turn the vertex towards the pubes, by gradually bringing the pivot to a vertical position—when this is done, this case is precisely like the first of these positions, and the labour must be finished like it. 790. I have, in several instances of this position, found it easier to introduce the second blade from below, pressing, the handle of the first blade, pretty firmly against the perineum— that is, instead of having the handle high over the abdomen, to place it under the left thigh of the mother, and make the extre- mity of the blade penetrate from downward, upward; care must be taken not to place the female blade below the male, in thw ease. Sect. IV.—d. 4th. Application of the Forceps in the fourth of these Positions. 791. This position (779) unites the difficulty of the oblique situation mentioned just now, with the disadvantage of the fore- head under the arch of the pubes ; and, though the application of the forceps is precisely the same as in the last described position, it will nevertheless be a more difficult operation, for the reason just stated. At the last period, when the head is escaping, it must be suffered to turn backward, as in the second position. Sect. V.—e. 5th. Application of the Forceps in the fifth of these Position. 792. This position (780) is of more difficult management than any of those I have yet described, owing to the necessity of placing the male branch above, and obliging the female * Baudelocque tells us, that he has occasionally failed to establish the vertex under the arch of the pubes; and, in these cases, the head has passed through the inferior strait and external parts in a diagonal direction. I have witnessed this direction of the head in a number of instances, where the forceps were not employed; but it has only occurred to me once, when employing these instru- ments—when this happens, it is generally owing to the sacrum being too straight. SPECIFIC APPLICATION OF THE FORCEPS. 319 branch to be placed below—but these difficulties may be sur- mounted by gentleness and perseverance, and,by a just know- ledge of the position of the head. 793. The male branch of the forceps must be conducted by the left hand behind the left foramen ovale ; this must be done by passing the extremity of the blade upon two or three fin- gers immediately under the left leg of the pubes; the handle of course must be depressed in proportion to the advancement of the blade, and made to incline towards the right thigh of the mother; and, when correctly adjusted, the pivot will take an oblique position, and look towards the right groin of the wo- man. The female blade must be introduced on the inferior part of the right side of the pelvis, and adjusted so as to cor- respond with the first introduced blade—the handles must then be locked, and seized by the left hand at the extremities of the blades ; while the right, will take hold over the pivot; a finger to be placed against the head of the child, as before directed. 794. It is not generally necessary to turn the vertex towards the pubes in this case, any more than when it was on the oppo- site side of the pelvis; this will take place as in the former case, by observing the proper direction, for the tractive forces, Sect. VI.—f 6th. Application of the Forceps in the sixth of these Positions. 795. The relations of the head and pelvis in this case, (781) as regards diameters, are precisely the same as the one just described; and the forceps must be applied in the same man- ner. The same precaution must be taken at the final passage of the head through the external parts, to permit it to turn backward. Sect. VII.—g. 7th. Application of the Forceps in the seventh of these Positions. 796. Dr. Denman, in his Aphorisms, seems to acknowledge but one mode of applying the forceps, for the four last posi- tions, and the one now under consideration; (782) and his 320 SPECIFIC APPLICATION OF THE T0RCEPS. directions for all, are applicable only to the last. This position of the h^ad must be rare ; at least, I have encountered it but once, and it was relieved by one blade of the forceps acting upon the vertex, so as to aid the efforts of the uterus, (which were verv strong,) in bringing it towards the symphysis pubis. 797. When the forceps are resolved on, and the vertex of the child is to the left side of the pelvis, the female branch of the forceps must be placed behind the symphysis pubis, and the male blade before the sacrum. The handles of the instru- ments should be made to incline towards the left side of the mother, that the vertex may descend rather more than the forehead. When the vertex is on the opposite side, the male branch must be inserted behind the pubes, and the female branch before the sacrum; the handles, in this case, must be inclined to the right thigh of the mother, for the reason just stated. CHAPTER XX. GENERAL REMARKS ON THE USE OF THE FOR- CEPS. WHKN THE HEAD IS ABOVE THE SU- PERIOR STRAIT. 798. Smellie appears to be the first who had either suffi- cient skill, or hardihood, to apply the forceps while the head was free above the superior strait; and since his time, he has had but few followers-* This however has not arisen so much from the contemplation of its dangers, as the consciousness of its difficulties. To employ the forceps with success under such * Dr. Davis (Elem. Oper. Med.) appears to have used the forceps, when the head was above the superior strait; and recommends it with every apparent con- fidence, in several cases where immediate delivery may be necessary. This however neither diminishes die difficulty, nor danger of these instruments, when awkwardly used. In his hands, the forceps may relieve the head from any situ- ation in which it may be placed; but it must be recollected, that few can boast of his experience, or adroitness. USE OF THE FORCEPS. 321 circumstances, it is necessary that the operator should be aware of all he might have to encounter, as well as to be well skilled in their application, in the situations we have just been consi- dering; therefore it cannot be recommended as a resource to inexperienced practitioners. 799. Baudelocque's observations upon this subject are so just and so important, that I must recommend them to the, se- rious consideration of every gentleman who may intend to pursue the practice of midwifery. Fortunately, the necessity for operating with the forceps, while the head is in this situa- tion, seldom occurs; especially, in this country, where the only apology for their use, namely, a narrow pelvis, is of but very rare occurrence. I have been obliged to use them but three times, in this situation of the head, in five-and-thirty years—my experience, of course, in this necessity, is very limit- ed. On this account especially, I refer to the high authority- just mentioned, and forbear to give directions for their use. I believe, that the frequent mention of difficult, dangerous, and rare operations, leads oftentimes to the unnecessary perform- ance of them; not always so much from the necessity of the case, as the eclat which attends them, however unsuccessful. In surgery, I have known it more than once to have been the case; and once certainly, in midwifery. 800. When a necessity arises to deliver, while the head is thus situated, it is much better to have recourse to the doubt- ful, but safer alternative, turning—for it will rarely happen, that this cannot be performed while the head remains free above the superior strait, even where the pelvis may be a little contracted, with at least as much safety to the child, and cer- tainly more to the mother.* I should therefore earnestly re- • Dr. Davis proposes to deliver from the superior strait, under circumstances not recognised by any other practitioner. He observes, " In profuse uterine hxmorrhage, for instance* the orifice of the uterus being supposed to be amply dilated, but the head of the child still at the brim of the pelvis, this method of treatment might sometimes very well deserve consideration, in comparison with delivery by turning." (Elem. Oper. Mid. p. 233.) I have already noticed this opinion of Dr. Davis, elicited by other considera- tions of his subject, at par. 631. I there suggested, and now repeat, that the use of the forceps, under such circumstances, must be uncertain, if not dangerous; [41] 322 USE OF THE FORCEPS. commend to every unskilled practitioner, not to attempt this difficult, nav, in such hands, dangerous operation. Even Smel- lie* himself, the original projector of the use of the forceps at the superior strait, deprecates their employment at this part of the pelvis; he says, "a long pair of forceps may take such firm hold, that, with great force, and the strong purchase, the head may be delivered, (from the superior strait,) but such violence is commonly fatal to the woman, by causing such an inflamma- tion, and perhaps laceration of the parts, as is attended with mortification. In order," continues he, " to disable young practitioners from running such risks, and to free myself from the temptation of using too great force, I have always used and recommended the forceps so short in the handles, that they cannot be used with such violence as will endanger the woman's life." From this it would appear, that even in the hands of one of the most expert accoucheurs that ever lived, there was much danger attending delivery by the forceps, while the head remained at the superior strait. CHAPTER XXI. OF THE LOCKED OR IMPACTED HEAD. 801. When the head has advanced some distance into the pelvis, and cannot proceed farther, and when it is immovable except upward in the pelvic cavity, it is then said to be locked or impacted. Baudelocque's account of this situation of the head, is by far the most lucid I have met with; he most suc- cessfully combats the opinions of both Levret and Roederer upon the mechanism of this arrest of the head, and completely establishes his own doctrines upon this point. I have so rare- and I must again declare, I think turning to be the proper operation, if necessan to have recourse to any. » Treatise, Vol. I. p. 221. THE LOCKED HEAD. 323 ly met with this situation of the head, that I feel almost alto- gether indebted to him for what I know upon the subject; I shall therefore adopt his account of this embarrassing case. 802. He admits but one general species of locking; and that is, where the head is fixed by two points of its surface diame- trically opposite each other; this species he divides into two varieties; 1st, where the head is jammed with its greatest length between the pubes and sacrum; and 2d, where its thick- ness cannot pass, owing to a narrowness of the pelvis; in the first case, it is the forehead and occiput which are in contact with the inner edge of the pelvis; and in the second, it is the parietal protuberances—this latter is the most rare. 803. Whenever the head becomes locked, it acquires the form of a wedge; or as Lamotte finely illustrates it, by com- paring it to the key stone of an arch. Sect. I.—Of the Causes, Signs, and Accidents of the Locked Head. 804. Several causes must concur to produce the locked head; 1st, the long continued, arid vehement action of the uterus, and the auxiliary powers of labour—therefore, this fixedness of the head never need be feared in a delicate woman, agreeably to Baudelocque; 2d, a disproportion between the pelvis and the head; this disproportion may depend upon the mal-situation of the head; upon its great size and solidity; or upon the de- formity of the pelvis. 805. The immobility of the head is the pathognomonic sign of its being locked; but after it has become fixed, other symp- toms arise, which, if they do not characterize this situation, are sure to accompany it—such as a swelling of the hairy scalp of the child; a thickening of the os uteri; an intumescence of the vagina, and external parts. These symptoms do not always declare a locked head, but a locked head is never without them. When the pelvis is so small that the head cannot engage in it, these symptoms take place, agreeably to Lamotte and Roederer; and sometimes are mistaken for signs of a locked head. 806. A locked head is always serious to mother and child; 324 THE LOCKED HEAD. the mother it exposes to inflammation, sloughing, or gangrene ; and the child to almost certain death. 807. The whole of the soft parts of the mother become se- riously injured, by the long-continued and violent pressure which the child's head exerts upon them ; the vagina, rectum, and urethra, sometimes receive irreparable injury. The blad- der also suffers from the accumulation of the urine, nor can it be relieved by the catheter, as the canal of the urethra is en- tirely obliterated. Sect. II.—Indications in the Locked head. 808. The principal indication in the locked head, is the deli- very of the child. This is to be effected by the forceps, in pre- ference to any other means, so long as the child is living; if its death be certain, the crotchet undoubtedly merits the pre- ference. If we consult the older writers upon this subject, we shall find they all had recourse to the crotchet upon such oc- casions ; and I am sorry to add, that but too many living au- thors, as well as practitioners, are too fond of following their example. For, though the forceps do not always insure safety to the child, they give it at least the best possible chance; they should, therefore, ever be preferred. In this country, this terrible case is comparatively rare ; this is owing princi- pally to the healthy construction of the pelves of our females. When it takes place, it almost always arises from the bad positions of the head ; and these positions must be either the third or sixth—now, these, as has already been observed, are of rare occurrence. 809. I especially recommend the reader to consult Baude- locque's very useful chapter upon this subject; he will find much excellent practical matter, besides the histories of seve- ral very interesting cases, which are of much importance, par- ticularly to the professed accoucheur. 810. The locked head is sometimes confounded with ahead merely arrested in its progress; this stoppage may arise from, 1st. Whenever the head maintains its diagonal or transverse position, at the lower strait; 2d. When the chin departs from THE LOCKED HEAD. 325 the breast too early in the labour; 3d. When the lower strait is less than the ordinary size ; 4th. When the external and internal parts make much resistance. 811. For the removal of the first cause, we must bring the vertex towards the arch of the pubes; by one blade of the for- ceps, or by a lever; this is not very difficult to perform; I have constantly succeeded, by applying the extremity of the instru- ment upon the vertex, by passing it at the bottom and side of the pelvis, until it has passed under the head; we then raise the edge of the blade, and insinuate it between the side of the pelvis and the vertex; then, if the handle be pressed against the perinxum, its curve will be placed upon, or near the poste- rior fontanelle. When thus fixed, we must draw the instrument downward and forward during a pain, until we can move the vertex to its proper situation. When the head is thus chang- ed, we may withdraw the vectis, and commit the rest to nature. 812. The mode of treating the second case has already been explained, (672, &c.) when speaking on this perverse situation of the head. When the arrest is owing to the smallness of the lower strait, as in the third (810,) the head must be extracted by the forceps, unless the defect be excessive; and if excessive, and the child dead, the crotchet must be used; but if living, Baudelocque proposes the Caesarean operation. If the external and internal parts, as in the fourth case (810,) offer the resist- ance, blood-letting will be the remedy. Sect. III.—Method of Using the Forceps in the Locked head. 813. When the head is locked by its greatest diameter be- coming wedged in the small diameter of the superior strait, it is either by the vertex or the forehead being towards the pubes. In using the forceps for either of these situations, we must conduct them so as they shall apply themselves over the ears of the child, or to the sides of the head. They must be so applied, that the concave edges must be towards the part which will eventually come under the arch of the pubes. When the head is embraced, we must endeavour to raise it up by a compound motion of the forceps; that is, by carrying the handles gently 326 THE LOCKED HEAD. from side to side of the pelvis, and at the same time pushing the instruments upwards, so as to raise it from its bed. When thi^ is done, the vertex or forehead must be turned towards the left side of the pelvis, if practicable; and, when there, the motion we have already described must be given to the handles of the instruments, until either the vertex or forehead, as the case mav be, is brought under the arch of the pubes. Baude- locque directs the head to be turned as it is brought along, but I do not think this necessary; for when the head arrives at the inclined plane, formed by the sacro-ischiatic ligaments, it will turn towards the opening of the pelvis spontaneously. It must be recollected, in order that the instruments shall be carried to such a height in the pelvis, the handles must be kept well pressed against the perinxum. 814. When the head is locked by the small diameter becom- ing jammed in the small diameter of the superior strait, the vertex must answer to either the right or the left side of the pelvis, and the concave part of the instruments must look to- wards it; consequently there will be a choice of blade to be fir.u introduced—if the vertex be to the left side, the male blade must be first, and the reverse. The head must be raised from out of the superior strait by the hand, and then the instrument* must be directed over the sides of the head, and the traction mu3t be in conformity with the axis of the upper strait; and this direction is given by pressing the handles against the peri- naeum. CHAPTER XXII. OF THE USE OF THE FORCEPS IN FACE PRE- SENTATIONS. 815. In considering face presentations, I was inclined to restrict their number to two, instead of the four described by Baudelocque—if I should not be correct in this reduction, 1 USE OF THE FORCEPS IN FACE PRESENTATIONS. 327 » am at least 6ure, that the first and second of my arrangement, are by far the most frequent, and can safely say, I have never met with the third and fourth, though recognised by Smellie and Baudelocque. Indeed the presentation of the face in any position is of veryr rare occurrence; I find I have met with it but seven times in very near nine thousand cases; and, upon consulting the table furnished by "THospice de la Maternite de Paris." I find, that of 12,751 women delivered in that insti- tution, there were but 40 face presentations; and of that 40, but one of the first presentation of Baudelocque, and not one of the second; whereas of the third, there were 22, and 17 of the fourth ; or 22 of my first presentation, and 17 of my se- cond. This is strong confirmation of the infrequency of the first and second positions, of Baudelocque. 816. When a labour in which the face presents becomes complicated by any of the before enumerated causes; or is rendered impracticable from mere position, without the appli- cation of adventitious aid ; and that aid, consisting of the pro- per application of the hand, prove insufficient for its accom- plishment, we must resort to instrumental delivery—this will comprehend, the use of the vectis, the application of the for- ceps, or the employment of the crotchet. 817. Of the mode of using the vectis I have already spoken ;* the forceps I consider of doubtful efficacy, not so much from the difficulty of application, as their mode of action in these particular cases; though, it would seem, Smellie had succeed- * Baudelocque's method of using the lever in this case, (System, Vol. III. par. 1836) appeai-s to me to be defective, as I have already stated. I have, in a few instances, used it as described before, with the most decided advantage—but how far it may be successful as a general practice, I have yet to learn ; for I again de- clare, my experience inface cases is very limited; but it appears to me to be more consonant with the principle to be acted upon in such cases ; which is, to reduce the vertex, and elevate the chin. But agreeably to him, we must act forcibly upon the vertex, that it may " be sufficiently brought down ;" but we cannot bring the vertex down alone by his plan, as the face will descend with if by obeying the same impulse which moved the vertex. Now, this disadvantage is avoided by the plan I propose; namely, after'fixing the vectis properly upow the occiput, we apply no more force to it Uian is sufficient to prevent it from rising in the pelvis, at the time we are acting on the face, by applying two finger? immediately at the extremity of the nose, and upon the upper jaw. 328 USE OF THE FORCEPS ed with them. I would, however, wish to be understood, in speaking of the use of these instruments, that I confine my ob- servations entirely to the two first presentations of the present arrangement,* or where the head is situated transversely in the pelvis. In such situations of the face, we are told, " that we must use the forceps," by both Smellie, and Baudelocque; the latter declaring, that " when we cannot rectify the relation of the face to the pelvis by the plan already advised, or with- out great danger to the mother, because the head is strongly wedged, and the uterus contracted and closed upon the child," —" we must use the forceps to bring the head along in the at- titude we find it in," because fewer inconveniences result from it to mother and child than from any other method. 818. Should the forceps be determined on, we must apply them over the ears; that is, one blade behind the pubes, and the other before the sacrum; they must be so applied that the concave edges must look towards the hind head, which must be brought under the arch of the pubes, and not the chin, as directed by Smellie. 819. Should all the reasons exist for using the forceps, and their application not prove successful, I feel that this is one of the very few cases, where the application of the crotchet is jus- tifiable, for the preservation of the mother, however repugnant I may be to its use, or however revolting its consequences. 820. Having considered all the most frequent and better known presentations of the head, with the various modes of conducting them when nature is sufficient to their accomplish- ment; the mode of operating by the hand alone when she is of herself incompetent to this end ; and the use of instruments when it becomes essential to employ them; I shall not con- sume the reader's time or patience by describing a variety of other presentations of this part as laid down by authors; first, because I have never seen them ; and, second, because I believe if they really exist, they must all, or with few exceptions, be * The third and fourth are so rare, or rather their possibility so doubtful, that I do not think it worth while to notice them farther than I have already done— those desirous of seeing all that can be said upon these positions* are referred to Smellie, and Baudelocque. IN FACE PRESENTATIONS. 329 treated by turning, as I shall direct for many other rare and perverse positions which the child's body may assume at the orifice of the uterus. 821. Nor shall I spend time in describing the form of the vectis, or its mode of application; because the one would be totally unnecessary without the other; and I decline the latter, because, I am not in the habit of using this instrument, except in rectifying bad positions of the head; and then, I have always found one of the blades of the forceps sufficient. I consider the vectis inferior to the forceps, in power, safety, and conve- nience : and I am truly glad to perceive the change which has taken place in the public mind, since the accurate and elaborate analysis of its merits, by the judicious Baudelocque. 822. I am pleased to find a change in Mr. Burns'* opinion upon the subject of the vectis ; he says that " a young practi- tioner shall be less apt to injure his patient, and less likely to be foiled, with the forceps than the vectis;" and particularly gratified that Dr. James, in a note to this paragraph, expresses the same belief. The latter gentleman's opinion, upon this and every other point connected with our subject, is highly' valu- able ; especially, in this country, where the opportunities to test the respective merits of these instruments, can fall to the lot of no one who is not extensively, and for a long period, en- gaged in obstetrics; for the facility of labours among our fe- males, owing to the almost entire exemption from rickets, and other causes which render this process one of much more difficulty in Europe, gives comparatively few opportunities to decide upon their respective claims. 823. I have for many years felt the superiority of the for- ceps over the vectis; but was reluctant publicly to express it, from an apprehension that I might have mistaken my own mal- adroitness in using the latter, for an imperfection in the in- strument itself; but, strengthened by the opinion of Dr. James, I have no longer any hesitation upon this subject. * Principles, James's ed. 1823, Vol. I. p. 447. [42] 330 PRESENTATIONS OF THE BREECH. CHAPTER XXIII. PRESENTATIONS OF THE BREECH. 824. The presentation next in frequency is that of the breech, though not so arranged by Baudelocque; but as before stated, I think it a good rule, to treat of labours in the order of their frequency. The breech may with great propriety be consider- ed as a variety of natural labour; since, the woman most fre- quently is able to relieve herself, though the process may be longer, and more painful, than when the vertex presents, in one of its best manners. And were I to institute a comparison be- tween the two, I should say it is not ordinarily more painful than the fourth, or fifth vertex presentation. I think also, that this presentation is more favourable for the child, than either the feet or knees; especially, in first labours; though the ope- ration, generally speaking, is slower, and perhaps more fa- tiguing to the mother. 825. The great risk, in all the labours, whether natural oi artificial, in which the child first offers the feet, is the delay in the delivery of the head, and the compression of the umbilical cord. Now, the latter very frequently depends upon the for- mer ; and the former upon the bad position of the head, as re- gards the pelvis; or from the rigidity of the external parts. This being the case, it is evident, that the risk of the delay of the head at the inferior strait, in consequence of the want of dilatation of the external parts, must be less in presentations of the breech, than of the feet and knees; because, its bulk is nearly equal to that of the head; and will by its passage through those parts so effectually dilate them, as very much to dimi- nish the risk of such delay. On this account, I think breech labours, caeteris paribus, safer to the child than those of the feet or knees, though they are not generally so considered.* * Baudelocquef says, that " delivery may be generally performed as naturally when the .child presents the breech, as when it offers the feet or knees; only * Syo.vni. Vol. I. par. 766, PRESENTATIONS OF THE BREECH. 331 826. The presence of the breech at the orifice of the uterus, cannot be very well ascertained, or distinguished, before the membranes are ruptured, and the uterus pretty well dilated. Under proper circumstances it may be known, by its forming a large softish tumour in the pelvis, which wants the characters of the head, only with which it is liable to be confounded; for it has neither the sutures, nor the hardness, of this part; nor the roughness of the hairy scalp.* A deep groove is observed in the centre of this part, which when traced, leads to the detection of the anus, and the parts of generation. A discharge of meconium, after the membranes have given way, tends to corroborate, but does not absolutely confirm, the presence of the breech. Sect. I.—Species of Breech Presentations. 827. There are four principal manners in which the breech may present at the upper part of the pelvis; a, the first, is where the lower part of the spine and sacrum offers to the left acetabulum, while its abdomen looks towards the right sacro- iliac symphysis; b, 2d, where the back part of the child answers to the right acetabulum, and the belly to the left sacro-iliac junction; c, 3d, where the spine and sacrum are behind the symphysis pubis, and the belly toward the projection of the sacrum; d,4th, the reverse of this. that, caeteris paribus, it will be a little longer, and more difficult; because the child does not then form so regular and lengUiened a wedge, as when the lower extremities are unfolded." I agree, that it may be "a little longer and more difficult" to the mother; but, for the reasons above stated, I think it safer for the child. * It must, however, be confessed, diat there is sometimes a great deal of diffi- culty in deciding, whether the presentation be the head or the breech—the for- mer, when veiy much swoln by becoming locked, may resemble the breech i and the latter, when very tumid, may have its principal signs so masked, as to render it doubtful whether it be breech or head. Baudelocquef tells of an expe- rienced practitioner, who mistook the breech for a locked head, and delivered it with the forceps. In all cases of ambiguity, I have constanUy made it a practice to introduce the hand, to ascertain the nature of the presentation, whenever it became important to decide the point. t System, Vol. I. par. 1251. 332 PRESENTATIONS OF THE BRF.ECH. Sect. II.—a. Mechanism of the First Presentation of thr Breech. 828. In this presentation the oblique situation of the breech at the upper strait, is soon changed by the contractions of the uterus, into one almost strictly transversal; so that the spine will at one time be found behind the symphysis pubis; but soon after, the left hip or spine of the ilium, will be made to * offer itself under the arch of these bones, while the right will be resting upon a part of the sacrum, and the inclined plane formed by the left sacro-ischiatic ligaments. The spine of the child will rest against the left leg of the pubes, and the hip which is under the arch will rise upwards, while the right will turn into the hollow of the sacrum, and travel successively over the point of the coccyx, and the face of the perinaeum, to offer itself at the bottom of the vulva, that it may escape through the external parts; which presently it does, with the other por- tions of the breech, by rising by a slight bend of the spine, toward the mons veneris. 829. When the breech has passed a sufficient distance through the os externum, the legs of the child fall down; and the remain- ing portion of the body, by the successive contractions of the uterus, will be delivered by passing a little obliquely through the external opening of the pelvis. When the armpits descend to the superior strait, there is a momentary interruption to the farther descent of the body of the child, occasioned by the size of the shoulders, and position of the arms ; but from the pliant disposition of these parts, it is but temporary; for they are made to accommodate themselves to the shape of the pelvis, by the repeated contraction of the uterus. The head now offers itself to the upper opening of the pelvis, the occiput is behind the left acetabulum, and the face before the right sacro-iliac junc- tion. The chin will be found descending before the occiput, in consequence of its having been against the breast of the child. 830. As soon as the head clears the superior strait, the fore- head inclines towards the hollow of the sacrum, by the same pivot-like motion which it performs to place the vertex under the arch of the pubes, in vertex presentations. The nape of PRESENTATIONS OF THE BREECH. 333 the neck will now be under the arch of the pubes, while the face will be lying on the face of the perinaeum. The chin will first escape from the vulva; the other parts of the face, and anterior part of the head, will successively follow; while the nape of the neck will execute a slight circular motion under the arch of the pubes. The arms are liberated, so soon almost as the shoulders are pushed through the os externum.* Sect. III.—£. Mechanism of the Second Presentation of the Breech. 831. In this presentation, the mechanism is precisely the same as that of the first; on the part of the child we must only substitute the right hip, offering at the arch of the pubes, for the left, as in the first presentation; and, at the last period of the labour, the vertex or occiput will be placed at the right side of the pelvis instead of the left. On the part of the pelvis, it is the right acetabulum, behind which the breech offers, &c. Sect. IV.—c. Mechanism of the Third Presentation of the Breech. 832. In this presentation, the breech engages in the superior strait, with its greatest width parallel to its large or transverse diameter^—the spine passes immediately behind the symphysis pubis; and it becomes a matter of some uncertainty, which hip will offer under it; but whichever it may be, it passes through a little obliquely, as in the other presentations. Though in this position the face of the child looks directly to the projection of the sacrum, it seldom happens, that the head becomes jammed with its greatest diameter, in the small diameter of the supe- rior strait; it is therefore almost always found to place itself diagonally, and pass down in that direction, as in the two for- mer presentations. 833. When the breech becomes free, the labour proceeds commonlv as has been described in the first or second positions, as it may be the left or the right hip which offers to the arch of the pubes. * It must be borne in mind, that a strictly natural delivery is here described— «>r in other words, where no adventitious aid is required. 3.34 PRESENTATIONS OF THE BREECH. Sect. V.—d. Mechanism of the Fourth Presentation of the Breech. 834. The only difference in the mechanism of the third and fourth of these presentations, is, that instead of the face being placed below, as in the third, it is found to be looking up, which creates the only peculiar difficulty in this case. The risk of the head engaging with its greatest length in the smaller dia- meter of the superior strait, is perhaps greater in this than in the third—but should this take place in either, difficulty might be created. The fourth presentation is decidedly a rare one— I have met with it but once; and upon examining the returns from "l'Hospice de la Maternite," but one case is recorded in more than 12,000. When it occurs, and we have not lost the opportunity', we should always seek for the feet, and deliver by them. 835. I have already observed, that all the presentations of the breech are attended with slower, and more painful labours; and that the child very frequently suffers. This is especially the case, where the labour has been improperly interfered with, either by rupturing the membranes unseasonably, or under the influence of false principles, seeking the feet, and causing the child to pass rapidly through the external parts, before they are properly relaxed, until the head becomes wedged in the inferior strait. Then, under the direction of the same errone- ous views, it is attempted to deliver it quickly, by making force supply the place of address; and the child becomes the victim of this unnecessary, and ill-directed violence. 836. It must constantly be recollected, in all cases in which the head is the last part to be delivered, that when it offer* itself to the os externum, it is entirely from under the direct control of uterine action; the auxiliary, and voluntary powers alone have an influence upon it, at this period of labour; and though external force may, and almost always does become necessary to terminate the labour, it must always be made to co-operate with these powers, by soliciting the woman to exert them as amply as may be in her power. PRESENTATIONS OF THE BREECH. 335 CHAPTER XXIV. CAUSES WHICH MAY RENDER PRESENTATIONS OF THE BREECH PRETERNATURAL. 837. In a breech presentation, the woman may be assailed by any of the accidents already enumerated, as complicating a natural labour, in which the child presents the head; and like such labours, this also must, when the cause is menacing, be rendered preternatural by the interference of art. Besides the causes just alluded to, there may be others connected with the child itself, which may cause us to aid in the delivery of the woman. But in the absence of any such causes, and especially, in a first labour, the process should be left to the powers of nature alone; or at least, until the breech is delivered. 838. I am aware that many respectable practitioners are in the habit of introducing the hand and bringing down the feet, in all cases of breech presentation; but I am abundantly con- vinced, that, as a general rule, it saves the mother nothing, and that it is highly injurious to the child. I am of opinion that this practice is very often the result of the classification of la- bours ; these being almost uniformly placed in the preternatural class, it has been too easily supposed that they always required extrinsic aid. May not this be the reason why so many chil- dren perish in this presentation ? What the general practice in breech presentations may be in Great Britain, I am not pre- pared to say ; but their result is extremely unfavourable; since Dr. Denman says, " I have considered one child in three of those born with these presentations, to be still-born." This proportion by no means coincides with my experience in such cases; the average of living children would be considerably- greater, though a number of my cases were second hand, and in which the first stages of labour were often very ill conduct- ed; I, nevertheless, think Portal's proportion rather excessive —he makes but twenty per cent., while Dr. Denman's is thir- ty-three—in this country, where we but very rarelv meet with 336 PRESENTATIONS OF THE BREECH. a deformity of pelvis; when there is not an excess of size in the breech ; and when the earlier stages of labour have not been disturbed, by ill-timed officiousness, or an entire ignorance of the correct rationale of such cases, I am, I think, warranted in saying, that the number of still-born children from breech pre- sentations, might be reduced to very few. 839. But should any one of the accidents which may disturb a labour, assail a woman whose child is presenting the breech, we are justified in giving such assistance as the exigency of the case may demand. The kind of aid we are to give, will depend upon, 1st, a, the degree of advancement, or the part of the pelvis at which the breech may be at the time; 2d, b, the position of the child; and 3d, c, the size of the breech. a. First Degree of Advancement. 840. A n accident threatening or endangering the life of the mother, may, a, attack her in the very commencement of la- bour, and where the child is still at the superior strait; b, it may attack, when the breech is pretty low in the pelvis, but still included by the uterus; c, it may attack when the breech is at the lower strait, but escaped from the uterus. 841. a. This may happen when the uterus is well dilated, or easily dilatable, or when rigid; the membranes may be either entire or just ruptured, or ruptured a long time. 842. Should any circumstance render it necessary to deliver the woman when the labour is but little advanced; the breech at the superior strait, or near it; the uterus dilated or dilata- ble ; the membranes entire, or just ruptured ; we must without hesitation introduce the hand and bring down the feet, and finish the delivery as directed, when turning is employed for a vertex presentation. But should the uterus be still shut, or but little opened and rigid, nothing should tempt us to enter the uterus forcibly, with a view to bring down the feet and de- liver; especially, if the membranes are entire; as, under such circumstances, there must be a reasonable expectation that the uterus will soon dilate, at least sufficiently to pass the hand without violence. As I have constantly inculcated the impro- PRESENTATIONS OF THE BREECH. 337 priety of dilating the uterus by force, whenever the labour is complicated by any supervening accident, I must be under- stood here to make no exception in favour of this presentation; therefore, when the uterus is rigid, and but little opened, we must treat the case by temporising agreeably to the nature of the accident, until either the remedies, or the influence of the accident, or the powers of the uterus itself, shall make such change as will render the attempt at bringing down the feet proper and safe. b. Second Degree of Advancement. 843. b. It may attack when the breech is pretty low in the pelvis, but still included in the uterus; this may happen when the uterus is well dilated or easily dilatable, or when rigid and unyielding; and when the membranes are entire or just rup- tured; or when the waters have been drained off a long time, and the uterus is firmly embracing the body of the child. 844. In the first instance, or where the uterus is in a condi- tion to transmit the hand without much force, the membranes entire, or the waters but lately passed off, we should bring down the feet as directed in the former instance, and finish the labour after the same manner. But should the os uteri be rigid, whether the membranes be entire or not, we must not force the mouth of the uterus, with a view to terminate the la- bour ; but, as just suggested, temporise, until the uterus will permit the hand to pass for this purpose, without difficulty; for it will rarely happen, even where the waters have long escaped, that we cannot pass the hand to the margin of the pelvis, and seize the feet, provided the proper hand be employed. c. Third Degree of Advancement. 845. c. It may attack when the breech is at the lower strait, but passed through the mouth of the uterus. This situation necessarily presupposes the dilatation of the uterus, and almost certainly the escape of the waters. In this condition of the breech and uterus, we must not attempt to bring down the feet, unless the breech be verv small, or the pelvis very ample, and [43] 338 PRESENTATIONS OF THE BREECH. the woman without pains, or at least efficient ones: for if they are protrusive, and under the circumstances just mentioned, they will deliver the breech in good time, or in such time as will prevent any serious inconvenience from the delay. But should the breech be large, and occupy the lower strait very strictly, we should not attempt to finish the labour by bringing down the feet. In this case, we must assist the passage of the breech, by acting, 1st, with the fingers; 2d, by the fillet; 3d, by the blunt hook or hooks. 846. When the breech is very low in the pelvis, or so low that we can place a finger into the groin, we may, by the force so applied, aid the descent of the breech; especially, if the ute- rus by its contractions still powerfully co-operate with our ex- ertions. Whenever attainable, we should prefer that groin which is most posterior to the arch of the pubes, wlien but one at a time can be operated on. If both groins can be reached, we mayr insinuate a finger of each hand into them, and have this double power to assist the breech to descend. 847. Should the force, just directed, be too feeble for the purpose; or too fatiguing to the operator, he may substitute the fillet with very great advantage. Baudelocque* makes a disparaging mention of this power; he says, " its application is so difficult, that it is with a sort of repugnance that he reckons it among the resources of the art." That it is sometimes diffi- cult in its application, I readily admit; but it is by no means impracticable, when the breech occupies the lower strait. If the passing of the fillet be attempted when the breech is pretty remote from the os externum, we may certainly be foiled; but this is not a case proper for this instrument; for it can only be used when the point of the finger can command the groin. 848. This fillet should consist of a piece of silk riband of an inch and a quarter or half wide, and at least two feet and a half long. When doubled, the point of the fore-finger should be placed in the centre of the fold and kept tight upon it, by draw- ing it sufficiently with the other hand—the parts of the woman and the fillet should both be imbued with lard or sweet oil, and * System, par. 1267. PRESENTATIONS OF THE BREECH. 339 the riband then passed into the vagina by the point of the fin- ger, and conducted over the hip, and into the groin towards the parts of generation of the child, as far as the point of the finger can reach; the finger is then to be retracted a little, that it may gather upon its point another fold of the fillet, which it also carries forward as far as it can reach ; and this to be repeated for several times, until the folds so multiply in the groin, as to move each other forward, so as to appear at the other extre- mity of it—when there, it may be drawn down by the fore-fin- ger of the other hand, introduced, after the first is withdrawn from the vagina; or it may be hooked, as proposed by Baude- locque, and as I have myself practised, by a hook, made ex- temporaneously, of a piece of pretty stiff wire. 849. When the fold of the fillet is seized by the finger and thumb, or hooked by the instrument just mentioned, we are to take hold of one of the outer extremities of it with one hand, while we draw the other end through the groin, by gaining successive portions of it. When the fillet is thus made single in the groin, we take hold of both extremities of the riband, and secure a good hold by passing it several times round some of the fingers. We then co-operate with the pains, if there be any, by pulling in the direction of the axis of the lower strait, until the breech is relieved from the pelvis. 850. But should we not be able to pass the fillet, because the breech is too remote for the finger; or because, the breech is very large and firmly impacted in the pelvis, we must then at- tempt assistance, by employing the blunt-hook, or hooks. I have found, more than once, the hook at the extremities of the French forceps answer extremely well, as Baudelocque has suggested. But, that they may be employed with advantage, they must stand very nearly at right angles with their stems; for if they are too much depressed, they cannot be introduced into the groins; and for this reason I would advise every gen- tleman who may adopt these instruments, to attend to this point at the time he is purchasing them. 851. The mode of using the blunt hook, is, by first placing the point of the fore-finger upon the groove which leads to the groin: then pass the handle of the forcep into the vagina, with i 340 PRESENTATIONS OF THE BREECH. the point of the hook looking upward or towards the point of the inserted finger, until it comes in contact "with it; then, by altering the position of the hook, and making it take the place of the finger, it may, by a gentle pressure, be made to place itself into the groin; when thus placed, we must aid the descent of the breech by pulling at the external extremity of the instru- ment, in the direction of the axis of that part of the pelvis through which the breech is to pass. 852. Baudelocque proposes blunt hooks to join something like the forceps for this operation; but this I do not think ne- cessary ; for when both groins can be commanded, and it is essential from the nature of the difficulties attending the labour, to act upon both of them at the same time, both handles of the forceps, I am of opinion may be employed advantageously, without being united—but I confess this to be conjecture; for I have had no experience of it. 853. When the breech is situated obliquely at the lower strait, we should apply the force whenever practicable, to the groin which offers to the sacro-iliac symphvsis, or side of the sacrum; as this hip should advance faster than the other, that it may arrive at the bottom of the vulva, to escape through the os externum. When placed transversely, we may act upon either, or both groins, until the breech is about to pass under the arch of the pubes—when here, we should endeavour to depress one of the groins, that the ilium may come under the arch, in- stead of the sacrum and spine, unless it does this spontane- ously. Sect. II.—2. Position of the Child. 854. The child may present so untowardly at the superior strait as to be unable to engage in it, in consequence of a se- vere obliquity of the uterus. In such case, one of the hips may only present itself to the opening of the pelvis ; of course, the labour, if not rectified by changing the position of the woman, will be either dangerous, or very tedious and painful. This situation of the hip will, of itself, offer great embarrassments to the woman delivering herself, and often render it proper that PRESENTATIONS of the breech. 341 we interfere without delay; but when this position is attended with either of the accidents heretofore enumerated, it becomes indispensable that we bring down the feet; provided, the con- ditions on the part of the uterus just mentioned, do not render that operation improper. 855. Should the breech present in the fourth position, and this be ascertained immediately after the rupture of the mem- branes, it would, I believe, always be best to bring down the feet; provided, the uterus be sufficiently relaxed to permit the hand to pass without difficulty ; but should this presentation be complicated by accident, it will become absolutely necessary ; but it must be under the provisions just stated. Sect. III.—3. Size of the Breech. 856. The breech may be absolutely large, or relatively so as regards the pelvis; in either case, the same difficulties will be experienced. If the labour be left to itself, it may consume so much of the woman's strength, without much advancing the la- bour, as to render her situation precarious, or even dangerous, without adventitious aid. This case may be complicated bv any of the accidents enumerated; or its difficulties may be in- creased, by being a fourth presentation. 857. When sufficient time has been given without advantage to the labour; and the cause of the delay satisfactorily ascer- tained, we should interpose and save the patient much una- vailing pain. The nature of the assistance to be given must depend ; 1 st, upon the condition of the uterus, and the degree of advancement of the breech; and 2d, whether it be still con- tained, or has escaped, from the mouth of the uterus. In the first case we must bring down the feet so soon as the uterus will permit; and in the second also, provided, the breech is still within the uterus ; and the waters but recently drained off; but if it has escaped from the orifice of the uterus, we must em- ploy the fingers, the fillet, or the blunt hook, as may appear expedient. J42 PRESENTATIONS OF THE BREECH. Sect. IV.— The Mode of bringing down the Feet, in the First Presentation of the Breech. 858. The success of this operation very much depends upon the choice of the hand to be employed. The rule on this subject is extremely simple—the hand, the palm of which will answer to the anterior parts of the child, is always to be used. In this presentation then, the left hand will be the pro- per one for bringing down the feet. It must be introduced with due attention to the rules already laid down, when speak- ing of turning, and passed upward before the right sacro-iliac symphysis, until it can grasp the breech—this must be raised, and carried into the left iliac fossa. We must then search for the feet, by tracing the posterior part of the thighs and legs, until we arrive at them; they must be seized as before direct- ed, and brought down. 859. If but one foot can be obtained, we may attempt the delivery, by acting upon it alone; but when practicable, it is ' best to search for the other, unless it will require too much force. If the breech be small, it will rarely happen that much difficulty will be experienced in doing this; but this is precise- ly the case where we can almost always succeed, by exerting a force upon the one. When delivering by one foot only, we should be very mindful of the direction in which we act upon it—we should always direct our force so as to carry the leg towards the retained one, lest we fracture or dislocate the thigh; and, when the folded leg begins to appear, we may as- sist it by acting with a finger on the groin. When the breech is without, we must conduct the body along, until the other leg and foot come down of themselves. 860. When the breech is still within the uterus, and is about to occupy the lower strait, or actually in it, we can very often, should the necessity of the case require it, gain the feet, and thus expedite the labour; provided, the waters have not been long drained off; when the pains are, and have been feeble; and when the breech is not of an unusual size. But if the breech has passed the os uteri, we must not think of this expe- PRESENTATIONS OF THE BREECH. 343 dient—when thus situated, the fingers, fillet, or blunt hook, must be our aids. Sect. V.— The Mode in the Second Presentation of the Breech. 861. A proper choice of the hand must be made in this pre- sentation, as well as in the preceding—when the emergency of the case requires bringing the feet down, we must make use of the right hand instead of the left, and conduct the rest as just directed. If but one foot can be obtained, we must proceed with it to finish the labour; but always recollecting the condi- tions which would render this partial action safe and proper. Should the breech, however, have escaped from the mouth of the uterus, it would be highly improper to pass up the hand with a view to bring down the feet—the aids just indicated (845) must then be resorted to. Sect. VI.—The Mode in the Third Presentation of the Breech. 862. The spine of the child, in this presentation, is to the symphysis pubis, and the abdomen to the projection of the sacrum—this position is less favourable than the first and se- cond, owing to the risk of having the head to engage with its greatest length parallel to the small diameter of the superior strait: this, however, is not a necessary consequence of this presentation, as we have already observed. 863. In this presentation, either hand may be used. When required to act, the hand must take a firm hold of the breech, as directed for the raising of the head, and carry it forward and upward, over the pubes, and then pass the hand along the legs, until the feet can be reached; they must now be brought down, as heretofore directed; only observing, when the feet are entirely without, to turn the breech so as to make the bodv have an oblique position as regards the pelvis. Sect. VII.—The Mode in the Fourth Presentation of the Breech. 864. I have already remarked how very rare this presenta- tion is; but when it does occur, there can be no doubt of the 344 PRESENTATIONS OF THE BREECH. propriety, if called to the case in proper time, of always search- ing for the feet. In this presentation, either hand may be used as mentioned for the third; only observing, that the breech, in this case, if possible, must be carried to one of the iliac fossse; to the right, if we use the right hand, and the reverse, that the body mayr enter the superior strait obliquely, so as to give the chance to the face to turn from the pubes—after this, we search for the feet, and bring them down as directed. When the breech is without, we must attempt to give an oblique position to the body, if it has not already acquired it. 865. It may be proper to observe, that all these cases are to be subject to the rules I have endeavoured to inculcate for the safety of the uterus : 1st. That no severity of accident can justify forcing a passage into the uterus, with an intention of gaining the feet, when the os uteri is unyielding. 2d. That when the breech is very large, the waters long drained off, the uterus firmly contracted on the body of the child, and much force would be required, (whatever address the accoucheur may possess,) the feet must not be sought for; but the labour must be terminated by the other agents already indicated. (845) 3d. But when the uterus is in proper condition; and the mem- branes just ruptured, or the contractions not severe, though the waters may have escaped some time, we should lose no time by temporising, when the nature of the accident is such as to render interference important to both mother and child. CHAPTER XXV. ON THE USE OF THE FORCEPS WHEN THK BODY OF THE CHILD IS DELIVERED, AND THE HEAD RETAINED. 866. The risk which a child always runs when its body is delivered first, is such as to make us consider all such labours hazardous, whether the necessity for this consideration be USE OF THE FORCEPS. 345 either natural or artificial. I have already adverted to this; but it may still be useful to repeat, that the danger to the child arises, 1st, from the severe extension to which the cervical vertebrae may be liable, when it is necessary to employ force for the deliverance of the head; 2d, the almost inevitable com- pression of the cord; especially, if the head be large, either positively or relatively, and thus occasioning delay; or if it be caught between the head and pelvis, or if it be tightly stretch- ed by its passing between the legs of the child, and we are un- able to relieve it, &c. These causes pretty constantly operate, where the head is the last part to be delivered, unless the pel- vis be very ample, or the head small, and the external parts readily disposed to yield, and the mechanism of this part of the labour well understood. 867. These considerations early engaged the attention of Smellie ; and the result of his deliberations was, the practica- bility of applying the forceps with success in such cases. Ac- cordingly,,!^ has left upon record his method of employing them, and the success attending them. He has been followed by De Leurie, Baudelocque, and others. I am every way dis- posed to do justice to the merit of this application of the for- ceps ; and consider it as a real improvement in the art, when- ever their application is guided by experience, or their employ- ment properly limited. 868. It will be readily admitted, by all who have essayed the application of these instruments, with a view to deliver the head when the body was delivered, that it is attended with no inconsiderable difficulty, even in the most simple of the cases in which they may be required; how much more, then, when the head is remote from the inferior, and perhaps tightly wedged in the superior strait; in both of which cases, the use of these instruments is recommended. I did not succeed in the two or three instances in which I employed them, under the circumstances described by Smellie and Baudelocque, and as represented by the former in his 35th, and by the latter in his 14th plate. I will not say that their application is imprac- ticable, because I failed; especially, as both Smellie and Bau- delocque declare they have succeeded: but there are several [44] 346 USE OF THE FORCEPS. serious difficulties to oppose their application : 1st. When the head of the child is at the superior strait, and engaged with its greatest length between the pubes and sacrum, or even the contrary, the axis of this strait is so much in advance of the inferior, that it seems almost impossible that the perinsum should be so far pressed back, as to permit the forceps to correspond with it, that they may securely grasp the head; 2d. That if the head be even grasped by the forceps, it must be in the direction, or very nearly so, of the perpendicular diameter of the child's head, instead of the oblique; a circum- stance of great consequence to the success of the operation: 3d. This disadvantageous position of the head for the use of these instruments, may lead to the belief that they are well placed, because their handles unite without difficulty; whereas, they but very partially embrace the head; and, if an effort be made to extract, they will most probably slip, by which the uterus, vagina, or bladder, may be severely injured. % Sect. I.—Cases proper for the Forceps. 869. From these considerations, I would confine the use of the forceps, in the cases under consideration, to two situations of the head, and those at the inferior strait, a. The first when the vertex is behind the symphysis of the pubes, and the face resting on the face of the perinaeum; b. The second when the forehead is behind the symphysis, and the vertex lying towards the hollow of the sacrum. a. Mode of Operating in the First Case. 870. It will rarely happen that the forceps shall be indicated in this situation of the head, since, when it arrives here, it may be almost always delivered by soliciting the voluntarv power* of the woman; by depressing the chin; and by a judicious force exerted upon the trunk. But at this moment, the woman may be attacked by some accident; or the head may be very large, or the pelvis narrow; the cord may be in danger of com- pression ; the woman may be too feeble to make any effort to relieve herself, and it might require too much force for the USE OF THE FORCEPS. i 347 safety of the child to attempt its deliverance by the body alone, yet the welfare of it may require immediate delivery. 871. When the circumstances of the case will most probably be profited by the use of these instruments, we should apply them, if at hand, without loss of time,* in the following man- ner : the body of the child must be carefully wrapped up in a cloth, and carried over the mons veneris as far as it can be done without injury to its neck, and supported there by a careful and judicious assistant; the chin of the child should be depressed, and the male branch of the forceps be passed to the left side of the pelvis, depressing the handle pretty suddenly against the perinaeum; this must be more or less, as we may find it neces- sary to make the blade conform as much as possible to the oblique diameter of the head; when this is arranged, the han- dle must be sustained until the other blade is passed on the opposite side of the pelvis, and made to correspond with its fellow—the handles must now be locked, and drawn in such direction at one and the same time, as shall tend to disengage the vertex from behind the pubes, and at the instant raise the face along the perinseum, until the chin and other parts of the face successively pass through the os externum. b. Mode of Operating in the Second Case. 872. The only difference in the mode of operating in this from the first, (871,) is, that the body of the child must be car- * It might on some accounts be proper to be provided with these instruments, whenever we have leisure to send for them, in, all such cases as we cannot decide positively they may not be necessary. I was once made particularly happy by having them with me, when sent for to the aid of a midwife. The patient was pretty far advanced in life before she married; she had lost three children previ- ously, and was now in labour with a breech presentation. The child was very large, and required the fillet—the breech I delivered, the body followed, and no difficulty was experienced until the head was stopped at the inferior strait, in consequence of its size. I employed as much force as I dared, and the woman exerted herself powerfully; but the head, though well situated, could not be made to pass. I was very anxious about the life of the child; and the poor mo- ther begged that I might save it at any expense of pain to herself, as she "had lost all her poor babes before." I determined to try the forceps, as I had brought them with me; and did, with the happiest effect. 348 PRESENTATIONS OF THE FEET. 4 ried backward, and gradually depressed as the head disengages backward.* CHAPTER XXVI. OF THE PRESENTATIONS OF THE FEET. 873. The presentations next in the order of frequency, are the feet; these presentations are with propriety ranked among the natural labours, because the woman is enabled to deliver herself. Baudelocque says that " those labours in which the child presents the feet, considered as natural, are not the most advantageous; but, as preternatural, they must be esteemed the easiest and the most favourable." In this I cannot exactly coincide; at least as far as regards the safety of the child, which, in my opinion, ought always to enter into the calcula- tion ; for its welfare must be regarded as constituting at least a part of what is to be understood by the words " most favour- able." I have elsewhere (825) assigned my reasons for this. 874. Had not the erroneous principle been but too often in- culcated, and still more frequently acted upon, " that in presen- tations of the feet, not to deliver the woman as speedily as pos- sible, was to exercise a cruelty towards her, by permitting her to endure hours of pain, when it was in our power to relieve her in a very short time, by exerting a force by the feet, which would speedily deliver the body," we should have had fewer occasions to complain of injuries sustained by the mother, and fewer opportunities to lament the death of the child. 