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.*£  NATIONAL LIBRARY OF MEDICINE
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AN
INTRODUCTION
TO
MIDWIFERY.
.~.«BBBOUHI 
 
AN
INTRODUCTION
TO THE
PRACTICE
OF
MIDWIFERY.
        BY THOMAS DENMAN, M. D.

LICENTIATE IN MIDWIFERY OF THE COLLEGE OF PHYSICIANS,
    AND HONORARY MEMBER OF THE ROYAL MEDICAL
            SOCIETY AT EDINBURGH.
IN TWO VOLUMES.

    VOL. II.
           NEW-YORK:

       PRINT1D BT JAMES ORAM,
FOR WILLIAM FALCONER AND EVERT DUYCKINCK.
1802. 
 
ic\i£*Cz'8«r bv'VH
     ^CONTENTS

              OF

THE  SECOND  VOLUME.
CHAPTER X.
                                                Page.
Sect.  III.    On the definition and diftinftion  of
                difficult labours                     l
      IV.    On the firft order ot difficult labours        3
      V.     On the fecond order of difficult la-
                 bours        -       -       -     17
      VI.    On the third order of difficult  labours     24
      VII.   On the fourth order of difficult labours     32
      VIIL  General oblervations on difficult labours   43

                    CHAP. XL

Sect.  I.      On the fillet, forceps and veftis     -     47
      II.     On fillets         -      -       -     ,50
      III.    On the forceps    -      -       -     ,51
      IV.    General obfervations on the ufe of in-
                 ftruments      -      '       *     54
      V.     On the application of the forceps        57
      VI.    On the Afction with the forceps when
                 applied                           58
      VII.   On the application of the forceps un-
                 der various circumftances       -     6i
      VIIL   On the vetlis      ...     63
      IX.     On the different kinds of veftis         6,5
      X.      On the comparifon of the vcftis with
                 the forceps         -        -67
      XL     On the manner of ufing the ve&is       70 
VI                    CONTENTS.


                     CHAP.  XII.
Page.
Sect.  I.       On leflening the head of the child         73
       II.      On the figns of a dead child        -      fj
       III.     On the caufes of the death of the child      83
       IV.     On theinftruments ufed in the opera-
                   tion         -        -              85
       V.      On the manner of performing  the
                   operation      .    -     -           86
       VI.     On the perforation of the head     -      87
       VII.    On the evacuation of the contents of
                   the head      ....      88
       VIIL   On the extraction of the head      -      89
       IX.     On the fubfequent treatment       -      04
       X.      On the propriety of bringing on pre-
                   mature labour         -             95
       XL     On the fettion of the fymphyfis of
                   the ofTa pubis                       99

                     CHAP.  XIII.

Sect.  I.       On the Cefarean operation        -     103
       II.      On the general reafons for perform-
                   ing the operation       -       -     \ql
       III.     On the  fuppofed reafons for per-
                   forming the operation          -     %q6
       IV.     On the aftual reafons  for performing
                   the operation         -       -     107
       V.      On the caufes oi death after the opera-
                   tion           .        -       -     lit
       VI.     On the  manner of performing  the
                   operation          -           -     112

                     CHAP.  XIV.
Sect. I.       On the diflin&ion  of preternatural
                  labours         -
      II.      On the figns  of preternatural pre-
                  sentations
"5

117
III.     On  the firft order of perternatural
            labours        -       .       -     118
IV.      On the difHn&ions  of  the  fecond
            order ot peternatural labours          124 
CONTENTS.
Vll
Sect.                                              Page.
      V.      On the firft diftincYion       -    -     125
      VI.     On the fecond diftin&ion    -    -     128
      VII.     On the third diftin&ion       -    -     130
      VIIL    On the evolution of the child      -     134
      IX.     On the diftortion of the pelvis     -     139
      X.      On the feparation of the head      -     142

            CHAP.  XV.  COMPLEX LABOURS.

Sect. I.       On abortion,  and labours  attended
                  with hemorrhage       -       -     145
      II.      On the frequency of abortion in wo-
                  men           -       -            148
      III.     On the treatment of abortion       -     151
      IV.     On the fymptoms  preceding and ac-
                  companying abortion     •    -   *  153
      V.      On  hemorrhages in the three  laft
                  months of pregnancy           -     159
      VI.     On hemorrhages in which the placen-
                  ta was attached over the os uteri      162
      VII.    On  hemorrhages occafioned  by the
                  feparation oi the placenta attached
                  to arty part ot the uterus        -     166
      VIIL   On  hemorrhages which come on af-
                  ter the birth of the child       -     169
      IX.     On the exclufion of the placenta         173
      X.      On the extra&ion of the placenta        178
      XL     On hemorrhages which  follow  the
                  exclufion  of the placenta        -     184
      XII.    On the inversion oi the uterus    -     189

  CHAP. XVI.  LABOURS ATTENDED WITH CONVULSIONS.

Sect.  I.      General obfcrvations on  labours at-
                  tended with convulfions '       -     193
       II.     On the reputed caufes of convulfions     196
       III.     On the figns  which precede  convul-
                  fions          -                   199
       IV.     On the means of preventing  convul-
                  fions          -        -       -     20t
       V.     On the treatment of convulfions         203
      V I.     On the delivery by art       .     -     207 
vm
CONTENTS.
                                                  Page.
  CHAP. XVII.  LABOURS WITH TWO OR MORE CHILDREN.


Sect. I.      General obfervations      -       -     212
      II.     On the fign of twins       -       -     214
      III     On the  management of  twin cafes     2 to
      IV.    On the management of  the placentae     219


CHAP  XVIII.  LABOURS IN WHICH THERE IS A DESCENT OF
  THE FUNIS UMBILICALIS BEFORE ANY PART OF THE CHILD.


Sect  I.      General obfervations      -       -     222
      II.     On the defcent of the funis when the
                  os uteri is but little dilated       -     224
      III.    When the os uteri is fully dilated         ib.
      IV.    Farther obfervations      -       -     22°
      V.  * Onmonfters      -      -       -228
      VI.    On the extrauterine foetus          -     231


                     CHAP. XIX.


Sect  I       On the management of women in-
                  childbed      -      -            *35
      II.     On mania        ...     269
      HI.    On the fwelled  legs      -       -     274 
         INTRODUCTION

                   TO THE

PRACTICE OF MIDWIFERY.
   CHAPTER IX.

       CONTINUED.

     SECTION III.


X)F DIFFICULT LABOURS.
 W ithout fome fettled form of diftinclion,  it will not be
 poflible for  us to comprehend fuch a knowledge of Difficult
 Labours, as will enable us to  condu£l women fafely and pro-
 perly through them ;  or to communicate our knowledge  to
 another perfon. It is therefore neceflary,  in the firft place, that
 we fhould define what  is meant  by the term;  and we will fay,
 that every labour,  in  which the  head of the child prefents,
 ■which is protra&ed beyond twenty-four hours,  fhall be called
 difficult*.

   * Fit partus difficilis et laboriojus, quod  nee modo nequc
 6rdine debito res peragatur, aut pravis aliquibus J'ypmtoma-
 tibus impediatur.  Harv.  Exercit. de Partu.
   Dicitur autem partus tile difficilis, qui cumjeetus vel matris
periculo accidit; vel quia cum gravijfimis fit Jymptomatibus,
 vel tardius procedit, ita ut longo  tempore prematur.   Roder-
 ic. a Caftro Lufitan.
   Partus  difficilis appellatur,  qui aebitas atque ordinarias
 naturae leges nonfervat, Jed longius tempus infumit, tt dolores
Jubito vehementiores, aliaque fymptomata graviora co?nttanti<t
 habit—Riverii Prax, Medic, De Partu difficili.
   Foetus maturi enixus laboriojiflimus.  Linnai Nofolosi^U
   Vol. II.                 B 
>a
INTRODUCTION TO MIDWIFERY.
   This definition, which is chiefly taken from time, is liable t»
 fome obje&ions, as there may be more pain endured, and great-
 er difficulties furmounted by one woman in fix hours, than by
 another in twenty-four;  but on the whole,  it will be found to
 apply to pra£Hce in an  advantageous, and often in an unex-
 ceptionable manner.  It will in particular, afford a remedy for
 impatience,  and guard the practitioner, in fome  meafure, from
 premature attempts to give affiftance, without incurring the dan-
 ger of thofe  evils, which might  be apprehended from too long
 delay.
   Of  thofe  labours,  which come under the denomination of
 Difficult,  there is an almoft enlefs variety in their  caufes or
 degrees.   Some are occafipned by one'caufe alone,  but more
 frequently by a combination of various caufes, though one may
 be more obvious and important than the reft*. For the ufes and
 purpofes of pra&ice, it is not fufficient  to fay, that all labours
 are rendered difficult, either from the greatnefs of the obftruc-
 tion, or by the infufficiency or debility of the power, by which
 the obftruction fhould be overcome ; or,  that fome depend upon
 the mother and others upon the child.   Suchdiftinfctions or re-
 ferences are  too general.   The  particular caufes of every in-
 dividual difficult labour fhould be pointed out,  as  well  as the
 conducl which each fpecific caufe may require.  Thefe  are to
 be ftated by every perfon who  teaches the art, and received for
 the prefent by the ftudent.  But  when ft'udents have gained ex-
 perience, they will, of courfe,  examine and judge the do&rinei
 which they have learned.   For there are advantages accruing td
 every man's own mind from experience, of which no doctrine or
 words  can convey an adequate idea, and thofe who are in pof-
 feflion of it feldom bend  to the rules or admonitions  of others.
 Nor indeed is this to be expefted, except in a very limited
 degree.  It is therefore of the greateft confequence to thofe,
 who have  not yet attained experience,  that they fhould gain,
 and exercife  themfelves  in, the  cuftom of regiftering and ar-
 ranging the particular knowledge they may have an opportunity
 ©f acquiring,  in  regular and fyftematic order, or they will lofe

   *  -4* many caufes  concur in  the produclion of compound
tjfetts, we  are liable to mijlake the predominant caufe, unlefs
 we can meafure the quantity of the effeds to be produced, com.
pare them with and dijlinguijh them from each other, and find
 out the adequate caufe of each Jingle effect, and what mull be
 tiu rejult of their jemt aclion.                          J
                          See  Dr. Defagulien's Preface. 
OF'DIFFICULT LABOUR,                 £
tfie benefit of it; for it will othenvife either be forgotten, or re*
colle&ed with difficulty, when they want to  apply an obferva*
lion made in one cafe to the exigencies of another: and it is
very poflible  that rules may be too refined for general praftice.
To leflbn thefe defefts, and to point out  a better method of
preferving  the advantages of experience, as  well as to record,
in the cleareft manner, what my own has taught me, we will
divide all  Difficult  Labours into four Orders or Kinds, and
then enumerate the  principal  caufes  of each Order.  As the
knowledge of caufes, and the management or  removal of effecH
or difficulties, fhould  accompany or immediately follow each
<Mher, the methods to be ufed for the relief of thefe will at the
fame time be pointed out.
   In the Firft order will be included all thofe labours,  which
are rendered  difficult from the  inert or  irregular a&ion of tha
uterus :
   In the Second, thofe which are occafioned by the rigidity
of the parts to be dilated:
   In the Third, thofe which are occafioned by difprOportioa
between the dimeniions of  the cavity oi the pelvis of the mo*
ther and the head of the child :
   In  the  Fourth,  thofe which are rendered difficult by dif-
eafes of the foft parts.
   Under one or other of thefe Orders may be  arranged every
labour which can be properly  called Difficult.
   This kind  of labour has by many writers been fubdivided
into lingering and difficult;  but as by the former appellation a
lefs degree of difficulty only is meant both with regard to caufe
and effect, the fubdivifion Teems unneceffary.

                      SECTION IV.

                  «N THE FIRST ORPERi

                            OR

 THOSE LABOURS WHICH ARE  RENDERED DIFFICULT  FROM THE
        INERT OR IRREGULAR ACTION OF THE UTERUS.


 1 he a£lion of the uterus, by which every child muft be ex-
pelled, is accompanied with pain proportionate to the force and
to the refiftance made.  But as-this action may become  imper-
 feft, irregular, or infufficient for the purpofe of expelling the 
4
INTRODUCTION TO MIDWIFERY.
child,  it is needful that we fhould be acquainted with  the can*
fes  of  fuch imperfeaion, irregularity, or  infufficiency.  Ok
thefe caufes there is,

          I. The too great diftention of the uterus*

  It was formerly believed,  that the uterus was diftended me-
chanically, by the increafe of the ovum contained in it.  With
this opinion, it might be concluded, that either from the fize
of the  child, or the quantity of water,  the uterus might be
brought into a ftate fimilar to that which takes place in the blad-
der, which, when diftended beyond a certain degree,  lofes all
power  of action.  But later oblervations have proved, that the
impregnated uterus is never completely diftended, nor in any
degree by its contents, but by the operation oi a principle,
which  it acquires in confequence of pregnancy ; which princi-
ple ceafes to aft at the conelufion of the term of  utero-geftation,
and is  immediately fucceeded by another direftly contrary,  that
of expulfion*.   But though the uterus, when in a healthy ftate,
cannot be diftended beyond its power of aftion, occafion has"
been before taken  to obferve, that, from the flownefs, and
fmalmefs of the effeft of the firft pains of labour, the power ex-
erted by the uterus is generally fuited to the ftate of the parts,
and the parts to that of the uterus, with a wonderful coinci-
dence.   Yet as every  principle in nature  may, in particular
cafes,  alter  or  fail, fo that c4 the diftention of  the uterus may
prevail to fuch  a degree, or may continue fo long a time, that
its poflible expulfatory force fhall be weakened, its energy lef-
fened,  and, of  courfe, the progrefs of  the labour be for the
prefent retarded.  This feems  to be proved, not  only  by the
flacknefs and feeblenefs oi the pains in the beginning  of all la-
bours, efpecially in thofe cafes in which  there are two or more
children, but by the increafe of that action, when part of its
contents  are evacuated.   It is however to  be recollected, that
the uterus  cannot be  diftended beyond its power of  action,
though when greatly  diftended it  is capable only  of  flow and
feeble  action,  which  is neverthelefs then fuited to the general
ftate of  the parts,  and preparatory to that which is ftronger.
This flow or feeble action, from diftention, is  not therefore an
 objeft of art;   and it  is perhaps  beyond the influence ot any
earthly power,  to give to the uterus its native or genuine difpo-
fition  to aft, before it is difpofed  to affume  it, to add to its
* See Vol.  L Chap. v. Seel. xi. 
ON  DIFFICULT  LABOURS.
9
power,  or in any material degree to increafe its energy, though'
many applications and medicines have been recommended and
tried for this purpofe.   Human art may put or preferve the con-
ftitution in a ftate beft fitted for fuch aftion,  or it may remove
any impediment to its effeft ;  but the  principle is wholly inde-
pendent of  the will of the  patient, or the fkill of the praftitioner.
When  therefore the pains  of  labour  are  in the  beginning
feeble and flow,  as no harm can arife from  this caufe, either
to the mother or child, except that the former  is under the ne-'
ceffity of bearing them for a longer time, though on  the whole,"
perhaps not in an increafed degree; and as the methods advifed,
and  ufually praftifed,  for the purpofe of accelerating  labours
rendered tedious from this caufe, are  either  immediately inju-
rious, or may lay the foundation of future mifchief to one or
both, it becomes our  duty, under fuch circumftances, to wait
with patience, leaving the bufinefs entirely to it's own  eoirrfe
without any interpofition.  Even when a labour has made con-
fiderable progrefs, and there was reafon to expeft, that it would
have been concluded in a fhort time,  there may be a  fufpenfion
of the aftion of  the uterus for  many  hours, without any mif-
chief or hazard, as experience has often fhewn, though the caufe
of fuch fufpenfion  may  not be obvious to,  or explicable by,
us*.             •
   Immediately on the acceffion of labour, it has been the cuf-
tom to confine women to their beds, or to fome particular po-
fition, on  the prefumption that it would be thereby rendered
more eafy  than in any other.  By fuch conduft,  expectations
of a  fpeedy delivery  are often raifed ;  and  when thefe are
baulked, the mind of the  patient will be difturbed, and the pro-
cefs  become irregular. But it will always be found more com-
fortable and ufeful, to leave the patient to her own choice in
thefe matters,  and her inclination will  be the beft guide.   Time
is the fafeft, and generally the only remedy, for lingering and
tedious  labours  occafioned by the too great diftention  of the

   *  With  the ancients it was a cuftom in thefe cafes, to intro-
duce ajlimulatingpeffary into the vagina: and lately  with a
phyfician  in France,  to  apply a mixture of the berries of the
Bay tree and oil to the navel, in the time of labour, by which
he was fuppofed to do fome good, and certainly gained fome
credit.  It would not however be unreafonable, to try the effeEl
of various applications  to the abdomen Jor this purpofe.  A
do/Jil of lint,  moiftened with  tinft. opii,  applied to  the navel,
does certainly, tnfomt cafes, appeafe  uterine pain. 
6             INtRODUCTlON TO MIDWIFERY*.
 Uterus,  a? u-fcil as by many other caufes: and the patient will
 often find relief, either by walking or Handing, purfuing fomo
 amufement,  or choofing that pofrtion which fhe herfelf prefer*;
 becaufe fhe will inftinftively feek that which is proper.  How-
 ever, in many  fituations of this kind, the repeated exhibition
 of emollient clyfters will be of fervice ;  and when the labour is
 far advanced, in fome cafes in which the aftion of the uterus
 is very feeble and flow in its returns, as if it were unwilling to
 come on,  a clyfter rendered ftimulating by the addition of one
 ounce of culinary or Cathartic fait, will often roufe the dormant
 powers  into aftion, and the labour will be much fooner com-
 pleted*.

              e. Partial aSlion of the uterus.

   It wtw obferved, that  previous to labour the uterus com-
 monly fubfided lower into the  abdomen, and that the  more
 »erfecr this fubfidence was, the more kindly would the labouf
 probably be; becaufe the uterus would aft with more advan-
 tage.  But in  fome cafes, the fundus of the uterus  does not
 fubfide before or even in  the time of labour, the patient herfelf
 being fenfible of, and complaining that the child is then very
 high in the ftomach.  Sometimes fhe will alfo complain of ve-
 hement and cramp-like  pains in various parts of the abdomen,
 producing no  good or adequate effeft, which are afterwards
 proved to have been occafioned  by the irregular contraftion  of
 the uterus.   This irregular and partial aftion, which is proper-
 ly  called fpafmodic, is  capable of  throwing the  uterus into
 various forms;  fometimes the longitudinal, and at others tb#
 honr-glafs, with all their varieties and degrees.   Every change
 ■in  the form of the cavity  of the uterus, from the  genuine,
 Will be productive of inconvenience, according to the peculi*
 arity and degree of alteration ; and it is to be wifhed,  that vt*
 could difcover the means of  altering the form  of the uteruS
 when thus irregular, of fuppreffing its aftion when too vehe-
 ment or diforderly,  and of  ftrengthehing it when  too feeble,
 according to the neceflities  of each  cafe, as they may arife.
 But  as thefe things, are beyoftd our power, and at  leaft  any
 inethod of producing them,  is at prefent unknown : all that we

   * Clyjleres injiciantux, quorum irritatione expultrix uteri
facultas excitatur,  el depleta inteftina ampUorem locum uter*
 rclinquartt.
                  Riverii Prax. Medic. De Partu Difficilr, 
PN DIFFICULT  LABOURS.
?
 ean generally do muft  depend,  not on commanding what we
 choofe, but on making the beft  of  fuch circumftances  as  do
 really occur;  and it is  neceffary to confider, whether by any
 previous management it be poffible  to prevent this irregularity
 of aftion, or remedy its effefts,  when it is in fuch a degree, as
 to  be  very painful or troublefome before, or productive  of
 inconvenience at the time of labour.   When there is any mi-
 ufuad kind of pain in the region of the uterus, greater than,  or
 different from, that which may be confidered as one of the com-
 mon effefts of pregnancy, there is generally an increafe of that
 feverifh difpofition, which in a certain  d«gree  is,  perhaps,
 natural  to all women with child ; and it will then be neceffary
 to take  away fmall quantities of blood, to give cooling medi-
 cines, to be very attentive that the reguja* courfe of the bowels
 be  procured or preferved, and I think I have feen much good
 done by gently rubbing the whole abdonten with warm oil.  At
 the time of labour the fame means may alfo be neceffary and}
 proper, on account of this irregular or  infufficient aftion of the
 uterus and the concomitant pains, which moft frequently hap-"'
 {►en to thpfe who are naturally too irritable, or who lead inactive
 ives.   To  fuch women fhould be pointed out the neceflity of
 acquiring a compofure of mind, and  of ufing exercife in the
 open air as far as their unwieldnefs  will with propriety allow;
 even in the time of labour,  if rendered tedious from this  caufe,
 in which the pains are very fharp yet ineffectual, it is of  ufe t<*
 bear them, when in an ereftpofition, and to walk about as long
 and as often as they are able, in the  intervals.  The chief pari:
 of what can be further done is, to imprefs upon their minds the
 neceflity of exercifing that patience,  which we on our parts
 ought never to want.   In  fome  cafes  of this kind, when  the
 patient  has fuffered much and for a long time,  after bleeding,
 and the  adminiftration of a clyfter, I have dire£ted twenty dropf
 of tind. opii to be given, with the intention of fuppreffing the
 prefent  pain,  which was irregular, and with the hope  that,
 when it  returned, it would be with regularity and efficacy.  But
 jn general I have great objections to opiates on flight occafion* foe
 women  in labour;  being perfuaded that, by difturbing the order
 of labour, they frequently  produce very untoward fymptoms,
 and make that  which was in itfelf natural become difficult  or
dangerous to the mother or child, as  evidently as any other kind.
ef unfeafonableintcrpofition.
               3.  Rigidity of the membranes.

  This  hai been mentioned by the generality of writers, as  a 
^             INTRODUCTION TO MIDWIFERY.
 caufe of difficult labours; and I have obfcrved, when a labour
 proceeds flowly,  the membranes  being  unbroken, that their
 rigidity is ufually affigned as the caufe of  the difficulty or delay.
 This fubjeft has already been confidered  in the hiftory of natu-
 ral labours ; but we cannot too often inculcate, as the obferva-
 tion  is of the greateft importance,  that neither the mother nor
 child is ever in any danger, on account  of the labour,  before
 the membranes are broken ;  and  that there is  infinitely more
 caution required, to avoid breaking them too early, than there
 is difficulty in breaking them when neceffary.  The true^caufe
 alfo, why the membranes do not break at the ufual or  proper
 time, is not in  truth from the rigidity of the membranes, fo
 commonly as from the weak aftion of the uterus ; becaufe the
 membranes are fcarcely ever fo rigid,  as  to withftand the force
 of very ftrpng pains,  and if they were, the whole ovum might
 be expelled at the fame time, a circumftance not unfrequent in
 premature births.   More than one cafe has occurred in my own
 practice,  to which  particular attention has  been paid, for the
 purpofe of regiftering the obfervation, in which the labour has
 commenced  properly, and proceeded with much  activity, till
 the os uteri was fully dilated, and then ceafed altogether for
 feveral days; at the end of  that time the membranes breaking,
 the aftion of the uterus has inflantly returned,  and the  labour
 been finifhed fpeedily,  with perfeft fafety to the  mother and
 child*.
   The circumftances  of labours are however fometimes, though
 very feldom, fuch as  make it not only juftifiable,  but eligible,
 or perhaps neceffary,  to break the membranes artificially. Yet
 before this is attempted,  we ought  firft to be affured of the ftate
 of the os uteri, becaufe this will fometimes be fpread over the
 head of the child,  fo thinly and uniformly, before it is  in any
 degree dilated, as to  refemble the  membranes.  But when the
 os uteri; is wholly dilated, and we have determined upon the
 propriety of breaking the membranes,  no  inftrument is required
 for that purpofe.  If they be confined  with the end of the fore-
 finger upon the head  of  the child, during the time of a pain,

   * When the head of the child is lorn with the membranes un-
 broken, it is faidto be born with a  cawl.   To this  cawl imagi-
 nary virtues have been attributed, and a fancied value has been
fet upon it.   It was efieemed the perquifite of the midwife, and
 perhaps the whole was the contrivance of Jo me intelligent man
 to prevent her from interfering with  any labour, which was
 going on in a natural way. 
                 ON DIFFICULT LABOURS.                r$

 they  generally give way ;  or if this be inefficient,  they  may
 be rubbed with the end of the finger, on one particular fpot, till
 they are worn through ; or they may be fcratched with the nail
 of the finger, cut and turned  up for that purpofe.   I am per-
 fuaded, that  no perfon, who is capable of judging when the
 membranes  ought to be broken, will ever meet with any dif-
 ficulty in breaking them.

     4, Imperfecl dijcharge or dribbling ojthe Waters.

   This circumftance is a caufe,  or  at leaft a frequent attendant
 on Difficult Labouis, efpecially when the membranes have been
 broken defignedly,  or fpontaneoufly, before the os uteri, was
 dilated, though far more  frequently in  the former cafe.  For
 if the membranes do not break, or be not broken, before the
 complete  dilatation  of the os uteri, the whole quantity of the
 water is generally difcharged at once, and the head of the child is
 fpcedily advanced by the fucceeding pains.  Sometimes indeed
 the head of the child is fo placed, as to lock up a great  portion of
 the water, which cannot efcape, till the head is expelled.  Should
 the water be imperfeft'ly difcharged, a further fmall portion of
 it is ufually evacuated whenever there is a pain, and the pain is
 not immediately efficacious, or entirely ceafes after the difcharge.
 In this fituation there are only two methods to be purfued ;  we
 muft  either wait till  all the water is drained away by thefe repeat-
 ed fmall difcharges, or we muft contrive fome method, by which
 their evacuation may be haftened.  It there be no particular rea-
 fon againft our waiting, it is better not to interfere,  but to  leave
 the bufinefs entirely to nature,  explaining the ftate of the cafe to
 the patient or her friends,  taking care to prevent their apprehen-
 fion of danger from the delay of the labour, and not by our foli-
 citude to  raife their expectations or their tears unneceffarily.—
 But when the water dribbles away in the advanced ftate of a la-
 bour, or there is reafon for our wifhing a fpeedy conclufion of it,
 either on account of the mother or child, it will be expedient to
 forward the difchargeof the water, by raifing the head of the child
 a little higher into the pelvis, by the introduction of the fingers
 and thumb of the right hand, which may be done without pre-
judice either  to the mother or child, during the continuance of
 the pains; or by preffing the head  towards  the hollow of the
facrum, by which means more room will be made for the water
 to efcape.  However, the  dribbling of the wafer is not a cir-
 cumftance of much importance, when  it is not combined with
 other caufes of difficulty ;  and it may be again mentioned,  that
   Vol! II.                      C 
XO             INTRODUCTION TO MIDWIFERY.
it is generally occafioned by the artificial or premature rupture
of the membranes.

           5. Shortnefs of the funis umbilicalis.

  The funis umbilicalis feems to admit of a greater variety,
both in thicknefsand in length, than any other part of the ovum
when at its full growth, being in one fubjeft feveral times thick-
er than in an other, or perhaps three or tour times as long in one
as it is found in another.   It may  be naturally very fhort,  or it
may be  rendered fo accidentally,  by its circumvolution round
the neck, body, or limbs of the child.   Whichfoever of  thefe
is the cafe, the inconvenience produced at  the time of labour is
the fame ;  that is, the labour may be retarded; or perhaps the
placenta may be loofened  prematurely ;  or the child may,  in a
tedious  labour,  be injured or in danger of being deftroyed by
the tightnefs of the ligature drawn round  its neck ; or by the
mere ftretching of it, as this muft neceffarily leffen theMiameter
of the veffels, if notperfeftly clofe their cavity.  But the two
latter confequences very feldom follow.
  The fhortnefs of the funis is always to be  fufpefted,  when the
head of the child is retrafted upon the declenfion of every pain;
and it may fometimes be difcovered, that it is more than  once
twifted round the neck of  the child, long before it is  born.
  Various methods  have formerly been recommended for pre-
venting this retraction of thehead, fome of which are infufficient,
and others unfafe*;  and the inconvenience is ufually overcome,
by giving the patient more time.  But  if the child fhould not
be born,  when we have waited as long as we believe to be pro-
per or confiftent with its fafety, or that of the parent,  it will be
requifite to change her pofition, and inftead of fuffering her to
remain in a recumbent one, to take  her  out of bed,  and  raifc
her upright, to permit her to bear her pains in  that fituation ;
or according to the ancient cuftom of this country,  to let her
kneel before the bed, and lean forwards upon the edge of it; or,
as is now praftifed in many places, to fet  her upon the lap of
one of her affiftants.  By any of  thefe methods the retraction
of the head of the child is not only prevented by its own gra-
vitation,  but the weight of the child will be added to the power
of the pain ; and it will  likewife be expelled upon an inclined
plane in-lead of a level.  In the courfe of practice, I can  with
infinite fatisfaQSon recolleft a great number of cafes, in which,

  *  Nocet objletricis digitus ano  immffus, item nimia, fcfti-
vatio.—RuyJ'ch. 
                 ON DIFFICULT  LABOURS.                11

By adverting to  the benefits to be gained by an erefi pofition,
labours have not only been accelerated, but the ufe of inftru-
ments,  which were before thought neceffary, has been avoided.
   When  the  head^of  the child is  expelled, if the Jums- be
twilled round its neck,  there is fometimes a little delay and diffi-
culty,  before the body can be protruded or extrafted.  We are,
in the  firft place, taught, that it is proper to bring this over the
head forwards, left the placenta fhould be feperated, or the body
of thcchild be hindered from advancing till it fuffers detriment,
or is brought into abfolute danger. But it is in fome cafes drawn
fo tight round the neck, that this cannot be done, without increaf-
ing  the hazard of the mifchief we wifh to avoid.  We have
then been advifed to Aide the Jums back  over the flioulders,
but this may be equally imprafticable with  the former method.
It either of thefe intentions  can be accomplifhed without  vio-
lence,  they  are  to be attempted, otherwife  they muft be omit-
ed.  The child will neverthelefs be  expelled, if we wait for the
return of a few pains, which we may fafely do, and without any
other inconvenience than fome increafed diftention ot the per-
ineum ; the  body making a fhorter bend or doubling,  on ac-
count  of the confinement of the neck by  the  twitting ot the
funis,
   Inftances have occurred, in which, though the head of the
child was expelled,  and the pains continued,  the body  has re-
mained, and  could  not even be extrafted  with  all the force
which  could be exerted, for a long time,  perhaps  for  feveral
hours.  Two things are then to be confidered, firft, whether
the child be living;  fecondly, whether it be hindered merely by
the  fhortnefs of the funis.   If a child in  this pofition  fhould
fhew  any figns  of  life, if  the  pulfation  in  the  navel-ftring
 fhould be vigorous,  or the child fhould breathe, though imper-
 feftly, we have no occafion to  be in a hurry, it being  only
requifite, that we fhould keep its mouth open, to allow ot the
 free accefs of the air, till it is expelled,  or can be more readi-
 ly extrafted ; for the internal organs will accommodate them-
 felves  to that ftate, and the child will poffefs a fpecies ot life
 half uterine, and halt breathing.  But when it has remained in
that fituation as long as we think confiftent with its fafety, and
 it cannot without great violence be extrafted ;  fhould it then be
 hindered by the fhortnefs of thej'unis only, we have been taught*,.
 that it is advifeable to divide the Jums,  before the body is ex-
 pelled.  Previous to our doing this, it will however be expedi*
* See Chapman—p. 63. and 85. 
18             INTRODUCTION TO MIDWIFERY.
 ent to tie the funis with two ligatures, and then to divide it
 between them, otherwife the child will be inftantly deftroyed by
 the fudden gufh of blood;  as happened in an unfortunate cafe
 under my own care, though  it was living when I divided the
funis, and was afterwards very foon expelled.
   When the child is dead, and the  total exclufion  of it is pre-
 vented by the tumefaftion of the body, by the fize or awkward
 pofition of the fhoulders, or any other caufe ; by paffinga nap-
 kin or handkerchief round its neck, and taking both the ends in
 our hands, we fhall be able conveniently  to exert much force ;
 and it we pull fteadily and in a proper dircftion,  we fhall ufually
 fucceed in  extrafting it.   But  it  we be yet foiled in our at-
 tempts,  by  turning the head on one fide, we muft endeavour
 to bring down one or  both arms, which being included in the
 handerkchief, will allow us tfo pull with yet more force, and fa-
 cilitate the  paffage of the  body, by  leffening  its bulk.  The
 greateft difficulty of this kind I ever faw, was  in confequence
 of the inflation  of  the whole  furface of the body from  its
 putretaftion,  and there was occafion for all the force I could ex-
 ert  for  feveral hours.  But  in other cafes  I have  fucceeded
 better, by availing my felf of the changes  produced, by waiting
 and  giving more time, rather than by the  exertion  of much
 force.   The  cafe of one woman, who abfolutely died  under
 thefe circumftances, was related to me; but I could not fatisfy
 my  mind, that her death was to be attributed merely to this
 fituation and retention of the  child.

               6.  Weaknefs of the confiitution.

   The health of women  at  the time  of parturition  is  often
 impaired, either by fome general indifpofition, which may have
 continued through pregnancy, though not altogether dependent
 upon it; or by fome difeafe with which they are attacked,  when
 they are perhaps in  daily expeftation  of falling into labour.
 The more perfect, their health is, the better fitted they are for
 child-bearing, as the  procefs will  not only  go on with  more
 regularity,  but they will alfo recover  more favourably, as is
 well known  to thofe who are engaged in the praftice of mid-
 wifery.  Becaufe, though it be allowed,  that the ftate of chijd-
 bearing is not a ftate of difeafe,  yet experience has  fhewn, that
 women are then more liable to be infefted with contagious dif-
 eafes than at  any other time, and that all difeafes,  with which
 they are then affefted, are not only apt to fall upon thofe parts
 which are left in a more irritable ftate,  in confequence of the 
ON  DIFFICULT LABOURS.                 1J
changes they have fo lately undergone,  but the progrefs of dif-
eafe  is alfo then more violent, and the event far more  danger-
ous*.
  But the cafe of which we are now fpeaking is, when the ge-
neral health of women is reduced below its proper ftandard,  by
fome previous or accompanying difeafe, not abfolutely  connec-
ted with a ftate of pregnancy ; ot which a confumption is a very
fair example,  as confumptive perfons feem  of all others to be in
the moft hopelefs ftate.  Yet though fuch are often in their own
minds, and in  the  opinion of their friends,  not able  to  go
through  the  fatigue and  other  unavoidable  confequences  of
child-bearing, I do  not recolleft one inftance of any  woman,
in that fituation,  being unequal to her delivery,  or having her
fate haftened  by it.   If  fuch women have little ftrength, they
have little difficulty to overcome ; the ftate of the parts,  which
in a common way might  require the exertion of much force to
dilate, correfponding with the force which they are able to exert;
and more time only is required.   When a prognoftic however is ■
made of the probable event of fuch labours,  it is to be prefum-
ed, that  no  particularly  untoward circumftance fhall occur ;
for if there fhould,  it cannot be expefted,  that with extreme
debility  there fhould be  the fame  power or refources,  as in
great ftrength and good fpirits.
   In conftitutions much reduced by a confumption, or  difeafe
of any  part not immediately affefted by child-bearing, there is
ufually not only fufficient ftrength for pertefting the bufinefs of a
common labour, but the patient appears  to be relieved for  a
certain time  after her delivery ;  and then, if the difeafes were
not dependent on pregnancy, or were incurable, they return ,and
make their wonted progrefs.
   The  effeft of difeafes feems alfo, in many cafes, to be fuf-
pended  during pregnancy.  Of the diftinftions to be made in
the opinion we may  be called upon to give of the event of acute
djfeafes,  during which a patient may either be delivered at  her

   * Hence at the time oj any epedemic difeafe, women more fre-
quently fail in child-bed, though they are managed with equal
Jkill and care.   In  the hiftory of the different plagues in Lon-
don, there are fometimes two or three hundred women who  are
put  down as dying in child-birth in one month.   Procopius has
alfo told us  in his account of the plague at Conltantinople—
Ties faltem puerperae convaluere ; that is, Iprefume, of thofe
who aclually had the plague.  On this Jubjecl  we fhall Jpeak
mgain in the  chapter on the puerperal fever.  • 
*4
INTRODUCTION TO MIDWIFERY.
full time, or fuffer abortion, we fhall  fpeak when we come to
the fubjcft of uterine hemorrhages.

               7. Fever or local inflammation.

   On theacceflion ot labours,  there is ufually fome increafe of
heat, of the quicknefs of the pu'fe, thirft, flufhed cheeks, and
a" general feverifh difpofition ; and  commonly thefe continue in
proportion to the exertions required or made tor the completion
of the labour, with refpeft to which they are,  properly fpeaking,
merely  fymptomatic.  But in fome cafes the excitement is too
great, and inftead of helping the aftion ot the parts  concerned
in paturation, it prevents their afting with regularity  or energy.
Whenever the pains of labour are  feeble, it is a vulgar cuflom,
without regard to the caufe, to give cordials very freely,  with
the view of accelerating their returns, or of ftrengthening them,
though, under many circumftances,  by fuch proceeding* we
evidently add to the evils we mean to remove.  In fome cafes alfo,
from the acutenefs and conftaiicy of the pain which  the patient
endures, and from its fituation  alfo, it  may  be readily diflin-
g"uifhed from that which is occafioned by the aftion of the ute-
rus,  giving us too  much rcafon to  fufpeft,  that fome of the
contents of the abdomerrare already in a ftate of inflammation,
Which may require immediate attention.
   It does not feem neceffary to bleed every  patient  on the ac-
eeffion  of labour, and for fome it muft be  highly  improper.
But wheneve r the feverifh fymptoms become violent, it is I
believe univerfally  proper, the quantity ot blood taken away
Ueirig fuited to the degree of fever, and to the* conftitution of
the patient; and much fervice will alfo be done by the frequent"
exhibition  of emollient clyfters, or even a common purging
draught, by keeping the  room  cool  and well aired,  by giving
cooling drinks and medicines,  and by keeping the patient in a
<juiet ftate.   When the fever is removed, the natural pains will
come on, and perform their oUace  with propriety and fuccefs,
Independently of fever,  when the  exertions  which the patient
makes are vehement, if fhe be plethoric, there  is on that ac-

  * Lord Bacon feems to have had a clear idea of this, though,
by the manner cf  expreffion, his meaning is renderedJ'omewhat
objeure.- "  To  procure ea/y travails of women, the  intention
is  to bring down the child, whereunto they Jay  the  load/tone
kelptth  ; but the beft help is tojlay the coming down  toofaft."
                                  Nat. Hift. cent.'x. 0,68. 
ON DIFFICULT LABOURS.
*5
■count fometimes a neceflity of taking away fome blood ;  tor du-
ring thefe vehement exertions, if the blood-veffels be diftended,
fome  of them  may give way, and the patient be brought into
the moft imminent danger, before the delivery, then at hand,  is
completed.   Of  one inftance I have been informed  by the
medical  attendant,  in which a  patient, thus circumftanceJ,
burft a blood-vellel in the lungs,  and died immediately, in the
exertions of the very pain by which the child was expelled.

         8. Want of Irritability in the Confiituticn.

   Under many circumftances which  occur in the praftice of
medicine, it has been obferved, that when a caufe ot  pain exifts,
it is found  to produce an effeft quite contrary to what might be
expected ;  that  is, inftead of exciting the powers of any one
part,  or of the whole frame to action,  it creates a partial  or
univerfal   infcnfibility,  and  a  difproportionate aftion.    la
fome  cafes, on the acceflion of labour, the  caufe, inftead of
raifing a dif pofition to a£t, or a power of acting with energy, in
the parts concerned, feems to leffen  both the difpofition and
power to aft, and fometimes evgn to deprive them,  for a certain
time, of all power, as effectually as if they were become  para-
lytic.   Inconveniences of this kind are moft frequently obferv-
ed to take place in fatand inaftive women ; and fuch, in fpiteof
all the means which can be fafely ufed,  will neceffariiy  often
have  very flow  and lingering  labours; and  though  they at
length be  delivered  by their pains, feeble as  they are,  when
there is no material  caufe of obftru6iion, much time will be
required for every part of the procefs.   I have often fu/pefted,
that the foundation of this imperfect, aftion, or total inaction in
the advanced flate of labour,  may have been laid by fome  error
or accident in the beginning, perhaps by exciting the aftion pre-
maturely,  which will, of courfe, ceafe when the artificial  caulc
is removed* ; but fometimes thefe imperfections have evidently
been occafioned by fome fpeciiic affection or aftion  of the con-
stitution.                                              ,
   The circumftances attending labours are generally alike, yet
in many women they are   marked with fome peculiarity,  moft
frequently in the time required  for their  completion. ' When
there has been  an opportunity of obferving the progrefs of a la-
bour  in two or three inflances,.we fhall. be able to tell what will
be the probable  termination of any future labours in the fame
•See Vol. 1. Chap. v. oV7:ci. 
 tfi            INTRODUCTION TO MIDWIIERY.

 perfon, and at what time it will take place;  but we car. no more
 control the order of a labour in one woman, fo as to make it
 correfpond with or exaftly referable that of another, than we ran
judge of the quantity of food which one perfon may require by
 that which is  fufficient for another, or regulate any other func-
 tion.   One woman may require twelve hours for the produftion
 of the fame effefts in the time of labour, that another may fi-
 nifh in four hours,  or even in lefs time; and it would be in vain
 to attempt to make an alteration by art, becaufe the reafon exifts
 in fome effential property of the conftitution,  beyond the pow-
 er of medicine, or of any method to alter.


                9.  PaJJions of the Mind.


   As the infirmities and particular ftate of the body, have a
 powerful influence upon the mind, and as  the  affeftions of the
 mind have, on  various occafions, a reciprocal effeft upon the
 body,  it might  be  reafonably expefted,  that the progrefs of a
 labour fhould fometimes be torwarded or hindered by the paf-
 fions.   It  is conftantly found, jhat the fear of a labour, or  the
 fame impreflion from any  other  caufe  at the time of labour,
 often leffens the energy  of  all the powers of the  conftitution,
 and diminifhes, or wholly fuppreffes  for a time, the  aftion of
the parts concerned in parturition.  It is alfo obferved,  that a
 cheerful flow of the fpirits.  which arifes from  the  hope of a
happy  event, infpires women with an activity and refolution,
 which  are extremely ufetul and favourable in that fituation.  In
the time of a labour  proceeding  very flowly or irregularly,
doubts and fears in the mind of the patient have an evident  and
great  influence upon the pains;  and when thefe are removed,
and her refolution confirmed,  fhe will go on with courage,  and
effefts  will be  produced, which would  have been impoffible,
if fhe  had remained in a ftate of depreffion.  The intelligent
practitioner, who fhould  be the laft perfon to defpond,  will avail
himfelf of  the knowledge of  thefe things, and by his difcretion
he will infpire  his patient with fentiments,  which  will enable
her to  go through difficulties, which to her feelings, and  per-
haps to his own judgment, appeared infurmountable.  He will
alfo regulate the conduft ot  all her attendants  and  friends,  and
lead them ftepby ftep to  co-operate in his views and intentions,
which  will at length terminate to the real advantage of his pati-
ent, the fatisfaftion of her friends, and the increafe ot his own
reputation. 
ON  DIFFICULT LABOURS.
*7
                 10. General Dejormity.

  Many women, who are gibbous or diftorted in the courfe of
the fpine, have the pelvis well formed ;  and there are a few in
general appearance perfeftly ftraight,' who have yet fome de-
left in the pelvis.  Of  the eafe or difficulty of  labours, de-
pending  fimply  upon the capacity or form of the pelvis, we
are to fpeak in another place.  Thofe who are gibbous, are not
untreqUently afthmatic, or have fome infirmity which prevents
their breathing freely, or retaining their breath; and fuch muft
fuffer fome inconvenience at the time of labour,  though the ac-
tion of the uterus may be proper, and all the parts concerned
in  parturition in a natural  ftate.  For as both the inftinftive
and voluntary force, efpecially  the latter,  are affefted by the
manner of breathing,  and duly exerted only when the breath is
retained,  and this not being under fuch  circumftances poffible,
of courfe the progrefs of the labour muft be retarded.  Should
there be any reafon  to fufpeft inflammation about the  thorax%
particular attention muft be paid to it, otherwife we have only
to give more time tor the completion of the labour,  and to wait
for that effeft from a repetition of feeble pains, which, with-
out this inconvenience,  would havebeen produced byafmaller
number.   I have known one inftance  of  a patient labouring
under a fit ot fpafmodic afthma, who was immediately treed from
the afthmatic fymptoms  on the acceffion of the pains of labour.
    SECTION V.


ON  THE SECOND ORDER;
THOSE  LABOURS WHICH ARE RENDERED DIFFICULT BY  TH.8
         RIGIDITY OF THE PARTS TO  BE DILATED.

                      1. Firjl  Child.


JLLvery  woman is expefted to fuffer greater pain, and to have
a more tedious labour with her firft, than with fubfequent chil-
dren, and the difference is not unufually in proportion to the
  Vol. II.                 D 
it            INTRODUCTION TO  MIDWIFERY,
  number which fhe  has had*.  Thus if a woman  were to be
  twenty-four hours in labour with her firft child, fhe might be
  fix with her fecond, and wijth the reft four, or perhaps two ;
  but from any general eftimate of this kind there will be many
  deviations.  It was before  obferved, that  when women have
  had feveral children, the practitioner is often able to form a to-
  lerably precift opinion of the kind ot labour, which they will
  in future be likely to have, and which may be as peculiar to their
  conftitutions, in manner and time, as any other funftionof the
  body.  It is no more in our power to change this conftitutional
  labour, as it may be called,  than it is to  alter the frame of  the
  body, or any of the functions thereon depending.
, The difficulty,  with which firft labour* are often  completed,
 "not only depends upon the greater rigidity of the parts, or up-
 on  their re-aftion, but on the imperfection  or  irregularity of
 the aftion  alfo,  by which they are to be. dilated ; for this^is ge-
 nerally far lefs perfeft and regular in the  firft  inftance, than
 when the fame office has been frequently performed, as in ma-
 ny  inftances which might be adduced.  But though there is a
 fomewhat greater chance of women wanting affiftance with firft
 labours than in fubfequent ones, there may he no fpecific caufe
 of difficulty, and they generally require only more time to be gi-
 ven for their completion.  We are to remember,  that even with
 a firft child it would not be proper to denominate a labour diffi-
 cult, till it had continued twenty-four hours,  if the prefentation
 were natural,  and no other adverfe circumftance fhould occur.

                   2, Advanced in Age.

   If a woman be far advanced in age at the time of having her
firft child, the difficulty attending her labour may be expeft-
ed. to be greater.   At a certain  time of life every woman  ar-
rives at maturity,  or that  period  when  fhe may  be confi-
dered as having acquired the  greateft degree  ot  perfection,
of which  her frame is capable; when  the inconveniencies of
youth are paffed, and thofe of age are not arrived.   The ftate
of perfection, the time of which will vary in different conftitu-
tions and climates,  and which may be determined as the beft fit-
ted for the  aft of parturition,  may include feveral years.  But
if a woman fhould  firft be with child before or after this time of
perfsftion,  fhe will be liable to difficulties,  as in the one  cafe
ihe would be fcarcely able to bear without injury the changes

  *  / have heard a voice of a woman in travail, and the an-
guifh as of her that bringeth forth her firft child.
                              Jeremiah chap. iv. ver. 31. 
•F DIFFICULT LABOURS,                1(>
 the muft undergo;  and in the other, thefirmnefs, which all the
 parts have acquired, might leffen their difpofition or capability
 of dilating.  Greater  force will therefore be neceffary, or the
 fame degree of force muft be continued for a longer .time in the
 fatter cafe; in other words, fhe muft have a (harper,  or a longer
 labour.  In  this country there has feldom been  any reafon  to
 fufpeft women to be pregnant, before they were able to bring
 forth  children without  any or much inconvenience on that
 account.   For the prevention of fuch difficulties,  as may  at-
 tend the firft aft ot parturition in thofe  who arc advanced  in
 age,  we have been advifed to order frequent and fmall bleedings
 towards the  conclufion of pregnancy,- that the  patient fhould •
 take fome emollient laxative medicine, and fit over the fteam ot
 warm water every night at bed time,  and afterwards anoint  the
 external parts with fome unftuous application.  Perhaps there is
 not authority for faying,  that no advantage can be derived from
 the ufe of thefe or fueh like means ; but certainly the impreflion
 made upon the mind of the patient by the novelty and peculiarity
 of the method will, in patients of a timid difpofition,  raife fuch
 apprehenfions of danger and difficulty, as  will over-ballance  the
 good which can poffibly be derived from  them.   It is therefore
 better,  to omit the ufe of any fuch means on this account; at
 leaft, not to recommend  them in a formal way, for this fpecific
 purpofe, more  efpeciaHy as it does not conftantly happen,  that
 the difficulty of  labour is in proportion to the age of the patient
 when fhe has her firft child; this being in many cafes as eafy at
 forty years of age or upwards, as if fhe were only twenty-five.
 In the worft labours arifing from this caufe, there is no peculia-
 rity m the difficulties, but merely a general  increafe of thofe
 which are produced by the rigidity of the parts,  and therefore a
 longer time only is commonly required for their completion.

          3. Too early Rupture of the membranes.

   The premature rupture of the membranes, whether natural or
 artificial, has been  often mentioned as the caufe of much mif-
 chief, and of many tedious or difficult  labours.  It it be al-
 lowed, that the membranes containing the waters were intended
 to be the medium by which, the os uteri, and other tender parts,
 ought to be dilated, fome inconvenience  muft arife when thefe
 are broken and the waters difcharged, the  head of the child be-
 ing fubftituted for diem ;  and this, being a firmer and lefs  ac-
 commodating body^annot, for a long time, be admitted with-
 in the circle of  the os uteri, which will of neceflity be dilated-
more untowardly and more painfully. 
SO             INTRODUCTION TO MIDWIFERY.
  , AfteT the rupture of the membranes, many hours,  or  feve-
ral days,  fometimes pafs before the acceffion of labour, and the
difficulties arifing from this caufe, even in firft labours,  will then
be very much leffened, if the patient have generally lain in a re-
cumbent pofition, and we have deferred, as far as was in our pow-
er, the coming  on of the aftion  of the uterus,  till  the  moft
perfeft difpofition to dilate was previoufly affumed by the parts.
   More pain will be endured, and a longer time will  csrtainly
be required for  completing labours attended with this circum-
ilance  only, principally thofe with firft children ;  but they may
in general be more properly called lingering or tedious, than re-
ally difficult, and they very feldom require the interpofition of
art.
              4. Oblique Pofition of Os Uteri.

   The natural pofition of the os uteri at the commencement of
labour, and that  in which it is moft conveniently diftended, is
at the  centre of  the fuperior aperture of the pelvis ; for when
thus placed, the effeft of  the aftion of the uterus is  moft fa-
vourably produced.   But the os uteri is feldom found exaftly
in this fituation, being in fome cafes projefted on either fide,
and in others fo far backwards, that it cannot even be felt for
many hours after the labour has begun.   This oblique pofition
Of the os uteri, to what  direftion foever it may tend,  has been
confidered not only as a frequent, but as the moft general caufe
ot difficult  labours; and  this doftrine, which was firft  pro-
mulgated by Deventer, was, at one period of time,  taught and
received in all the fchools of midwifery in Europe,  in every
inquiry atter knowledge, in almoft any fcience, opinions  may
be advanced,  which fometimes lead to further improvement;
but  when experience has proved, opinions'fhould end ; for if
fo much regard  be paid to opinions, as to found any certain
practice upon them,  and they fhould prove erroneous,  they, be-
come  the fource ot much mifchief,  the  praftice remaining,
"when the doftrine on which it was founded may have been dis-
proved, become  abfolete,  or  forgotten.  The  prefent cafe  is
a ftriking example of the truth of his obfervation; for when it
was prefumed, that every difficult labour was occafioned by the
oblique pofition  of the os uteri, it waS immediately" fuppofed
neceffary to remedy the inconvenience thence arifing by manual
affiftance, and to drag the os uteri  from its oblique to a central
pofition during the time  of every pain, which muft have been
greatly prejudicial.  The opinion of the oWque pofition of the
os uteri being the chief caufe of difficultilabours was foon fully 
ON  DIFFICULT  LABOURS^                mi
proved to be  erroneous, yet the practice remained.  Though
it were oblique,  fuch pofition is not to beconfideredas a gene-
ral caufe  of  the  difficulty,  but as an accompaniment of fome
other  primary caufe.  Thus  when the pelvis is diftorted,  the
os uteri is conftantly found in an oblique fituation, yet the dif-
ficulty of the labour, as well as the obliquity,  is occafioned by '
the diftortion.
  It muft however be allowed, that fome labours are procrafti-
nated by the mere oblique pofition ot the os uteri,  and that it is
often  combined with other caufes of difficult labours, though,
fingly, it may not be of  fufficient importance, to be the caufe
of truly  difficult ones.  But when it does retard a labour,  or
accompany a difficult one,  it does not require any manual af-
fiftance,  or that we fhould retraft it to a central pofition with re-
fpeft to the cavity of the pelvis ;  both the thing itfelf, and the
difficulty thence arifing will be obviated, without detriment or
much trouble, it the patient be confined to a proper pofition.
If,  tor example, the os  uteri be  projected to the left fide, fhe
ought to reft as much as poffible on the fame fide, and fo of the
right ; if it  be projefted backwards, which is always the cafe
when we cannot reach the os uteri in the beginning or early part
of a labour,  fhe  ought to lie upon her back.  By this method
the fundus  of the uterus-,  conftantly leaning or inclining to the
fide of the obliquity, will gradually but effectually projeft the
os uteri more and more towards a central pofition.
  Cafes have been recorded,  in which  it was faid, that the os
uteri was perfeftlyjclof'ed, and in which it has not only been pro-
pofed to make an artificial opening inftead of the clofed natural
one, but the operation has aftually been performed, the  labour,
it is faid,  being thereby accelerated, the patient recovering with- '
out inconvenience.  I do not know that I fhould be juftified in
faying, that  fuch cafes have never occurred, becaufe they have
not occurred in my practice ;  but I am perfuaded, that there has
been an error in this account, and that what has been, in fome
cafes, called a perfeft cloture of the os uteri has not been fuch,
but'that" the practitioner has, at an early period of a  labour,
been unable to difcover it by reafon of its obliquity.

            5. Extreme Rigidity of the Os Uteri.

  Difficult,  as well as tedious and very painful labours are fre-
quently occafioned by the unufually rigid ftate of the os rteri.
The manner of, and the time required tor, its dilatation, will
depend upon two circumftances;  firft, the degree of difpofition 
 ft*            INTRODUCTION TO  MIDWIFERY.

 to dilate which it may have previouffy acquired ; and fecondfy,
 the degree or force of the aftion exerted by the uterus.  The
 former of thefe is, in general, far lefs perfect with firft than
 with  fubfequent children, as well as in premature labours,  even
 prefuming that it was in its moft natural ftate ; but when the os
 uteri affumes from any caufe a ftill greater indifpofition to di-
 late,  of courfe the labour will be b, oth more difficult and tedious.
 In a firftlabouf it hot unfrequently happens, that the os uteri may
 riot be dilated in lefs  than twenty-four or even  forty hours,
 when the reft of the labour may be completed in four,  or per-
 haps  a fhorter time, yet  the very fame perfon may have the
 whole procefs with her next child completed within fix hours,
 or even a fhorter time.
   We have before taken notice of the advantages  arifing from
 the changes In the ftate of the foft parts being pertefted, before
 the acceffion of labour.  But when thefe are as favojlrable as
 can b.e wifhed,  by the  very action of  the uterus preffing its con-
 tents  upon the os uteri, and much more frequently by attempts
 to dilate it artificially,  this part may become inflamed, and indif-
 pofed to dilate according to the degree ot inflammation*  The
 inflamed ftate  of the part  is often  indicated by its heat and
 drynefs; but  whenever  it is  extremely rigid, and  there has
 been  a long continued aftion of the 'uterus, with little or no
 advantage, the impediment to the progrefs of the labour being
 clearly occafioned by the  refiftance made by the  os  uteri,  I
 believe it is always right to confider that part as inflamed.  If
 this be allowed, inftead of attempting to dilate it artificially, it
 is the proper objeft  ot  art, to recover  in the firft  phvce the
 natural difpofition to dilate,  and then the pains of labour will be
 equal to the purpofe.   With  this view it will be neceffary  to
 take away fome blood,  to give cooling  medicines and  drinks,
 to direft emolient  clyfters to be frequently injefted, and, in-
 ftead  of ufing any  means with the  intention  of increafing the   j
 force  of the pains, to confine the patient to a recumbent pof- *  ^
 ture;  to gain,  if it were  in  our power, a  fufpenfion  of the
 labour, till the inflammatory difpofition  be removed, when the
 dilatation will proceed more fpeedily, lefs painfully,,  and with-
 out danger of affecting the conftitution.
   When a labour comes on prematurely, or  before the parts
have acquired their dilatable ftate, as it may be called,  the po-
 fition  of the os uttriviiW at that  time  be very  different.  In
fome  cafes it begins to dilate when it is high  up in the pelvis*
but in others, efpecially when the pelvis is, in comparifon with
the child, very large,  the os uteri may be protruded very low 
ON DIFFICULT  LABOURS,                «J
down before there is any degree ot dilatation,  though it is fpread
fo thin  over the head  of the child,  or the  membranes,  as to
give the feel of the membranes alone.   If, under thefe circum-
ftances, the external parts fhould be  much relaxed, and the
pains at the fame time  ftrong,  it is poflible for the head of the
child to be expelled, though enveloped in  the  os  uteri, and
much mifchief  may be thereby occafioned*.  For the preven-'
tion of this accident, or any tendency to it,  when there is rea-
fon to dread it,  the patient ought to be confined to an horizontal
pofition, and the practitioner to  reftrain^he advancement of the
head ; or,  it the cafe  fhould aftually have happened before ho
was called, he muft ufe all the means he fafely can, to extricate
the head,  and to fupport or replace the  os uteri.   When the
pelvis is large, and the  head of the child, being moved from its
retting place upon  the pubis,  drops by ks own weight into the
lower part of the  cavity of  the  pelvis, bearing the os  uteri
before it,  the accident often becomes a caufe of a procidentia*
oxprolapfus of the uterus, which cannot, as far as I know, be
always prevented.   All that art diftates to be done  at the tima
of  labour, is to render this as flow and gradual as poflible, and
after delivery to confine the patient longer to her bed, ufing at
the fame time fuch applications as may ftrengthen the tone of
the parts,  without  interrupting the cuftomary difcharges.

        6.  Uncommon  Rigidity oj the external Parts.

   The ftate of  the external, as well as of the internal parts is
very different in different women, both in the beginning and in
the  progrefs of labours.  Even in  firft labours they  readily
yield in fome women, fo as'to allow the head of the child to
pafs through them with.great facility and fafety, but in others
they are extremely rigid and unyielding,  and withftand  the ac-
tion of the uterus, though ftrong, for a very long  time  ; and
then do not dilate without great danger of laceration.  A  more
difficult dilatation is  always to beexpeftedin firft labour than in
others,  and more care is required to prevent a laceration.  In
the original ftrutlure or formation of thefe parts there is  alfo a
confiderable difference, as  well as in their ltate or  difpofition,
and thefe  require fome attention in every labour.  There ought
to  be, and ufually  is  a  correfpondence between  the*ftate of
the  parts  and  the  power of the  pains:  but  in fome cafes the

   * Os uteri aliquaitdo prolabitur—RuyJch,  Obf. Anatom.
XXV. 
4«             INTRODUCTION TO MIDWIFERY.
 external parts are rigid  when the pains are feeble,  whilft in
 others, when the parts  are indifpofed  to dilate, the  pains are
 exceedingly ftrong,  pufhing, with unabating force, the head of
 the child, fo that the parts muft either dilate or be lacerated.  Of
 many of thefe circumftances we have already fpoken.
   In firft labours the external parts may require one, or feveral
"hours continuance of the pains, before they are fufficiently dila-
 ted to allow the head of the child to  pafs through them without
 danger of laceration ; but the difficulty thence arifing does not
 feem to require, or to be relieved by our interpofition, farther
 than to prevent  injury as far as that  is in  our power,  from too
 fpeedy an exclufion of the head  of the child, in the manner be-
 fore advifed. The merit of our conduft under thefe circum-
 ftances will be  chiefly  negative ;  for if we cannot give to the
 parts their difpofition to dilate, and ought not to dilate them
 artificially,  there only remains for us to wait the due time in or-
 der to avoid mifchief;  art being more  frequently exercifed on
 fuch occafions  in remedying the evils,  which the  miftaken
 exercife of the  art  has before produced,  than in  reftitying
 thofe which are neceffary or unavoidable.  It  is alfo  to be ob-
 ferved, when the head  of  the child  paffes through the  inferior
 aperture of  the pelvis with difficulty,  though the external parts
 are preffed upon with confiderable force, that the impediment to
 the delivery does not^always arife from the refiftance made by
 thefe, but properly  fpeaking from the elongation or bending of
 the fpinous proceffes of the ifchia,  and the labour fhould the*
 be referred to the next order.
                       SECTION VI.

                   ON THE THIRD ORDER j

                              OK

  LABOURS RENDERED  DIFFICULT BY DISPROPORTION  BETWEEN
    THE DIMENSIONS OF THE CAVITY OF  THE PELVIS  AND  THX
    HEAD OF THE CHILD.

         •     i. Original Smallnefs of the Pelvis.


   J. HE cavity of the pelvis in women  generally bears a certain,
  proportion to the common fize of the heads of children ; yet as
* they both admit of confiderable variation, independent of dif> 
ON  DIFFICULT LABOURS.                £5
toption or difeafe,  it is poflible,  that a woman with  a pelvis
rather under the common dimenfions may have conceived  a
child far beyond the ufual fize j  and when this is the cafe, there
muft of  courfe be an increafed difficulty at the time of  parturi-
tion. When therefore the fmallnefs of the cavity of the pelvis,
and the  largenefs of the head of the child are mentioned,  they
are to be  confidered as relative and not as pofitive terms; be-
caufe the  pelvis of fome individual woman may be fo large,as
to fuffer the largefthead of a child, ot which we* have  any ex-
ample,  to pafs eafily through it; and the fmalleft head may he
efteemed large, if  compared with a yet fmaller pelvis.
   Though a labour may from either of there caufes, feperate or
combined, be rendered more tedious and pairttul than rfual, as
in Confequence of the  aftion of the uterus the head of a  child
rather larger than ordinary will be compreffed into a much lefs
,compafs,  and moulded to  the form as well as the demenfions of
the cavity of the pelvis, there is not ufually occafion for the af-
fifiance of art, if the labour  be in other refpefts natural.   But
we are to wait patiently for thofe changes, which  in due time
may be  reafonably expefted,  and fcarcely ever fail to take place.

                2. Diftortion oj the Pelvis.

   On the caufes, kinds, and degrees of diftortion of the pelvis,
we have already fpoken very fully*.   The  effefts produced,
or the impediments occafioned by this diftortion,  at the time of
partnrition,  will fomewhat depend upon the part  diftorted, or
upon the kind of diftortion, but chiefly on the degree of change
made in,  or reduftion of, the dimenfions of the cavity, by
which the natural relation  between it and the fize of the head of
the child is perverted or deftroyed,  Diftortion of ihe pelvis at
the fuperior aperture creates an obftruftion to the paflage of the
head of the child,  which will be overcome with more difficulty
by the powers of the  conftitution, and which will be more in-
conveniently managed by  art, than an equal degree of obftruc-
tion in the lower part of the pelvis.  The  greatnefs of the dif-
ficulty  will neverthelefs chiefly  depend upon the degree ; and
in the various degrees which are found to occur, every perfon
muft fee an evident caufe tor all the kinds of difficulty which he
may meet with in praftice.   A fmall degree of diftortion. like
an originally fmall pelvis,  may occafion a difficult labour of that
kind which may not be an objeft proper for the exercife of his

               * See  Vol. I. Chap. i. Seel.  x.
   Vol. II.  v             E. 
Q6            INTRODUCTION TO MIDWIFERY.
 art, as it will at length be completed by the long continued ac-
 tion of the uterus, firft moulding and  reducing the form  and
 fize of the head till it is adapted to that  of the pelvis, and then
 forcing it through the diminifhed cavity.   Or, the degree of
 diftortion may be fuch, that,  notwithftanding all the moulding
 and reduction of the head,  which can be accomplifhcd by time
 and the efforts of the conftitution,  there does not remain fuffi-
 cient  room for the paffage of the head  through the pelvis, but
 it may neverthclefs beat length brought into fuch a fituation, as
 to afford us the hope of fafely delivering the patient by art  and
 of preferving the lite ot the child.  Or, the diftortion may be
 fo confiderable, that it is impofhble for  the head of the child to
 be expelled without leffening it,  and the child, if  living, muft
 be facrificed to the fafety of the parent.   Or, laftly,  the  dif-
 tortion may  be aftually fo great, that if the head of  the child
 could be leffened, there would not be a poffibility of extracting
 it, and we muft either fubmit to lofe the lives both of the  pa-
 rent, and child, or attempt to fave that of the latter, by the ceja-
 rean feftion,  or by fome other operation almoft equally hazard-
 ous, fuch as thedivifion oi  the fymphyfis of the off a pubis.
   In many of thofe cafes in which there is a very great degree
 of diftortion of the pelvis,  the impoflibility ©I the head  of the
 child  palling through it is felt-evident, and readily difcovered
 on the firft examination per vaginam.   But in lefs degrees of
 diftortion, no judgment can be  formed a priori whether the
head can pafs or not; and we ought to defer any determination
upon the  neceffity or propriety of giving affiftance, as well as
 the kind of affiftance to be given, till we are convinced bv con-
 fequences, that the difficulty cannot be overcome by the powers
 of the conftitution ;  and the conviftion is in many cafes not fa-
tistaftory,  till  the efforts  of the patient are  difcontinued,  or
 ceafe entirely.   Degrees of difficulty to our apprehenfion in-
 furmountable are often overcome by the mere force of the pains,
and fo long as thefe  continue vigorous, we are not to defpair
of a happy event; but encouragedby experience,  and fupportr
ed  and juftified by moral as  well as fcientific principles,  we
muft rely  upon the advantages, which time and proper conduft
may afford.
   The far greater part of thofe labours,  which are rendered dif-
ficult by the diftortion of the pelvis, only require a longer time
for their completion.   Some however demand the affiftance of
art; and when this is the cafe, the kind of. affiftance muft vary
according to the circumftances.   But thefe will be more  parti-
cularly ftated, when  we come to fpeak of  the various opera*
tions in the praftice of midwifery.             — 
ON  DIFFICULT LABOURS
*7
 3. Head of the Child uncommonly large; or too much ojjified*.