875. It should be held as a fundamental principle in this order of labours, and all others enumerated under the title of natural, that they must be considered as such in the true sense of the word, at least until the uterus is dilated, and the mem- branes are ruptured; and after these have taken place, only to consider them as preternatural, or labours requiring assistance, • Baudelocque advises the forcep^ in these cases, when the child is dead, in- stead of the crotchet. PRESENTATIONS OF THE FEET. 34<* when they are complicated by accidents, or when their pro- gress is retarded by causes existing in the uterus itself, or from the position of the child. Under such circumstances, we are not only justified in aiding the woman in her struggles, but it becomes a duty to do so, in the best, and most efficient manner, the case will admit. But to do so with the greatest advan- tage to both mother and child; and that the former need not suffer from the effects of ignorant rashness, or the latter fall a victim to it, requires a thorough knowledge of the mechanisms of these labours, as well as considerable address to fulfil the various indications, their different positions create. 876. The presentations of the feet are readily distinguished from allothers, by there being no other parts of the child which resemble them; the hands alone bear any analogy; but from them they are easily told by the projecting heels, the short toes, and especially by the absence of the thumb. Baudelocque, whom I shall follow, has divided presentations of the feet into four species—the distinguishing marks of each being derived from the part of the pelvis to which the heels and toes are di- rected. Sect. I.—Species of Feet Presentations. 877. In the first presentation, the heels are a little anterior to the left acetabulum, and the toes are directed towards the right sacro-iliac symphysis; the breast and face are above and over it, while the back is placed to the anterior and left lateral part of the uterus. It may, perhaps, be proper to remark, that in these presentations, the feet and legs do not hang loose and dangle in the pelvis, but, on the contrary, the thighs are flexed against the abdomen, the legs folded against the thighs, while the heels are almost always placed against the breech, or are in its immediate vicinity. I thought it best to state this, as the difficulty7 which is sometimes experienced in bringing down the feet, will be much better comprehended. It must also be borne in mind, that both do not always present at the same time, and that they are so moveable in the pelvis oftentimes, that it is more difficult to locate their exact position, than to distin- guish it is the feet that are presenting. 350 + PRESENTATIONS OF THE FEET. 878. In the second presentation, the heels are behind the right acetabulum, or a little forward; the toes look toward the left sacro-iliac symphysis; while the breast and face are above and over it; the back is placed to the right anterior portion of the uterus. 879. In the third presentation, the heels are to the symphy- sis pubis, and the toes toward the sacrum; the back is placed to the anterior part of the uterus, while the breast and face look towards the lumbar column. 880. In the fourth presentation, the position of the child is exactly reversed; the heels are to the sacrum, and the toes to the pubes; the back towards the lumbar column, and the breast and face are turned towards the anterior part of the uterus. 881. Nature seems to have been particular in the arrange- ments of the presentations of the breech, feet, and knees, by making the numerical order of each resolve themselves into one general position* so soon as the legs are without; so that the most favourable situation, or the first presentation of the breech, of the feet, and the knees, have each of them the legs in precisely the same situation when delivered: so true is this, that did we not arrive before this happened, we could not tell with which of these presentations the labour commenced—the same may be said of all the rest. We are, therefore, much indebted to Baudelocque, for his ingenious and natural ar- rangements of these labours. It is also remarkable, that the frequency and infrequency of each of these different species of natural labour, should be with few exceptions in the order of their numerical succession: thus, the first presentations of the breech, feet, and knees, are more frequent than the second; the second more frequent than the third; and the third most generally more frequent than the fourth, &c. 882. Why is it that we meet with more presentations of the feet in premature deliveries, than in those at full time ? or, is this mere coincidence? PRESENTATIONS OF THE FEET. 351 Sect. II.—Preternatural Labours in which the Child presents the Feet. 883. The causes which may render a labour preternatural, in which the child presents the feet, may be any of those al- ready enumerated, or may depend upon some irregular and inefficient action of the uterus, or the mere position of the child itself. Should any of the accidental causes complicate a labour in which the child presents the feet, we must consider it a sufficient reason for interfering with its progress; and we must expedite the delivery by bringing down the feet; the mode however of doing this, will depend upon the particular presentation with which we have to contend. 884. From the position which the breech almost always as- sumes in these presentations, it will be readily perceived, that one cannot well descend without the other, and that it is the width of the breech, thighs and legs, which offer together at the superior strait; hence, they will sometimes become jam- med, at this part, and the feet or foot will cease to advance— now this situation of things may happen, when the difficulties of the labour may be increased, by some one of the accidents already enumerated; (625) or this may exist alone, and become a sufficient reason for manual interference. Or the uterus may, from any of the causes we have already acknowledged as ca- pable of such effect, be incompetent, though no embarrassment be created by position, to force the parts down to the bottom of the pelvis. Or the fourth presentation itself may be con- sidered as essentially bad. 885. Under either of these circumstances, we are obliged to convert an otherwise natural, into a preternatural labour. It will be constantly kept in mind, when I recommend taking hold of the feet, that I always suppose the membranes to be ruptured, and the os uteri dilated, as I have uniformly incul- cated for every operation of the kind. I may remark here, that there will be some difference in the mode of acting in foot- ling cases, arising from the circumstance of presentation, or of one or both feet being within reach; but these will be illus- S52 PRESENTATIONS OF THF. FEET. trated as I proceed. I may repeat here, lest it be forgottea, that the woman is supposed to be constantly placed upon her back, as recommended for all cases of preternatural labours. Sect. III.-—Mode of Acting in the First and Second Presenta- tions. 886. I have already remarked, that when the feet are with- out in both these presentations, they are precisely the same in mechanism as the first and second breech presentations; there- fore, I shall only point out the mode of treating the labour un- til that period, as then every thing must be conducted as di- rected for those presentations. 887. When it is agreed there is a necessity to expedite the labour, it must be done by introducing the hand into the vagi- na, if the feet still remain at the superior strait; if this be the case, we pass the hand until we can by a proper grasp possess ourselves of the feet; when secured, we draw them downward; but if this require more force than it would be prudent to ex- ert, we must desist, and act upon the breech by gently raising it up, which will almost always permit the feet to fall down; or at all events, enable us to proceed with them through the pelvis. Should but one foot offer, we may act upon it, and oftentimes successfully, when the child is small compared with the size of the pelvis; but if it come reluctantly, and evident- ly require an improper degree of force to bring it along, we should cease to act upon it, and search for the other foot. 888. When the second foot is accessible, it is always best to make it descend with the other; and not merely push it up that it may unfold itself along the abdomen of the child; but let it be recollected, when we are obliged to search for the se- cond foot, it is a matter of consequence to make a proper choice of hand; for it may be resting on the margin of the pelvis, or it may be unfolded and high up in the uterus; therefore, in either case, the facility of the operation will very much depend upon the hand—this I well know from experience. The rule in these cases is precisely the same as in the breech cases ol PRESENTATIONS OF THE FEET. 358 the same numerical denominations; namely, the left hand for the first, and the right hand for the second presentation. 889. The reasons wherefore I prefer having both feet to act upon in these cases, are; first, we can exert the necessary- force to much greater advantage by acting with both; second, we run much less risk of doing injury to the limbs; for if we act by one alone, we may chance to hurt it by the force not being divided ; third, we can give a better direction to the body- as it descends, when it is necessary to effect any change upon its course. 890. The only difference in the mode of acting in the se- cond presentation and the first, is the necessary choice of hand -—in every other respect the mechanism is the same. 891. Should more than two feet appear, as in twin cases, in the passage, we must be careful to select those which belong to the same child; this sometimes creates more difficulty than would at first be imagined; for simply selecting a right and left foot, by no means proves they belong to the same body; and if they should not, much inconvenience jnay be experi- enced. It is true, this circumstance will rarely occur, as it sel- dom happens that the membranes of both give way at the same time, or before one of the children is delivered; yet it happens. An instance of this kind occurred to myself; that is, in attempt- ing to bring down two feet, properly selected as I supposed, where there were three, I got a foot of each of the children; I discovered this, however, sufficiently early, to enable me to pass up my hand, and select the proper foot; but not without difficulty. Sect. IV.—Method of acting in the Third and Fourth Presen- tations of the Feet. 892. If I be permitted to draw a conclusion from my own experience, or take for fact what is stated in the register of "PHospice de la Maternite," I find either of these presenta- tions extremely rare, and especially the last. Of the third pre- sentation, I find but three instances recorded in nearly 13,000 cases, in the practice of that institution, and of the fourth but [45] 354 PRESENTATIONS OF THE FEET. one. In examining my own practice, I find two of the third, and but one of the fourth presentation. 893. The third presentation is not so replete with inconve- niences as the fourth, nor so uniformly fatal to the child; yet it is sufficiently so to make us fear it when it occurs; especially, if the forehead does not spontaneously turn from the projec- tion of the sacrum, and place itself before the sacro-iliac sym- physis of one side or other of the pelvis, that the head may descend in a diagonal situation to the lower strait—when it arrives at this place, in this direction, it will rarely happen that the face cannot be made to apply itself to the perinaum at the last period of labour. 894. Should this favourable disposition of the head, how- ever, not take place spontaneously, it points out what should be done, to make the labour more advantageous to both mother and child. Should we have charge of the case sufficiently early, that is, before the fVet have descended, and when the mem- branes have but lutely y ielded, we may dispose the head to turn to one side, by making the body observe an oblique posi- tion in its descent, by turning the toes to one side of the pelvis. Indeed, this would seem to be almost the only period at which we could, pretend, with any certainty, to do this by any ma- noeuvre performed on the body of the child; for, after it is either in part or wholly delivered, they would be almost nu- gatory. 895. We are directed by most writers who have mentioned this case and the fourth, to attempt this change, by gi|ring an extensive twist to the body, for this purpose. Thus, La Motte, Levret, and Smellie, advise this motion to be made, by turning the child's body, under the expectation that the head and face will obey the impulse; without seeming to recollect that in these cases, the head is not very moveable in the pelvic cavity; especially, when the waters have been long drained off, and that to change it would require much more force than can be safely exerted, or a much more extensive twist of the child's neck than is compatible with its safety. 896. When the body is delivered, and the shoulders have descended sufficiently low to permit it, we should immediately PRESENTATIONS OF THE FEET. 355 ascertain whether the position of the head be correct or not— should its position be favourable, we should proceed^ with the labour, as has been already directed for the breech; should it not, we must endeavour to rectify it, by acting upon the face so soon as the shoulders have been cautiously delivered; that is, without having exerted a force upon them, sufficient to jam the head in a bad direction at the superior strait. 897. Should the head be jammed in the superior strait by any ill-directed force, it must be relieved as quickly as possi- ble, if we expect to preserve the child—this must be done by passing the hand under the head at the bottom of the pelvis, and gently raising it, so as to lift the vertex from behind the puhes, and at the same time turn the face to one side. The side to which the face must be turned, will depend, first, upon the inclination it may have to either the right or left side; choosing that always, to which it most tends; and, second, upon the hand which may be employed to rectify the position, when no inclination toward one side or the other is observed; if the right hand be used, it will be easiest, ca;teris paribus, to turn it toward the left, and the reverse. 898. Before, however, this reduction is attempted, it will be well to have the body of the child carefully raised by an assist- ant, towards the abdomen of the mother, that the hand may be introduced with more certainty and facility; care being taken in doing this, that the head is not drawn down, by the body being carried up. When the position of the head is adjusted, we must act as has been directed in such cases for the breech. 899. In the fourth presentation, we can scarcely expect to improve its position, unless we are very early with the patient; that is, immediately after the yielding of the membranes, and have, at the same time, the os uteri sufficiently dilated to en- able the child to obey the direction we mean it should take. Unless we can take advamtage of this period to move the face toward one of the sides of the pelvis, I am disposed to believe, that very little can be done, until the shoulders are without-— except indeed the head be small compared with the pelvis; in this case there is very little necessity for assistance, as it will pass, face upward, under the arch of the pubes, without much difficulty. 356 PRESENTATIONS OF THE FEET. 900. When the shoulders are without, I am sure it will sometimes succeed, to turn the face towards one of the foramina ovalia; the occiput, by this change, will descend a little, and offer itself toward one of the tubers of the ischia, or a little obliquely as regards the lower strait; and may, by a well-direct- ed force, aided by the voluntary contributions of the mother, be made to escape in this diagonal position. 901. I would always recommend to the young practitioner, in cases of such very doubtful issue to the child; and more especially, in the fourth presentation, to advertise the friends of the patient of the risk the child must inevitably run in its delivery, that no exorbitant hopes may be entertained, of eventual safety. 902. There will be, of course, the same propriety in using the forceps in any of these cases, as was expressed for their employ- ment, in breech cases. CHAPTER XXVII. PRESENTATIONS OF THE KNEES. 903. The presentations of the knees are very rare indeed; and I might perhaps have passed them over in silence, without incurring much censure for the omission. But I have chosen to notice them, because they are rare; and because they are sometimes embarrassing to the young practitioner; for I well recollect my trepidation, when called to a case of this kind, in the very commencement of my practical career. To add to my embarrassment, I was called to the assistance of a midwife, who could not have been well more ignorant of what was pro- per to be done than myself. I will not pretend at this time to designate the particular presentation of the knees, as I knew nothing about them at that time; I only recollect, that I rea- soned in the following manner upon the subject:—"If the feet were without, I should feel little or no difficulty in the case, as PRESENTATIONS OF THE KNEES, 357 I once attended a labour of this kind successfully; and it can- not be very dangerous to pass the hand to them, space they must be in the neighbourhood of the knees." With these re- flections, I passed a hand into the vagina, and tracing the legs, soon obtained the feet, which I had the good luck to bring along, by accidentally (this it must have been, for I had no principles to direct me) disengaging the knees from the margin of the pelvis, against which I now know they must have butted ; and terminated the labour successfully to both mother and child, but with severe agony to myself. 904. These presentations are more unusual than any I have hitherto considered; not occurring oftener, perhaps, than once in a thousand or more times. They are less favourable than any of the presentations I have classed as natural; and agreeably to Baudelocque, they may present in four ways: 905. In the first presentation of them, the legs are to the left side of the mother, and the thighs to the right. 906. In the second, the legs to the right, and the thighs to the left. 907. In the third, the legs under the arch of the pubes, and the thighs towards the sacrum. 908. In the fourth, we find the reverse of the third. 909. The mechanisms of these labours are precisely the same as those of the feet; for the latter must be quickly developed, if die labour proceed; and then they are reduced to footling cases. 910. The knees may be distinguished, when together, by their similarity, and the roundness of the bony angles they form. When but one presents, which is most commonly the case, it is not so easy; but we may trace the leg, and find by this means the foot, which puts the matter out of doubt. Sect. I.—Causes which may render Presentations of the Knees preternatural. 911. Until the membranes be ruptured, and the uterus pro- perly dilated, a presentation of the knees is to be treated as I have directed for the breech or the feet; if the presentation can be discovered before that period. 358 PRESENTATIONS OF THE KVFfS. 912. Baudelocque directs, that we should not in these pre-* sentations search for the feet, unless the labour be complicated by some accident; but the difficulties which a woman almost always experiences in delivering herself in these cases, are such as to render it, I think, the better practice always to bring down the feet; especiallv, in the earlier part of labour, when neither force is required, nor inconvenience hazarded, by the proceeding. I once witnessed a case, where many hours of severe suffering had been experienced, from a presentation of the knees, without its having made the smallest progress, after the first hour or two : the breech and knees had progressed together in such manner as to completelv occupy7 the pelvis; several pretty severe attempts had been made by the midwife, as she herself declared, to make the knees descend, by acting upon them, to the serious injury of the child. After this pe* riod, I was requested to visit the patient. I found the pre- sentation to be the first; but the breech had descended so much as to carry the knees against the right sacro-iliac symphysis, and thus prevented the farther progress of the labour. I in- troduced the right hand, and,with some exertion was enabled to raise the breech sufficiently to permit the feet to fall down near to the os externum; the knees were then readily7removed from their position, and the delivery speedily effected. 913. Now, as there is no security that the breech will not descend in proportion to the advancement of the knees ; and if it do, the knees will almost certainly be arrested against some portion of the pelvis ; in which case the contractions of the ute- rus and the efforts of the woman are almost sure to be-unavail- ing, though continued for hours, I think it always best to bring down the feet and knees, by pushing up the breech, whether the case be free from, or complicated by, any of the accidents which might happen it, unless when the os uteri is sufficiently dilated, the feet are found to unfold, or the knees to advance: then we may trust the labour to nature. Sect. II.—Mode of operating in presentations of the Kn$es. 914. When we attempt the relief of the woman in such cases, I am decidedly of opinion we should commence as early as the PRESENTATIONS OF THE KNEES. 359 state of the uterus will permit; and especially, when it may be either the third or fourth position; in either of which, however rarely they may happen, we should experience all the inconve- niences which are found in the third and fourth presentations of breech and feet, with the contingency of the knees stopping in their progress, and at a time when it might be either diffi- cult or dangerous to attempt making the changes upon the di- rection of the body, so important to the safe delivery of the head. 915. Baudelocque recommends pushing up the knees when we attempt their reduction; but, so far as I am capable of com- paring the two methods, I think acting upon the breech the better plan, j • 916. He also advises the employment of the fillet, or blunt hook, for the delivery of the knees—I confess I have tried neither—but it appears to me they7 cannot in every position of the knees be employed with advantage ; but in one I think they may aid (that is, the fourth), when these parts have descended low in the pelvis ; as then the direction necessary to the deli- vering them will be the one, and the only7 one, we can give them by either fillet or blunt hook. The proper hand must be employed, when we attempt to raise the breech, or we may fail in the attempt to liberate the feet and knees—in the first presentation, we must use the right hand; in the second, the left; and in the third and fourth, either. CHAPTER XXVIII. OF RIGIDITY, Kc, OF THE SOFT PARTS. AS THE CAJUSE OF PRETERNATURAL LABOUR. 917. Writers upon midwifery have but very imperfectly considered the rigidity of the soft parts as a cause of difficult or tedious labour—some indeed do not mention it, and others do so, merely en passant, without proposing any specific treatment 3 30 RIGIDITY OF THE SOFT PARTS. for its relief. It is so common a case, that every practitioner must have met with it; but it has failed to make a proper im- pression, because time and severe suffering have eventually overcome it, though not always with safety to either mother or child. 918. It is decidedly the most frequent cause of tedious la- boar ; and it may occur in such as we regard as strictly natural, as well as in those, which are confessedly7 preternatural; and when it does occur in the latter, it adds much to their difficul- ties, while it renders the former tedious, and terribly painful. I cannot pretend to point out the cause of this rigidity; and shall therefore, not lose myself in the wilds of conjecture, but merely state the various conditions under which it may present itself. Sect. I.—Species of Rigidity. 919. a. First, it may arise in the mouth or neck of the uterus, from the circular fibres of these parts maintaining their power inordinately long : but not inflamed. 920. b. Second, this condition may be attended with inflam- mation. 921. c. Third, it may arise from previous injury done the parts, by7 either mechanical violence, or inflammation, and its consequences. 922. d. Fourth, it may happen from a relative cause; as the disproportionate powers between the longitudinal and circular fibres. 923. e. Fifth, it may proceed from the too powerful exertion of the tonic contraction of the uterus, especially of the fundus and body. a. Rigidity of the first Kind. 924. This species may be divided into three varieties; viz 1st, when the subject is very young; 2d, where she is advanced beyond the twenty-fifth year; and, 3d, where the uterus jfc pre- maturely excited into action. RIGIDITY Of THE SOFT PARTS. 361 Var. 1. 925. In this variety the soft parts are found to yield very often with great reluctance ; and thus making this labour ex- tremely tedious and painful; it would seem to arise from the incomplete development of the uterus—each of the species and varieties will be best explained, by appropriate cases. Case First. " Miss V., aged fourteen years and a half, was taken in la- bour, January 14, 1790. She had been in pain thirty-six hours before I saw her; that is, she complained for that period, though the pains were not very severe; about twelve hours be- fore I visited her, the waters were discharged; the mouth of the uterus was but very little opened, and the external parts not favourably disposed; the pains now were very severe, and the head was pressed pretty deep into the pelvis; she was ex- tremely costive, and had passed no urine for many hours; an injection was ordered, which operated very freely; the catheter was introduced, and nearly a quart of water was drawn off— she was much relieved by these discharges. An hour was given, in hope that a favourable change might take place in her labour. There was but very little heat in the vagina, for she had been rarely- touched. She had, however, by the advice of her midwife, been placed over water, and fumigated with burning onion-shells, but to no purpose. 926. I now bled her fifteen ounces; this produced some little change in the mouth of the uterus, but not sufficient to permit the head to pass, as it contracted and stiffened with each pain. In an hour more she was again bled fifteen ounces; this produced sickness of stomach, which was my signal for stopping. Upon examination now, the parts were found suffi- ciently7 dilated; there was a temporary suspension of the pains, but they soon returned, and were of competent force, and much more tolerable—the labour was soon after terminated. [46] 362 RIGIDITY OF THE SOFT PARTS Var. 2.—Or where the Subject is not young, but with her first Child. 927. The same general phenomena present themselves in this variety7 as in the first, but it is generally rather more obstinate. Case Second. 1798, February 17th, Mrs.----, aged forty, in labour with her first child; she had been long in labour previously to my seeing her, and had suffered much pain—her pains were in quick succession; the waters were still undischarged; the ute- rus opened to about the size of a quarter dollar; its edges very firm; no disposition in the external parts to relax—she was bled largely (40 ounces,) and was delivered in half an hour after. Var. 3.—Or where the Uterus is prematurely calledfinto Action. 928. This may happen at any period of gestation, or in any subject; but I am only now considering those cases where this takes place at the last period. It would in this variety be highly useful to distinguish it from the two just mentioned; as in the beginning it would require very different treatment. The following marks may serve to detect it: 1st. The unex- pended portion of the neck of the uterus may sometimes be perceived by the touch, as at the eighth month or a little after; 2d, the os uteri is rigid, during and in the absence of pain; 3d, the pains are more irregular in their accessions and in their continuance; 4th, no secretion of mucus, nor disposition in the perinaeum to relax; 5th, no subsiding of the abdominal tumour; and the knowledge of some violent mental excitement, or mus- cular exertion having preceded the onset of pain. 929. Should these pains however be suffered to proceed without interruption, it will eventuate in a painful and tedious labour—it therefore should be our first care to appease uterine contraction, by remedies suited to the condition of the patient —blood-letting should be premised, if the pulse merely permit it, and without declaring its absolute necessity; especially, as RIGIDITY OF THE SOFT PARTS. 363 the case may require repeated and large doses, sometimes, of laudanum. Rest should be strictly enjoined; the bowels should be opened by mild laxatives, if costive; this should be follow- ed by injections of laudanum and water, pro re nata—the diet should be mildvand in small quantities. By this kind of treatment we may very often have it in our power to interrupt this disagreeable anticipation of labour, as the following case, among many others, shows. Case Third. 1790, January 29th, Mrs. M. L----, aged twenty, pregnant of her first child, after standing all day at the ironing table, was seized with pretty regular pains. There was no subsiding of the abdominal tumour; no secretion of mucus; the os tincse not entirely obliterated. There was very little tension of the membranes during a pain; from these circumstances I was disposed* to believe the uterus had been prematurely excited to action. She was ordered to lose twelve ounces of blood; to keep quiet, and receive an enema of a gill of water and a tea- spoonful of laudanum—pain soon subsided; she went a fort- night longer, and her labour proceeded kindly, and was not of long duration. 930. In case's similar to the above, much mismanagement frequently takes place, especially when the patient is under the care of an ignorant midwife; as she supposes the attending pains can only proceed from a commenced labour, particularly if her reckoning is nearly expired, she is frequently and often- times rudely handled; the uterus irritated, and the whole sys- tem stimulated by improper drinks or remedies, with a view to hasten the labour as it is called—the following case is in point. Case Fourth. 1790, August 11th, Mrs. C. pregnant with her third child, aged twenty-eight, after a severe fright, was attacked with pains; as her midwife was engaged at the time she was sent for, I was called on. From her being disappointed in her mid- wife, she became very much alarmed, and her pains ceased for 364 RIGIDITY OF THE SOFT PARTS. six hours. At the expiration of this period they returned, and the midwife arrived soon after; she examined her and found nothing like labour. She gave her a large dose of laudanum, which not easing her, was repeated in two hours more. Her pains became more violent; she had much fever, attended with delirium. I was now sent for a second time ; upon examining the pa- tient, the uterus appeared evidently to have been forced into contraction's by the fright, and these perpetuated by the impro- per conduct of the midwife; but things were now in such a situation, that it would have been in vain to have attempted stopping their progress. The mouth of the uterus was thick and hard, and opened to about the size of half a dollar. As there was so much fever, I thought proper to bleed and purge her; these had a good effect, as her fever and delirium were diminished, but the ute- rus was firm, and not augmented in size since she was examin- ed before (six hours;) she was again bled pretty largely, the delirium went off entirely, the uterus opened, and she was de- livered in less than an hour. 931. Had not this patient been bled very liberally, there is every reason to believe her labour would have had a serious termination—she lost in the two bleedings about fifty ounces. This case serves as a contrast to the one just before related; as I believe the bleeding which preceded the anodyne enema, en- abled the latter to produce its beneficial effects; and I am also of opinion, that had a bleeding been premised, in this case, the patient would have suffered much less, and gone some time longer. 932. I think it an important rule in the further manage- ment of these labours, when pain cannot be suspended by the means indicated above, to abstract as much as possible stimuli of every kind; to have the bowels well opened; and then to allow the circular fibres of the mouth of the uterus to be a lit- tle fatigued, before we employ a large or sufficient bleeding to effect the farther dilatation. We may easily know when they begin to be fatigued, by their readily yielding when the finger RIGIDITY OF THE SOFT PARTS. 365 attempts to stretch it in the absence of pain. Bleeding alone sometimes quiets this premature motion of the uterus. c. Rigidity from Local Injuries. 933. It was not until the year 1796 that I learnt the value and certainty of blood-letting in cases of local injury from in- flammation, or from a solution of continuity in the soft parts concerned in labour, where in healing they7 became contracted and otherwise severely7 injured, though I had so frequently ex- perienced its value in cases where they had obstinately refused to yield to the common agents of delivery7, when in the natural condition. The long continued pressure of the child's head during its passage; the ill-judged use, and the worse directed application of instruments; and the reprehensible neglect of the perinaeum when much distended—have all given rise to in- juries of these parts, more or less grievous. These accidents will retard delivery in proportion to their extent; and if some oppose but a trifling resistance to the passage of the child, there are others, from their severity and extent, that render it im- possible without adventitious aid. 934. Cutting instruments have been not only considered as justifiably employed in such cases, but deemed absolutely7 essen- tial for the termination of the labour,* in many instances where bridles, indurations, and cicatrices have deranged the natural order of these parts, or so disturbed their natural functions, as to render them no longer subservient to their proper uses— hence the necessity of means so severe as the scalpel or bis- toury for the relief of the mother and child. 935. I trust, however, this terrible alternative is no longer, or, at least, not so frequently necessary as heretofore; since, it is found, in some of the most distressing and extensive in- juries of this kind, to yield in a very short time to the relax- ing influence of a copious bleeding. To show the certainty of this remedy, even in the most unpromising cases, I will relate several, where it was employed for this purpose with the hap- piest effects. • Baudelocque, &c. 366 RIGIDITY OF THE SOFT PARTS. Case First. 1796, June, I was called to Mrs. T , in labour with her second child. When I arrived, I received the following ac- count of the case from the midwife : " Mrs. T----has been in labour sixteen hours; the waters discharged six; the mouth of the womb is but little opened; and, when in pain, the os exter- num seems to close up; the child is as high as ever, though many things have been given to force the labour. She has passed no water for twelve hours, and she is very costive." I found her very feverish ; complaining of great heat in her abdomen, and violent pain in her head. On examining per vaginam, I found, as the midwife had stated, that the os tincae was but little dilated; its edges very rigid and hot—as was the whole tract of the vagina; the rectum much distended with faeces, and the bladder, by urine. The head of the child was still above the brim of the superior strait; but its situation could not be exactly determined, as the os uteri was not suffi- ciently opened for the purpose. She was bled immediately7, to the amount of twelve or four- teen ounces, and an injection was thrown up, which procured two stools, and a discharge of urine. Upon examination, I found the mouth of the uterus more dilated; and I was enabled to deter- mine, that the presentation was a perfectly natural one; and the head lower in the pelvis. The pains were very powerful; the head at length cleared the upper strait, and the vertex was about to turn under the arch of the pubes, but completely en- veloped in the uterus—during a pain, the perinaeum was much distended; the os externum, instead of yielding to the impul- sive force of the uterus, rather closed, so that two fingers could not be retained at once. A seam, or cicatrice, formed a kind of barrier in the vagina; and the head in consequence, was thrown to the right side of the inferior strait; where the parts were so extremely stretched, that I feared at each pain, the head would burst through them, in spite of every exertion to the contrary.* * The cicatrice just spoken of, was formed hy the healing up of an extensive laceration which the patient suffered in her former labour. It ran from the infe- RIGIDITY OF THE SOFT PARTS. 367 From the oblique situation of the head with respect to the vagina, the os externum, instead of answering to the axis of the inferior strait, was mounted up directly to the pubes; con- sequently the right side of the vagina, perineum, and rectum, had to support the greater part of the force exerted by the ute- rus and its auxiliary powers. In order to counteract their in- fluence, I supported the external parts with my hands; and made, during each pain, a strong pressure against the head; directing the woman at the same time to suspend her volunta- ry powers, as much as possible. Six hours were spent in this manner without advantage ; the os uteri still rigid, hot, and but partially dilated; the os exter- num not disposed to yield, and the cicatrice as firm as ever. The head advanced, notwithstanding my efforts to prevent it; so that the vertex, covered with the uterus, had partly emerged from under the arch of the pubes. At this period it was ex- tremely difficult to touch the mouth of the uterus; as it had receded towards the sacrum, in proportion as the vertex had descended. The soft parts were very hot and dry; and I began to enter- tain serious apprehensions for the patient. I was ten miles from the city; and no one was near, on whose judgment I could rely. In this dilemma I had nearly resolved to divide the parts; believing it preferable to permitting the head to force its way through them ; which I began to consider as inevitable; when fortunately Dr. Physick's case of luxated humerus occurred to me; which determined me to try the effects of bleeding, ad deliquium animi. I represented to the friends of the patient, the danger of her case ; the possible result of the bleeding; and the inevitable one, did it not succeed. They agreed to the trial. I had the patient placed on her feet, while the midwife rior termination of the left labium, to about the, termination of the sacrum. I judged of the extent of the injury, by the cicatrix; and this could be traced to this point. Conversing upon this case, some time after, with the practitioner who had delivered her before, he confirmed my supposition. It was a long time before the wound healed; and the woman's healdi suffered much from the exces- sive, and long-continued discharge; but from this she recovered ; and was, when I was called to her, apparently in robust health. She was about twenty-two years of age; of short stature, and rigid fibre. 368 RIGIDITY OF THE SOFT PARTS. firmly supported the perinamm, &c. A vein was opened, and allowed to bleed, until she fainted.* She was now placed on her side, in the bed. On examining her, every thing appeared better; the external parts were perfectly soft and yielding; and the os uteri pretty fullv dilated ; but no pains succeeded, during the time I thought proper to wait; (which was half an hour, the patient continuing very faint all this time;) the parts being now in a proper situa- tion for deliverv, I introduced the forceps; and delivered a living, and healthy child. The parts yielded very readily with- out laceration; and the woman had a rapid recovery. 936. As cases of the kind I am now cr.usidering, are highly interesting; both from the extent of injury done to the parts, and their rarity, I trust I shall be excused for detailing an- other ; especially, as the mode of treating them is as certain, as it is novel. Case Second. On the 12th September, 1798, I was requested to visit the wife of Samuel G., in consultation with Dr. Jones. I was in- formed by the doctor, that Mrs. G. had been in labour sixteen hours; the waters evacuated themselves early; her pains were frequent and strong; but there was not the least disposition in the soft i arts to dilate.f I examined the patient, and found the os externum scarcely large enough to admit the finger, and mounted against the symphysis pubis, in consequence of the perinaeum being very • The quantity of blood drawn was upwards of two quarts. ■J- This patient, like the one whose case has just been related, had also suffered a laceration of great extent; the parts, after a considerable lapse of time, healed up ; but so unfortunately, as almost entirely to obliterate the vagina I was called upon for advice; the woman's situation was truly distressing; the passage, or vagina, was so much contracted, as not to exceed in size a common writing quill; the parts extremely callous ; and a continual and profuse discharge of acrid, fetid pus, kept her in a constant state of misery, and ill health. My friend, Dr. Phy- sick, was also consulted : by a persevering use of sponge tents, &.c, the parts became sufficiently dilated to admit imperfectly the venereal congress; soon after, she became pregnant; and the consequences of this pregnancy, furnish the above case. RIGIDITY OF THE SOFT PARTS. 369 much distended by the head of the child. The os uteri was rigid, and but little opened; a kind of bridle, or small column of flesh ran from the inferior edge of the symphysis pubis, and lost itself in the perinaeum below: against this the head was Tirmly pressed. The head was situated naturally; and so far advanced, that the vertex was about to emerge from under the arch of the pubes, covered with the uterus; and had been in this situation six hours previous to my visit. All that had been done during this period, was the occasional exhibition of lauda- num, with-a steady pressure against the perinaeum, to prevent the head escaping through it. In this situation of things, what was to be done ? My ingenious and much lamented friend, Dr. Elihu Smith, of New-York, upon the receipt of the history of the case just related, suggested the trial of an infusion of tobacco in similar cases, as a substitute for such extensive bleeding; affirming the effects were very like those produced by copious blood-letting; such as nausea, vomiting, syncope, and relaxation. I was pleased with the idea; and determined to employ it, the first opportunity—the case under consideration I believed to be as favourable a one, as could well occur; I accordingly proposed the tobacco infusion to Dr. Jones, who cheerfully consented to the trial. A strong infusion of tobacco, after several ineffectual trials, was thrown up the rectum; it produced great sickness, vomit- ing, and fainting; but the desired relaxation did not take place —we waited some time longer, with no better success. In the course of an hour, or an hour and an half, the more distressing effects of the infusion wore off; resolved to give the remedy every7 chance in our power, we prevailed on our patient, with some difficulty7, to consent to another trial of it; its effects were the same as before—great distress, without the smallest benefit; the soft parts remaining as rigid as before its exhibi- tion. Supposing the bridle just spoken of, might have some* influ- ence on the development of the parts, we divided it, but with- out any evident good. We now proposed the remedy that had so completely succeeded in the former case—namely, bleeding [471 370 RIGIDITY OF THE SOFT PARTS. nearly to fainting; to this the patient consented. We placed our patient on her feet; taking care to have the perina-um guarded, during the operation. Upon taking away about ten ounces of blood, she became very faint ;* she was immediate- ly laid upon the bed; but the most complete relaxation had taken place; the forceps were applied, and our patient was de- livered in a few minutes, of a fine healthy girl. The mother was comfortably put to bed; and every thing went on in the ordinary way, until the sixth day ; at which time, she was seized with a violent cholera morbus, and convulsions, (to which complaints she was subject,) and died in twelve hours. This case, notwithstanding its unfortunate termination, fully establishes the influence of blood-letting in this very distress- ing kind of rigidity ; and proves its action to be different, from that of tobacco; though the latter produces sickness, vomiting, and syncope. I do not think the slightest blame can attach to the bleeding; as the woman was very well until the sixth day; when diseases to which she was subject, supervened, and car- ried her off. Case Third. On the 26th September, 1800, I was called in consultation with Dr. Ruan, to a woman in labour. She had been twelve or fourteen hours in travail with her second child.f The pains were frequent and strong; the waters had been discharged some time; the head was favourably situated, and completely occu- pied the vagina; the perineal tumour large; the os externum^ which did not exceed in size a finger ring, admitted the finger with some difficulty, in the absence of pain; during a pain it would be thrown up against the inferior edge of the symphysis pubis, so as not to admit the finger, or permit it to remain, if it had been previously introduced. Externally, a large cicatrix was found to run to the very verge of the anus; internally, it could be traced farther. This seam prevented the unfolding • The subject of this case was a delicate woman, and wont to become very faint upon the loss of a little blood. f With the first she had suffered an extensive laceration of the perinaeum. RIGIDITY OF THE SOFT PARTS. 371 of the external parts so effectually, that the repeated efforts of the uterus for several hours, were insufficient to make them yield; though, the head had been closely applied to them for that period. The patient was a strong healthy woman; considerable fever was excited; the pulse was strong, frequent, and hard. I pro- posed bleeding ad deliquium, to which Dr. Ruan consented. A vein was opened immediately; and we took away about forty ounces of blood; but as her pains were very rapid, we were obliged to draw it from her while in a recumbent posture; no disposition to syncope was manifested. This quantity, however, had some effect; as there was evidently a disposition in the parts to relax, and an abatement of the severity and frequency of the pains. A second bleeding was determined upon; and to perform it, while the patient was in an erect position. We effected this with some difficulty; but upon taking five-and- twenty or thirty ounces of blood more, she fainted—she was laid on the bed; and in a few minutes was delivered by the forceps, of a fine healthy boy—the patient recovered rapidly, without accident. About three years after, I again delivered the same person, by the same means. d. Relative Rigidity. 937. I have maintained, that not only the different parts of the uterus into which it is usually divided, may act separately and independently of each other, but that even the different sets of fibres of which it is composed may do the same: hence that peculiar rigidity I have denominated "relative;" by this we are to understand, that the circular fibres act with a force superior to the longitudinal. This may happen from the latter losing a portion of their strength; which will necessarily give to the circular a relative superiority of force: or it may hap- pen, that the circular fibres from some cause or other, may have an increase of power; which will, of course, make the longitudinal relatively weaker. Whichever way it may take place, the result is the same; for the labour will become sta- tionarv. 372 RIGIDITY OF THE SOFT PARTS. 938. This case may7 be known by labour coming on kindlv, but gradually diminishing in force, after a certain period; by the niouth of the uterus having a disposition to dilate ; by its thickening; by the presenting part not protruding during a pain; by pain, extending itself, over the whole abdomen ; by a sense of suffocation; by a hard, full, or depressed pulse ; by the irregularity of the pains, both in force and frequency—the mouth of the uterus in this case, cannot open, agreeably to the order of nature ; though disposed to do so; as the fibres destin- ed to keep it shut, are relatively stronger than those intended to open it. 939. In consequence of this transfer, or peculiar disposition of power, the longitudinal fibres contract more feebly, and tran- sitorily ; the mouth of the uterus does not dilate, though not positively rigid; the abdominal tumour does not continue to subside ; there is a secretion of mucus, and a disposition in the external parts to relax, which pretty clearly points out the fa- vourable disposition of the mouth of the uterus ; but it cannot dilate until the longitudinal fibres have shaken off their torpor; or in other words, not until the cause of this torpor is removed; when this is done, they resume their healthy contractions; and the labour, for the most part, is quickly terminated. Case. Mrs. W----, June 10th, 1805, was taken in labour with her tenth child: her pains began smartly, but soon ceased almost entirely—she continued in this situation from ten o'clock in the evening until six the next morning; at this time I was called; I found her with nearly all the symptoms above enumerated} she was bled twenty ounces; pains came on immediately, and she was quickly delivered. e. Tonic Rigidity. 940. This only takes place after the waters have been along time discharged—the tonic contraction of the uterus then takes place ; and its force will be in proportion to the healthy disposi- tion of this organ, and the time which may have elapsed since RIGIDITY OF Till. SOFT PARTS. 373 the waters were drained off. I have already remarked upon this disposition of the uterus when freed from its contents ; and stated its high and important uses, to the woman at that time ; I have also referred to the inconveniences to which it some- times gives rise, when speaking of the causes of preternatural labours, and given a case illustrative of it. Cases of this kind have frequently occurred to me; but in some I have been obliged to turn, after bleeding, (which was impossible before,) and in one or two others I was obliged to use the forceps. CHAPTER XXIX. ON UTERINE HAEMORRHAGE. 941. In prosecuting our inquiry into this subject, I do not feel myself bound to give a detailed account of the notions en- tertained by every writer within my reach; I shall merely pledge myself to the faithful selection of such opinions, and observations, as appear most to merit consideration. The mode I shall pursue is— First. To consider very briefly the nature of the connection of the ovum, with the internal face of the uterus. Secondly. To investigate the causes which may impair this connection, and thus expose the source from which the blood is derived. Thirdly. To examine into the mode of action of these agents in effecting this lesion. Fourthly. To point out the several periods of utero-gesta- tion, at which this may take place—and trace the various con- sequences which may result from these periods. Fifthly. To notice the mode of treatment under the different stages and circumstances, which may aecompany the disease. 374 KONNECTION OF THP OVUM Sf.ct. I.—1. The Connection of the Ovum with the Uterus. 942. Soon after the ovum is deposited within the cavity of the uterus, we find it connected through the whole extent of its surface, with the internal face of this organ. Both uterus and ovum contribute to this end; on the part of the womb, we find it produce a soft spongv substance called decidua; on the part of the ovum, we discover its external covering or chorion shooting out innumerable vascular fibres—and both, when united, serVe as the bond of union between ovum and uterus. 943. The efflorescence on the uterine surface, like that which covers the ovum, is decidedly vascular; and it would seem, that these minute vessels interlock with each other, after a cer- tain period ; and this so firmly, that they cannot be well sepa- rated without rupture.* 944. It is not necessary to my present purpose, to inquire in what manner these vessels subserve the purposes of foetal growth: I only clearly7 understand, that, when the integrity of either is injured, there will follow a discharge of blood pro- portionate to the extent of injury; the part of the uterus at which it may happen, and the advancement of gestation. Should a large portion of the ovum be detached in the earlier months, the quantity of blood that may issue, will be commen- surate with that surface ; especially, if it be from the body or * Mr. Burns (Principles of Midwifery, p. 181, 2d ed.) who is high authority, is of opinion, that a separation of the maternal and foetal portions may take place. This may be, though not very susceptible of proof; nor is it perhaps of any great practical importance ; yet if it be a fact, it should be known. He says, " at times the foetal and maternal portions separate, and the first is expelled before the se- cond, forming a very beautiful preparation." I have seen several ova of the kind to which I believe Mr. B. alludes; but their appearance would lead me to a very different conclusion. But, lest I may misunderstand him, I will describe what I have seen, more particularly. In several instances, I have known ova expelled from the uterus, after a considerable continuance of severe efforts, which were decidedly without a vestige of the uterine product attached to them—they were, evidently and indisputably, examples of the ovum being surrounded or covered by the entire product of the chorion, without their having formed :my union with the decidua. Their expulsion was not attended-by haemorrhage, though there were slight discharges of blood. I have at the present moment, it very beautiful preparation ef this kind. WITH THE UTERUS. 375 fundus. If the separation take place near the neck, the dis- charge will not, perhaps, be so abundant; as this part is con- sidered to be less vascular, than the other portions of this viscus. 945. But the latter of these circumstances will be influenced by the period of gestation. As a general rule it may be said, that the quantity of blood which may be expended, will be in proportion to the advancement of pregnancy7. Sect. II.—2. The Causes which may tend to destroy this Con- nection. 946. In consulting authors upon this subject, we shall find a variety of causes enumerated, as capable of destroying, to a greater or less extent, the connection between the placenta and uterus—and it is agreed by7 far the greater number, that no con- siderable haemorrhage can occur unless this happen. By a few it is believed, that a mere separation of the membranes was sufficient for this purpose; but of this there is no good evidence —and even should it be true, it can only refer to this accident after the fifth month—for, until this time, the whole uterus may be considered as being lined with placenta. 947. In enumerating the remote causes of haemorrhage, I shall only name such as are most generally believed capable of this effect, either before or after delivery. Before delivery : 1st, too short a funis ; 2d, mechanical vio- lences ; 3d, passions or emotions of the mind; 4th, plethora: and after delivery, 1st, atony; 2d, spasm; 3d, humoral en- gorgement ; 4th, unequal contraction of the uterus; 5th, in- version. 948. Though all these causes have been assigned for the disease we are considering—still it is sufficiently difficult of explanation how some of them act to produce it. When vio- lence of any kind is offered a pregnant woman, and she miscar- ry, or is prematurely delivered, the cause, from its force or extent, at first sight appears capable of the end; and there, all investigation ceases. It may not, therefore, be time ill spent, to inquire into their respective agencies. 376 CONNECTION OF THE OVUM Sect. III.—3. Mode of Action of Certain of the Remote Causes. 949. And, first, too short a cord. It was the opinion of I,a Motte, that the cord may be naturally or accidentally too short— and that in either case it may be the cause of hexmorrhage. He gives a case purporting to illustrate this assumption—but confesses it was the first, and only one, he ever met with. The bleeding proceeded from one of the umbilical vessels, at a por- tion which was folded into a kind of knot, and which yielded, from the accidental shortness of the funis. Levret met with a similar instance. And Baudelocque also mentions a remark- able case of this kind.* It must, however, be confessed by all conversant with the practice of midwifery7, that though this may be a cause of haemorrhage, it must be a very rare one— or the extensive practice of these three celebrated practition- ers, would have furnished more examples. 950. It is not at all extraordinary that we should have only a few cases of this kind upon record, since it is not easy to per- ceive how it can take place. Though the cord may be very short, either naturally or accidentally, still there must be great difficulty7 in breaking it by7 any effort of the child; for if the waters be preserved, the specific gravity of the child and them, will be so nearly in equilibrio, that the weight of the child may be considered as next to nothing—so that whenever the cord is put upon the stretch, the child will instantly move towards the force ; and thus destroy its influence. If, on the other hand, the uterus be emptied of the waters, it would almost instantly embrace the body of the child so firmly, by virtue of its tonic contraction, as to render it almost immovable; and consequent- ly, it could not exert so much force as to injure the continuity of the cord. We may then safely conclude, that if it take place, it must be attended by such a combination of circumstances, as will always render it of extremely rare occurrence. 951. Another inconvenience is said to arise from too short a cord; namely, a separation of a portion, or even the whole of the placenta during labour. Leroux says " that the placenta Midwifery, par. 1084. with the uterus. 377 may7 be separated entirely, or in part, in consequence of too short a cord. This case," he says, " is met with in practice, and he is persuaded that the greater part of the floodings which happen during labour, after the escape of the waters, and when the head is in the lower strait, and the pains almost useless, has no other cause."* I was not a little surprised at this de- claration, as I did not recollect a single instance, nor could I find one among my notes, where the haemorrhage was attri- buted to this cause. And I am of opinion, that whenever too short a cord shall become a cause of flooding before delivery, there must exist, at the same time, a preternatural feebleness of union between the placenta and uterus: for, if the usual ad- hesion obtain, the cord would break before the placenta would separate; as the force which it must employ upon this mass, would be at right angles with its surface, and would require a much greater power to separate it, than could possibly be ex- erted by any movement of the child; more especially, at the time indicated; namely, after the discharge of the waters. 952. I grant, too short a cord may be extremely inconveni- ent, and create considerable embarrassment at times; especial- ly, after the head is protruded through the external parts: at this time all the accidents stated above may happen; indeed can only happen then. 953. Secondly, mechanical violence: Thirdly, passions or emotions of the mind: Fourthly, plethora. Each of these causes may produce uterine haemorrhage ; and perhaps all have. However, the mode in which they effect this, is not so well un- derstood as it deserves to be—the whole of these causes have one common operation upon the system—they all induce an increased force of circulation; and this is generally considered sufficient, under certain circumstances, to produce the evil in question. It has been thought, that whatever gave an increase of force or velocity to the circulatory system of the mother, must almost necessarily, in consequence of the large size of the hypogastric and spermatic arteries ; the short distance they have to travel before they arrive at the uterus; together with * Pertes de Sang, par. 162. [48] 378 CONNECTION OF THE OVUM their great increase in that viscus as gestation advances; very tf much affect the condition of the ovum within its cavity—that the arterial vis a tergo must act mechanically upon the ovum; and by mere force of circulation drive it from its connection with the uterus—that plethora must act pretty much after the same manner—and, as a proof of this, it is said, that the periods at which the menses are wont to return, are those at which abortion is most readily provoked ; for, at these times, though the uterus is impregnated, and this discharge has ceased, still the blood is sent in greater abundance than usual, until the de- mands of the embryo are such as to employ it, without suffer- ing the vessels to become engorged. 954. But those who reasoned in this manner, did not seem to have a very clear idea of the nature of the union between the ovum and the uterus; since, they differed as to the mode. While some insisted that the blood was transmitted, plena rivo, by continuation of canal from the mother to the placenta, others did not think this necessary; ai a mere turgency within that mass was all-sufficient for the end proposed. Though I do not mean to deny altogether the influence of an increased circula- tion, I am disposed to limit its agency very much in producing a separation of the ovum from the uterus, either in part, or entirely. 955. For, if a mere increase of circulation is all that is re- quired to effect this end, no woman would escape abortion, who may labour under high arterial action—thus, fevers of all kinds should be followed by this accident; but this is contrary to all experience. I am obliged then, to suppose something more necessary7 than an invigorated circulation, to produce this effect. 956. I might, indeed, insist that nature has attempted, and with some success, to guard against this contingency, by the peculiar construction of the uterus itself. For in the early months, there is comparatively but a small quantity of blood sent to the uterus; because, the necessity for it is compara- tively small—and the force of even this is diminished, by its passing through vessels of small size, and much folded, or convoluted. 957. This provision is highly important to the welfare of WITH THE UTERUS. 379 the ovum at this period ; as its connection is not so well esta- blished as it afterwards becomes, as gestation progresses. The liability7, therefore, to abortion, is greater in the early, than in the later periods of pregnancy—for as the union between the chorion and decidua is not well confirmed—as the attachment of the latter to the internal face of the uterus is proportionably slight—and as the extent of surface which the ovum now pre- sents, is very small to that which it offers in the more advanced state of pregnancy; and, as it can of course be affected by smaller causes, it will be seen, that a separation will be more easily induced, and prove much more injurious to the well-be- ing of the embryo, than a larger one at another stage. 958. In the more advanced periods of utero-gestation, the circulation becomes freer; and the vessels pretty rapidly in- crease in size.* Yet, as I have just intimated, the woman is not so liable to the accident we are considering—now, were nothing more required to induce haemorrhage than an increase of circulation, why should it not more readily occur at this time, than earlier ? Since it must be admitted that more blood * is now sent; because, more is required—the vessels larger-— and arterial action increased, in the exact ratio of the aug- mentation of the uterine vessels. 959. To comprehend this, we must advert to another part of the uterine economy, in which nature appears to have been studious of the safety of the ovum, by a new provision in or- ganization. Thus, however much the vessels of the uterus may become augmented in size, those which directly administer to the necessities of the fcetus do not alter in the same proportion. There is every reason to believe that the relative sizes of these two sets of vessels' bear a much nearer relation to each other in the early, than in the later months of pregnancy—so that the risk of injury, from an impetuous circulation, is diminished instead of being increased. 