  No arguments are required to prove, that a fmall body will
pafs  through  a fmall fpace with more  facility  than one that is
large;  the fize of the body being fuppofed to bear any reafon-
ble comparifon to the dimenfions of the fpace.  Of  courfe, it
may  be prefumed,  that the larger the head ot  the child is at the
time of birth, with the greater difficulty it will be expelled.—
Should lhzpelvis not be diftorted,  but of a common fize, we
may always expeft that the woman will be ultimately deliver-
ed by hernatural pains, if there be no other caufe of  difficulty
than the  largenefs of the head, though  a longer  time may be
required  for the  completion of the  labour.
  It is not merely from the fize of  the head of the  child, that
a labour may be rendered more tedious,  more painful, or even
truly difficult.   The ufual connexion of the bones of which
the head is  conftrufted,  is  fuch as  to  allow  of confiderable
diminution and  change  of form  in its paffage through the
pelvis.   The extreme degree of diminution aad change, which
it is  generaHy capable of undergoing, is perhaps impoffible to
be determined;  but it does not feem unreafonable to conjecture,
that it may be reduced to one third of its original fize, without the
deftruftion or even injury of the child from the compreflion ;
the alteration  being fo gradually made.  The advantages gained
by  this  compreffion of the  head  in all cafes of  difficulty,
occafioned by the natural fmallnefs of the pelvis, or in lefs degrees
of diftortion,  are often greater than  could have been hoped for,
on almoft any calculation, as was before obferved. But as there
is great difference in the degree of oflification in the heads of
different  children at the time of  birth,  thofe heads,  which are
moft perfectly offified, muft of courfe be capable of undergoing
the leaft  change ;  and the  degree  of change, which  they can
undeqro, muff be produced  with  the greateft difficulty, and
purchafed at  the expenfe  of  more fevere or longer continued
pains.   On this account a large head,  with a very imperfect.
oflification, is often  found to pafs through  a pelvis, which
might  be confidered as relatively fmall,  with more eafe  than  a
fmallcr head in which the oflification was more complete;  and
yet the caufe of the delay may not be difcovered before the
bhth of  the  child.  In  cafes of  difficult  labour proceeding
from thefe and  fimilar caufes, it  not being in our  choice to
feleft the circumftances,  all that we can do is, to manage fuch
as occur in the mod prudent manner; and we have commonly
to wait only for thofe effefts to be produced, which may be. 
28".             INTRODUCTION TO MIDWIFBRY.
eftecm«d as confequences of the efforts of the conftitution fairly
exerted, and never to defpair fo long as thefe efforts are properly
eontinue*d.
          4. Head of the Child enlarged by Difeafe.

  Two difeafes have been mentioned by writers as the caufe ol
this enlargement,  tumours growing on the heads of children,
and ihe hydrocephalus ; but either of thefe very rarely occurs.
With refpeft to the firft, it has been faid, that when the tumour,
of whatever kind it may be, is of fuch  a fize  as to be  an
abfolute impediment to the birth of the child,  it fhould, and
may be opened or extirpated, and that the operation is not only.
perfeftly confiftent with the fafety of the mother,  but frequently
with that of the child alfo.  Of the exiftence of thefe tumours
the inftances recorded do not  leave a doubt*; or of the pofli-
bility, when they are large, of their obitrufting the delivery of
the patient; but of  their extirpation with fafety  to the child I
fhould very much doubt, though no human being can circum-
fcribe poffibility.  As it is the duty, and muft ever be the foli-
citous with of  every practitioner, to preferve a life, when it is
in his power,  he may be induced  to try the extent of his art,
when there is little hope ot  fuccefs.  From long continued
compreffion the  integuments  of   the. head of the child may
become fo much tumefied, and altered from their natural form
and ftate,  as fometimes to give the feel of a diftinft and adventi-
tious tumour; and yet fimply confidered, fuch are fo far from
requiring  any fuigical affiftance, that it  would be abfurd  and
flagitious to intermeddle with them. Xet when there really are
any unnatural  tumours or excrefcences, the  point of practice
would depend upon the degree of impediment to the paiffage of
the head,  which  might be  thereby occafioned ;  or upon the
nature of  the  tumour, whether it could be extripated, or only
admitted  of an opening  to be made into it for the purM^Ce of
leffening its bulk ;  or if neither of thefe could be done with
propriety, by  acting as if no fuch tumour exifled, on the gene-
ral principles by which we are to be guided in difficult labours.
   With regard to the hydrocephalus,  which, if ot  a  certain
fize, would certainly be a great obftacle to the delivery,  this is
not  readily to be diftinguifhed in the  early part of a  labour,
becaufe the membranes of the ovum, in fome cafes, refemble
by theii^lhicknefs the integuments of the head in others.  But
if  we  were  affured, that an  hydrocephalus  did exift,  there

   * Partus difficilis a tumoribus, i capitibusJletuum dependttt*.
 tibus.—RuyJch.Obf Anatom. LII. 
ON  DIFFICULT LABOURS*                 *9
would not always be occafion  for us to aft ;  as it is far more
eligible even then to wait fo long,  as to give time fortheexpul-
fion of the head of the.child by the natural efforts, if they bo
equal to that effect.   Should the head be fo much enlarged by
the quantity ot fluid contained in it, that it is too large to pafs,
even in this cafe the integuments will generally burft by the
force of the pains.  But when the faft is afcertained, and  the
labour is rendered extremely  tedious and  lingering from  this
caufe, or if any fufpicious fymptoms fhould arife, it would not be
juftifiable  to allow the patient to undergo fuch long continued
pains, as when we have any hope of faving the lite of the child,
or of producing  a child  with a reafonable chance of  living.
The delay  recommended is not intended, therefore, to go farther
than  the prevention of miftakes.   But when we have determin-
ed upon the neceffity or propriety of delivering the patient, all
that generally is neceffary to be done,  is merely to perforate the
integuments of the  head, immediately after which the water
flowing away,  the head is fpeedily expelled, and the birth foon
and eafily completed.   In the extraction of the  child by  the
feet  there is not much more difficulty  on this account,  as the
force with which we have the power of extracting is fo great, as
to burft the integuments.

            5  Face inclined towards the Pubes.

   On a former occafion we have mentioned, that there are four
varieties in the  pofition of the head of the child at the time of
birth.  The firft when the vertex or hind head  is turned to-
wards  the pubes:  the fecond  when  the  face is  turned  to-
wards the  pubes :  the third,  when the head prefents with  one
or both arms : the fourth when the face prefents.  The firft ot
thefe may be confidered  as the ftandard pofition, becaufe it is
not only the moft common, but the moft eafy  alfo;  the head of
the child  being fo conftrufted as to admit, in this pofition, of
the greateft and moft  ready compreffion and  adaption  to  the
pelvis, and of court; the eafieft paffage through it.  Yet  the
other pofitions are not to be confidered as  conftituting labours
ot any other clafs, but  as varieties of the  natural  pofition :
though they muft of neceffity occafion confiderable delay in all
labours in which they happen ; either becaufe  a portion  of that
fpace,  which fhould be wholly devoted to the head of the child,
is occupied by fome other part unfavourably; or becaufe  the
bones ot  the era mum, in fuch pofitions, more flowly and  im-
perfectly conform to the fize or fhapeof ihe pelvis.  When the
face ot the child is  inclined towards the pulis, the peculiarity 
30              INTRODUCTION  TO MIDWIFERY.
 of the pofition is not ufually difcovered in the early part of the
 labour,  or even when the  firft ftage is completed, the practiti-
 oner being generally  fatisfied with knowing,  that it is a presen-
 tation of the head.  But when there is any unufual delay,  per-
 haps without any very obvious caufe,  it then  becomes a duty to
 inveftigate and explore the caufe, and it is not a very unfrequent
 thing to find the face turned towards the pubes.   This pofition
 is moft readily known by our being able to feel the greater  fon-
 tanel ina common examination, though it is alfo proved by other
 circumftances  relating to various  parts of the head, which  may
 be readily difcriminated.   When this is found to be the pofition,
 it does not follow that any artificial affiftance ought to be given,
 but knowing that thefe cafes are  not  in  general  dangerous, we
 are to wait a longer time for the effeft of  the natural pains; ex-
 perience having proved, that  the head in this pofition may be,
 and almoft univerfally is, ultimately expelled without  the affift-
 ance of art.  Yet in fome of thefe prefentations,  that of the face
 towards the pubes in particular, it. is faid, that by preffure with
 the fingets the face may be gradually inclined to the facrum,
 and the head reduced  without much difficulty to the firft, or that
 which was ftated as the moft eligible pofition*.  But when the
 pains ceafe, or when we are fully convinced  that they  are une-
 qual to the exigencies of the cafe, fuch affiftance muft be given,
 as the fituation of the parent may require, and allow.
   With this pofition of the head, befides the  greater length
 ot  time  which maybe required for moulding and expelling it,
 there will alfo be a greater diftention of the external parts,  be-
 caufe the hind head cannot properly be cleared of the perineum
 before the chin has defcended as low as the inferior edge of the
fymphyfis of the offapubis ; by which an inconvenience is pro-
 duced equal to what an increafed depth of the cavity of the pel-
 vis  would occafion, or a deficiency in the arch of the pubes.
 There are alfo fome peculiarities in the operation when we deli-
 ver with theforceps or veciis:  but of thefe we fhall fpeak, when
 we come to the direftions for the ufe of thofe inftruments.

                6. Prejentation  of the Pace.

   The prefentation of the  face is  difcovered by the general in-
 equalities of the prefenting part, or by  the  diftinftion of the
 particular parts, as the eyes, the nofe, mouth or chin,  which is

   * See Tranfaclions Medical and Chirurgical, Vol. 'n. in which
 there is a paper on thisfubjeel by  Dr. J.  Clarke. 
ON DIFFICULT LABOURS.                 Jl
itfuajly turned towards the pubes.  In this prefentation the child
will generally be expelled by  the natural efforts, but a much
greater length of time will be required for the completion of the
labour, efpecially with firft children,  for the reafons mentioned
under the laft caufe,  which are in this perhaps increafed.  But
the child may be and generally is born without any in j ury, though
the face will fometimes be fwelled in an aftonifhing manner, and
the external parts ot  the mother being infinitely more diftended
than in a natural pofition, greater care is  neceffary to prevent
their laceration.
   If after a  long continuance  of the labour we fhould be con-
vinced, that extraordinary affiftance is required,  then the fame
obfervation may  be made with regard to the ufe of the forceps
or veclis as in the preceding article;  but of the peculiar conduct:,
which, it may be neceffary to purfue, we fhall fpeak  hereafter.

         7. Headprejenting with one or both Arms,

   Though the head fhould prefent with one or both  arms, ex-
perience hath fully proved, that a woman may be delivered by the
natural efforts with fafety to herfelf, and without prejudice to
her child, if the pelvis be well formed.   But as a part of the
cavity,  which fhould be appropriated to the head, will be filled
by the additional bulk of the arms, there will be an evil fimilar
to what would be produced by a fmall, or by a, fomewhat dif-
tcnted'pelvis.  Should the pelvis be barely of fufficient dimen-
fions to al|ow the head of the child  to pafs through it, then the
additional bulk of the arms  may render the paffage of the head
impoflible ;  or the labour may be fo much retarded,  as to make
it what is properly called difficult.
   In  the beginning or in the  courfe of a labour of this  kind,
the practitioner will often be able to return and to detain thepre-
fenting arm or arms beyond the head withoutany detriment;  at
all events, he muft make the attempt,  and be very careful not
to folicit the defcent of  the  arm before the head, left he fhould
change the whole fituation of the child, and convert that which
would ha've been only a variety of a natural, into a preternatural
labour.
   In fome cafes  we are enabled to feel  the head, a foot and an
arm at the fame time, and it  will then be expedient to grafp arid,
bring down the foot, and to  deliver in that manner.  But  it be-
hoveth  us to diftinguifh very  cautioufly between a hand and a
toot,  becaufe the miftake would lead us to the neceflity of turn-
ing the child, an operation which would otherwife not have bee*
rcutiired. 
 3*            INTRODUCTION TO MIDWIFERY.

   In presentations of the head together with one or both arms,
 unlefs there fhould be anv particular reafon for wifhing to turn
 the child, the propriety of  which muft reft upon the judgment
 of the praftitioner,  unlefs we have the power of returning the
 arm,  we are to be prepared to wait with patience for the expul-
 sion of the child thus placed, by the natural efforts.  When we
 are convinced bv the failure or ceflation, that thefe are not equal
 to the effeft,  fuch affiftance is to be given as the nature of the
 cafe may require ; and whatever the inftruments, which it may
 be neceffary to ufe, are, their aftion muft be nearly the  fame,
 as if the arms had not been in the pelvis.
   Whether thefe cafes are completed by the natural efforts,  or
 by the affiftance of  inftruments, the arms of the child will  be
 very  much tumefied or  bruifed, and the child is for a certain
 time  as unable to ufe them,  as it they were paralytic.  But
 by the help of fomentations and poultices, if needful, and by
 moderate  motion and gentle friction, their natural appearance
 and ufe  are recovered in the courfe ot a few days; at leaft I
 have not feen an inftance ot any permanent mifchief from this
 caufe.
   When the extremities prefent  at the time of birth,  there is
dften  a doubt whether the child be living or not, unlefs it can
be perceived to move.  Now  the faftmay be afcertained by the
 confequences of any violence, as no part of a dead child can
either tumefy or change its colour, however compreffed it may
be, and only fliews one effeft of violence, that of folution of con-
tinuity.
       -«  •          SECTION VII.

          '      tTN THE FOURTH  ORDER;
                            ok

LABOURS RENDERED DIFFICULT BY  DISEASES  OF  THE *OFT
                          PARTS.

                  I. Suppreffton of Urine.

 J. he various affeftions of- the urinary bladder during pregnan-
cy have been already mentioned.  On the commencement of
labour, it was faid, that an involuntary difcharge of the urine
might be occafioned, but in its progrefs, there is more com- 
ON  DIFFICULT  LABOURS.                $3
 monly  a  frequent  inclination  with a difficulty in voiding it,
 and fometimes there is a total fupprefTion.  The inconveniences
 thence  arifing will be accoidingto the  quantity of urine re-
 tained,  and to the length of time that the bladder may continue
 diftended.  The firft may hinder the proper action of the uterus,
 and of courfe be an  impediment to the paffage ot the head of the
 child, by occafioning a lefs fpace for it to pafs through, and
 projecting it alfo out of its proper  direftion.  By the latter the
 bladder itfelt may be injured in confequence of the continued
 prellure,  which fome part of it may undergo from  the repeated
 actions of the uterus, caufing inflammation terminating in partial
 gangrene; and in fome cafes in which relief was not given,  the
 bladder has even been ruptured, the patient being thereby fpee-
 dily deftroyed*.
   In the beginning and courfe of labours, efpecially of thofe
 which are expefted to be tedious or difficult, great attention is
 therefore to be paid to the ftate of the bladder; the patient is to
 be frequently admonifhed to void  the urine, and in all cafes of
 doubt we are to be fatisfied only  with feeing the  quantity  of
 urine which  has been difcharged ;  error being often committed
 by confounding jthe water ot  the ovum with the urine.   Ry
 ihe application of the hand to the abdomen of the patient, itjs
 generally  an eafy matter to diftinguifh between the tumour ot
 the uterus,  and the flattened  but  circumfcribed tumour  of
 the bladder,  which lies  below and before that formed by  the
 uterus.    The patient  herfelf  is   fometimes capable alfo  of
 diftinguifhing that  pain which is the  confequence  of  the
 aftion ot  the uterus, from that which is  occafioned  by  the
 preffure upon the diftended bladder.
   To remove the obftacle, to the paffage of the child, which
 may be produced by the diftention of the bladder, and to pre-
 vent any  injury to the bladder  itfelt, it is neceffary to draw off
 the urine with a  catheter, whenever it is retained beyond a cer-
 tain time or degree.  In flighter cafes the common catheter will
 anfwer the purpofe ; but when the  head has been long wedged
 in ihe pelvis,  there is not fufficient room fgr that to pafs, even
 though the head be elevated or preffed towards the hollow of the
facrum.   But in fuch cafes the flattened catheter, contrived by
 my worthy and  ingenious friend Dr. Chriftopher  Kelly,  will
 often pafs with eafe and convenience ; though the elaftic cathe-
 ter, or that  kind which is made of a foft and pliable metal, is

   * See Chapman, page 143; fee alfo Medical Obfervations and
 Inquiries, vol. iv.
   Vol, II.                   F 
34            INTRODUCTION TO  MIDWIFERY.
 often to  be preferred even to this.  But  whatever catheter tt
 may be found expedient to ufe, or however neceffary it may be
 to draw off the urine, we are to take great care not to introduce
 the inflrument with violence,  becaufe we may do as much pofi-
 live mifchief with the inflrument, as we aim or with to prevent.
 In  fome cafes,  from want perhaps of timely care, though we
 are allured there is great quantity  of urine in the bladder, the
 head of the child  is fo immovably locked in the pelvis,  that we
 cannot poffibly  introduce any catheter,  and are therefore oblig-
 ed to fubmit to  the inconveniencies,  which may follow the uii-
 tention of  the bladder.   But if  care were taken in the  begin-
 ning of  labour, this does not often happen ;  nor is it always at-
 tended'with the evils we might dread,  the  head of th^  child
 being at  length pre fled fo low as to allow the urine to  efcape,
 though very {lowly.  But in all fuch cafes it will be prudent and
 neceffary, to introduce  the catheter before  or  foou after the
 expulfion of the placenta, that we may prevent the  mifchief
 which might be expected to follow fuch great diftention of the
 bladder,  it this  were to remain many hours after delivery.

                  2.  Stoneinthe  Bladder.

   If a woman fhould have a ftone in the bladder, this would be
 no caufe to prevent her being with*child, or proceeding through
 her pregnancy without moleltatioru  Nor if  it were of a fmall
 fize, would it be any  impediment to her delivery ; though if it
 were large, the head  of  the child  could not pals  through the
pelvis, or not without much trouble and inconvenience.  Of
 this cafe  I  have never met with  an  in fiance in practice, and
 may therefore be allowed to confider it as  very rare,  though
 there does not appear  to be any reafon for judging it impoffible.
 I iRve reflefted upon  the cafe, and upon the conduft which it
 might be  neceffary to purfue, if it had occurred to me ; and
 though it behoves me  to  fpeak withreferve, and to be fatisfied
 it  little confidence be placed in what I advance, it is better on
the whole to give my  opinion than  to leave the matter  without
confidering, or making mention of  it.
  In the beginning ot labour,  fuppofing there is a ftone of a
large fize  in the bladder,  one of thefe confequences muft fol-
low  ; the  head of the child muft advance before the ftone or
the ftone muft be protruded before the head ot  the child.  If
the former fhould be the cafe, we might prefume that the labour
would proceed in a natural way, as  if the ftone did not exift -
there would, at leaft,  be  no demand f>, the affiftance of art' 
                 ON  DIFFICULT LABOURS.                35

and no juflifiable  reafon  for exercifing it.  But if the ftone
fhould be protruded before the head of the child,  our conduft
muft be regulated by the circumftances.   It feerrfs reafonable,
that we fhould firft attempt to raife the head in  fuch a manner,
and to fuch a degree, as to allow us to return the ftone beyond
the head.  Or it  this fhould  be found  imprafticable, either
becaufe the head of the child was too far  advanced, or firmly
locked in the pelvis,  we muft then weigh the evils to be appre-
hended, from the  compreffion of the foft parts, that is. ot the
anterior  part ot the bladder, between the head ot the child,
and the ftone in the bladder; befides the diftraftion of the parts
which muft be neceffariiy occafioned.  Whatever conduft we
might purfue muft be attended with fome  evils, as it is only in
our power to choofe the leaft of thefe,  it teems better, even in
the time  of labour, to fuffer the evils  which might follow the
performance  of the operation for extrafting the ftone,  than to
fuffer thofe which may be occafioned by the comp'reflion  and
probable laceration of the  parts.  With regard to the operation,
there is both lefs difficulty and danger in  it to women than to
men,  though thefe will  in fome meafure depend upon the fize
of the ftone.   In fome cafes independent of pregnancy  alfo,
in which the ftone is  contained in a chftinft cell of  the bladder,
and coukl not dierefore be grafped or extracted by the Jo weeps
when introduced; it  has  been  propofed  to  make  an  incifion
through the anterior part of the vagina, directly upon the ftone.
This operation, which may in fome cafes be eligible, has been
performed twice,  by two furgeons of great ability and eminence
in the  country, and,  as I was informed,  without  occafioning
the effeft to apprehend; that of  leaving a fiftulous opening, by
which  the urine would have been voided  for the remainder ot
the patient's life.

              a.  Excrejcences of the Os Uteri-

   Lxcrcfcsnces of the os  uteri are  ufually  combined  with
fome   degree  of fcirrhous difpofition of  that  part.  It was
be fore obferved that thefe  excrefcences do not prevent concep-
tion, or ,diflurb pregnancy,, at leaft in the early period but ac-
cording to  their fize  and  fituationr  they  muft  neceffariiy  be
obftacles at the time ot labour.  The following cafe, which was
curious in ihe circumllances attending, as  well as the nature of
the complaint,  I  may be  permitted to  tranferibe,  as it was an
ex.nnple of anexcrefcence of the large ft fize I have ever feen.
  In June 1770, I was de fired to feea patient in the eighth month 
3*
INTRODUCTION TO MIDWIFERY.
of her pregnancy, who in the  preceding  night had a profufe
hemorrhage.   Her. countenance fhcwed the effefts of  the great
lot's of blood fhe had fuffained ;  and from the reprefentation of
the cafe given me by the gentleman who was firft called in,  I
concluded  that the placenta was fixed over the os uteri.   On
examination I felt a very large flcfliy tumour at the extremity of
the vagina,  reprefenting and nearly equalling in fize the pla-.
centa,  which I judged it to be.   Had this  been the cafe, there
could not be a doubt of the propriety and neceffity of deliver-
ing the patient fpeedily; and with that  intention I paffed  my
finger round the tumour, to difcover the ftate of the  os  uteri.
But this I could not find, and on a more accurate examination,
I was  covinced that this tumour was an excrefcence growing
from  the os  uteri, with a  very extended  and broad  bafis.   I .
then concluded that the patient  was not with child,  notwith-
ftanding  the diftention of  the abdomen, but that fhe  laboured
under lome difeafe which refembled pregnancy, and the hemorr-
hage was the confequence of the difeafe. A motion which was
veryevidently perceived when I applied my hand to the adomen,
did not prevail with me to alter this opinion.
  It was of all others a cafe in which a  confultation was defira-
ble both  to decide upon the difeafe, and the meafures which it
might  be neceffary topiirfue;  and feveral  gentlemen of emi-
nence were called in.   That fhe was actually pregnant, was af-
terwards  proved to  the fatisfaftion of every one ; and it was
then concluded,  that  fuch means fhould be ufed as might pre-
vent or leffen the hemorrhage, and that we fhould wait and fee
what efforts might be naturally made for accomplifhing the de-
livery.
  No very urgent fymptom occurred till the latter end of July,
when the hemorrhage returned in a very alarming way,  and 'it
was thought  neceffary  that  the  patient fhould  be delivered.
There  was  not a foffibility of extirpating the tumour, and yet
it was of fuch a fize,  as to prevent the child from being born
in any other  way than by  leffening the  head.  This was "per-
formed ;  but  after many attemps to extra6t the child,  the pati-
ent was fo  exhaufted, that it became neceflary to leave her to
her repofe,  and very foon after our leaving her,  fhe expired.
  We were permitted to examine the body.  There was no ap-
pearance ot difeafe in any of the abdominal vj'cera, or on the
external furface of the uterus, which was of  its regular  form ;
and when a large oval piece was taken out of the anterior \y.m\
the child, which  had no marks  of putrefaction,  was found in
a natural pofition.  An  incifion was made  on each fide of the 
ON  DIFFICULT  I-AROURS.
37
 cervix to the vagina, and then a large cauliflower excrefcence
 was  found growing to the whole anterior part of the os uteri,
 The placenta adhered with its whole furtace ; fo that the blood
 which fhe bad loft muft have been wholly difcharged from  the
 tumour.   This uterus, containing the child,  is now in the mu-
Jeum of the late Dr.  Hunter.
   The propriety or advantage of  a praftice, by which the  life
 of neither the parent nor child was preferved, ought to be con-
 fidered ;  but fuch cafes occur  fo  rarely, that there is always
 room for aniinadverfion,  when they  are concluded.  Yet  the
 general principle of its being ever our duty to prefervc both their
 lives, if  poflible ;  or to preierve that  of the parent;  or, if fhe
 cannot be preferved,  then to lave  the child, if it be in our pow-
 er ;  would have been abetter guide on this occafion, than that
 which was followed.
   Excrcfcences of a fmallerfize are not unfrequently met with
 in praftice ; and as even thefe  are ufually accompanied with
 fome degree of fcirrhous difpofition of the os uteri,  more time
 is required for the  completion of the labour.  It is to be  re-
 marked,  that in cafes of this kind, there is often a long conti-
 nuance of the pains without any fenfible effeft ; but all at once,
 the  rigid os uteri  yields and dilates fpeedily and unexpeftedly,
 or  perhaps in fome inftances is lacerated.   In fome cafes &lfot
 the excrefcences are of fo tender a ftrufture, that they are crufh-
 cd by the paffage of the head over them, and entirely deftroyed.
 During labours of this kind, and after delivery alfo, the  great
 object is to guani again ft all caufes of inflammation, at firft per-
 haps local,  but afterwards extending  to other parts, connefted
 or readily contenting with the uterus, and  more immediately
 neceffary tor the. funftions of life ; but  I have not known any
 cafe of this kind to prove fatal, except that above defcribed.

                 4.  Cicatrices in the  Vagina.

   From  difeafes of the foftparts,  efpecially thofe arifing from
 violence fuftained in formetjiard labours, the vagina may have
 become  ulcerated  ;  and vJfen care  was not taken to prevent
 the  furfaces from abiding in contaft with  each other, the  op-
 pofite fides might  adhere in different degrees, according to the
 depth and extent of the ulceration is flight, and the inflamma-
 tion is not fo great as to bring  the tumefied parts  into contaft,
 after a certain time they -heal;  but  circular cicatrices being
 formed in the vfigina,  the diameter  of the paffage is leffened,
 and the part is left with a difindination to yield to any future 
38             INTRODUCTION TO  MIDWIFERY.
 occafion,   In fome cafes a  fupcrficial flough has been thrown
 off from the whole internal furtace of  the vagina, and  the ci-
 catrices of an irregular kind were formed from the os  uteri to
 the external orifice.   In other cafes there has been a cicatrice
 only  at one part,  and if this fhould happen near the external
 orifice, the  contraftion has been fuch as to mimick an  unrup-
 tured hymen.
   Amidft a great number and variety of cafes of cicatrices  in
 the vagina, I  have not  met with one example in  which they
 were  able to withftand the preffure of the head of the child, if
 the pains were of  the cuftomary ftrength.   The  labours have
 indeed  been confiderably retarded, but they have terminated
 favourably.   But  when the difficulty arifing from this caufe
 has been combined with other caufes, it muft of courfe have
 added to the trouble,  which the patient would otherwife have
 undergone.   Or, if the pains fhould ceafc before tfee labour is
 completed,  then fuch affiftance muft be given as the cafe may
 require; being on our guard that we do not offer affiftance be-
 fore there are proofs of the neceffity,  and are affured that the
 difficulty cannot be overcome by the natuial efforts.

                g. Adhefion of the Vagina.
                      \
   Adhefions of  the vagina are occafioned by an increafed de-
 gree of  the fame caufes as thofe which occafion  cicatrices.
 There may  be an adhefion  from difeafe. in women who were
 never pregnant, or it may be the confequence oi; a flough thrown
 off after a former  labour, with or without  the  ufe of  in lini-
 ments*.   Cafes of  adhefions of this kind are comonly mentioned
 as of very eafy management,  nothing  more being required,  it
 is faid, than to fcparate the united furfaces with a knife,  and to
 prevent their re-union  by the introduction of  a  tent or  cannhi
 lor this purpofe.   It is true, when an  adhefion has  taken place
 near the external  orifice, that it may be in  general managed    «
 without difficulty ; but when there las  been a deep flough,- and
 the parts adhere high up in the vkvinfl,  perhaps  through its
 whole extent,  it is clear from trttfdtjJuftWe and connexion that
 there  is need  of the grateft circumfpeftion,  left on the one

  * I have  been informed q'f thefrafe  of a*patient, zvho  was
 in the hands of a very fkilful praclitioner, in whom, after her
 delivery, which  was not attended *urith any circumjlances  of
peculiar difficulty, the whole  interv.,d Jurface of  the vagina;
 andall the externaj. parts, entirely fiougheel  avuiy. 
OF  DIFFICUIT LABOURS,
39
{.and  we  perforate  the bladder, or,  on the other, the reclum;
all thefe parts being drawn eiof'e together.  This accident I
hive feen  happen under the iiands of a very dexterous li:i«-eon,
ami h fecmcd unavoidable.
  In feme cafes thtii it appears, that  the adhefion is of fuch  a
kind,  as lut to admit or juflity any attempt to feparate the parts «
with a knife;  but even in thefe,  by fuffering-the menftruous
difcharge  to be collected,  after a certain time, the part, where
an incifion or punfture with a trocar may befafelv made, will
fometimes be  pointed out,  and this being gradually  dilated,  a
cure may be affefted.
  It is  poflible for an adhefion to take place after a  woman is
become pregnant, and of this I have  known one inftance.   Of
courfe when labour comes on, the contents of the gravid uterus
would be impelled againftthe adhering part, which would either  /
feparate, or* refill the exclufion of the child.   In the former
cafe  nothing-would be required to be done  by art; but in the
latter, it would be neceffary to divide the united parts by an in-
cifion made with great  care, and  to  a certain degree, leaving
the full feparation to be made by the membranes containing the
waters,  or by the  head of the child, which will then effeftually
anfwer the purpofe, m a better way than by any  iteration.

                 6. Steatomtofe Tumours.
              ■ t-        .»•
  Of this caufe ot  difficult labours I have never met with an
inftance in my own praftice ; but the following cafe was com-
municated to medby a gentleman, whole authority and accuracy
are unexceptionable.
  A lady, after the birth of her eighth child, fell into a ftate of
bad health, withdiianv painful and troublefome fymptoms,  but
no marked difeafe.  Thefe were by fome phyficians confidered
as nervous, by others as fcorbutic, and by others as rheumatic,
or of a gouty nature.  Various medicines were given, and-dif-
ferent  means tried lor her relief, but without any good effeft.
At the expiration of  two years ffiebecameagain  pregnant.  All
her former labours had been very eafy and  natural ; but when
Dr. Hu./tcr was called at the commencement of this,  he found
an obftruftion at the fupeiior aperture of the pelvis, which he
believed could only be occafioned by the projection of the low-
eft of the lumbar veitebrce, or the upper part  of the facrum.
It was then fuppofed,  that fhe had the  ojleojacrofis, of which
her complaints had been the fymptoms.   It  v/as impoffible tor
her to be  delivered in any  other way  than by leffeniiw, ibe head 
4O             INTRODUCTION  TO MIDWIFERY.
of  the child.   She died on the fourth day after her delivery.
Leave was given to open the body, and  when the pelvis was
examined, the tumour, which was imagined to be a projection
of the bones, was found to be an excrefcence of a firm, tatty
fubftance, fpringing from one fide of the  upper part ot the fa-
crum, and paffing acrofs fo as to fill up a great part of the fupe-
rior aperture of ihe pelvis.
  It is probable, that the preceding complaints of this lady were
occafioned by the preffure of this tumour upon the uterus ; and
had the real ftate of the cafe been known before the time of la-
bour, or even during her labour, it does not appear to have
been proper, or within the bounds of art, to have attempted or
to have afforded her any other afhftancc.

               7. Enlargement of the Ovaria,

  Difeafes of the ovaria, both  of the fcirrhous and dropfical
kind efpecially the latter, are known to be very frequent.  Either
of thefe muft generally prevent conception;  but as oneot the
ovaria may be very much difeafed, when the other is in a per-
feftly healthy  ftate, inftances fometimes occur of women be-
coming pregnant under fuch circumftances, and then the enlar-
ged or difeafed ovarium  may produce inconveniences during
pregnancy, or become an obftacle to the progrefs of labour.
  With the hiftory ot two cafes ot this kind  I was many  years
ago favoured by Dr. John Ford,  a gentleman of great fkill and
experience. In the former he was furprifed to find a large and
firm tumour, lying between the reclum and vagina,  filling up
all the concavity of  the Jacrum, and a  confiderable fhare 01 the
cavity of the pelvis.  Being convinced of the impoffibility ot
the child paffing by this tumour,  which did not yield or dimi-
nifh by the force of the pains,  it was determined,  in confuta-
tion, that the patient ought to be delivered bylefleningthehead
of the child.   The operation was performed  with great care,
but the patient died at the end of three weeks.  When the bo-
dy was opened,  the tumour was found to be an encyfted droply
of the ovarium, in which there was a confiderable quantity of
hair,
  In the latter cafe, which in all its circumftances refembled
the former, inftead of leffening the head ot the child, a trocar
was paffed through the pofterior part of the vagina, directly in-
to the tumour.   A  large quantity of water was immediately dif-
charged,  the tumour fubfided, and a living child was born with-
out any further affiftance.   This patient recovered from her ly- 
ON  DIFFICULT LABOURS.
41
 ing-in, but fome time after becoming heftic, fhe died at the end
 of about fix months, though from the fymptoms it did not ap-
 pear, that the fever was occafioned either by  the difeafe or the
 operation.  This patient was not examined after her death.
   Having related thefe two cafes,  I have faid all I had  to advance
 on the fubjeft, except that  I have met with more than one in-
 ftance of a  circumfcribed  tumour on one fide of  the pelvis,
 which I at firft fufpefted to  be difeafed ovarium.  But as thefe
 tumours have always given  wav to  the preffure of the head of
 the child, the paffage ot  which they have  only retarded, for a
 fhort time, I have concluded they were formed either by fome
 fatty  fubftance collected there, or were  cyfts containing lymph
 cafually  effufed, and forming to itfelt a  cyfl  from the cellular
 membrane.   But on taking  an examination  after delivery,  trie
 tumours were found to have  again acquired their primitive form
 and fize, and to have refumed their former fituation.

                 8.  Rupture of the Uterus.

   The human  uterus is found to retain its  original  thicknefs
 during the time of pregnancy, notwithftanding its diftention ;
 or to become fomewhat thicker than it was in'the unimpregnat-
 ed ftate.  This thicknefs, we have therefore reafon  to think,
 is confequent to fome principle acquired coeval with concep-
 tion,   But if the whole, or  any part of the uterus, fhould be
 deprived of this principle,  or affefted with any difeafe deftruc-
 tive of its operatjjjm,  then  the whole uterus, or the part fo af-
 fefted, would be mechanically diftended, and become thinner
 in proportion to its diftention ;  and at the time of labour,  when
 the aftroja exerted might become greater than  the unthiekened
 part Was able to bear, the uterus would be of courfe  ruptured.
 Or if "the uterus, which had  acquired its proper thicknefs, be-
 came affefted with inflammation or any other difeafe,  weaken-
 ing its power, and fpeedy in its progrefs, the  texture o/  feme
pafiifo affefted might be deftroyed, and the uterus ruptured by
its own action in the time of labour.   Or independently.of dif-
eafe,  the uterus may be worn through  mechanically, in long
and fevere labours, by preffure aud attrition between the head ot
the child and the projecting bones  in a diftorted pelvis, efpeci-
ally-if they be drawn in points or a  fharp edge.   Or, it has been
fuppofed, a rupture may be occafioned by a violent and fpafmo-
dic aftion of the whole or  fome part ot the  uterus, independ-
ent ©f difeafe, or any mechanical caufe.   Or the uterus may be
Ruptured by  violent accidents happening to the mother in the
   Vol. II.                 Q 
 4&            INTRODUCTION TO MIDWIFERY.

, advanced ftate of pregnancy.  If the uterus be ftrongty cort-
 trafted, it may be ruptured alfo by attempts to pafs <the hand
 for  the purpofe of turning a child; but in this laft cafe a rup-
 ture  could only happen, when  the force with which the hand
 was  introduced was combined  with the proper a£tion of  the
 uterus :  for the ftrongeft perfon has not the power to force his
 hand through a healthy and unafting uterus.  The part of the
 uterus  which commonly gives way, whether pofterior, which
 is moft  common, or anterior,  or  lateral, is  ufually near the
 union of the cervix with the vagina, in which fuch a change is
 made at the time ot labour,  when the os uteri is completely di-
 lated, that the diftinftion between them is loft,  the vagina  and
 uterus forming together one cavity,  though of unequal dimen-
 fions.
   Some of the caufes of die rupture ot  the uterus are unavoid-
 able, for it is not within the fphere of human abilities,  to give
 to any part the principle by which it has the difpofition or pow-
 er to perform any funftion ; though art may fometimes excite
 the  power to aftion, if the principle be dormant,  or reprefs it
 when too vehement.  Nor is it often poffible to difcover or pre-
 vent the degree of preffure or attrition, which fome particular
 part  may undergo in a difficult labour,-  before the effeft is pro-
 duced.  But the two other caufes, that which is preceded by in-
 flammation, or that which  may be occafioned by attempts to
 turn the child,  may be  corrected or avoided, byabftainingfrom
 the  ufe of all fuch means as are likely  to aft as caufes  or pro-
 moters of inflammation, or by  proper treatment when  it does
 exift; or from making fuch attempts as may be neceffary for
 the purpofe of  turning a child,  when the aftion of the uterus is
 ftrong.
   The rupture of  the  uterus is accompanied with a fenfe of
 fomething giving way internally, always perceptible by the pa-
 tient, with fudden excruciating  pain in fome part of the abdo-
 men, with an inftant vomiting of the contents of the ftomach,
 or of a brown fluid, and an abatement or a total ceffation of the
 pain, together with fome degree of hemorrhage from the vagi-
 na ;  as the placenta has uniformly been found to have been
 partly or  wholly feparated in every cafe which has come within
 my  knowledge.  After thefe fymptoms, by the application oi
 the  hand to the abdomen, the limbs of the child are fo eafily
 diftinguifhcd through the integuments,  as to leave no room to
 doubt ot the  accident; and if the head of the  child  be  not
 locked in the pelvis, it immediately recedes or even  goes out of
 the   reach of a common examination, however low  it might
 have dcfcended.  The death oi  the patient ufually follows foon, 
ON  DIFFICULT LABOURS.
43
though not immediately after the accident; but I have feen one
cafe,  in  which there was reafon to believe, that fhe walked a
confiderable diftance, and lived  feveral days after a rupture of
the uterus.
  In general there is reafon to think, that the children have di-
ed immediately or foon after this accident; and there is certain-
ly little chance of any perfon furviving a rupture ot the uterus.
It therefore might be doubted,  whether it would be more eligi-
ble to fuffer the patient to die  without giving her further trou-
ble, or whether it were our duty, hopelefs as the cafe muft be,
to pafs the hand into the uterus, to turn and deliver the child by
the feet;  br with the forceps, or veclis, or in any way the cafe
would allow.  What might be the  fentiments of former prac-
titioners, is not tp us very material; for befides feveral others
of which I have been informed,  or which are recorded, a cafe
has occurred to my very worthy, able, and experienced friend
Dr. Andrew Douglafs, in which, though the uterus was rup-
tured, he turned the child,  the patient recovered, and after-
wards had children,  at the birth of one of which I was prefent.
If no other cafe had been recorded, this would be ot  fufficient
authority, to render it in future the duty of every pra6titioner,
to  attempt  without  delay to deliver the patient, and bad as
her chance certainly would  be, to be  ftrenuous in ufing all
the means which art diftates, to extricate  her, if poffible, from
danger, and to preferve the child.  But for more particular in-
formation on this fubjeft I muft refer the reader to  an effay on
the rupture of ihe uterus by Dr. Douglas, and to feveral peri-
odical papers  of this time in which fimilar cafes are related;
but from the ftatement ot fome of thefe, one cannot help doubt-
ing whether the uterus was aftually ruptured.

                     SECTION VIIL

  These caufes of difficult labours I have enumerated  in  this
order, with a hope of  pointing, out a more ufetul method of ar-
ranging the knowledge we poffefs, of increafing our knowledge
and of removing fome part  of that obfeurity, in which the
praftice of midwifery has been involved,  and by which its fur-
ther improvement hath been hindered.   Two things appear in
the general refult; firft, that the evils attending parturition are
more  frequently  adventitious, than unavoidable  or ot jiecef-
fity ;  and fecondly, that  the native powers of the conftitution
when  not interrupted, are not only fuperior to the common ob-
ftruftions of the procefs but  in general to the various kinds, 
44             INTRODUCTION TO MIDWIFERY.
 and degrees of deviation from  the natural courfe of labours,
 Yet with  every prudential regard to our own conduft,  and the
 moft judicious regulation of that of our patients,  we fhall in
 praftice certainly meet with cafes, in which, either from the
 debility of thofe powers which commonly exift,  and which are
 generally exerted; or, from the greatr^efs or ftubbornnefs.ot fome
 obftrufting  caufe;  or, from  fome caufe aftually produced by
 the labour itfelt, we  fhall  be compelled  by neceffity  to  give
 artificial affiftance, orthe mother, or child,  or both, will be loft.
    Before  we proceed to the confideration ot the various means,
 which have been contrived for the relief of women in cafes ot
 difficult parturition, it may be again obferved, that thf caufes©£.
 difficulty are generally combined ; and as there are few inftances
- of a difeafe according to the fimpledefinition of it  in nofoiqgjcal
 writers, fo there are few examples of difficult labours produced or
 attended by one tingle  caufe.  Together with the dribbling of
 the waters, there  will often be a retraction  of the head of the
 child from the  fhortnefs of the Jums ; and  with great rigidity of
 the pans,  or a  fmall pelvis, there may be a weak  aftion of the
 uterus; and fo on to an almoft endlefs variety, One caufe will
 however predominate, and ot courfe become the principal ob-
 jeft of our attention,  But  when by time, or art, this caufe is
 removed,  we muft apply ourfelves to the removal of that which
 is important in the next degree ; and fometimes the fame means
 may be properly ufed for the removal of difficulties proceeding
 from feveral different caufes.
   But befides the caufes already mentioned, there is one much
 more  ii. quent  than the  reft, which is the  derangement of the
 order ot the labour by an officious interpofition,  or  by impro-
 per management.   Upon this fubjeft it wrould be  unpardonable
 to  make an affertion, which is  not fupported by experience;
 but I  am fully  convinced, that the far greater number of really
 difficult labours,  to which I have been called, and I muft  not
 conceal the truth on this  occafion, fome of thofe which have
 been originally under my own care, were not of that deno-
 mination from unvoidable neceflity, but  were  rendered fuch
 by improper management, in the commencement or courfe of
 the labour.  Nor does the difturbance of the order of a labour
 depend upon the practitioner alone ; for the intractability of the
 patient heifell'*, or of her friends and attendants, which, though

   * De la part de la mere c'efl quelquejois fa mauvaije humeur,
Jon. impatience, Jon indociltie, la violence  et I'irrgularite  dcs
 rhouvements.
   Pvu la Pratique des Accouchments.—Livre II. Chap. 1. 
ON  DIFFICULT LABOURS.
45
it may be founded in affeftion and compaffion to her fufierings,
may alfo arife from many other motives,  is too frequently pro-
ductive of the fame  effeft.
  In the management of difficult labours there is required much ■
previous knowledge and prefent judgment on  the part of  the
practitioner, to diftingnifh in cafes of great difficulty,  which of
them  may demand the affiftance of art, and when this ought to
be  employed,  and which may be refigned to the efforts  of  na-
ture ;  and no fituation can be imagined, that requires greater
addrefs  to procure  the confidence and co-operation of  all  the
parties concerned ; or more firmnefsinthe purfuit of the nega-
tive conduft,  which  it is often abfolutely neceffary, yet  ex-
tremely difficult to follow.   Whatever may be the refolution of
particular women, and whatever n#y be the general eftimation
ot  natural labours, every woman is impreffed with the opinion,
and the opinion is often well founded, that in difficult ones,  her
life is to be preferved by the fkill and judgment of the  practi-
tioner,  under whofe care fhe is placed.  If therefore her con-
fidence be fecured,  the delay to give affiftance will beconftrued
into  a proof that none is required, and of freedom from dan-
Ser-
   The diftrefs and pain, which  women otten endure while they
are ftruggling through a difficult labour,  are beyond alldefcrip-
tion,  and feem to be more than human nature would be able to
bear  under any other circumftances.  The gre?t principle of
all their patience and refolution is perhaps that  deep-rooted af-
feftion of the parent to the offspring,' implanted in the female-
mind.  But the principle of felt-prefervation,  though varying
 in its operation, will recur, and demand its fhare of regard.  In
 long  continued labours it is  therefore proper, by frequent allu-
 ftons to the child, to encourage and ftrengthen the former prin-
 ciple, for its  power is leffened or overcome by the weight of
 their prefent diftrefs ;  their love for their child is conquered ;
 and theprofpeft ot diftant pleafure is not able to fland in com-
 petition with the evils of the prefent moment.  With the firm-
 eft determination, to.do what is right, they willingly perfuade
 themfelves, that  the  child is dead;  that the objeft, for which.
 they fhould perfevere,  no'Tongeir exifts; and  the praftitioner,
 in oppofition to  his own feelings, and againft  the felicitations
 of thofe who confide in him, is often the only advocate for the
 child.  But his decifion to  aft, in cafes in which the life of a
 child is concerned, muftftand upon abetter piinciplethan con-
 formity to  the inclinations  ot others ; for though he might
 avoid prefent cenfure, or even gain prefent credit by giving ar- 
46             INTRODUCTION TO MIDWIFERY.
 tificial affiftance unneccffarily, when the cafe comes to be re-
 viewed, and it always is reviewed, the blame of afting precipi-
 tately, in cafes which do not terminate fortunately, will be  caft
 upon him, and  the fatisfaftion of others will  be eftablifhed by
 the difcovery of fome caufe of blame in his  conduft.  In the
 exercife of the  moft hazardous part of a profeffion,  perhaps in
  feneral more fubjeft to cenfure than any other,  it behoves us to
  e particularly circumfpeft: and though events are often beyond
 the power of human control, we may always aft with intelli-
 gence, with prudence and  firmnefs; and no man's character
 car} long be fupported, if he be not governed  by the  determina-
 tion to do what is right, to the beft of his own judgment and
 power, under every circumftance.
   The events of difficult labours, either with  refpeft to the mo-
 ther or child, very much depend upon the prudence and fore-
 fight, with which  women may be conducted  through them;
 but however averfe the practitioner may be from the ufe of fuch
 means as may prove hazardous to or even deftruftive of the
 child, cafes  muft occur, in  which the affiftance of  art  will be
 abfolutely needful,  and  the  ufe of inftruments juftified.  A
 time does certainly conic when, if they be not delivered by art,
 in cafe of the inability of the powers of the conftitution to ef-
 feft the purpofe, women would inevitably perifh.   As  correft
 a judgment muft therefore be exercifed,  and  equal care taken,
 that he does not delay that affiftance  which may be neceffary, fo
 long,  that it cannot anfwer the end for which  it was  given ; or
 while he is endeavouring to preferve the life of the child, he
 may lofe that of the mother alfo,  which is undoubtedly of
 more  value.
   The intentions in the  ufe  of inftruments  may be of three
 kinds. Firft, to preferve the life  both of the parent, and child ;
 fecondly, to preferve the life of  the  parent ; and  thirdly,  to
 preferve the life ot the child.  The  inftruments which have
 been contrived to anfwer the firft intention,  are, the  fillet,  the
forceps,  and the veclis.   Of each of thefe,  together with all
 the collateral circumftances which demand our regard, we fhall
 fpeak  in their turn, and then  proceed to the  confideration of4
 other parts of our fubjeft. 
ON  DIFFICULT LABOURS.               47
                     CHAgTER XL

                      SECTION I.

          ON THE FILLET, FORCEPS,  AND VECTIS.


 W hen men,  firft collefted into focieties, had provided for
their fubfiftence, they would endeavor to amend their ftate, by
removing fuch evils and inconveniencies as were moft urgent,
either from their importance or frequency.   Next to thofe arts
by which the means of fupport were acquired,  that of medicine
would be of principal confideration, as from the nature of their
employments, hunting, fifhing, paftoral or agricultural, men
muft have been liable to  difeafes  and to injuries, which  by
accident or trial they  wrould learn fome method of relieving :
and he that fhould have gained the greateft colleftion oi" know-
ledge, or the moft  dexterous method  of applying it to ufeful
purpofes, would have become a phyfician.   But the origin and
progrefs of that branch of medicine of which we are treating
would be fomewhat different.  When  the cuftoms and manners
of life were fimple, and not much difpofed to produce difeafes,
difficulty or danger in the parturition ot women would feldom
occur;  and,  notwithftanding the diftrefs  with which they
might fometimes be accompanied, the  general termination of
labours would be eafy and fate.  In the very  few cafes which
might require more than ordinary  affiftance, there were  none
to afford it; and thofe women, who could not bring forth their
children by their own efforts,  were fuffered to die without any
attempts being made to relieve them, according to the relations
which are given of the people of  fome countries, even at this
day.
   As mankind advanced in civilization,  the evils attending par-
turition would probaly increafe, though ignorance or inability
to give relief might long  continue.  But the fupplications toe
affiftance, and the  affeftions of men,'would  not permit them
to remain unconcerned or inaftive fpeftators  ot the mifery of
thofe, to whom they were indebted for the chief part of their
happinefs.  They gave fuch aid as  their information or ingenu^
ity enabled them to devilV, and this,  in the firft  inftance,  con-* 
 48            INTRODUCTION TO MIDWIFERY.

 fitted of ceremonies, or of particular precatory exclamations*,
 ot amulets, or of medicines,  to which fome myfterious pro-
 perties were attributed,  as the flcins and fome other parts of fer-
 pents, the eagle  ftone, the blood ftone,  the  ftony  fubftance
 found in the h ad of a fhark, witPmany others of the like kind;
 and fuch things would, by their influence on the  imagination,
 mightily luccour the minds of women, ftrongly impreffed with
 a fenfe of their utility, in a ftate of aftual danger, 'overwhelmed
 at the fame time with extreme pain and apprehenfion.   In times
 more enlightened, for every kind of  diftrefs religion offered its
 confolations,  by foothing the mind,  by  teaching  mankind,
 when oppreffed with difficulties,  to ufe their own endeavours,
 by inculcating  the neceffity of fubmiting to evils which could
 not be prevented or avoided, and by encouraging with the hope
 of happy  events.   After the  difcovery of  the mechanic arts,
 fhefe were applied  to the exigencies of every occafion ; and
 when the fufferings of women in child birth could no longer be
 endured,  attempts were made  to  relieve them by extrafting,
 without regard to its fafety, the head of a child which could
 not be expelled by  the efforts of the  mother ; and for this pur-
 pofe the firft kind  of forceps was  invented and ufed.  The
 fame motives of compaffion or affection, which led to the with
 of relieving women, would readily extend to  children  ; and,
 to combine the  interefts of both,  fillets and the forceps, now in
 Common ufe,  were contrived.   When the head of a  child wa$
 found to be too large, to pafs through a very fmall or diftorted
pelvis with the  help ot fuch contrivances, there was  no relief
to be obtained  except the head of the child was lefferred, and
 for  this  purpofe, perforators  and hooks or crotchets  of vari-
ous kinds weie  invented.  The intrepidity of fome man  feeing
no other way of giving relief, or the delperate refolution of
fome woman frantic with her-fufferings, might lead to a more

   * It is extremely curious to fee the many ancient  cujtoms
preferved by Ovid,  in feveral parts of the Meiamorphojes.

     -------Nechabentjua verba  dolor a ;
   Nee Lucinapotefi parientis voce vocari.
   Confiitit ad tamos mitis Lucina  dolentes ;
  Admovitque man us ; et verba puerpera dixit.
  Reddit onus,  vagitque puer, quern mollibus herbis
   Naiades tmpofttum, lachrymis unxireparentis.
                             Metamorphos. Lib. x.  Fab.  x.
"S 
OF DIFFICULT LABOURS.1               40
 fummary way of obtaining it*; and, with a determination to
 free herfelf from the caufe of her mifery, or to put an  end to
 her exiftence, a child might  have  been extrafted through a
 wound made into the part which contained it, and the manner
 of  performing the Cearean operation would be fhewn.
   In fome times and countries, in which the Jorceps and other
 inftruments of that kind were not known, or their ufe not ful-
 ly underftood, and afterward,  in fome cafes not thought fuita-
 ble for their ufe, it became acuftom in many  difficult labours,
 by whatever caufe  produced, to return the presenting head,
 to pafs the hand into the uterus, to turn and deliver the child
 by the feet.  But this operation of turning could only be per-
 formed under very limited circumftances ; for if the head of the
 child were very  low in the pelvis,  or the uterus  ftrongly con-
 tracted round its body,  it could not be turned,  or not without
 defeating the very purpofe for which the operation was per-
 formed,  producing at the fame time  great danger to the parent.
 This praftice was in general very unfortunate in the event,  yet
 cafes may occur, in which, by turning the child,  the chance of
 faving its Jife is  greater than can be  gained by the  ufe of'any
 inftrument, of which the following is an example.
   Many years ago I  attended a patient in two  labours, in both
 of  which there Vas a neceffity of delivering with inftruments,
 ■on account of the fmallnefs and diftortion of  the pelvis, and)
 neither of the children could be preferved.  In her next preg-
 nancy I made a propofal to bring on premature labour,  to which
 fhe and  her  friends would not confent, and I  was difmiffed
 from my attendance.  In the courfe ot twelve or fourteen years
 (he had five more children, not one of which was born living.
 In the iorty-fixth year  of  her age fhe proved  with  child, and
 again applied to me.  When her labour came on, the firft ftage
 was  fuftered to  proceed without interruption, but when the
 membranes broke,  I without delay paffed my hand into the
 uterus, and eafily brought down the  feet and body of the child,
 but the head being flopped by the narrownefs of the  fuperior
 aperture ot the pelvis.  I was obliged to exert,  and to continue

   * See  London Medical' Journal, Vol. VI. and  VII. in
 which there is a curious hijiory  of  a Negro woman,  who, in
 the agony of her labour, performed this operation upon herfelf,
 given  by  Mi. E. Home.   I was informed by Dr. J.  Hunter,
 that the fame womanj'srjhe recovered, was obliged to be watch-
 ed in her liibfequeWlabours,  to p.r^it her from  again per-
forming  tiie fame operation.
   Vol,  II.                H 
5«             INTRODUCTION TO MIDWIFERY.
much force, before it could be extrafted,  The child was born
with very little or no appearance of life ; but by the ftrenuous
ufe of the common means recommended for this purpofe it was
recovered.   On the left parietal bone there was a depreflion of
confiderable extent,  and to my ap'prehenfion of full one inch in
depth, occafioned by the projection of  the facrum ;  but the de-
preffed part  gradually rofe, in the courfe ot a tew months the
bone  regained its natural form, and the child was tor feveral
years in good health, with its faculties perfeft.   The woman re-
covered without any untoward circumftance.
  But the fuccefs of fuch attempts' to1 preferve the lite of a
child  is very precarious; and the operation of turning a child,
under the circumftances before ftated,  is rather to be confidered
among thofe things, of which an  experienced  man may fome-
times avail himfelf  in critical fituations, than as fubmitting to
the ordinary rules of praftice.

                      SECTION II.

                       ON FILLETS.

  The fillet ufed in the practice of midwifery isa  fingle band,
intended to be fixed upon the head of a child detained in its paf-
fage through the pelvis, for the purpofe of extrafting the head.
  It has been fuppofed, that fillets Were ufed in the praftice of
midwifery as early as the time of Hippocrates ; but whenever
they were  invented, they  have  fince undergone a variety of
changes, by which it was  intended to  gain fome advantage, or
to avoid fome inconvenience.  Fillets  nave been conftructed of
filk, cotton, linen,  orleatherof divers kinds, ftrengthehed, or
rendered more  commodious for application, by the addition of
cane, whalbone,  wire, or  very trim and narrow plates of iron
varioufly braided and worked together  according to the opinion
or judgment of the  contriver.
  The manner of applying the fillet was, by conducting it with
the finger,  or  an inftrument contrived for the  purpofe,  to
fome  fixed point, as the chin, or  round the circumference of
the head of1 a child, as high up in the pelvis as could be reached;
then,  atter twifting the two ends together¥to acquire a firm hold,
we  were taught to extraft,  in a proper direftion, with all the
force  the  fillet enabled us to ufe,  or the neceffity of the cafe
might require.
  The peculiar advantages expected to be  derived from fillets
were thefe.  They were fuppofed  to  be applicable with "real 
ON  DIFFICULT LABOURS.
5*
  facility in every direftton of the head, or when this was  too
  high to allow of the ufe  of any other inftrument recommended
  with the fame intention  ; to fupply  us with fufficient power to
  extract, the head when detainea an unreafonable  time, by any
  caufe, to the hazard of the mother or child; and to do lefs injury
  to either, on account of the foftnefs  and pliability of the mate-
  rials of which they were compofed.
    But experience has fully proved, that a fillet of any kind could
  not in many cafes be either fafely or effeftually applied without
  much, difficulty and trouble ;  that when applied it was very apt
  to flip ; that when it remained fixed, it was often  inadequate to
  the purpofe of extrafting  the head; that it created new difficul-
  ties, or added to thofe which before exifted, by changing the di-
  reftion of the head difadvantageoufly ; and that fhe injury done
  to the mother or child was not in proportion to the hardnefs of the
'  materials of which inftruments were conftrufted, but according
  to the force or violence with which they were ufed.
    For thefe reafons fillets of every kind gradually declined in
  eftimation, and they are now wholly  neglefted.   They may be
  confidered among the firft attempts of art to give relief, which
  have been fuperfeded by other  contrivances, equally fafe and
  more efficacious.

                      SECTION III.

                     ON THE FORCEPS.

    The forceps ufed in the praftice of. midwifery is an inftru-
  ment compofed  of two  equal parts, each part confifting of a
  curved blade and a handle,  fo formed that, when applied fepa-
  rately upon the head of  a child obftrufted in its paffage through
  the pelvis, they may be  connefted  together, and ufed as two
  alternate or conjoined levers, for the purpofe of  extrafting it.
    Forceps have been occafionally made of  wood or filver, but
  thofe now generally ufed are formed of iron properly tempered,
'  with wooden handles, and when ufed, are covered with fmooth
  and  thin leather ; which, without any fignificant increafe of
  bulk,  renders their introduction more eafy, and takes off, both
  in appearance and m)ity, theafperity of the inftrument.  Each
  blade  muft be introduced feperately, but  in fuch  directions,
  th;... when introduced they may be connefted as antagonifts to
  each other ;  and there have been different contrivances or locks
  at the part where the handles and blades unite, to  keep  them
  fixed together. 
5»
INTRODUCTION TO MIDWIFERY.
  It would he difficult to determine the time when forceps
were firft ufed, but we have very early accounts of two  kinds»
with one of which  it was intended to extraft the child, with-
out regard to the injury which might be done to it, and with
the other to extraft and preferve its life.   The firft was  armed
with  teeth or fharp protuberances on  the internal  furtace
which grafped the head ;  but thofe of the fecond kind had no
protuberances, and  when  ufed,  were clothed  with linen or
iome  foft material,  to  prevent their doing any injury to the
child.   The firft are never ufed at the prefent time,  and would
have been forgotten,  except for the patterns which are preferv-
ed in the colleftions of thofe who, teach the art.   Of the latter
kind there is  an endlefs variety,  but every variety regards one
or  other of thefe conditions;  their length, their ftrength, or
their different degrees or kinds  of curvature.
  From the length of the jorcebs formerly made,  we may con-
clude that it  was  ufual, at leaft fometimes the praftice, to ap-
ply them before, or  as foon as the head of the child had entered
the fuperior  aperture of the pelvis ;  and from their ftrength,
that it was thought neceffary  to provide for the exertion of great
force.   The common curvature  was varied  according to the
opinion entertained of the form and dimenfions of the head of a
child at the time ot birth ; but the lateral curvature was given
for the  accommodation of the inftrument to the form of the
pelvis,  or  for leffening the  preffure upon, and  ot  courfe the
danger of lacerating, the external  parts,  while  the  child was
extrafting.  As the Jorceps, though well applied,  fometimes
flipped from  the head when brought into aftion, a groove, with
a flight eminence  on each fide,  was propofed to be made on that
part of the internal furtace which embraced the head, to prevent
that accident, and to allow of a change in the manner of acting,
by  admitting of fome degree  of rotation.
   Forceps have alfo been contrived in fueh a manner, that one
blade received the other, and thefe were called male and female.
They have alfo been made with hinges  or joints between the
handle and the t lade of each, anfwering no other purpofe than
that of concealing them, that there might be  an opportunity of
performing the opeiation with them in  a clandeitine manner.
But as the  reafons for ufing  the Jorceps^kiU juftify  the opera-
tion to- the moft fevere examiner; and as thefe may be explained
without adding to the terror or diftrefs either of the patient or
her friends, there never can be occafion for concealment, whic h,
in  thefe cafes, ought to raife a fufpicion of the judgment or in-
tegrity of thofe who fhould attempt to pra£tife it.  There ist In 
ON  DIFFICULT LABOURS.
58
truth, at the prefent time, more frequently a neceffity for refitt-
ing the felicitations both of patients and friends, urging us to
the ufe ot inftruments, than of perfuading them to comply with
our propofals when we really think them needtul.
   Befides  the different  kinds of forceps which confift of two
blades, others have been contrived with three, which,  when
feperately applied, were received and fcrewed in a  hollow han-
dle, or fi"xcd by  fome other contrivance.  By thofe who fup-
pofed  labours to be chiefly obftrufted or rendered  difficult by
the infleftion of the os coccygis, a third blade was added for the
purpofe of raiting  the head  of the child over that part.  But
thofe who fuppofed difficulties to be occafioned by the facrum
jetting, and ot courfe projefting the head of the child over the
fymphyfis ot the offa pubis, added a third blade, for the purpofe
of bringing back the head thus  projected into  a right line with
the cavity of the pelvis, before any attempt was made to extraft
it with the other two blades.  Whatever credit may be due  to
the authors ot thefe contrivances for their ingenuity, the third
 blade  has certainly been added on  erroneous  principles ; and
forceps  thus conftrufted would not  only be  embarraffing  in
 praftice, but in every cafe, as far as can be judged, ufelefs, or
 extremely injurious*.
   It is remarkable that forceps were made of an unneceffary
 length, when we were forbidden to apply them before the head
 of a child had defcended very low into the pelvis ; and they
 were made very ftrong, when it was  well underftood, that the
 force, which they enabled us to ufe, was far greater than could
 be exerted with propriety or fafety to the mother.   They were
 however  by  degrees made  fhorter and  lefs cumberfome, and
 about the year 1748, Dr. William  Smellie, who was eminent in
 praftice, and as a teacher of midwifery in London, after many
 trials, altered them, and brought into general ufage a kind of
forteps,  more convenient than any before contrived.  Thefe
 before they are curved  do  not meafure more than twelve inches
 from the end of the handle to the extremity of the blade ; and,
 when properly  curved, little more than eleven inches, of which
 the handle meafures near five inches.  The wideft part of the
 blade meafures about one inch and five eighths, and this gradu-
 ally declines towardUhe handle, preferving at the  fame time the
 flatnefs of the  blade till it meets the handle.   Being fimple m
 their conftruftion, applicable without difficulty,  and equal  to
 the management of every cafe in which the forceps ought to be
* Set Chapman. 
54
INTRODUCTION TO MIDWIFERY.
ufed,  I have, with very little alteration, adapted the following
rules to them.  But if forceps of any other kind fhould be pre-
ferred, though the principles will hold good, the rules muft be
varied according to their fize and form, at the discretion of the
perfon who may perform the operation.
SECTION VI.
CENERAL OBSERVATIONS.
   It has been long eftablifhed as a general rule in this country,
that the ufe of inftruments ot any kind ought not to be allowed
in the praftice  of midwifery from any motives ot eligibility*.
Whoever will give himfelf time to confider the poffible miftakes
and want of fkill in younger praftitioners, of which I fear many
of us may have recollection, the inftances of prefumption  in
thofe who by experience have acquired dexterity, and the acci-
dents, which, under certain circumftances, feem fcarcely to be
avoided, will be ftrongly impreffed with a fenfe of the propriety
of this rule, as well as from the general reafon of the thing.  But
when, from any caufe, the parent becomes  unequal to the ex-
pulfion of the child, the affiftance of art, by whatever  means it
can  be afforded, is juftifiable  by neceffity ; becaufe without
fuch affiftance the parent would die  undelivered, and  with her
life, that ot the child would alfo be inevitably loft.  Yet it be-
hoveth every perfon, who may ufe inftruments in the praftice
of midwifery, to be well convinced of this neceffity before they
are ufed,  and to" be extremely careful in their  ufe ; that he
may not create new  evils, or aggravate thofe which might be
exilting.  But though it be our duty to avoid, it poflible, the
ufe even of thofe inftruments, which are intended to be employ-
ed without injury either to the mother or child, it would, on the
other hand, be abfurd to defer their ufe till the child was dead,
and the mother reduced to a ftate, not of apprehended,  but of
real danger ; or, which is worfe, that if the fhould furvive, her
life would be rendered miferable from the confequences of mif-
chief done before the inftruments were ufed.

  *  Non nifijumma neceffitatt illud exigente atque turn demum
educendis ex utero infantibus abmovenda effe ferramenta, quum
nihil omnino Jpei rehquum eft Jore, utjolarum manuumfubfidio
extrahere  ipjos liceat.—Heifter,  Capt. Liij.  ix.  and many
other writers. 
©N DIFFICULT  LABOURS.
55
  When it is propofed to deliver women with the Jorceps, the
intention is, to fupply by thefe means the total want, or defici-
ency, of the natural pains ot labour ;  in other words, to extraft
the headof a child, which cannot be expelled by the efforts of the
mother.  But fo long as thefe efforts continue with any degree of
vigour, there is always reafon to  hope, that they will ultimately
accomplifh the effeft of expelling the child without any artifici'-
al affiftance, in which cafe the ufe of the Jorceps is not required.
We are moreover to recolleft, that in labours of long continu-
ance there will often be an abatement, or even a temporary ceffati-
on of the pains, tor many, hours, without any apparent reafon or
alarming fymptoms ; but that ceffation of the pains, which is
the confequence of long continued, fruitlefs aftion, and ot great
debility, is to be confidered as the only juftification of the ufe of
 the forceps.
   Before the completion ot the firft ftage of a labour, that is,
 before the os uteri is perfectly dilated,  and the membranes
 broken,  the ufe of the Jorceps can never come under contem-
 plation.   Becaufe the difficulties before occurring may depend
 upon caufes, which do not require  their ufe ; or, if required,
 they could not be applied with fafety or propriety before thofe
 changes were made.
   There is  infinitely greater difficulty in deciding upon  the
 proper  cafe and time  when the Jorceps ought to  be applied,
 than  in applying  or ufing them ; but it is  univerfally agreed,
 that the lower the head of the child has defcended into the pel-
 vis, the eafier will their application be, and the operation with
 them more certain and fuccefsful.   With a view to this obfer-
 vation, a praftical rule has been formed, that the head of a child
 fhall have refted for fix hours, as low as the pennxum, that is,
 in a  fituation which would allow of their application, before the
forceps are applied, though the pains*fhould  have altogether
 ceafed during that time.   This, with other rules, was intended
 to prevent the rath or unneceffary ufe of the forceps, and cer-
 tainly time, in thefe and many other cafes, is  a  very good cor-
 reftor of praftice.  It is  fcarcely  poffible to fay too much
 againfl a hafty recourfe to ihe Jorceps, even in cafes which may
 ultimately be relieved by ufing  them.
    The Jorceps oughfto be applied over the  ears  ot the child,
  becaufe when thus placed, there is the leaft likelihood of doing
  injury to the child, or of their  flipping, and  they enable us  to
  a6l with the greateft advantage and faiety to the mother.   It
  muft therefore  be improper to attempt to apply them before an
  ear can be telt, either becaufe the head is too high to allow  us 
$6            INTRODUCTION  TO MIDWIFERY.
 to reach that part, or becaufe it is fb clofely locked in $£pSvis,
 that there is not fufficient room to pafs the finger for that pur-
 pofe between the head of the child and the pelvis.  If an ear of
 the  child can be felt, the cafe is always  manageable with the
forceps, fhould their ufe be required.  But when the queftion,
 whether they ought to be applied, comes under confideration, the
 ears are not turned to the fides of the pelvis, but that ear which
 isto guide us will be found towards the pubes, or in a diagonal
 direction with regard to the pelvis.  However we are always to
 remember, that the Jorceps are not to be applied becaufe we
 have the power of applying them, but becaufe the neceffity of
 the cafe is fuch as to requre their ufe.   Yet cafes fometimes
 occur  in  praftice, in which  we may defpair of the ability ot
 the mother to expehthe child ; and which,.though not  fuch as
 have been ftated as perfeftly fuitable, for the ufe of the Jorceps,
 become fuitable, merely by waiting a certain number of hours,
 and a repetition of the flight efforts of the parent. '  In that def-
 ponding ftate, with which every tedious and difficult labour  is
 accompanied, I have alfo  found the patient very much comfort-
 ed and  encouraged, by having fome diflpnt time held up to her
 when flie  fhould be aflifted, if tlit labour were not before con-
 cluded  : as this gives her new refolution, by offering to her
 imagination a certain period to her fuffering.
  Every change in the pofition of the head, and. every alteration
 in the conftruftion of the Jorceps from thofe already ftated, will
 require fome difference in the manner oi applying  and ufing
 them,   But the preference, which ought in reafoh to  be given,
 of one kind of forceps to another, is merely becaufe one inftru-
 ment may be more handy and convenient than another, for an
 intelligent and fkilrulman would be able to apply and ufe thofe
 of any form or fize, in fuch a manner that they fhould effeftually
 anfwer  his purpofe ; #s  an expert furgeon would be able to
 amputate  a limb with a  knife of any kind.   No confideration
 or  advantage  to be gained by inftruments  of  any  particular
 ftrufture   ought to leffen our attention  and  care when  we
 ufe them; as  the fucccfs of  every  operation muft neceflarily
 depend, not upon the excellence of the inftrument,  but upon'
 the juftnefs ot the ici'.?a entertained ot it in the mind of the per-
 fon  who may perform it,  and the dexterity or fk.il! with which
 the inftrument may be guided by his hands.
   When we have determined on ufing ihejorceps  according to
 the  preceding obfervations, corrected by our own judgment;
 and when  we have reprefented our opinion, and explained the
 reafons for it to the friends of the patient, as is cuftomaxy in aii 
                  ON  DIFFICULT LABOURS.              &J

other operations, we muft  prepare  for  this in the following
manner.   The patient is to be placed upon her left fide, acrofs,
and very near the edge of the bed on which fhe is laid, with her
knees drawn  up to the abdomen, and a pillow placed between
them, that we may be able to reach the patient with all  conve-
nience, and  poffcfs the free and uninterrupted ufe of our own
hands.  The inftruments, being warmed in water, and fmeared
with fome unftuous application, are to  be fo placed, that they
can be readily taken hold of by ourfeh es,or handed to us by an
affiftant*  '
         ,+
                     SECTION V.
          ON THE  APPLICATION OF  THE FORCEPS.