960. It must, however, be understood, that a given space of exposed uterine surface, will yield blood (caeteris paribus) in •proportion to the advancement of gestation; because, the ves- * Baudelocque, &c. 380 CONNECTION OF THE OVUM sels which furnish it,.have increased in proportion to this ad- vancement. Now, should the deciduous portion of this viscus be removed, it would necessarily expose the extremities of those vessels which yield a supply to an infinity of others that termi- nate in, and in part constitute, the placenta. 961. I know of no one who has clearly explained the manner in which the blood is conveyed into the minute vessels which constitute the decidua. That there is, however, a peculiar ar- rangement for this purpose, is certain; because, there is an abso- lute necessity for it; for, were the blood conveyed to the ovum, pleno rivo, by vessels of the same size as those which furnish it from .the proper substance of the uterus, or even of much smaller capacity7, but subject to the same impulse, it would be liable to injury from every increase of arterial action; which, as I have attempted to prove, is not the case. 962. Besides, injections prove that a portion of the decidua can be completely filled—and that it consists of an infinite con- geries of vessels, whose respective size bears no proportion to those terminating immediately upon the internal face of the uterus, or those which are directly interested in conveying blood to the ovum. 963. Is it not more than probable, then, that each vessel which may terminate in the uterine cavity, has a great number of very fine ones corresponding with it, and which in part con- stitute the decidua ? Is this not the mode which nature has adopted to prevent the evils which must necessarily result from a hurried circulation? Is this not partly proved by the fact, that, when the placenta is removed, and the uterus does not contract, we have an overwhelming flooding ? And may we not add, that such a contrivance is essentially necessary to the well-being of the ovum, as well as to the security of the woman after she has expelled it? for, were it otherwise, we should always have a rupture of vessels upon the separation of the ovum, or upon the casting off the placenta from the uterus—but, agreeably to this scheme, we have only an exposure of their extremities, which the contracting uterus almost immediately shuts up. 964. The decidua then performs two important offices in the economy of gestations first, by its great vascularity; as I have WITH THE UTERUS. 381 « just .pointed out; and, secondly, by its sponginess and com- pressibility. 965. I trust no absurdity is advanced, when I say, that one of the reasons for the cellular and compressible character of the decidua, in the early months of pregnancy, is probably that it may obviate consequences, which might result from external Violence, or internal impulse, to the feebly fixed ovum, were it otherwise. By its interposition and softness, vibration, however excited, will in part certainly be arrested; and, in more ad- vanced gestation, the same immunity from risk of this kind will follow, from the peculiarly soft and yielding texture of the placenta—for, at this time, injury could only happen from a separation of one of its portions; as that of the membranes would yield little or no blood. (946) 966. From what has been said, I think it is rendered pro- bable that something more is required than an increased force of circulation, to effect a separation of the ovum in the early months, or of the placenta in the more advanced periods of pregnancy—and that something, I believe to be uterine Gontrac- , tion; as without this, I am at a loss to understand the modus agendi of the remote causes. 967. I shall not pretend to say how the various causes enu- merated above, induce this action—though certain that this effect is produced through their agency, and for the following reasons : 1st. Because mere circulatory impulse appears from the anatomy of the uterus and ovum to be inadequate to pro- duce this effect—since neither abortion nor premature delivery follows as a consequence, when this condition has been present in its .highest degree. 968. 2dly. Because, contraction in every instance is essen- tial to the separation of the placenta; whether in abortions, premature labour, or delivery at full time. 969. 3dly . Because we frequently detect this cause, hours, or sometimes even days before the eruption of blood; and be- cause, so long as this contraction continues, haemorrhage will not cease, unless we diminish the bulk of the ovum, or inter- rupt its return by proper remedies. (963) I am aware that ob- jections may be raised against the reasons just given ; it may 382 CONNECTION OF THE OVUM be ?-ud, that all testimony is against our first, as we are told by writers from the time of Hippocrates downward, that plethora is frequently a cause of haemorrhage ; and that abortion is often prevented by the loss of a few ounces of blood. 970. Be it so. I also believe such to be the fact. But there is no contradiction in this ; since, this condition of the system may act very differently in separating the ovum, than by mere impulse. For the vessels in the proper substance of the uterus will and must partake of the general fulness of the system. Thev are of course distended more than ordinary; in conse- quence of which, they must act as so many wedges* to the uterine fibres, which, by being thus stimulated, are made to contract.f 971. To the second, it may be said, that we have no evi- dence of this, in the cases under consideration. It is true, there is no positive evidence; but we have strong presumption. Thus, in those instances which fall immediately almost under our inspection, we find that the placentary mass is separated only by contraction—for, when this does not take place, the after-birth retains its adhesion with the uterus—hence, it is always solicited for this very purpose, when absent, at the ter- mination of labour. 972. To our third, it may be objected, that in many instances haemorrhage comes on without being preceded or accompanied by the slightest pain. This, though admitted, does not prove there has been no contraction of the uterus; for we well know that pain, is not essential to this end—the uterus may and does contract, and sometimes with great violence, without the addi- tion of pain—and this is well illustrated, by what almost always * By the action of wedges, I wish to be understood, that separation of the fibres composing the placenta, which must take place, by vessels insinuating themselves between them. f I cannot perhaps better illustrate my idea of the connection of the vessels of the decidua with those of the uterus, than by comparing them to fine camel*s hair pencils; the quill part representing the uterine vessel, and the hairy fibres the vessels of the decidua attached to it; the caliber of the quill being equal to the area of the hairy fibres. By this arrangement, the circulating force will be necessarily so much diminished by its almost infinite division, that little injury can be caused to the ovum, by a mere increase of circulation. WITH THE UTERUS. 383 happens after delivery; namely, the spontaneous separation of the placenta as it is termed; in which case, contraction is not accompanied by pain—and, also, by what very uniformly takes place previous to the painful state of labour; namely, the al- ternate contractions of the uterus, as detected by passing a finger into the os uteri; it will be found by the finger placed against the membranes, that they are alternately tense, and re- laxed; and, if a hand be applied to the abdomen, the uterine globe will be felt to harden, and relax, as contraction may be present or absent. Yet during this time no pain is experienced. Furthermore, by that peculiar contraction of the uterus called the hour glass contraction—where the placenta is imprisoned in the upper chamber of the uterus, by the body contracting very forciblv below—and so firmly does it maintain this con- dition, that it requires no common force to overcome it—yet there is no pain. 973. To the fourth it may be observed, that pain, when it at- tends, is rather a consequence than a cause—for such disturb- ance has been given to the uterine economy by an increased circulation, as to call in the aid of pain to free itself from the useless burthen, as the ovum has now become, because of its extensive or entire separation from the uterus ; and must be considered rather as an extraneous body, than a living sub- stance. To this I would answer, that it is sometimes strictly true as regards the ovum ; aqd is an event which always takes place, when the embryo or fcetus has lost its life. 974. But does it follow, because pain, (which must be con- sidered only as an evidence of contraction,) generally attends the expulsion of the qvum, that it may not have existed before, or that contractions may not have been often repeated without manifesting themselves by pain ? Certainly not. Besides, we know that painful contractions may7 have accompanied haemor- rhage, for a considerable length of time, without the ovum be- ing destroyed, and the woman, notwithstanding, go her full time. Of this I, as well as others, have seen more than one instance. Yet had these contractions been permitted to con- tinue, they would inevitably have caused abortion. 975. It may also be alleged, that those cases of haemorrhage 384 CONNECTION OT THE OVUM which are accompanied by pain, consequently by contraction, are less dangerous, and of more easy management, than where this does not obtain. Now, were contraction necessary to pro- duce this disease, how is it that it can serve to remove it? This presents no difficulty. 976. The whole truth is not told. Where the ovum is about to be cast off either in the early, or later periods of pregnancy, or, where there is no chance of its preservation from the effect already produced upon it, then contraction is useful, as it proves the healthy disposition of the uterus, so far as this circumstance is concerned. By7 it, the ovum is completely separated, and cast off; the bleeding put a stop to, and the woman secured from danger. 977. But, let me ask any practitioner of experience, whether he has not uniformly found those cases which have been at- tended with pain, always of more difficult management, than where none existed? he will surely answer, yes. Now, if this be true, does it not decidedly prove that contraction tends to increase the disunion, or maintain the separation, as well as to have produced the original lesion ? This fact is so notorious, that every body who has a view to the security of the ovum, endeavours in the first instance, to diminish or destroy uterine contraction, by the exhibition of such remedies, as may be eapable of such effect. 978. It may not be amiss to inquire how far we may have a control, or whether we have any, over uterine contraction, after it has once been called into action. The no small authority of Mr. Burns is against me when I say, I think we have; though confessedly itxis difficult of subjection. Yet, as it is a matter of high consequence to ascertain the truth upon this subject, I hope to be forgiven, if I differ from that respectable writer. He says, " when abortion is threatened, the process is very apt to go on to completion, and it is only by interposing before the expulsive efforts are begun, that we can be successful in preventing it; for, whenever the muscular contraction is universally establish- ed, marked by regular pains, and attempts to distend the cervix and os uteri, nothing, I believe, can check the process.." 979. That it is a matter of uncertainty, whether we succeed WITH THE UTERUS. 385 in our attempts to arrest uterine contraction after it is " esta- blished," must be acknowledged. But that it is never attended by success, I cannot concede; nor should the principle ever be inculcated, as it paralyzes exertion, and withholds from the suffering female, a comfort which the attempt rarely fails to give. My own experience would, I think, in more instances than one, declare that I have been occasionally rewarded; and should it fail nineteen times out of twenty, we are surely not justified, in withholding the probable means. I therefore make it an invariable rule to treat the case, as if I expected success. 980. There is one case however, in which I never interfere, with the slightest prospect of a happy issue; and that is, where the process of gestation has unequivocally ceased; and of which I take but one circumstance to be absolutely certain ; namely, where the breasts have become tender and tumid, and then pretty suddenly subside. It would here be a forlorn hope to administer remedies with a view of retaining the ovum. 981. I am disposed to believe that this circumstance is the only one, which marks the loss of life of the ovum with suffi- cient certainty; it is perhaps the only one that is unequivocal; since, all others may be said to be deceptive. This mark was known to Hippocrates; and has, I believe, ever since his time, stood the test of experience. So long then as this sign be ab- sent, I do not relax in my attempts to preserve the ovum. It must however be confessed, that I have known the ovum to be cast off, where this symptom was wanting. Yet I am persuaded, in each of these instances, that the ovum preserved its vitality almost to the last moment; and that its expulsion was owing to the indomitable nature of the contractions of the uterus; I think this has obtained most generally with women who are in the habit of miscarrying. I do not stand alone in my opinion upon this subject. 982. Puzos (Mem. de l'Acad. de Chirur. vol. I, p. 203) de- clares, that neither pain nor haemorrhage necessarily produces abortion. La Motte (Obs. 305) gives an instance where the woman went her full time, after the orifice of the uterus was considerably dilated. And, above all, I may cite Mr. Burns himself, for an example most strictly i" point. (Princip. of [49] 386 CONNECTION OF THE OVUM Mid. ed. 2d, p. 195, in a note.) He relates with seeming be- lief, that cases have occurred of twins, one of which has been e\ re lied, while the other remained, and the " action of gesta- tion," as he happily terms it, was still maintained to the proper period. 983. Now this is demonstration, that after muscular action has been t>- universally established," it can be suspended for a considerable time: if this be so under the circumstance of one fcetus being expelled, and the uterus, by7 a cessation of action, shall permit a second to remain until the proper time, I should expect it, a fortiori, when the uterus is not so extensively, or so powerfully excited. 984. Besides, I might urge cases related by both Mauriceau, and La Motte, where the uterus was emptied of its waters, and yet the women went their full time, though they were not within six or seven weeks of it.—In these instances, the uterus could not fail to have contracted. I however, must fully agree with Mr. Burns, that where the " action of gestation" has ceased, it would be unavailing, if not injurious, to attempt the preser- vation of the ovum—for it must, sooner or later, be cast off. Denman is also of opinion, that uterine contraction can be sub- dued. He says, " that experience has fully shown, that women who have had not one, but repeated discharges, with consider- able and regular pains, have gone to their full time." (Introd. to Mid. Francis's ed. p 472.) 985. The remote causes which I have hitherto been tracing, may7 with propriety be considered as contingent, or accidental in their application and influence. But one still remains to be noticed, which must be regarded as absolute in its effects, whenever it may chance to exist—I allude to the implantation of the placenta over the mouth of the uterus. 986. The knowledge of this particular location of the pla- centa^ is of modern discovery—and, perhaps, Levret is the first, who decidedly taught this doctrine. Mauriceau, La Motte, and others before their time, met with the placenta in this situation, but they all believed it was a mere precipitation of this mass, after an entire separation from the fundus of the uterus. 987. The whole process of generation is involved in such WITH THE UTERUS. 387 complete obscurity, that conjecture is constantly made to sup- ply the place of facts, or of well ascertained processes. It seems that the daring or hardihood of the theorist is augmented, in. proportion to the obscurity of the subject, or the difficulty of ascertaining truth—hence, we have nothing to rely upon but conjecture, as to the manner in which the placenta becomes situated over the os uteri—nor shall we, perhaps, ever be more enlightened than at present. ' 988. Generation, with all its attendant circumstances, most probably will ever remain among the arcana of nature. Lereux* says," Lorsque l'ceuf humain fecunde a parcoura le trajet de la trompe, et est trombe dans le matrice, il se trouve dans tine cavite qui est beaucoup plus ample que le canal d'ou il sort. Son pedicule, qui doit former le placenta, et qui est sorti le der- nier de la trompe, reste le plus ordinairement sup-?rieur; cepen- dant, comme l'ceuf est encore flottant, le pedicule peut se tourner par quelque accident plus ou moins inferieurement." 989. Mr. John Burnsf follows Lereux very closely in his con- jectures, or rather his assumption of facts, upon this subject: he says, u as that part of the membranes of the ovum to which the embryo is attached, generally enters last, it follows, that the placenta will be formed originally over that part of the ute- rus where the tube enters the decidua, at that spot joining with the chorion to form it. But in some instances the case is re- versed, and the embryo enters foremost, the rest of the mem- branes following it. When this happens, then the inner layer of the decidua, which was stretched across the orifice of the tube, and which is afterwards to become the decidua reflexa, will contribute to the formation of the placenta. In this case, by the distention of the ovum, and the yielding of the decidua reflexa, the placenta will come at last to be inserted over the mouth, or over some inferior part of the uterus." 990. In this manner do these writers account for this unna- tural situation of the after-birth. The only difference in their views is, that Lereux, not understanding the nature of the de- * Obs. sur les Pertes de Sang, p. 13. t/ Gravid Uterus, p. 153. 388 CONNECTION OF '1 !', T. OVUM cidua, or perhaps ignorant of its existence,* supposed that the ovum, after it was deposited in the uterus, was unconfincd, or rather floating in its cavity, and might in consequence of this, by some accident, turn its "pedicle," which was to become placenta, downwards, though it generally7 remained upwards, and thus become situated over the os uteri; while Mr. Burns supposes the portion which is to constitute this organ, enters the uterus by some chance first, and thus will have or assume this inferior situation. 991. Here, much is taken for granted; and one conjecture may be as good as another, where nothing can be proved; pro- vided, it be not found at variance with any well-established fact. In this instance, perhaps, hypothesis can do as little mis- chief as in any case in which it is employed; and as all prac- tical ends are answered by the knowledge that the placenta is sometimes thus engrafted, I shall not attempt a refutation of it; especially, as I have none better to substitute. 992. The order of development of the uterus is so uniform, that a deviation can only result from accident, or such a com- bination of circumstances as very rarely happens; we can then with absolute certainty declare, that when the placenta is un- happily situated over the mouth of the uterus, a flooding, to- wards the latter periods of gestation, must be inevitable—hence the propriety of the term " unavoidable," for this kind of hae- morrhage. 993. During the first six months of utero-gestation, the body and fundus alone yield to the distending power of the ovum: after this time the neck is called upon (if I may so term it) for its proportion, as the other parts of this organ seem to refuse any farther supply; in consequence of which, it, in its turn, becomes distended; and, in this act, a portion of the placenta is necessarily removed; and a bleeding, according to the extent of injury, or the number of vessels exposed or ruptured, ensues. • It is remarkable, that none of the French physiologists (so far as I at present recollect) have faith in Hunter's description of the decidua. Baudelocque, Mey- grier, and Gardien, declare, if it exist at all, it is only in the early months of ges- tation, and then perhaps oidy observable towards the lower pail of the uterus. From my own observations, I have no hesitation to declare its existence, but not precisely as laid down by either Hunter or Burns. WITH THE UTERUS. 389 994. After discharging more or less blood, the haemorrhage may cease; or it may be so reduced in quantity, as to excite little apprehension. But this is a false security7—it is sooner or later renewed, either by a farther stretching of the neck, by the augmentation of the ovum, or by the removal of the coagu- lum, which had until now stopped the bleeding. 995. In this manner may things proceed, until near the last stage of pregnancy7—or the extent of separation may be such, or the size of the vessels exposed be so large, that the woman's life is instantly jeopardised, and from which she can only be protected bv the most prompt and efficient remedies. Sect. IV.—4. The Periods of Pregnancy at which Hemorrhage may take place. 996. There is no period at which this may not take place, after the first month of pregnancy; since it is presumable, that after the fourth or fifth week, a union more or less strict is formed betwixt the ovum and the uterus, by means of the cho- rion and the decidua; it must therefore necessarily follow, that a separation may be effected, and a bleeding ensue. Until about the fourth, or between the fourth and the fifth month of gestation, this accident may happen to any portion of the ovum; since, up to this period, the placenta, or what is to become pla- centa, completely surrounds the ovum.* 997. After this time, there is a portion of its surface which becomes transparent; and that uniformly augments, so long as the uterus continues to increase in capacity. This transparent portion is what is technically called the membranes—and to- wards the full completion of pregnancy, they occupy a larger surface than the placenta, from which they appear to emanate. * 1 am of opinion, that the whole of the vascular covering, until the time above indicated arrives, is destined for, and converted into, placenta. I do not believe that any of these vessels become "blighted;" (Burns's Gravid Uterus, p. 196,) »s this would seem to be a work of supererogation ; and further, that there is a point in every ovum, from which the U-ansparent portion of the membranes pro- ceeds; and that that point is most probably opposite to the insertion of the cord into the placentary mass. (See Chapter on Placenta, &c.) 390 CONNECTION OF THE OVUM 998. In consequence of this, there is a portion of the uterus from which no haemorrhage can proceed; namely, where this transparent portion occupies the uterus—this portion increases as gestation progresses—and, of course, the source of flooding is confined to that part which is covered by the placenta—for all the remaining surface is lined by these membranes, and is incapable of furnishing such a quantity of blood as shall be denominated a flooding. 999. As a general rule, then, we find the risk from floodings in proportion to the advancement of pregnancy; because the vessels are larger, and, in a given time, yield a much greater quantity of blood—though the chance of occurrence is in the earlier months. Puzos says, that abortions under the fourth month are rarely fatal—and this observation is perhaps con- firmed by the experience of almost every practitioner; pro- vided, a sufficiently early attention had been paid to it. 1000. It must be confessed, that it is very difficult to esta- blish any certain rule upon this subject; since, I have seen as alarming symptoms attend an abortion of six weeks, as I have witnessed from a premature labour of the seventh month; or indeed, at any other period. It may, however, with confidence be advanced, that alarming symptoms do not show themselves as quickly in the early, as in the latter months; and, of course, we have much more time for the employment of proper reme- dies. 1001. I may farther observe, that it is frequently from ne- glect, that any danger arises in the early stages of pregnancy: this inattention may proceed from the aversion that many wo- men feel to let any thing be known that has reference to their situation ; from an ignorance of consequences; and from a long established opinion, that a moderate discharge is useful; espe- cially, in plethoric women, &c. 1002. Time, of great consequence, is lost by this improper procrastination, and many an ovum has been cast off, attended with threatening haemorrhage, which, by early attention and proper care, might have been preserved. Besides, the period of gestation has sometimes been permitted to lull the practi- tioner into dangerous security. Many of considerable expe- WITH THE UTERUS. 391 rience maintain, that there is no danger from floodings, before, or at the period of three months. This is decidedly an error; and the sooner it is corrected, the better. Whenever preg- nancy is attended by a flooding, there is danger; nor will the period of advancement, however short, protect, of itself, against hazard. Of this, Mauriceau, La Motte, Giftbrd, &c, give us examples; and I may add, my own experience furnishes the same results. 1003. We should not wait for extreme symptoms, before we act—it is this delay, which in most instances creates the dan- ger; and sometimes it has its victim. The authors just men- tioned, and more could be cited, have furnished us with cases, not only of great danger, but of death, before, and at the fifth month. It is wrong, then, to treat such cases with indifference* —for though death may not be the consequence, extreme weak- ness, or a state of subsequent ill health, or the calling into ac- tion of some latent disease, may result from it. In another point of view, it is highly important that early attention be paid to such cases—namely, the prevention of its recurrence : for after a woman has once aborted, there is no security against the second; and by and by, a habit of it is established, which the best devised means within our knowledge is not always able to destroy7. 1004. I now come to the more important part of my subject, namely, the mode of treatment. In pursuing my inquiry into this, I shall endeavour to be as explicit as the nature of the subject will admit; for I can only establish general principles, * Rigby treats this subject with great indifference; and the weight of his au- thority has doubdess tended to perpetuate, if not to establish, a most erroneous practice in the early months of gestation. He s:iys, "the treatment of floodings that come on before the uterus has acquired any considerable size, must be very obvious; and the consequences of them at diat early period of pregnancy are seldom to be dreaded, as, if the patient lose blood from the arm, be kept cool, and in a horizontal posture, and such mild astringents and anodyne medicines be administered to her, as have been found by experience to restrain discharges of blood, they will very frequently stop entirely, and the woman go on to her full time; and "if this should not be the case, but the haemorrhage should still increase, it will seldom increase to a degree to endanger tiie life of the mother." (Essay on Uterine. Hemorrhage, 5th ed. p. 2.) 392 CONNECTION OF THE OVUM and modes of management; as every individual case will pre- sent a shade of difference ; and the treatment of this shade of difference, whether important or otherwise, must be very much left to the good sense and judgment of the practitioner. I however trust, at the same time, that little embarrassment will be experienced, as the indications and their fulfilment will be so distinctly pointed out, as to render the one pretty certain, and the other without much ambiguity. 1005. With a view to perspicuity, I shall divide the consi- deration of floodings into the several periods at which they may appear; and the remedies into their nature, or supposed mode of action. The peculiarities of each period, shall be pointed out; by which means, we can establish more clearly and certainly the mode of treatment. The nature of each remedy shall also be considered; and the period at which it is more especially indicated; together with its mode of action, and the degree of confidence to be placed in it. 1006. In the division of this part of my subject, I shall near- ly follow the arrangement of Dr. Denman; as it embraces every essential variety of period at which haemorrhage, as a conse- quence of utero-gestation, may take place; this will embrace four periods. 1st. That period of its occurrence, in which the ovum is entirely surrounded by the decidua and decidua re- flexa ; this will comprehend the first four, or four and a half months of pregnancy7.2d. Into all the remaining period of utero- gestation. 3d. Into the period between the birth of the child, and the expulsion of the placenta. 4th. Into that which may follow the expulsion of the placenta. 1007. This division is by no means arbitrary; it is founded upon principles, and circumstances, that must not carelessly be lost sight of, if we wish either to understand the nature of the disease in question, or become acquainted with its most successful nriode of treatment. For instance, until after the time pointed out in our first division, it would be highly im- proper, under almost any circumstance, to pierce the ovum with a view to the discharge of the liquor amnii; yet, at the second period, it may become an essential remedy. In the third, the woman's safety may depend upon the immediate deliverv of WITH THE UTERUS. • 393 the placenta, and the subsequent contraction of the uterus; while, in the fourth, her life may be hazarded, by having this important mass hastily withdrawn, when the uterus was not in a condition to contract. Sect. V.—First Period. 1008. Until the period of four and a half months, or even to the fifth, the ovum, when separated entire from the uterus, ap- pears to be an ovular, spongy, fleshy mass : it bears evidence of attachment to the parietes of the uterus, in every point of its surface—and seems to show, that at any one part of this, it may be subject to separation; the effect of which will ne- cessarily be, a solution of continuity of more or less vessels; and a consequent haemorrhage. I have just intimated that this separation may be at any jpoint of the ovum; but the effects will be in some measure different, as it may happen near the neck, or at the body, or fundus, of the uterus. When the separation happens at the body or fundus, before the blood can issue from the os tincse, it must necessarily loosen the attachment between the spot of commencement, and the point at which the blood issues; it will, therefore, follow, that when this takes place, the chance of arresting a flooding, and pre- serving the ovum, must be diminished in proportionate the destruction of the connecting medium. But when the dis- union takes place near the neck, the mischief will be- less seri- ous, though the discharge may be very abundant. 1009. We can probably discover the cause, why an haemor- rhage of great pertinacity and extent, shall sometimes not be followed by abortion; while one of a much less threatening as- pect, shall eventuate in it. It is a fact notorious to every prac- titioner of experience, that, when an haemorrhage is accompa- nied by pain, the chance of preserving the ovum is diminished almost in proportion to its intensity; while a flooding, which is not attended by pain, constantly presents a hope that it may escape destruction, however profuse the discharge. (979) Now, when a considerable separation takes place, as must be the case when it commences at the upper parts of the uterus. [50] 394 , CONNECTION OF 1 HE OVUM pain will be more likely to occur, than when it happens near the neck—hence, we sometimes have pain before the blood issues externally ;* the uterus in this instance suffers irritation from partial distention, by the blood insinuating itself behind the ovum; contraction ensues, and the blood is forced down- ward; and is thus made to separate the attachment between the ovum and uterus in its course, until it finally gains an outlet at the os tinea'. 1010. In consequence of the uterus being excited to con- traction, the friendly coagula, which may have formed from time to time, are driven away, and the bleeding, each time, re- newed ; and this will be accompanied, most probably, with an increased separation of the ovum, until at last, from its extent, the ovum becomes almost an extraneous body, and is finally cast off. Now, the contrary of all this obtains, (at least for some time,) where tire point of separation is near the neck of the uterus; since much less destruction can happen; owing to the proximity of the denuded surface to the place of escape, even though this case be attended by pain. The blood, instead of forming coagula above the point of separation, will find im- mediate issue through the neck of the uterus; and thus a power- ful, and mischievous agent will be removed. 1011. It must, then, clearly7 follow, that there are many cases of severe flooding, in which the ovum may be preserved; owing, sometimes perhaps, to the part being separated by the action of the remote causes; and in others, to the extent of lesion, not being considerable. Now, as we have no unequi- vocal mark by which the case, which is susceptible of success- ful treatment, can be distinguished from the one which can- not, it becomes a duty, in the management of such cases, to act as if the ovum could be preserved]—I have, myself, constandy * Does this not seem to prove the separation to be remote from the os uteri, and serve to distinguish these two cases; especially, in the commencement of haemorrhage ? Dr. Bard says, that " when labour pains precede the discharge, miscarriage can seldom be prevented; when they follow, it sometimes may." , (Midwifery, p. 138.) f Mauriceau gives an instance, where the ovum was preserved, though then were frequent returns of hemorrhage, until the t'lird month, fobs. 60.) Another. WITH THE UTERUS. 395 acted upon this principle; and have sufficient reason to believe I have been rewarded in a number of instances by success, when the hope was truly a forlorn one. 1012. It might sometimes lead to happy results, could we certainly determine, a priori, when our endeavours would be followed by success, and when they would not—much time might sometimes be saved, and much anxiety be avoided; but as this, with our present knowledge, can be ascertained but in few instances, we shall constantly err on the right side, by supposing that the ovum may be preserved. 1013. As far as my experience goes, I must say, I have never been able in the commencement to determine with certainty, the cases which would eventuate in safety to the ovum, from those in which it would be expelled. This has not been owing, I believe, to inattention to the subject; for I can truly say, much pains have been bestowed upon it; but it is dependent upon the influence of a variety of causes, some of which are so occult, as to elude our search; and to others, so little under control, as to render opposition entirely unavailing. We are told by some, that if the orifice of the uterus be open, and clots freely pass, we may be sure the woman will miscarry.*! 1014. It has been supposed by some, that the os tincae was always soon affected, in cases of haemorrhage threatening abor- tion. Spigelius-f: declares he always found it open; but this where there was almost a continual discharge for five weeks, and that at times very abundant. (Obs. 678. )i To these I might add several instances of like kind in my own practice. Puzos declares, that pain and flooding do not always pro- duce abortion. (Mem.de TAcadem. torn. I. p. 211.) Kok declares women have gone their full time after severe haemorrhages. (See Pasta, p. 215.) Dr. Bard says, " a discharge of blood from the womb, though a veiy frequent, and gene- rally the most important symptom, is not necessarily followed by miscarriage." (Midwifery, p. 138.) * Mauriceau, &c. f Pasta declares this not to be strictly true : he says, there are instances of women going their full time, after severe flooding in the early months, where the uterus was sufficiently open to allow the finger to pass; and others, where abor- tion has ensued, though the os tineas was a long time closed. (Pasta, Traite des Pertes de Sang, Vol. I. p. 28.) t Pasta, Vol. I. p. 38. 396 « CONNECTION OI THE OVUM neither accords with my own experience, nor that of many others. Mauriceau declares, he could not discover it open, up- on the most careful examination, in many instances of flood- ing.*! 1015. I am rather of opinion that the uterus has been sup- posed to be open, because clots were expelled from the vagina —but this by no means follows: for the coagula are almost al- ways, perhaps, but certainly much the most frequently, formed in the vagina, when an ovum occupies the cavity of the uterus. Of this the most decisive proof can often be given, in the very early months of pregnancy, by a mere survey of the size of an expelled coagulum; many times it is five or six times the size of the uterine cavity, were this not filled by the ovum. The conclusion, then, that the uterus must be open to give passage to coagula, is not a correct one; nor is the supposition, that after having dilated to give passage to the clot, it will imme- diately close again, more consistent with fact.f; 1016. From this it appears, that little information can be derived from an examination of the state of the uterus in the commencement of a flooding; for the os tincae may be complete- ly closed for a long time in some instances, and the ovum be eventually cast off; while in others, it may be naturally a little open, without offering additional risk to the embryo. 1017. But I may safely declare, when the neck of the uterus is distended, so as to resemble in feel the extremity of an egg, that abortion will sooner or later take place, however small the opening of the os tincae may be. In this case the uterus is thrown into complete action, and the extension of the neck of the uterus just spoken of, is the effect of its contractions. There is another mark equally unequivocal; and to which I have already adverted, namely, the cessation of morning sick- ness ; a diminution of the abdominal tumour; and, above all, * Maladies des Femmes grosses. T Dr. Kigby declares, that women have died of haemorrhage, without the uterus being much opened; but supposes, in such cases, it may be in a dilatable state. p. 42. ^ Pasta, Vol. I p. 34- WITH THE UTERUS. » 397 the secretion of milk; followed by flaccid breasts. In both these cases, all attempts to save the ovum, will be unavailing; and our whole care, must be directed to the state of the flooding. 1018. Nor is the quantity of blood expended, any positive evidence that abortion will take place; especially, when unac- companied by pain—for I have repeatedly seen a very large waste, without any other evil attending; while, on the contrary7, I have witnessed the expulsion of the ovum with the loss of a very few ounces, when attended by pain;* As a» general rule, perhaps, it may be said, that those cases of flooding following any violence, more certainly end in abortion, than those which come on silently, and slowly, without any apparent cause. 1019. No reliance should be placed upon the opinion, that a moderate discharge of blood from the vagina, during pregnan- cy, is useful, by removing topical plethora.f On the contrary, we should look upon every appearance of this kind with great suspicion, and treat it as if it were to become decidedly mis- chievous. Even the legitimate returns of catamenia, when there is reason to believe the uterus is impregnated, should be treated with caution; since, we cannot satisfy ourselves at first, that it is merely a monthly purgation.:): In all sueh cases, when consulted, I have prescribed as if the discharge were of an in- jurious character; this I believe to be right; since, no evil can result from its adoption; but from a neglect of it, much mis- chief may ensue. 1020. All cases then, where there is a sanguineous discharge from the vagina of a pregnant woman, should be treated with the utmost care—all the essential indications for haemorrhage, should be instantly complied with; and no time should be lost by temporising. 1021. The essential indications are, 1 st, to arrest the bleed- ing; 2d, subdue pain if present; and 3d, prevent a recurrence of the haemorrhage. * Pain accompanying flooding should not make us abate out endeavours to save the ovum, but under the circumstances stated above : and I have witnessed several instances of ova being cast off, where neither pain nor flooding accom- panied the expulsion. f Kok says, that local plethora is a cause of hemorrhage. (See Pasta, p. 275.) t- Sec Chapter on this subject. 398 CONNECTION OF THE OVUM 1022. These three points are constantly to be kept in view, as the preservation of the ovum, or even of the woman, is de- pendent u-;ori their fulfilment. Therefore, whenever a woman is attacked with an haemorrhage from the uterus, the sooner it can be arrested, the better; every known remedy of efficacy is to be employed in succession, should the antecedent ones fail of success; and every advantage must be given to these means, bv the patient and her attendants, by a strict adherence to the directions enjoined. It would be in vain for the physician to prescribe, if either the patient or attendants run counter to his instructions; and in no case, perhaps, is this observance of more decided consequence, than in the complaint, I am now considering. 1023. One of the first steps to be taken, is to command the most perfect possible rest of body and of mind. The patient should be placed upon a mattress, sacking-bottom, or even the floor, in preference to a feather bed. The room should be well ventilated; the patient very thinly covered; her drinks, toast water, cold balm tea, lemonade, ice-water, &c.—no sti- mulating substance of any kind should be permitted. Care should be taken, even in the administration of food and of drinks, that the patient be not subjected to exertion to receive them; they should be given to her while in a horizontal posi- tion. Her food should also be of the same character with her drinks—thin sago, tapioca, gruel, or panada—in neither of these should wine, or any other liquor, find admission; they can be rendered agreeable by lemon juice, sugar, or nutmeg. All animal food, or the juices of them, in the commencement of flooding, should be forbidden. Let whatever is given, be given cool. Absolute rest of every member of the body should be enjoined. 1024. The officiousness of nurses and of friends very fre- quently thwarts the best directed measure of the physician, by an overweening desire to make the patient " comfortable." This consists in changing of clothes, " putting the bed to rights," or altering her position; all this should be strictly forbidden. Conversation should be prohibited the patient; and all company excluded. Much mischief is frequently done by the talk of WITH THE UTERUS. ♦ 399 bystanders, who delight for the most part in tbe marvellous; and but too often relate the histories of cases, which are every way calculated to appal the already too much alarmed patient; this kind of gossipping should be peremptorily forbidden, even at the risk of giving offence ; rather than permitted to the cer- tain injury of the sick. 1025. Having established a proper svstem for the repose of the patient, and the government of the attendants, we should next determine the propriety of blood-letting—this becomes very often of high importance ; especially, at this division of our subject; plethora is a usual attendant at this time; nay, may be, as I have hinted, the very cause of the alarm. Blood should be taken from the arm in a quantity proportionate to the exigency; remembering, we do little or no good by the operation, if we do not decidedly diminish the force of arterial action; let the pulse rather sink under the finger than other- wise ; its repetition must be regulated by circumstances ; recol- lecting, however, that haemorrhage is sometimes maintained solely by exalted arterial action; as the following case will very clearly7 show: 1026. I was called to Mrs. B. in January, 1796, whom 1 found much exhausted by uterine haemorrhage, in the fourth month of gestation. She had, several days previous to my visit, returns of flooding, which were little attended to. The usual means were now employed, and for the time, the dis- charge was arrested; this was early in the morning of the 16th. She remained very well until 5 o'clock, P. M. At this time she had a return of flooding; I was instantly sent for; and liv- ing but a few steps from the patient, was very7 quickly at her bed-side. She was found to be flooding very rapidly; the pulse was very active; and the eruption of blood appeared to be pre- ceded by a slight rigor, followed by high arterial action; she was instantly bled from the arm, and the abdomen covered with ice and snow, until there was a reduction in the force and fre- quency of the pulse; so soon as this took place, there was an abatement of the discharge; this condition was followed by slight alternate pains in the back, shooting towards the pubes. Forty*five drops of laudanum were now given; and strict in- 100 CONNECTION !». 1. . WITH THE UTERUS. 417 senses would wait for this as a remedy in uterine haemorrhage; since, it can only occur from the extreme weakness of the pa- tient ? Who would wait for this forlorn effort of nature, when he could command a tampon ? If the practitioner were absent during an exhausting profluvium, and learned, before he could exert his skill, that the patient had fainted, he might suppose it to be useful, pro tempore; but he should never look upon it, but as a dernier remedy. 1088. Dr. Denman's opinion upon this subject, is certainly calculated to do mischief. It makes a young practitioner in- different to the quantity of blood that is wasting, because a state of faint has not come on—and when this condition does come on, he hails it as a most friendly visitation—forgetting, that fainting is a decided proof of extreme exhaustion; and that his patient may never recover from it. Dr. Denman emphati- cally calls it " a remedy provided by nature for averting the immediate danger of all haemorrhages, and to prevent their re- turn." Who, with this belief, would not rather invite fainting, than avoid it ? But let us not be deceived by terms. 1089. That a state of syncope favours, or promotes coagu- lation, is agreeable to all observation; but whether this arises from an inscrutable law of the animal economy, and for pur- poses entirely out of view, or instituted for the end assigned by Dr. Denman, may admit of much doubt. For, were it for this latter purpdse, it would be much more advantageous to the individual to have it answered at a less expense; or at a more suitable period—for, on such occasions, it would be much bet- ter to imitate nature in the end, than in the means; and this is what is constantly aimed at, when we use lead, digitalis, the tampon, &c. 1090. Again, I cannot agree with Dr. Denman, in his pro- scription of " cordials or stimulants," in the state of extreme exhaustion to which women are sometimes reduced by flood- ings; I think I am as certain of the propriety of this practice as of any practice whatever; and have employed it when the pulse was very much reduced, or extinct, the extremities cold, the breathing hurried and short, vision imperfect, and voice almost inaudible, with the most decided advantage. It is true, I ad- .[53] 418 CONNECTION OF THE OVUM minister them with caution, but with steadiness; and in such quantities as shall neither offend the stomach, nor invite too much re-action. In this I persist, until there is evidence that the system will re-act—so soon as this appears, I desist from all stimuli, until a fresh necessity is created. 1091. There is another position of Dr. Denman's, arising from his particular views upon this subject, which, to say the least of it, wants confirmation—namely, that " during faintness, the advantage arising from the contraction of the uterus, is likewise obtained." I have no hesitation in saying, I have re- peatedly seen the contrary happen—I will illustrate this from one of several examples. Mrs. B----was delivered, after rather a tedious, though pretty severe labour ; the placenta was in due time spontaneously expelled, and the uterus well con- tracted. About half an hour after I had taken my leave, I was very suddenly7 summoned to Mrs. B.'s bed-side, as she was extremely faint, and had lost considerable blood. I immedi- ately7 commenced brisk frictions with the hand upon the abdo- men ; and continued them until the uterus was felt firm under it—the discharge immediately ceased—in a few minutes after, Mrs. B. told me she was again very faint; at the same moment the uterus was found to become flaccid under the hand, and again there was a return of discharge—the friction was con- tinued until the uterus was made to pucker itself up; the faint- ness went off, and every thing promised well, until another at- tack of syncope again relaxed the womb; and another gush of blood instantly7 followed; in this way did the faintness and re- laxation of the womb follow each other, for eight or ten times; but a perseverance in the frictions, and the exhibition of some wine and water, eventually overcame the disposition to faint, and there was no farther return of the relaxation, or of the flooding. 1092. Now, in this case, the state of faintness was constant- ly followed by a relaxation of the uterus, so that when syncope arrests haemorrhage, it must be more by7 the formation of co- agula, than by effecting the contraction of the uterus. 1093. And though it is strictly true, as Dr. Denman asserts, that the uterus " acts, or makes its efforts to act, in sleep," and WITH THE UTERUS. 419 according to him and others,* " sometimes even after death," yet it does not prove that a state of faintness is favourable to this end. Indeed, in many instances the uterus appears so in- dependent of any condition of the other parts of the body, that it may be said, with much proprietv, to be governed by laws and conditions of its own, and over which, other portions of the system do not seem to exert the smallest control. WTho has not seen an alarming flooding from the inertia of this vis- cus, in a woman whose physical strength has been almost in excess ? And, on the contrary, witnessed its firm and secure contraction, where every other power almost has been exhaust- ed by previous disease ? 1094. As it is confessed, that after the failure of the reme- dies recommended for the suppression of haemorrhage, the ap- plication of the tampon, &c. there is but one means left in our possession by which the flooding can be arrested, and the life of the woman preserved—yet it may be asked, is there no con- dition of the patient in which it would be improper to attempt delivery, besides the rigidity of the os uteri ? To this, I an- swer, yes—I would say, that a woman reduced to the last ex- tremity of weakness, but with a suspension of the discharge, should not be meddled with, so long as the haemorrhage was kept in check. 1095. But suppose the same degree of weakness, with a con- tinuance of the flooding; should we in such case attempt de- livery ? I have no hesitation in answering this in the affirma- tive—but, previously to the operation, the condition of the patient should be candidly stated to her friends ; it should be undisguisedly declared, that no undue calculation should be made of the benefit of delivery; but, as it offers the only pos- sible chance of relief,'it should be adopted. We should be the farther encouraged to do this, as it now and then happens that the woman has recovered, contrary to all expectation. 1096. Hitherto, I have said nothing of opium as a remedy in uterine haemorrhage; the reason is simply this—it has never in my hands merited the smallest commendation; for it has * Baudelocque, Leroux, Kok, &c. 420 CONNECTION OF THE OVUM never been attended with the slightest success ; of course, I cannot be of opinion it deserves the encomiums which have been so freely bestowed upon it by Dr. Hamilton and othe'rs. I have read dispassionately, and with care, Dr. Stewart's book upon this subject; and have cautiously examined the cases de- tailed there; but they have not afforded me the slightest grounds to believe that the opium had any agency in arresting the flood- ings, for which it had been so liberally administered—the ces- sation uniformly appeared to be the result of the natural pow- ers of the system in general, and of the uterus in particular. That it is highly beneficial, at all periods previous to delivery, in allaying pain, and in this way putting a stop to farther mis- chief, I most freely confess—but I cannot yield any thing more. I am not alone in this respect; Dr. Denman seemed to enter- tain a similar opinion; and Barlow has advanced the like sen- timents. 1097. It may be proper to say a few words upon the subject of cold applications; as no remedy has been more extensively employed, or more certainly abused. Cold, as a means to ar- rest flooding, is in almost universal employment; is usually one of the first resorted to, and .the last that is abandoned—it has acquired so much popularity among the vulgar, as to ren- der its omission, in the treatment of this complaint, unsafe to the reputation of the practitioner. 1098. Though confessedly an agent of great power, it has nevertheless its limit of usefulness; and beyond this limit, it should never be urged—its efficacy is entirely confined to its influence on the circulating system; by diminishing its vigour, and abating its velocity. When these ends are answered, it is truly doubtful, whether it should be farther persevered in; at least, its value is much diminished. 1099. I employ it very liberally; and sometimes, if the case be urgent, at a very low temperature—in general, the best mode of applying it is by a large bladder, as has already been directed—(1027) but in very sudden and alarming cases, I have found teeming it from a height upon the abdomen, to bt decidedly better, owing to the promptness and extent of it* effects. WITH THE UTERUS. 421 1100. But if the pulse flag, and the woman is much exhausted, I not only forbid it, but have a warm blanket, or other articles, to supply its place. During the use of cold water, he. to the abdomen, I order warm applications to be made to the feet and legs; a bottle or jug of warm water well corked, is one of the best, and handiest—this last direction I am particular not to omit, should the feet and legs be preternaturally7 cold. We also should be particularly careful not to wet the bed and clothes of the patient, if it can be possibly avoided; as it cre- ates much, inconvenience, without doing the least good—it will render the poor woman's situation extremely unpleasant, be- sides obliging her to be disturbed, that dry things may be sub- stituted. 1101. The injecting of cold water, cold alum-water, the so- lution of the acetate of lead, the introduction of ice into the vagina, and even into the uterus, &c. have all been practised; and, it is said, with advantage. The merits of such applica- tions must rest upon the authority of those who recommend them; for I confess I have no experience in either of them; nor should I be tempted to rely upon them in very pressing cases. 1102. It maybe proper to observe, in addition to the reme- dies and modes of proceeding pointed out in this division of our subject, that, in certain cases of uterine haemorrhage, the forceps are the only means to be employed or relied upon. They are exclusively indicated, 1st. W'here the discharge is threatening, and the labour well advanced; but where the membranes have been long ruptured, and the uterus is firmly7 embracing the body of the child, or the head does not advance with sufficient rapidity to afford security. 2dly. Where the head is low in the pelvis, and has escaped from the orifice of the uterus—in this case, turning must not be thought of, how- ever recent may have been the escape of the waters; or how- ever moveable the head may be in the pelvis. 3dly. Where the uterine efforts are either feeble, or suspended; and where the os uteri is sufficiently distended, but where the waters have been long discharged. 4thly. Where the head occupies the inferior strait; the orifice of the uterus sufficiently expanded; 422 CONNECTION OF THE OVUM the waters either recently7 or a long time expended; but where, the natural agents of delivery, would act too slowly for the safety of the patient. 5thly. Where the natural powers are incompetent to the sufficiently speedy delivery of the patient; owing, either to the ma/-position of the head, or to such a dis- parity between it and the pelvis, as shall prevent its timely ex- . pulsion. Sect. VIII.—Hemorrhage from the Situation of the Placenta. 1103. I must now speak of that haemorrhage which is so ap- priately termed the " unavoidable,"* and which, as I have al- ready declared, arises from the peculiar location of the placenta. The first evidence of the placenta being over the mouth of the uterus, may declare itself so early as between the sixth and se- venth months of utero-gestation. At this time, the neck of the uterus begins to be stretched for the more complete accommo- dation of the foetus—in consequence of which, a small portion of the placenta will be separated from the uterus; this of course will be followed by a discharge of blood, commensurate with the extent of the lesion, and the size of the vessels involved in this separation. 1104. This discharge may, by proper management, be made to cease; nor will it return until the uterus and placenta are again forced to separate—then, another slight haemorrhage en- sues, which may also cease; and not be renewed perhaps until the last period of pregnancy; or there may be, as happens some- times, a constant stillicidium of a bloody sanies. Dr. Rigby, who. is considered the highest authority upon this subject, seems not to have bestowed as much attention to the condition of the patient before the full period of utero-gestation, as he * We are indebted to Dr. Rigby, for this term being in general use—he has written a valuable treatise upon this subject; though anticipated by Levret, in the discovery that the placenta might be originally fixed upon the os uteri. But it would appear, it was an original suggestion with him, as well as with Levrct | for he assures us, at the time he promulgated this doctrine (and no one will doubt Dr. Rigby's word,) he had never seen that author's work ; and that his "ideas upon this subject were derived from his own personal observations, and experi- ence." (Essay on Uterine Haemorrhage, p. 13.) WITH THE UTERUS. 4*3 did to the consequences, when that time arrived, or he would not have held the doubtful language he did when speaking of the "time and manner" in which the "accidental" and un- avoidable haemorrhage came on ; he says, "probably that which is occasioned by the placenta being fixed to the os uteri, will, for the most part, not come on till the full term of parturition, when the uterus begins to dilate from the approach of labour;" which is contrary to the history I have just given, as well as to the experience of almost all the writers* upon this subject. Besides, the verv economy of the uterus makes my account correct. 1105. Therefore, when the full time arrives, the woman may be surprised by a sudden, and an alarming issue of blood, with- out the smallest premonition—for it sometimes makes its ap- proach so rapidly, and so insidiously, that the patient may be attacked in the midst of her domestic duties, or while in the enjoyment of company. At other times, it is preceded by slight and distant pains ;f and when this is the case, the dis- charge, for the most part, is neither so sudden, nor so alarm- ingly extensive; for haemorrhage is never so overwhelming nor appalling, as when the os uteri silently and rapidly yields, and in an instant exposes a thousand bleeding vessels.-}: 1106. The blood flows in an almost unceasing stream, till the woman becomes much weakened and faint; coagula may • See Leroux, Kok, Baudelocque, Denman, Burns, &c. f When this species of flooding is accompanied by pain, it will in general be found, that the waste is neither so sudden-nor so profuse, as when none attends; though each contraction of the uterus augments, for the time being, the haemor- rhage. It must, however, be observed, that in proportion to the discharge, will be (caeteris paribus) the diminution of uterine force—and hence the infrequency of natural deliveries, in this kind of flooding. Indeed the pains seem almost to cease; or, in other words, the contractions yield almost as soon as they com- mence ; for a certain fulness of blood in the uterine vessels, seems essential to healthful contraction. * This circumstance, however, rarely obtains, but where the woman has arrived at, or very near, her full term, and where she has been teased by some previous discharge. May not the pretty constant, though inconsidcrabk- discharge just noticed, contribute to th'u sudden dilatation of the os uteri, by acting as a uniform local depletion' 424 CONNECTION OF THE OVUM then form, and a temporary truce ensue; but this in general is treacherous, and of short duration; especially, if pains attend; for the coagula which had partially arrested the hemorrhage are now driven away by the contractions of the uterus, or by the operation of some other cause, as accidental as unavoidable, and the discharge is renewed with perhaps even increased vio- lence ; and in this way do things proceed, until the poor suffer- er is cither exhausted by the waste of blood, or relieved by the judicious and successful interposition of art. 1107. When the discharge is so extensive and sudden as I have just described, no time should be lost before it be ascer- tained whether the flooding proceeds from a separation of a portion of the placenta remotely situated from the os uteri, or from this mass being placed over it—the symptoms which de- signate these different situations, though perhaps pretty strong- ly7 marked, are not sufficiently accurate to render a more cer- tain and decided examination unnecessary. 1108. We should, therefore, upon such occasions, always examine the mouth of the uterus with great care. In conduct- ing this, the finger, merely introduced into the vagina, will rarely inform us with sufficient accuracy, to prevent all error; the hand should be conducted into this canal, that the utmost freedom may be given to this important examination. A pro- per moment, however, should be chosen for this purpose, that no evil may result from the operation; for I have just remark- ed, that a suspension of the discharge is sometimes effected by a coagulum within the vagina or mouth of the uterus, which being removed in making the examination, may renew the flooding, to the decided injury of the patient; while the blood is flowing, is the time to make this attempt. 1109. When the hand has possession of the vagina, a finger should be carried within the os uteri; it should then carefully and with certainty, determine the nature of the substance pre- sented to it: if it be the placenta, it can be easily distinguished from a coagulum (the only thing to which it has any resem- blance) by the following characters : 1st. The placenta always presents a fibrous structure, of pretty considerable firmness. 2d. When this is pressed upon by the extremity of the finger, WITH THE UTERUS. 425 a sensation of tearing an organized mass is excited. 3d. It being much firmer in its consistence, and offering more resist- ance to the play of the finger within it, than a coagulum. 4th. Its not escaping from the finger, Avhen its substance is in some measure broken down by the pressure and free movement of it—it can never be mistaken for the membranes. 1110. In a case of such importance, we should neither per- mit a false humanity, nor a false delicacy, to get the better of an imperious duty; for upon the early knowledge of the species of flooding, the woman's life may unquestionably depend. We should therefore, without reserve, state to the friends of the patient, our opinion of the nature and tendency of her case, and the importance of ascertaining it, by a proper examination. This will almost always be acquiesced in; and, if it be pro- perly conducted, will neither excite any severity7 of pain, nor wound.the most fastidious delicacy. The hand for the most part, from the relaxation consequent upon a continued discharge, will pass without much difficulty; or it may be made to do so, by proper lubrication. 