  The firft  part of the operation confifts In paffing the fore«?
finger of the right hand between the offa pubis and the head of
the child to the ear.   Then taking the part of the forceps to be
firft introduced,  by the handle, in  the left hand, the point oi
the blade  is to be flowfy  condufted  between the head of the
child and the finger, till the inftrument touches the ear.
  There can be no difficulty or hazard in carrying the inftru-
ment thus far, becaufe it will be guided, and in fome meafure
fhielded, by the  finger.  But the farther introduftion muft be
made with a very flow femi-rotatory motion, keeping the point
of the blade, as  it is advanced, not rigidly, yet clofely to the
head of the child, by raifing the handle towards the pubes.   In
this manner the blade muft be carried gently along the head,
till the lock reaches the external parts near the anterior angle.
oi ihe pudendum.
  The point of the blade, while introducing, fometimes hitches
upon the ear of the child, and then it requires a little elevation,
which is given by depreffing the handle.   But  when it  has
paffed the ear, and is beyond the guidance of the finger, fhould
there be any check to the introduction  either of this or the other
blade, it fhould be withdrawn a little, to give us an opportunity.
of difcovering the caufe of the obftacle, which we muft  never
ftrive to overcome with violence, though  we muft proceed
with firmnefs.  When the firft blade is properly introduced, it
muft be held fteadilv in its place, by preffing the handle towards
the pubes, and it it will be a guide  in the introduftion and ap-
plication of the fecond blade. ■
   Voi>. II.                   I 
$$            INTRODUCTION TO MIDWIFERY.

  Let the fecond blade be introduced in this manner.   Keep
the blade firft introduced in its place, with the two leffer fin-
gers of the left hand, and carry the fore-finger of the fame hand
between  the perinatum  and the  head of the child, as high as
yoti can reach.  Then take the fecond blade of the Jorceps by
the handle, in the right hand, and, conveying the point between
the finger placed within the perinatum,  and the  head of the
Child, conduft the inftrument with the precautions before men-
tioned, fo far that the lock fhall  touch the interior part of the
perinatum, or even prefs it a little backwards.  In order to fix
the two blades thus introduced, that which was placed towards
the pubes muft be flowly withdrawn, and carried  fo far  back-
wards, that it can be locked with the fecond  blade retained
wholly, or nearly, in its firft pofition : and care muft be taken,
that nothing be entangled in the lock,  by  paffing the  finger
round it.   When the Jorceps are locked, it will be found con-
venient to tie the handles  together, With fufficient firmnefs to
prevent them  from Aiding or changing their pofition,  when
they are not held in the  hand, but not in fuch a manner as to
increafe the compreffion upon the head of the child.
  Should the blades of the Jorceps be introduced  fo as  not to
be  oppofite to each other, they could  not be locked ) or if
when applied the handles fhould  come clofe together, or be at a
great diftance  from each other, they would probably flip, or
there would be a failure  of fome kind in the operation, as the
bulk of the head would not be included, or they would be fixed
on fome  improper part of the head ;  though allowance is to be
made for  the difference  in the  fize of  the  heads of children.
But if a cafe be proper for the Jorceps, it they  be  well applied,
and we were to aft flowly with them, there would  not be much
rifk ot failure or difappointment.
  The difficulty of applying the forceps is moft frequently oc-
cafioned by attempting to apply them too foon ; or by paffing
them in a wrong direction ; or  by entangling  the foft parts of
the mother between the inftrument and  the head of the child,
againft all which accidents we are to be on our guard.


                     SECTION  VI.

    ON  THE ACTION WITH THE FORCEPS WHEN  APPLIED.

  IT was before obferved, that the forceps, when applied, and
fixed upon the head of a child, might be confidered as a com*
pound inftrument, which allowed of a  feparate  aftion, with 
©N  DIFFICULT LABOURS.
59
♦ither of the parts of which it was compofed ;  or of a conjuft,
aft ion, as if the two parts formed one inftrument.  The feparate
aftion with either part will be on the principle of the lever; but
that with both the .blades will be fimple traftion.  Yet in prac-
tice we fhall find very few cafes, in which it will not be necef-
fary to exercife or to combine both thefe kinds of aftion.
   As it is  the intention, when the forceps are ufed, to fupply
with them  the total want or infufficiency ot the natural pains ot
labour, the whole power or force, which the inftrument enables
us to ufe, ought not to be exerted in the firft inftance, but luch
a degree as any  individual cafe may require; which can only
be known  by the firft trying a moderate degree of  force, ;n-
creafing it  flowly and deliberately, according to the  exigence
of each cafe.  Becaufe the impediment may not be great, and
the point of  obftruftion may exift only at one part; and thefe
being furmounted'by one, or a few aftions with the inftrument,
there would  be  no caufe  for afting any more.  In fome cafes
alfo, though the pains  had entirely ceafed, they will return with
force fuflicient to expel the child, from the irritation made by
the mere application ot the inftrument.  But when the Jorceps
have been  applied, they fhould not be removed before the head
is expelled, though their affiftance be not required ; left the
pains fhould ceafe, and we fhould again be  obliged  to apply
them.
   The  effefts of the Jorceps, or the confequences which refult
from their  aftion, are thefe ; compreffion of the head, defcent
of the head, inclination of the face to the hollow of the facrum,
extraftion of the head.  As the defcent of the head precedes the
inclination of the face to the hollow, of the Jacrum, it would be
improper to attempt to change the pofition of the head before it
has descended, and it is afterwards unneeeffary.   Becaufe if the
aftion with the forceps be flow, and,, according to the direftion of
the handles, the pofition ot the head becomes altered in proportion
to its defcent, without any aim on the part of the operator, and
without his guidance.
   When the Jorceps are firft locked, they are placed far back-
wards,  with the lock cjofe to, or juft  within the internal fur-
face of the perinaum ;  and  they can have no  fupport back-
wards, except the little which is afforded by the foft parts. The
firft aftion  with them fhould therefore be made by bringing
the  handles,  grafped  firmly  in one or both hands, to prevent
the inftrument from playing upon the head of the child, flowly,
towards the pubes, till they come to a tuil reft.  Having waited
a fhort interval with there  in that fituation. the handles. uv-.{\ be 
&?            INTRODUCTION  TO MIDWIFERY.
 carried back in the fame flow but fteady manner to the perU
 nceum, everting,, as they are carried in the different directions,
 a certain degree of extrafting force ; and after waiting another
 interval, they are again to be raifed towards the pubes, accord-
 ing to the fituation ot the handles.  Throughout the operation,
 efpecially the firft part, the action  of that blade of the Jorceps,
 originally applied towards the pubes, muft be ftrongerand more
 extenfive than the a£tion with the other blade ; this having no
fulcrum to fupport it, and chiefly anfwering the,, purpofe of re-
 gulating the aftion with,  the other blade.   If there were any
 labour  pains when the operation  was begun, or fliould they
 come on  in the courfe  of it, the forceps fhould only be afted
 with during the continuance ot the pains; the intention being
 not only to fupply the want or  infufficiency of the pains, but
 to follow  them, and imitate  alfo by the aftion ^vith the Jorceps
 the manner in which they return.
   By a few repetitions of this alternate aftion and reft before
 defcribed, we fhall f'oon be fenfible of the defcent ot the head;
 and it will be proper to examine very frequently, to know the
 progrefs made, that we may not ufe more force than needful,
 or go on with more hafte than may be expedient or fate. In every
 cafe, even thofe which allow of  the eafieft management, we
 ought to proceed flowly and circumfpeftly,  not forgetting that
 a fmall  degree of force, continued for a long time, will in gene-
 ral be equivalent to a  greater force haftily, exerted, and with
 infinitely  lefs detriment either  to the mother or child.   But
 after fome time, fhould we  not perceive the head to advance,
 the force hitherto ufed muft  be gradually  increafed, till it  is
 fufficient  to overcome the obftacles to the delivery  of tfic
 patient,                                                ,
   It was before obferved, as the head ot the  child defeended,
 that the face would  be accordingly turned towards  the hollow
 of  the Jacrum, without any aim  or affiftance on our part.  Of
 courfe  the pofition ot the  handles of the Jorceps, and the direc-
 tion in which we ought to aft with them, fhould alter ;  for they
 becoming firft more diagonal or oblique,  wkh.refpeft to the
 pelvis,  and  then more and more lateral, every change in their
 pofition will tequire a differently direfted aftion, becaufe the
 handles fhould  ever  remain, and be afted with, as antao-onifts
 to  each other.  In proportion  alio to the defcent of the  head,
 the handles of the Jorceps  fhould approach nearer to the pub's ;
 fo that  in the beginning  of tie  operation, though wc acted  in
 the direftion of the cavity of the pelvis,  towards the conchifion
 we fliould act in that of the vagina, to  prevent a  laceration o£ 
-  ON  DIFFICULT* LABOURS.                &
the parts.  When we  feel that we have  the  command ot the
Lead Iv its being cleared of any obftru6tion in the pelvis, and
the external  pans begin to be diftended, we ought to aft yet
more flowly, efpecially in the cafe of a firft child, or there
would be the greateft danger of a laceration of the foft parts :
and this can only be prevented by aftingmoft deliberately ;  and
in the direftion of the vagina ;  by giving the parts time to dif-
tend ; by duly  fupporting the perinaum, which is the  part
chiefly in danger, with the palm of the hand firmly applied ; by
.foothmg and moderating  the hurry and efforts of the patient ;
and, in feme  cafes, by abfolutely refilling for a certain time the
paffage of the head through the external parts, as in a natural
labour.  When the head  of the child is  born, the forceps are
to be removed, the delivery being completed as far as  their af-
fiftance was required, and the.remaining circumftances are to be
managed as if the labour had been natural.
   On the whole it appears,  that  neceflity alone, and not any
fenfe of eligibility or expediency,  will juftify the ufe of the
Jorceps ;  that when fuch  neceflity exifts, their ufe is not only
juftifiable, but highly advantageous  ; that with care they may
be fately applied 5 that flownefs and fteadinefs in our aftion
with them  will effeftually fecure both  the parent and child
agauift untoward accidents ; but that no fkill or knowledge can
prevent difappointment or mifchief, if they be improperly or
prematu-iely applied, or if the operation with them be performed
with hurry  or violence.   It is not poflible to fix any  limits to
the time that may be  required for the operation with the^r-
ceps, but I  have frequently known more than an hour to pafs
 from the fixing ot the inftrument, before I  could with fafety
extraft the head of the  child through the external parts.


                      SECTION VII.
  ON THE  APPLICATION OF THE  FORCEPS,  UNDER VARIOUS
                     CIRCUMSTANCES.

  We have before confidered the manner of applying and ufing.-
the Jorceps, when the head of the child prefented in  the moft
natural way, that is, with the face inclining towards the Jacrum.
But  they may be equally neceffary in other pofitions of the
head, that  efpecially which is the  next place moft frequent,
when the face  is inclined towards the pubes,   This pofition 
6ft              INTRODUCTION TO MiDWIFERY.

is difcoverable by the readinefs with which we can feel the great-
er fontanel  in  the  common examination, by the  direftion of
the ear, and often by feeling diftinftly the features of the fact
tending towards the fymphyfis.
  It was before  obferved, that  this pofition of the head  only
conftituted a variety of natural  labours, as  far as pofition was
concerned in the definition.  We are not therefore to be guid-
ed in our opinion of the propriety ot ufing the Jorceps by any
pofition of the head of the child, but, whatever the pofition
may be, by the neceffity of any  cafe, proved  by the abfolute
inability of the mother to expel the child.  Should fuch necef-
fity exift with this pofition of the head,  the Jorceps are to  be
applied, in the  manner before dcfcribed, over  the  ears of the
child.   But when they are applied we  muft  aft with them
with the greateft caution ; for having a different and lefs per-
feft hold of the head, they are apt to flip, and,  acting with lefs
advantage, muft be more precarious.  But if we fucceed, when
the head, thus  fituated, is  brought fo  low as  to  diftend the
external parts, there will of courfe be greater danger of lacera-
tion, it we be ever fo much upon our guard ; becaufe, in extract-
ing the head, the chin of the child, unlefs  the head be unufually
fmall, ar admits  of a change of pofition,  fliould be cleared  ot
the offa pubis, before  the hind head is  fuffered to  Aide  over
the perinaum, which will very much increafe the diftention,
and produce the fame  effeft as  if the arch ot the offa pubis was
too fmall to receive the head oi the child.
   The fame obfervations are alfo generally true when the face
of the child prefents ;  or when, together with the head, th< re
are one or both arms.  For though in fuch cafes there might
be a neceffity  for, and a propriety in,  ufing  the forceps1, the
operation with them would neither be fo ctitain nor fo  eafy as
in the pofition of the head firft ftated.
   In labours attended with convulfions, or dangerous hemorr-
hage ; or when from any other urgent caufe it  may be neceffa-
ry to haften the delivery of the patient, to free  her from imme-
diate danger, fhould die Jorceps be ufed,  the general rules will
be  fufficient to  guide  us, varying and fuiting our conduct to
the exigence of  any particular cafe.
   Laftly, when  there  are  figns ot imminent danger, however
averfe we may  be to the ufe  of inftruments, we  may  be in*
duced* to try  the Jorceps, though a cafe might not  be al-
together fuch  as  may be  efieemed moft eligible  for  their
application ; merelv to take an indifferent  chance  of  laving
the lite of a child, which muft otherwife be inevitably loft.   In
fuch cafes we rnufl advert to  the general principle, and make 
ON  DIFFICULT LABOURS.
61
our attemps in a'manner confiftent with the fafety of the parent;
and, from motives ot prudence, prepare the friends for that dif-
appointment, which it may not be in our power to prevent.


                     SECTION VIIL
                     ON THE VECTIS.

  The veclis ufed in the praftice of midwifery is an inftrument
confifting of one blade, flightly curved, and a handle; fomewhat
larger, but fimilar in form to one of the blades of the forceps. *
  The true origin ot this inftrument, or time  when it was firft
difcovered,  it is not known ; but  before any accounts of the
veclis were publifhed ;  fome difficult  cafes  were recorded*, in
which women had heen delivered with  one blade  of the forceps,
which might then be well confidered   as a veclis, though  not
called by that name.   But when only  one blade  of the forceps
had been ufed, the operation was mentioned  as fomething  ex-
traordinary, to fhew perhaps the  judgment, fkill, or good for-
tune of the perfon who performed it;  and not as leading to the
ufe of a particular inftrument, or to a rule  of praftice.  It is
 firobable, that the inftruments ufed by the  Chamberlens in the
 aft century was the veclis ; but this  is conjefture, for, after
much inquiry, though fcarcely credible, no perfon has'yet been
able to difcover, that any of them left either  a pattern or  de-
scription of the inftrument  which they ufed.  In the fecond
volume of Heifter's Surgery there is a  delineation of a true yec-
hs, by Palfyn, a furgeon of eminence at  Ghent;  but neither
this  inftrument nor its defcription engaged much attention,
nor was the veclis generally known in this country,  before the
year 1750.  For though  it  had been ufed  before that time by
Rhonhuyfen, a  furgeon at Amfterdam, after whofe name it has
been fince called, it was referved by him with great feerefy, to
his own credit and advantage ; and, after his death, became th?
property ot his  only daughter, from whom it was purchafed bv
De Bruyn,  an  eminent furgeon of the fame place.   It appears
that De Bruyn concealed the fecret with as  much  caution as
Rhonhuyfen ; or  that he mftrufted ftudents in the ufe ot the
veclis at a confiderable price, and with an obligation not to di-
vuhje to otheis what he taught them ;  which  r-iuft luve rai.ei
* See CbaDrrun. 
64            INTRODUCTION TO MIDWIFERY.
    great fufpicion of impofture on his part, and of credulity  in
    thofe whom  he taught.  The  names ot other gentlemen who
    changed or improved the inftrument foort became known ; and,
    annexed to a paper written on  this  fubjeft  by the celebrated
    profeffor Camper,  in the fifteenth volume of the Memoirs of
    the  Royal Academy of Surgery, is a plate reprefenting the
    veclis ufed by Rhonhuyfon, Boom, and Titjing.
      The advantages arifing from the ufe of the  veclis in the hands
    of De Bruyn, oftentatiouffy urged, appearing to be very great,
.*-   Vijcher and  Vander Pol, two phyficians at Amjlerdam, from
    motives of pure benevolence,  purchafed the fecret trom De
    Bruyn, in the year 1755, and immediately publifhed a descrip-
    tion of the inftrument, with directions for ufing it ;  but none
    of the papers printed on  this  fubjeft in the Dutch language
    have ever been tranflated  into our own.   While the veclis
    remained a fecret, the reports of the benefits obtained by it were
    probably  much exaggerated, efpecially thofe of  De  Bruyn,
    though Van Suneten fays he was an honeft man ;  but, when  it
    was  divulged, and the pofiti^e and  comparitive merits of the
    veclis ftriftly examined, it retained its credit and eftimation, in the
    ©pinion of many competent judges, in different parts.of Europe.
      When the  veclis was very much  ufed, and highly efteemed,
    at Amjlerdam, as an invaluable improvement in the praftice of
    midwifery, the Jorceps was the favourite inftrument  in this-
    country, efpecially as  altered  by Smellie, who was  then the
    principal teacher of the art in London.   But the chief praftice
    in this  city*  was fucceffively in the hands  of Drs. Bamber,
    Griffith, Middleton, Nefbit, and Cole, fome, if not all of whom,
    except Dr. Bamber, whofe Jorceps I have feen, preferred the
    veclis to  the forceps.'  To  thofe gentlemen fucceeded Dr.
    John Wathen, a  man of great ingenuity, and moft pleafinjf
    manners, who altered the  form and reduced the  fize of this
    veclis, and frequently ufed it with dexterity that has aftonifhed
    me.  In the year 1757, that moft excellent charity for deliver-
    ing poor women at their own habitations was eftablifhed ; and
    Dr. John Ford was the firft phyfician appointed to conduft it.
    On every occafion which, required  inftruments of  this kind,!
    Dr. Ford ufed the veclis ;  and his coadjutors and fuceeffctt*
                                                        * *
     *  Mr. Maiden of Putney, very obligingly Jhtwed me a letter.
    of Dr. Griffith's containing direSions Jor the application and
   ufe of theveftis, but in that there was nothing particularly ex-
    cellent.   Dr.  Sims has alfo a letter on the Jamejubjed, w-i-
   ten to his father by Dr. Cole, 
ON  DIFFICULT LABOUR8.
65
Drs. Cooper, Cogan,  Douglafs,  Sims, Dennijon, Squire and
Croft, with many others, have followed his example.  From the
deferved reputation of thefe gentlemen, who have at all times
expreffed their approbation of the veclis in preference to the Jor-
ceps, many have been induced to try it, and the general opinion
of its utility  has increafed.   At the prefent time, alt who arc
engaged in the praftice of midwifery would confider themfelves
as deficient, if they were not acquainted with the ftrufture and
manner ot ufing the vedis ; fome who formerly pretered and
ufed the Jorceps, relinquifhed the ufe of this  inftrument for the
vedis ;  and others who,  from education or habit, continue to
ufe ihe Jorceps, are very willing to allow the equal, if not fupe-
rior utility ot the vedis.


                     SECTION  IX.

           ON  THE DIFFERENT KINDS OF VECTIS.

   The firft vedis of which we had any knowledge in thij
country, was fimilar to that of Palfyn before  mentioned.  The
inftrument purchafed  by  Vijcher and Vander Pol, which was
made public in  a pamphlet written in  the  Dutch  language, i3
different from that of Palfyn.  In the  account given by Cam-
per, there appears to be fome  difference in  the form,  length
manner,  and degree  of curvature  of the vedis ufed by De
Bruyn,  Boom, and Titfing.   But if the powers of the inftru-
ment were preferved, and the general principle of ufing it fol-
lowed, it is probable that all  thofe who  preferred the vedis
thought themfelves  at liberty  to alter  its  form, or to vary its
dimenfions, making the inftrument, by fuch alterations, fuita-
ble to their own ideas of the properties required.
   When the veclis was firft known in this country, that defcrib-
ed by Heifer was preferred to thofe recommended by the fur-
geons at  Amflerdam.   The veclis  ufed by  Dr. Cole was like
one blade of the Jorceps, fomewhat lengthened and enlarged.
That of Dr. Griffith was of the  fame kind, with a hinge be-
tween the handle and  blade; and that of Dr. Wathen was not
unlike Palfyn s but with a flat handle, and a hook at the extre-
mity of the handle, which prevented its flipping through the
hand, and might be occafionally ufed as a crotchet.   Many
other changes have been made in the conftruftion ot the inftru-
ment, but the vedis now  generally  ufed is ot the following di-
menfions :
   Vol. II.                  K 
66
INTRODUCTION TO MIDWIFERY.
  The whole length of the inftrument, before it is curved, is
twelve inches and a half.
  The length of the blade, before it is curved, is feven inches
and a half.'                                             ,
  The length of the blade,  when  curved,  is fix inches and a
half.
  The wideft part of the blade is one inch and three quarters.
  The weight of the vedis is fix ounces and a half.
  The handle is fixed in wood.
  From this defeription, any perfon acquainted with the Jorceps
< oula find no difficulty in forming a jnft idea of the vedis, or
an artift in making it.  It appears that a fingle blade ot the for-
ceps might, in many cafes, be ufed not inconveniently, inftead
of any other  vedis, and  would generally anfwer the purpofe
without the trouble of introducing the fecond blade,  as I have
often-experienced before I was acquainted with the vedis.
  With  refpeft to the part of the blade  of  the vedis  which
ought to be curved, and the degree of curvature, there has been
fome difference of opinion ; but  this muft relate either to the
eafe of introducing, or the advantage of afting.  With a fmall
degree of curvature, diffufed through the blade, the inftrument
may be moft eafily  introduced, and  it is moft fuitable to the
form ot the head, nor can the degree  of curvature required, on
any principle, be very great.  But if, together with the power
of the lever, we  aim at  acquiring much extrafting  force, the
curvature fhould be fomewhat increafed towards the extremity ;
becaufe the two centres, on which the force ufed would reft,
would be at thofe parts of the head on which the inftrument might
bear, and the part on which it would  reft, whether the fides of
the pelvis or the hand of the operator.
   For rendering the introduftion  of ,the inftrument  more eafy,
and for preventing all the inconveniencies which might  arife
 from the difference of curvature, Dr. Aitkin of Edindurgh con-
 trived a vedis, which he has fancifully called the living lever.
 When this is at reft it is quite ftraight; but while  it is intro-
 ducing, by turning a fcrew in the handle, the blade is jointed
 in fuch a manner as to bend  gradually forwards as the inftru-
 ment is advanced, fo that  the extremity of the blade is always
 kept clofe to the head of the child,  whatever dimenfions that
 may be.  There is much ingenuity in the contrivance; but of
 the effeft in  praftice I cannot fpeak, having never tried this in-
  ftrument, not wifhing for one more perfeft than that in ordinary
 ufe.  But a gentleman informed me, that in a trial he made, the
  chain, on which the mechanifm chiefly depends, broke, and he 
OF DIFFICULT LABOURS.                67
was obfiged to finifh the operation with a common vedis  ; fo
that in all probability the common vedis are aftually preferable
to any ot the complex kinds.
  To leffen the preffure made by the inftrument, when in afti-
on, upon the parts of the mother, on which it might bear, fome
perfon contrived two holes on a part of the blade, near the han-
dle, through which a ftrong ribband or  tape was to be paffed,
which being afterwards tied and pulled firmly, when the inftru-
ment was   afted with, was fuppofed to confine it firmly to the
head of the child, and prevent or leffen the preffure which might
otherwife  be made upon the parts  of the mother ; but it appears
that the fame end may be anfwered better by an intelligent and
dextrous  management of the inftrument,  than by this  con-
trivance.

                      SECTION X.
 ON THE COMPARISON  OF THE VECTIS WITH THE FORCEPS.

  The general principle ot praftice, that the ufe of no inftru-
ment  is to be allowed,  except in cafes ot abfolute  neceffity,
ought not to be infringed, becaufe we entertain a high opinion
ot any inftrument, or becaufe we may have acquired dexterity
in ufing it, for fuch  reafons would be indefenfible,  and any
conduft founded upon them would be highly culpable.   That
principle  founded in common fenfe as well  as medical know-
ledge, and confirmed by daily experience, muft be held invi-
olable.  Thereat value of any inflrument will be  fhewn by
its efficacy to  anfwer the  purpofe  for which it may be ufed,
and by the fafety and convenience with which it can be man-
aged,  when its  ufe becomes abfolutely neceffary.
 °There has been much veibal difpute among thofe who vin-
dicated the fuperiority of the vedis to the Jorceps,  and thofe
who maintained the long eftablifhed credit ot the jorceps againft
the encroachments of the vedis : but the companion between
the two inftruments has  never been brought fairly to an  1 flue,
which might have been done by a difcuffion of the two follow-
ing queftions.            '                .       _
  Is it poflible to deliver a woman fafely with the Jorceps, m
any cafe not manageable with the vedis ?              .
  Is ft poflible to deliver a woman fafely with the vedis, in any
cafe not manageable with the jorceps  ?
  We m.iy take it for granted, and I believe it is  true,  .n.'t v.. 
68            INTRODUCTION TO MIDWIFERY.
far the greater number of cafes which occur in praftice, either
of thefe inftruments may be ufed indifcriminately, with equal
fafety, advantage, and eafe,  allowing tor the dexterity which
may have been acquired by the habit ot ufing either inftrument.
It is but lately that thofe who prefer the Jorceps, have aflerted,
that they could  deliver a woman in any cafe of difficulty not
manageable with the vedis ; but, as far as my experience ena-
bles me to judge, fuch a claim in favour of the Jorceps cannot
be fupported.   The debate on this point of the  queition feems
to have turned formerly, not upon the fuperior efficacy, but up-
on the greater fafety and facility with which the Jorceps might
be ufed ; and upon the abufe, rather than upon the proper ufe
of the vedis/ 1 have not heard  of any well authenticated in-
ftance, in which after being foiled with the vedis, and without
a change of circumftances, any operator,  who had acquired a
commonly dextrous ufe of this inftrument, was able to fucceed
with the forceps ; though it is worthy of notice, that fome who
are accuftomed to the ufe of the forceps only, think themfelves
at liberty to depreciate the veclis, and others  who do  not ufe
them, fpeak of the jorceps in terms of unjuftifiable contempt.
  It  might be questioned, if we were toadmit the obje£iions made
by the approvers of  fuch inftrument, whether they do not ulti-
mately lead to the abandonment of both ; and it is certain, that the
greateft improvement in the praftice of midwitery»atthe prefent
time is to be  attributed to an eftablifhed averfion to the ufe of
inftruments  of  any  kind,  whenever  they  can  poffibly  be
avoided.
   With refpeft to the fecond queftion, we will take the fafts, and
relinquifh the arguments, ufed by thofe who  have preferred the
vedis 10 the forceps ; which  I allow fometimes to have  been
extravagant, as is not unufual with thofe who  are the introducers
of novelties to public notice, till experience has correfted par-
tialities.  If any confidence may be placed in medical reports,
it appears that  many cafes have occurred, in which\ after the
introduftion ot  the  firft blade of the jorceps, it has been very
difficult, or fcarcely poffible, without the hazard of mifchief,
to introduce the fecond blade, and the operation ha§ been, per-
formed with the fingle blade, ufed as a vedis.  Ot this I have
known and been informed ot feveral inftances.   It appears alfo,
that  before the head ot the child has been fo low down as was
ftated to be eligible  for ufing the forceps,  that the vedis has
fometimes been  readily applied, and effectually ufed, with fafe-
ty both to the  mother and child, when  the neceflity ot Ionic
particular cafe required  the operation.  When the head of a 
ON  DIFFICULT LABOURS.
69
child has not only been high up, but locked alfo in the pelvis,
when there was not fpace fufficient to admit the two blades, or
more force perhaps was required than the Jorceps in that fitua-
tion enabled us to  exert, and we fhould otherwife  have been
compelled to leffen the head, it has been feafible to apply the
vedis, and the patient has been fafely delivered, with a probable
chance of preferving the  life of the child ;  but  of this  I have
not myfclf known  any inftance.   Moreover, in all the deviati-
ons  from that pofition of the head,  which  is moft natural, as
when it is turned with the face towards the pubes, or when the
face prefents, in which it is allowed that the forceps cannot be
ufed with the utmoft advantage or certainty; in all fuch cafes,
1 know,  the vedis  may be applied and ufed both with fafety
and efficacy.  From this  ftatement it may be prefumed, that
the  vedis, prudently ufed, is, in every cafe, an equally  fafe
and efficacious inftrument with the jorceps, and a better adapt-
ed  inflrument in  many cafes which occur in praftice.  It- is
with this perfuafion, that feveral teachers in the art of midwifery
in London, at the  prefent time, never ufe the jorceps, or fpeak
ot  them in their lectures ;  while others, to whofe  judgment I
owe much refpeft, continue to ufe the Jorceps, and  I  think I
have advanced more than experience will juitify in  favour of
the vectis.  But thefe different opinions refpefting the prefer-
ence due to the jorceps and vectis prove to my mind, that in
the generality of cafes, either inftrument may in expert hands
be  ufed with equal fafety  and  advantage.  I  may alfo  be
permitted farther to obferve, that I know feveral gentlemen of
eminence, in the early part ot their lives, accuftomed to  ufe the
jorceps,  who difcovcring, by accident or trial, that  they were
able to afford every affiftance with a tingle blade, have abandon-
ed  the forceps, afterwards never ufing more than a fingle blade,
or  the vectis ; but I never knew  an example of any perlon,
who, having been  accuftomed to ihe vectis, relinquifhed its ufe
and referted to  the Jorceps.  The reader will obferve, that in
giving my opinion of thefe inftruments, I do not fpeak of their
abufe, but of their ufe on really neceffary occafions ; and may
be  aflured that I generally confider difputes about the  prefer-
ence of  inftruments, among the frivolous and moft unworthy
ocninations of men of underftanding. 
7o
INTRODUCTION  TO MIDWIFERY.
SECTION XL
          ON THE MANNER  OF USING THE VECTIS.