1111. It is true, indeed, with a first child, and at an incom- plete period of utero-gestation, there may be some difficulty in passing the hand, if the discharge have not been pretty abundant—but in this case, the examination is not so immedi- ately important; should it, however, be so, from the excess of the haemorrhage, the parts will then be found almost always sufficiently yielding to permit the passage of the hand without great difficulty. 1112. Having ascertained it to be a placental presentation, the condition of the mouth of the uterus should next be care- fully examined—the degree of opening, and its disposition or indisposition to dilate, should be marked; for on this much depends. It will be found in one of the following situations: 1st, but little opened, and very rigid; 2d, but little opened, yet disposed to dilate; 3d, opened to some extent, but very un- yielding ; 4th, opened to the same extent, but«oft; 5th, fully dilated. 1113. The nature of the case being thus ascertained, the mode of treatment is next to be considered. This will neces- [54] 426 CONNECTION OF THE OVUM sarily be much influenced by the particular condition of the woman, and the period at which the discharge may show itself, and its quantity7 make interference necessary. I have already noticed, that when the placenta is situated over the mouth of the uterus, slight discharges of blood may take place after the sixth month, as a consequence of the economy of the uterus (1103) at this period; when these are moderate, they may, for the most part, be arrested by the means usually employed for flooding, when the placenta is not placed over the mouth of the uterus; thev should therefore be put into immediate requisi- tion, and the patient placed under the strictest injunctions of obedience, and conformity to directions. 1114. For a discharge of blood at this period is always to be looked upon as liable to extreme augmentation; and we should never lose the suspicion, that it may arise from the situ- ation of the placenta. We have no certain means, by which the " accidental" may at this time be distinguished from the "unavoidable," unless it be by a careful examination—but this is never necessary7, so long as the flooding is moderate. I think, however, I have observed in the " unavoidable," that the flow of blood is more sudden and copious, in a given time; and that it is more fluid and florid, than in the " accidental." In the commencement, the " unavoidable" is never accompanied by coagula; and' when pain attends, the discharge is always in- creased at each contraction. But in cases demanding precision, these marks cannot be relied upon. From the proximity of the bleeding vessels to the os externum, the blood will issue so quickly from them, as to appear both more fluid, and more florid, than in the " accidental" species; for in the " accidental," the blood may escape remote from the os uteri, and be obliged to travel slowly through the meshes of the connecting medium of the ovum and uterus; and hence will appear less florid, and fluid, and be more disposed to coagulate than in the "unavoid- able." 1115. But coagula will form in the "unavoidable," when the discharge is about to cease, either by proper treatment, or by the mere efforts of nature; and it is in this way, that a stop is put to farther waste. WITH THE UTERUS. 427 1116. As we cannot determine the situation of the placenta without much pain and force, before the full period, when the flooding is moderate, it may always be well to treat them as if they7 were cases of placental presentations; as in doing so, we shall be erring on the safe side. We should insist upon the most perfect tranquillity, and an almost constant confine- ment to a horizontal position, whenever practicable. Blood at this period may be taken from the arm, if the arterial force be too great; cold applications should be resorted to; and the sugar of lead be exhibited in sufficient doses, either by the mouth or by enemata, as already advised. Kok and others recommend cold astringent injections into the vagina: of the utility of these, as I have said before, I have much doubt—at least, I have never been tempted to employ them. I rarely pay any7 attention to the state of the bowels, unless they be very costive—then a mild, warm injection of molasses and water, or soap and water, will be every way sufficient. I am thorough- ly convinced that much mischief is sometimes done, by the exhibition of even the very mildest purgatives ; and the reason will be immediately obvious, when we consider the effects of them. I have frequently permitted my patients, under treat- ment for uterine haemorrhage, to be five or six days without a discharge from the bowels; and when I have thought it neces- sary to stir diem, it has been, for the most part, by means of mild injections. 1117. Kok also advises the introduction of some substance, such as lint or rags, into the vagina, well imbued with a fluid styptic, such as a strong solution of alum, or of wine in which alum is dissolved. I should place more reliance upon this latter means than upon the former; as it would in some mea- sure act as a tampon, and serve as a. point d'appui for coagula to form upon; for at last we must have these form, if the hae, morrhage stop without having done much mischief. 1118. I have advised bleeding when the pulse is active; Kok says, this is useless, if not injurious, in this kind of flooding. In this I cannot altogether agree with him, at this period of utero-gestation; and for the following reasons:—1st. Under any kind of active haemorrhage, when the pulse is vigorous, the 428 CONNECTION OF THE OVUM taking awav blood from the arm has-uniformly been found use- ful, by producing contraction by merely unloading the vessels; and more especially, in diminishing the velocity of the blood within them. 2dly. At the period we are speaking of, as wt cannot from the contingencies just mentioned, decide with certainty that the discharge is from the peculiar location of the placenta, without manifest violence, -we may act, as far as the bleeding is concerned, as if it were an " accidental" haemor- rhage ; especially, as the blood detracted will not seriously weaken the woman, and as there is a strong probability that it may be arrested until the last period of pregnancy, by proper applications and treatment. 3dly. That at the time this accident shows itself, it is for the most part from the mechanical sepa- ration of a portion of the placenta, which will not generally be renewed for some time; as the separated vessels, and the other connecting media, possess considerable elasticity; therefore, time will be given for the formation of coagula, provided, the proper means be pursued to favour their production; among which we must reckon bleeding. 4thly. If the fluor be not pro- duced by external violence, or any other cause which will cer- tainly excite the action of the uterus, there is a strong proba- bility, that the discharge will cease for the time being; unless, it be improperly treated, or unnecessarily provoked. 1119. Should any cause whatever excite the contraction of the body and fundus of the uterus at this period; and the dis- charge be rather the effect of such contractions, than the natural and unavoidable stretching of the neck of this organ, we have great reason to fear, that we shall not be able to suspend these efforts, so as to enable the woman to go her full term of gesta- tion. But we should ever have this intention in view, as it may sometimes be happily fulfilled; and, if it be not, it is decidedly the most proper mode of treatment. 1120. In such cases, we should endeavour, as quickly as possible, to interrupt uterine contraction; for this purpose, we should bleed under the restrictions just mentioned; we should exhibit the sugar of lead with laudanum, as frequently as the exigencies of the case may require; and by enemata, I think, WITH THE UTERUS. 429 is much the most prompt and efficacious mode of administering them. From a scruple to a half drachm of this salt, with a drachm of laudanum, and a gill of water, may be thrown up the rectum every hour, or more seldom, as occasion may call for them. All the auxiliary plans I have already7 recommend- ed, should be put in requisition, and their full adoption rigidly- enforced. 1121. Should these means moderate the discharge, and the blood be found disposed to form coagula; and if at the same time uterine contractions have ceased, or even have consider- ably diminished, we may be encouraged to persevere in the use of these remedies, and entertain an expectation of future success. The introduction of a moderate sized tampon at this time, as a mere point d'appui, I am persuaded is highly useful; for, without some such support, the coagula may be discharged, and the haemorrhage renewed. 1122. The artificial support for coagula, which I have re- commended above, is of more consequence than we would at first imagine. It permits the thinner parts of the blood to escape through the meshes of the sponge, by which means the coagula are rendered more firm and tenacious; besides diminishing, by a counter action, the influence of the vis a tergo, which is constantly operating to throw them off. 1123. I am aware, that some would rely upon the coagula without it; and I must admit, that they have occasionally been sufficient to save the woman's life; a case of this kind, is related by Leroux ;* but he expressly declares, they are not to be re- lied upon. The sudden movement of the woman's body, for even necessary purposes ; uterine contraction; the escape of the waters ; &c. may all serve to derange the coagulum which has arrested the haemorrhage. But the most important use of the tampon under these circumstances, remains to be mention- ed ; which is, that it causes the coagulation of the blood, merely by presenting a surface favourable to this change, long before this disposition would spontaneously show itself; for in gene- ral, this effect is not produced, but when the woman is much * Observations, p. 25R 430 CONNECTION OF THE OVUM , exhausted, or bv the rather tardy, though successful influence, of the remedies previously employed.* 1124. Should our endeavours, however, fail to arrest the discharge, we should, without further loss of time, ascertain the condition of the os uteri, and then proceed precisely as if the woman had arrived at her full time when the haemorrhage com- menced; for it will now be found, they are reduced exactly to the same condition, and will require the same mode of ma- nagement ; of which I shall speak more at large presently. 1125. A woman may escape these anticipating discharges until she complete her full term ; but at this time it will be seen that the uterus cannot expel its contents without necessarily exposing the patient to the most imminent risk. So alarmingly profuse, and so suddenly dangerous, are these discharges in some instances, that a few minutes are sufficient to exhaust the strength, or deprive the woman of life. 1126. I once witnessed a case in which there was discharged from the uterus, in the course of about fifteen minutes, a full half gallon of blood; and was sent for in another instance, where the woman had expired before my arrival, though there had not, as the midwife assured me, more than a half hour pass- ed from the commencement of the flooding to its fatal termina- tion. These are, however, extreme cases; yet they show how suddenly7, and certainly, they may be alarming or fatal. It is confessed, on all hands, that no accident attendant upon con- ception is equally menacing as the disease in question; and it also emphatically declares to the physician, that much de- pends upon him that it shall not be very often fatal. It is one of those extraordinary cases, in which nature does less for the preservation of the individual, than almost any other. 1127. This does not arise so much from want of exertion, if I may so term it, on her part, as from the almost entire incom- patibility of giving birth to the child, and protecting the wo- man against flooding, at one and the same time. Yet we learn, from such authority as cannot be doubted, that the woman, left * Mr. Burns assures us, he never saw a case which required delivery during the first paroxysm, if a proper treatment had been adopted. (Principles of Mid- wifery, 5th ed. p. 323.) WITH THE UTERUS. 431 entirely to herself, will not always perish. The means, how- ever, which nature employs to procure this security, neither offer a practical hint, nor hold out the smallest inducement to imitate her; for they7 are so entirely contingent, and sometimes so long withheld, that the woman, from her great exhaustion, can scarcely be said to profit by the interposition. 1128. Baudelocque* says, the woman may be preserved " when the orifice is fully dilated, and the mass separate en- tirely from it, and be so far removed from one side, that the membranes may present. The membranes may then tear spon- taneously, and delivery be performed naturally, if the woman, notwithstanding her loss of blood, still preserves sufficient strength, as has sometimes happened." Leroux,f by the for- mation of coagula, and the spontaneous action of the uterus. Smellie,i. to the entire separation of the placenta, rupture of the membranes, and the placenta being first delivered, &c. &c. 1129. From this it would appear, that in some rare instances the woman has been saved, by the natural agents effecting the delivery, before she was too much exhausted; but we do not profit by the knowledge of the manner in which this was per- formed. It is, therefore, now completely established, that the. only chance the woman has for life, is by a well-timed, and well-conducted delivery in every7 case, ceteris paribus, of pla- centa presentation. , / 1130. Though it be. universally admitted, that in the cases we are now considering, there is but one certain mode of pro- ceeding, yet it is not so generally conceded, that it is essential to the entire success of that mode, that the delivery be proper- ly timed, and as properly conducted. All who have written upon this subject, seem to agree in one of the positions, name- ly, that delivery is absolutely necessary; but many, and in- deed I may add too many, have been regardless of the con- ditions which serve to render this operation availing. 1131. It would be a needless repetition, to cite authorities * System of .Midwifery, Vol. II. par. 986. | Observations, &.c. p. 306. t Midwifery, Vol. ll. Col. 18. No. 3. Cases No. 3, 4, 5, 6, 7. 432 CONNECTION OF THE OVUM in proof of this; as I have already animadverted upon the same error, when speaking upon the practice of forcing the mouth of the uterus in the accidental haemorrhage, when not readily- disposed to yield. The same, or perhaps more sudden mischief, would follow this rashness in the cases under consideration, than in the former; for the flooding would almost always he increased, in addition to the evils already pointed out. 1132. The time when we shall attempt delivery, is of the greatest moment, and deserves particular investigation. Dr. Denman says, " it would be of great advantage in practice, if some mark were discovered, or some symptom observed, which would indicate the precise time when women with haemor- rhages of this kind ought to be delivered;" but declares, "we do not at present know any such mark." Yet almost immedi- ately after decides, that "whenever the case demands the ope- ration, on account of the danger of the haemorrhage, the state of the parts will on this account alway7s allow it to be perform- ed with safety, though not with equal facility." 1133. If this be true, we are certainly in possession of what Dr. D. thought so great a desideratum-—for if the parts be in a condition to turn with safety, it is certainly all that is re- quired, when "the danger of the haemorrhage demands the operation." For if the parts permit turning without risk, they must be in a dilated or a dilatable state, and this is all that is or can be required when the condition of the flooding "de- mands the operation." Then we have a rule which is never failing, when this condition of the parts obtains, if it be true that this can always be done with safety, if not with equal fa- cility. 1134. Now it is of importance to inquire whether turning can always be performed with safety when the parts are in a condition to permit it; for upon this much depends. It would seem, agreeably to this position, that the whole risk the wo- man runs in these cases, arises from the " state of the parts," opposing the introduction of the hand; and when they do not, then turning may be performed with safety—experience con- stantly contradicts this unqualified opinion, for the woman may WITH THE UTERUS. 433 be so far reduced, that she may expire before the operation is completed, or very quickly after.* 1135. Besides, the manner in which we find the opinion stated by Dr. D., would lead to the persuasion, that so long as the os uteri was not opened, there could be no danger, whatever might be,the quantity discharged; than which nothing can be more unfounded. For it is a well-known fact, that the powers of the uterus may be so far impaired as not to perform this office, even at the last moment of existence. In this I am supported by Rigby,| wno declares, that were "this rule invariably ad- hered to, in some . cases, it would be attended with danger, as we might wait for the opening of the uterus till it was too late to relieve the woman by turning the child." 1136. This will be very readily understood, when it is re- collected, that the opening of the uterus mainly depends upon the longitudinal fibres acquiring the mastery of the circular; but when the uterus is so far exhausted of contractile power as to remain passive, or nearly so, we shall always find the os uteri closed, (unless previously distended by an exertion of its powers,) though it may be most easily dilatable. I may per- haps even acquiesce in the explanation of Dr. Rigby7"}: upon this subject; who supposes that the position of the placenta may serve to keep the uterus closed, by surrounding its mouth, by the attachment of its fibres to this part, which is now perfectly passive and unresisting—this is both ingenious and probable. 1137. I must now make a distinction of great practical im- portance, that has never, so far as I know, been attempted; which, if it be just, (and my experience gives me every reason to believe it is,) will in some measure serve to reconcile the conflicting opinions of writers upon the subject of the time when it would be invariably proper to attempt the relief of the pa- • Of this we have ample proof, in cases 58, 81, 82, 89, 98, &c. of Rigby, in each of which the condition of the parts easily permitted turning, but not with safety. But I am clearly to be understood, that I attach no censure to the ope- ration ; for I am of opinion, it was the only thing that could be done to give the woman a chance—and I have no doubt, it was properly performed. But these cases go to prove the incorrectness of the position I am now examining. f Essay, 6th ed. p. 40. * Ibid. [55] 434 connection or the ovum tient by turning—it is simply this, that there is a most mate- rial difference between the dilatation of the os uteri, or even its dilatability, when effected by the natural powers of this organ, and that passive or quiescent condition, which results from the languor of death. 1138. The one is the result of its organization, when its powers are not impaired or prostrated by disease ; while the other is a syncope, if I may so term it, produced, when these powers are exhausted byr an excessive waste of blood. This distinction must constantly be kept in view; for on it depends the rational mode of treating this formidable complaint; for if it be not, we prescribe both uncertainly and empirically. An attention to the one, leads us to husband, with the utmost care, the strength and vigour of the patient; while the other makes us regardless, if not prodigal, of it; the one is almost always crowned by success; the other makes us constantly anticipate a doubtful issue. 1139. We can readily account, with this distinction in view, for the difference of success in the operation of turning. When it has been performed, and the dilatation of the uterus effected by the natural agents, it has perhaps almost always been at- tended by the much desired issue ; but when performed, after the flaccidity of approaching death had ceased to make it dif- ficult, it too often has been followed by the loss of the patient. Under this impression, I should say, that, when the os uteri was either dilated or dilatable by the spontaneous operation of this organ; and before the strength of the patient was materially impaired, that then, and then only, was the desira- ble time to operate; but that, if circumstances prevent advan- tage being taken of this proper moment, and nothing but a choice of difficulties remain, we should certainly attempt to snatch the woman from her impending fate; but under the cautions already suggested. 1140. But I will attempt to put this subject in a clearer point of view, by considering what ought to be attempted for the re- lief of the patient, under each of the conditions of the uterus pointed out above; and which necessarily comprehends every state of which it is at this time susceptible. WITH THE UTERUS. 435 Sect. IX.—-1. Where the Uterus is but little opened, and is very rigid. 1141. In this situation of the uterus, all the evils I have al- ready enumerated, when speaking of a delivery under our se- cond division, and the uterus in this condition, would attend a forced delivery at this time—it must not,therefore, be thought of, by whatever authority it may be recommended. Indeed, this has ever been a case of great embarrassment to the writer upon this subject; and makes him, in too many instances, at variance with himself; or he gives his directions so obscurely, and so hesitatingly, as to corifuse the judgment of the young practitioner.* It has given rise to two modes of proceeding, each of which is equally wrong. 1142. The first is to force the uterus, however rigid, pro- vided a finger can be introduced; I have already said much upon this plan, and shall only add in proof of it a quotation from Dr. Rigbyf every way illustrative of the impropriety of this outrageous practice. " In recommending early delivery, I think it right, however, to express a caution against the pre- mature introduction of the hand, and the too forcible dilata- tion of the os uteri, before it is sufficiently relaxed by pain or discharge, for it is undoubtedly very certain that the turning may be performed too soon, as well as too late, and that the consequences of the one may be as destructive to the patient as the other. I am particularly led to observe this, as I have lately been informed, from very good authority, (namely, a * For an instance of this kind, I may cite even Mr. Burns himself—he tells us, in one sentence, "if the haemorrhage have been or continues to be considerable, we must not wait until the os uteri be much dilated, as we thus reduce the wo- man to great danger, and diminish the chance of recovery." A few lines far- ther, in the same page, he says, " a prudent practitioner will not violently open up the os uteri, but will use the plug." A little farther on, he declares, " he (a prudent practitioner) will not allow his patient to lose much blood, or have'many attacks; he will deliver her immediately, for we know that whenever that is necessary, that it is easy, the os uteri yielding to his cautious endeavours."— (Princip. 5th ed. p. 324.) t Essay on Uterine Haemorrhage, 5th ed. p. 40. 436 CONNECTION OF THE OVUM gentleman to whom one of the cases occurred,) of three unhap- py7 instances of an error of this sort, which happened some years ago to three surgeons of established reputation, who, from the success they had met with in delivering several who were reduced to the last extremity7, were encouraged to at- tempt it where but very little blood had been lost, in hopes that their patients' constitutions would suffer less injury, and their recovery be more speedy; which, till the experiment was made, was a very reasonable supposition—the women died, and they seemed convinced that their deaths were owing to the violence of being delivered too soon, and not to the loss of blood, or any other cause." 1143. The other is, to permit the flooding to proceed until the woman shall be so much exhausted as to render the uterus pliant. Dr. Denman, as I have just noticed, supposed that when danger created the necessity for delivery, that then, from the loss of blood, the uterus would permit it with safety. Dr. Rigby says, that when the uterus contracts firmly round the fingers, we should desist from any attempt to deliver, and wait till the part be more relaxed by pain or discharge; and adds, " as an encouragement, that we may safely suffer a woman to lose more blood, the contraction may certainly be looked upon as a proof that there still remains a considerable portion of animal strength, and that she has not been so much affected by the loss as we before imagined." 1144. I cannot recommend this plan, though it be the advice of the first authority upon this subject. I am convinced, from both reason and experience, that it is seldom or never neces- sary; and is perhaps always injurious. To save the woman an ounce of blood, is, as I have already declared, a duty: to save her forty, or perhaps much more, is still a greater one. To follow, then, the speculation of Dr. Denman, or the advice of Dr. Rigby, would be widely departing from that duty. I do not, I cannot adopt them. 1145. What is essentially important to be done in this case? 1st. To save as much, and as quickly as we can, the further expenditure of blood. 2d. To obtain, as soon as the natural powers will effect it, the dilatation or dilatability of the uterus. WITH THE UTERUS. 437 3d. To then deliver with as much speed as is consistent with the welfare of both mother and child. 1146. The first and second of these indications are, as far as I have witnessed for the last thirty years, readily complied with by7 the use of the tampon, and the other auxiliary remedies. They should be instantly had recourse to, and the discharge will almost immediately abate; and in a short time be so di- minished, as to give no immediate concern for its effects. By this means we not only staunch the haemorrhage, but gain most important time; for during this truce the natural agents of de- livery will effect the desired relaxation of the os uteri. 1147. This plan, I believe, originated with Leroux; and has been adopted with entire success by myself for many years past. It has also the sanction of Mr. John Burns, who recom- mends it by saying, " a prudent practitioner will not violently open the os uteri at an early period, but will use the plug, until the os uteri become soft and dilatable." It is true, Gardien thinks the plug will do harm, by exciting the uterus, and thus increase the separation of the placenta—but this is theory; it is not consonant with experience. 1148. The following case, selected from several of a similar kind, will place in a clear point of view the promptness and efficacy of this plan. Mrs.----, while looking out of her window, was suddenly surprised by a profuse discharge of blood from the vagina. Before I arrived, though near at hand, more than half a gallon of blood was expended upon the floor and in a pot. The patient was upon the bed, pale, feeble, and excessively alarmed. I examined her immediately, and found the uterus rigid, and the placenta presenting. She had no pain; nor had she any, previous to the irruption of blood. The dis- charge was verv profuse, and exhausting; but as the os uteri was none dilated, and rigid, I introduced the tampon, and se- cured it within the vagina by a compress upon the external labia with a T bandage. The flooding ceased immediately, and there was nothing passed the os externum but some of the thinner parts of the blood. After the tampon had been applied about four hours, pains commenced pretty briskly, and in about two hours more, they were of considerable force, so much so as 438 CONNECTION OF THE OVUM to press against the external compress with some violence. 1 now removed the tampon; and the os uteri was found suffi- ciently dilated to allow the hand to pass with entire freedom; and the delivery was quickly effected, with safety to both mo- ther and child. 1149. For the successful fulfilment of the third, and last in- dication, it is necessary that the practitioner should be well acquainted with the condition of the uterus, at the moment he is about to commence the operation; that is, he should know how far he may rely7 upon its co-operation, or how far it may be capable of that degree of contraction which shall secure the woman against'a farther loss of blood. This can only be pre- sumed, from taking into view the quantity of blood lost; the debility or exhaustion it has occasioned; and the degree of force the uterus may exert, at each return of pain. 1150. If it be found, that the quantity of blood is not exces- sive; if tthe degree of exhaustion be not alarming; and if, above all, the uterus manifest considerable vigour; the delivery may be accomplished in much shorter time, and with much greater promise of success, (especially to the child,) than if the contrary of these obtain—in the latter case, the delivery must be conducted with the utmost caution, that the uterus may not be too suddenly emptied, and augment the danger to both mother and child. I shall again advert to this subject, when I come to describe the manner of conducting the opera- tion of turning, or effecting the delivery in such cases. Sect. X.—2. When but little opened, but disposed to dilate. 1151. In this situation of the uterus, but few obstacles to turning or delivery will present themselves; since, if the neces- sity of the case require the operation, the great objection to it is in some measure removed; for this disposition to yield to a moderate force, will secure the woman against an excessive loss of blood, by taking advantage of it, and effecting the deli- very in proper time. 1152. But it must be recollected, that though the uterus may be disposed to yield to a certain extent, with even a moderate WITH THE UTERUS. 439 force, if it be slowly and judiciously applied, yet it may refuse to relax beyond this, or to such a degree as would not embar- rass the operation; nor can it sometimes be made to yield more, unless a dangerous or reprehensible force be applied.* 1153. In a case of this kind, we should gain time, by the employment of the tampon, as directed above; and not subject the woman to unnecessary risk, by attempting to overcome the resistance of the uterus by violence; and it must also be recol- lected, that, in cases like these, cases so replete with risk, we are to devote ourselves to the best interest of our patients— thev should never be subjected to the chance of a fatal haemor- rhage, by our leaving them even for a short time ; for neither the plea of other engagements, nor a persuasion they can re- ceive no injury during a short interval of absence, can justify our withdrawing ourselves from them ; I could cite a number of instances in support of this, were such confirmation neces- sary. If it be judged necessary to employ the tampon, we should wait patiently for its effects; but we should wait at the bed-side, or near the person of the sufferer, that we may take immediate advantage of any favourable change in the condition of the parts, for which we were so anxiously looking; or guard against any unfavourable contingency, that may suddenly or unexpectedly arise. 1154. Sometimes, indeed, the os uteri appears entirely closed, though at the time, it is easily dilatable; this case should not be confounded with the one just considered; for here the wo- man may be readily delivered, should the urgency of the case require it. This situation of the uterus, for the most part, only takes place when the woman is nearly exhausted, and its powers so far impaired, that the agents for the absolute dilatation of its orifice are incapable of the effort. Should we wait for the ex- pansion of the os uteri in such instances, we should wait in vain; and perhaps even be made witnesses of the death of the patient, f * Leroux, Mauriceau, Rigby, &c. f See Rigby on Uterine. Haemorrhage- 440 CONNECTION OP THE OVUN Sect. XI.—3. Opened to some extent, but very unyielding. 1155. Were we to consult authors upon the point of practice in this condition of the uterus, we should find but too many sanctioning forced delivery; while some others, would severely reprehend it. I might employ7 the same arguments here, as have already been used against any7 violence being committed upon an unyielding uterus ; for it may sustain as much injurv in the condition supposed here, as in the instances I have been considering; for if the opening be insufficient to permit the hand to pass without the employment of force, it will certainly be insufficient to allow the foetus to pass without using much more; it should, therefore, be considered full as ineligible to operate in this case, as in the two I have just noticed. 1156. Besides, there is less excuse for being precipitate in this case; since, the desired relaxation will most probably soon ensue, as the os uteri has already yielded to some extent; therefore, by giving it a little more time ; by employing the tampon, the delivery may be accomplished without either vio- lence or risk. 1157. Had we no command of the haemorrhage, we perhaps might be justified in the employment of force; as it would then be a dernier resource ; but as we can certainly control the dis- charge by the tampon, we should be inexcusable to attempt delivery, until it had been properly7 tried, and it had failed. 1158. But let this case not be confounded with the condition next to be mentioned. For when it is ascertained, that the ute- rus, though opened to some extent, is, notwithstanding, very unyielding; a young practitioner may, in the confusion and embarrassment created by the exigency of the case, easily run into the error, that this case must be treated as the one just considered. To prevent this, he should carefully examine the condition of the os uteri, by placing, or rather hooking a finger within it, and drawing the edge towards him ; if it readily yield, he may be pretty certain it will stretch by a well directed force within its circle. 1159. But, in conducting this examination, I must caution him against a mistake he may readily make, if he be not put WITH THE UTERUS. 441 upon his guard; which is this—he may mistake the movement of the whole os uteri, for a portion of it; but this error may without difficulty be corrected, by deliberately performing the examination, and attending strictly to the following marks—if a rigid os uteri be drawn, say towards the pubes, its edge against which the finger is placed, will maintain its rigid feel; and if the finger be made to pass round the whole of its circle, it will be found to be uniformly stiff and round, and not any, or very little enlarged by the effort made upon it—but, on the other hand, if the os uteri be dilatable beyrond the size we suppose it to be by the touch, it will be found soft; and will yield with- out difficulty to the effort made to stretch it: and if the finger be then allowed to pass round it, it will be perceived to be of a lengthened shape, and to have been entirely obedient to the force employed to draw it forward. Sect. XII.—4. Where opened to the same extent, but soft. 1160. I have just declared an error may be committed by an inexperienced or timid practitioner, in this condition of the uterus; and have pointed out the method by7 which it may be instantly corrected; it therefore behooves him not to neglect to entirely satisfy himself, as to the situation of the os uteri, before he finally makes un his opinion on the proper mode of practice. 1161. A careless or ill-conducted examination, may in this instance lead to the loss of the patient; for, by mistaking the absolute diameter of the uterus for the possible, he may delay operating so long, as to render it totally unavailing; for I per- fectly agree with Dr. Rigby,* that however important it may be as a general rule, that the uterus must be opened to the size of a shilling, or a half crown, before any attempt is made to introduce the hand, yet if this rule be rigidly enforced, "it would in some cases be attended with danger, as we might wait for the opening till it was too late to relieve the woman by turning; and for this reason, it seems right we should be some- times as much influenced by the os uteri being in a state capa- • Rigbv, p. 42. [56] 44*2 CONNECTION OF THE OVUM ble of dilatation without violence, as by its being nearly open."* In my directions for the management of cases in the second condition of the uterus, I noticed this situation of this organ, and remarked that it usually occurred when the woman had flooded to excess—but I have known at least two exceptions to this. Sect. XIII—5. Where fully dilated. 1162. When a case presents this condition of the uterus, there can be no hesitation about the proper mode of proceeding, if the exigencies of it require instant interference; for here all objection is removed to the operation of turning, so far as any mechanical injury to the uterus is to be feared—but this is a rare case; and when it does occur, it would seem to happen but under the following circumstances :—1st. In those women who are wont to have very rapid and very easy labours. 2dly. Where the edge of the placenta extends over the os uteri, and where, in consequence of this, the haemorrhage has not been sufficient to seriously injure the contractile powers of the ute- rus, though rather profuse. 3dly. Where the pains have been so rapid and powerful, as to suddenly dilate the os uteri, and cause the head to carry the placenta some distance before it. 1163. In the first case, the haemorrhage will be of the most profuse and alarming kind ; and if the woman be not very quick- ly aided, she will most probably die—this was the case with the poor woman who lost her life before I could get to her assist- ance—here, not a moment is to be lost; turning must be in- stantly had recourse to. 1164. In the second instance, the discharge, though perhaps very free, is never so overwhelming as in the first; for the edge of the placenta may be passed over the os uteri but a small dis- tance, and the flooding will of course be in proportion as this may be more or less extensive—in these cases the membranes may even present, rupture spontaneously, and thus save the woman; here the natural agents may accomplish the delivery— but more of this by and by. • Ki^-by, p. 43 WITH THE UTERUS. 443 1165. In the third case, the flooding will be perhaps, for a pe- riod, as alarming, and, for the time of its continuance, as pro- fuse as in the first—but the uterus acting promptly and vigor- ously, the head of the child is made to press so effectively upon the mouths of the bleeding vessels, as to arrest the haemorrhage* —here we must act according to circumstances; if we see the patient during the time of her profuse flooding, we should not hesitate a moment to deliver, even though the pains be brisk; for it is entirely contingent that the discharge will be stopped by the intervention of the head—but should we not see the patient until by the progress of the head the bleeding be arrest- ed, we should not interfere, but commit the case to nature. 1166. It has been recommended by some, to rupture the membranes in the expectation of stopping the haemorrhage, as it frequently does when the placenta is not fixed at the mouth of the uterus—but this should never be done; especially, before the uterus is well dilated or easily dilatable, and for the fol- lowing reasons :—1st. Because they cannot be reached without great difficulty in some instances, and in these cases, when they are reached, it is either by piercing the centre of the mass, or separating a portion of the placenta, and thus increasing the bleeding surface. 2dly. When they are pierced, and the waters evacuated, it will very rarely stop the haemorrhage. 3dly. When it does not do this, we are sure to have the difficulties of turning increased. 4thly. That should the flooding for the moment cease after the discharge of the waters, it is sure to return as the pains increase, and as the uterus expands. The only exceptions to these rules, are the cases just mention- ed above, where the membranes present themselves in part. 1167. Baudelocque assures us he had seen but one case, where the haemorrhage ceased after the discharge of the waters, ;md that was where the placenta was first delivered by a mid- wife, and the head of the child was made to press so firmly on the mouths of the bleeding vessels as to stop the hsmorrhage.f 1168. It may be inquired, what mode of relief is to be pur- sued in placental presentations, when they happen at or near the * Baudelocque, Leroux, &c. t System, Vol. II. par. 982. 444 CONNECTION or TUT OVUM sixth month? These are truly embarrassing cases when thev occur; as, for the most part, the uterus is not sufficiently en- larged to admit the hand to turn, and the haemorrhage is some- times very alarming; the great risk in these situations arises from the want of disposition in the os uteri to dilate; and, be- fore this is accomplished, the woman sometimes succumbs, from the unrestrained flow of blood. 1169. But women in this situation, even when unaided, do not necessarily die; nature being now and then competent to the task of delivery.* I may remark, as a general rule, and as a consolatory circumstance, that nature, if not interrupted, or when given the best chance, will almost always effect the ex- pulsion of the ovum, previously to, or soon after the sixth month, without the manual interference of the accoucheur— for the most part, then, in such cases, our attention should be directed to the diminution of the haemorrhage, by such pallia- tives as we have constantly in our power; among these the tampon stands foremost. 1170. This remedy should be early employed, as it will, by proper management, save a prodigious expenditure of blood; we gain by its application important time; time that is essential for the successful delivery of the foetus—-for by it, the woman's strength is preserved; pain is permitted to increase ; and even- tually7, though tardily, the os uteri is dilated; the placenta and foetus thrown off; and the flooding almost immediately control- ed. The other means which I have already advised, should also be tried; they may aid the general intentions; and render the operation of the tampon more certain. 1171. We have the examples of Mauriceau and others, to attempt the relief of the woman by manual exertion in these cases ; but I should, neither from the history of their cases, nor my own experience, be tempted to recommend this plan. I am persuaded, that the temporising mode I have just suggested, is the proper one to pursue—Leroux long since adopted this method, and I have for many years but trod in his footsteps; * Rigby, Leroux, &c. WITH THE UTERUS. 445 and it is but just and proper to add, I have had abundant rea- son to be satisfied. Besides, in this, all the best writers concur. 1172. Dr. Rigby, though by no means confident of the effi- cacy of the tampon, confesses, in the cases I am now consider- ing, it.might be used with propriety. Had he put this plan in execution, I am persuaded he would have been satisfied with its effects, and would unquestionably have prevented his giv- ing the hazardous advice, "to wait for relaxation," by permit- ting the patient to flood, until the collapse almost of death should effect it. 1173. Experience has often convinced me, that the relaxa- tion of the os tincae, so desirable in the cases I am now con- sidering, will be as certainly achieved by time, as by this ex- cessive expenditure of blood; and this time procured by the interruption of the flooding by the tampon. When we effect this by this means, we assuredly gain a great deal—strength is saved by saving much blood, and the woman's future safety is almost insured; for as a general rule I may declare, that when no violence is committed upon the uterus by an attempt at forced delivery, the only thing we have to apprehend, is the consequences of the haemorrhage. 1174. When the woman is farther advanced, say at the se- venth month, artificial delivery may most generally be effect- ed,* provided we do not destroy the advantages this period gives us, by improper treatment;—for instance, by rupturing the membranes, and the consequent discharge of the waters; this should, therefore,be especially guarded against. An atten- tion to this point, in these cases, is more important than at the full period; notwithstanding the advice of some accoucheurs to the contrary. 1175. It now only remains to describe the mode of effecting the delivery, when it is judged proper it shall be performed. In doing this, we can give only general directions for the situa- tion of the woman, as we cannot, from her extreme weakness and other causes, always command the most proper or conve- nient; it may nevertheless be well when we have a control, to * Leroux, Rigby, &c. \ 446 CONNECTION OF THE OVUM say what in our opinion is the best—that disposition of the wo- man's body, which will give us the most entire command of the uterus and its contents, will certainly be the most conve- nient for the accoucheur, and also the safest for the woman, and this position is upon the back, as has been already direct- ed. (/'02, &C.) 1176. Many accoucheurs, and especially7 the British, recom- mend the patient being placed upon her side ; I have ever found this less convenient than the plan just suggested; and have always adopted this method, where the situation of the woman would, without injury, permit a choice. The advan- tages of this position are, first, we may employ either hand, as may be most convenient to the practitioner, without changing the situation of the patient. Secondly, we always have one hand at liberty to co-operate with the introduced one, by placing it upon the abdomen. Thirdly, we can pass the hand more readily in the axis of the superior strait, by having the perinaeum free over the edge of the bed. Fourthly, we can re- gulate the discharge of the liquor amnii, ad libitum, a matter sometimes of great moment. But it must be remembered, we are never to attempt to procure these advantages by moving the patient, when that movement would be injurious to her; therefore, when she is very weak or faint, we must operate as well as w7e can in the position we find her; this is sometimes very awkward and inconvenient, but these are of no considera- tion, when the life, perhaps, of the poor sufferer, is to be put in competition with our ease. There is not, for the most part, much to be apprehended from merely changing the woman from her back, should she be lying upon it, to her side ; but a greater change might be very mischievous; we are therefore frequently7 obliged to do this before we can operate, as it would be almost impossible to turn, when the patient's back and hips are some distance from the edge of the bed.* 1177. Should circumstances, or choice, induce me to deliver from the side, I always give a preference to the left, provided * We must always remember to have pressure made upon the abdomen by a judicious assistant, when we deliver the woman upon her side ; as we cannot, in this position, as when she is upon her back, perform it ourselves. WITH THE UTERUS. 447 an election can be made. The hips should be drawn near to the edge of the bed, and made as salient almost as may be, by the flexion of the body, and the drawing up of the knees. In this position, the left hand is to be used, as with the right it would be very difficult to operate, owing to the axis of the su- perior strait being very much in advance. If on the right side, the right hand should be employed, and for the reason just stated. 1178. The woman being properly placed (if in our power,) the hand should be gently and gradually introduced into the vagina, and then into the mouth of the uterus, separating the placenta and membranes from it as it advances towards the fundus—when arrived there, the membranes should be broken by pressing firmly against them ; but the, waters should not be permitted to escape but at our pleasure. 1179. We can command this almost always, as our arm fills up the os externum, and prevents its passing out—from time to time I permit some to escape by pressing the arm firmly against one side of the vagina, until it is sufficiently evacuated; the object of this gradual discharge of the waters, is at once obvious, as it prevents the uterus from falling into a state of atony, by its being too suddenly deprived of them. The feet are now to be seized, and the body made to descend by draw- ing them down to the superior strait. We should now allow a little time for the uterus to contract; when we are assured it has done so, either by pains declaring themselves, by the child advancing further into the pelvis without our exertion, or by the firm and hardened feel of the uterus through the parietes of the abdomen, we may most safely proceed with the delivery to its termination. 1180. But should the woman be very much exhausted be- fore we commence our operations, we should use additional caution in the delivery—it should be very slowly performed, and we should have, at each step of the progress, assurances, if possible, that the uterus has not lost, or rather that it pos- sesses, sufficient contractility to render the completion of the operation eventually safe, if performed with due and necessary care. 448 CONNECTION OF THE OVUN 1181. We are advised by some, to pierce the placenta by the hand; but this should never be done; especially7, as it is impossible to assign one single good reason for the practice, and there are several very strong ones against it. 1st. In at- tempting this, much time is lost that is highly important to the patient, as the flooding unabatedly, if not increasingly goes on. 2dly. In this attempt we are obliged to force against the mem- branes, so as to carry or urge the whole placentary mass to- wards the fundus of the uterus, by which means the separation of it from the neck is increased, and consequently the flooding augmented. 3dly. When the hand has even penetrated the cavi- ty of the uterus, through the placenta^ the hole which it made is no greater than itself; and consequently, much too small for the foetus to pass through, without a forced enlargement; and this inust be done by the child during its passage. 4thly. As the hole made by the body of the child is not sufficiently large for the arms and head to pass through at the same time, they will consequently be arrested; and if force be applied to over- come the resistance, it will almost always separate the whole of the placenta from its connection with the uterus.* 5thly. That whenjdtis is done, it never fails to increase the discharge; be- sides adding the bulk of the placenta to that of the arms and head of the child. 6thly. When the placenta is pierced, we augment the risk of the child; for in making the opening, we may de- stroy some of the large umbilical veins, and thus permit the child to die from haemorrhage.fi. 7thly. By this method, we increase the chance of an atony of the uterus, as the discharge of the liquor amnii is not under due control. 8thly. That it is sometimes impossible to penetrate the placenta; especially, when its centre answers to the centre of the os uteri; in this instance much time is lost, that may be very important to the woman.§ • Baudelocque. -j- Ibid. t Dr Denman confesses, though he recommends the searching for an edge of the placenta, and penetrating it, that, in performing the latter, " there is rather more danger of losing the child." (Midwifery, Francis's ed. p. 484.) § Dr. Rigby admits this, and declares he has " more than once found it." p. 64. I WITH THE UTERUS. 449 1182. It is a mistake to suppose we produce a greater separa- tion of the placenta when we pass the hand between it and the uterus, than when wc pierce the placenta; but if true, it would be no objection to the method I advocate; since both uterus and placenta are pretty firmly compressed by the arm in its passage to the fundus, and the bleeding by this means restrain- ed; and as this is the only7 objection which is raised against the method recommended, I shall consider it as completely answered by what is now 6aid. 1183. Should the placenta not be found entirely detached from the uterus after the birth of the child, we should give a little time for it to separate spontaneously; and we must en- deavour to promote this by friction upon the abdomen over the uterus, unless the flooding continues to be violent; it will then be proper to pass up the hand and separate it, for it may be the bulk of the placenta which keeps up the haemorrhage, by preventing the uterus from closing sufficiently upon the bleed- ing vessels. 1184. Before I proceed to the consideration of the third di- vision of my subject, it may be well to inquire into Dr. Rigby's opinion concerning the nature of the uterine vessels, which I am content to call arteries. He sayrs, " the uterine vessels dif- fer very materially from arteries, and particularly in having no such power of contraction within themselves, their contraction and dilatation being absolutely dependent upon the state of the uterus. In the unimpregnated state, they7 are so small as scarce- ly to be discovered ; but they are well known to increase when the uterus receives the ovum, and to grow in.exact proportion to its gravidity; and when, by the complete distention of it, they have acquired their utmost magnitude, their diameters cannot be lessened, until the womb, being again»emptied, closes them by the contraction of its whole capacity, and restores them to their original size." 1185. There is no one circumstance in this history that would lead me to reject the idea, that a part of the uterine vessels are arteries, and for the following reasons : 1st, the sper- matic and hypogastric arteries furnish the uterus with these vessels; and it is well known that they increase in proportion [57] 450 C'ONNKCTION OF THE OVUM as gestation advances ; consequently, vessels which all agree are arteries, enlarge, and in almost the same degree as those within the substance of the uterus, and which are but continu- ations of them; 2d, no physical difference has ever been dis- covered between them. 1186. These two circumstances I consider in themselves aa conclusive of the identity of the uterine, and the spermatic and hypogastric arteries. If not so, why should these vessels en- large in proportion to each other ? And why should the sper- matic and hypogastric arteries contract when delivery has taken place, without being dependent for this effect upon the" con- traction of the uterus?" Now let us see what would really pre- sent itself, were Dr. R.'s opinion substantially true; he declares, in the unimpregnated state of the uterus, that these vessels "are so small as scarcely to be perceived." Now, how should this happen if they possessed no contractile power within them- selves ? The mere contraction of the uterus could not alter their real capacity ; it could only change their form by strongly compressing them ; therefore, if what he supposes were even true, they should constantly present to us the shape of flattened cylinders, or puckered tubes; but the contrary of all this apt- pears when we cut into the substance of the uterus, for we then find that, though the vessels are " so small as scarcely to be perceived," yet those we do see, constantly present to us a circular form. 1187. That they7 do not contract during pregnancy, or im- mediately after delivery, as closely as arteries in many other parts of the body do, I admit; not because they do not possess contractibility in an equal degree with these, but because they cannot exert it to the same extent, in consequence of their pe- culiar connection with the general substance of the uterus—they are every way surrounded by, and connected with, cellular membrane,* which will permit them to lessen themselves but * I am not wishing to be underwood, that there is any thing peculiar in the uterine arteries being surrounded witli cellular membrane ; for I am aware that this obtains wherever there are arteries—I merely wish to insinuate an opinion, that they have positively less freedom than the arteries in the other parts of the body, by being more closely tied by their connecting media ; and that, a% I sh«H WITH THE UTERUS. 451 to a certain degree, so long as the muscular fibres of the uterus remain in an uncontracted state, and for this plain reason, that the sum of their power or disposition to shut themselves up, is inferior to the power which keeps them in some measure upon the stretch. But that they do diminish in size to a cer- tain degree, after being exposed by a separation of a portion of the placenta during pregnancy, I have no doubt, as the cellular membrane by which they are surrounded, will, from its elasti- city,* permit them to do so, and thus contribute to the sup- pression of haemorrhage. 1188. We must regard the uterus during gestation, as in a state of coercion—every part and portion of it sooner or later is put upon the stretch ; consequently, the vessels entering in- to its substance must enlarge with it, or put the Cellular mem- brane by which they are surrounded, upon the stretch; but as there is a most important intention to be fulfilled by their en- largement, they are found to augment in a ratio correspondent to the distention of the uterus; and they are not only made to yield in proportion to the increased demand for blood, but are also kept in that state by its constant influx, to supply the exigencies of the uterus in a state of gravidity. 1189. This condition of the uterine vessels, then, has two causes contributing to the same end—namely, the unfolding and separating of the fibres constituting the proper substance of this organ, and the constantly increasing tide of blood which flows within it: the first, if it does not directly administer to the enlargement of these vessels, will, to a certain extent, favour it, byr taking off that restraint which a state of contraction im- poses upon them, and thus make them more certainly obedient immediately say, for very important uses: and that they have relatively less, would appear evident, when we reflect on the immense increase they suffer during ges. tation; and though they may contract very considerably, yet it may be insufficient to stop their bleeding without the co-operating contraction of the muscular fibres, for the reason I shall presently assign. Levret makes the proportion of the un- impregnated uterus to that of the impregnated, to be as eleven and a half to one. Now, if the arteries augment (as is reasonable to suppose they do) in the same proportion, it will be seen how much their calibers must be reduced, before their contraction alone can stop haemorrhage. * Bichat, Anatom. Gen. 452 CONNECTION OF THT OVUM to the impulses of the spermatics and hypogastrics—-the vis a tergo, then, of these vessels, may be considered as essentially contributing to their distention. Hence we can no longer re- cognise the almost imperceptible vessels of the unimpregnated, * in the large canals, if we may so term them, in the advanced impregnated uterus. 1190. Let us now suppose the supply to the uterine vessels to be cut off by any means whatever, and we make a section of the uterus near, or at the full term of gestation, and while yet occupied by the ovum—what will this section discover to us ? One of two things certainly—-either the vessels small and con- tracted, or still patulous and large. If in the first situation, Dr. Rigby's opinion of their nature, is at once proved to be unfounded; if in the latter, will it not confirm the notion I en- tertain, that they are kept in this situation by force, as above suggested? (1187) If this be true, will not the same cause produce the same effect, when the uterus is emptied of its con- tents, but remains in a flaccid and uncontracted state ? And will not the same consequences follow from the same cause in both instances, namely, a discharge of blood from the separa- tion of the whole, or a part of the placenta ?* 1191. If these statements be true, (and I sincerely believe them to be substantially correct,) it will follow, that the uterine arterjes cannot contract sufficiently to stop haemorrhage, how- ever eminently they may possess contractibility, so long as the muscular fibres of the uterus are in an uncontracted state; because, their peculiar connection with them, will necessarily prevent it—and farther, I believe, that this kind of union is highly important to the uterus after the expulsion of the foetus, to enable it, or perhaps I may say to induce it to contract, to throw off the placenta, and prevent after haemorrhage. * I might also nsist, that, should the uterine vessels be found large and patu- lous, when the fl;.7c <1 uterus was cut into, that it would not confirm Ur R's opi- nion, should the explanation just offered not be admitted; as it might be area- sonaM conjecture to suppose, that a cause capable of producing an atony of the muscular fibres of the uterus, might also be capable of rendering the uterine arte- ries passive ; and consequently, this uncontracted condition of them would tend to prove that this was 11 ally the case, rather than that they had been endowed with the power of self-diminution. WITH THE UTERUS. 453 1192. They perform this valuable end by lessening them- selves, and obliging, in a certain degree, the muscular fibres to follow them—this proves an extensive and congenial stimulus, which, for the most part, is successfully exerted to this end— but, should the contractile fibres of the uterus be indisposed, or unable, from the action of any cause capable of this effect, to manifest this power, haemorrhage must necessarily ensue; for the arterial extremities, which are exposed by the separa- tion of the placenta, will and must remain open, not because they do not possess the faculty of contraction, but because it cannot be successfully exerted, for the reasons I have already assigned—therefore, for haemorrhage to cease, requires the co- operation of the contractile fibres of the uterus; and to make them obedient to this end, is the great aim of all our exertions. 1193. From a review of the inquiry I have just made, it will be evident, that as far as regards effects, there is but little dif- ference between Dr. Rigby and myself; but much, as regards structure and function—my object, in this attempt, is the re- moval of error, and not the expectation of any great practical advantage, though I am persuaded some benefit may be de- rived from these considerations, in the cure of haemorrhages of this kind—for, upon the notion of the uncontractibility of the uterine arteries, Dr. R. condemns the use of that class of me- dicines I call astringents ; now, I have declared, I have fre- quently found advantage from the sugar of lead in such cases, (and have recommended its employment with no inconsider- able confidence,) which must be admitted to be an astringent, and one of no common power—in the modus operandi of this medicine I may be mistaken, but I cannot be in its effects. There may be many other substances belonging to this class, which may be equally, or even more efficacious upon trial; but we are to be deterred from employing them, because the uterine arteries " cannot contract of themselves." 1194. In entering upon the third and fourth divisions of my subject, it will be important to their consideration, that I say a few words upon the changes effected in the uterus itself, by the delivery of the child, and the expulsion'of the placenta. 1195. I regard the uterus as a hollow muscle ; and, like the 454 CONNECTION OF THE OVUM other hollow muscles, it has no separate or independent an- tagonising power; but it has, like them, a compensating one within its own organization or structure ;* and also, like all the muscles of this kind, when not distended by some dis- tracting force, will contract by virtue of some power of its own, and upon the healthy disposition of this power in the uterus does the welfare of the woman depend, in every instance of child-birth or abortion. 1196. I shall not stop to inquire, as its consideration is not immediately involved in my present investigation, whether this is a legitimate muscular contraction, or the exertion of that power, common to many organic, as well as inorganic sub- stances, termed elasticity. My own opinion, however, is de- cidedly made up, that the efforts the uterus makes to expel its contents, and to close itself after it has performed this office, is by virtue of a genuine muscular contraction. 1197. In the performance of these duties, two distinct pow- ers are concerned. One is shown by its constant disposition to lessen the cavity of the uterus, whenever it may be put upon the stretch, or at least whenever the cause is removed^, that placed it in this condition. The other declares itself by alter- • I say, diat the uterus has, like the heart, and perhaps all other hollow mus- cles, an antagonising power within itself, and this by its own organisation. I shall attempt to prove this> by stating, that in consequence of that contraction, which we call the alternate contraction of the uterus, having taken place, a con- siderable portion of the blood which at that moment occupied the uterus, is driven quaqua versum into the general system; a facility for which is derived from the frequent anastomoses of the arteries and veins, and by the latter not having valves. This is proved by the diminished thickness of the uterine parietes, and by the whole surface becoming paler at the moment of contraction. This state of things continues, until this effort has ceased—so soon as this happens (which may be longer or shorter, according to the power which governs the contraction, and the state perhaps of the muscular fibres of the uterus itself,) the vessels, which had just been deprived of a portion of their contents by the contraction, will at the moment of relaxation be but imperfectly filled, and perhaps even a genuine vacuum be induced; but, so soon as the restraint imposed upon the whole of the uterine vessels by this contraction is taken off, the blood will in- stantly rush into them, to restore the disturbed equilibrium, and thus again dis- tend these vessels; which distention will prove a stimulus to the uterine fibres, and thus induce a new contraction : and in this way would I account for the alter- nate pains of labour. WITH THE UTERUS. 455 mate contraction, and is, perhaps, only an exalted degree of the same power, when urged by stimuli to this exertion, as in child-birth, abortion, or from any other circumstance which may require its interferemce, to expel a foreign body7 from its cavity. 1198. The first of the powers just noticed, has been termed utonic contraction;" and the second "spasmodic contraction," from its being usually, though not necessarily7, attended with pain. This latter, it must be remembered, cannot take place without the former having preceded it, though the former can happen without the latter.* (170, 171) 1199. Such then is the economy of the uterus in its healthy condition, that it immediately exerts the tonic force with which it is endowed, to close upon its contents, and accommodate it- self to the exact size of such contents—thus, so soon as the liquor amnii is discharged, the uterus instantly diminishes its size, by virtue of this tonic power, and this in the exact pro- portion to the quantity of water displaced; and so plastic is this power, that it makes the parietes of the uterus take the inequalities presented by the surface of the child; and, when the child is delivered, it reduces itself so much as to compress the placenta, and force it from its attachment; and eventually expels it from its cavity: when this is achieved, it goes on reducing itself, until it interrupts in a great measure the supply of blood from the spermatics and hypogastrics ; closes almost completely the mouths of the vessels exposed by a separation of the placenta, and thus prevents any inordinate flow or haemorrhage. 1200. From this it appears, that the safety of the woman depends almost entirely upon the healthy exercise of that power I have just termed the " tonic contraction ;" and, on the con- trary, that the risk she may run in giving birth to her child, is in exact proportion to the diminished force of this power; of course, the preventing and stopping of floodings, will de- pend upon recalling it when absent, or upon augmenting it when deficient. * See Ksbuy on thr means of lessening Pa .i in certain Cases 456 CONNECTION OF THE OVUM, Clr. Harlow. 470 H.CMORRHACI., BEFORE the cavity of the uterus; from a belief (not, however, I confess, confirmed by trial) that it would be every way as effectual, if it were held in the vagina. I shall illustrate this condition, by a case taken at random, from a number of similar ones—for all these cases are so much alike, as to require but one general mode of treatment. Mrs.----was delivered by a midwife, after a very easy, but rapid labour'—the placenta was very quickly expelled, as it was found, as the midwife said, loose in the vagina; a very profuse flooding immediately ensued, for which she attempted nothing, assuring the friends of the lady it was a common occurrence, and from which nothing was to be apprehended—but the pa- tient becoming pale and faint, her friends were alarmed, and I was sent for in great haste; when I arrived, it was said the patient had been delivered about twenty minutes, and the pla-' centa had been extracted about fifteen of that time. When I came to the bed-side, I was persuaded the patient was dead—no pulse could be felt, and for some time, there was no respiration; syncope had just taken place; I instantly commenced a brisk friction upon the abdomen—ordered brandy and water by the tea-spoonful to be given with frequency; warm applications to be made to the feet and legs—the curtains to be opened, and fresh air admitted from door and windows, and immediately sent for pills of the acetate of lead and opium. In the course, perhaps, of two minutes after the abdominal frictions were commenced, I had the satisfaction to feel the uterus beginning to harden under the hand, and every instant after, to acquire more and more firmness; in about ten minutes, it was found much diminished in size, and much more solid—in the act of puckering itself up, a large quantity of coagula and fluid blood were expelled from the vagina, which so alarmed the ignorant midwife, to whom was consigned the task of watching the dis- charge, that she declared the woman must die, if I did not de- sist from "rubbing the womb so violently;" but the cause of this poor creature's alarm, was to me great comfort, and only induced me the more steadily to persevere in the plan of irri- tating the uterus. The disposition to syncope was now much lessened, and the THE PLACENTA IS EXPELLED. 471 pulse could, by a nice examination, be felt returning to the wrist—increasing in volume and force, as the faintness dimi- nished ; and in about half an hour more, the patient was con-. sidered out of immediate risk; to guard against a return of the flooding, as effectually as might be, I directed two grains of the acetate of lead, and a half grain of opium, to be given every half hour; the frictions upon the abdomen to be renewed, should the uterus be found to relax ever so little; and for this end, a very intelligent lady present, was instructed to perceive any change of this kind that might take place—the brandy and wa- ter to be given only7 pro re nata; and the most perfect rest was enjoined, though the position of the patient's body, was a very- constrained one. I again saw my patient in about two hours, (having given orders to be instantly7 sent for, in case of any unfavourable change before I returned,) and found her situation, in every respect, improved; she had had no return of haemor- rhage ; but was occasionally troubled with after pains—her faintness had gone off entirely; and her system was re-acting, with considerable force—her position was now altered, very much to her satisfaction; the brandy and water was forbidden, and she was permitted, instead of it, to take a few spoonfuls at a time of tapioca, seasoned with lemon-juice and sugar—the pills of the acetate of lead, were directed once in two hours. From this time, her recovery was as rapid as such a prodigious waste of blood would permit; milk was formed in sufficient quantity,after rather a longer period than usual; and the only subsequent inconvenience she experienced, was a headach, which almost invariably follows excessive uterine haemorrhage; this was relieved by keeping the bowels freely open. /. VI.—Where there is either a partial or complete separation of the Placenta, and where the body and fundus are in a state of inertia, while the neck enjoys its tonic powers. 1236. This is the most insidious situation in which the ute- rus can well be placed; and it is one in which inexperienced practitioners lose patients more frequently than any other, after the birth of the child. The neck of the uterus enjoying its powers, at a time that both fundus and body are in a state of +72 HEMORRHAGE, BEFORE inertia, gives rise to such an accumulation of blood within the uterine cavity, as will destroy the patient, without its being suspected that such a discharge is going on—in this case, the haemorrhage will be cone aled ; for a coagulum blocking up the os uteri, will prevent either fluid blood, or coagula, from issuing; and as there is no apparent flooding, the inexperienced accoucheur rests satisfied that all is going on well; nor is he roused always from this state of security, until the patient is in articulo mortis; or when, perhaps, all human aid would be unavailing. 1237. This case should warn the practitioner of limited ex- perience, against a false estimate of his patient's security; and should teach him never to fail to ascertain the state of the ute- rus, by a careful examination, through the abdominal parietes, as already advised. If, upon placing his hand upon the abdo- men, he find the uterus voluminous, but far from being hard; if upon inquiry he learn, that there is little or no discharge from the vagina; if he observe his patient become pale and faint, with a hurried breathing; if, upon touching the wrist, he find the pulse weak, frequent, or extinct; the skin cold and clammy, he may be pretty7 certain there is a concealed haemor- rhage ;* he has now not a moment to spare, to rescue the wo- man from an impending fate—he must be firm, prompt, and self-collected; and instantly put in practice, every remedy that may promise relief. 1238. He should commence, by abdominal frictions; and, if he find the uterus becoming harder in consequence, he should persevere, until he thinks it has acquired a disposition to contract—should the hardening of the uterus not be attend- ed with a discharge of coagula, &c. from the vagina, he must conclude, either that the neck of the uterus is too resisting to be overcome by the contraction of the body and fundus, with- out further aid; or that these are too feeble to overcome the resistance of the os uteri, though the latter may be compara- * I say, "pretty certain there is a concealed haemorrhage ;" for I cannot say, he may be altogether certain ; since, a rupture of the uterus may be attended with all these symptoms. THE PLACENTA IS EXPELLED. 473 tively weak—in either case, he must attempt to give to the ute- rus an increase of power, by removing its contents. 1239. This must be conducted with much cautious coolness, that the remedy may not increase the evil—the frictions upon the abdomen must be intrusted to some proper assistant, and they should be kept up with persevering constancy, while the practitioner carefully inserts his hand into the vagina—should he find clots there, he should remove them, if they are not im- mediately forced off by7 the effort which will most probably be excited, by the introduction of the hand. 1240. This being done, he is to insinuate finger after finger into the os uteri, and gradually attempt its dilatation ; should it be very resisting, the resistance must be cautiously over- come; and if this be properly conducted, it will perhaps, never offer such opposition, as to render any considerable force ne- cessary—perseverance in a well directed manner, I am per- suaded, will be all that is necessary7. 1241. When the hand has gained possession of the cavity of the uterus, the wrist should be so pressed against the side of the neck of the uterus, as to make room for the escape of any coagula or fluid blood, that may be disposed to issue—by managing in this way, he may7 empty the uterus so gradually, as almost to insure its subsequent contraction, and this will be much aided by the external friction. He is now to search for the placenta;* if it be but partially detached, he must cautious- ly separate the remaining adhesions—when this is done with care, and under the precautions above suggested; he is to re- * It may be well to observe, that, in every attempt to separate the placenta, we should, before we commence the operation, fix the uterus as firmly as it can well be done, by the external application of the unemployed hand upon the fun- dus—in fact, it should never be attempted widiout this precaution; as the opera- tion is not only very difficult, if Uiis be neglected, but is also very uncertain—the woman, if possible, should be placed upon her back, as I have directed for other purposes. It may also be proper to suggest another caution connected wiUi this- operation ; which is, that we be certain that we have removed the whole of the placenta; except in those cases, where it is expedient to leave a portion to the natural efforts of the uterus, as in the too adherent placenta. It is, however, sometimes almost impossible to determine this, where the placenta is tabulated, as now and then happens. See Leroux, Baudelocque, &c. [60] 474 U/EMORRIlAUi:, AFTER move itbv rotating the hand, now in possession of the placenta^ against the internal surface of the uterus, until it manifest a disposition to contract; and then, and not till then, should the hand be withdrawn. 1242. Should the placenta be found entirely detached, it must be delivered with the same regard to uterine contraction. After the delivery7 of the placenta, pressure and friction should be continued upon the abdomen; nor must these be abandoned, until the contracted uterus give assurance of recovered energy. 1243. In addition to what has now been directed, the other remedies which have been suggested should be had recourse to—the sugar of lead, ergot, and cold applications, under the restrictions alreadv proposed, should be tried—this case, and the one next to be considered, offer, perhaps, the best chances for the ergot; the brandy and water should not be omitted, if the woman be verv faint, and much exhausted. The after treatment will suggest itself; and after symptoms must be treated pro re nata. Sect. XV.—Of Flooding after the expulsion of the Placenta. 1244. When the placenta has been expelled, and is followed by flooding, the mode of proceeding is so similar to the last, that it will require but a few words to make its management perfectly7 clear. In this kind of haemorrhage, like the one we have just been considering, it is required that the uterus should contract before it can be possibly arrested ; therefore it will be necessary to employ all the means already pointed out for this purpose; and here, as in the other cases, I rest, my great de- pendence upon abdominal frictions, the acetate of lead, ergo^, cold applications, &c. 1245. Should the concealed haemorrhage take place, it must be treated much after the same manner as before the placenta is expelled,* (1218) that is, the hand must be introduced into * This case is sometimes very suddenly fatal. I was once called by a midwife, to visit one of her patients; but upon my arrival, I found the woman dead. The midwife was much surprised, and could not account for her death ; since, "the labour was natural and easy, and the placenta had come quickly away." I told hrr THE PLACENTA IS EXPELLED. 473 the uterus, and the coagula suffered gradually to escape, while the uterus is gently stimulated by the hand, passing cautiously over its surface; and when it is found to contract upon it, it may be slowly withdrawn; the after treatment must necessarily be the same. This case, generally speaking, is of much less difficult treatment, than where we have the placenta to contend with ; and will always, so far as I have yet experienced,yield to the treatment proposed, provided a proper chance be given to their employment—it cannot be supposed they will be avail- ing when the patient is in articulo mortis. 1246. It sometimes, however, happens, that a portion of the placenta may be left, either entirely, or partially attached to the uterus, which will give rise sooner or later to haemorrhage— this may sometimes be immediately detected by the inspection of the placenta itself—at other times this will be found impos-» sible; especially in those cases where we are under the neces- sity of bringing away this mass piecemeal—if this accident be discovered at once, it is best, I believe, to remove it; unless, it should be a portion that is too adherent to the uterus. Should this not, however, be discovered before the uterus has contract- ed firmly upon it, it will be much better to suffer it to remain, and trust to nature for its expulsion, than to run the risk of provoking a flooding; exciting a great deal of pain ; or of pro- ducing inflammation. But should flooding attend, we must deliver the retained portion; and this can almost always be done, as the mouth of the uterus is generally found open or yielding, when haemorrhage attends; but should it be found otherwise, it must be trusted to nature; the excess of discharge must be moderated by the tampon—if this be employed, it will be well to renew it every twelve hours; taking care to wash out the vagina before it is replaced, with the infusion of camo- mile tea, wine and water, &c. 1247. The retained portion of the placenta sometimes may my suspicions of the case; and these were afterwards confirmed, by opening the body—the whole cavity of the uterus was filled with blood, and distended to nearly the size of one at the full period of gestation—the mouth of the uterus was found sufficiently closed to retain the blood discharged from the surface to which the placenta had been attached-. 476 MEANS FOR PREVENTING HEMORRHAGE. not, however, be suspected, for several days after delivery; but we have a right to conclude that it is retained, when there is frequent return of pains, and a discharge of coagulum after co- agulum, from the vagina, followed by fluid blood upon each relaxation of the uterus. When the discharge of fluid blood happens in quick succession and in weakening quantities, we should immediately attend to the condition of the uterus; if it be found sufficiently yielding to admit the hand, it must be care- fully introduced, and the portion detached, and withdrawn.* We may sometimes succeed in detaching it by insinuating a couple of fingers into the uterus, and moving them in a circu- lar manner between it and the placenta, so as to loosen it, and then remove it either by hooking it with the finger; by the na- tural efforts of the uterus; or by the small crotchet recommend- ed for the removal of the secundines in cases of early abortion. If neither the finger nor the crotchet succeed, we must trust to nature; taking care to keep the discharge in subjection by the tampon. 1248. The young practitioner is cautioned against treating this case with indifference ; it is one not un frequently attended with danger, and sometimes death has ensued very quickly, as La Motte and others assure us. Should he be doubtful of his own judgment in this case, let him, by all means, (as well as in every other case of danger,) request the advice of an older practitioner. Sect. XVI.—On the means for preventing Flooding. 1249. Having at some length considered haemorrhages which may accompany pregnancy, and follow delivery, let me say a few words upon the mode of preventing those which may suc- ceed to labour; for I am of opinion that much may be done to this purpose. From what I have said it will be evident, that whatever interrupts the contraction of the uterus, or produces its relaxation after it has contracted, will occasion a flooding; * Baudelocque tells us, he has known this kind of haemorrhage show itself on the tenth day, and has been obliged to pass the hand into the uterus, to extract it. (System, Vol. II. p. 27.) , MEANS FOR PREVENTING HEMORRHAGE. 477 provided, there be a separation of a part, or of the whole of the placenta; it is equally evident, that whatever will insure this contraction, or contribute to it, will either prevent or diminish haemorrhage from this part. Much, then, will depend upon the manner in which the la6t stage of labour is conducted, to insure the future contraction of the uterus. 1250. This subject has been treated by Dr. Denman, with much apparent interest; but his advice upon this point is not conformable to my7 own experience. I shall quote his own words. The Doctor says, " when I have been attending wo- men who were prone to violent haemorrhages after the birth of the child'in former labours, I have made it a rule to keep them in an erect position, till the waters were discharged by the spontaneous breaking of the membranes, and the child was on the point of being born. By this method it appeared clearly to me, that the uterus acted more favourably, the placenta came away more naturally7, and the quantity of blood lost was often much more diminished."* 1251. Now, I ask any one at all conversant with the econo- my of the uterus, during, and after labour, how an erect posi- tion, the sudden evacuation of the waters at the moment " the child was about to be born," can contribute to the only circum- stance at all available in the case under consideration; namely, the permanent contraction of the uterus ? In the first place, an erect position will always be attended with a quicker circula- tion than a recumbent one; and will permit the waters to es- cape with more suddenness and rapidity; consequently, the risk of atony must be increased. It is admitted upon all hands, and by Dr. D. himself in other places, that if the uterus be too suddenly emptied, there will be a risk of inertia, or, at least, of great irregularity of action; if this be so, how can the interest of the woman be improved by this practice ? 1252. All writers upon midwifery declare, that the sudden emptying of the uterus, by the evacuation of the waters, and the rapid delivery of the child, are the most common causes of the atonic state of this organ; yet we are advised by Dr. D. to * Introduction to Midwifery, Francis's ed. p. 494. 478 MliANS FOR PRKVENTINO HEMORRHAGE. permit all this, with a view to the prevention of it! So far all theory is against it; and I will now appeal to my own experi- ence, to prove it to be at least a doubtful practice. 1253. There was a period of my life at which I looked upon Dr. Denman to be the highest authority in midwifery; and, at that time, almost implicitly followed his instructions upon everv point of practice; consequently, upon the subject in ques- tion, as being one of high importance; but in doing so, I was persuaded, from sufficient trials of the plan, that it not only did not answer the end for which it was proposed, but that it was decidedly mischievous; I of course abandoned it so soon as I was convinced of this truth, and substituted one almost dia- metrically opposite, with which, I have every reason to be well satisfied. As it was impossible to determine, a priori, which patient might be attacked with a flooding after delivery, it be- came necessary to follow some general rule with all, (where practicable,) by which the risk of this accident should be di- minished. 1254. It therefore suggested itself, that whatever would in- sure, with most certainty, the tonic contraction of the uterus, would best guard the patient against the contingency of a flood- ing; and what appeared to me the most rational to insure this, was to take off the distention of this viscus as gradually as possible, by the early evacuation of the waters; to diminish the force of the circulation as much as was practicable, by making the woman preserve a horizontal posture when the pains be- came urgent; and to interdict stimuli of every kind, as wine or any other liquor, heat, and all unnecessary exertion. 1255. But let me make myself understood, when I say "the early evacuation of the waters." It is a fact notorious to every practitioner, that the membranes, if left entirely to the force of the uterus, would remain entire in many, and, perhaps, in most instances, until the child was about to be pushed through the os externum. If this plan were to be pursued, the uterus would be suddenly, instead of gradually emptied; and consequently, the risk attendant upon this (as agreed upon by all) would be incurred, and the most probable consequence would be a flood- ing. But if, instead of this, we rupture the membranes so soon }IEANS FOR PREVENTING HEMORRHAGE. 479 as the labour is active, and the os uteri sufficiently dilated or easily dilatable, we should give opportunitv and time for the uterus to contract, before the child would be expelled, and thus guard against the evil we were apprehending. The uterus would, by this plan, diminish in size, in the exact proportion to the water displaced; it would apply itself to the whole sur- face of the child, the inequality of which would serve as an important and healthy stimulus, (all things being equal,) and prompt it to more certain contraction. 1256. Daily experience proves the justness of this reasoning and practice; for how rarely7 do we see a flooding follow those deliveries where the liquor amnii has been discharged even some hours previously ! and what can produce the exemption from this accident, but the uterus having had sufficient time and Opportunity to contract ? It is true, that this alone may not always be sufficient to protect the woman against a haemorrhage, but I am convinced, from many years of experience, it is the principal one.* The directions given for the delivery of the body of the child, after the head has escaped, and the abdomi- nal frictions, must also be considered as matters of great mo- ment, and should never be neglected, especially with women who are "prone to flood" after delivery. * I have in several instances lately given the secale cornutum, a short time previously to the delivery of the child, with the happiest effect. It was given, as declared in the following case:— Mrs.----, aged thirty-three years, in labour with her seventh child. One of her friends informed me, that she had always been liable to flood excessively, very soon after the expulsion of the placenta; and that with the last, (before the present case,) she had been nearly exhausted by the profuseness of the discharge To prevent a recurrence of this, I prescribed the following mixture:— R. Pulv. Secale Cornut. SJss. Sacch. Alb. 5SS- Aq. Cinnam. Sirup. ? j.----M. Of this, one-third was given every twenty minutes, about an hour before the chili i was expected to be born. The child was delivered in three quarters of an hour after the first dose. The placenta was soon detached, by the efforts of the uterus alone; and was found to be firmly contracted, immediately after. No flooding supervened—indred, nothing hut a moderate lochia followed. +80 PUERPERAL CONVULSIONS. CHAFTER XXX. OF PUERPERAL CONVULSIONS. 1257. This truly frightful disease may attack a woman, per- haps, at any period of utero-gestation; but more frequently after the sixth month—the causes assigned for them have been various ; some suppose they arise from some peculiar irritation of the uterine fibre from pregnancy; others consider them truly epileptic; while others regard them as nervous,or hysterical. 1258. This difference in views, necessarily7 leads to a differ- ence in treatment—the first, makes safety to consist only in im- mediate delivery; the second, forbids the practice; while the third relies upon the use of opium. From what I have seen of this formidable complaint, I am persuaded, that there is no one cause constantly operating to produce puerperal convul- sions ; nor is there an}' one mode of cure applicable to all cases. To be successful in the management of this complaint, atten- tion must be paid to the species of this disease, with which the woman may be attacked; I have, therefore, from a conviction that they do not all depend upon one and the same cause, di- vided them into, first, epileptic; second, apoplectic; and third, into the hysterical; each of which may attack under two distinct conditions of the uterus, and requiring from that circumstance a difference of management. 1259. Convulsions are all preceded by symptoms which denote their approach : in the epileptic species, the premonitory symptoms may exist a number of days before they show them- selves ; it is uniformly attended by a strong determination to the head, producing an engorgement of the vessels; headach, of greater or less intensity, ringing of the ears, a temporary loss of vision, giddiness, &c. are all present before the convul- sive stage shows itself. From these symptoms being followed by convulsions, I have uniformly, when consulted upon such occasions, advised the immediate loss of blood, pretty smart purging, and an abstemious diet. By thus anticipating, I feel PUERPERAL CONVULSIONS. 481 assured I have in a number of instances prevented this terrible disease. 1260. Some are attacked by a severe pain in the stomach, which Dr. Denman considers as more fatal than when the head is the seat of pain ; of this I can say nothing from my own expe- rience. I may remark, that the longer the premonition, the milder the attack appears to be. In the most suddenly fatal case I ever saw, the patient suddenly cried out, " my head, my head!" convulsions instantly ensued, of which she died in a few hours. 1261. Pregnant women may7 be attacked with convulsions from causes not connected with gestation, or at least with labour—as the attack is not accompanied with any signs of it. These, if my observations be correct, are more unmanageable and fatal, than when pregnancy may be the remote cause. When pregnancy is instrumental to the production of convulsions, it is almost always at that period, when the uterine fibres are at their greatest stretch, and when the os uteri is disposed to di- late ; or, where they suffer some peculiar irritation, over which we have no control, or from the contents of the uterus, which has the same effect; and such convulsions are almost always of the epileptic species. 1262. These convulsions, so far as my observations have ex- tended, are never preceded by an aura, as in epilepsy, properly so called. But after the patient has suffered for a longer or shorter period the symptoms just named,y(l259) she is sud- denly seized with quickly repeated spasms—the face and eyes are twitched in all possible directions, with incredible quick- ness—the arms, legs, nay, the whole body, are violently agi- tated—one side is sometimes more affected than the other; the face becomes flushed, livid, black ; the tongue is strongly thrust forward between the teeth, by which it is almost always severe- ly wounded. Respiration at first is much hurried, but even- tually becomes almost suspended; the carotids beat violently; the jugulars much distended; a peculiar sibilating noise is made by the mouth, not unlike what is termed " a cat spitting;" froth issues from the mouth, tinged with blood from the wounded tongue. The pulse in the beginning is full, frequent, and tense; [61] 1 • * 482 PUERPERAL CONVULSIONS. but quickly becomes rapid, small, and eventually almost inipei- ceptible—the urine and faxes are sometimes discharged invo- luntarily; a cold clammy sweat bedews the whole body, and the fit begins now to subside. 1263. The convulsive motions gradually subside—they never cease suddenly and at once—their force and frequency7 abate; the pulse becomes more distinct and less frequent; the breath- ing is less hurried and less oppressive ; the face'loses part of its lividity ; the muscles are agitated but at intervals, and then- action resembles the commotion excited by passing a brisk electric shock through them, and eventually they sink into re- pose. The patient, however, remains for the' most part insen- sible or comatose, with stertorous breathing or loud snoring; she cannot be roused by «.ny exertion for some time, and if she recover for a moment her scattered senses, she is without the slightest recollection of what has passed. This truce is almost always of short duration ; convulsion follows convulsion, with- out our being able to determine the period or cause of their return. 1264. When convulsions attack a woman absolutely in la- hour, or when this is about to take place, we may observe a pretty regular recurrence of the fits with the probable return of the pains—for though the patient be insensible to external occurrences, she appears to manifest, by her moans and the suspension of respiration, her sensibility to uterine contraction. This appears to me to be so manifest and decided, that I think I could tell what is going on at the mouth of the uterus, with- out an examination per vaginam. 1265. The face becomes very much swoln, especially the lips and eye-lids; indeed the whole body seems to partake in a greater or less degree of this intumescence, but not so conspi- cuously as the face. So completely is the countenance changed, or rather disfigured, that oftentimes it could not be recognised by the dearest or most intimate friend; nor does this swelling immediately subside with the convulsions which caused it; it frequently remains many days after they have ceased. Dim- ness of sight, nay, blindness for weeks, are not unfrequent con- sequences of this disease. 1266. In the apoplectic species we have nearly all the pre- PUERPERAL 60NVULSI0NS. 483 monitory symptoms enumerated above, (1259) but of much shorter duration.* It may, like the epileptic, attack at any period of gestation, but does not almost necessarily produce or be accompanied by labour. From this, it would seem it may be brought on by causes independent of pregnancy, though this process may with propriety be regarded as an exciting cause; for it sometimes takes place when this process is at its height, but is no otherwise accessary to this end, than increasing by its efforts the determination of blood to the head. * In a case of this species, which fell under my notice within a few days, ] thought it was not accompanied by cither as much frothing from the mouili, or with as much sibilation, as in the epileptic. Mrs.----, aged seventeen, pregnant with her first child, complained, on the 20th of July, 1824, of slight pains resem- bling labour, and a generally diffused pain ; but severest in her limbs; so much so, in these parts, as to render her almost incapable of moving them; some fever, though slight. Dr. Shaw, under whose care she was, ordered her to be bled and purged. 29th, 4 o'clock A. M., was attacked with labour pains; at fiist slight, but had much increased at the time the doctor was called. Upon examination, the os uteri was found a little opened; and at 8 o'clock A. M., she was attacked with strong convulsions, which were repeated about every twenty minutes. She was bled about twenty ounces; convulsions continued to recur. At ten o'clock the same morning, the os uteri was pretty well dilated; and from a belief that convulsions were at least maintained by uterine distention and irritation, Dr. Shaw ruptured the membranes, with a hope of tranquillizing them. At this time, I was called in. I found the patient totally insensible to any external impressions; nor had she discovered any sensibility after the second fit; breatiiing with considerable difficult)-, and snoring pretty loud. The pulse was full, frequent, and hard, and the skin hot. L'pon examining per vaginam, the head of the child was found at the lower strait, presenting with the posterior fontanelle behind the left foramen ovale, and entirely within the uterus—up to tiiis time, about Uiirty-five ounces of blood were drawn. She was attacked with a fit, soon after examination. There was something remarkable in the character of her convulsions—her eyes were but little agitated; the pupils much contract- ed; her face was but little suffused; there was less frothing at the mouth, and less sibilation, than is usual. I applied the forceps, and delivered her in a few minutes, without the slightest difficulty. She remained, after this, for two hours without a fit: at the expiration of this time, they recurred about eveiy half hour, until 9 o'clock P.M., when they ceased; but without any amendment in the condition of the patient—she appear- ed completely apoplectic. She continued much in this situation, until 6 o'clock in the evening of the 31st, at which time she died. Leave could not be obtained to inspect the body. She did not complain of headach until die 29th, and then but a short time before she became convulsed. She lost, altogether, eighty-two ounces of blood; was freely purged, and once cupped. 484 PUERPERAL CONVULSIONS. 1267. In the hysterical species, we have not the same train or continuance of the premonitory symptoms. If headach at- tend, it is neither so severe nor so permanent; there is a ring- ing in the ears, globus hystericus, and palpitation of the heart. The face is much less convulsed—less vacillation of the eyes, while the larger muscles of the body are much more violently agitated; the patient, at times, is very obstreperous: and the muscles on the posterior part of the body, are almost always violently7 contracted; so much so, that the body shall describe an arch backward. I have considered this last circumstance, as strongly marking this species of convulsion. The face is much less flushed, than in either of the two other species; but never pale, agreeably to my observations, as some have Temarked. 1268. There is no frothing at the mouth; and the peculiar sibilating noise which so strongly characterizes the first, and perhaps the second species, is entirely wanting in this—the patient, after the fit, can, for the most part, be roused to atten- tion, or will frequently become coherent, so soon as she reco- vers from the fatigue or exhaustion occasioned by her violent struggles ; and, though she may lie apparently stupid, she will, nevertheless, sometimes talk or indistinctly mutter. After the convulsion has passed over, she will often open her eyes, and vacantly look about; and then, as if suddenly seized by a sense of shame, will sink lower in the bed, and attempt to hide her head under the clothes. The pulse is much less disturbed, nor does it ever acquire that extreme velocity and tenuity it does in the other two species, for respiration is never so much in danger of being suspended. 1269. This species attacks women of delicate and nervous habits; the recovery from it, is always more rapid, and never, so far as I have yet observed, leaves any imperfection of vision. 1270. As nothing is so satisfactory, as regards the applica- tion of remedies for any disease, as the detail of cases, in which their routine is exhibited, I shall make no apology for inserting the following from my " Essay on Puerperal Convulsions."— See "Essays upon various Subjects connected with Midwifery." PUERPERAL CONVULSIONS 485 Case First. Mrs.----, a delicate small woman, twenty-three yrears of age, pregnant with her first child, was attacked, on the 16th of November, 1809, at 8 o'clock, A. M. with epileptic convulsions, I saw her in an hour after the attack—previously to my seeing her, she had had three fits, and a fourth was coming on just as I entered the door. Three or four days previously to the at- tack, she complained*of a violent jaw or tooth-ache, which was looked upon as rheumatic, and no attention was paid to it. On the 15th* that is, the day before her illness, she was seized with an extremely acute headach; and, during the night, and just before the onset of the fits, she was extremely sick at stomach, and vomited a large quantity of thick glairy mucus; immedi- ately after this, she said she could not see, and was, in a few minutes more, seized with convulsions. She laboured under the appearances as the ultimate symptoms, in a violent degree. I instantly bled her from a large orifice in the arm ^xxxv, by- measure—this, as I have just said, was at 9 o'clock, A. M. Eleven o'clock, had two fits during my absence, and was now in the third—bled ^xii.—Ordered a strong infusion of senna as an enema—os tincae a little opened, but rigid. One o'clock, P. M., had two fits since last visit—injection operated—pulse still active—face flushed—very restless and uneasy, arising, as I believe, from the pains in the uterus—os tincae rather more dilated—to be bled by cups |x. Four o'clock, P. M., one fit; cups drew well; senna operated again two or three times; very comatose—ordered cold applications to the head by means of a large bladder, partly filled with water and some ice—blisters to the legs. Seven o'clock, P. M., no fit since last visit—pulse very active—very restless, constantly making efforts to get out of bed*—os tincae not much more dilated; took §x blood; sen- na continued to operate. Ten o'clock, P. M., no fit since last visit; pulse still too active; took §x more of blood; cold appli- cations. Seventeenth, Mr. Purnell, now Dr. Purnell, one of my pupils, staid all night with the patient. He said she had me fit, after which he took |x ounces of blood; senna con- * I have considered this as a pretty certain sisrn of labour going on. 486 PUERPERAL CONVULSIONS. tinued to operate. At 10 o'clock, A. M., I saw her; stupor much less; recognised her friends, and asked some questions; she did not see well, a slight squinting was observable. Seven o'clock, P. M., better, pulse less active ; had had three stools since the morning visit. Eighteenth, Mr. de la Motha, now Dr. de la Motha, another of mv pupils, staid with the patient last night. She passed a good night, was tranquil and rational; no return of fits during the night; two stools. Saw her at 10 o'clock, A. M., skin dry and hot, face a little swelled, but per- fectly collected. Eight o'clock, P. M., face more swollen, and a little flushed; much headach; pulse very active ; great thirst; took ^x of blood, much relieved by it; pulse softened, and di- minished in frequency; cold applications continued. Nine- teenth, passed a good night, free from fever and pain; no re- turn of convulsions ; bowels rather tardy; ordered senna tea. Continued much in this condition until 28th, twelve days from the first attack; this morning was seized with brisk labour- pains, and was soon delivered of a dead child. From the de- gree of putridity, it is presumable that the child died early in or before the attack. On this case it may be proper to remark: 1st. That the child had not been felt to move for several days before the patient was taken ill—but this is by no means a certain proof of its death. 2d. Signs of labour were manifested on the first day of the illness, but were evidently suspended, or at least not pro- gressive, after the second. I occasionally examined for several days, but found the os tincae so rigid, as to preclude the idea of manual assistance ; it was therefore not attempted. 3d. Had manual aid been resorted to, I have no hesitation in believing it would have been extremely injurious. 4th. That the convul- sions were controlled ten days before delivery took place, al- though from the state of the uterus it was evident it would sooner or later take place. 5th. That the attack commenced between the seventh and eighth months of pregnancy. This lady's next pregnancy was not attended by this untoward ac- cident; strict attention was paid to her during the whole period of gestation. She was kept on a milk and vegetable diet—her bowels were kept open. She was occasionally blooded, espe- PULRPERAL CONVULSIONS. 487 oially when she complained of headach—she took, for several months, three or four doses daily of the tincture of fox-glove, with, I think, evident advantage, and was at the proper time happily delivered of a fine child. In her third pregnancy she attended much less to herself, and was not under medical re- straint, in consequence of which she was again attacked by con- vulsions, and was held very much as above related, with the exception that labour was much more rapid. Her fourth preg- nancy was again fortunate, as she again submitted to medical direction. Her fifth pregnancy I have understood was again unfortunate, and attended with convulsions like two of the former—I did not see her in this last pregnancy, having been absent in the country when it happened. Case Second. Mrs. ——, aged twenty-six years, pregnant of her first child —a large plethoric robust woman, was, on the 9th of Septem- ber, 1811, at about 5 o'clock, A. M., taken with labour-pains, and sent for her midwife ; before the midwife arrived she was seiz- ed with terrible convulsions, and I was immediately sent for— the fits were frequently repeated, and were from their extreme violence very threatening—her face was immediately swelled— her eyes fairly protruded from their sockets—her tongue terribly wounded, &c. I instantly bled her from the jugular vein more than three pints—examined her, and found labour approaching —ordered a brisk injection—saw her two hours after—had had several severe fits—pulse extremely active—labour advanc- ing__bled her twenty ounces—injection rf^eated—a stream of cold water was poured on her head during the interval of the fits—11 o'clock, A.M., fits not so severe, but pretty fre- quent—pulse still very active—took a quart of blood—appa- rently much relieved—lay quieter—1 o'clock, P. M., had had two or three fits—very restless—mourned every feAV minutes, desirous of getting from the bed—bled her ^xii—examined, and found the head low in the pelvis, and delivered with the \ forceps—she had two or three fits after delivery; and remain- ed insensible to every thing for forty-eight hours. She now began to show some signs of returning sensibility—was bled 488 PUERPERAL CONVULSIONS. twice in that interval—cold was applied to the head, and the legs blistered—she was purged freely by senna tea. After this, she gradually recovered her senses. She was left completely blind for two weeks; she then began to see imperfectly, but was six weeks before she could distinctly discern objects. It may not be amiss to observe, the child was living. This case is remarkable, on account of the severity of the disease, and the large quantity of blood that was drawn in the short period of a few hours. She lost, in the first six or seven hours of her illness, one hundred and twenty ounces of blood, and about one hundred and forty altogether: a quantity that might, at first sight, startle the timid or inexperienced practi- tioner ; but when he reflects, that here was a patient labouring under one of the most ferocious complaints in the whole cata- logue of human diseases; the brain threatened with immediate destruction; the patient of prodigiously full habit; one who not only7 neglected the kindly warnings of headach, giddiness, and occasionally loss of vision, by not having recourse to bleed- ing—but, contrary to the advice of her midwife, fed freely, and remained long costive—what then could avert the threatening consequence of this disease, but the most prompt and the most subduing remedies ? Had not the bleeding been carried to the extent it was, I really believe it would have been unavailing. Even as it was, it did not prevent temporary blindness. Her second pregnancy was not attended with any untoward circum- stance. 0 Case Third. Mrs.----, Nov. 10th, 1797—pregnant with her second child, and in the eigh thr month, was seized while at the ironing-table with the vertigo.*—She fell, and was immediately attacked with convulsions. I was living near, and was instantly sent for—I found her labouring under the general symptoms of this disease —I bled her from both arms at once, and took from each arm nearly, if not quite, a quart of blood. She appeared for a short * She had complained all the morning of intense headach, and several times said she could not see—she was advised lo leme off work, but would not. PUERPERAL CONVULSIONS. 489 time much relieved; that is, the convulsions were abated—I examined her, but found no change in the os tincae. An injec- tion was ordered, which operated well—about an hour after the bleeding, her pulse rose very much; her breathing was more laborious and stertorous, and some convulsive twitchings played over the whole body.—She was entirely insensible to all external impressions—the pupils of the eyes were much dilated; fearing a violent repetition of the convulsions, I again tied up the arms, and took about twenty-five ounces more of blood— this seemed again to moderate the symptoms—no change in the os tincae. 4 o'clock, P. M., three hours after the attack, the convulsions were renewed with considerable violence.—She was let blood to the amount of twenty ounces—cold water was poured on the head—she was again more tranquil, but not less comatose, though the breathing was less loud; she had a copi- ous black stool. 6 o'clock, P. M., had had several fits, but not as violent as at first—pulse still too active; took eighteen or twenty ounces of blood from the arm—as the pulse was now considerably reduced, applied a pair of blisters to the legs, and sinapisms to the feet. 10 o'clock, no convulsions since last visit, breathing freer, but loud—swallowed a little water with some difficulty—passed no water since the attack; introduced the catheter, and drew off a large quantity—had two stools— made an effort to vomit. 11th, 6 o'clock, A. M., was called to her suddenly, as her breathing was becoming more laborious and loud, and face more flushed, with some convulsive agita- tions ; pulse rather too active; had ten ounces of blood by cups, and a large blister placed between the shoulders. From this time, there was no return of convulsions.—She gradually reco- vered her recollection, but remained until some time after her delivery (which took place at the regular time, and with a living child) with imperfect vision, especially in one eye. She was, for many years after this, subject to violent headaches, which were relieved constantly,by bleeding.—She had several children after this attack, without convulsions. [62] 490 PUERPERAL CONVULSIONS. Case Fourth. Mrs.----, October 1,1803, had been m lab6ur several hours; she had every appearance of being happily delivered of the fifth child, when, during a strong pain, she instantly cried out, "my head, my head!" and immediately fell into convulsions. She was under the care of another physician, to whose aid I was instantly called by his own desire—the convulsions were strong, and very frequently repeated—she was largely bled; on exa- mination, the child was found to be far advanced, and was speedily7 delivered by the aid of the forceps—the convulsions, however, continued in spite of every exertion to relieve them, and she died in about three or four hours from the attack. Leave was obtained to open the body ; the longitudinal sinus of the dura mater contained (by estimate) between two and three ounces of blood; the posterior left ventricle was filled with a bloody serum—the other ventricles appeared sound, as did the other parts of the brain—no other part was examined. Case Fifth. Mrs.----, aged 24, pregnant for the first time, was taken ia labour on 10th March, 1797—her labour proceeded regularly, and the child's head was at the inferior strait, and every ra- tional expectation was entertained of a speedy delivery, when she suddenly cried out with pain in her head, and declared she could see no one in the room; these symptoms had continued but a few minutes, when she1 was seized with convulsions— she was under the care of the late Dr. Shippen, who requested that I might be sent for, and desired I would bring my forceps with me. I found the patient in a strong fit, with her face literally as black as a negro—it was agreed she should be bled extensively—this was done from the left jugular vein, to the amount of nearly two quarts; it had aii immediate effect in tranquillizing her. I now examined her, and found the head low in the pelvis; I applied the forceps, and delivered her of a dead child. Upon examination, it was found there was an- other childj the uterus soon discovered a disposition to act; hut fearing injury from delay, I immediately delivered by the PUERPERAL 60NVULSIONS. 491 feet, which were the presenting parts; the child was healthy, and did well; the mother had no return of fits, and she rapidly recovered her usual health, excepting that of her eye-sight, which did not return so as to discern objects for several days; and her vision was very feeble for several weeks. Case Sixth. I was called on the 10th of July, 1811, to Mrs.----, who was, at the moment of my arrival, and had been for a considerable time before, in a strong convulsive paroxysm. 1 found several men diligently employed in holding her, and opposing her mo- tions; she was raised in the middle like an arch, while her feet and head nearly met. She was between seven and eight months pregnant, and subject to hysterical affections.—She was thrown into this, by some altercation with one of her neighbours—cold water was dashed in her face, and she was blooded to the amount of sixteen ounces. The spasms began to give way soon after, and in the course of about fifteen minutes ceased. She sighed very deeply, and struck her arms very forcibly against the bed, and in a few minutes more, inquired what all these men were doing with her. I gave her fifty drops of laudanum, and two tea-spoonsfull of the tincture of assafoetida in some sweetened water, and she had no return of the fit.—She went her full time without a repetition of them, and was safely delivered of a healthy child. I shall now subjoin two other cases, to show of how much consequence a proper distinction is, in the treatment of puerpe- ral convulsions. . Case Seventh. I was called on the 16th of April, 1810, to Mrs.----, said to be in strong convulsions. I was from home when the messenger arrived, but went so soon as it was in my power. When I went into the sick chamber, I found Dr.----with the patient. He told me u Mrs.----had been attacked about two hours befdft with convulsions, and was in the ninth month of pregnancy— that, previously to the attack of the fits, she had ^n plained of violent pain in the forehead, which she told her husband she 492 PUERPERAL CONVULSIONS. could cover with her anger. She had this pain several days, but it was much m^re intense this morning, and was attended with a sensation, as >f a piece of black gauze was before her face. She was stopping for some time over a trunk, in which she was arranging some articles, when she was seized, and fell on the floor in strong convulsions." f She was now lying senseless and without motion on the bed; she breathed very heavily, and snored loudly—her face much swoln and of a purple hue—the pulse frequent and small, and the extremities cold. I inquired what had been done, and was informed by Dr.----he had given her, twice, sixty drops of laudanum at a time, and that since the last dose she had had no fit, and was, in his opinion, very much better, requiring no- thing but sleep to restore her.—I told him very plainly, that I thought Mfe had mistaken the patient's case, and had, in my opi- nion, sealed her fate by the use of the laudanum.—He appeared alarmed, but ttot altogether convinced.—We did every thing that we thought might be useful; but all exertion was unavail- ing, and the patient died in about three hours.—I could not procure leave to open the body. Case Eighth. About three months after the above event had taken place, viz. on the 20th of July, 1810, the same gentleman was called to Mrs. ----, labouring under convulsions. I was sent for at his request. Before I arrived, he had bled the patient very freely (40 ounces,) by which she was considerably relieved— she ^vas near her full time of gestation. From her peculiar mo- tions and breathingfhl suspected labour had commenced—she was exajnined, and the os uteri was dilated to about the size of a«dollar. It was, however, pretty rigid. The convulsions re- turned with considerable force; the patient was again bled about thirty ounces; a stimulating injection was thrown up the rectum, which operated freely; the mouth of the uterus was now well dilated ; I turned, and delivered a living child. Mrs.----had one fit after delivery, but it was not severe. She recovered her senses and ^pdings on the second day after delivery, and no other inconvenience was experienced, except some dimness of i PUERPERAL CONVULSIONS. 493 sight, and slight headach. Several days before the attack of convulsions, she had complained of the headach, and that par-. ticular sensation of a nail being driven into the head, and also of an occasional loss of sight. The two cases just related, form a happy contrast in the mode of treatment; the first case proving so unfortunate, made a strong impression on the mind of Dr.----, who very properly profited by it in the second case. He candidly confessed they were as similar as any two cases of disease could be, and de- clared himself much shocked at the reflections which the un- fortunate case gave rise to. In every case of convulsions, it is but too common for by- standers to oppose, by strength, the contractions of the agitated muscles. This practice cannot be too severely reprehended; for it is both injurious and unnecessary; it subjects the pa- tient to severe muscular pains, which last for very many days after the fits subside. All that should be done in such a case is, to prevent the patient doing herself mischief, or prevent her throwing herself from the bed; a very moderate exertion is sufficient for this purpose, therefore violence should never be employed. CHAPTER XXXI. OF THE ASSISTED DELIVERY OF THE PLACENTA. 1271. It is almost exclusively, by the tonic contraction, that the placenta is detached from the uterine surface, that it may be expelled. This takes place at various periods, as the tonic power of the uterus may be in greater or less perfection, or as the connecting medium may be more or less dense—it will, therefore, be found, that the placenta may be cast off immediate- ly after the expulsion of the child, or it may require some time to effect this end, without considering it to be a«ciorbid adhe- sion of this mass. 494 ASSISTED DELIVERY OF THE PLACENTA. 1272. It is desirable, at all times, that the placenta be ex- pelled prettv quickly after the child; and if it do not take place in proper time spontaneously, it is proper that we should givr such assistance as will facilitate its exit, without the introduc- tion of the hand. There has been much diversity of opinion, what period or interval, constituted " the proper time/1 for the extrusion of the placenta—some fixing a longer, and others a shorter term, much to the embarrassment of the young practi- tioner—but this point, I conceive, is easily settled, by taking the indications from the condition of the uterus itself, rather than from elapsed minutes, or hours. 1273. I have alwayrs set my face against " time" being made the criterion for action, in midwifery; and my aversion is by no means abated, when it is attempted to form a rule from it, for the delivery of the placenta; for the same objections must obtain here, as in the cases I have alreadv declared it should not govern in. I have already stated (1271) by what power the separation of the placenta is effected; and that this would necessarily7 require a longer or shorter interval, as this agent may be more or less active. It will follow, then, that the ex- pulsion of this mass may be either very prompt, (1271) or be rather tardy; I have already pointed out the duty of the accou- cheur in the first instance, and the mode by which he is to exe- cute this duty; (507) I shall, therefore, here, only consider what is to be done in the latter. 1274. I have stated in effect, (1271) two principal causes for the tardy separation of the placenta: namely, 1st. A diminu- tion of the tonic power; and, 2d. Too great a firmness in the connecting medium of this mass with the uterus; each of which requires a little difference in management. The first of these may be known: 1st, by the uterus being rather larger and softer than it should be, a short time after delivery; 2d, by no por- tion of this mass being within reach of the finger, when intro- duced into the vagina; 3d, by there being no return of the al- ternate contractions of the uterus; and, 4th, when a force is n applied to the cord, it gives the idea that the placenta is de- | scending; but this is known not to be the case, so soon as we^ eease to draw upon the cord, as it then instantly mounts again into the pelvis. ASSISTED DELIVERY OF THE PLACENTA. 495 Sect. I.—1. Mode of acting in Retention from want of Tonic Power. 1275. When this state of things presents itself, all attempts to deliver the placenta must be forborne, until we have, by pro- perly instituted frictions over the region of the uterus, obliged it to contract, and harden itself under the hand; and at the same time retire lower into the pelvis—when these alterations show themselves, we almost always find they will be accompa- nied by pain; and, if we now co-operate in a proper manner, we shall find the placenta to arrive within reach of the finger, and announce its separation by a small discharge of fluid blood, or coagula, or both, and fall into the vagina, from whence it may be extracted, as has been directed. (507) Sect. II.—2. Retention from too firm adherence. 1276. In the second case, we shall find the uterus reduced in size; firm, and pretty well sunk into the pelvic cavity; and may be even attended with pain, without bringing the placenta within reach of the finger, and if we draw upon the cord as in the other case, there is little or no retraction after we intermit the force. 1277. This case requires, for the separation of the after-birth, not only a firmer contraction of the uterus, but a longer continu- ance of it; as well as a particular application of force to the placenta itself, by means of the cord. Force, to be successful- ly applied for the separation of the placenta, must be directed in such a manner, as to act perpendicularly to its surface; or its influence will be destroyed—to effect this, we must first ascertain the part of the uterus to which this mass adheres. This is to be done by observing the part of the pelvis to which the funis seems inclined; as this will point out the portion of the uterus to which the placenta is adherent—thus, if the cord descend behind the symphysis pubis, the placenta will be at- tached to the anterior part of the uterus; if before the projection of the sacrum, it will be found at the posterior part of the ute- rus; if to either side, the placenta will be to the side on which the cord is found. +96 ASSISTED DELIVERY OF THE PLACENTA a. Mode of acting in this Case. 1278. Having ascertained the location of the placenta, we must so arrange a couple of fingers within the vag'n.a, that drawing the cord horizontally, will act in the desired direction; thafis, if the placenta be attached to the anterior portion of the uterus, we place the cord behind the fingers, and press it back toward the projection of the sacrum, while we draw the cord with the other hand; if to the posterior portion, we place the cord before the fingers, and carry it as high as we can well reach, toward the superior strait, and then draw with the other hand; if placed at the lateral portions, we must introduce the fingers of either the right or left hand, as it may be the right or left side of the uterus to which the placenta is attached, and then place them in such a manner as that the horizontal draw- ing will act in a proper direction—if the placenta be at the left side, we must introduce the fingers of the right hand, and vice versa. By thus acting, we may succeed in bringing down a placenta, which, without it, might require the introduction of the hand. 1279. In this situation of the placenta, we are almost certain to have the co-operation of the alternate contractions of the uterus : and it is desirable that we take advantage of them, by making gentle exertions by the cord at the same time; if no pain come on, we should solicit the farther contraction of the uterus, by frictions and moderate pressure upon it, while we gently and steadily pull at the cord. We should now and then ascertain whether the placenta is descending; this is best done by slacking the tractive force; and then observe whether the cord remounts, or whether it remains stationary. If it ascend, we may be certain that the placenta is either not detached, or that the uterus is not aiding in its expulsion—in such case, we should be very careful that the degree of force applied to the cord, be not sufficient to destroy its union with the placenta; and that we do not urge its deliverance too importunately. » 1280. If we find the cord not to remount, or if it remount! but very little after we have ceased to draw, we may be assured^ the placenta is descending, and will be within reach of the ASSISTED DELIVERY OF THE PLACENTA. 497 finger, by occupying the vagina; from whence it may7 easily be extracted. 