   By the firft accounts it appears that the vedis  was recom-
 mended, not only in fuch cafes as were thought fit and fuitable
 for the forceps, but to fuperfede the neceflity  of  leffening the
 head of the child ;  It was, in fhort, afferted, that no other affift-
 ance could, in any cafe, be required, beyond that which we were
 enabled  to  give with, the vectis.   But if thofe accounts were
 allowed to be true, they would prove the miferable ftate of the
 principles and  praftice of midwifery at  the time, and in the
 country in which  they were written,  in  much ftronger terms
 than they would defcribe the excellence of the inftrument ; or
 that fuch degrees of obftruftion did not exift, as are frequently
 met with in this country.
   The general  condition and circumftances  of labours before
 ftated, as requiring the ufe ot the Jorceps, will hold good, and
 withcqual propriety, when the veclis  is intended  to be ufed ;
 and the rules already given for the Jorceps  will fhorten what
 we have occafion  to fay refpecting the  manner  of ufing the
 vectis.   For though this inftrument might be applied when the
 head of the  child" was high in  the pelvis,  or even  when it was
 firmly locked in the the pelvis, in cafes  of great emergency, fuc-
 cefs in  the  management of fuch cafes depending  upon much
 previous knowledge and experience with the inftrument, I dare
not attempt to form a precife rule for the extent of our conduft
 with the vectis,  that is, how high  we may venture to introduce
 it, or with what degree of force we may ufe it.   But  when,
 without regard  to  the facility with which  the  vectis  may be
 introduced,  or any other confideration except the  neceffity'of
the cafe, under the circumflances before ftated, we have deter-
mined upon  ufing this inftrument, the patient being placed in
the fame fituation, and every thing prepared as when the Jorceps
are to be ufed, the operation is to be performed in the following
manner  :
  Pafs two fingers, or the forefinger of the' right hand, to the
ear of the child, and introducing the  vectis between the1 mi-
gcrs  and the head of the child, conduft it fh,w!y forwards till
the point of the vectis reaches  the ear, wherever that  mav be. 
ON  DIFFICULT LABOURS.
7*
 Then advancing the inftrument as if it were a blade of the for-
 ceps, carry it on till, according to your judgment, the extremity
 of the blade may reach as far, or a very little beyond, the chin of
 the child, when the line of the head, on which  the inftrument
 refts, will be in a  ftraight direftion from  the vertex, owr the
 ear, to the chin of the child ;  and this is the moft favourable
 pofition in which  it can be placed.  Then grafping the handle
 of the inflrument firmly in the  right hand, wait for the accef-
 fion of a pain, during the  continuance of which, raife the han-
 dle of the  inftrument gently but firmly  towards  the pubes at
 the fame time exerting a fmall degree of extrafting force. When
 the pain ceafes, let the inftrument reft;  and when it returns, repeat
 the fame kind of aftion ; and every time of afting endeavour to
 leffen the preffure on the foft parts of the  mother, with the two
 fingers, or the inferior fide of the palm ot the left hand placed in
 fuch a  mariner as  to form, in fome fort, a cufhion  on which
 the inftrument may play, or be  fupported.  By a repetition of
 this action during the continuance of the pains, the head of the
 child will foon be perceived to defcend,  and the face  to  turn
 gradually towards the hollow of the Jacrum.   But fhould the
 very "moderate  force we have recommended be found infuf-
 ficient to bring down the head of the child, it muft be gradual-
 ly and cautioufly  increafed, till it is fufficient  to anfwer the
 purpofe ; and this may be done confiftently with the fafety both
 of the mother and  child.  When the vertex  begins to  fill and
 protrude the external parts, it is probable  there may be no far-
 ther occafion to aft with the inftrument ; or, if further aftion
 be required, it muft be extremely gentle, taking all poflible care,
 by turning the handle towards the ifchia or fide  of the pelvis,
 by fupporting the perineum, and by flow  proceeding, to guard
 againft a laceration of the parts, as was before advifed.
   During the operation, the vectis being confined to that part
 of the head where  it was  originally placed,  muft, as the head
 defeends, neceffariiy change its relative fituation to the mother,
 and be gradually turned from the pubes to the  fide of the pelvis,
as was remarked of  the handles ot the Jorceps.
  It is alfo to be obferved, though from the name of the vectis,
it might be fuppofed we had the power of afting  with it as a
lever only, that it will be found to poffefs a confiderable degree
of extracting force, even when the curvature is but fmall;  and
thaf*we are able at  the time of ufing it, to direft with  conve-
nience,  and  in various ways,  the head  of  the  child  a  i:
defeends.
  In ufing the vectis fome have recommended the application ot 
72             INTRODUCTION TO MIDWIl'ERY.

it towards the hollow of the facrum, and fpokcn of the advan-
tages of this mode of application.  But  I have perfuaded my-
felf, that the opinion which could lead to this praftice was er-
roneous, that the inftrument  would then be  worked with lefs
efficacy, and there would be a greater hazard of doing mifchief
to the mother and child.
  It may laftly be obfervcd, that fome gentlemen have,  by fre-
quent praftice,  acquired fuch wonderful dexterity in the ufe
of the vectis,-as to finifh the operation of extrafting the head of
a child  with one tingle aftion of the inftrument.  But being
ever afraid of facrificing fafety to dexterity, I only pretend to
defcribea method of ufing this inftrument fecurely and efficaci-
oufly ; and muft therefore be excufed from commenting farther
on all that has been unadvifedly objected againft, or advanced
for, the ufe of the veftis, under various circumftances*.

  *  See a jull and accurate hiflory of the Veftis in,  Obferva-
tions on Human and Comparative Parturition by R. Bland M.
D. A. S. S. 
ON  DIFFICULT LABOURS.                 73
CHAPTER  XII.
SECTION I.
          ON LESSENING THE HEAD OF THE CHILD.


 Having finifhed all the obfervations we had to make on the
 ufe ot thofe inftruments, which have been contrived to anfwer
 the firft intention in praftice, that ot preferving the lives of both
 the  mother and  child, we come to confider an operation yet
 more important, though the neceffity  of performing it far lefs
 frequently occurs.   In this operation being convinced that,*
 under certain circumftances, it is impoffible that both their lives
 fhould be preferved, we feel ourfelves juflified  in afting as if
 the child were already  dead, as the only meafure by which the
 life of the mother can be preferved.
   This opeiation has ever been efieemed of the utmoft confe-
 quence with regard  to  its  principle and  praftice.  The right
 or equity of taking away one  life tor  the preservation ot ano-
 ther being doubted, the queftion was referred to divines, as the
 moft competent judges ot the cafe;  and by them it was decid-
 ed to be  unlawful to take away one life, on any account, for
 the prefervation of another*.   The reference of the queftion
 may perhaps be confidered as an inftance ot humanity and be-
 nevolence,  and in fome meafure, as a  proof that this operation
 had been  performed  too frequently ; and the  decifion feemed
 aftually to  forbid it altogether,  But,  as far as the general de-
 termination could be fuppofed to relate to this opeiation, there
 appears to have been fallacy in the ftatement ot the queftion,
 and fophiftry in  the reply. For by  the] firft it was prefum-
 ed that the child was always living when this fatal operation was

   * Pen in his Pratique des Accouchements, has preferved the
forms of the Jtatements and decifions  upon this Juljcct by the
 Doctors of the Sorbonne.
   Non enim licet unum interficere alterius vitae gratia.  RoJe-
 ricus e Caftro.
   Vol. II.                  f. 
74
INTRODUCTION TO MIDWIFERY.
to be performed, though that could not univerfally, nor indeed,
very frequently, have been the cafe ;  and by the latter it was
allowed, that the authority uf the decifion did not apply, or
might be fufpended, it  there were reafon to  believe that the
child was already dead.   It was probably for thefe caufes that
all the fymptoms of a dead child, certain and equivocal, were
collected and diftinguifhed by authors  with fuch great afliduity
and  circuinfpeftion,  becaufe  they  were the  authorities  for
and  the juflifications of, a praftice, which,   without  them,
would have been very reprehenfible, if not punifhable.
   In cafes of dangerous parturition the prerogative ot deciding  '
upon the life or death of the mother or child, was fuppofed by
fome to be inherent in the hufband, to whofe powers of judging,
or of feeling, appeals  were to be  made.  This erroneous  opini-
on, though I have formerlyheard it mentioned in praftice, being
alfo contrary to the rights and  interefts of fociety, never could
have fatisfied the mind, or juftified the conduft of any perfdn,
'who fhould have fubmitted to be governed by it.  Nor do thefe
cafes admit of fuch eleftion ; for if the hufband had preferred
the child, his with of  preferving  it at the expenfe of the life of
the mother  could feldom have  been gratified ; he at leaft could
be no competent judge ot the neceffity of the cafe, and certain-
 ly could claim no peculiar dominion  over the  life of either of
them.  Nor do I think it reafonable and juft, that the head of a
 child fliould ever be  leffened  on the  teftimony and judgment
 of  any  tingle  perfon, however  well he may be  informed  and
 experienced.
   True religion, and the common fenfe of mankind, appear to
have nothing contradiftory.  The doftrine they  teach of its being
 our duty to do all the good in our power, and  to avoid  all the
Tnifchiet we can, is applicable  to the exigencies  of every ftate,
 and we may be eafily reconciled to it on the prefent occafion.
 In fome cafes  of difficult parturition  it is not  poffible that the
 lives both of the mother and  child fhould be preferved.  Of
the life or death of the mother,  we can, under all circumftan-
 ces, be affured ; but of the fife or death of the  child there is of-
ten reafon to doubt, when we  are called upon  to decide and to
 aft.  The  deflruftion of the  mother, or, which has by many
"been confidered as fynonimous,  the cefarean operation,  would
 not,  in  the generality of cafes, which may  bring the operation
 of which we are fpeaking under contemplation, contribute to
 the  preservation of the child, that being already dead ;  but the
 treatment of the child as if it were aftually  dead, with as much
 certainty ot fuccefs as is found in other operations,  fecures the 
                ON DIFFICULT  LABOURS.                 75

life of the parent.'  It then becomes our duty, and is agreeable
to our reafon,  to purfue that conduft,  which will give us the
moft probable chance ot doing  good ; that is, of faving one
life, when two lives cannot probably or poffibly be faved.
   I forbear to inquire  into  the comparative value ot the lives
of an adult and a child unborn, becaufe that does not feem to
me to be the prefent queftion ; and the fubjeft has been in that
view well confidered*.   Nor does it feem neceffary to our pur-
pofe to difcufs another queftion, which has been lately agitated,
whether a child unborn has any feeling, becaufe the faft of their
having feeling, ot feme kind, or in fome degree, may be clearly
proved by any one  who will obferve the effeft of irritating the
the foles of the feet of a living child when thefe prefent, or the
palm of the hand when  that prefents, the body and head being
yet retained in the uterus.   But  there is  an argument to be
drawn from the circumftances which fometimes occur in cafes
of laborious parturition,  which applies with greater force to-
 wards juftifying this operation, in preference to any other which
 might prove move  hazardous to the mother,  than any abllraft
 realoning.  In all difficult labours, properly fo called ; efpeci-
 ally fuch as are occafioned  by difproportion between the head
 of the child and a fmall or diftorted pelvis,  one of the  firft ef-
 fefts of long-continued and  ftrong pains  is  the death of the
 child.  The head  of a dead child collapfing  and admitting of
 pre flu pe into a form more fuitable to the dimenfions ot the pel-
 vis, than a living one,  will  frequently b'e  expelled through a
 fpace too fmall to allow that of a living child of the fame fize to
 [ufs  But  after this change,  which follows the death of the
 child, fhould the head remain too large, putrefaction advancing,
 the integuments ot the head begin to decay, and the bones to
 loofen from each  other.  By the  continuance of the aftion oi
 the uterus upon the child the integuments ot the head at length
 burft, and the bones being feparated, the brain of the child may
 be evacuated through the opening.  The bulk ot the head thus
leffened may be excluded by the force of the pains, and the bo-
dy, impaired  by an equal degree  of putrefaction, may  readily
follow, and the labour  terminate without the  affiftance of art.
All thefe changes  may be,  and  fometimes,  to my own know-
ledge, have been gone through withperfeft fafety to the mother,
without the interpofition of  art, fo  that the artificial opening of
the head of a child is, in faft, no more  than an imitation in one
cafe of what happens fpontaneoufly in another ; and fuch imi-

   * See Dr. Ofborn's  Effay on  Laborious  Parturition. 
y6             INTRODUCTION TO MIDWIFERY.
 tation is the true  ground, on which the whole praftice of for-
 gery  has been founded.  It  may  alfo be  oblerved, that the
 refources of nature, in every thing which relates to parturition,
 are infinite, and conftantly exerted for the preservation of both
 the parent and child  ;  yet when the two objefts are incompa-
 tible, the life  ot the child is almoft uniformly yielded to that of
 the parent.
   trom the number of figns of a dead child given by authors,
 and by  the context of their writings, it appears to have been the
 praftice, whenever the  death of a child was afcertained, to ufe
 the means of extrafting it; or to have given medicines to excite
 and aid  the conftitution for  expelling.it,  without any  reafon
 drawn  from the prefent ftate of the mother, but to prevent re-
 mote and and fufpefte^ danger.  This praftice conelponded
 with  the theory of the ancients, that a living child was born by
 its own efforts, but a dead child, being deftitute of all power,
 muft be excluded or extrafted by  art.  But no fact, is  more
 clearly  proved than that of a dead child remaining in the uterus,
 inoffenfively, for  feveral weeks before the accemon ot labour,
 and being then expelled  in a manner perteftly natural.  No
 injurious abforption takes place, nor does the uterus fuffer by
 being in contaft  with  it.  The certainty  of the death  ot the
 child would not  therefore, immediately, indicqfe the neceffity
 of the operation we are confidering*; but the reafons for, and
 juftification of it, muft be deduced from  the ftate of the mo-
 ther ; and that ftate muft be fuch as to prove her abfolute ina-
 bility to expel the child ;  and the irapbffibility of extrafting it
 by any of thofe means, which have been contrived for the pur-
 pofe  of delivering women, giving at the fame time a chance for
 preferving the  lives  of children ; together with the ufeleffnefs
 and danger ot delay.  But as the figns of a dead child,  if de-
 cifive, would on  many occafions, have their influence on prac-
 tice,  and might at leaft induce the moft cautious and prudent
 man  to haften the time of performing this operation, which he
 might otherwife defer ; and as the knowledge of thefe  figns
 will lead to a more full inveftigation of the  fubjeft, it is proper
 to enumerate them,  and to  inquire at the fame time how far
 each  of them may be allowed to determine the faft  which they
 are adduced to prove.

   *  Sijub ipfis partus dolor ibus ac laboribus injans em oritur,
 nee tamen minus decenter,fed natural iter compofitus-effe depre-
 henditur, ncfh ftatim, quamdiu Jcilicet de morte nan fatis certi
Jumus,  unci  vel  alia  admovenda Junt inflrumenta.  Heifter.
 Cap.  CLIII. 
ON  DIFFICULT LABOURS.
77
SECTION  II.
ON  THE SIGNS OF A DEAD CHILD.
  1. Receffion of the Milk, and Flacciddity  of the Breafts.

  Should the child die when a woman is far advanced in her
pregnancy, and before the commencement of labour, thefe figns
are  feldom wanting.  But if they  were to be offered as proofs
ot the death of a child deftroyed by the feverity of a  labour, it
would  have been  needful to have compared the  ftate  of the
breafts at two fpecific times ; firft, on the acceflion of labour,
when the  child was livingand they might be turgid ; and, fe-
condly, in the advanced ftate ot labour,  when the  child was
dead, and they might  have  become flaccid.   But as it is not
cuftomary to  inquire into the ftate of the breafts before  fome
fufpicion js entertained  of the death of the child, and as thofe
ot no two  women, under any circumftances, exaftly refcmble
each other, and as  the milk is often Secreted  irregularly at dif-
ferent periods  of pregnancy, all indicationYtaken from the ftate
ot the  breafts, or the Secretion andvquantity  of milk, muft be
uncertain, and any judgment founded upon  fuch  indications,
extremely liable to error ;  granting, however, that in fome fix-
ations, they do become 'common, or collateral proofs of the
queftion we may wifh to determine.

                2 Coldnejs  of the Abdomen.

  When  children die towards the conclufion of pregnancy,
women not unfrequentry complain of coldnefs of ihe abdomen,
and, .at the irritant of their death, there is ufually  one violent
ihivering.  But when women in labour fpeak of this coldnefs,
there is not actually external coldnefs, but a  fenfe of it felt  by
the patient.  A fiippofition that a  dead child is colder than a
living one, is the principle which gives to this fign its chief im-
portance.   But whether a child has been dead  for  a ftiort or a
long time,  it is generally found to  be of the fame degree of heat
with the uterus in which it was contained,  and it is even hotter
than the uterus while it is in the a6t of putrefying.  The prin-
ciple being fallacious, the inferences muft often miflcad,  and a 
78
INTRODUCTION  TO MIDWIFERY.
child is, not unfrequentlv, born living, though"the mother, be-
fore her delivery, complained of  this coldnefs ; which may be
produced  by fome contingent circumftance, as the great heat
of the room  when fhe is in a prof ufe perforation,  or the hidden
admiflion of cold air under the bedclothes  in winter.   Little
ftrefs is to be placed on this fign alone, but, when accompanied
with others,  particularly a confiderable diminution of fize, it
muft increafe our fufpicionsof the perilous ftate of the child.

            3, Mechanical weight of the Uterus.

   If a woman in labour,  or  in  the latter end of  pregnancy,
fhould feel the uterus tall  with a  fenfe of increafed  or unrefift-
ed weight, when fhe turns from one fide to the other, or changes
her pofition,  it  is often  furmifed  that thejehild  is  dead; the
bulk of the child being diminifhed, and all that refilition ob-
served to exift in every living body being loft.  But this fenfe
or effeft may'oftcn be explained  in a more fatisfaftory manner
from other  caufes,  efpecially  when a  woman  is  in labour.
Should the waters of the ovum be fuddenly difcharged, the ute-
rus will contraft till it comes into contaft with the body  of the
child; but  the  integuments of the abdomen, not  contra£ting
with equal celerity, and the uterus wanting that Support which
they afforded wdien it  was fully diftended, muft of courfe fall
to which ever fide the woman may turn.  Should the waters be
difcharged flowly, or fhould the  integuments of the abdomen
contraft Speedily, or fhould the head of the  child drop into the
pelvis  immediately after their dif'char^, there^would.not be this
fenfe of unfuppovted weight, whether the child were living or
dead ; becaufe in one  cafe the uterus would  be held him by
the general  contraction,  and  in  the  otfier,  the child would
be prevented from that kind of  motion by its  confined po-
fition.                               i.
   When a child  dies in the latter  part oTpregnancy,  the flaccid-
ity and fobfidence of the abdomen are  confideftble ;  but it is
from a very  great d'gree of thefe we are led to f ufpeft either the
death or wafting of the child, fome fubfidence being one  of the
natural changes which precede labours.   From the  appearance
of infants  born alive, it is  often evident, that they are lefs than
they were fome weeks before they were born ; and the manner
in which thefe-changes are made,  frequently ffiews>  whether
they died fuddenly, or declined gradually. 
ON
DIFFICULT  LABOURS.
79
             4. Want of Motion dj the Child.

  The kind and degree of motion which m-.v be caufed by the
child varies in different women, and at different periods of preg-
nancy.  By fome  the child  is fcarcely ever perceived, and
with others it is fcarcely ever at reft, but it is often quiet a few
days before, and  in the time  of labour.  Bv the motion of the
child its living ftate is afcertained ;  but the want of motion does
not prove that it is dead nor would it, for  that reafon, be jufti-
fiable to perform any operation, which might be injurious to it,
if living,
  Some pregnant women,  even among thofe who  have before
hart feveral children, have fcarcely eyer been able to perceive
the motion of the fihild through the whole time  of pregnancy,
and then the regular increafe ot fize is our bed proof of its well
doing.  Others have afferted that  they have felt the motion of
the child, though the event has  proved that they were not preg-
nant.   Others have not doubted ot the lite of the child, though,
after its birth, there were certain marks of its having been long
dead.  In long  and very  fevere labours natural affection may
beovercome by prefent fufferingand diftrefs, and women might
conceal  their knowledge of the motion  of the child from the
hope of  a more  fpcedy delivery,  it they concluded, that the
judgment of the  attendant  was guided by this circumftance.
Every allowance muft ^e made,  and every confideration had
for human nature, humbled by  infirmities and mifery.  The
tears and affeftlon of  friends  will alfo warp their judgment  ;
but our grcateft tendernefs  and the propriety of our conduft
will be fliewn, not by a compliance with requefls and Solicitati-
ons, but by'following the diftates  ot our own reafon and judg-
ment,  for we are not to be governed or alarmed  by unfounded
appreherifions of dan^r, but by its actual  exiftence.

          5 fator in the Apartment of the Patient.

  The putrefaftion ot the  child would be an indubitable mark
of its death,  and  might create a  very off'enfive fmell in the
apattment ih which the patient  was confined ;  but every putrid
child does not yield  an offenfive Smell, and fuch fmell may be
occafioned by feveral other circumftances.   If a child fhould
die in the uterus from external injury, or any internal caufe,
and become  putrid before the membranes of the ovum were
broken, it would h've a peculiarity of fmell. but not tk&tjator 
8o
INTRODUCTION  iO MIJWIFERY.
which every animal fubftance emits, while it is in the aft of pu-
trefying under the influence of the open air.  The fa-tor to
which we now allude, car. only appertain to a child whicfewas
living in the beginning of labour, and died in the courfe of it, af-
ter the difcharge of the waters ;  and in fuch cafes, when putre-
faction does begin, it is  commonly very rapid in its progrefs.
The general fmell of putridity in the apartment ot a perfon in
labour, is to be admitted with very great caution as a  fign of a
dead child ;  for if the room be fmall, or crowded with company,
or long  kept hot and uncleanly, or the common offices of lite
are performed in it, as is ufually the cafe among people of the
lower clafs, a fimilar effeft would be produced as when the child
is dead and become putrid.

       6. Fator and ill Appearance of the Dijcharges.

  The Jcetor here meant is  alfo, fuppofed to arife from the pu-
trefaftion of the child, and the ill appearance to proceed from a
mixture of meconium, fanious, or other matter which might be
fuppofed to flow from a putrefying child, with the common uter-
ine difcharges.   But the appearance of thefe difcharges naturally
varies in different women, according to their conftitution, and
to the qualities of the waters of the ovum,  in  the appearance  of
which there is a very great  difference.  They become altered
likewife by contingent circumftances, as the cafual retention
ot the difcharge, the mixture of a fma^ll quantity of blood, or
flight inflammation of the parts, whichin fome cafes give a ftrong
fcent to them, hardly to be diftinguHhed from putrid Jcetor.
With every appearance  of the uterine difcharges, children have
been born living and healthy ;  and when they have been long
dead, thofe have in many  inftances been fo little" changed,  as
not to raife fufpicion of any harm having befallen the child, in the
minds of very experienced  men.  The propofal of any operati-
on which would be injurious to the chid, if living, would not
therefore be juftifiable,  merely on account of the fmell or ap-
pearance  of the difcharges, without  other  collateral proofs of
its  death, or a conviftion from other circumftances of  the ope-
ration being abfolutely neceffary.

7.  Evacuation of the Menconium when the Head of the Child
                         prefents.

   Should a child prefent with  the breech or inferior extremi-
ties, the evacuation of the meconium, which is an abfurd name 
ON  DIFFICULT LABOURS.
Si
given to the excrements firft evacuated  by the child after its
birth, is one of the proofs of fuch prefentation.   But when the
head prefents, if the labour be very  fevere or tedious, the wa-
ters will be tinged ot a greenifh colour, or pure meconium may
be forced away, and, with fuch appearances, the child is often
fuppofed to be dead ; iromaprefumption, that if it were living,
the fpkinder of the anus would aft with power fufficient to
prevent any difcharge.  But by experience it is fully and  fre-
quently proved,  that a child may be born living,  though the
meconium fhould come away when the head prefent? ; its eva-
cuation proving no more than the weaknefs of the child, or the
degree of compreffion  it has undergone.  The difcharge of the
meconium may alfo  depend upon the quantity contained in the
bowels, or fome cafual preffure upon the abdomen of the child.
We may however,  in general conclude, when the meconium
does come away in a natural prefentation,  that the ftate of the
child is not void  of danger; and for many years I never faw  a
child, prefeoting with the head, born living, when the meconium
had come  away more  than feven hours before its birth.  But
at length, \ met with a  cafe, in which the meconium was  dif-
charged for more than thirty hours, at the end of which time,
though the  woman was delivered with the forceps^ the child
was born healthy and ftrong;  and fince  that time  I have  had
many equally convincing proofs, that the coming away of the
meconium  is a very doubtful  fign  of the death or  dangerous
ftate of the infant, whatever may he the prefentation.

8. Edematofe, emphyfematoje, or other  peculiar Feel of the
                    Head of the Child.

  In many cafes in forgery, information may be gained, and
the judgment aflifted by what is called the  tadus eruditus, or
that faculty  which enables us  to perceive and diferiminate by
the touch, with greater ^accuracy than by any evident or defen-
bable marks.  , It has alfo been faid, that we may decide  in ma-
ny doubtful  cafes, by  the feel ot the head, whether a child be
living or dead.  But as we know that in forgery, the  moft dil-
cerning and  expert  in this faculty are often miftaken,  when
they defert common evidences, fo, opinions  formed on fuch
ground, would not authorize an one^tion to which they might
be fuppofed to lead, in the queftion on. which  we  are now
fpeaking.  For the integuments of the head of a child often be-
come edematofe to a confiderable degree, from preffure in  its
  Vol. II.                  M 
3a            INTRODUCTION TO MIDWIFERY.
paffage through the pelvis ;  and  fometimes emphyfematofe
from a continuance or increafe of the fame preffure, when the
child may,  in all other refpefts, be perfeftly well.  If the in-
teguments be fqueezed into a fmooth, round form, this is faid
to be unfavourable; but when  they are corrugated, the  tume-
faftion, though equally great,  is thought to  be of lefs  confe-
quence ;  the former being fuppofed to prove the ablolute fepe-
ration of them from the cranium, and the latter, that their at-
tachment remains ; but this difference is in many cafes acci-
dental.  The original  connexion of the bones of the head  is
fuch as to  allow of their being preffed clofe to, or over, each
other with  fafety to the child  ; yet when this has been long
dead, and their natural connexion deftroyed, they may fome-
times be perceived to be loofe and diftinft.  The loofe ftate  of
the bones  ot the cranium is  frequently fuch as  to leave no
doubt of the death of the child, as well as the abrafion of the
cuticle or the falling off of the hair; but  proofs of things felf-
evident are not wanted in praftice, but  fuch as will guide  us
in  doubtful cafes.  In  very difficult labours, I have more
than once feen a portion ot the integuments of the head of the
child flough away, and the bone laid  bare, without deftroying
the child.-  Probably I may have betore  obServed, that when-
ever children die in the uterus, the greater the degree of putre-
faction in which they are expelled, according to the  time dur-
ing which  they have been dead, the more favourable is the in-
dication to the mother ; fhewing I fuppofe, that the health and
vigour of her conftitution in general, and of the uterus in par-
ticular, are not impaired.   But if a child fhould  remain dead
in the  uterus, for any length of time, without becoming putrid,
this circumftance might be confidered as a proof that the pow-
ers of aftion in the mother were reduced to a ftate of dangerous
weaknefs ;  as food remaining unchanged  in the ftomach would
be a proof of the debility of the part.
   Many figns of a dead child have been mentioned by authors,
under  the denomination of  equivocal, as  the extreme languor,
or livid palenefs of the countenance of the mother,  the offen-
five fmell of her breath, and feveral others.  But  if it appears
that thofe  figns, which have been called certain, are  in faft
doubtful, it will follow, that very  little reliance  ought to  be
placed inthofe, which are acknowledged to be equivocal.   If,
however the propriety  of performing this operation  ought not
to be decided even by the certain knowledge ot the death of the
child,  but by the circumftances of the mother abfolutely requir-
ing it  for her prefervation ; then, the confideration  of the life 
ON  DIFFICULT LABOURS.
83
or death of the child becomes of lefs importance.  Becaufe if
the operation, when really neceffary for her fafety, were not to
be performed, the life of the child would not be preferved, and
that of the parent would be inevitably loft.


                     SECTION  III.
ON  THE CAUSES OF THE DEATH OF THE CHILD.
  The proportion of children ftill-born to the number of births
has not been accurately determined, nor is it eafy to decide the
queftion ; as  it may probably vary in different countries and
fituations, and in different years.   But it  feems to be generally
greater than from a tranfient view would be apprehended, and
perhaps it is far greater in human beings than in animals.   The
death of  a child in the uterus may be occafioned by various
caufes independent ot the mother, as by  local inflammation or
other difeafe of fome part of its own body, effentially neceffary
to life ; by fome original imperfeftion in its ftrufture, which
may prevent its acquiring more  than a certain fize, 01 exifting
beyond a certain time ;  by the fmallnefs  or morbid ftate of the
placenta,  hindering the proper  communication between the
child and the uterus.; by  a partial or total feparation of the
placenta, or, by the rupture of fome of the large veffels which
run upon its furtace :  by the  veffels of  the funis  umdilicalis
becoming impervious ;  by the circulation through them being
obftrufted by the cafual tying of a knot ;  by untoward preffure
of the body of the child upon the Junis ; or by this becoming
dropfical  or  otherwife difeafed,  and probably  various other
caufes.
| .The child may alfo be deftrqyed by affections or difeafes of
the mother, as by the hidden and violent impreffion of fear,
joy,  or  other tumultuous paffion ; by the irregularity of the
parent's  life ; by fever  ;  by improper or unwholefome  diet;
by any caufe capable of depriving the child of a proper quantity
 of nutriment;' or depraving the quality of that  with which it
 may be fupplied ;  or by accidents which  produce fome pofitive
 injury upon the  body of  the child, through the integuments
 ,md  parts with  which it  is invefted  and naturally  defended.
 Some of thefe are beyond the power of art to prevent or reme-
 dy,  though  others might  by proper c*re  and management be 
84
INTRODUCTION TO MIDWIFERY.
obviated Or relieved ;  but at prefent we want only to difcover
thofe caufes of the death of a child,  which may  occur in the
time ot  labour.
  To the inconveniencies and danger, which may arife in the
courfe of a labour from the difproportion between the fize ot
the head of a child and the dimenfions, of the pelvis, we rnuft
fubmit ; as no judgment or fkill  can  do more  than teach us to
wait patiently tor the effeft to be derived  from the  efforts ot
the mother, and  the accommodating conftru6tion ot the  head
ot the  child.  Though the degree of compreffion, which  this
may undergo in a very tedious  or difficult labour,  might be
judged inconfiflent with the fafety of children, they will often,
under fuch conditions, be born healthy and vigorous, and the
parents  recover more fpeedily and perfectly, after  fuch labours,
than after thofe which  were natural and  fhort.  The fame ob-
servation will alfo hold good ot the refiftance  made by the foft
parts to the paffage of the child through the pelvis, unlefs their
rigidity fhould  proceed from local inflammation.   But fhould
the natural efforts be interrupted or fubdued by fever, debility,
or any other adventitious caufe, or fhould there be local difeafe,
the flate of the patient would require the affiftance of medicine
or-of art, according to the  circumftances which  might  fuper-
vene.   Yet it is  in common observation, that far the greater
number of  thofe labours which have been confidered as difficult,
and which  really were fuch towards the cortclufion, were not
in faft  occafioned by the abfolute ftate ot the patient, but by
interpofition, and the defire of accelerating labours, which  in
their nature required a certain time for  their  completion.
This interpofition has chiefly confifted of two points of practice,
both extremely  reprehenfible ;  the  artificial dilatation  of the
os uteri, and the premature rupture of the  membranes.   By
fuch praftice the order of the labour  becomes disarranged, and
there often follow occafions  to  exercife art, for the relief of
thofe evils which were originally caufed by the improper ufe of
art, to the great h.izard of the parent  or child.  So long there-
fore as  labours proceed naturally, they may be proper objefts
of our observation, reafon, and judgment, but  cannot be confi-
dered as the objefts of art.  Yet when they  are proved to  be
beyond the efforts of nature to accomplifh, the affiftance of art
becomes juftifiable becaufe it is neceffary, and we may be iccon-
ciled to the fate of the child, it the life of the mother  cannot
poffibly be preferved by any means confiftent with its fafetv  ; but
we are to he convinced of this neceffity by the moft  fubftantial
poofs, before we prefumeto decide upon an aftion foimportant
both in a moral and fcientific view. 
OF DIFFICULT LABOUR.
8,
SECTION IV.
     ON  THE INSTRUMENTS  USED IN THIS OPERATION.

  The inftruments with which this operation was anciently
performed, do not appear to have been well calculated to an-
fwer the intention of the operator, effeftually or fafely.  They
confifted chiefly of hooks, tingle or double,  blunt  or fharp
pointed, differing in form and  length,  which were fixed upon
any part of the head with the view  of extracting it forcibly.
It being fometimes found impracticable to fix a hook firmly
upon the head,  other  inftrtments  were invented and ufed to
make an opening in which a hook  might be fixed, but without
any intention of leffening the bulk ot the head.  All thefe in-
ftruments it would  be ufelefs and tirefome even to enumerate;
but it is remarkable that Mauriceau, a man of great experience
and real  ability in  his proteffion,  fhould have complained of
difficulties in this  operation which he could not  furmount,
from the want of proper inftruments.
   Perhaps there is no operation  in forgery, which  admits of
a more precife dcfeription or diftinftion; than this of leffening
the head.   It confifts  of three parts : perforating the cranium ;
evacuating the brain and cerebellum ; extrafting the head ;  and
three inftruments have been commonly ufed tor thefe purpofes.
The firlt was the feiffars originally ufed by  La Motte, altered
.md improved by Smellie ; the  fecond was in the form of a large
Spoon  with ferrated edges ;  the third was a hook or crotchet,
ftraight or  curved, to  be ufed fingly,  or in pairs, like the
jorceps.
   Many years ago, Savigny the inftrument-maker, at my re-
 queft, prepared  two inftruments, which I fuppofed to be fully
 fiifficient for this operation, the evacuation of the brain not re-
 quiring a feperate inftrument.   The firft was a perforator  in
the  form of Smellie's feiffars, the blade being flightly curved
in the manner of  the feiffars ufed for extirpating the tonfils,
but without  any cutting edge, which is Somewhat dangerous
 and altogether ufeleSs ; the fecond was a crotchet with a  little
 degree of curvature and a very fmall hook, if compared  with
 thofe before ufed.   The perforator meafures about nine inches
 in length, and has a flop on each  blade one inch and a quarter
 from the point.  The crotchet, which has a wooden  handle 
$6
INTRODUCTION TO MIDWIFERY.
and a flat ftem, fhould, when properly curved, be of an equal
length with the perforator.  Thefe inftruments,  which are
now almoft in general ufe, are found to be very convenient,
and fully adequate to every purpofe in the performance of  this
operation ; and  as the intention  is  well underftood, and the
inftruments  Simplified, both the difficulty and danger of the
operation are infinitely leflened.


                     SECTION V.


    ON THE MANNER OF PERFORMING THE  OPERATION.