1281. It very rarely happens that the introduction of the hand is necessary to deliver the placenta, in the situations I have just indicated—a little method and address, are all that are required to overcome existing difficulties; and, perhaps, there is no situation of it in which it has been dragged from the uterus so often, and so wantonly; because a little resistance was offered by the causes just stated. It would seem to be a sufficient reason with every inexperienced practitioner, to introduce his hand for the delivery of the placenta, whenever it does not precipitate itself into the vagina immediately after the birth of the child; or does not instantly obey the force that is applied to it; howeve ill-directed, or inopportune, that at- tempt may be. 1282. Or if he,be timid, and obey a direction but too com- mon in books upon this subject, that a certain period of time must elapse before any attempt be made to deliver the placen- ta, he may let the proper moment elapse for the successful ap- plication of well-directed force, and thus convert a case of great simplicity7, into one which will require the aid of art. 1283. I say, that the time for the interference of the accou- cheur for the delivery of the placenta, should always be regu- lated by the condition of the uterus itself; and that, that con- dition is, whenever it is firmly contracted—in this I believe I can never be mistaken; or, at least, I have uniformly acted upon this principle ; and so far, I think I am safe in saying, I have not had cause to believe it wrong. I acknowledge that some address is required, for the successful delivery of this mass ; but as this is easily acquired by a proper attention to the laws of the uterus at this time, I should hold that man in some measure accountable, if he produced mischief by an im- proper, or ill-directed manoeuvre. Time, simply considered, can never form a safe rule for the delivery of the placenta; the degree of contraction of the uterus alone can insure success, or Lpoint out the proper moment to operate. f 1284. I am decidedly of opinion, that the necessity for artificial delivery of the placenta is often created by obeying a res] ^98 ASSISTED DELIV1.RY OF THE PLACENTA. rule taken from time, let the period be longer or shorter; for time in itself, can neither produce the conditions required, nor command them if thev be absent. For the uterus may be dis- posed to throw off the placenta, and would, if properly aided, long before the fixed period may arrive ; or it may be in a state of such feebleness at that moment, as to render it highly dan- gerous to attempt it—hence, on the one hand, an injury may be done to the uterus by the manual delivery of the placenta, by the resistance which it now offers to the attempt; or the woman be exposed to a severe and perhaps a fatal ha;morrhage, by our acting at the moment limited; it is, therefore, improper to permit the uterus to contract so as to enclose this mass, and require force to open it, by improperly delaying the moment to act; or by inattention to its state of imperfect contraction, to induce a flooding, by acting, because, a specified time ha* elapsed. 1285. Should a portion of the placenta be separated, and a flooding accompany these conditions of the placenta, it must be treated as directed for this case in the chapter upon uterine haemorrhage. (1207, &c.) Sect. III.—3. Of the Delivery of the Encysted Placenta. 1286. In consequence of the contraction of a portion of the body of the uterus, before the placenta is delivered, it is some- times confined in a distinct apartment as it were, of this organ; and this, agreeably to my own experience, is always at the fun- dus. The mechanism of this accident is easily understood, if we recollect the strong disposition the body, and especially its lower part, has to contract, or narrow itself, when the distend- ing cause is removed; and especially, while the placenta re- mains undelivered. 1287. Some have thought this contraction could take place only when the placenta was attached to the side of the uterus; and others, when it adhered to the fundus; of this last opinion was Baudelocque; and it entirely comports with my own ex- perience of this 'condition of the uterus—indeed I might say' limited experience; for such it truly is; as I have very rarelv ASSISTED delivery of the placenta. 49i> met with it; and never, so far as my recollection may be de- pended upon, when I have had the entire management of the case. Dr. Douglass, of Dublin, has considered this condition of the uterus altogether artificial; or arising from some irritation near the mouth of this organ; either by acting upon the cord, or by the introduction of the hand. 1288. He says, " the exciting cause of the uterus assuming the hour-glass form, is irritation, produced either in the vagina, by injudicious pulling at the umbilical cord; or in the cervix uteri, by the accoucheur's hand, searching there in vain for the placenta." 1289. "That the proximate cause is a spasmodic constric- tion of the muscular fibres of the uterus at the lower verge (not the centre) of that section termed its body, and just where it ceases to be thickly muscular." 1290. "Thence I conclude," says the doctor, "that this hour- glass contraction is not produced by any principle of action in- herent in the uterus itself; and that whenever it does occur, it is caused by mismanagement." 1291. " Therefore, in order to avoid such occurrences, the practitioner should always refrain from exciting unnecessary irritation." 1292. " And, in those cases of unavoidable retention of the placenta, wherein it may be necessary for the accoucheur ma- terially to interfere, he should, having cautiously inserted it within the vagina, push his hand briskly up to the very fundus of the uterus. And in this operation, he should direct the hand forward towards the umbilicus." This case is rarely at- tended by haemorrhage. 1293. This case may be known, by the fundus of the uterus reaching higher than common; by its being smaller in its trans- verse direction, as can be detected through the abdominal pa- rietes; by an elastic feel of the cord; by no pain attending; by the placenta not being within reach of the finger; upon the in- k troduction of the hand, the cord is found to pass through an H aperture of greater or less size, and tljp placenta felt to lie ^ within the cavity formed by this contraction. 500 ASSISTKD DELIVERY OF THE PLACENTA. a. Mode of Operating in this Case. 1294. In the hour-glass contraction of the uterus, it becomes always a matter of necessity to operate; and this should be un- dertaken so soon as this situation is ascertained; as I believe no advantage has ever been derived from waiting. It is in vain the action of the uterus is solicited; or that force, how- ever well directed, be applied to the cord; nothing but the in- troduction of the hand, and that made to pass the stricture, can relieve the placenta from its confinement. 1295. The woman should be placed upon her back, as di- rected for turning, (702) or the application of the forceps; (724) the hand must be cautiously introduced into the vagina, and forwarded agreeably to the direction of the cord; taken always for a guide. This will be found passing through an aper- ture of uncertain size ; sometimes larger, sometimes smaller; into which the fingers, one after the other, must be introduced, and its dilatation gradually effected, until the whole hand is enabled to pass the stricture. When the hand has possession of the chamber which contains the placenta, this mass must be separated carefully if it be adherent,* or if loose, it must be seized with sufficient firmness to secure its following with the hand, when this is withdrawn. 1296. Some little management is required in withdrawing the placenta, or rather in the mode of seizing of it—it must not be grasped by the whole hand, and kept in it by contracting the fingers, or its bulk, with that of the hand, will exceed the open- ing through which it has to pass. This is not an unusuabpre- dicament; and has sometimes been attempted to be overcome by force, to the discomfiture of the operator, and to the serious injury of the patient. 1297. During the introduction of the hand into the uterus, and especially, while contending with the stricture, the uterus must be fixed firmly by the other hand being pressed upon its 0 * Dr. Douglass says, it^jalways found adherent, or rathae that it is never fot^nd detached. (Observations^ah the Hour Glass Contraction of the Uterus, p. 10.) Dr. Ramsbotuam says, that it is generally found detached, (Practical Observa- i'.f-ns, Am. ed. p. 114.) and this comports with my own observations. > ASSISTED DELIVERY OF THE PLACENTA. 501 fundus, until possession is taken of the placenta, and the hand* is about to be withdrawn. After the after-birth is delivered, I have thought it best to re-enter the uterus to the very fundus, so as to be certain that neither a portion of the placenta, nor coagula are left behind. 1298. This operation is always to be slowly7 and cautiously- performed, as the woman may be much endangered by a con- trary practice—she may, by rudeness and want of tact, be lia- ble to subsequent inflammation of the uterus, or its immediate rupture. It is to the patient always an operation of severe suffering, however well conducted, unless the stricture resists very moderately; therefore, to add to it, by rudeness or mal- adroitness, is truly cruel. Sect. IV.—4. On the enclosed and partially protruded Placenta. 1299. It sometimes happens that the placenta is confined in the uterine cavity, though detached from its surface, in conse- quence of the sudden contraction of the mouth of the uterus. It would perhaps be difficult to assign the reason of this dispo- sition in the mouth of the uterus to close, before the placenta is expelled—it may arise from some peculiar stimulus, or fro^i some preternatural irritability of this portion of the uterus, \ over neither of which, have we any control. 1300. This situation of the uterus and placenta may be known, by the latter being unusually long detained, when, from the hardness and well contracted condition of the former, we should not have anticipated any such delay; by the force ap- plied to the cord, not making the placenta descend; by an ab- sence of hemorrhage; nay, almost of discharge; by the con- tracted condition of the os uteri; by the placenta being felt, when the finger is passed through it; and by the absence of pains. 1301. It would be in vain to attempt the delivery of the pla- centa, by any exertion made upon the cord, though this almost Always is resorted to; and as the whole of the uterus will sink lower into the pelvis by this effort, the inexperienced practi- S 502 ASSISTED DELIVERY OF THE PLACENTA. * tioner imagines it to be the placenta descending—he continues his traction under this illusion, and thinking a little more force wili overcome the difficulty, he multiplies it; the cord is rup- tured, and his difficulties increased—he now becomes alarmed; and the panic spreads to the patient and her friends; every thing is thrown into confusion; a consultation is demanded, and a rival practitioner robs him of the little reputation he may have acquired, and thus interrupts his progress in busi- ness. Or, fearing the consequences a discovery of this accident might produce, he disingenuously7 conceals it; and attempts, without method, the delivery of the imprisoned placenta, to the immediate torture, and the subsequent injury, of his patient— not knowing exactly what causes the delay, or what the nature of the difficulties is which oppose him, after-excruciating the poor woman almost to death, by unavailing efforts, he in a pa- roxysm of mental anguish, abandons her; or declares the case must be left to nature. 1302. The mode of proceeding in such cases is: 1st, to try to recall the contractions of the body and fundus byMhe exhi- bition of the ergot in common doses; should this not succeed within an hour, the uterus must be gently entered, by slowly ^JKlating the os uteri, and the placenta removed—this, if care- ± fully and methodically attempted, is not so difficult as might at first be imagined. The woman should be placed as directed for turning, (702) and during the passage of the hand through the os uteri, the uterus should be firmly supported as suggest- ed. (1297) 1303. I have ventured to suggest the exhibition of the ergot in this case rather from analogy, than experience—-as in a case of retained placenta, after a premature labour of the seventh month, and another under similar circumstances at the sixth month, I happily procured the expulsion of these masses, by this remedy. 1304. As a general rule, I am of opinion, that the sooner we operate, all things being equal, the better, as the obstinacy of contraction is in proportion to the lapse of time, unless the al- ternate contraction of the uterus come in to our aid. ASSISTED DELIVERY OF THE PLACENTA. 503 1305. There are three other situations of the placenta, which * may be regarded as varieties of this case; the first, is where a small portion of this mass is pushed through the os uteri; the second, is where about one-half has escaped; the third, is where the greater part of this body is without the mouth of the uterus. In all these instances, the farther progress of the placenta is prevented by the os uteri firmly embracing it; at least so jirmly, as to render every attempt to relieve it by the cord, not only fruitless, but, perhaps, mischievous, by causing its rupture. Mode of acting in each Case. 1306. To relieve the placenta from its first situation, we must aid its descent by employing the crotchet recommended for the deliverv of this mass, in cases of flooding by abortion, (see figure, p. 404,) or by dilating the os uteri as recommended, (1295) first pushing up the protruded portions. 1307. For the second condition, the hand must be introduced into the vagina; and a finger passed under the edge of the os uteri, by which successive portions of the placenta must be hooked and brought downward, until the whole is relieved. 1308. In the third instance, all that is required is, the intro- duction of the hand, and the firm seizure and compression of the placenta, as near the os uteri as possible; this compression near the stricture diminishes the bulk'f the placenta so much, as to permit its escape, by drawing the whole mass toward the os externum. 1309. The cases I have just described, are far from being uncommon; and few offer greater embarrassment, to the young or inexperienced practitioner. The cause in many cases of placental detention, is not sufficiently- well understood, or suffi- ciently early ascertained, to render them free from risk-*-E| should, therefore, recommend to the yroung practitioner, to - search for it, whenever any unusual delay7 takes place, though 1^ the case be not attended by flooding, or other accident, after A having put in practice all that is important or essential to its V expulsion; or having waited until the condition of the uterus, 504 ASSISTED DELIVERY OF THE PLACENTA. as felt through the abdominal parietes, gives evidence, it has contracted sufficiently, if not successfully.* Sect. V.—Of the Delivery of the Placenta, when the Cord h broken or very feeble. 1310. An undue force applied to the cord, for the delivery of the placenta, may rupture it; hence, the important caution, of not applying too much. It sometimes happens, however, that a very moderate stress will destroy its connection with the placenta—this may7 arise from a weak state of this production, though it maybe sound; it may7 arise from a morbid condition of it; or from its being in a state of putrefaction. 1311. Those who are in the habit of seeing many cases of midwifery, can pretty well judge of the firmness or strength of the cord, so soon as they see it; and will from that judg- ment, regulate their endeavours to extract the placenta by it. When the funis is frail, or very tender, it should never be used as a means to deliver the after-birth; it should always be pre- served as a guide for the hand, should it become necessary to enter the uterus. The rupture of the cord in itself, does not necessarily7 create difficulty; since, when this part is very deli- cate, we do not employ it, in our attempts to free the uterus of the placenta—therefore, in such cases, the placenta derives no advantage from its preservation, as regards its unaided deli- very; but it may be of important service, should it be necessary to relieve it by the hand. 1312. It will follow from what has been said, (1311) that it is not always necessary to make an artificial case of a ruptur- ed cord; for the expulsion of this mass is in nowise promoted by its preservation, if the cord be too feeble to act with it; deliverv, therefore, in such case, must depend upon the spon- r * For the mode of acting in "placental presentations," or where this mass is attached to the mouth of the uterus, under all its various forms; for the plan of proceeding in haemonhagy from a partial separation of the placenta; for the rule of conduct where it is too adherent, and attended by flooding; tor rules to be observed in haemorrhage from atony of the uterus after the separation of th«> placenta, &c, see Chapter on Fterine Hemorrhage. ASSISTED DELIVERY OF THE PLACENTA. 505 taneous efforts of the uterus to clear itself of this burthen, and not upon any force that may be applied to the funis. 1313. But, though the preservation of the cord may not aid the placenta in its descent, when this is too tender to be an agent, yet it is highly important it should be carefully preserv- ed; since, we cannot determine a priori when it may be neces- sary to deliver this mass artificially; for, during its continu- ance within the uterus, some accident may attack the patient, and render it indispensable to interfere with its delivery. 1314. It may, however, as a general rule, be remarked, that the placenta is longer in descending when we cannot aid it by the cord, or when the cord is separated from it, than when it is strong and preserved—the reason is obvious. We should, therefore, in such cases, promote the contraction of the uterus by frictions; and, from what I have experienced of the action of the ergot, (1302) I should be induced to give it a trial be- fore I would pass the hand into the uterus; nor should the hand be introduced until it was satisfactorily proved, it had failed. 1315. Should we not succeed by these means in relieving the uterus of its burthen; and, especially, should any accident complicate this period of labour, we must introduce the hand, and deliver the placenta. The difficulty in this case is no greater than in common cases, provided the cord (however feeble it may be) is preserved, since this will, with proper ma- nagement, conduct us to the placenta, as certainly as a stronger one—but, if it be separated, a great deal of embarrassment may be sometimes created, by not being able to distinguish the placenta from the uterus, unless this mass is detache^f; if it preserve its connection with the uterus, the unskilled hand will find much difficulty in distinguishing it from the sur- face of this organ. jf a. The Signs by which the Placenta may be detected. 1316. The following marks will, however, lead to the detec- ,tion of the placenta; 1st. If the fingers pass over the internal surface of this body, its vessels, distended by blood, will be distinctly felt; 2d. If the placenta be pressed by the fingers, [64] 506 ASSISTED DELIVERY OF THE PLACENTA. the woman will scarcely perceive their presence; whereas, if the uterus were touched, she would complain; 3d. If the hand be placed externally over the uterus, opposite the one within the uterus, the thickness of the parts will declare, whether it be the placenta which interposes between them, when this mass is on the anterior part. b. The mode of acting in this case. 1317. When it is ascertained that the hand is in contact with the placenta, the latter must be cautiously separated from the uterus, by insinuating the fingers between them. There is some- times a difficulty in getting behind the placenta, in consequence of the membranes interposing between the hand and the surface of the uterus. To overcome this hinderance, the hand should be placed behind the membranes, and then permitted to travel up to the placenta itself, and effect the separation. 1318. Should the placenta be found loose in the uterus, it must be taken hold of and withdrawn. 1319. I have a few times met with difficulty in the delivery of the placenta from its excessive size. These cases have uni- formly occurred in instances of premature delivery7, or rather where the delivery was not premature, but where the child had died some time before its birth. In.the particular cases al- luded to, the children were not found putrid; but, on the con- trary, were hard and rigid, though a little swoln; the funes were always much enlarged, very tender, and engorged with a brown blood; the placentae were found, in these cases, so large as to distend the uterus so much, as to give the suspicion, to those unacquainted with the nature of the case, that there was another chiM. 1320. In looking over my records of these cases,. I do not find one that did Tiot require artificial aid for its deliverance by the introduction of the hand; and, in two of these, the pla- centae were so enormously large, as to nearly fill a common- sized chamber-pot. This prodigious increase appeared to be owing to the infiltration of water into the meshes of the placenta. In all the cases of the kind now under considera- INVERSION OF THE UTERUS. 507 tion, no aid was derived in the delivery of the placenta from the funes, as they were uniformly found so frail as to permit no force to be applied to them. CHAPTER XXXII. ON THE INVERSION OF THE UTERUS. 1321. This untoward, and too fatal accident, is, perhaps, more frequent than is commonly supposed. Instances of sud- den death after delivery, often remain unaccounted for; and there is every reason to believe, that this displacement of the uterus is sometimes the cause. Examinations of women who have died during, or soon after delivery, are not so frequent as their importance seems to demand. This indifference to examinations after death, arises, first, from a proper estimate of their value not being made, even by medical practition- ers ; second, from the aversion most people feel to have their friends' remains disturbed; third, to the disingenuous con- duct of the attending physician himself, who may not wish the cause of death to be ascertained, lest it should do injury to his character, either from his not having known or suspect- ed the true one, or by exposing some accident for which he fears the world would hold him accountable. Hence, as I have just observed, this complaint is, most probably, every now and then concealed; and therefore, its frequency in producing death, cannot be exactly estimated. 1322 Inversions of the uterus may be either complete, or incomplete—by a complete inversion, I mean the passing of the fundus and body of the uterus through the os internum; or being turned entirely inside out, to the very neck of this organ. But it is not necessary to the complete inversion, that the body and fundus escape through the os externum; as this condition may happen, and yet the uterus be concealed withm the vagina. 508 INVERSION OF THE UTERUS. 1323. The incomplete may be in different degrees; first, where the fundus falls down to the mouth of the uterus ; but is prevented from passing through it, by the latter being con- tracted; or the force may have been insufficient for this pur- pose ; second, where it has passed perhaps half its length through the os uteri; third, where it is completely inverted, with the exception of a small portion of the body and neck. In the two latter conditions, the body and fundus may be com- pressed, or strangulated, by the neck of the uterus contracting forcibly upon the protruded part; or it may be free from this restraint; each of these presents different indications. 1324. Proximate cause.—For the uterus to become com- pletely inverted, several circumstances must combine ; first, the fundus must most probably contract, while the body and neck must be flaccid; second, a force or weight must be ap- plied to the fundus, capable of making it descend through the os internum: this force may be a power applied to the cord; and the weight may be the placenta itself, engrafted immedi- ately upon the fundus. 1325. Remote cause.—The remote cause of this accident, is the want of power or disposition, in the body and neck of the uterus, to contract. This may be occasioned by an over-dis- tention of this organ, from an excess of liquor amnii; from the unusual size of the foetus; from a compound pregnancy; from hxmorrhagy; from passions or emotions of the mind; from exhaustion, in consequence of previous disease; from long- continued uterine efforts to effect delivery7, &c. 1326. Symptoms.—When this accident takes place, the wo- man almost instantly complains of a severe and distressing pain about the region of the uterus ; an effort to force or bear down; nausea, and sometimes vomiting; great faintness,with more or less haemorrhage; cold clammy sweats; pulse small, frequent, or extinct. A variety of nervous symptoms may also occur of a most distressing kind, arising most probably from the new situation the abdominal viscera are forced to take, when deprived of the support of the uterus. 1327. If we examine per vaginam, it will be found that the vagina is occupied by a firm resisting tumour, covered by the INVERSION OF THE UTERUS. 509 placenta, or otherwise, as the period may be at which this ac- cident occurs; or the fundus and body may be pushed through the os externum, either bare, or covered by the placenta. This casualty may take place immediately after the birth of the child; or it may not occur for hours, or even days, after this event. If the hand be now placed upon the abdomen, we shall fail to find the uterus. 1328. Incomplete.—The incomplete must have the same general causes as regards the effects upon the fundus and body —that is, the fundus cannot be supported by the body, from its loss of power, by the operation of either of the same remote causes, (1325) but is prevented from entirely passing through the neck, by the latter contracting, and arresting it within, or only permitting it to pass in part. The same general train of symptoms occur, but this condition is almost always attended with a greater discharge of blood, than when the inversion is complete.* If an examination be carefully made per vaginam, the fundus of the uterus may be detected in one of the situa- tions mentioned for this species or variety of inversion. (1323) 1329. The mechanism of inversion is sufficiently simple ; it would seem to require but a state of atony of this organ to pro- duce it, with (perhaps) more or less pressure upon the fundus; or the mere contraction of the fundus ; or the implantation of the placenta on this part. When this derangement takes place before the delivery of the after-birth, we have much reason to suspect that its weight, as well as its location, materially con- tributes to its production—location, indeed, would seem almost a sine qua non to inversion; for we either find the placenta dis- charged from the vagina, or else attached to the fundus of this organ; now, had the placenta been attached to any portion of the uterine parietes, that part must have contracted that it might be thrown off; and that contraction of the body of the uterus, ' It is a remarkable fact, that less blood is lost when the uterus is completely, than when it is partially inverted. This is not, pgrhaps, of difficult explanation; since, when the inversion is complete, the uterus contracts to a certain extent; and, by this contraction, the now internal surface of this organ is made to impinge upon the vessels which carry blood to it, and thus interrupts or cuts off fresh supplies of this fluid. 51-0 INVERSION OF THE UTERUS. most probablv would have given such support to the fundus as to have prevented its falling down. 1330. It is almost universally supposed, that an undue force applied to the cord for the delivery of the placenta, is the prin- ci; ..I cause of this accident; but in this I differ from such as have adopted this opinion; and for the following reasons: first, because the accid.nt has occurred after the delivery of the pla- centa ; second, because it has taken place, when no such force has been applied. But the caution, not to apply too much force to the cord to withdraw the placenta, is founded upon just and important principles; since, did the disposition to inversion exist, and this mass be attached to the fundus, it would be almost certain to produce it; when, perhaps, without such force, the woman might escape from the danger. 1331. Mr. Burns, after enumerating several causes of inver- sion, such as pulling of the cord; the too sudden delivery of the child when the cord is too short, &c. says, " from the same cause, or sometimes perhaps from sudden pressure of part of the intestines on the fundus uteri, occasioned by strong con- traction of the abdominal muscles, a part of the fundus becomes depressed like a cup, and encroaches on the uterine cavity. This generally rectifies itself if let alone." I would inquire, for the sake of information, how this dipping of the fundus is known to exist? and how it is ascertained, that it "generally rectifies itself if let alone ?" 1332. I can readily comprehend, that an unusually short eord, with the sudden expulsion of the child, may produce in- version, even when there is no disposition to atony in the ute- rus ; as the fundus may be dragged down at the instant relax- ation is about to take place ; but I confess myself entirely at a loss to comprehend what Dr. Merriman* may mean by a short cord, when its length permitted a child, by a sudden effort of the uterus, to be " thrown to the extremity of the bed," though this cord was" naturally short, besides being twice passed round the child's neck," and the placenta retained," though low in the pelvis." Quere, if this be a short cord, what constitutes a long one ? * Denman's Midwifery, Francis's ed. p. 514. INVERSION OF THE UTERUS. 511 1333. The indications in inversion are simply these; first, to restore the prolapsed fundus when practicable ; second, to pre- vent a reinversion after restoration ; and third, if the fundus cannot be restored, to take off the constriction occasioned by the contraction of the mouth of the uterus. 1334. When the fundus is prolapsed to the mouth of the uterus, but contained within it, should the mouth of the uterus be sufficiently yielding, the hand must be gradually passed through it, and the fundus carried upward until restored—if the placenta has been thrown off, we need but retain the hand within the uterine cavity until we have sufficient evidence of its disposition to contract, and to maintain that contraction. If the placenta has not been thrown off, it will be found either loose, or adherent—if loose, it must be withdrawn with the hand after we are satisfied we may trust the uterus to itself. If adherent, we must gently separate it after the uterus shows signs of returning power; and, when separated, it must be taken from the uterus, when the hand is retracted. 1335. Should the fundus have escaped in part through the mouth of the uterus, it should be as quickly as possible return- ed, by pressing the most depending and central portion of the tumour, gently, steadily, and perseveringly in the direction of the axis of the os uteri until it retire; then if it does not return to its proper situation by its own resiliency, we must pursue it with the hand through the mouth of the uterus, nor leave it until placed in situ. The hand must be kept in the uterus, un- til, by the contraction of the uterus, there is assurance it may be withdrawn with safety. 1336. If the placenta offer itself before the prolapsed fundus, we may, if detached, deliver it immediately; but if it be adhe-^ rent, and the mouth of the uterus does not offer too much re- sistance, it must be carried up with the fundus, and separated, as before directed. (1334) Should we, however, find much opposition to reduction, and this evidently, in part, arising from the bulk of the mass to be restored, it will (perhaps)* be best to separate it carefully, and then carry up the fundus. • I say, "perhaps," because t cannot speak more positively upon a subject where my experience is so limited. The propriety of this practice I wish t« 512 INVERSION OF THE UTERUS. , 1337. Should the inversion be complete, it will, for the mosl part, be impossible to restore it, especially if several hours have elapsed since the accident. Dr. Denman says, " the impossi- bility of replacing it, if not done soon after the accident, has been proved in several instances, to which I have been called, so early as within four hours, and the difficulty will be increased at the expiration of a longer time. Whenever an opinion is asked, or assistance required, in those cases which may not improperly be called chronic inversions, it is almost of course that the reposition should be attempted; but I have never suc- ceeded in any one instance, though the trials were made with all the force I durst exert, and widi whatever skill and ingenu- ity I possessed ; and I remember the same complaint being • made by the late doctors Hunter and Ford; so that a reposition of a uterus which has been long inverted, may be concluded to be impossible. It seems as if the cervix of the uterus conti- nued to act, or had soon acted in such a manner, as to gird the inverted uterus so firmly, that it could not be moved." This account of the impracticability7 of restoring the fundus when the inversion is complete, is in strict conformity with my own experience of .this accident. 1338. It is said, the uterus has been reinstated after "com- plete inversion;" but of this we may justly entertain strong doubts; for the one recorded by Mr. White, purporting to be of this kind, was certainly not one of u complete inversion." In Mr. White's patient, we recognise nothing more than a par- tial one, as the symptoms declare. Mr. W. says, he saw the patient, about an hour after the accident, and " found the ute- rus of the size of a large new-born infant's head, totally in- verted.'''' Yet he declares the woman " was in great pain, and had lost much blood," neither of which circumstances attends complete inversion; for it seems to be agreed, that there is not much haemorrhage at this time; and I know that pain imme- diately ceases when it becomes complete, as I shall state pre- sently. leave to farther observation; for, having met with but four cases of " inversion," I think that number inadequate to establish the beet mode of practice. ( INVERSION OF THE UTERUS. 513 1339. This patient "was very faint, and no pulse could be felt in either arm;" a condition which constantly attends the partial inversion; especially, when the mouth of the uterus contracts firmly7 upon the body, producing a strangulation of the uterus: which was precisely the situation of Mr. W.'s pa- tient; for he declares, "the neck was a little contracted." Now, it must be obvious, upon a moment's reflection, that, if the inversion were complete, there is no mouth of the uterus to feel; for this part now offers its opening in the abdomen, and is not tangible by the finger. See case second. 1340. There is a condition of even a partial inversion, where it is as certainly7 impossible to restore the fundus, as if the in- version were complete; and this is when the fundus and a part of the body have passed the os uteri, and the latter contracts firmly, " so as," as Dr. Denman expresses it, " to gird the in- verted uterus firmly, so that it cannot be moved." When this happens, the stricture occasioned by the contracted mouth, is so firm and resisting, that a finger cannot be placed between its edge and the confined uterus—here I believe it is impossi- ble to pass the fundus, as the constriction will not yield. 1341. This variety of partial inversion, produces the most terrible and alarming symptoms imaginable; pain, faintness, vomiting, delirium, cold sweats, extinct pulse, convulsions, and, if not speedily relieved, death. Under such sufferings, where all chance of restoration is at an end, I have advised, with a view to terminate such severity7 of suffering, and to pre- serve life, the drawing down of the fundus and body, so as to complete the inversion. Should the placenta be attached, it must be carefully separated before we draw down the fundus. 1342. The propriety and safety of this plan, are, it must be confessed, predicated upon the happy result of a solitary case; but, from its entire and speedy success in this instance, it is rendered more than probable that it will be of equal advantage, if employed in others. " All reasoning upon the subject," is certainly in its favour; and experience, so far as a single case may be entitled such, is equally so. 1343. Should the practitioner, however, be so fortunate as to meet with a case where the mouth does not confine the pro- [65] 514 INVERSION OF THE UTERUS. truded part, he should attempt restoration, however large a portion of the uterus may have passed through, by gently, but firmly compressing it, so as to reduce its size ; having first re- moved the placenta, if not previously7 done, and urging the pro- lapsed part upward in the axis of the os uteri. In such case, perseverance may, I am willing to admit, do much ; it ought most certainly to be tried, if there be the smallest chance of success. 1344. This chance, however, should be clearly ascertained, by carefully examining the condition of the constricting part— if it be soft and yielding, a hope may be indulged that the re- sistance may, by proper proceeding, be overcome. If this friendly condition obtain, there will be, beside this pliant dis- position of the os uteri, an absence of all, or nearly all of the terrible symptoms just enumerated (1341;) but, if he cannot find the mouth of the uterus by a careful examination after the placenta is removed, and if there should be an absence of the train of appalling symptoms above named, he should desist at once from every attempt at reduction, as his efforts will not be attended by success; and the continuance of them will not only give his unhappy patient much unnecessary pain, but will hasten her death. 1345. The mode to be pursued, when it is necessary to com- plete the inversion, is simply to place the woman upon her back near the edge of the bed; and have her legs supported by pro- - per assistants—the hand is to be introduced along the inferior part of the vagina, but sufficiently high to seize the uterus pretty firmly; it is then to be drawn gently and steadily down- ward and outward, until the inversion is completed; this will be known by a kind of jerk announcing the passing of the confined part through the stricture. Traction should now cease, and the part be carefully7 examined; if the inversion be com- plete, the mouth of the uterus will no longer be felt, and there will be an immediate cessation of pain, and the other distress- ing sensations. 1346. The situation of the uterus, is the very reverse'of what it was a short time before; it^ internal face is now the external; while the external or peritoneal surface, has become r INVERSION OF THE UTERUS. 515 the internal, or the uterine cavity—it is probable that the ova- ries, tubes, and broad ligaments will be included in this space. Dr. Denman informs us these surfaces do not coalesce. The woman may menstruate from the now external surface. Case First. On the 2d of July, 1807, at ten o'clock, A. M., I was called to the wife of Samuel N----, in labour with her first child. Her pains were weak and irregular, but pretty7 frequent; pre- sentation perfectly natural. As every thing appeared promis- ing, I left her to the care of her midwife. At four o'clock, P. M., she was suddenly delivered—considerable haemorrhage with faintings followed. I was again sent for, but did not see her until six o'clock, as she lived at some distance from the city. I found her without pulse, cold, and covered with per- spiration; with laborious and hurried breathing; the placenta not delivered, and the haemorrhage continuing. I ordered her such remedies as appeared most pressingly indicated, and im- mediately examined her per vaginam. I found the placenta just within reach of the finger, and attempted to withdraw it, but it gave great resistance and extreme pain. I now intro- duced my hand, and found a tumour resembling in shape and size the indentation at the bottom of the common black bottle, over which the placenta was spread. This case was perfectly new to me, although I strongly suspected the nature of the disease. I searched for the detached portion of the placenta, from whence the flooding proceeded, and carefully'detached this mass from the tumour; I then endeavoured to push up this body, but quickly desisted, from the extreme pain it occa- sioned, and the uncertainty that it was the best mode of pro- ceeding to procure relief. My patient died in half an hour. I obtained leave to inspect the body, and Dr. Rush very kindly accompanied me. It proved, as I had previously sus- pected, to be a partial inversion of the uterus. I dissected out Kthe uterus, which was still so flaccid, as to be turned inside out with as much facility as a soaked bladder. The fundus dipped into the body of the uterus about three inches. 516 INVERSION OF THE UTERUS. Case Second. On Friday, 24th March, 1808, at half past 5 o'clock in the morning, Mrs. P. was delivered of a living child; her waters discharged themselves six or seven hours previously, and be- fore her midwife was called. The placenta came away spon-> taneoush', as the midwife asserted, and to which the patient herself agreed; its expulsion was attended with great pain and great flooding; she vomited severely for an hour, and several times fainted without an abatement of the discharge. This, however, was eventually -moderated by the acetate of lead, and perhaps contraction of the uterus itself. After this, she continued pretty tranquil, but weak, until Sunday morning, when there was a renewal of the haemorrhage, with pains resembling those of labour. These ceased in the afternoon; but she became more alarmingly ill. She now fainted frequently, and the discharge continued. In this way she kept until Tuesday, at which time I was called, at the desire of Dr. Atlee, whose patient she now was. The doctor suspected the true state of this woman's case, and mentioned his opinion to me, to which at first I could scarcely assent, as almost all the cases I had ever heard or read of, as well as I recollected, had soon proved fatal; and the case I had witnessed a few months before, but served to make me doubt the doctor's representa- tion, or rather opinion. Here, if his judgment were correct, was an instance of inverted uterus of four days' standing; a case giving contradiction to all I had heard or believed on the subject.* I however visited the patient by7 appointment, and found her almost exhausted—her pulse so frequent as not to be numbered, and so small as scarcely to be perceived; had great difficulty in breathing, and became faint on the least mo- tion; insatiable thirst, frequent vomiting, cold extremities, and a continuance of uterine discharge. I examined her, and found, as Dr. Atlee had declared, the uterus to be inverted. The fundus • Since writing the above, I have strong reason to believe, that the inversion did not take place until the morning, namely, Sunday; on which there was a re- newal of the flooding, and the uccirrcnce of pains leseinbling labour; as at th;i time, the uterus suffered a universal atony. t _ INVERSION OF THE UTERUi "»17 was down at the os externum, and could readily be seen par- tially covered with a thin coagulum of blood, when the labia were separated. The places not hid by this coagulum, were rough or spongy, and of a dark brown colour. A very7 dreary prospect presented itself, by ascertaining this. poor woman's situation ; we believed death to be inevitable. But one resource offered itself, namely, to attempt the reduc- , tion of the fundus, hoping, as the uterus had not escaped from the vagina, the inversion might not be so complete, as to render this impossible. We accordingly7 proposed this attempt to the husband and friends of our patient, candidly7 stating her situa- tion, and the almost certain result, if relief was not obtained in this Way. They without hesitation submitted the case to our management. We carefully drew her to the side of the bed, and had the knees drawn up and supported. I gently introduced my hand under the tumour, and gradually raised it; this gave me suffi- cient room to examine the nature and extent of the inversion. The instant I raised the womb, there was a large and sudden discharge of urine; this gave still more freedom to an exami- nation, that was to terminate in the disappointment of my hope of the reduction of the fundus. I found so much of it had passed through the mouth of the uterus, as to render any attempt at reduction futile; and the more especially, as the tumour was aug- mented by its having swelled since its prolapsus. The stricture occasioned by the contracted mouth was readily felt, and was very strict. I was extremely perplexed for the moment how to proceed, or to announce the failure of an attempt, that alone, at first sight, appeared to promise success or even relief, but it fortunately occurred to me, before I withdrew my hand, that I might take off the stricture by inverting the uterus completely. Agreeably to this suggestion, I grasped the tumour firmly7, and drew it prettv forcibly towards me, and thus happily succeed- ed in slipping the remaining portion through the constricting mouth. The woman was almost instantly relieved from much of the anxiety and faintness, she had before experienced; but as she was so exhausted by previous suffering and discharges, and as the internal surface of the uterus was now exposed to 518 INVERSION OF THE UTERUS. the influence of the external air, I was prevented from feeling or giving the slightest encouragement of recovery to her friends; but fortunately the event proved how groundless were my fears; for from this day, she rapidly recovered, without another alarming or troublesome symptom. Milk was freely secreted on the fourth day after, and con- tinued freely. Our patient was twenty-three years of age, delicate, but always healthy, but more especially so during her pregnancy. I visited this patient to day, November 26, 1808, and found her at the wash-tub, perfectly well; suffers no inconvenience whatever from the uterus; menstruated regularly for three periods; had more or less discharge of mucus tinged with blood for four months; this last four months has had no dis- charge of any kind; suckles her child, which is remarkably thriving. The uterus is so much contracted, as to be no longer within reach of her finger.* Case Third. On the 23d of November, 1808, Mrs. G----was suddenly delivered of a large female child, which breathed and cried freely immediately after its birth. The funis was not cut until after the pulsation in the cord had entirely ceased, which was in about ten minutes. After the child was taken away, I took hold of the cord, and merely tightened it, on which she begged me to wait, as it gave great pain. I, however, traced the cord to the vagina, and found at the os externum a placenta I thought unusually dense and large. On gently attempting to with- draw it, as I thought it loose in the vagina, I found uncom- mon resistance, which I attributed to its bulk, and desisted * I was this day (June 1, 1810) called to Mrs. P., on account of indisposition. She gave the following account of her situation : " She had been pretty regidar ever since last report, but for the last few periods it has been more abundant, and is sometimes accompanied by the discharge of coagula; it continues longer than formerly, and, when it ceases, it is followed by profuse fluor albus." I saw Mrs. P. again in April, 1818, and found her enjoying a very fair proportion of healtii—the catamenial discharges had ceased for the last five years, and she has been a widow several years past. She has never been impregnated since her accident. INVERSION OP THE UTERUS. 519 from further effort, hoping the uterus would, by contracting, push it completely down. In this I was disappointed;—some haemorrhage ensued. I now expected a more than common cause detained the placenta in the vagina, and began a more minute examination. I pierced the substance of the placenta with the fore finger of my left hand, and tightened the cord with my right; beneath the placenta I perceived a round hard substance, which I but too quickly discovered to be the fundus of the uterus inverted. I immediately7 introduced my hand into the vagina, and found the detached edge of the placenta from which the discharge proceeded. I carefully separated the whole of this mass, and withdrew it from the pelvis with- out the least difficulty. A considerable flooding ensued. As Mrs. N----'s case (case first) gave me a complete in- sight of the mechanism of this displacement of the fundus of the uterus, and as I had resolved to attempt its reduction if ever an opportunity again offered, I instantly, after withdraw- ing the placenta, introduced my hand, and pressed the prolapsed fundus firmly with the back of my fingers, and carried it up- wards in the direction of. the axis of the uterus, and in less than half a minute, succeeded completely in restoring it. Mrs. G----has not had a single unpleasant symptom. Case Fourth. Mrs. G----was delivered on the 25th of December, 1808, at six o'clock, P. M., after a labour of some hours, of her first child. The placenta was extracted in about fifteen minutes without force. There was some haemorrhage, and considera- ble pain. She was put to bed, and became very faint, and complained of great pain, which was occasionally augmented. She continued in this way, only gradually becoming worse, un- til nine o'clock, at which time I was sent for. I found her with a small frequent pulse, great anxiety, ex- tremely pale and cadaverous, and in a profuse cold sweat. I inquired respecting the flooding; but this did not appear to be sufficient to account for her present situation. I immediately suspected a partial inversion of the uterus, and thought proper to apprize her friends of the probable cause of her distress 520 INVERSION OF THE UTERUS. and danger, and of the possible result of it. Every thing was left to mv management. I immediately7 after examined hel- per vaginam, and found my conjecture true. The uterus was found inverted, and its fundus was just within the os externum. I was much alarmed for my patient, as three hours and more had elapsed between the time of her delivery and mv being called; she was much exhausted, and in extreme agony. I quickly introduced my left hand into the vagina, and applied the back of my7 fingers firmly against the tumour, while I moderated its influence in carrying the uterus directly up through the pelvis, by having a gentle pres- sure made upon the abdomen above it. The tumour soon be- gan to yield, and in about two minutes the fundus was com- pletely restored. On the third day after, my patient complained of a severe pain in the right side just above the ilium, for which I bled her freely, and purged her briskly. Nothing unpleasant super- vened ; she might be said to have had a good getting up. CHAPTER XXXIII. OF TWINS. &r. 1347. Under this head I shall consider pregnancies com- posed of two or more children. Twins are of rare occurence; so much so as to render it difficult to establish the proportion between them and single births; especially, as their production seems to be governed by contingencies not within control, or altogether inscrutable. Thus, in the Middlesex Hospital, Lon- don, there was but one in about ninety-one; while in Dublin the proportion was greater. In France, agreeably to one re- turn of" I'Hospice de la Maternite," the proportion was about one in eighty-eight; but, according to that of Madame Boivin of the same institution, the proportion was only one in about OF TWINS, &C. 521 one hundred and thirty or forty, while in that of the "Maison d'Accouchemens," the proportion was about one in v.inety-one. 1348. In this country7, the average is about one in seventy- five. From this it would appear, that climate, or the state of civilization, agreeably to the remark of Dr. Denman,* exerts an influence upon the multiplication of the human species; and that where the means of life are more abundant or more easily procured, the proportion of twins is probably increased—this however is by no means proved; but that there are conditions and circumstances which give rise to more double births in this country is certain, if reliance can be put upon the various tables of births.f It would be a curious subject of inquiry to the political economist, and to the physiologist, to ascertain on what depends the frequency of plurality of children. 1349. It is thought by many women, that the disposition to double births is hereditary; and some facts within my own knowledge seem to countenance this supposition; but they7 are by no means sufficiently numerous, or sufficiently strong, to confirm it. I can say, however, with some safety, that it is in some instances constitutional; I know one female, who has had five twins in succession, and had not, when I conversed with her on the subject, (three years since) ever had a single birth. I knew another who had twins three times; but not immedi- ately following each other. 1350. Were I to decide from my own practice, the average would be higher than I have stated above ; (1347) it would be one in about fifty or sixty—but this would not altogether be correct; as for many years I was frequently called to the aid of many midwives in this city, among which there were a num- ber of cases of twins—this would increase the average as re- gards my own practice, without giving a just view of their fre- quency; since, these cases should be ^considered as properly belonging to the averages of these midwives. 1351. Triplets are very much more rare—in the returns of the cases in the " Maison d'Accouchemens," as furnished by * System, Francis's ed. p. 534. . f Francis's ed. of Denman, in a note, pp. 613, 614. Dr. ArnoH'« average rs one in seventy-five; Dr. Moore's, one in seventv-six [66] 522 OF TWINS, &C Baudelocque, there appears to have been but one in more than eight thousand cases; in the return of Madame Boivin of the cases of " I'Hospice de la Maternite," one in rather less than seven thousand; Dr. Arnell one in twelve hundred, and, in mv own practice, in nearly nine thousand cases,* I have not met with an instance of triplets. Of more numerous progeny, the proportion must be infinitely small; since, in the practice of the two hospitals above mentioned ; in the private practice of Drs. Arnell, Moore, and myself, amounting in all to more than 50,000 cases, there is no mention of an instance of four children at a birth. 1352. Women who are more than ordinarily large, are apt to suspect themselves pregnant with twins; and, on this ac- count, much anxiety is always expressed. The accoucheur is not unfrequently consulted; and his opinion requested on this momentous subject, so soon as this fear is excited; but much caution should be used in answering this question; indeed it should always be resolved in the negative, and for two reasons especially; first, because it is impossible to decide it positive- ly ; and, secondly, if it could be, it never should be, as much mischief might arise from the anxiety it would produce. 1353. We have no certain marks before labour to determine there is more than one child in the uterus; a number of signsf are recorded, purporting to declare this condition, but not one of them can be positively depended on. Baudelocque and Denman say the same thing; the former is of opinion that the union of all these signs sometimes gives strong presumption of the existence of twins, but that "touching alone can dissipate our doubts, and that only at the last months of pregnancy." " For," says he, " when the belly is so large as to give a sus- picion of two children, if there is but one, it is always very moveable; because it is then in a large quantity of water: we * I may now say, in rather more than nine thousand cases. | The enumerated signs which purport to declare the woman pregnant of twins are—1st. The extraordinary size of the abdomen of the woman; 2d. The division of the abdomen into tumours upon its anterior sin face, occasioned by the unequal stretching of the r«cti muscles; 3d. An oedematous condition .of the inferior ex- tremities, after the tliird or fourth month ; and, 4th. The various or numerous places at which the woman feels motions or stirrings. OE TWINS, &C. 523 easily move it by means of the finger introduced into the vagi- na, and its rolling is never more manifest than when we do that. When there are two, that movement is scarcely sensi- ble; we easily distinguish that the child we endeavour to move by touching, is surrounded by only a little fluid, and that it is encumbered by another solid body; if we apply the hand on the woman's belly in one of these movements, when the pa- rietes of the uterus are supple, and, as it were, slackened, we may discover these children as clearly as in other cases we distinguish the feet, the knees, or the arm of that which is single."* 1354. The whole of the information we can gain, either by taking into consideration the enumerated signs, or by touching as proposed by Baudelocque, can never amount to more than presumptive evidence; as the whole of the signs have been known to exist without the woman being pregnant of twins. And the quantity of liquor amnii differs from a few ounces to several pounds in even single pregnancies; therefore, no certain conclusion can be drawn from the mobility or immobility of the foetus in utero. 1355. This uncertainty whether a woman be pregnant of one or more children, fortunately is of no consequence, until the la- bour has positively commenced: for, previously to this time, our conduct in every respect should be the same, as if there were but one child. But at this period it would in many in- stances be extremely useful, when the children were offering untowardly; as the cause of difficulty would then be ascertained, and the indications fairly declared. In cases then of twins, the situation of the children, either as regards themselves, or the pelvis, may be more or less favourable, and, consequently7, complicate the labour in proportion. 1356. Twins may, first, be enclosed in one common covering of membranes, and inhabit the same nidus, and float in the same waters; second, they may each have a separate amnion, while the chorion may be common to both; third, each may- have its own membranes, waters, and placenta. * System, Vol. HI. p. 442. j24 of Twins, &c. 1357. The different situations in which twin children may- be placed while in utero, especially the two first, (1356) disturb every projected scheme, with respect to impregnation: they unsettle all that has been hitherto thought to be pretty well proved, as regards the ovaries, the fecundation of ova, and the absolute nature of the ovum itself; and throw into confusion all that has been thought clear; or, they oblige us to extend our opinions of#the powers of the corpora lutea, very much be- yond what has hitherto been thought of. 1358. They disturb (1356) all the schemes for impregnation, since they all suppose, that each ovum is a separate and dis- tinct germ, and included in distinct coverings; yet two ace found involved in the same common covering, with two umbili- cal cords, and with one placenta. It unsettles that which has been thought pretty well confirmed as regards the ovaries, to wit: that they furnish ova for impregnation, upon different portions of its surface, yet two embryons are found to bathe in the same waters, and with one placenta for their support; proving, it would seem, that an ovum may contain more than one germ, which may be fecundated at one and the same time. They throw into confusion that, which has, especially of late, been thought perfectly clear and well understood: as follows, that the cor- pora lutea furnish the ova for impregnation; that each corpus luteum yields its own ovum, and that each ovum brings with it, from its nidus, its own chorion and amnion; yet they are both found common to two children; or the chorion alone com- mon, and each has its amnion; yet with distinct cords and a "placenta in common—now I would ask, how can this be, agree- ably to our present notions of impregnation ? Does it not oblige us to extend the powers of a corpus luteum, and make us admit, that one ovum, may contain the rudiments of two foetuses, or oblige us to call in question the arrangements just spoken of?* (1357) • May we not reasonably doubt, that two children can float in the same waters, as an original disposition of them ? May we not suppose that the muscular exer- tions of the children may have broken the separating membranes, and thus per- mitted the waters to unite ' For it cannot be doubted, that they have been found together: as Dr. Denman (Francis's ed. p. 541.) tells us, his friend, Dr. Hims, informed him of a case of twins, where the funes were so closely twined together, as to appear but one. OV TWINS, &C 525 1359. The third situation of foetuses in utero (1356) proves, that two ova may furnish embryos with their own coverings, since they exist separately and distinctly in some cases of twins, and their separate existence renders it more than probable that they were the product of different ova, and as probable that each issued from a separate ovarium. For, if we do not admit this, we must admit that, which not only wants proof, or even proba- bility, but what is very much more difficult to reconcile; namely, that a fallopian tube can successfully transmit two ova at one and the same time, or consecutively; which, agreeably to all the present known schemes of the ovum getting possession of the uterus, would be very difficult to reconcile, though not, perhaps, impossible ; but by admitting a simultaneous action in the tubes, and each ovarium furnishing an ovum, the explana- tion is easy; therefore, to be preferred. But a truce with speculation. 1360. The labour of a woman pregnant with twins, begins in every respect like a labour in w7hich there is but one ; but it« progress is neither so regular nor so rapid. This is not diffi- cult to explain; since it is impossible that either child can re- ceive the undivided influence of the contracting uterus, and therefore it cannot be so rapidly expelled; or they may be so situated as to impede, if not to oppose, each other's exit: hence, the labour is slower, at least with the delivery of the first of the children; but with the second it may be quicker, nay, even rapid. This being the case, if we could even determine beforehand with certainty, that the labour is a twin case, w* should not alter our conduct, except there be something in the labour itself, which would require interference, independently of its being a compound pregnancy. 1361. In general, nay, almost always, we do not know we are encountering a twin case, until after the birth of the first child; we may then suspect this to be the case : 1st. When the child is small, compared with the size of the abdomen of the mother, and the quantity of water discharged; 2d. If the abdo- minal tumour has not subsided as much as if it were a single child: 3d. Because the child may be felt through the abdomi- nal and uterine parietes: 4th. Because, there is, in general, a 526 OF TWINS, &C. renewal of uterine contractions, and the child can be felt per vaginam, if its membranes have given way, or the membranes themselves when distended with the waters, if they are entire. 1362. After the birth of the first child, and we have ascer- tained that there is a second, it then becomes a question, what is to be done with the second ? Accoucheurs seem to have puzzled themselves in answering this plain and simple ques- tion, and have attempted to lay down rules, which are calcu- lated to embarrass, rather than instruct the inexperienced prac- titioner. The rule upon this subject is plain, and void of all ambiguity, since it is founded upon the disposition and situa- tion of the uterus itself. Baudelocque alone is rational on this subject. 1363. I have said the rules of practice in cases of twins, after the birth of the first child, were free from all difficulty or am- biguity; for after one child is expelled, one of two things must happen; either, that pains will pretty quickly ensue, and deliver the second if its position be natural, or there will be a sus- pension of pain. 1364. If in the first case, we must conduct the labour, as if it were an original labour, and not to be interfered with so long as there is a rational expectation, that nature is competent to relieve herself; and if this promise be not made, or season- ably7 fulfilled, we must interfere as upon any other occasion, where this interference might be necessary7. When pains fol- low the expulsion of the first child, there is every expectation they will accomplish the delivery of the second; first, because it will receive the whole influence of the uterus, which was divided before; second, because the .subsequent pains will be more powerful than the antecedent ones: since the uterus is now smaller, and its tonic contraction more perfect, which (caeteris paribus) always increases the alternate contractions of this organ; third, because the parts have been dilated, and are of course made to yield by the passage of the first child; there- fore, there is no resistance to be overcome. 