'  Much confideration is  required before we determine to per-
form this operation, and, according to my judgment,  it ought
never to be performed on the opinion of  any  fingle perfon, if
that of two can be procured.  But when we have decided upon
the neceffity ot its being  done, befides great circumfpeftion in
the manner of doing it, there is occafion for our being refolute
«tnd perfevering in our attemps to accompliflj it ;  even, when
the difficulties to be furmounted appear to be too great for any
degree of fkill, or any force we have the power of ufing.  One
common error formerly prevailed in this and many other ope-
rations founded on an opinion, that it was needful  to perform
it fpeedily ; but it is now  proved by experience, and generally
acknowledged, that the more calmly and flowly we proceed, the
lefs chance there will be of failing, or doing mifchief.   As the
fole aim of this operation is to preferve the life of the mother,
without regard to the child, whatever its ftate might be, it will
be our duty to be extremely careful to guard againft every acci-
dent which might prove injurious or hazardous to the mother.
But, as by following the diftinftions fpecified in the laft feftion
we fhall be able  to mark and explain all the circumftances of
the operation as they  occur, we will abide  by thoSe diftinftions
in defcribing the manner of performing it. 
ON  DIFFICULT LABOURS.
«7
SECTION VI.
            ON  THE PERFORATION OF THE HEAD.

   The eafe or difficulty attending this and every other part of
 the operation, will depend upon the diftance the head may be
 from us ; whether, for  inftance, it be defcended and locked in
 the pelvis, or be lying at the fuperior aperture ; and upon the
 degree of diftortion of the pelvis,  which may  be only fo much
 as juft to prevent the paffage of the head, or fo great as to render
 the  ufe of the inftruments  both  troublefome  and dangerous.
 Some inconvenience may alfo be produced by  the  os uteri,
 fhould it not be completely dilated ;  but this may  rather be
 efteemed for extraordinary care than  as a caufe of difficulty.
   Without regard to the part of the head which we  mean to
 perforate, but deciding upon that which is moft obvious and eafy
 of accefs, as the moft proper, the left hand flattened is to be in-
 troduced into the vagina, and the fore  finger ot the fame hand
 is to be directed upon  that  part  of the head where we intend
 to fix the point of the inftrument.  The perforator, held in the
 right hand, is to be condufted with the convex part towards the
 palm of the left hand, and with the point kept clofe to the fore-
 finger, till it reaches the part where we have determined to per-
 forate. The fore-finger of the left-hand is then to be pafl'ed round
 the  point  of the inftrument, that we may be affured  we have
 fixed it in the right place, and that none of the Soft parts oTthe
 mother are in the way  of being  hurt.  With the inftrument
 held firmly in the right hand, we muft then prefs through  the
 integuments of the head ; and,  the point being fixed  upon the
 bones ot  the cranium, begin to perforate, by turning with  a
 femirotatory motion the handle of the  inftrument.   This motion
 ot the inftrument, care  being taken to  confine  the point to the
 place where it was originally fixed, is  to be continued till we
 judge the bone to be actually perforated ; and we are to try occa-
 fionally,  by advancing  the inftrument, whether  the  bone be
 perforated or not.  When the  bone is perforated, the inftru-
 ment being preited forwards will penetrate the  head, and go on
 till  it  reaciies the flops  formed upon the blades.  Theii, fixing
^the  finger and thumb of  the right hand in the bows of the handle,
 or  preffing  the thick part of the hand between  the  ftems, or
 calling for the help of an afliftant, we fheuld feparate  the han- 
88
INTRODUCTION  TO MIDWIFERY.
dies ot the inftrument to fuch a diftance as to make a flit or
opening of Sufficient length  in the cranium ;  judging of, and
in fome meafure guiding, the cffe6t produced  upon the blades
by the Separation of the handles, and by the finger of the left
hand  retained  in its primitive  pofition.  The handles being
then  clofed, the inftrument muft be turned in a tranSverfe di-
reftion, and they are again to be Separated in the fame cautious
manner, by which means a crucial opening of proper fize will
be made in the cranium.  This being completed, the perforator
is to be clofed, and withdrawn in the fame cautious manner in
which it was introduced.
   In this part of the operation the principal things which de-
mand our attention are, firft, that the inftrument be carefully
introduced ; Secondly,  that  we be not alarmed at the difcharge
Which follows  the perforation of the integuments ot the head,
as  that is to be expefted; thirdly, that the point of the inftru-
ment does not flip while we are perforating ; and fourthly, that
the crucial opening in the craniumhe fufficiently large, to allow
of the exclufion of its contents.
SECTION VII.
  ON THE EVACUATION OF  THE CONTENTS OF  THE HEAD.

  A very large opening  of the cranium has been generally
confidered as neceffary for the well performing of this operati-
on ; but this is not abfolutely required in any point of view,
nor can it always be made with fafety.   It muft, however, be
fufficient  for the purpofe of fuffering the contents of the head
to pafs through it and for the evacuation of thefe, it was betore
mentioned, that various inftruments had been contrived.   But
thefe inftruments, efpecially the  Serrated  fpoon, appear to be
both unneceflary and dangerous ; unneceffary, becaufe  the tex-
ture of the cerebellum being broken down, their evacuation will
follow of courfe, as the head is propelled or extrafted ;  danger-
ous, becaufe  an inftrument with many Sharp points could not
be  frequently introduced and withdrawn  without hazard of
being hitched on the  Soft  parts of the mother.  Any  fmooth
inftrument of a proper fize and length, fuch as  the  handle  of a
filver fpoon, or a blade of the forceps, will anfwer the purpofe
of breaking down and evacuating the contents of the head fafely
and effeftually.  But I have  generally introduced the crotchet 
ON  DIFFICULT LABOURS.                89
into the  opening in the cranium ;  and, turning it  round fre-
quently, in various  direftions, efpecially near the bafis of the
fkull, have completed this part of the operation without  diffi-
culty.  With all the care which can be taken, it is not always
poflible to do this on the firft attempt;  but, if in the courfe of
the operation it fhould be found that the head does not readily
collapfe, becaufe feme part ot its contents had efcaped the aftion
of the inftrument, the fame method may at any time be repeated,
without delaying the operation.


                    SECTION VLII.
            ON  THE EXTRACTION OF THE HEAD.

   It was formerly a rule of praftice, whenever the head of the
 ehild was opened, that the efforts to extraft it fhould immedi-
 ately commence, and be continued till the purpofe was accom-
 pli flied.   With all the  cautions which  have been given for
 ascertaining the  neceffity ot the operation before it was  per-
 formed, it  was ftrongly inculcated, that we fhould be on our
 guard not to defer it till the ftrength of the patient was too much
 exhaufted ;  left by fuch delay we fhould altogether lofe the
 advantage that "would  refult  from  the natural efforts, which
 might otherwife be made for the exclufion of the leffened head ;
 and  when the child was extrafted,  left the patient fliould be
 reduced  to  a  ftate of the greateft danger  from mere debility ;
 more efpecially if there fhould be a lofs ot much blood, before,
 or after  the exclufion  of the placenta.  Our conduft,  with
 regard to  the extraftion o\ the head, muft then  depend upon
 the ftate  of the patient ; whether that ftate will  permit us to
 wait for the advantages  to be derived from the putrefaftion and
 compreffion of the head from the natural pains, or whether the
 head fhould be fpeedily extrafted by art.  If, from the great
 diftortion of the pelvis, we fhould have been convinced of the
 neceffity of performing this opeiation in the beginning, or early
 part of a labour, the head when leffened  may be  left for many
 hours to undergo thofe changes which putrefaftion occafions,
 to the diminution of its bulk by compreffion, to  its  gradual
 defcent into the pelvis,  when it may  be readily extracted, or to
'the chance of its final expulfion without affiftance,  as the reafon
 and nature of  the cafe  may indicate or require.  Under fuch
   Vol. II.            ■'      N 
9»
INTRODUCTION TO MIDWIFERY.
circumftances the late Dr. Chriftopher Kelly* informed me,
and I  believe the praftice originated with him, that he had left
the head of a  chili, after the evacuaion  of  its  contents, tor
more  than twenty-four hours,  without making  any artificial
attempts to extraft it ;  and that the operation was, by this delay,
rendered more  fate, and infinitely more  eafy.  The late Dr.
Mackenzie alfo informed me, and many other perfons, that he
had in the latter part of his life followed this praftice with fuc-
cefs.  But the matter has been more fully dffcuffed, with great
ingenuity, and as much  precifion as the queftion admits, by a
late very fenfible and judicious writer*, who in a cafe of which
I was a witnefs,  left the head of a child  more than thirty-fix
hours after it had been leffened, and then extrafted it ; the wo-
man recovering without anyTintoward Symptom.   Of the pelvis
of this  woman,  who, I am informed, is now dead, we were
never able to get the exaft dimenfions, as fhe rqmoved from her
ufual habitation, and could not afterwards be traced*
   When the head of the child has been leffened, the length of
time during which the patient may therefore  be trufted in ex-
pectation of favourable  changes, muft be left tj the judgment

   * The papers of my worthy Jriend Dr. Kelly are in the hands
qfmyjon-in-law Mr. Croft, who found among them  the follow-
ing account of the individual cafe, probably, of which the dodor
had informed me, which I tranfcribein his own precife words.
   "  March 11, 1763.  ----has a  pelvis extremely narrow,
 and, by the meafure I took, do firmly believe the diftance be-
 tween the os pubis and projedion of the facrum is not more
 tlian two inches, therefore I knew it was in vain  to hope to
 bring the child  alive by any means whatever, : therefore, for
 her fafety,  I opened the head freely jtrind emptied the cranium,
 in about fixteen  hours  after being firft called to her, and then
 left it to fettle into the  pelvis twenty jour hours (as in the cafe
 of Mr. Ford's patient) before I delivered her, which I did with
 tolerable eafe, by means of the blunt hook only.   She recovered
 as well as poffible.  This was hfr firft child.  She  was Jo
 rickety when  a child, as  not to be able to walk til$ nine years
 of age, and is now Very Jhort.   Her name is----■-----."
    The pelvis of this woman came at length into my  hands, and
 in fome parts of thejupenor aperture does  not meafure more
 than one inch and a quarter, though on onejide the Jpace is
 equal to two inches,  D.

    * Eflay  on Laborious Parturition, by W. Ofborn,' M. D. 
ON  DIFFICULT LABOURS-.
9*
that may be formed of every individual cafe which may be the
immediate objeft of praftice.  In fome cafes, from the precari-
ous ftate of the mother, there will exift a neceffity of extrafting
the head as fpeedily as we can with fafety ; yet the general prin-
ciple to be  eftablifhed is, that the longer we have waited in any
cafe, the more eafily will the head be afterwards extrafted.  But
the patient is to be carefully watched that we do not wait too
long,  left unfavourable  fymptoms fhculd come on, and the
end for  which  the  operation  was performed  be ultimately
defeated.
   Sooner, or later then, according to the ftate of the mother, it
will be neceffary that  we fhould begin to make our  efforts to
extraft the head of the child ; and taking care,  in the firft place,
to remove  cautioufly any loofened or  fharp pieces of bone, I
have been accuftomed to avoid ufing the crotchet, or any kind
of inftrument, till  I have tried  what advantage was to be gained
with my fingers^1  With this view, introducing  the fore-finger
of either hand, armed with my glove, or fome fuch contrivance,
into the opening in the head, and then  bending  it in the fhape
ot  a  hook, I have pulled with all the force it  enabled me  to
evert, repeating my attemps at  intervals when the natural efforts
ot the mother returned.
   Should the head of the child be fo  high in, or above,.the
fuperior aperture of the pelvis, or this  be fo much diftorted  as
not to admit of my giving this kind of affiftance, or fhould it be
unequal  to the purpofe, I  carefully  introduce the  crochet;
guided by  my  left hand, into the opening in the head ;  and,
fixing the point of the  hook as far from the edge of  the bone
as its  curvature will  allow, I begin to  pull moderately by the
handle held in my right hand, guiding at the fame time the hook
of the  crotchet with  the fingers of the left, if  it  fhould happen
to tear away the bone, or flip.
  If on trial the crotchet be  found firmly fixed, but the head
be  too  much impacted in the  pelvis to be brought  down  with
the force firft ufed ; that is, fuppofing  the force required  to
extraft the  head be equal to 10,  and the force  which can be
exerted  by the crotchet not to exceed 5  ; no other purpofe can
be anhvered by ftriving too earneftly with the force which can-
not be made to exceed 5,  except tearing away the piece of bone
in which the crotchet  may be fixed, which does not facilitate
the operation.   We are to be fatisfied with the fteady exertion
of the force 5, which being continued, will at length be found
fufficient for our purpofe, the refiftance gradually diminifhing,
andtlie force 5 remaining. In  the repetition of. our attempts to 
9»            INTRODUCTION  TO MIDWIFERY.

extnSk the head, which muft be made at intervals, fliould the
bone in which the inftrument was fixed, be loofened and come
away, wholly or in part, the crotchet muft be again introduced
and  fixed in another place and the fame method of proceeding
followed ; remembering alfo when we extraft,  to  pull  with
fome variation in the direftion, but always in the line of the ca-
vity of the pelvis.  Inalmoft every cafe of difficulty the principal
obftacle or caufe pi the difficulty is at one particular part of the
pelvis, and when the head has paffed that part there is no farther
occafion for ufing much force  ; and we are afterwards to pro-
ceed very circumfpeftly,  that there may be no  laceration of,
or injury dope to the parts of the mother, internal or external.
The principle I with to  imprefs on the minds of thofe who
may be  embarraffed with difficulties of this kind is, that time is
equivalent to force, and that no advantage will  be obtained by
pulling  away fmall pieces of bone except fuch as were loofe
and likely in their paffage to injure the Soft parts of the mother,
or by afting haftily or violently.  On the contrary, when the
inftrument is once firmly fixed in a part of a bone which afford*.
a good hold, I have been cautious not to tear it away by pulling
ralhly, confideiing that as Something like breaking the inftru-
ment with which I was performing the operation.  Where the
refiftance has been very great, after making my firft efforts with
all the force and fkill I could fafely exert without fuccefs, leav-
ing the  crotchet fixed, I have defined  for an hour or longer,
and then renewed my attempte.
  In a cafe ot very  great difficulty it is however poffible, that
all the bones of thetranium might be brought away fucceflively,
and nothing of the head remain but the bafis of the fcull, with
the integuments.  In fuch a cafe it has happened,  quite unex-
peftedly, that I have fucceeded in bringing down the remainder
of the  head, merely by grafping the integuments  firmly in a
mafs, or even in diftinft parts, and  pulling by them in a pro-
per direftion.  But, if thefe  fliould be found  infufficient, the
crotchet is to be introduced again, and fixed upon the bafis of
the foull on any part where we can get a firm hold, and this
affuming a more convenient direftion will be readily brought
down.    I have not found, in  cafes of this kind,  that  I have
afted from  a preference for fixing the inftrument  in  this or
that part, or in this or that manner; but giving myfelf time to
reflect, the exigence of the cafe has diftated what I ought to do,
fo that I  am  not Solicitous about any partieular method.  Some
have thought that it was of great importance to fix the crotchet
on the outfide of the head, and others have infilled on the pro- 
                  ON  DIFFICULT LABOURS.              93

pricty and fuperior advantage of fixing it on the infide ; but I
am ^erfuaded that fuch things are of  little confequence,  and
that in the courfe ot a difficult operation it may be found ne-
ceflary and ufeful to fix it in either way.
   If the difproportion between the cavity of the pelvis and the
head ot the child be very  great, we may allow it to be poffible,
that all the bones of the cranium, together with the bafis of the
fcull, may be brought away, yet the hody of the child may
remain above the fuperior aperture of the pelvis, with abfolute
inaction of the uterus.  This circumftance may require differ-
ent methods of treatment.   If the fpace between the projefting
bones of the pelvis would permit  the flattened hand to be paffed
into the uterus, it might  be moft expedient to turn the child
and delivery by the feet, which, thus  fituate, I have more than
once done.  But, if the diftortion of the pelvis will not allow
the hand to pafs  into the uterus, or if there be reaSon to appre-
hend mifchief to the uterus, from the jagged or loofened pieces
of bone, the crotchet muft be again introduced, and fixed upon
the cheft of the child, where it may probably meet with fome
part that will bear a fufficient degree of force for extrafting it.
Should this  not  be the cafe, the crotchet muft be repeatedly
tried, by  which the contents of the thorax and abdomen may
be evacuated, anch the general bulk  of the child's body very
much leffened.  Then, trying to fix the hook of the inftrument
on fome part of the  fpine, or bringing down the arms, we fhall
at length fucceed and extraft the body of the child, whole or in
parts, though we may have been frequently baffled.   In an
operation difficult as this now deferibed, difagreeable as it may
appear, and"really is, having only occafion to attend to the ex-
traction ot the child, in any manner, without doing mifehief to
the mother, the mind of  the operator may  be at  eafe, and he
will  then  avail himfelf of every advantage which may offer
towards anfwering his purpofe.   On the whole, I have never
known a cafe attended with fo much difficulty, that it could not
be Surmounted by fteady and flow proceeding ; and the opera-
tor, after all his difficulties,  if he have afted  cautioufly, may be
repaid by feeing his patient recover, as well, or better, than after
the moft eafy labour. 
94             INTRODUCTION  TO MIDWIFERY.
SECTION IX.
             ON THE SUBSEQUENT TREATMENT.

  When a child^ias been extrafted in the manner before defcrib-
ed, the placenta will commonly be expelled  in a natural way ;
but fhould any difficulty arife, this muft be managed according
to the  rules which will be  given in the chapter on  Hemorr-
hages.
  Women in general recover well after this operation, provided
it was not delayed till fome irreparable injury was already done
to the parts of the mother, and was performed with care.   Be-
fides the treatment which may be proper for all woman in child-
bed,  it  will be incumbent upon us to be particularly  careful in
thefe cafes that the urine be voided; and, if the patient fhould not
be able to do it by her own efforts, that it be drawn off with the
catheter, within a fhort time after her delivery,  The ufe of the
catheter is alfo to be continued, twice in the courfe ot twenty-
four-hours, till fhe may become able  to expel the urine ; left
there fhould be inflammation on any part of the bladder or meatus
urinanus, and a flough be caft off, which, unlefs it were merely
a fmall portion of the meatus, might be followed by an involun-
tary  difcharge of urine ever afterwards ; which I confider as
one of  the moft  deplorable  accidents  in the praftice of mid-
wifery.
  While I am correcting thefe papers, a cafe of this kind has
unfortunately occurred, and with circumftances that  no know-
ledge pr caution could have forefeeji or prevented.  This pati-
ent, after a very hard labour of a dead child, voided her urine
without trouble  of any kind, for ten days after her delivery.
She then complained ot fome uneafinefs after every evacuation,
but no difficulty in voiding it.  Yet on  the fourteenth  day, a
fmall flough was thrown off from the  bladder.   I mention this
cafe, becaufe I have always fufpefted the floughing to be occa-
fioned  by the want  of due attention to the urine, or a prudent
ufe ot  the catheter ;  and there can be no doubt but that negli-
gence in theSe two points has generally been the caufe of fuch
accidents. 
ON  DIFFICULT LABOURS.
95
SECTION  X.
    ON THE PROPRIETY OF BRINGING ON PREMATURE LABOUR, AND
            THE  ADVANTAGfiS TO  BE DERIVED  FROM  IT.

      We have before alluded to this operation as a method of pre-
•   ferving the lives of children,  without  adding to the danger  of
    women ;  if in any cafe the pelvis were fo much diftorted, or fo
    fmall,  as abfolutely to prevent the paffage of the head of  a full
    gt own child,  and yet not fo far reduced in its dimenfions, as to
    prevent the head ot a child of a  much lefs. fize from paffing
    through it.  Melancholy are the refleftions when a women has
    a pelvis very  much  diftorted (and fuch women  have  ufually a
    wonderful aptitude to conceive) that there fliould be no chance,
    or very little, of preferving the lives of her children ; and yet,
    in the  courfe  of praftice, I have in feveral inftances been called
    to the  fame women, in five or fix fucceffive  labours, merely to
    give a fanftion to,an operation, by which the children were to
    be dcftroyed,  It is to the credit of  the profeffion, that  every
    method,  by which the lives of parents and  children  might be
    preferved,  has been devifed and tried ; and, though frequent
    occafions for ufing fome of  thefe  methods cannot  poffibly
    occur  iri any  one perfon's praftice, it  is right that all fhould be
    acquainted with what has been propofed and done in every cafe,
    with or without Succefs.
       A great number of inftances have  occurred to my own ob-
    fervation, of women fo formed, thatrit was not poffible for
    them to  bring forth a living child at  the termination of nine
    months,  who have been bleffed  with living children, by the
    accidental  coming  on of labour  when they were only feven
    months advanced in their pregnancy.  But the firft account
    of any artificial method of bringing on premature  labour  was
    given  to me  by Dr. C. Kelly.  He  informed  me, that about
    the year 1756,  there \\   a confutation of the moft  eminent
    men in London at that time, to confider of the  moral reftitude
    of, andadvanuges which might be expefted  from, this prattice,
    which met with  their general approbation.  The firft cafe in
    which it was deemed neceffary and proper fell  under the care
    of the late Dr. Maculay, and it terminated fuccefsfully*.   Dr.

       * The paii.r:'  was the wife  of a Inen-draper in the Strand. 
 96            INTRODUCTION TO MIDWIFERY.

 Kelly informed mc that he himfelf had praftifed it, and, among
 other inftances, mentioned that the operation had been performed
 three times upon the fame woman, and twice the children had
 been born living.   The thing has often been the fubjeft of con-
 verfation, and propofed by writers, but fome have doubted the
 morality of the praftice ; and the circumftances which  may
 render the  operation needful and proper have not been ftated
 with any degree of precifion.
   With regard to  the  morality of the  praftice, the principle
 being commendable (that of making an attempt to preferve the
 life of a child which muft otherwife  be loft), and nothing be-
 ing done in the operation which can be injurious to the mother,
 but, on the contrary, a probability of leffening her fufferings;
 I  apprehend,  if there  be a reafonable profpeft ot fuccefs, no
 argument can be adduced againft it, which will not apply with
 equal force againft inoculation, againft medicine  in general,
 and, in  faft againft the interpofition ot human reafon and facul-
 ties in all the affairs of life.  Such an argument would lead us
 back to the abfurd doftrine of predeftination, if, with juftifiable
 intentions, and without producing any comparative prefent evil,
 we may  not  ufe our  endeavours to extricate our fellow-crea-
 tures from evils  which threaten them, or  under  which they
 may be  aftually oppreffed.
   If the morality be juftified, we are next to confider the fafety
 and utility of the pra6lice.
   As to  its fafety,  having reafoned upon the ftrufture of the
 parts concerned in the operation, and having carefully attended
 to all the circumftances which have occurred when it had been
 performed in more than twelve cafes, in which I  have either
 performed it, or it has been done by my advice and purfuafion,
 I have not known one untoward or hazardous accident  that
 could be imputed to it ; and jn  the  greater number of thefe
 cafes the children  have been born living.   Many inftances of
 this operation being performed  fuccefsfully, have, fince my firft
 propofal of it, been recorded by others.  I therefore feel autho-
 rized to fay, as far as my reafon or experience enables  me to
judge, that  the operation of  bringing on premature  labour, in
 the cafes to which this djifcourfe has any reference,  is perfeftly
 fafe to the perfon on whom it may by performed.
   But refpefting the  utility of the operation, the ftatemenf firft
 made of the  intention or purpofe with which it ought to be
 done, that is,  to try whether the head of a fmall child will not
 pafs through a pelvis too  much narrowed in its dimenfions to
 allow one of a common fize to pafs,'will Shew, that the objefts 
                 ON DIFFICULT LABOURS.                9/

 of the operation are circumfcribed within certain limits.  Should
 the cavity  of the pelvis be of its natural fize, this operation is
out of the queftion, and never can be required on that account.
 It the cavuty of the  pelvis, though reduced in its dimenfions,
 be fuch  as  to  permit the head of a  full  grown child to  be'
Squeezed through it by the force of ftrong and long  continued
pains, this  operation is not required, and ought not to be per-
formed.  It  the  pelvis be fo  far reduced in  its dimenfions as
not to allow the head of a  child of fuch a fize  as  to give hope
of its living, to pafs through it, the operation cannot be attended
with fuccefs.   It is  in thofe caSes only  in  which  there is a
reduftion of the  dimenfions of the pelvis to a certain degree,
and not beyond that degree, that this  operation ought to  be
propofed, or can fucceed.
   It would be highly fatisfaftory, if I were able,  to  ftate with
precifion the exaft dimenfions of the cavity ot  the pelvis of the
perfon, on whom it might be needful to perform this  operation,
and on whom it might  be performed with fuccefs.   But, as all
the inftruments, contrived for meafujing the pelvis in the living
woman, too imperfeftly anfwer this  purpofe,  to enable us by
them  to  form a guide  of praftice ; and as the head  of a child
before it is  born can  never be accurately meafured, and  of
courfe the  relation  between  them  muft be unknown ; the
determination muft be  left  to  opinion,  or  to  former proofs:
and thofe who are  experienced will not commit any.great miftake
in their conjeftures, even if they have no other than this proba-
ble evidence.  Under circumftances and in'fituations juft pre-
venting the fuccefsful ufe of the vedis or Jorceps, and juft com-
pelling us to the fatal meafure ot leffening the head of the child,
it may become a duty  to propofe, on a future occafion,  the bring-
ing on premature labour; at Seven months, or any later time,
according to our fenfe of the disproportion exilting between the
head ot a child  and the cavity of any particular pelvis.  It can
hardly be doubted, but that the  cafual  events ot praftice firft
infpired the notion of this  method in the mind of fome perfon,
who,  adverting to  the fortunate termination of  premature
labours coming on Spontaneously, or of very Small children, in
cafes of diftortion of  the pelvis, endeavoured to imitate by art
what not unfrequently happens naturally.  It is alfo to be con-
fidered, that  in a  child born prematurely, the bulk of the head
is not only  much lefs than at the full time, but the component
parts of the head are more loofely connefted and far more plia-
ble, and ot courfe its volume is  more  readily adapted to the
fpace through which  it is to pafs.
   Vol. II.                   O 
<Q,8             INTRODUCTION TO MIDWIFERY.
  I cannot deny myfelf the pleafure of relating the following
cafe, which occurred very lately.
  A lady of rank, who had been married many years, was Soon
after her marriage delivered of a living child, in the beginning
of the eighth month  of her pregnancy.   She had afterwards
four children at the full time, all of which were, after very diffi-
cult labours,  born dead.  She applied, in her next pregnancy,
to Dr. Savage, whom I met in  confutation.  By fome accounts
fhe had  received, the was prepared for  this Operation, to which
Ihe fubmitted with great  refolution.  The  membranes were
accordingly  ruptured,  and the waters difcharged, early in the
eighth month of her pregnancy.  On the following day the had
a rigor  fucceeded by heat and other fymptoms of fever, which
very much alarmed us for the  event.   On the third day, how-
ever, the  pains of labour came on, and  fhe was after a fliort
time delivered, to  the great comfort and  fatisfaftion of herfelf
and friends, of a fmall but healthy child, which is at this time
nearly of the fame fize it would have  been, had it been born
at the full period of uterogeftation.  In a fubfequent preg-
nancy, the fame method was  purfued,  but whether the child
was of a larger fize than before, whether there was any miftake
in  the reckoning, or whethar the child fell into any untoward
 fiofition, I could not difcover, but it was  ftill.born, though the
 abour did not continue longer than fix hours.
   There is another fituation in which I have propofed, and tried
with fuccefs, the method  of bringing on premature  labour.
Some women, who readily conceive, proceed regularly in their
pregnancy till they approach the  full period, when,  without
any apparently adequate caufe, they have been repeatedly Seized
with rigor, and the child  has  inftantly died, though it may not
have been expelled for fome  weeks afterwards.   In two cafes
ot  this  kind  I have  propofed to  bring on premature  labour,
when I was  certain the child was living,  and have  fucceeded
in  preferving  the  children  without  hazard to  the  mothers.
There is always fomething of doubt in thefe caSes, whether the
child might  not  have  been preServed  without the operation ;
 but as Such cafes often come  under confideration, and as I am
difclofing all that  my experience has taught me, it Seemed ne-
 ceffary to mention this circumftance,
   I may  by  allowed to conclude this fubjeft, without entering
into a detail of the manner in which premature labour may be
 brought  on  ; becaufe  no  perfon  qualified to decide  on the
 propriety of this operation can be ignorant of the manner of
 performing  it.  I  muft  however  take  notice, that when the 
ON  DIFFICULT LABOURS, j
99
 membranes of the ovum are punftured or ruptured,  fome cau-
 tion is required to avoid injuring the head of the child, which
 may lie clofe to them, and after the difcharge of the waters, it
 is neceffary  to obferve, that the time when the aftion of  the
 uterus may come on will be very different;  this happening in
 fome inftances  in twelve hours, and in others not for twelve or
 fifteen days.  During this interval we have  only to wait pati-
 ently for the event,  and when the pains come on, the labour, if
 natural, is to be fuffered to proceed without  interruption ;  or,
 if irregular,  fuch affiftance is to be given, as the peculiarity of
 the cafe may require.  It is fcarcely neceffary to  mention, that
 when we are  confidering the propriety of  this operation, it
 ought not to be performed when the patient labours under any
 hazardous difeafe; and that if complaints fhould afterwards arife,
 our endeavors  muft be exerted to  remove  them before  the
 acceffion of labour.

                     SECTION  XL

  ON THE SECTION  OF THE SYMPHYSIS OF THE  OS6A PUBIS.

   It was before obferved, that an opinion of the gradual and
 fpontaneous Separation of the Jymphyjis of the offa pubis previ-
 oufly to the  commencement of labour had generally prevailed*;
 though fome had denied both the faft  itfelt, and the advantages
 that were fuppofed to accrue from the feparation, if it wereaftu-
 ally made.  With a ftrong perfuafion or conviftion however of
 thofe advantages at the time of parturition, fome rude and evi-
 dently dangerous attempts were formerly  made with very awk-
 ward but powerful inftruments, to promote or increafe the fepa-
 ration beyond its common degree ; but the praftice,  probably
 never frequent, had for many years fallen into total difufe, and"
 was almoft forgotten.  Latterly this idea has been refumed, and
 among others, Camper, a celebrated anatomift and profeffor at
 Groningen, in order to try the effeft of the feparation, and dis-
 cover its confequences, had, in living animals, divided the Jym-
phyjis, without  much apparent injury, either  at the time of  its
 i eing divided, or at  any future time. * But in  the year 1777 M.
 Sigault, a furgeon at Paris, firft perfromed this operation  on
 the human fubjeft, in the time of labour, the patient  recover-
 ing, and the life.of the child being preferved ; but it is not clear
 from the context, that the operation was, in that cafe abfolutely
 neceffary.   Some credit might have been due to M.  Sigault-
* See Vol, I. Chap. i. .Sed. §. 
ioo
[INTRODUCTION TO MIDWIFERY.
for the fpirit of enterprize which fuggefted the operation, and
for his refolution in performing it ; but the applaufc given to
him by many of the faculty at Paris (though, if I miftake not,
the Royal Academy refufed to give any teftimony of their ap-
probation) and by the nation at  large, was beyond all meafure
extravagant ,  a medal was  Struck to  perpetuate the faft, and
there could fcarcely have been greater exultation and triumph,
had he invented a method by. which the whole human race fliould
in future have been univerfally  freed from the pains and dan-
gers of parturition.   The influence ot vanity was at  leaft as
ftrongly  marked in thefe proceedings as the diftates of huma-
nity, and far more than the encouragement of fcience ;  fo that
the fteps taken to  aggrandize the merits of the operation, then
fupported only, by  a  fingle faft, and the reputation of the fur-
geon who performed  it, were too hafty and too enthufiaftic, not
to raife a fufpicion ot error or deceit in  the eftimate  of the
operation, or in the  account given of it.   But the conduft of
the French extended its  influence on  the Continent, where the
operation was feveral times performed with various fuccefs.
   Immediately after the accounts of the operation were brought
into this country,  wifhing,  as a matter of duty, to underftand
the ground of the fubjeft, I  had a conference with the late Mr.
John  Hunter; in which we confidered its  firft principle,  its
Safety  ; and after  the moft ferious confideration it was  agreed,
that if the utility could be  proved, there  appeared from the
ftrufture of the parts,  or from  the injury they were likely to
fullain by the mere Section of the Jymphyjis, no Sufficient objec-
tion againft performing it.   Of its real utility it was  however
impoffible to decide, before  many experiments had been made
on the dead body,  to afeertain the degree of enlargement of the
capacity of the pelvis,  well formed  or diftorted, which could
be thereby obtained,^ Such experiments were foon made,  and
their refult publifhed by the late Dr. William Hunter, and thefe
proved on the whole, that in extreme degrees of diftortion of the
pelvis, the advantage to be gained was wholly infufficient to
allow  the head of a child to  pafs without leffening its bulk, and
and in fmall  degrees of diftortion, that the  operation was unne-
ceffary, fuch cafes admitting of relief by lefs defperate methods.
They  proved  moreover, that irreparable injury would be done
by attempts to increafe the  common advantages gained by the
feftion of the Jymphyjis, by ftraining  or taring afunder the
the ligaments which  connect the offa  innommata to thejacrum,
and to the Soft parts contained  in the pelvis, particularly to
the bladder.   For the  reafons  advanced  by Dr. Hunter, the 
ON  DIFFICULT  LABOURS.               101
operation was never (excepting in one unhappy cafe) performed
in this country, and So perfectly were the minds ot men Satisfied
of its impropriety and insufficiency, that I do  not believe the
fcftion  of  the Jymphyjis ever came into contemplation in any
one cafe ot difficult parturition, with any of the gentlemen who
praftile  midwifery in this city.  But as accounts of the opera-
tion were frequently  brought from the Continent, and as aftive
meafures were purfued for Supporting the celebrity with which
it had  been firft  brought into  notice,  Dr. William OJborn
examined all the cafes then published, ftated with precifion the
little advantages gained, the injuries  occafioned, and the general
refult of the operation,  and proved both by fafts and arguments
the cruelty and futility  of it, in a very fenfible effay firft written
profeffedly on the fubjeft.
  Here the matter might  for ever have refted, but in writing on
the praftice of midwifery, as well as  any other art, it Seems
neceffary to record not only what has been propoSed and done
with fuccefs, but the trials that have been made of things propo-
fed,  though unfuccefsful and on what  circumftances the want
of fuccefs depended ; otherwife there might be at different times
a repetition of rhe fame trials and of the fame misfortunes.
Perteftly  convinced though  I am  of the impropriety of this
operation, and hoping that no attempts will ever be again made
to bring it into praftice, it feemed  neceffary to give this ffiort
account of it, and I  cannot refrain  from making the following
obfervations.
   It is  proved in the  firft place, that Some enlargment of the
capacity of the pelvis is aftually  obtained by  dividing  the
Jymphyjis ot the offo pubis.
   Secondly, That the evils, which have followed this operation,
have been  very much occafioned by  its being performed un-
fkiltully, or by injudicious endeavors to increafe that enlarge-
ment of the capacity  of the pelvis  beyond the degree, which
naturally follows the divifion of the Jymphyjis.
   Thirdly, That many women who have undergone this oper-
ation have recovered ; though of thofe who recovered, many
fuffered very Serious  complaints for a  long time, or for the
remainder of their lives.
   Fourthly,  That fome children were born living when this
operation was performed.
   We  may therefore prefmne to fay, that if a cafe could' be fo
 precifely marked, that there fhould  only be a deficiency of juft
 fo much  Space as would be fupplied by the  Simple divifion of
 the fymphyfis, the  operation might in  that particular cafe be
 confidered. 
f02             INTRODUCTION TO MIDWIFERY.
   We may alfo fay, that this operation  is not fo certainly fatal
 to thofe women on whom it may be performed, as the Cefarian
 operation ; nor fo certainly deftruftive of children as that of
 leffening the head.
   We may then be allowed to fuppofe a cafe and fuch a one is
 more than  poffible, in which a perfon  of very  high rank, the
 life of whofe child might be of the greateft public importance,
 could not  be delivered, without the deftruftion of the child, or
 her  child  be  preferved but by  the  Cefarian operation at the
 expenfe or great hazard of her life ;  and that fhe through  hu-
 man  frailty might retufe to Submit to the Cefarian operation,
 yet the great interefts and policy of the nation might torbid the
 deftruftion of the child.  Of courfe both the mother and child
 would be inevitably loft.   Should Such  a cafe occur, which, as
 I  faid before,  is more than poffible, then  the  feftion of the
fymfhyfis of the offa pubis might be  propofed  and performed,
 as it would in fome  meafure meet both  their interefts ; being
 lefs horrid to  the woman the  Cefarian operation, and inftead
 of adding  to the danger, give fome chance of  preferving the
 life of the child.
   But, from the ftatement of this cafe, or any thing before
 advanced, I hope it will not be concluded, that I mean to in-
 sinuate a with,  or  to  advance  an argument, in  favour of this
 operation,  in the cafes for which it was originally propofed,  or
 any other which can be imagined. 
ON  DIFFICULT LABOURS.               103
CHAPTER  XIII.
SECTION I.
              O.N  THE CESARIAN OPERATION.