1365. If in the second situation^ namely, where there is a suspension of pain, our duty is equally clear—for it will de- OF TWINS, &C. 527 pend altogether upon the situation of the uterus itself. This condition will consist in its being uncontracted, or contracted. 1366. If in the first condition, it will be attended by haemor- rhage, or be free from it—if with flooding, we are to deliver as we would in any other case of haemorrhage, and be regulated by the same rules which govern upon such occasions; if no hemorrhage be present, we must solicit the contraction of the uterus by frictions upon the abdomen, until it contract. If it be contracted, and pains do not pretty soon follow, I have long thought it best to make the labour an artificial one, and for the following reasons : 1367. First, because if pains do not come on in the course of a half hour after the tonic contraction of the uterus is well established, it is altogether uncertain when they may take place; and the patient is then left in great anxiety for the event; second, after the expulsion of the first child, a haemorrhage may ensue, which will oblige us to deliver under all the embarrass- ments it gives rise to; third, there is nothing to apprehend in terminating the labour, as the tonic contraction is secured, and no difficulty can be created, since the uterus will readily permit turning if the head present, or the delivery, as directed, if either the breech, feet, or knees present, when there is a ne- cessity of making either an artificial labour; fourth, we remove at once the anxiety of the woman; which, if long continued, may have a very unfriendly influence upon the powers of the uterus. 1368. All rules for conduct, taken from the lapse of time, are liable to very serious objections; for mere waiting does not insure the proper condition of the uterus to render our acting safe; and we are never to act if that proper condition (1272,1273) does not follow, however long we may have wait- ed: for, at the end of four hours, (Dr. Denman's* rule,) it may be just as improper to deliver, as it was fifteen minutes after the birth of the other child; and if contraction will justify us to deliver at the end of four hours, it ought to justify us at any intermediate period. And if we are to act at the end of four • Introduction, Fraud .'s ed. p. 5A0. 528 nr TWINS, Jki hours, be the condition of the uterus what it may, (for nothing is said of the state of this organ,) we shall as certainly do mis- chief by our interference, if the uterus be not contracted, as if we had acted at any other antecedent period. If then we do not insure the contraction of the uterus by waiting, we gain nothing; and it will be proper, therefore, to act whenever we are assured, that the powers of the uterus are in full and healthy play. 1369. Should any of the enumerated accidents (625) com- plicate a labour of twins, we must act as in any other case; taking care, at the same time, to distinguish the proper feet, if we turn, and the membranes are ruptured; and if they are not ruptured, and we discover it to be a twin case, in proper time after we have commenced the operation, not to rupture the membranes of the remaining child. If the breech, feet, or knees offer, we must bring down the feet, or act upon them, as has been directed—or if the head present, and the labour be far advanced, we must use the forceps, though we are certain it be a twin case. Or should any thing untoward take place during the transit of the second child, we must act as the nature of the case requires, without reference to its being a twin. 1370. Mr. Burns,* I think, lays down two very doubtful rules for the management of twin cases—the first is, that " if effective pains do not come on in a quarter of an hour, the child ought to be delivered by turning." The second is, "if the position of the second child be such as to require turning, we are to lose no time, but introduce the hand for that purpose before the liquor amnii be evacuated, or the uterus begin to act strongly on the child?'' ' 1371. If we were to act agreeably to these directions, we should almost constantly have cause to repent the enterprise; for we certainly should do mischief, by exposing the uterus to a state of atony; and thus provoke, perhaps, a fatal hemorrhage. I must repeat, in such cases, we should pay no regard to the time, which may elapse after the birth of the first child; it •• 1 Principles, .lumen'* ed. p. 406 f)F TWINS, SCC. 529 to the condition of the uterus alone we should direct our atten- tion, and that alone must regulate our conduct. a. On the management of the Placente. 1372. From what has been said above (1356, &c.) it will not always be found, that each child in twin cases, will have its pla- centa; yet it is generally the case; and though only connected by interposing membrane, we are obliged to deliver them to- gether. Before, however, we make this attempt, when*we have reason to suspect there is another child; or when this has been ascertained, we should apply two ligatures upon the funis of the delivered child, and cut between them; as the cut extremity in such cases yields a good deal of blood sometimes; and occasionally it is said, even to the exhaustion of the second child'. We should never attempt the delivery of a placenta, until both children are born. 1373. This bleeding may happen where both funes belong to one placenta, or where the two children are supplied by one original cord, branching some distance from the placenta to furnish a funis to each—and, as we cannot beforehand ascer- tain such deviations, it is best to guard against the chance of mischief by the application of a ligature ; this may be removed after the birth of the second child, that it may discharge some of the blood contained in the placenta, for the reasons before stated (506.) 1374. The delivery of the placentae of twins must be con- ducted upon the same general principles, as if there were but one—but rather more time should be given, and caution exer- cised in twin cases; because, the uterus has been more distend- ed during gestation, and more severely exercised sometimes during parturition than with a single birth: consequently, the tonic contraction will be more slowly and reluctantly perform- ed, and the woman more exposed to flooding. Brisk frictions should be immediately instituted, and sufficiently persevered in, to insure the object for which they were employed. 1375. When the tonic contraction of the uterus is confirmed, we may then, and never until then, proceed to the delivery of the placentae—they will be found either occupying the vagina, [67] 530 OF TWINS, &C. or be beyond the reach of the finger. If in the first situation, they may7 be extracted by a small force exerted upon the cords, and the aid of a finger introduced into the vagina. If in the second, we must co-operate with the uterine contractions when they exist, by7 pulling gently, but pretty firmly, by the cords, but not with equal force on each—if we do, we tend to bring both placentae at the same time to the os uteri; and their united bulks, will not readily pass it—we should therefore act more firmly upon the cord first out, as it is more than probable its placenta is nearest the uterine orifice, and will more easily descend, and at the same time, bring the other with it. 1376. Should no pain aid in the expulsion of the placenta?, we must continue the abdominal frictions, and act occasionally upon the cords, by applying father more force upon the first, than upon the second, for the reason just stated. (1375) A sdight discharge of fluid blood, or small coagula, almost always announces the descent of the placenta; this is equally observed when there are two; and when we find this taking place, we must continue a gentle tractive effort, until they are lodged in the vagina—from this they must be withdrawn as already intimated. (1375) 1377. Dr. Denman says,* "when the placentae are separate, that of the first child should not be extracted before the birth of the second child, as a discharge of blood must necessarily follow, and perhaps a haemorrhage." This is certainly rational advice; and would be highly useful, were we informed, how we are to know beforehand, when the placentae exist separately. I have already directed, (1375) that the first placenta is not to be meddled with, in twin cases, until the second is ready for delivery; and with this direction I believe we must rest satis- fied ; and without ascertaining whether it be separate or not. 1378. Dr. Denman farther says, " if there have been a neces- sity of extracting the children by art, it is commonly, but not universally, necessary to extract the placentae also by art; but if the placentae are detained beyond a proper time, we will say two hours, after the birth of the second child, it is desirable, though there may be no very urgent symptom, that we should * Francis's edition, p. 541. OF TWINS, &C 531/ inform ourselves of the cause of this detention, and act ac- cordingly." 1379. The first of these remarks, namely, that the interfer- ence of art is necessary to the delivery of the placentae, if it has been necessary for that of the children, is by no means agreeable to my experience; nor do I see the slightest rela- tion between these events ; and if acted upon by inexperienced practitioners, as it certainly will be, when advised by such high authority, much mischief will ensue. And to the second, I must again object, as the rule is taken from time; which can never in itself constitute a reason, nor develop a principle; for, as I lhave upon another occasion remarked, it may be just as improper at the end of two hours to deliver the placentae as it was immediately after the delivery of the last child. 1380. If artificial means be resorted to, care should be taken that both placentae are detached if they exist separately, or if they be merely joined by membrane; if there be but a pla- centa, it must be removed, as upon all similar occasions. 1381. In cases of twins, a much larger surface is occupied by the placentae than if there were but one ; we should on this account be very careful to renew the frictions upon the abdo- men, after their expulsion, that the uterus may contract as much as possible; and thus tend to diminish the subsequent discharges, which are but too apt to be in excess. CHAPTER XXXIV. OF PRETERNATURAL LABOURS. 1382. Agreeably to the classification I have adopted for labours, it will be at once understood, that the class termed preternatural, will consist of all such, as shall not present either the head, the breech, the feet, or the knees. Authors have made a very numerous collection of such cases; many of which occur so rarely, as to be seldom or perhaps never met with, even by an old and experienced practitioner. f 532 PRETERNATURAL LABOURS. 1383. Baudelocque has been too lavish, in his divisions, and subdivisions of this class of labours; for they serve rather to confuse, than to elucidate. To the inexperienced practitioner, his distinctions are appalling; since, they cannot well be retain- ed; consequently, his rules cannot be rigidly acted upon. But, there can little injury arise from this want of memory; pro- vided, the general principles which are to govern in such cases be recollected; for they are all to be treated by "turning."* If, then, the principles laid down for this operation be well recol- lected, little or no embarrassment can present itself. 1384. It may, however, not be amiss to remind the inexpe- rienced practitioner, of several of the most important rules upon the operation of "turning." 1385. 1st. This operation must never be attempted, so long as the os uteri is not dilated or easily dilatable. 1386. 2d. That the woman must be placed upon her back, that the utmost freedom may be given to the operator's hands. 1387. 3d. That the time for the introduction of the hand into the vagina, is during a pain, after having been well lubri- cated. 1388. 4th. But after the hand is in the uterus, every attempt to turn must be made in the absence of pain. 1389. 5th. That it is rarely a matter of indifference, which hand is to be employed for the purpose of turning; therefore, the rule upon this subject must never be violated. 1390. 6th. That whatever be the situation of the child with- in the uterus, the feet must be brought into the pelvis, so as to bend the body forwards. See Chap, on "Turning." 1391. I shall, however, select one case of " preternatural la- bour," from the general class; because, it is by far the most frequent, as well as the most difficult—this case is the "present- ation of the arm and shoulder." * Except such cases, as leave no doubt of the death of the child, and v.-hic'. may be terminated by the crotchet. »RF.SENTATI0N OF THE ARM AND SHOULDER. 533 CHAPTER XXXV. OF THE PRESENTATION OF THE ARM AND SHOULDER. 1392. Should the hand descend into the pelvis, either by not keeping it up as directed, (686) when it accompanies the head, or any other part; or when it seems to fall into that ca- vity at the time the membranes give way; it will almost al- ways become a source of trouble; especially, if under the care of a practitioner, who supposes, he cannot do better than to act upon it, to effect delivery. When the hand is not support- ed, so as to allow the head to descend without it, the arm is almost sure to come into the passage ; this frequently, but not necessarily, declares the shoulder, at the orifice of the uterus. 1393. Or the shoulder itself may present originally, without the hand being down, as a necessary consequence. This pre- sentation is more frequent than any other, in which the head, knees, feet, or breech, do not present. The roundness of the shoulder favours its taking this position. 1394. I have chosen to consider under one head the present- ations of the shoulder, and the arm ; because, the indications are precisely the same, as well as the mode of acting; for the arm itself produces no essential difference in treatment. 1395. Before the mouth of the uterus is well opened, and the membranes are rent, it is difficult to distinguish the shoul- der; but when these changes have taken place, the clavicle, scal- pula, and ribs, serve to point out this part. 1396. The shoulder may present in four different ways at the superior strait; but these positions become very difficult to distinguish, unless the arm be down at the same time. When the arm is down, the hand will serve to discover the position of the shoulder. The hand will offer itself at one of the side* of the pelvis; and its back or palm, will present either anteri- orly, or posteriorly: the position of the shoulder must there- fore, in such cases, be learnt from tKe particular situation of the hand. • )34 PRESENTATION OF THE ARM AND SHOULDER. 1397. In the first position of the shoulder, the head and side of the neck of the child will be to the left side of the pelvis; the right arm will then be down; the back of the hand will be anterior, the palm posterior. 1398. In the second, the head and side of the neck will be toward the left iliac junction; the palm of the left hand will then face outwards; the back will look to the posterior part of the pelvis. 1399. In the third, the head and side of the neck will be to the right side of the pelvis; the left arm down, with its back looking outwards, and the palm inwards. 1400. In the fourth, the right arm will be down, with its palm looking outwards, and its back inwards. 1401. If turning be resorted to, it will avail much to employ the proper hand. In the first, and fourth, the right hand must be used; in the second and third, the left. 1402. In performing this operation, the rules I have laid down for turning in general, must not be neglected; that is, the feet must be brought down in such a manner as to bend the spine anteriorly, &c. &c. 1403. The presentations now treated of, are certainly very far from favourable; yet they are by no means so menacing as is commonly represented. If these labours are treated accord- ing to correct principles, they offer, under circumstances not complicated by accident, (625) no difficulty beyond what is usually encountered in turning. But if the favourable moment for acting be not taken advantage of, or should not have pre- sented itself, much difficulty may be experienced; and the case become subject to interference, by cutting instruments, &c. 1404. It should be borne in mind constantly, that the arm itself offers no indication, save that of pointing out the posi- tion of the shoulder; therefore, no manoeuvre performed upon it, can advance the interests of either mother or child, or faci- litate the object of the operator. Consequently, all the cruel, as well as absurd treatment to which the arm is sometimes subjected, such as scarification, amputation, &c. should always be avoided; since, it can never improve the prospect of the f PRESENTATION OF THE ARM AND SHOULDER. 535 operation, if the child be dead; and will most unnecessarily destroy it if living. 1405. In a well formed pelvis, the presence of the arm offers no embarrassment to the operation of turning; therefore, every attempt to* remove it from the inferior portion of the pelvis, either by trying to replace it within the uterus, or by amputa- tion, is only losing time, or improperly irritating the parts, or subjecting the protruded part to an unnecessary, and some- times to a cruel operation. 1406. It is therefore best not to meddle with the descended arm; for if turning be attempted, it offers no difficulty to the passage of the hand; and if the crotchet, or any cutting instru- ment be resorted to, it cannot interfere with the operation. 1407. The indication in these presentations is, to bring down the feet, and deliver. It has however been suggested, that wfe may attempt the restoration of the head to the cavity of the superior strait, by removing the shoulder from it: I believe this to be altogether theory. I do not even advise the at- tempt ; for independently of its difficulty, I am persuaded, that it would be attended with more pain and risk to the patient, and injury to the child, than a well-conducted turning. 1408. For the circumstance which would render the resto- ration of the head to the axis of the pelvis practicable, (if it be practicable,) will also give facility to bringing down the feet; namelv, a sufficient relaxation of the uterus, and the absence of pain. Moreover, if these conditions obtain in the first instance, it will of course be very uncertain whether the powers of the uterus will be sufficiently restored, to expel the child, after the adjustment of the head ; consequently, much time would be lost, and much anxiety be created. 1409. There are two modes of proceeding in presentations of the arm; the first, as I have just stated, is to turn; the other, to trust to the powers of nature to produce what has been termed the "spontaneous evolution of the child." 1410. When the arm presents in a labour, at the full period of gestation,,we should entertain no hope or expectation, that nature will relieve herself, while the child continues in this 536 PRESI NTATION OF TUJ.ARM AND SHOULDER- position ;* consequently, this case must be always regarded a* " preternatural;" and, that bringing the child by the feet, is the onlv operation that can be performed with a view to the safety of both mother and child. 1411. Notwithstanding the indication in this case is so ob- vious, yet it is not always practicable to fulfil it. This arises from, 1st, the condition of the uterus; and 2d, from the situa- tion of the arm and shoulder within the pelvis. Sect. I.—Of the Condition of the Uterus. 1412. I have already noticed above, that the protruded arm or hand, offers of itself, no difficulty to turning ; the difficulty exclusively depends upon the condition of the uterus; and es- pecially, of that of its mouth. If both be in a state of relaxa- tion, so as to admit without much force, the passage of the hand, as often happens, soon after the escape of the waters, where the labour has progressed regularly, no more, or perhaps sometimes even less difficulty7 will be experienced than in turn- ing, when the head presents, and the uterus is equally favoura- bly disposed. 1413, Our attention should therefore be constantly directed to the state of the uterus, and of that of the neck especially; and our conduct should be regulated alone by their condition: for whatever may be our desire to aid the suffering woman, or relieve the threatened child, we must never incur the risk of being disappointed in both, by forcibly entering the resisting os uteri. When violence has been committed on this part, by mechanically making it yield to the hand, inflammation, laceration, and gangrene have sometimes followed; nor is this all: the operator has not only been foiled, in his attempt to bring down the feet, by the os uteri contracting itself round his wrist, and thus obstructing the descent of the child, f once witnessed death to follow immediately, or rather during a rude attempt to turn. The operator had with great diffi- culty passed her hand (the patient was under the care of a • Unless the rare occnm no? of " spontaneous evolution" may he considered »■; an exception PRESENTATION OF THE ARM AND SHOULDER. 537 midwife) through the os uteri; and after a long and uncer- tain search, became possessed of the feet: in attempting to bring them down, she exerted so much force, as to rupture (I believe*) the uterus. The poor woman expired in about five minutes after I entered the room, and while the midwife was still exerting all her force upon the legs of the child. The persons present informed me, that after the midwife had learnt I had been sent for, she declared it was unnecessary, as she "could deliver the woman as well as any body"—she therefore redoubled her exertions, to make good her assertion: the con- sequences I have just related. She was most industriously at work for more than an hour. 1414. The midwife told me, that "the arm had been down many hours, and the pains were very strong"—but added, "notwithstanding this, the child did not come nearer the world; I therefore determined to wait no longer, and proceed- ed to turn, as I had several times done in like cases. The mouth of the womb was close round the arm of the child; but I did not mind this; for I got first one finger in it, then another, and at last my whole hand. But indeed, doctor, this was hard work. When I got through, I never was so long finding the feet; but all my strength could not make them come down; and the poor woman died, because I did not begin sooner." I took this poor ignorant creature aside, and frankly told her, she had destroyed her patient; and exacted, on pain of exposing her, a solemn promise, that she would never attempt the like opera- tion again. 1415. Therefore, where the mouth of the uterus opposes the easy introduction of the hand, it should never be attempted; in such case, it will almost always be found, if the waters have been long drained off, that the tonic contraction of the body and fundus, will also offer much difficulty to turning. This being the situation of the patient, nothing can justify the at- * This belief is founded on what occurred during this attempt to turn; namely, a slight hemorrhage from the vagina; sickness, and vomiting, &c; cold clammy sweat-of the pulse, I can say nothing; it was extinct when I saw the pabent-. the attendants of course could give no account of it, and tho m.dwife was to. much occupied bv her operation to examine it. [68] 338 PRESENTATION OF THE ARM AND SHOULDER. tempt to turn; for one of the following consequences will al- most certainly follow: 1st, if the hand be made to pass the stricture, it will be at the expense of so much injury to the neck of the uterus, that the one or other of the evils stated above will follow. 2d. If the hand be made to pass the con- stricting os uteri, the body and fundus will offer so much re- sistance, as to defeat safe turning to the child; or 3d, if the child be safely delivered, it may be at the expense of the life of the mother. 1416. It would then seem to follow, that this condition of the os uteri, as well as of the body and fundus of this organ, must be changed before any attempt be made to bring down the feet of the child. With this in view, we must induce such a state of relaxation, as shall enable the hand to pass, and the turning to be performed, without the risks stated. This can be almost certainly effected, by a sufficient loss of blood. With a view to exemplify the practice in this case, I shall relate a case from my7 " Essay on the Means of lessening Pain," &c. in which this remedy7 was successfully7 employed. 1417. " 1802, January 29th, Phccbe Hall, a black woman, in. labour with her seventh child; arm presented, and down for several hours; arm considerably swelled, as the midwife had exerted considerable force upon it; the mouth of the uterus contracting closely round it. I got Dr. Carter (a gentleman who accompanied me) to introduce his hand into the vagina, and place a finger within the os uteri—this he did with some difficulty7, as the uterus was very rigidly closed upon the arm. I tied up her arm, and let her bleed until he should tell me the mouth of the uterus was sufficiently7 dilated. When I had drawn from forty to fifty ounces of blood, she became sick and faint; at this instant, Dr. Carter cried out with rapture, that the uterus was sufficiently dilated—upon my examining, I found it to be the case ; the turning, and delivery, were soon accom- plished." 1418. It must be observed, that such labours as are attended with fever, always require the loss of considerably more blood, than when none attends; and it has been found best, in such cases, to draw the blood at two or three operations; but carry- PRESENTATION OF THE ARM AND SHOULDER. 539 ing the last to faintness, or sickness. Now, the labours in ques- tion are almost always accompanied by fever, if they have been long protracted ; consequently, will frequently require the adoption of the plan just proposed. Sect. II.—Of the Situation of the Arm and Shoulder within the Pelvis. 1419. The situation of the arm and shoulder within the pel- vis, may be such as to render turning, if not impracticable, at least unsafe. 1420. The arm, to the very shoulder, may be- protruded through the os externum; and the shoulder itself so impacted, and the contraction of the uterus so firm, as to render it im- possible to turn, with any prospect of success to the child, or safety to the mother. Our conduct, in this situation of things, must be regulated altogether by the condition of the child; and this will be either living, or dead. It must therefore be ascer- tained in which of these states it may be, before we decide on the mode of acting. 1421. With a view to determine this, the hand should be passed into the uterus, until it can reach the umbilical cord— if this be pulsating, the child is of course living; if it have no pulsation, the child is certainly dead. Sect. III.—The Manner of Acting, if the Child be living. 1422. Having ascertained the child to be living, our conduct should be such, as to give it the best possible chance to be de- livered alive. The choice of means will lie between turning, and waiting for the spontaneous evolution of the child. As regards turning, it must not be disguised, that it is an operation of some hazard to the child, even under the most favourable circumstances of the uterus, or position of the child; and of course, the risk will be in proportion to the departure from these best conditions : yet it offers, in this case, almost the only alternative. 1423 In the situation of the parts in the presentation now under consideration, two difficulties will necessarily present 540 PRESENTATION OF THE ARM AND SHOULDER. themselves: 1st. The uterus will be found firmly contracted on the bodv of the child; so much so, sometimes, as to render it almost impracticable to turn; or at least, it would be hazard- ous, unless the operation be very carefully7 conducted. In such a case, it should not be attempted,but with the utmost caution; and not without previously endeavouring to diminish the re- sistance of the fundus and body of the uterus, by free blood- letting, as just proposed for the rigidity of the os uteri, when it creates the difficulty. After the patient has been liberally bled, the opposition to turning is sometimes so much dimi- nished, as to render the operation not only practicable, but safe even to the child. Should the blood-letting procure no relaxa- tion, the case becomes a forlorn one; especially, for the child. 1424. We should not, however, for this reason, abandon the poor woman to her fate; for even under a severe contraction of the uterus, a well directed gentle force will overcome diffi- culties, that at first appeared insurmountable; especially, some- times, after a liberal dose of opium. If the practitioner be inexperienced, he should, if possible, call to his aid a more skilled operator. He should never attempt to overcome, by force, the difficulties which oppose him ; a proper exercise of patient address, should ever govern in such cases, if he mean to succeed. 1425. Secondly. In consequence of the firm contraction of the uterus, the shoulder, we are told, is found so tightly wedged in the inferior strait, as sometimes not to permit the slightest motion upwards. I will not say, that this is never the case : but I must declare, it seldom happens, unless the proper time for acting has been lost, either reprehensibly or unavoidably. So far, I have never met with a case, in which I could not turn, if turning were the desirable mode of acting: but this has arisen, perhaps, from carefully watching the proper moment for the operation. 1426. In these cases, the proper moment to act, is, so soon as the os uteri is sufficiently relaxed to permit the passage of the hand; and if this relaxation does not take place spontane- ously, it should be procured as early as the nature of things will permit, by blood-letting and opium; and this as soon after PRESENTATION OF THE ARM AND SHOULDER. )41 the escape of the waters, as practicable. If the case has been mismanaged, before a judicious practitioner has been consult- ed, he may not perhaps be able to terminate the labour by turning, with any prospect of success to the child; he is then to consult the interest of the mother alone ; and this will per- haps be best advanced by waiting, so long as the child may continue to live. 1427. But should any accident complicate the labour, and render immediate delivery proper, he should try to relieve the patient by turning, though it offer but a bad chance for the pre- servation of the child's life. If this be impracticable, (a cir- cumstance, I am warranted in saying, of rare occurrence,) he must relieve the mother at the expense of the child, as will be directed presently. 1428. The only other resource which presents itself for the preservation of the child, is the waiting for what is termed the " spontaneous evolution of the child." Sect. IV.—Of Spontaneous Evolution. 'l429 Dr. Denman, I believe, was the-first to notice this remarkable resource of nature, in shoulder or arm presenta- tions. He enriched the profession by his history of it, and by instructing the practitioner, that in some instances, nature achieves, with even safety to the child, that which art cou d not perform. His explanation of this phenomenon is certainly ingenious, and was for a long time the received one ; but it appears to have yielded to that of Dr. Douglass, even by the confession of Dr. Denman himself. See Dr. Douglass s Essay on Spontaneous Evolution. 1430 This chance for the preservation of the child, is, how- ever, of extremely rare occurrence ; for in by for the greater number of instances of " spontaneous evolution the child has been expelled dead. Indeed, the delivery of the woman, by this change of position of the child, is in itself very rare I have never seen a case. Yet the testimony on thspont conclusive, and will justify us in considering it a chance for the child. •342 PRESENTATION OF THE ARM AND SHOULDER. 1431. I say, chance for the child; for such only should it he considered; for if the child be dead, we have no longer terms to keep with it, and our attention must be directed to the mo- ther. I should, therefore, recommend waiting for this " spon- taneous evolution," whenever turning forbad the hope of sav- ing the child; provided, the labour was complicated by no ac- cident: (625) but if the child be dead, and this ascertained as directed,* we should not wait for the uncertain event of " spon- taneous evolution." Sect. V. Mode of acting, if the Child be dead. 1432. If it be ascertained, that the child is dead; and it should be impracticable to turn, we must attempt the delivery of the child, by7 the use of instruments. The instruments necessary for this purpose, may be, the scissors, and crotchet, or simply the blunt hook. Before, however, either is employ- ed, the uterus should be either dilated, or dilatable; and this will almost always be found the case, where the shoulder is forced down to the os externum. 1433. In this situation, we can always command the thorax or abdomen of the child; either of which may be penetrated by the scissors; and these aided by the crotchet, or blunt hook. 1434. It has been usual, it would seem, in cases where turn- ing was impracticable, to wait for the " spontaneous evolution" to take place; but I would not recommend this plan, when it was certain the child was dead; and for these reasons; 1st, this "evolution" is not certain to take place; 2d, if it do not, we certainly7 expose the woman to-much suffering; and perhaps even to danger, for the hope of a favourable contingency. * It must be recollected, we can pass the hand to the umbilicus of the child, when it might be impracticable to turn. RUPTURE OF THE UTERUS. 543 CHAPTER XXXVI. OF THE RUPTURE OF THE UTERUS. 1435. During labour, the uterus every now and then is rup- tured; and, perhaps, even oftener than at present I dare assert —sometimes this accident is concealed from ignorance; and at others, from design; hence, many cases must occur of which the public remains uninformed. Nothing can justify the con- cealment of this event, though we can promise ourselves but little by the avowal; but it is a duty we owe the connections of the unfortunate woman, as well as the profession itself. Con- cealment often arises from a previously adopted theory upon this subject; and the supposed risk of professional reputation; dian which, nothing can be more disingenuous, or hypothetical. I would, in one word, in all such cases, recommend its most speedy avowal, to those immediately concerned in the event: and must declare, I should consider the contrary conduct, as highly derogatory to the honourable feelings which every me- dical practitioner should be possessed of; as well as doing seri- ous injury to the advancement of obstetrical knowledge. 1436. In treating this subject, I shall, first, consider whether it be proper to attempt any thing for the woman's relief, as there is much authority against it; and because it is constantly made the plea, for the concealment of this accident; second, I shall take into view the variously i vjmtecl causes of it, with their mode of action; third, detail the symptoms and consequences of the rupture; and fourth, indicate the mode of proceeding, under the various circumstances with which this accident may be complicated. 1437. Dr. Hunter considered any attempt to relieve a woman who had suffered a rupture of the uterus, as cruel—therefore it was not to be attempted. This opinion was afterwards more strongly enforced by the late Dr. Denman, who declared, that "when the uterus is ruptur.-H at the time of labour, both ren- 544 RUPTURE OF THE UTERUS'. son and experience show, that the patient has a better chance of recovering, by resigning the case to the natural efforts ol the constitution, than by any operation, or interposition of art.'1 1438. I consider this assertion of Dr. Denman, rather in opposition both to " reason and experience;" to reason, because it would be a natural suggestion, that that woman's chance w7ould be best, from whom many of the causes were removed, that would hinder recovery7, by the delivery of the child, &c.; and to experience, because we have the most unequivocal proofs of recovery upon record, where "the interposition of art" was resorted to. 1439. Thus Heister,* Douglass,! Hamiltons,! Ross,§ Kite,|j Madame La Chaple,^ relate cases of entire recovery after the delivery of the child, through the natural passages; while Hamil- ton,** Thibault,ff Lambron,t! &c. give others of equal success, where gastrotomv had been performed. In all of these, how- ever, the success was confined to the mother; the child was uniformly dead—but I have strong reason to believe, that this was entirely owing to the delay before the operation was un- dertaken. Indeed, Burton§§ renders this almost certain, by the relation of a case which fell under his notice; in this, the child was delivered alive, though the mother died; while Mr. Haden relates an instance of the preservation of both mother and child.|| || 1440. Thus, we can most successfully destroy Dr. Denman's celebrated aphorism on the subject of the rupture of the ute- * Instit. de Chir. torn. II. p. 137. j- Essay on Rupture of the Uterus, p. 7. \ Outlines, p. 344. MS. Lectures. § Annals of Med. Vol. III. p. 377. I Mem. Med. Soc. Vol. IV. p. 253. \ Annuaire Med. Chir. torn. I. p. 542. ** MS. Lectures. \\ Jour, de Med. for 1768. %% Baudelocque, Vol. HI. p. 430. §§ Syst. of Mid. § 43, p. 110. \ \ Dr. Davis relates a case of the rupture of the anterior portion of the uteru% from which the patient recovered in about six weeks. In this case, the cliild was delivered by the craniotomy forceps, after having its head opened by Smel- lie's scissors. The neck of the bladder was so severely injured, from its connec- tion with the portion of the uterus injured, as to prevent her retaining her urine ever after. This case, though unfortunate as regards the last named injury, is nevertheless a case in point, to show that the woman may recover after the uterus has been lacerated. RUPTURE OF THE UTERUS. 545 rus, by producing cases, in which the " interposition of art" was followed by success. This, I think, should put the matter to rest; especially, as there is no instance extant, at least with which I am acquainted, where the woman recovered at the full period of utero-gestation, when the child was permitted to remain undelivered. 1441. There are a number of instances upon record, which purport to be recoveries, after the rupture of the uterus, where the foetus was permitted to remain in the abdomen—but they are liable to strong suspicion, and far from standing the test of rigorous examination; they appear to be cases of extra-ute- rine conceptions chiefly, or of but the partial rupture of the ute- rus. By partial rupture, / mean, where the muscular substance ef this organ has suffered laceration, but where the wound does not pass through its peritoneal coat. Of this kind are the cases related by a writer in the Jour, de Med. for 1780, also those by Drs. Bell and Sims.* Dissection proved in several of the«e cases, that the peritoneum suffered only from distention. From all that I can learn from others, or my own experience, I cannot see any reason for withholding aid from the afflicted woman, who may have suffered this calamity—except, indeed, in that forlorn condition of the patient, where she would die before this aid could be given to her. But what can we pro- mise ourselves, by not attempting delivery ? for I must again repeat, there is no instance of recovery at full time, from a rupture of the uterus, where the fcetus was permitted to remain in the abdomen of the mother—nor should the opinions of Dr. Hunter, Dr. Denman, and Mr. Burns, be considered sufficient authoritv in such cases, to screen from reprehension any one who may have neglected an opportunity to discharge what I consider his bounden duty, by delivering his patient instantly, if practicable, when she has suffered a laceration of the uterus. 1442. Indeed, the objections of Dr. Denman are not entitled to the smallest weight upon this point; since he is entirely at * Sec Kss:.ys on Subjects connected with Midwifery, wiiere this subject is treated at huge. (p. ~01.) [69] 546 RUPTURE OF THE UTERUS. variance with himself. In his " Introduction to Midwifery,"* he appears to have entertained rational and liberal views upon this subject; he there tells us, that, " beside some few others (cases of rupture) of which I have been informed, or which are recorded, a case has occurred to my very worthy, able, and ex- perienced friend Dr. Andrew Douglass, in which the uterus was ruptured; he turned the child, the patient recovered, and had afterwards children." And Dr. Denman observes upon this case, " if no other case had ever occurred, I apprehend this would be sufficient authority to render it in future, the indis- pensable duty of every practitioner to act in a similar manner: and bad as the chance is of the patient, to be strenuous in using all the means which art dictates to extricate her, if possible, from danger, or to preserve the child." 1443. Dr. Denman has-by no means satisfied me, or perhaps anv one, why his sentiments underwent a change upon this sub- ject; and the more especially, as it is a change to be considered as unfriendly to the cause of science, and to the interests of humanity—it seems he has drawn a conclusion upon this point, that satisfied himself; though totally gratuitous, in the estima- tion of every body else; namely, "that there are more instances upon record of recoveries of women who have not been deli- vered, than those who have been delivered after rupture of the uterus." 1444. Were this position of Dr. Denman founded really in fact, it would deserve the most serious consideration; but as strong doubts must be entertained upon this point, it has not changed my opinion; first, because the subjects of comparison are not equal; as very many more women have been suffered to remain undelivered after rupture, than have been delivered; consequently, a conclusion cannot legitimately be drawn; as the proportions they bear to each other cannot be known; second, because I deny that there is a well-attested instance of the woman's recovery, when she was permitted to remain undelivered. 1445. From all I can collect from the histories of cases of ruptured uteri, it would appear, that life is prolonged and suf- * Vol. n. p. 117. RUPTURE OF THE UTERUS. 547 fering abated, by delivery;* it therefore involves a great moral question; and, if the facts be as I have stated, and as I most seriously believe them to be, it must resolve itself into incul- cating it as an obligation, that we deliver whenever practicable, after the uterus has suffered laceration. 1446. Upon a comparison of an equal number of cases deli- vered after rupture, with those not delivered, it was found, that the women who were delivered, lived much longer on the average, than those who were not delivered; now, if death be suspended by our efforts, it will follow, it becomes a duty to make them; and, if we add to this, what has been very confident- ly asserted, that there is no instance of recovery where delivery has not been performed, this first part of my inquiry, must be terminated by declaring, it is almost always proper to inter- pose art, in cases of ruptured uteri. 1447. Very many causes are assigned for the rupture of the uterus; some of which appear totally incompetent, while others of powerful agency, are but slightly glanced at. La Motte believed that the struggles of the child, were capable of this accident; hence, by him, they are enumerated as a cause. In this he has been followed by Levret and Crantz—indeed I may say some late writers. But the child is almost always passive when the accident happens ;f and I may add, in proof of this, that the uterus has given way, after the death of the child. 1448. Dr.Denman-f, says, "the uterus may, independently of disease, be mechanically worn through in long and severe la- bours, by pressure and attrition between the head of the child, and the projecting bones of a distorted pelvis; especially, if they be drawn into points or a sharp edge." To this doctrine I can- not subscribe; first, because, before the membranes are rup- tured, the head cannot rest with sufficient firmness against any given point to produce the necessary degree of " attrition;" second, that after the evacuation of the waters, the body of the child is so firmly embraced by the contracting uterus, that "at- * See Essays on various Subjects connected with Midwifery, p. 227. f Baudelocque. * Introduction, p. 105. .>4R RUPTURE OF THE UTERUS. trition" cannot take place; third, there could not be sufficient friction generated between the smooth surfaces of the child's head and the uterus to produce it; fourth, in such cases the child's head should also exhibit marks of this "attrition," yet of this no mention is ever made. 1449. Salmathus, agreeably to Mr. Burns, considers a "thin- ness" of the uterus as a predisposing cause of rupture—but we have no evidence in any case whatever of this "thinness" ex- isting as an original conformation of the uterus before the rup- ture took place—if k be found thin, post mortem, it may be oc- casioned from mere exhaustion of blood, and not be an original condition of this organ. Mental agitation and frights are also said to occasion rupture of the uterus; but strong doubts should be entertained of such causes. 1450. I shall, therefore, pass without notice many causes reputed capable of causing this accident; and consider only such, of whose agency no reasonable doubts can be entertained. I shall divide these, first, into those which act directly upon the uterus; second, those which have an indirect influence. 1451. The first may be considered mechanical violences; and may be both external and internal. The external may be blows, kicks, or violent pressure; the internal may be, ill-con- ducted attempts to turn the child; the attempt to return a pro- lapsed limb; the mal-adroit use of instruments; or the unequal surface of the child itself. 1452. The second, or indirect, are such causes as may have a tendency to injure the continuity of the uterus by mechani- cally impeding the passage of the child; as a contracted pel- vis; an unusual sharpness in the linea ilio-pectinea; exostoses, tumours, scirrhi, and ulcers. 1453. The action of these two sets of causes are different; the first act directly, by exerting a force beyond the resisting power of the uterus; the second, by diminishing the strength of a particular portion of this viscus, so that its own contraction may be sufficient to overcome the resistance which this weak- ened part offers. 1454. The mode in which the first set of causes acts, is suffi- ciently obvious without further explanation. The second is RUPTURE OF THE UTERUS. 549 uot so clear, yet of most easy explanation. The head of the child, covered by the uterus on all sides, cannot, in a contracted pelvis, readily engage in the opening of the superior strait; it must, therefore, rest for a long time stationary, or nearly so, at its margin—if this be sharp, or projecting, the uterus will suf- fer in proportion to the weight of the child, the force of the contractions of the uterus, and the period it may suffer this compression—inflammation ensues; and, if the cause be not soon removed, gangrene will follow; when the uterus is thus weakened, it will be easily understood how a small force may rupture it. 1455. The second set of causes acts by preventing a regular development of the different portions of the uterus during preg- nancy ; consequently, one portion or other is put unduly upon the stretch, and of course weakened; and, by its remaining pas- sive during labour, by being diseased, it cannot resist the efforts of the healthy portions. When the action of the uterus itself is the cause of the rupture, it always takes place at the moment of the greatest severity of pain. 1456. This accident may happen to any portion of the ute- rus, or in any direction; or at its connection with the vagina __it may be more or less extensive ; and the child with its appurtenances may pass entirely, or partially, into the abdomi- nal cavity. 1457. When this accident happens, it almost always deslares itself by such symptoms as cannot well be mistaken. I shall now consider those symptoms, under the third division of our subject. 1458. Crantz, Levret, and others, have supposed that the rupture of the uterus might be foretold by premonitory symp- toms ; but I am very certain that few things can be more equi- vocal than the symptoms pointed out by Crantz; namely, that, u when a woman is threatened with a rupture of the uterus in a laborious labour, the belly is very prominent and tight; the vagina lengthened, and the orifice of the uterus very high; the pains are strong, leave little interval, and do not advance de- livery." I have seen all these symptoms in their most exalted form, without the labour terminating by rupture ; and in Mrs. 550 RUPTURE OF THE UTERUS. M.'s case, which fell under my notice, and of which I have given a detail,* "strong pains with little interval" were not among its precursors; though a very extensive laceration of the uterus took place. M. Levret has added to these symp- toms, but without increasing their certainty, " that the pain the woman suffers, is always seated towards the middle of the epi- gastric region; that a last effort or violent leap, succeeds to the repeated strugglings of the child, which announces its death and the rupture of the uterus." 1459. Did the signs just detailed, portend a rupture of the uterus, every laborious labour would be threatened with one— every symptom enumerated above, is almost the necessary ef- fect of the tonic action of the uterus, after the evacuation of the waters ; yet fortunately7 for suffering woman, this accident is of comparatively rare occurrence. 1460. The signs added by Levret are frequently witnessed, without a rupture supervening; and it has occurred, where these marks were absent—it is also well known, that the uterus has given way after the death of the child ;f I therefore per- fectly agree with Baudelocque, " that the rupture of the uterus has often taken place without being preceded by any of them, and has not happened in other cases where their union declared it inevitable." The conclusion from this must be, that it would be extremely hazardous to act upon the presumption, that a rupture of the uterus was about to take place, because of the presence of several of the symptoms just mentioned—who could justify the employment of the forceps, or crotchet, or perform the difficult and oftentimes dangerous operation of turning, upon a mere surmise that this accident might take place ? 1461. I have said enough, I trust, upon the uncertainty of any sign or signs that would announce a rupture to be at hand: I shall therefore pass to the enumeration of the symptoms which declare it, after it has taken place : 1462. The woman feels for the most part, an acute pain at the place where the rent happens—she generally cries out, and i * See Essays on Subjects connected with Midwifery, p. 238. t Annals of Med. Vol. 111. p. 293. 303. RUPTURE OF THE UTERUS. 551 declares that something terrible has happened within her—" the rupture is said sometimes to be accompanied by a noise which has been distinguished by the bystanders—a discharge of blood of greater or less extent takes place from the vagina —her face becomes cold and pale—her respiration hurried— she is sick at stomach, and most frequently vomits—the matter discharged is sometimes the common contents of the stomach, at other times it consists of a very dark, even black coloured substance, resembling coffee-grounds—the pulse is extremely7 frequent, small, fluttering, or extinct—she complains of a mist before her eyes, loss of sight, and extreme faintness—a cold clammy sweat bedews the surface of the whole bodv, and if not speedily relieved, convulsions and death follow. 1463. These symptoms are however modified by7 several cir- cumstances : 1st, whether it be the uterus itself, or its connec- tion with the vagina, that may be ruptured; 2d, whether the child has escaped in part, or entirely into the cavity of the ab- domen; 3d, whether the lesion has passed through the sub- stance of the uterus alone, or has penetrated the peritoneum. 1464. 1. When the rupture has taken place either in the bodyr or neck of the uterus, the pains either cease, or slacken so much as not to propel the child if it be still retained within the uterus. 1465. 2. When the child escapes entirely into the cavity of the abdomen through the torn uterus, the most distressing and alarming symptoms quickly follow—if but partially protruded, pain may effect the delivery of the child, or it may be extracted bv art. 1466. 3. Should the wound stop at the peritoneal covering of the uterus, and not penetrate the abdomen, there is reason to believe, that the symptoms will not only be milder, but the chance of recovery increased. 1467. However strongly and decidedly marked the symp- toms which accompany rupture may be, they are not exclusive- ly to be relied on—but when they have excited suspicion, by7 their severity and character, we should lose no time, before .iscertain it—this is to be clone by a careful examination of i, abdomen and the uterus ; the first by the application of the land externally; and the other by the finger or hand per vagi- 352 RUPTURE OF TflE UTKRIm. nam. Should the accident occur before the rupture of the membranes, the tumour which they formed will shrink away ; for, if the rent be through to the abdomen, it is more than pro- bable that the membranes will give way, and the waters be dis- charged within it; but should the lesion stop at the peritoneum, they may7 remain entire for some time, though they may not again form a bag within the circle of the os uteri. 1468. When the abdomen is examined by the hands exter- nally, the foetus, if the rupture be complete, may readily be dis- tinguished through its parietes ; if the foetus cannot be thus detected, it is presumable it has not escaped entirely from the uterus—but we are to ascertain this by a careful and more extensive examination. 1469. If the accident take place after the discharge of the waters, the presenting part will either recede beyond the reach of the finger, or can be most easily forced back by its pressure (provided the head or presenting part has not already engaged in the pelvis)—if the former obtain, the hand should be intro- duced, and the nature of the case clearly ascertained—should the os uteri be well dilated or easily dilatable, the hand should be passed into the cavity of the uterus, so that the extent of injury7 be well understood. But should the os uteri be firmly contracted, so as to refuse admission to the hand, without the application of much force, the point should be given up; for nothing can justify a violent entry into the cavity of the uterus. 1470. When the laceration takes place at the neck of the ute- rus, or at its union with the vagina, the child, with its appurte- nances, almost always pass into the cavity of the abdomen; in either of these cases, the presenting part will immediately re- move itself from the superior strait; when this happens, we should, as quickly as possible, ascertain whether the accident has taken place, of which this circumstance would instantly give the suspicion. In cases like these, the examinations to this effect are more easily conducted, than when the body or fundus is the subject of the laceration ; as the parts involved in the mischief, cannot contract like the uterus itself—the ute- rus, under such circumstances, will be found, for the most part, firmly contracted either on the posterior or anterior por- RUPTURE OF THE UTERUS. 553 0 tion of the pelvis, as it may7 happen to be the posterior, or an- terior portion of the vaginal circle, that may have sustained the injury—the intestines will frequently prolapse through the wound, which removes at once all doubt as to the nature of the accident—it is almost needless to suggest the propriety of a cautious and gentle examination, after the hand has entered the abdomen. 1471. When the nature of the accident is ascertained, it be- hooves us immediately to attempt the relief of the unfortunate woman; and the means for this purpose are, first, to attempt delivery per vias naturales; and second, to perform the opera- tion of gastrotomy. 1472. We may perform the first, whenever the neck, or its union with the vagina, is the seat of laceration, provided the pelvis is of a good conformation, and the child has escaped in the cavity of the abdomen—the feet of the child should be sought for, and the delivery accomplished as in a case of turn- ing—but should the pelvis be so contracted as not to permit the child's head to pass, this mode of delivery must be changed for the second. Should but a portion only of the child have escaped through the rent, and the head be engaged in the pel- vis, the forceps should be used; or, if we are certain of the child's death, the crotchet may be employed. 1473. When either the body or fundus, or both, have suffered, and the child has escaped into the abdomen, the delivery per vias naturales may be either difficult or impossible, even in a well formed pelvis; for the uterus will most probably contract itself so much, as to render the re-passage of the child imprac- ticable ; the only chance, in this case, is the immediate per- formance of gastrotomy; should a contracted pelvis compli- cate this case, the latter operation is the only alternative. But should the uterus remain flaccid, and its mouth yielding, and the pelvis well-formed, we may succeed, though with difficulty, through the natural passages—but if this flaccid state of the uterus be attended by a deformed pelvis, the abdominal section is the only resource. 1474. Should the vagina alone suffer, and the child pass into the abdomen, we should deliver by the natural passages, pro- [70] 554 RUPTURE OF THE UTERUS. vided the condition of the pelvis will permit: if it should not, gastrotomv must be had recourse to.* 1475. The operation of gastrotomy, I believe, is one, which has never been performed in this country, for rupture of the uterus; but there is no reason why it should not, when circum- stances are sufficiently imperious—we have the experience of the European surgeons in its favour; and, however appalling it may appear, when viewed merely as an operation, it neverthe- less would seem to add but very little additional suffering, to the unhappy woman.f 1476. But to derive advantage from this operation," it should be performed as quickly after the accident as possible, while the patient still retains strength ; and the incision should always be made on the side of the abdomen, which corresponds with the rupture of the uterus,"-}: if practicable, or I may add, if that side can be detected. Should either the anterior, or posterior portion of the uterus have yielded, the child would most pro- bably be in the middle of the abdomen, (provided the woman had not changed her position after the accident,) in which case the incision would perhaps be best made in the linea alba, as if the Caesarean section were about to be performed. 1477. Dr. L. Frank relates the following interesting, though rather too generally described case, in which gastrotomy was successfully performed:— 1478. "Angela Grossi, of Parma, aged forty-four, had borne five children, and had reached the ninth month of her sixth pregnancy, without the occurrence of any accident. On the morning of the 9th of August, 1817, labour commenced; and whilst standing up, she was seized with a faintness, accompa- nied by vomiting. She was therefore placed on her bed, by the assistance of her husband and midwife. At that moment, she stated that she experienced a feeling of laceration in the abdo- men, and also a sensation of there being two children. A sur- • The reader, if he wish to see this subject more amply treate J, may find it in "Essays on various Subjects connected with Midwifery," p. 201. ■f Thibaut des Bois, Jour, de Med. for 1768. * Path. Chirur. torn. II. p. 239, par M. Lussus. RUPTURE OF THE UTERUS. 559 geon, who was called in, asserted that the effort of vomiting had carried the child upwards ; adding, that another might propel it downwards; and advised the patient to remain quiet." 1479. "The midwife,however, remarking that the abdomen swelled, that the vomiting did not cease, and that the breathing became irregular, called in Dr. G. Rossi. On examination, he detected a rupture of the uterus ; and on consultation with his father, and other medical men, it was unanimously7 resolved, to have recourse to gastrotomy." 1480. "Two hours after the occurrence of the accident, the operation was performed by Professor Cecconi, in the left hy- pogastric region, precisely at the point where the feet of the child were felt. When the incision was made, the child pre- sented with the feet, and was extracted alive, together with the secundines. No bad symptoms are alluded to, and it is stated that the patient was perfectly recovered forty days after the operation. Three years afterwards, she had a seven months' child, which lived a fortnight. After her recovery, a ventral hernia presented itself in the situation of the cicatrix, which, though irremediable, was not productive of much inconveni- ence."* • Anderson's Quarterly Journal, Vol. II. No. 8. for Oct. 1825. PART IV. ON DELIVERIES PERFORMED BY CUTTING IN- STRUMENTS, APPLIED EITHER TO THE CHILD OR MOTHER. 1481. Hitherto I have been considering labours which could be terminated by the natural agents of delivery; those in which the hand alone could perform it; and those in which it was necessary and proper to employ such instruments as were calculated to preserve both mother and child. I have now to consider those unfortunate instances, in which the la- bour is impracticable, without either mutilating the child, or subjecting the woman to the Csesarean section, or the section of the ossa pubis, commonly7 called the Sigaultean operation. 1482. There are a number of causes which may place an unfortunate woman in the predicament of having her child mutilated, or force her to submit to the alternatives just men- tioned. These causes are, 1st. A deformity of the pelvis; 2d. A deformity of the child, or its monstrosity; 3d. Acci- dental deformity, as hydrocephalus, dropsy of the abdomen, &o. CHAPTER XXXVII. I. DEFORMITY OF PELVIS. 1483. This subject has already been treated of, (27, &c.) as a deviation from the healthy measurement of the pelvis: I shall now consider the indications it produces. When the de- viations are but small, a child may be delivered alive, and at full time; but the labour will be more tedious and painful, if the child be of the ordinary size, than if the pelvis enjoyed its deformity of pelvis. 557 full and proper proportions. But the variations may be great- er, or even at times excessive—the degree, therefore, will ne- cessarily give rise to various modes of terminating the labour by artificial means. 1484. The resources of art, under deformities of pelvis, will be— a. Turning. b. Forceps. c. Cephalotomy. d. Cesarean operation. e. Premature delivery. f. Section of the pubes. g. Regimen during pregnancy. Sect. I.—a. Of Turning, in a Deformed Pelvis, as a Means of saving the Child's Life. 1485. When treating upon this operation professedly, I took occasion to observe, (706) that it was one always of hazard to the child, even in a well-constructed pelvis; a fortiori, that risk must be greater in a contracted one. For this operation to be successful, even under the best management, it will require, that there shall exist a proper relation between the diameters of the child's head, and those of the pelvis; that the waters shall not have been too long drained off; that the breast of the child, and cord, shall not suffer compression; that the head shall not be too long detained; nor the neck suffer too much extension. 1486. To obtain these advantages, requires no very common combination of favourable circumstances; and as these for the most part must necessarily be contingent, it is no way surpris- ing, that this operation should so often fail of success—to all that may be required on the part of the mother and child, to ren- der it even probably safe, there must be added skill on the part of the operator; for, without this, Very often the child would perish, though the case may have been the most proper, or most easy of performance. 1487. Should the deformity, then,leave less than three inches 558 OKFOKM1TY of pklvis. and a half in the antero-posterior diameter of the superior strait, we need scarcely look to this operation for success, as regards the child; and when resorted to under such circum- i stances, it must only be considered as a remedy for the safety of the mother. In this country, indeed, even the diameter just ' specified, would rarely be sufficient to give promise of success, under the best and most skilful management; for the transverse diameter of the head of the greater part of the children bora at full time, would exceed three inches and a half: now, should this diameter exceed this measurement but one quarter of an inch, or even less, it would create a difficulty that would menace the life of the child. I well remember once to have sorely repented the trial, where I judged the small diameter of the supeior strait, would certainly7 have been equal to three inches and an half. 1488. It will, therefore, follow, that turning in a confined pelvis is, and must be, of doubtful efficacy, as regards the child. As .one calculated to relieve the mother, or simply for terminat- ing the labour, without taking into view its result on the child, it might in many instances be successful; or, if the practition- er has been debating within himself, the comparative merits of the crotchet or turning, the, latter will unquestionably merit the preference; since it gives a chance, though a forlorn one, to the child. But let it be observed, the consideration should have turned upon the employment of the forceps, and not upon that of the crotchet, for this should always be considered as a dernier resource. Sect. II.—b. Of the Forceps in a Deformed Pelvis. 1489. In my general view (730) of the forceps, I endeavoured to prove that their powers were pretty extensive, yet sufficiently limited. That their mode of action (752) was that of a double lever, with a considerable compressive power—that this power, however, could not be successfully employed (749) beyond a certain degree, with safety to the child. That, if more were exerted, it would be at the expense of the bones of the cranium, and the brain of the child; therefore, there was a limit to their • EFORMITY of pelvis. 559 usefulness. In a pelvis where the opening of the superior strait in its small diameter will give three inches, these instru- ments have been successfully employed; of which, Baude- locque* gives us an example, which not only proves the useful powers of these instruments, but shows the little certainty with which the death of the child is marked, even by the combina- tion of many of the most formidable signs. This case is full of instruction, and should be carefully read. 1490. But when the small diameter of the superior strait has less than three inches, these instruments cannot be employed at the full period of utero-gestation, with any chance of success. To be useful even then, requires that the head of the child shall be of moderate size, and yielding; well situated, and that a skilful hand should apply them.f As, however, thev offer a better chance, if properly conducted upon the head, than turn- ing, they should be employed always in preference to this ope- ration, when even a force not to be called great, would be re- quired to make the head pass the superior strait; for the child will suffer less from a compression of the head, than from a severe extension of the neck; which must necessarily happen* when the opening is less than four inches. 1491. It must, however, not be concealed, that these instru- ments are not safe, under the circumstances we are now consi- dering, but in the hands of a few; and are only rendered so to them, by their superior attainments in their profession, and the long habit of using these instruments. To the inexperienced practitioner, they should be entirely forbidden; not only be- cause they may7 destroy the child, but also because the mother may be severely, or irreparably injured by their use. Should, however, the defect of size be in the lower strait, and that not * System, par. 1898. f " But, inasmuch as we have not discovered the means of applying such pressure to and for the benefit of the child, without, in the meantime, compro- mising the more important interests of the mother, it should be held as the bounden duty of our art, in the treatment of such cases, (cases witli narrow pel- ves,) to refrain from all inordinately forcible attempts to deliver with the forceps." ■ F.lom. Oper. Mid. p. 140.) 560 DfFORMITT OF PELVIS. excessive, the forceps will every now and then answer a valu- able end, as the following case will prove:— Mrs.----had been in labour nearly six-and-thirty hours, with a first child; the early part of her labour had been slow, but regular in its progress. The midwife to whose aid I was called, informed me, that the waters had been discharged after the uterus was well dilated; the pains had all along been good; that the child was very low, and seemed every moment ready to come, yet did not advance; for so soon as the pain ceased, it flew back to its old place, and had done so for many hours. The woman was in good health and spirits, notwithstanding the length and severity of her sufferings; she was free from fever; had had her bowels opened, and passed urine but a short time before my seeing her—she was short of stature; waddled when she walked; and was very bow-legged. Upon examin- ing her, I found that the lower strait was defective in its small diameter; the tubers of the ischia approached too much, and thus did injury to the arch of the pubes also. I waited for a pain to determine its influence—:the head was well situated, but could not descend low enough to enable the vertex to pass under the arch of the pubes; it was, therefore, found rather mounted behind it. The head did not appear large, and its bones were supple. When a pain came on, the parietal bones rode over each other, and the scalp was pushed considerably in advance. I waited to try the influence of two or three more pains; but the head only advanced during their action; for so soon as this ceased, it raised upwards, as it had done for a long time, as stated by the midwife. The cause of the delay was obvious— the parietal protuberances could not be forced by the uterus, below the tubers of the ischia, that the head might pass through the external parts. I was of opinion that nothing could relieve the head from its perilous situation but the forceps; accord- ingly, I made it known to the friends of the patient, and sub- sequently to the patient herself—she cheerfully acquiesced in the decision; they were applied, and by merely maintaining the ground gained by each uterine effort, without exerting much tractive force, I succeeded in half an hour to deliver the DEFORMITY OF PELVIS. 561 poor woman of a living female child. The head was elongated to an unusual degree ; but it recovered its natural shape in a few days.* Sect. III.—c. Cephalotomy. 1492. This operation destroys the child, with a view, it is said, to save the life of the mother; by preventing her from dying undelivered, or subjecting her to the Caesarean operation. Dr. Osborn has treated this subject under two distinct heads: He inquires, 1st. "The degree of deformity, requiring the crotchet, the Caesarean operation, or the division of the sym- physis pubis; their comparative merit examined;" 2d. He has given a "comparative estimate of the mother's life, and the life of the child4n utero." 1493. He answers his first inquiry by giving the preference to the crotchet, from the following views. He say7s, "when- ever the pelvis is so distorted in its form, and so contracted in its capacity, as not to permit the head of the child to pass unopened, it constitutes that degree of laborious parturition," for which the comparison of the merits of the crotchet, with that of the Cesarean operation, &c. was instituted, p. 25, Essays. 1494. That, "whenever a woman falls in labour, the small diameter of whose pelvis measures only two inches and three quarters, one of the following circumstances must take place." 1495. " First, the child's head must be opened, and the con- tents discharged, that the bones may be permitted to collapse; and the volume being thus diminished, it may afterwards be extracted with the crotchet;" or, 1496. " Secondly, for the certain preservation of the child's life, the mother must be doomed to inevitable destruction, by the Caesarean operation;" or, 1497. " Thirdly, as a mean between the two extremes, the mother must submit to the section or division of the symphysis pubis; an operation of less danger to the parent than the Cae- * I was ever after obliged to deliver this patient with the forceps : this happen- ed four times ; and without the smallest accident to either mother or child. [71] 562 DEFORMITY OF PTLVIS. sarean section, but at the same time certainly less safe for thr child;" or, 1498. " Lastly, if none of these means will be permitted, the wretched mother, abandoned by art to the excruciating and unavailing anguish of labour, will probably expire undelivered." 1499. From this it would appear, that every woman who has less than three inches in the small diameter of the superior strait, must die, or be delivered by the crotchet; by the Cesa- rean operation ; or the section of the pubes, if at the full period of utero-gestation. In this all writers agree. But Dr. Osborn is of opinion that nothing but the crotchet should ever be em- ployed under such circumstances, unless the opening at the superior strait has less than one inch and an half; for when there is "this opening in the antero-posterior diameter of the superior strait, the child can be extracted by the crotchet, p, 64, and whenever a child can be extracted by the crotchet, neither of the other operations should be thought of. 1500. He is led to this conclusion, first; from his estimate of the value of the child's life while in utero, when compared with that of the mother. He declares the former to be " incom- parably small," nav, "diminished almost to nothing, and af- fords the most irrefragable argument in favour of the delivery by the crotchet in preference to either of the other methods," p. 24. And second, from his having delivered a woman safely by the crotchet, whose pelvis was said not to exceed one inch and three quarters, at the upper strait. 1501. Dr. Osborn commences his inquiry by stating, "a be- ing in the uterine state of existence, sustains no immediate loss by the deprivation of the living principle, and can scarcely be said to incur any other positive injury. Before the operation, the child in utero cannot suffer mental anxiety, or apprehension from the threatened violence ; nor does it feel, I am persuaded, the smallest bodily pain, in the actual commission even of such violence." The question here is not fairly stated—it is not whether the child suffer from this violence or not; the question is, whether it shall have a chance to live, or be destroyed ? the feelings of the child must not be taken into consideration, in weighing the question, which life must be sacrificed. For if DEFORMITY OF PELVIS. 564 we deal honestly upon this subject, and conclude, that the life of one or the other must be forfeited, we are forced to the con- clusion, that the child must be immolated to preserve the mo- ther; it becomes then a matter of comparison which is the most valuable to society in all its relations, and I yield the point in favour of the mother's preservation; and I should do so, were the child a thousand times more sensible than it is. For did we withhold an operation from a persuasion that the child in utero is endowed with great sensibility, and that, like " the poor beetle that we tread upon, in corporeal suffering finds a pang as great as when a giant dies," I say, did we withhold an ope- ration essential to the mother's welfare, from these considera- tions, we should be exalting the mere sensibility of the child above the usefulness and importance of the mother, to the hus- band, parents, friends, and to society. I must therefore insist, that the sensibility of the child, be it what it may, must not be taken into the consideration. 1502. But let us believe the child to be as void of sensibili- ty, as a cabbage, or any other vegetable, while in utero; what would this prove as regards the proper question ? certainly nothing—for necessity, and that necessity, absolute, can be the only justification of the operation. For, if we permit our sym- pathies to get the better of our duty, and suffer the mother to die, from feelings toward the child, we destroy her by such an exercise of our sensibility; and on the contrary, if we wantonly or heedlessly kill the child because we have persuaded our- selves it possesses nothing more than vegetable life, or life without sensation, we murder it, by conforming to an hypothesis. I therefore repeat, the properties of the child, be they what they may, must never enter into the calculation, when it is un- relentingly fixed, that it or the mother must be the victim. 1503 The Doctor next declares, "as children before birth are incapable of mental apprehension, so it is as undoubtedly true, that they are not yet arrived at, or in possession of, bodily sensation, and therefore cannot suffer pain or become objects of cruelty." I would inquire, how has the Doctor ascertained that "children before birth are incapable of mental apprehen- 564 DEFORMITY OF PELVIS. sion ?" for on this his remarkable conclusion is founded. Has he any proof whatever that this is really the case ? 1504. But before I proceed farther, let me show what Dr. Osborn means by "mental apprehension."—"Before the ope- ration, (of cephalotomv,) the child in utero cannot suffer men- tal anxiety, or apprehension from threatened violence; nor does it feel, I am persuaded, the least bodily pain in the actual commission even of such violence," p. 36. Again, " it is cer- tainly from that apprehension, combined with other circum- stances of misery, which usually precede and accompany the act of dydng, that death can in itself be considered as the great- est of human evils—and from every one of those, the child in utero is exempt." p. 37. 1505. From this it is evident, Dr. Osborn supposed bodily sensation was dependent upon "mental apprehension," or in other words, there could be no "corporeal suffering," if there were no " mental apprehension." Is this agreeable to common, and daily observation ? Has not the devoted ox, power to per- ceive the " smallest bodily pain," because it cannot, or does not, anticipate its fate from the butcher's axe on the morrow ? Were we to adopt this hypothesis, it would make " mental apprehension" the cause of corporeal sensation, which would most effectually confound all our philosophy. 1506. If I should be charged with having wrested Dr. O.'s opinion, though I have fairly quoted his words ; if it should be insisted that, " mental apprehension," meant perception, still the doctor is chargeable with having employed a gratuitous datum—for he has not proved, that the brain of the foetus, espe- cially7 at full time, (the period at which the operation he advo- cates is to be performed,) is incapable of perception; and until this be done, it is in vain to contend, that the child in utero cannot feel " the smallest bodily pain." On the contrary, does not the child acknowledge this in many instances ? Is it not frequently provoked by external causes to move its little limbs? Nay, does it not do this very frequently without anv, to us, ob- vious cause ? May these stirrings not be considered as the exercise of volition ? Has it not a brain, and nerves emanating from it? Are these nerves mere cords without sensibility? Is DEFORMITY OF PELVIS. 565 the brain a mere glandular mass without function ? I can readi- ly believe their condition to be imperfect, but I cannot admit them to be without power or property. 1507. Does not the heart carrv on the circulation as certain- ly, and as perfectly quo ad hoc, in the foetus as in the born child ? Could this organ perform its functions without a certain condition of the nervous system ? If this be so, can the nerves be mere cords, without sensibility ? If the nerves belonging to the heart be sensible, may not all others be so ? 1508. In my opinion, then, Dr. O. has not made good his position; a position on which he appears to place much reliance for the support of his thesis, though in mine it has nothing to do with the question, as I have just observed (1051;) for I must repeat, that necessity, and strong necessity, alone can jus- tify the operation under consideration^the preservation of the mother's life is the only motive to action, and the only object in view—if the child must be the sacrifice for the mother's safety, that sacrifice is imperious, be the condition of the child what it may. 1509. Dr. Osborn next informs us, "that they (children in utero) cannot suffer from mental apprehension, is notorious to general observation. Even years elapse after birth, before the mind is susceptible of fear, or apprehensive of danger." Ad- mitted : but what does this truism prove, as regards the subject in question? Nothing; for I still must insist, that necessity alone is to -govern us ; and if governed by that, the only ques- tion to be debated is, whether the child is to be absolutely sacrificed, for the probable safety of the mother ? I say proba- ble safety—for such only is it, as I shall attempt to prove presently. 1510. If we are under the necessity of opening the child's head, our social feelings would derive some solace, could we be certain, or even doubtful, that the child suffered nothing from the operation; but ever)' thing opposes our drawing comfort from this source ; for however our understanding may be con- founded by specious argument, or wily sophism, our feelings will constantly bear witness against the truth of the proposi- tions, and the legitimacy of the conclusions. And I believe that 566 DEFORMITY OF PELVIS. God intended it should be so. What evils would flow from this source, did we but convince ourselves, that foetal life was void of sensibility or sensation! 1511. The crotchet has been but too often wantonly employ. ed, even where the practitioner had not adopted Dr. Osborn's opinion on the subject of foetal sensibility; how much more frequently then, will it be employed, when the wholesome re- straint of the contrary opinion is removed ? I am persuaded that the exercise of true feeling toward the unborn babe, has more than once saved it from a severe and painful fate; but it must also be declared as mv opinion, that it has but too often fallen a victim to a false estimate of the mother's danger—for I have known it used where there was the most* healthy con- struction of the pelvis, and where a little address in the use of the forceps, or even a little more patience, would have pre- served the child from a premature death.* 1512. Dr. Osborn farther informs us, that "diseases which at any period attack the human body possessing sensation, with sufficient force to destroy7 life, are in general attended with such a degree of pain, as to excite extraordinary motion, and some struggle; at least in articulo mortis. It is highly impro- bable that this should take place in the uterus, and the mother be insensible of their effect," p. 40. This statement at once brings Dr. Osborn's arguments to issue. He declares the struggle of an infant in utero would be an evidence of pain, and of course of its possessing "sensation;" and that if this struggle did take place even in articulo mortis, it is highly probable that the mother would be sensible of it—now, what is the fact upon this subject? Why, that I have been repeatedly informed by mothers, that they7 were apprehensive their children were dead, because, after a severe struggle or kind of fluttering, which has been described of longer or shorter duration, they felt them no more—every accoucheur can bear witness to such statements from mothers. * 1 am happy to find my opinion on this subject strengthened by a similar re- mark by Dr. James, whose opportunities afford him ample room to witness the abuse of tliis instrument in the hands of ignorant practitioners: in a note to Burns's Midwifery, p 35, note k, he says, he fears that " embiyulcia is frequently resorted to very unnecessarily at least, to make use of the mildest tern)." DEFORMITY OF PELVIS. 567 1513. Dr. Osborn again urges, that, " when we are compelled by dreadful necessity, to open the child's head while we know it is living in utero, that operation requires such extreme and painful violence, that, were the child endowed with the slightest sensation, he must of necessity feel it; and his feelings must necessarily be accompanied with such struggles and exertions, as would be emphatically expressive of pain, and must be rea- dily perceived by the mother, in a part so sensible, and irritable as the uterus." p. 41. 1514. This is sheer sophistry—it is making a negative con- dition prove a positive position; or, in other words, it is mak- ing the absence of struggling prove the want of sensation; when the situation of the child in utero is such, very often when it is necessary to perform this operation, as to render such evidence of its sufferings impossible. For this operation is recommended to be performed after the waters have been expended, and the uterus is firmly contracting round the body of the child. Now, it is well known to every accoucheur of anyr experience, that the uterus in many instances will so strictly gird the child, as to preclude the possibility of " exertion," be its feelings what they may. 1515. Besides, in a case which I witnessed of the operation of cephalotomy7, the woman declared to me without inquiry, that the most painful part of it was the struggles of the child. Now in this case the waters had been but recently discharged, and the uterus contracted but once in about twenty minutes. I mean not to lay undue stress upon this case; for it is not es- sential to my argument. I well know the imagination does much upon such occasions, and a convulsive action of the ute- rus may have been mistaken for the motions of the child; though it was precisely such a case, as would lead to the belief, that the poor woman was correct; for the child was certainly alive when the operation commenced; the waters had been ex- pended but a short time; and the woman's observation was spontaneous, and unprovoked. 1516. Dr. Osborn, however, tells us on the contrary, that "upon accurate and repeated inquiry in several such cases, he could not learn that the mother was sensible of any such alter- 568 DEFORMITY OF PELVIS. ation in the motion of the child, even at the commencement of the operation, when the violence offered to it first takes place, and must be most painful." This statement of Dr. O.'r amounts but to this negative; that in the cases in which he made "repeated inquiry7," no struggles were perceived; but this is very far from proving, that none upon anv occasion could take place. For this might well happen in " several cases," yet not be true in all; and if there have been one case in which the child was known to struggle in consequence of the operation, it is every way sufficient to confute the arguments of Dr. O.: since, he makes struggling a proof of sensibility—and I most sincerely believe many such cases have occurred. There are two especial reasons why this may not commonly happen: 1st, as stated (1514;) and 2d, the child is sometimes dead before the operation is commenced. 1517. "Having proved," continues Dr. O., "that the los« which the child sustains, by the deprivation of the living prin- ciple, is so extremely small as almost to vanish to nothing, and that its bodily sufferings in the act of deprivation are absolutely none, it becomes proper, next, to inquire what is the value of an unborn child to its parents and to the community." p. 42. 1518. "Before the birth of the child, parental affection has not taken place, which, for the wisest and best purposes, is one of the strongest, the most universal, and perhaps, the most uncontroulable passions of the female breast; often changing, even in the subordinate parts of the creation, the very nature of a timid mother, into that of a ferocious animal. Disappoint- ment of expected pleasure only7, not the loss of an object of this powerful passion, or the loss of any actual enjoyment, is the sacrifice the unhappy parent makes on this occasion." p. 43. 1519. In my opinion, Dr. O. is far from having proved what he states to have done, (1516) with so much self-complacency, to any other human being than himself; and, if he had really "proved" what I think he has merely taken for granted, it still would have no bearing on the subject—the degree of sensibility of the child while in utero, or whether it possess any, is not the question, as I have before declared: neither view, then, should DEFORMITY OF PELVIS. 569 prove a motive for the operation, or should deter from it; for this point must be settled upon other principles. 1520. But where Dr. O. learned that parental affection did not exist before birth, is difficult to say; for I must declare, and I do this without fear of contradiction, that the affection of the parent is strong, nay, oftentimes very strong, for the child while in utero—and if any accident befall it, a sorrow, and that sometimes of a deep kind, is for a long time indulged —I have known two instances of protracted, and deep seated gloom, follow the birth of still-born children; and in one, it was not removed until a subsequent pregnancy gave promise of a more fortunate result; the other gradually yielded to time, and change of scene. 1521. It would be idle to say that these were not cases of disappointed or lacerated affection, but the mere privation of a promised or anticipated pleasure. Besides, Dr. O. tells us, that " parental affection" converts, in the brute, " the timid mother into the ferocious animal;" from whence arises this recklessness of danger in the " timid mother," in defence of her offspring, when she exposes herself to death, and often meets it fearlessly in attempting its protection ? What antici- pation of future or" expected pleasure" exists in them ? there are not, nor cannot be, any promised joys here; they look not forward for such reward ; yet they unceasingly display affection and courage, that might put to shame some, who should de- rive delight from offspring. Dr. O. could not have been a father. 1522. Dr. O. pursues this subject by observing, " had paren- tal affection commenced at the time of conception, or when the embryo is first formed; and had it continued increasing during gestation, as the fcetus advanced in growth, by the time of birth the passion would have been mature, and its influence most powerful, and the mother's sufferings would have been greatly aggravated by the loss of a beloved child." And is this not precisely what happens in a large proportion of cases ? Who has not witnessed the joy of a mother at the first evidence she has that her child lives within her ? Who has not witnessed fhe growing affection of the parent as gestation advanced? and [72] 570 DEFORMITY OF PELVIS. who has not observed the sorrow, when all this maternal soli- citude had proved unavailing ? What motive governs the mo- ther, when she submits to the Caesarean operation,, or yields to the section of the pubes ? Love, unbounded love for her unhappv offspring! And who cannot bear testimony to the agony7 of the mother for the loss of her unborn babe, that has witnessed the dreadful operation of the crotchet? If these things were denied by Dr. O., I must repeat, he is no father. 1523. Dr.O. goes further; he declares, "such a passion (ma- ternal affection) could not be directed to any useful purpose, during the existence of the child in the uterus; nature, who never performs works of supererogation either in the physical or moral world, has not yet kindled it in the mother's breast: it begins onlv with birth: and parents in general may, I think, be literally said to suffer nothing, by the loss of an unborn child." 1524. To this I will briefly state, that maternal affection is constantly necessary, from the- moment conception is believed to have taken place, un il the final expulsion of the child from the uterus. Were a woman not influenced by7 strong affection to the protection of her child while in utero, she would have no reward for the many, and oftentimes severe sufferings, and privations, during that period; and were not this love for the child paramount to every other feeling, as a general rule, there would be no motive for its preservation—carelessness, or de- sign, might constantly circumvent the great object of creation. And, With respect to his conclusion, I appeal to the whole svorld for its refutation. 1525. Again, the Dr. says, "to society, likewise, the loss of any individual child must be exceedingly small, when it is known by daily observation, what great numbers of children are still-born, or die without such violence before birth; when it is likewise known, how very precarious is the chance of a child's living two years; but how most of all precarious, is its arrival at that period of life, when it can be of any service to its fellow-creatures, or even participate itself in the enjoyments of the world." (p. 45.) 1526. To me it is truly a matter of surprise, that the various DEFORMITY OF PELVIS. 571 eontingencies which may prevent a child from being born alive; from its continuing two years upon earth after birth: or from arriving at manhood; should be employed as an argument against the value of the child's life. It appears to me, that it should have a diametrically opposite bearing: for, were the birth of a still-born child a rare occurrence; were it almost certain that children should arrive at the age of two years; their arrival at puberty, or beyond it, nearly sure; the occa- sional loss of a chilr' by embryulcia, or any other violence, would then be but little felt: but when such violences are to add victims to the already too large list of human deaths, they must be considered as evils; whatever may7 be the necessity for employing them. 1527. I admit, that society suffers but little loss on account of "any7 individual child," so long as the loss is confined to that individual child; but when this indifference to " indivi- dual" life, goes beyond a single instance, we cannot foretel where it may stop—it may extend to thousands; for thousands are but aggregated units. 1528. Dr. O. concludes this remarkable essay, in these words: " In estimating the value of the life of the unborn child at so low a rate, I most earnestly request the medical reader will never lose sight, that it is only in comparison with the mother, or when the child's life is put in competition1 with her safety, that any arguments on this score are entitled to the smallest weight. It is for the preservation of the mother's life only, that we can justify the practice here recommended and insisted on." (p. 45.) 1529. It does not appear to me at all necessary, that the value of the child's life should have so low an estimate, in order to have arrived at the above conclusion—it was every way suffi- cient for the purposes for which the comparison was instituted, that the value of the mother's should have been deemed great- er. I fear, Dr. O. is chargeable with having done mischief, by the view he has taken of this subject; for I do know full well, he has been quoted in support of " cephalotomy," where its necessity, in my estimation, was far from being absolute. 1530. As no possible advantage could result from the man- ner in which Dr.O. has treated this inquiry, it is to be lament- 572 DEFORMITY OF PELVIS. ed that it was ever agitated; since the subject has not derived the smallest elucidation from it; yet it may occasion serious, and often-repeated mischief. Had he treated this matter dif- ferently, and shown how precious is the life of the child; yet, however precious, that that of the mother is still more so; and that nothing but imperious necessity should be permitted to institute a comparison of their respective values, when one or other must be the sacrifice ; it would, in my opinion, have more certainly served the cause of humanity, and much more effec- tually have promoted the interest of science. 1531. I shall pursue this subject a little farther, by offering a few remarks upon " Elizabeth Sherwood's case," by which Dr. O. supposes he has ascertained the minimum opening of a pelvis, through which a child at full time may be extracted by the crotchet, at the full period of utero-gestation. .Observations, &?c. on Elizabeth Sherwood'*s Case, as related by Dr. Osborn. 1532. The whole of Dr. Osborn's arguments on the subject of "embryulcia," are intended to show; that this operation decidedly merits the preference over the Caesarean section, wherever there is an inch and a half of opening at the superior strait; and that it is never justifiable to perform this latter operation, when a diameter of this size really exists: and he attempts to illustrate this position, by the recital of the melan- choly case of Elizabeth Sherwood. 1533. The comparative merits of these two operations should alone be decided by7 the advantage one may possess over the other; and this advantage determined by the general results of the respective operations. Dr. O. condemns without reserve the Caesarean section, as consigning the woman to " inevitable destruction," while a number of equally respectable men, re- commend it in preference to the crotchet; affirming it to be equally safe, and decidedly more advantageous, as the child has a chance of life. I shall, however, reserve my considera- tion of this subject, until I speak of the Caesarean operation itself: and shall now proceed to make a few observations upon DEFORMITY OF PELVIS. 57S the case on which Dr. O. is determined to rely, for the support of his opinions upon this point. 1534. Elizabeth Sherwood's was a case of extreme deformi- ty ; she was but forty-two inches in height—she could neither move nor stand, but by the aid of crutches. It her 27th year she became with child, and was admitted, for the purposes of delivery, into the Store Street Hospital, London. After her labour commenced, it was first contemplated to perform the Caesarean operation, as " there would be a certainty of preserving one life at least.'1'' But this humane and proper determination was abandoned, it would seem, with as much facility, as cruelty, because Dr. O. and his friends " were rather disposed to believe, that the child was dead." 1535. Not a single reason is given for the disposition to be- lieve the child to be dead—nor were they satisfied themselves that this was the case, from the doubtful and careless way Dr. 0. has expressed himself on this point. It was due to the pub- lic, to the profession, and to themselves, to have stated at large, the grounds of this belief; and, if they were well founded, the operation which was soon after commenced, was certainly jus- tifiable ; if the child were not dead, it might admit of doubt— however, the opening of the head was decided upon; and the child was ultimately delivered. It is upon this delivery, and the state of the pelvis, as declared by Dr. O., I propose to offer a few remarks; remarks, which have been suggested by carefully reading the case; and which has given rise to strong doubts of the fidelity of the representation ;* but if faithfully related, it is entirely beyond my comprehension, and would dispose me to say, he had performed impossibilities. 1536. Dr. O. commences his account of the examination of this poor woman, by stating, "that immediately upon the in- troduction of the finger, he perceived a tumour equal in size, * In this remark, I am by no means to be understood to insinuate, that I call into question the veracity of Dr. O. I merely suggest, that as mathematical precision could not be arrived at, an error in estimate may have crept into the account; since, from the great interest which was excited, as well as the confu- sion consequent upon such an operation, under such circumstances, extreme accuracy could not perhaps reasonably,be expected. 574 DEFORMITY OF PELVIS. and not vcrv unlike in the feel to a child's head." Tliis was the projection of the sacrum, and so advanced toward the pubes, as to leave but a space of three quarters of an inch. On the left side of this projection, towards the ilium, there was a dis- tance of about two inches and a half; leaving a space of three fourths of an inch. On the right side, there was rather more than two inches; with an opening in its widest part of one inch and three quarters, gradually, however, narrowing each way— so much of the pelvis. 1537. From the data here given, both the superior, and in- ferior strait must have been faulty—the lower, I presume, to such a degree (though nothing of the kind is mentioned) that "the hand could not be introduced; or, at least,not easily; since, the projection of the sacrum was " in size and feel like a child's head;" consequently, there must have been extreme difficulty in ascertaining the situation of the head, either as regards po- sition or firmness; for the finger could not reach so high, with- out the introduction of the hand. 1538. He next informs us, "the os uteri, though but little dilated, was soft and flabby;" "the membranes were not yet broke, but with some difficulty he perceived the child's head through them, situated very high above the projection." From whence did the difficulty to touch the child's head arise ? its remoteness from the finger—the hand then could not have been introduced into the vagina, or this " difficulty" would not have existed—in an examination so important to the welfare of his patient, it is presumable that Dr. O. would have intro- duced his hand had this been practicable. I shall employ this conclusion presently. 1539. Next morning "no alteration had taken place either in the state of the os uteri, or the position of the child's head." The membranes had given way during the night. Dr. O. now availed himself of the opinions of several celebrated accou- cheurs and surgeons, none of whom, gave greater dimensions to the upper strait than had been given by him; some even less. The Caesarean operation was first suggested; but aban- doned, as stated above, without any apparent good reason. 1540. Dr. O. now commenced the operation of "embryul- DEFORMITY OF PEL\ iS. 575 cia," and says "even die first part of the operation, which in general is sufficiently easy, was attended with considerable dif- ficulty, and some danger;"'' from whence arose the danger? the wounding of course of the soft parts of the mother, I presume. "The os uteri was but little dilated, and was awkwardly situ- ated in the centre, and most contracted part of the brim of the pelvis"—that is, where there was but a .space of three fourths of an inch. "The child's head lay loose above the brim, and scarce within reach of the finger, nor was there any7 suture di- rectly opposite to the os uteri.", WTould it not seem to require an unusual perfection in tact, under such circumstances, to satisfactorily determine there was no suture opposite the os uteri?-—probably there was none ; but to ascertain and satisfy ourselves, as Dr. O. appears to have done, would require, as I have just stated, an uncommon degree of nicety of touch; for it must be borne in mind, there was no pressure at tliis time on the head to make the bones ride over each other, and by which the presence of a suture might be detected or even suspected; on the contrary, "the head lay loose above the brim, and scarce within reach of the finger." 1541. I grant, however, it is not fair to suppose another can- not do that, which I should find impossible. Yet I must con- sider myself safe in the remark, that a little pressure from the finger, and some resistance from the head, would have been essential to the discovery of a suture, had one even been there. 1542. Dr. O. proceeds, and says, "he desired an assistant to compress the abdomen with sufficient force to keep the head in contact with the brim of the pelvis, so as to prevent its re- ceding from the scissors, upon the necessary pressure of the point, to make the perforation; I introduced them, with the ut- most caution, through the os uteri, and, after repeated trials, at length succeeded in fixing the point into the sagittal suture, near the posterior fontanelle." All this is so very circumstan- tial, as to excite my wonder in no small degree—first, there was no suture opposite the os uteri; second, the os uteri was in the centre of the projection, and not well dilated, and at a part where there was a space but of three quarters of an inch; third, the head was forced to keep its situation, that the scis- 576 DEFORMITY OF Pr.LVlS. sors might enter; in which, after several attempts, he succeed- ed to penetrate a suture, and that, the "sagittal suture near the posterior fontanelle!!" Now, I think I do not disparage the tact of any man, either living or dead, when I say, that none other than Dr. O. could have told into which of the su- tures he plunged his scissors under the same circumstances. 1543. Dr. O. now tells us of some of the difficulties attending his enterprise, arising from his attempts to break down the bones of the cranium; confessing that " the instrument at first inva- riably slipped, as often, and as soon as it was fixed, or at least before he could exert sufficient force for this purpose." It would be instructive to know what parts of the mother received the point of the crotchet "when it slipped;" for we are forbid- den, from the description of the pelvis itself, to suppose the point was guarded by the other hand, since it could not pos- sibly be introduced profitably, (1538) if at all, into the vagina, for this purpose. 1544. At length the Doctor succeeded in firmly7 fixing the instrument, even into, he believes, the foramen magnum, of which he availed himself " to the utmost extent, slowly, gradu- ally, but steadily increasing the force, till it arrived to that de- gree of violence, which nothing could justify but the extreme necessity of the case." I would ask what must have been the condition of the soft parts against which this force was'exert- ed ? I have known much less force than that " degree of vio- lence which nothing could justify but the extreme necessity of the case," followed by severe, and even hazardous, if not fatal consequences. But in this case Dr. O. was ordained to tri- umph ; over not only nearly insuperable difficulties, but also over the consequences of the extreme violence he was obliged to use to accomplish the delivery. In my hands, after such violence, I am disposed to believe, nay almost sure, the woman would have died; not so, Elizabeth Sherwood; for she was re- served for another trial of a similar kind, and not being under the care of Dr. O. she died. 1545. But, notwithstanding this great exertion of force, it was urged to no profitable purpose; he therefore abandoned the idea of breaking down the base of the cranium by the DEFORMITY OF PELVIS. 577 crotchet, and then most happily succeeded in effecting by_ ad- dress, that which could not be overcome by force ; for, by a little management with two fingers, he was fortunate enough to place the base of the scull edgeways, which permitted it to pass, by a continuation of the force applied ;wi:ks. Sept, 2H(/i, 18JL DEFORMITY OF PELVIS. 593 vis that had not two inches complete in its antero-posterior diameter, because a child at seven months, would require an opening of that size to permit it to pass; and it has been very universally supposed, that a child who has not enjoyed " seven months complete" residence in the uterus, will not live after its delivery. This must then be considered, as a valuable ge- neral rule; and if the state of the pelvis will admit of farther delay, it will unquestionably be to the advantage of the child. 1598. But what shall be done with women, whose pelves have rather less than two inches ? shall they be abandoned to the Cesarean section, or their children to the crotchet? either of these alternatives is certainly terrible; and, if nothing better present itself, must be submitted to—it may7 become a profit- able inquiry to determine, from what has really happened upon other occasions, on the propriety of inducing premature labour at an earlier period than seven months ; say at six. Children have lived, when delivered at this period, where there was no deformity of pelvis to contend with, (but this circumstance, it is true, may occasion a different result,) and it perhaps would merit a trial in cases of more excessive deformity; since, neither mother nor child can have any greater injury offered them, than the dreadful operations just named. I have witnessed two children living, one at this moment, and arrived at womanhood; the other several months, who were, as far as could be ascer- tained, not more than six months advanced in gestation. 1599. It might be worth the trial, in cases where the choice is not only so limited, but so almost certainly fatal, to one, or perhaps both, of the individuals concerned. I am fully aware of all the contingencies attendant upon the proposition, yet it seems to me to hold a remote chance to the child, without in- creasing the risk to the mother. I know full well how frail and tender the whole organization of the fcetus is at this period; and how many dangers await its delivery; but with me, they are not of sufficient force to destroy the possibility of success —the extreme pliability of the cranial bones at this period, gives a promise that the head may pass without so much injury, as to forbid all hope of its success; and if it succeed once in ,75) 594 DEFORMITY OF PI.LVIS. twenty times, it is certainly better than opening the head always; or subjecting the mother to the other alternative. 1600. " II. The practice should never be adopted, till expe- rience has decidedly proved, that the mother is incapable of bear- ing a full-grown fcetus alive." 1601. "III. It is sometimes necessary to have recourse to the perforator in a first labour, though there may be no consi- derable distortion of the pelvis; therefore, the use of this in- strument in a former labour, is not alone to be considered as a justification of the practice." 1602. " IV. The operation ought not to be performed, when the patient is labouring under any dangerous disease." 1603. " V. If, upon examination, before the operation is performed, it should be discovered that the presentation is preternatural, it might be advisable to defer it for a few days, as it is possible that a spontaneous alteration of the child's position may take place; particularly, if the presentation be of the upper extremities." 1604. I have introduced this rule, because I am not certain that it may not be an important one; but to me, reason and experience, seem to be against it. Reason is against it; be- cause, the length of the child from the points of the nates to the top of the head, would exceed the transverse diameter of the uterus, and, therefore, it could not perform the movement called the "Somerset," which would be essential to such a change of parts. See Baudelocque, on the movement called " Somerset." 1605. And experience, I am disposed to believe, must be against it, since before the rupture of the membranes at full time, and when the mouth of the uterus is even pretty well di- lated, it is very difficult sometimes to determine the part which may offer to the finger—I believe that no accoucheur would always pronounce positively on the part which may present itself to the os uteri. If then he cannot at full time, when it must certainly be less difficult and less hazardous, how can he, without a prodigious risk of being mistaken, decide at seven months, when the neck of the uterus is not effaced; when it requires some force to pass the finger; when it must be passed DEFORMITY OF PELVIS. 595 with great care and delicacy, that the membranes be not rup- tured ; and where, did we employ a pressure sufficient to de- termine the nature of the presenting part, the membranes would almost certainly give way; i ask, under all these disad- vantages, how can we ascertain with such precision, as would render the examination available ? Dr. James gives us an in- stance in point; in this case the membranes yielded, by some little damage being done to the membranes by a previous ex- amination. See his interesting case, Eclectic Repertory, vol. I, p. 105. 1606. "VI. The utmost care should be taken to guard against an attack of shivering and fever, which seems to be no unusual consequence of this attempt to induce uterine action, and has often proved destructive to the child, as well as alarm- ing with regard to the mother. The peculiar circumstances under which the operation is performed, and the habit of body of the patient, will determine the accoucheur either to adopt a strictly antiphlogistic plan, or to exhibit opium or antispas- modics and tonics." 1607. "VII. In order to give every possible chance for preserving the life of the child, it will be prudent to have a wet nurse in readiness, that the child may have a plentiful supply of breast milk from the very hour of its birth." 1608. This last direction would seem to intimate, that the woman who has undergone this operation, is incapable of nursing the child after it is born—but this is certainly not so— I have seen as abundant flows of milk after premature (spon- taneous, if I may so term them) labours, as when the child was carried to the full time. Nor do I see any good reason, why an immature child should suffer more than a mature one, for the want of "breast-milk" for a few days—yet the caution may be useful. 1609. "Lastly. A regard to his own character, should deter- mine the accoucheur not to perform this operation, unless some other respectable practitioner has seen the patient, and has ac- knowledged the operation as advisable.'''' 1610. It is not necessary to describe the mode of operating in this case; for, as Dr. Denman very justly observes, "No ->96 1JK1-OR.MITY OF PELVIS. person, properly qualified to decide on the propriety of this Operation, can be ignorant of the manner of performing it." He cautions against injuring the "child in this operation—this cannot happen, if a blunt* instrument be used instead of a ■marp one. Sect. Yl.—fi Section of the Pubes. 1611. I should not have enumerated this Operation as one of the resources of the art, but to have it in my power to de- clare it not to be one—and though the operation has been per- formed twice, lately, with success, it is said; (that is,the chil- dren were born alive and did well, and the mother recovered;) yet it is evident, from the relation of the cases, there could have been no very great deformity of the pelvis, or much room to applaud the operator for his "success;" since, after the operation, the patients were placed in warm baths, and the far- ther separation of the bones and dilatation of the parts were left to the efforts of nature. On delivery, the bones were found separated an inch and a half, a proof there could not have been much restriction of the superior opening of the pelvis, as a separation of even two inches gives, as a general result, but six lines, or half an inch, in the antero-posterior diameter of the superior strait; therefore, less than half an inch must have been obtained in the cases just mentioned; yet with that additional capacity,the women were enabled to deliver themselves; con- sequently, there could have been but little deformity. 1612. Besides, it is stated, that in one of the cases no re-# union of the bones took place, owing, it is supposed, to their not having been placed in apposition—this being so, one of two things must account for the defect; either that the operation must have been most bunglingly performed, not to haVe secured the bones in apposition; or, if this be not admitted,-there must be a risk of union not taking place, however well per- formed. Sect. VII.—g. Regimen. 1613. It was long taught, that as the child was entirtlv de- pendent upon the mother for its nourishment while in utero; deformity of pelvis. >»/ and that for the increase of the body, it was constantly neces- sary to have a supply of it; and that this increase of the body was in proportion to this supply, that the ingesta of the mother must have a decided control upon the size of the child—hence, a woman with a deformed pelvis, has been advised to live very abstemiously, with a view to diminish the size of the child. This speculation was both natural and ingenious, and has but one argument to be urged against it; namely, that experience has proved it not to be true. This scheme, therefore, is now, entirely, I believe, abandoned. Dr. Holcombe, however, in a letter to the author, has related several instances of success from diet and medicines, in considerable deformities of pelvis. See his letter, in the Phil. Jour. Med. Sciences, Jan. 1826, CHAPTER XXXVIII. II. III. MONSTROSITY AND ACCIDENTAL DEFORMITY. 1614. Both of these may render it necessary to mutilate the child, even in a well-formed pelvis; for they may produce a relative narrowness of this cavity—no certain rules can be laid down for the former, since their peculiarity cannot be ascer- tained beforehand—much must then be left to the good sense and discretion of the practitioner. One thing, however, is certain, monsters can onlv interfere with labour from an excess of parts—should the pelvis then be faulty, it may7 subject the woman to all the penalties of a positively deformed pelvis. The accidental deformity can rarely cause a more serious evil than delay in a well-formed pelvis, though it may, in a narrow one, create all the embarrassments of a too narrow cavity— when the head or abdomen are dropsical in a well-formed pel- vis, perforating them will almost always relieve the woman by the evacuation of the water, but in a narrow pelvis, this is not sufficient; since by that operation only the excess of size is re- moved. I once saw rupture of the uterus from a hydroce- phalic head. See "Essay on Rupture of the Uterus," bv the author. 598 UNCERTAINTY OF THE CHILD'S DEATH. CHAPTER XXXIX. UNCERTAINTY OF THE CHILD'S DEATH. 1615. In many instances, it would be highly important to us, did we with certainty know that the child was dead in utero— it would often abridge the sufferings of the poor woman, and sometimes spare the accoucheur many a deep drawn sigh, or even perhaps appease a disturbed conscience ; but this is a mat- ter of great difficulty, as well as oftentimes of great moment to decide. All the commonly enumerated signs have been known to fail, and even when many of the strongest were united; of this, Baudelocque* gives us a most memorable and interesting example—an example that should be well studied, and care- fully treasured against the time of need. 1616. The reliance upon certain of the signs which are said to characterize the loss of life in the child, has been the cause of the immolation of thousands; and, we cannot too earnestly deprecate this facility of credence, when we have but too much reason to wish it were so. There are but two unequivocal signs of the child's death, namely, a cessation of pulsation in the umbilical cord when prolapsed; and the scalp forming a soft tumour, in which the bones of the cranium can be felt loose and detached. 1617. The escape of offensive gas, a separation of the cuticle or hair, a rolling motion within the abdomen, a shrinking of the abdomen, and the cadaverous appearance of the woman, are but uncertain signs of the child's death. * System, par. 1898. FINIS. nu, 43 ( 599 ) EXPLANATION OF PLATE I {FROM BA UDELOCQ UE.) A, A, A, A, The ossa ilia, properly so called. a, a, The iliac fossae. bb, bb, The angle which divides transversely and ob- liquely from behind forward, the internal face of the os ilium into two parts, and which makes part of the brim of the pelvis. cc, cc, The cristse of the ossa ilia. e, e, The anterior superior spine of the ossa ilia. f, f, The angle formed by7 the internal lip of the crista of the ilium towards the extremity of its ante- rior two thirds, and to which is attached a ligament inserted at the other end in the trans- verse apophysis of the last lumbar vertebra. g, g, The inferior angle of the os ilium, which makes part of the acetabulum. B, B, The os ischium. h, h, The tuberosities of the ischia. i, i, The branches of the ischia. k, k, The posterior parts of the ossa ischia, which make parts of the acetabula. C, C, The bodies of the ossa pubis. 1,1, The angles of the ossa pubis. m, m, The posterior extremities of the ossa pubis, which make part of the acetabula. n, n, The descending branches of the ossa pubis, which unite with those of the ischia. D, D, D, The os sacrum. 1, 2, 3, 4, The anterior sacral holes. o, o, o, The base of the sacrum. p, p, The sides of the sacrum. E, The coccyx. F, The lumbar vertebra. r, r. The transverse apophyses of the vertebra ( 600 } s, s, The ligaments which go from the transverse apo- physes of the last vertebra, to the angle of the internal lips of the cristse of the ilia, indicated by the letters f, f. t, t, Two other ligaments which descend from the same apophyses to the superior edge of the sacro-iliac symphyses. G. G. The femurs or thigh bones. V, V, The heads of the femurs received into the aceta- bula. u, u, The foramina ovalia. Symphyses of the Bones of the Pelvis. H. The symphysis of the ossa pubis. I, I, The sacro-iliac symphyses. K, The sacro-vertebral symphysis. If'I,. II ( 601 ) EXPLANATION OF PLATE II. This figure represents*the entrance of a well-formed pelvis, a, a, The iliac fossae. b, The sacro-vertebral angle, or the projection of the sa- crum. c, The last lumbar vertebra. d,d, The lateral parts of the base of the sacrum. e, e, The sacro-iliac symphyses. f, f, The parts over the acetabula. g, The symphysis of the pubes. The lines indicate the different diameters of the superior strait. A,B, The antero-posterior, or little diameter. C, D, The transverse or great diameter. E, F, The oblique diameter, which extends from the left ace- tabulum to the right sacroiliac junction. G, H, The oblique diameter, which goes from the right ace- tabulum to the left sacro-iliac junction. [76] ( 602 ) EXPLANATION OF PLATE III. Ihis figure represents the inferior strait of a well-formed pelvis. a, a, The external faces of the ossa ilia. * b, b, The anterior superior spines of the ossa ilia. c, c, The anterior inferior spines of the ossa ilia. d, d, The acetabula. e, e, The foramina ovalia, with the obturator ligaments. f, f, The ischiatic tuberosities. g, g, The ossa pubis. h, h, The branches of the ossa pubis and ischia united. i, i, The sacrum. k, The coccyx. 1,1, The sacro-ischiatic ligaments. m, The symphysis of the pubes. n, n, The arch of the pubes. The lines indicate the diameters of the inferior strait. A, A, The antero-posterior diameter or great diameter. B, B, The transverse or small diameter. C,C,D,D, The oblique diameters. PLATE m PLATE IV ( 603 ) EXPLANATION OF PLATE IV. This figure represents a deformed pelvis. a, a, The ossa ilia. b, b, The ossa pubis. c, c, The ossa ischia. d,d,d, The last lumbar vertebra. e, The projection of the sacrum. f, f, The sacro-iliac symphyses. g, The symphysis of the pubes. h, h, The foramina ovalia. i, i, The branches of the ossa pubis and ischia, which form the anterior arch of the pelvis. k, k, The acetabula. The lines indicate the diameters of the superior strait. A, A, The antero-posterior diameter; its natural width re- duced to fourteen or fifteen lines, or so many por- tions, twelve making an inch. B,B, The transverse diameter—its length, in this subject, four inches, ten lines. C, C, The distance from the projection of the sacrum, to that of the margin which answers to the left acetabulum, thirteen lines. D, D, The distance from the same point of the sacrum, to that of the margin which answers to the right acetabulum, twenty lines. ( 604 ) EXPLANATION OF PLATE V. This plate is intended to represent the first presentation of the vertex, or where the posterior fontanelle is behind the left acetabulum, and the anterior to the right sacro-iliac symphy- sis. In this position, the head offers itself diagonally to the opening of the superior strait; the left ear will correspond- with the right foramen ovale, and the chin is pressed against the sternum. a, The left acetabulum. b,b, The, symphysis of the pubes. c^c, The oval foramens. d, The spine of the ilium. e, The uterus. f, The dotsvmdieating the posterior fontanelle. g, The anterior fontanelle, or right sacro-iliac symphysis. h, The arch of the pubes. i, i, The tubers of the ischia. k, k, The margin of the pelvis, or superior strait. ^ For the mechanism of this labour, see page 239. For the mode of turning in it, see p. 287. For the application of the forceps, see p. 315, and following. PLoVo pl, r:u ( 605 ) EXPLANATION OF PLATE VI., OR SECOND PRE- SENTATION. , • a, The right acetabulum. b, The symphysis of the pubes. c, Left foramen ovale. d, Spine of the right ilium. e, The uterus. f, Dots representing the site of the posterior fontanelle. g, Anterior fontanelle, or left sacro-iliac symphysis. h, Arch of the pubes. i, Tuber of the left ilium. For the mechanism of this labour, see page 240. For the mode of turning, see p. 288. For the application of the forceps, see p. 318, and following. • • ( 606 ) EXPLANATION OF PLATE VII., OR THIRD PRE- SENTATION. a, Left acetabulum. b,b, Symphysis pubes. c, Left foramen ovale. d, Spine of the right ilium. e, The uterus. f, The posterior fontanelle, indicated by the dots. g, Left sacro-iliac symphysis. h, Arch of the pubes. i, Tuber of the left ischium. For the mechanism of this labour, see page 241. For the mode of turning, see p. 288. For the application of the forceps, see p. 315, and following. • * FI0 TMo FLA1IL s ( 607 ) EXPLANATION OF PLATE VIII., OR FOURTH PRESENTATION. a, Left acetabulum. b,b, Symphysis pubes. c, Left foramen ovale. d, Spine of the ilium. e, The uterus. f, Anterior fontanelle, indicated by the dots. g, Right sacro-iliac symphysis. h, Arch of the pubes. i, Left tuber of the ischium. For the mechanism of this labour, see page 242. For the mode of turning, see p. 289. For the application of the forceps, see p. 318, and following. ( 608 ) EXPLANATION OF PLATE IX., OR FIFTH PRESEN- TATION. a, Right acetabulum. b, Symphysis pubes. c, Right foramen ovale. d, Spine of the ilium. e, The uterus. f, Anterior fontanelle, indicated by the dots. g, Left sacro-iliac symphysis. h, Arch of the pubes. i, Tuber of the ischium. k,k, Margin of the pelvis. For the mechanism of this labour, see page 245. For the mode of turning, see p. 290. For the application of the forceps, see p. 318, and following. FF, IX J'Jj.X (609 ) EXPLANATION OF PLATE X., OR SIXTH PRESEN- TATION. a, Right acetabulum. b,b, Symphysis pubis. c, Foramen ovale. d, Spine of the ilium. e, The uterus. f, Anterior fontanelle behind the symphysis pubes, as indi- cated by the dots. g, Left.sacro-iliac symphysis. h, Arch of the pubes. i, Tuber of left ischium. For the mechanism of this labour, see page 245. For the mode of turning, see p. 290. For the application of the forceps, see p. 316, and following. [77] ( 610 ) EXPLANATION OF PLATE XL Fig. I. This plate represents the middle-sized pessary. From a, a, Two inches and four-tenths. b, A central hole to permit any discharges to pass, three-tenths of an inch in width. c, c, An excavation for the neck of the uterus to lie in, when applied. Fig. II. Is a central section of the same pessary. a, a, Represents the internal cavity of the pessary. b, b, Represents the depth of the excavation of c, c, of Fig. I. 5\ tenths of an inch deep. c, A section of the central hole, b, of Fig. I. FF,XF riff.:' Section mtough me (bare. Fie-.l. %. '% v^i- - 27*171 a ( 611 ) EXPLANATION OF PLATE XII. EXPLANATION OF THE FORCEPS OF PROFESSOR SIEBOLD. I have been favoured, by the politeness of Dr. Eberle, with a sight of professor Siebold's forceps. In their general form and size, they differ but little from the forceps of Baudelocque; they are rather longer in the clams, and a little more curved, as will be seen by examining the plates. What I value in them is, their very ingenious mode of lock- ing; I am persuaded this has a decided advantage in some po- sitions of the head, and will contribute to the success of appli- cation. Fig. I. a, The top of the screw which serves to unite the blades. * b, The head of the shoulder of the screw, which is received a very7 small way into the counter-sink f. fig. 2. c, The conical body of the screw, which is received in the excavation g. fig. 2. d, The cut part of the screw, which passes into the female screw cut in the body of the blade of the forceps. e, The head, or but, against which the lower extremity of the screw is received. Fig. II. f, The counter sink for receiving the shoulder b, fig. 1. g, The conical excavation for the reception of c, fig. 1. Fig. III. The forceps united and reduced to one half the proper size. h h The manner in which the screw unites the blades. i i The turned extremities of the handles, which serve like those of Baudelocque, as blunt-hooks. C 612 ) The forceps represented in Plate XIII. are reduced two- thirds from the proper size—they are called the long French forceps, or Baudelocque's forceps, though they differ a little from them, but not materially. These instruments are well made by Mr. John Rorer, Arch Street, above Fifth, from a Paris pattern. DIRECTIONS FOR PLACING THE PLATES. The plates are to be placed at the end of the book, making them face their explanations. PLA TE XIH i :&\ X>' \:^ r-\fk\. s NLM020926399