 A ins operation is to be performed by making an incifion firft
through the integuments of the abdomen,  and then into the
uterus, for the purpofe of extrafting a child therein contained.
In cafes of extra-uterine children, an incifion, for the purpofe
ot extrafting a child contained in the cavity of the abdomen,
under various circumftances, has been called the Cefarian oper-
ation ; but in the  importance and confequence  of thefe two
operations there is an evident and very great difference.
  It has beqn fuppofed by fome writers, that a name was given
to this operation from a circumftance common to it and every
other  in forgery in which a knife was ufed (a^cafo  matris
uteroj;  by others, that it had its name from the extraordinary
courage of the perfon on whom, or by whom, it was performeU;
but it  was more generally explained by the imagined qualities
and rank of the  perfons, whofe lives are Said  to have  been
preferved  by it.   Thefe, and their defcendants, according to
Pliny, were called Cafars, as thofe born with the feet foremoft
were called Agrippce ; or when there were twins, and only one
was born living,  Vopifci,  and when they were left-handed
Scavola*.  It feems not to have been thought refpeftful, that
men, who in the courfe of their lives proved  extraordinary,
fhould have been prefumed  even to come into  the world in a
common way*.  But it is well known, that the name of Cafar
was not conferred on that great  man, or the family who bore
it, from the manner of his birth, but was  derived from quite
another  fourcet.   Nor  do any of the very ancient writers  in

  * Aufpicatius, enefta parentc, gignuntur, ficut Scipio Afri-
canus prior natus, primufque Casfarum a caefo matris ntero
diftus.                  Plin. Hiftor, Nat.  Lib. vii. cap. ix.
  t The mother of Caefar, according to Suetonius, was living
at the time of her Jon's expedition  into Britain, fo that JJie
muft ha+> furvived the opera^on, herd it. been p.-formed upon
her. 
S04
INTRODUCTION  TO MIDWIFERY.
 medicine take  notice of this operation, and we cannot fufpe$
 they were So negligent as to have omitted the  description of it,
 or fo  ignorant as to be unacquainted with it, when in all pro-
 bability, had it been performed, they would have been the very
 perfons confulted and employed to perform it.
   Pliny*, who lived  in the time Vefpafian, is the firft author,
 as far  as I know, who mentions this operation ; but he fpeaks
 of it with reference to thofe who lived before his time, and his
 account does not give much fatisfaftion.  Rouffel\, who was a
 ftrong advocate for the operation, wrote profefledly on the fub-
 jeft in the year 1581.   But the records of this operation have
 been imperfeftly preferved even in modern times.   For, from
 the context ot the cafes recorded, it appears tjiat fome hay,e been
 mifrepreSented ;  that Some are fiftitioup and were  alleged to
 anfwer other purpoSes, as was  the Suppofed one ot lady Jane
 Seymour, to ftamp a character of  greater cruelty, than even he
 deferved, on  Henry  the Eighth\; and that others are related
 with a change of circumftances, fo as to appear  different,
 though they were in faft the Same.   From a deteftation of the
 apparent cruelty of this operation, from a doubt ot its neceffity,
 or of the advantages to be derived from it, from the deflruftive
 event  which was to be expefted, or from fome  other caufe, it
 was never performed, or even propofed, or hardly fpoken of, in
 this country, till within thefe  few years.  But at prefent we

   * Plin loco  citato.

   t Bauhin, in the appendix to Rouffet, dated 2^588, gives the
following Afe : Eliz. Alefpachen had this operation performed
 upon her  by her hufband,  who was a gelder of cattle at Sier-
 genhaufen in Germany, in  the  beginning  of the fixteenth cen-
 tury.  She had feveral children born afterwards in  the  natu-
 ,al way.
   Pare and Guillemeau wrote againft the operation.
   M. Simon wrote two papers on thefubjed in thejirft volume
 of the Royal Academy.
   Heifter and  manv  others have written on the Jubjed ; but
 Weideman oj Duffendrop, in his Thefis, has given an account
 of all  the cafes oj this operation,  which had  been  recorded
 before  his time, and the refult of them.

   % It appears Jrom the beft authority, that  the queen died on
 the twelfth day after her  delivery, no fuch operation having
 been performed upon  her.   See Rapin, vol. i. p.  817, note 6. 
ON DIFFICULT  LABOURS.
10£
have  well authenticated  accounts  of more than ten cafes in
which the operation has been performed, under the direftion of,
and by,  men of unexceptionable abilities ; and thefe may be
efieemed Sufficient to enable us to form a judgment of the bene-
fits to be derived from the  operation, as well as of the manner
in which it ought to be performed,  and of its constant or pro-
bable  confequences.

                     SECTION  II.

   By the firft writers on this fubjeft nur.v circumftances are
recited, which were Suppofed to render this operation neceffary,
Some  reSpefting the parent,  others  the child.  Of the  -firft
kind  were extreme fmallnefs or diftortion of the pelvis ;the
ftraitnefs- or clofure ot the natural paffages, from cicatrices, ad-
hefion, or any other caufe ; the rigidity of the parts from old
age. Or their imperfection from youth ; almoft every caufe of a
difficult labour, when extreme in its  degree, has been mentioned
as a poflible  reafon for propoftngor performing this operation.
Thofe which refpefted the child, not only <rejated to its compa-
rative fize, but to its pofition alfo;  and on this oceafion twins,
and even monfters, which there was no vrifh to pntferve, have
been  mentioned.  But whatever  was the  exilting  caufe, it
appears that there  muft  have  been a full  convi&ion on the
mind of  the perfon who propofed this  operation, of the im-
poflibility of  delivering the  patient by  any other  means.
Some writers  have   indeed  fpoken of this   operation,  not
with a view  to its abfolute  neceflity*  but%s elligibilhy, or as
deferving preference to  other methods of  delivery which
might be practicable.  Such writers have not met with general
approbation, but their influence has been too great ; for in the
hrftories of the cafes recorded, we find in feveral of them fome
circumftance,  which  proves that the operation  was not necef-
faiy, or  that the grounds on  which it ought to be performed
were  not well underftood.  The ideal glory of the  operation
has perhaps had its influence in France,  where it hss  certainly
been often propofed, and fometimes performed  unneceflarily,
and Some other parts of the Continent.  No other principle but
that of neceffity can certainly be admitted  as a juftification of
this operation ^ that is, whenever it is propofed, there fhall be
no other way or«iethod, by which the life, either ot the mother
or child,  can poflibly be preferved ; and  the impaffibility ftiatl
be confirmed,  not by the ojutifowofone, but as many compe*
   Vol. II.                   P 
106           INTRODUCTION  TO MIDWIFERY.
tent judges as  can be procured.   If fuch fatisfaftion could be
£lven, I fliould then  confider this operation juftified by every
principle of religion and the laws of civil fociety, upon as good
and decifive evidence as any other operation, which we never
hefitate to perform, becaufe it fubmits to  the general principle
ofpraftice ; by giving us a chance of preferving a life, which
muft otherwife be inevitably loft.

                      SECTION III.

   Three general fituations have been ftated in which.it has been
fuppofed that the Cefarean operation might be neceffary*.
   i.  When the parent was dead,  and the child living.
   2.  When the child was dead, and the parent living.
   3.  When both the parent and child were living.
   With refpeft to the firft fituation, when the parent  is dead,
and the child living, there cannot be any debate ;  becaufe, with-
out  giving pain, or incurring any other inconvenience, an
attempt is made by this operation to preferve the  life of a child,
which, if it be not performed, muft foon and inevitably  perifh.
   With reSpeft to the Second fituation, as in almoft every cafe
 in which the operation has been performed in this country, the
 parent has died, but  the lives of many of the children have been
 preferved, the operation holds fogh, as its principal advantage,
 which is a very important one, the hope of preferving the life,
 of the child ;  the chance  of preferving the parent being much
 leffened, at leaft not improved, by an operation fo full of dan-
 ger.   It will therefdfc, I think, be generally acknowledged,;that
 the operation ought fcarcely ever to be performed upon a liv-
 ing mother, when there is proof, or good reafon for believing,
 that the child is dead.
   The Third is the ftatement attended with any difficulty, and
 being the only cafe which, ftriftly fpeaking, comprehends) in its
 true fenfe, the Cefarian operation, it might lead to a  compar-
 ative eftimation between  the life of the child and  that of the
 parent.  But the common fenfe of mankind, being agreed in
 the general  principles adopted and purfued throughout this
 work, ot its ever being our duty, in the  firft place, to  preferve
 the lives of both the parent and child ; in the  fecond, to pre-
 ferve the  life ot the parent; and in the third, that of the child,
 which have been on various occafions inculcated and  applied,
 will point out the general line of conduft we ought to follow,
 according to  the exigence of every cafe which may occur  in
 praftice.
              * See Bonet. Sepulchr, Anatomic. 
ON  DIFFICULT LABOURS.
tof
   Without regard to the ftate of the child,  this operation has
 alfo been propofed  for our confideration under  circumftances
 which relate to the mother alone.
        i. When fhe was living.
        2. When fhe was dead.
   Some have been of opinion, that this operation ought never
 to be performed on the living fubjeft.   Impreffed, perhaps,
 with the dread  of the operation, they  did not  diftinguifh be-
 tween  the neceffity and eligibility, and therefore  wifhed 'to
 abolifh  it altogether.  But if it were  to  be performed  only
 when the  patient was dead, more particularly  if we were to
 wait for her death, as the only proper time of performing it, it
 Would always be fruitlefs.  For I do not find any inftance of
 a living child extrafted by this operation after the death of the
 mother, unlefs the child efcaped by the fame ftrokeas that which
 pfoVed  fatal to the mother, of  which the accounts feem to be al-
 moft fabulous, or merely accidental.  But.as, ih cafes of women
 dying in convulfions, hemorrhages, rupture of the Uterus, or
 other rapid difeafes, at different periods of pregnancy, or of a
 labour,  it is poffible for a living child to be  extrafted after the
 cfeath of the mother, by fpeedily performing this operation ;
 and as no harm can poflibly refult from the operation, fuppofing
 ourfelves difappointed,  no reafonable objections can  be made-
 to Our performing it under fuch circumftances.   In fome coun-
 tries the laws  forbid  any woman  who may have died daring"
 pregnancy, to be interred before the child fhall have been taken
 away.   A  prohibition to bury the  living with the dead is the
 foifft of fuch laws.

                     SECTION  IV.

  If  it  be  admitted, that neceffity alone can juftify the Cefa-
 rian operation, we are next to  inquire into the caufes and proofs
 of fuch  neceffity.
  Many of the caufes which have been  fpecified by writers, as-
 producing  a neceffity of performing this operation, are cer-
 tainly unequal to fo great an effeft.  The fize of a child how-
 ever large,  unlefs the pelvis be  at the fame  time very much
 diftorted ; nor any untoward pofition of the child ; nor twins;
nor monfters; nor  the  ciofing or ftraitnefs of  the Soft parts,
 can ever compel us to the neceffity of performing this operation;
becaufe  we know from reafon and experience, that difficulties
arifing from fuch caufes muft admit of relief by lefs defperate
means.  It may be afferted in general, terms, that there is only 
*0$            INTRODUCTION TO MIDWIFERY,
one  caufe which  can iuftify .our propofing or performing
this  operation on the  living fubjeft,  and that is, fuch  an ex-
treme degree of diftortion of the pelvis as renders the extrac-
tion of the child, in its prefent ftate, when diminished in its bulk,
or even reduced  into pieces, abfolutely impracticable ;  in
other words, when the Situation is fuch, that the woman would
in all probability die,  if  this operation  were  not performed.
But it is alfo true, if any  other caufe could be  prayed to exiftj
which  produced the fame impracticability, then the opeiation
would be equally requisite and juftifiabie*.
   To make a precife Statement of that degree of diftortion ,or
confequent diminution of the cavity of the p4l*is  which might
require this opeiation, is not perhaps poflible m the living fub-
j'e6t.  The natural fpace of the cavity of a well formed  pelvis,
from the  offa pubis  to the Jacrum, is about four inches and a
half, and in Some fubjefts rather more ;  and the heads of chil-
dren at the time-fit birth   bear a general relative proportion to
this Space*  But living children of the full fize have  been born,
frequently, by the natural efforts, when thefpace^fcas preSuraed
to be lefs than four inches  ; and if the  children, were fmall,
when it did not  exceed three inches : and we may  judge that
the head ot a child is capable of being reduced by compreffion
one third of its natural bulk, without  deftruftion  of its parts,
or any  permanent injury.   But fliould the capacity of thepeluis
he reduced under three inches,  we have not  much reafon to
expeft a living  child, of its  full growth, to pafs through it,
either naturally,  or by the affiftance of art ; though the head of
one that is dead,  efpecially if it be putrefied, or one much below
the common fize, may be prefled through the pelvis of about
thofe dimenfions, even without artificial affiftance.   Should
the capacity ot a  petvis not exceed, according to our judgment,
two inches and a half, then the head of a-child, unlets the. con-
tents be evacuated,  cannot pafs or be  extrafted through it,
But if the cavity be fo far clofed, that it Should in any part very
little exceed one inch,  of which examples  have fomctivcs
occurred, we  might then prelume that the head of a  child,
though it could  be reduced to the leaft poffible fize, could not
be extrafted through it ;  and then the neceffity and propriety
of performing  the Cefarian operation would  be allowed  what-
ever averfion we might have to  it,  efpecially  if we  had* reafon
to think that the child was living.

   *  See the Fourth Order of Difficult  labours, Seel. ifi. in
(his volume,. 
CN  DIFFICULT LABOURS.                10$
 '*Thefc general-pofitions every perfon engaged in praftice will
bear in his mind, in cafes of difficulty arifing from diftortion of
the pelvis.  But he muft alfo recolleft, that the remaining fpaco
of tbe/aavity of the pelvis, in? cafes of diftortion, will be differ-
ently eftimated by  different perfons, and cannot be ascertained
with precifion by any one, during the'life of the patient.  _He
will alio remember, that the kinds of diftortion are as various as
the degrees, and that the cavity, though much diminifhed in one
part, ma^be far>lefs<altered in another ; and that even one fide
of the pelvis may meafure two inches, when the other is fcarcely
equal to one, which confideration may make a change  in our
judgment of the kind ot operation required, widely different, as
well as in the operation itfelf.   It fhould  alfo be remembered,
that the fize ot children at the time of birth, and the firmnefs
of the bones, together with the compaftnefs ot their union with
each other, are very different, and might add to, or leffen,  the
difficulty  ot a birth,  whether  natural or artificial.  After a
 mature confideration of the whole matter, I  am however of
 opinion,  that no rule of fufficient authority to guide us  in any
 particular cafe can be formed from fuch calculations only, and
 that our  conduftd6 not to be governed wholly by them;  but by
 the reflections of common fenfe working in a reafonable mind,
 ftored withthe knowledgeof fuch calculations, and of many other
 collateral circumftances relating to the mother or child, which
 it is impofiible to enumerate or delcribe,  fo as to render them
applicable in any  particular cafe.  Befides the pofitive diftor-
 tion of the pelvis,  there is in fome crooked  people fuch a twift
 or projeftion of the laft-lumbar vertebra over the Superior aper-
 ture, as to increafe, or  conftitute an obftacle of the paffage of
 the head, as infurmountable as  any degree t»f diftortion exilting
 in the bones of the pelvis.  Of this the cafe  of the woman on
whom .the operation was lately performed at Manchefter is an
 example, which fully juftified the operation.
   I cannot  however rclinquifh  the fubjeft without mentioning
 another ftatement  of this  queftion,  which  has often employed
 my  mind, efpecially when the  fubjeft has been aftually patting
 before me.   Suppofe, for inftance, a woman married, who was
fo unfortunately framed, that fhe could not poffibly bear a liv-
 ing  child.  The firft time of her being in labour, no reafonable
 perfon could hefitate to afford relief at the expenfe of her child ;
 even a fecond  and a third trial  might be juftifiable  to afcertain
 the  taft  of  the impoflibility.  But it might be doubted in mo-
 rals, whether children  fhomd be begotten under fuch circum-
 ftances, or whether, after a Solemn determination that fhe can- 
HO           INTRODUCTION TO MIDWIFERY.
 not bear a living child, a women be entitled to have a number
 of children  deftroyed for the purpofe of faving her life ; or
 whether, after many trials, fhe ought not to fubmit to the Cefa-
 rian operation, as the means cf preferving the child at the rifk
 of her own life.  This thing ought to be confidered.   More-
 over, when it has been ascertained, that women could not poffi-1
 bly bear living children, naturally, or  by any affiftance  which
 art can afford, and one great end of marriage has been%iftrated>
 fome  have  determined  on a voluntary Separation  fr&rn their
 hufbands, from a  fenfe of the moral  turpitude fof conceiving
 children without the  chance of bringing them living into the
 world.  But the law of the land has afforded no remedy  for the
 cafe,  though,  as this taft fometimes admits of unqueftionable
 proof, it would not be difficult to adjuft terms  of. feparation.
 between a hufband and wife thus circumftanccd,  fo "cautioufly*
 that they fhould not be abufed, yet without the imputation of •
 criminality to either party; and many evils  might be thereby"
 prevented.                                               ■ ...
  I take this opportunity ot making another observation on thfSf^ v
 fubjeft, which affords but gloomy  refleftions.   Formerly the
 cafes in which the Cefarian operation could come to be confi-
 dered, were almoft univerfally confined to cities, or very large
 towns, where the cuftoms and manners of life readily occasi-
 oned,  with every other kind ot decrepitude,  diftortioiis  of tne
pelvis  and all  its confequences.  But within thefe few years,
 from  the general diffemination of manufaftures, efpecially that
 of cotton, over many parts of the country, thefe evils have be-
 come much more frequent; and as the children employed in
 them are obliged to  Stand, or are confined to one pofture for
 many hours together, before their bones have acquired fuffici-
 errt liability to Support  them, many have  become deformed.
 To boys it may be a great evil and mortification to have  bandy
 legs, yet this  does  hot prevent their  becoming  fathers y but
 girls  under the fame  circumftances  muft often be precluded
 from  being mothers ;  nor can they go through the prdeefs of
 parturition without infinite Suffering and danger.  It therefore
deferves  confideration, both as it is of great political impor-
tance, and as a moft interefting cafe of humanity, whether fome
means  cannot be contrived, by which fuch misfortunes may be
prevented. 
ON  DIFFICULT LABOURS.
111
                          SECTION V.

       In almoft every cafe in which the Cefarian operation has
    been  performed in this country, the patients have died.  It
    may be of ufe to inquire,  whether their death were occafioned
    by any difeafe, with which they were afflifted before the time
    of labour ; or were fhe confequence ot the ftate to which they
    were reduced from the occurrences of labour, before the oper-
    ation was performed ;  or it were the inevitable confequence ot
    the operation.   In cafes of death occafioned  by wouwds, the
    following order  in which  the dahger is "produced may be ob-
    ferved : firft,  from convulfions, or immediate lofs of blood ;
    Secondly, from inflammation ; thirdly,  from gangrene ;  fourth-
    ly, from exceffive or long continued fuppuration,  under which
    the patient becomes heftic.  Though almoft all the patients, on
   ^.whom this operation has been performed, died, their death hap*
  ^^Jened at different  periods ; but not one  died, either while the
    operation was performing,  or immediately after it.   No convul-
    fions were brought on by the incifions ; nor does it appear,
•   that any of them funk  through the lofs of blood accompanying
    or fucceeding the operation.   Some died within twelve, others
    at the end of twenty-four hours, and a few died on the third day
    after the  operation.    It we  may judge of the  caufe of the
    patient's death by the time of her dying, it might be faid, that the
    death of thofe who failed within twenty-four hours, was proba-
    bly  owing, not to  the  operation alone, but to the violence of
    this,  combined with  that oi previous  difeaSe ; but when they
    Survived Uventy-four  or forty-eight hours,  then  their death,
    might be attributed to  the fucceeding  inflammation, in a body
    predifpofed  to difeafe.   If we had the  liberty  of felefting  a
    patient on whom to try  the merits of this operation, we certainly
    fhould not choofe one who was either  very much diftorted, or
    who had the  mollities offtum, or who  was evidently under the
    influence  of  fome dangerous difeafe,  or  who had  even been
    feveral days in  labour; hecaufe the event muft  very much
    depend upon her ftate at the time when the operation was per-
    formed.
       It is not my intention by this kind of inveftigation, to leffen
    the general averfion to  this opeiation when it  can be avoided ;
    but  I believe we cannot tall into  error by conforming to fuch
    conclufions as thefe.   Every  woman, for whom the Cefarian
    operation can be propofed to be performed, will probably die, 
 112            INTRODUCTION T,) MIDWIFERY.

 and fhould any one Survive, her recovery might rather be con-
 fidered as an efcape, than as.a recovery to be expefted, though
 there is always a probable chance of Saving the life of a child.
 But as fuch an efcape may happen  in any caSe, in which  the
 operation might be performed, we  may  and ought  to efteem
 every cafe which  can come before us, as the individual cafe, in
 Which a happy event is to be cxpc6fed.  Thefe conclufions
 will lead us to the principle of neceffity as the Sole juftifieaftion
 of this operation, and urge us, wjaen we'do perform it, and as
 lar as it may be in-oufr power, to Select, the moft eligible time ;
 and from every motive to" exert, all our judgment and Skill  for
 the fervice of the patient, as if we were certain  fhe Avould Sur-
 vive.  This "operation can feldon* be required,  and will,-.of
 courfe, never be performed on the opinion or judgment of any-
 one perfon, unlefs in fome eaSeof great and urgent neceflity ; and
 a concurrence of opinions willra&rdthe beft Security againft its
 bemg- performed- unneceffartfy 4 and if it were to be prefumritli
 by a fubfcquent measurement ot the pelvis, and a new confider*^
 ation-'of all" the circumftances, that it ever had been performed^
without Such neceffity, that would prove only thatthe operation
had been abuSed, and  not Serve as a valid argument againft its
ufe When Such neceffity really exifted.
                     SECTION VI.

  Having never performed the Cefarian operation, nor Seen it
performed, I offer the description of the cafe related in the fourth
volume of the Medical Obfervations and Inquiries, as the beft
example which has been recorded.;.  The operation  was per-
formed  by  Mr. ThMkfon, one  of the furgeons  of the London
Hvjpital*.       ' ■ "
  ■••  A table being prepared, the. patient was placed upon it
lying on her back, her head being Supported by pillows/ and
her legs hanging down.  The belly-appeared prominent chiefly

  *  It is remarkable, thatthe  oldeft phyfician or Jwrgeonir
London could not recoiled a  cafe of this  operation, or had
heard' it Jpoken of by  their frtdecefftrs, yet that two cafes,
in thejame flreet, Jhould have 0U#rrtd to one  gentleman,
vfithin a very fhort fpace of time.   ---v
  For a More full and accurate account of all ihe circmnffatt.
ces relative to this operation,  fee a zvork lately publiffied  hi
Dr.  Hull, en eminent phyfician at Manchefter.
• 
ON  DIFFICULT LABOURS.
»>3
  on the right fide, the protuberance of the uterus extending but
  about two or three fingers breadth on the left of the linea alba.
  There was no difficulty therefore to determine where the inci-
  fion was to  be made.
    " Accordingly, about a hand's breadth from the navel on the
  right fide, I began the incifion in  a longitudinal direftion, and
  continued it about  fix  inches  in length, the middle of ♦hich
  was nearly  oppofite  to  the navel  ; the Skin  and adipofe mem-
  brane being cut through on the outer edge of the redus  mufcle.
  I carefully made an incifion through tfie tendinous expanfion of
  the  abdominal mufeles and the peritonaeum, Sufficient to in-
  troduce  the forefinger of  my  left  hand, when with a curved
  knife  condufted on  my finger, an opening  was made  into the
  cavity of the abdomen, and the uterus expofed.
    " The uterus appearing very Solid to the touch,  it was ap-
  prehended by fome gentlemen, that the placenta might  perhaps
  adhere to that part of the uterus  whicn lay bare, and which
  might confiderably obftruft theremoval of the  child or endan-
ger an hemorrhage.   With precaution, therefore, an aperture
  was made in the  centre of the uterus  fufficient  to admit my
  finger, with which  conducting the  curved knife, I dilated the
  wound in the uterus, upwards and downwards, to the full
  extent of the outward wound.
    " The placenta, which aftually adhered  to this part of the
  uterus, eafily gave way, and receded as my finger advanced in
  making the  opening.
    " The placenta, and membranes immediately began to pro-
  trude.  Dr. Ford at this juncture flipping his hand into the
  uterus, while the fides were kept afunder, brought forth the
  child by the feet, and immediately afterwasds the placenta and
  membranes  were extrafted with  the greateft eafe.   Dr. Ford
  took upon himfelf the management of the child and Separation
  of the umbilical  chord, and in a  few minutes  the child cried
  ftrongly.
    " The uterus being difburthened of its contents, and con-
  trafting  amazingly faft,  the  omentum and  bowels began to
  protrude ;  Mr. John Hunter was So obliging as to aflift me in
  retaining them within the belly,  whilft  I  cleanfed away the
  grumous  blood  (which  was fmall in quantity) and made the
  gajtroruli'is or future of the belly.
    M  I made four futures at nearly equal diftances  irom each
  other, and about  on? inch and. halt horn the ed^e of  the lips
  of the wound.
    Vol. II.                  Q 
114            INTRODUCTION TO MIDWIFERY.

  " The ligatures being double,  pieces  of  linen Spread with
common plafter, and rolled up in the form of bolfters, or com-
preffes, were applied  between them, after the  manner of the
(milled future, and the wound was thereby  brought into and
retained in clofe contaft ; and lint and a common pledget being
applied, finifhed the operation."   This woman died  about five
hours after the operation. 
ON  PRETERNATURAL LABOURS.
^i
 CHAPTER  XIV.

    CLASS THIRD.

PRETERNATURAL LABOURS.
                      TWO  ORDERS.

                        ORDER FIRST.

      Prefentation of the Breech, or Inferior Extremities.

                       ORDER SECOND.

'tftfh Prefentation of the Shoulder,  or Superior Extremities.
SECTION L   -<
The  technical terms  which are ufed to Specify all the other
claffes  ot labours,  relate to fome circumftance  in  which the
mother is wholly or partly concerned.  But the term preterna-
tural applies merely  to the pofition of the  child ; and  this
kind of labour may occur in a woman in  perfeft health, when
all the changes incidental  to the ftate of parturition are made
in the moft favourable manner, and in whom there is the beft
poffible formation. In ffiort,  there  may be  no deviation or
irregularity  ot  any kind,  excepting  only that the head of the
child does not prefent.  Should the prefentation ot another
part  be combined with hemorrhage, or any other circumftance
of dangerous importance, either to the mother or child, the title
of preternatural would be generally loft, and the labour refer-
red to  fome other clafs.
  The prefentation of children at the time ot birth may  be of
three kinds: firft, with the head; Secondly with the breech, or
inferior extremities ;  thirdly, with  the fhoulder, or Superior
extremities.  With the firft of thefe the  labour, as far as relates-
to the pofition of the child,  is called natural; but with the two 
Il6           INTRODUCTION TO MIDWIFERY.
latter, preternatural.   Pretei natural labours have been  fubdi.
vided, by fyftematic writers, into a much greater number and
variety ; but as all diftinftions are to be made and regarded
according to their utility in praftice, and as no poffible advan-
tage can be derived from their multiplication, but on the con-
trary much confufion, it will be  found expedient to abide by
thefe diftinftions only.   For though there may be a difference in
one reSpeft or other in every labour of this kind, and ot courfe
a neceflity for fome change in our conduft, yet notice cannot
poffibly be taken ot  every  alteration, and thefe diftinftions
will be found fufficient for all the geperal purpofes ot praftice.
   Great pains have  been taken to difcover the cauSes  ot  the
preternatural prefentation of children, and with the beft inten-
tion  ; that of pointing out the errors and irregularities by which
they were fuppofed to be produced, in order to prevent them.
On this part of our fubjeft, though there have been many dif-
ferent opinions, I think it has been generally prefumed,  that
preternatural  presentations happen more frequently to  women^
in the lower ranks of life, than to thofe in a more affluent coA-"^
dition :  the accidents and exertions, to which the  former are
chiefly liable, being confidered as the caufes.  Before we con-
Sent tt> this inference, it would however be neceffary to examine
into  the truth of the affertion.   I believe it has never been
fatisfaftorily proved,  that preternatural prefentations are really
more common in the lower than in the higher ranks  of life;
the number of the former being, almoft beyond any eomparifon,
greater than thofe of the latter.   No Station of  life is  exempt
from  thefe prefentations,  though  they rarely occur in any,
efpecially thofe of the Second order ; and it is wonderful, that
thofe women who have had fuch accidents, at different periods
of utero^geftation, as would be deemed moft likely to produce
them, have eScaped them.   But  though preternatural presenta-
tions feldom occur, when they are dreaded and expefted, it is
remarkable that feme women are peculiarly fubjeft  to  them  ;
not once only, which might be confidered as the effeft pf Some
accident,  but exaftly  to the fame prefentation, whether of the
fuperior  or  inferior extremities, in feveral fucceffive or alter-
nate  labours.  It Seems doubtful therefore whether we ought
not to exclude accidents as the common caufes of thefe prefen«.
tations,  and Search for the real caufe in fome more intricate
circumftance ; fuch as the manner after which the ovum may
pafs out of the ovarium into  the uterus ;  fome peculiarity in
the form of the cavity ot the uterus, or abdomen ; in the quan-
tity of the waters of the ovum at feme certain time of pregnancy; 
ON'  PRETERNATURAL  LABOURS.          117
in the circumvolution of the funis round the haunches or lower
part  of the back of the child ;  or perhaps  ih  the infertio'n of
the Junis into  the  abdomen of the child,  which is not in all
cafes confined to one prccife part,  but admit* of confiderable
variety.


                     SECTION II.
     ON THE  SIGNS  OF PRETERNATURAL PRESENTATIONS.

  Several prefuraptive figns of the preternatural prefentation of
children have been mentioned ;  Such as an unequal diftention of
the abdomen during pregnancy; Some peculiarity in the motion of
the child ; the Sudden riling of the child, when the woman is in a
recumbant pofition, fo  as to affeft her ftomach, or to incommode
her breathing; the flow progrefs of the firft ftage of a labour;  the
early rupture of the membranes ; or the elongated form which the
membranes containing the waters affume, while the os uteri is
dilating.   But thefe fymptoms and appearances will  be found
very uncertain ;  nor can We confide in any mark or indication,
until we are able  to feel and diftinguifli the part which really pre*..
fents.  It will often  be in our power, before the membranes are
broken, todifcover that the presentation of the child is preterna-
tural ; and Sometimes, though not conftantly, to Say what the pre-
senting part is.   But when  the membranes are broken, a Small
ftiare of fkill  and circumSpeftion will enable us to determine
what that part is  ; efpecially if we have  accuftomed ourfelves
to handle  the limbs ot new-born children!  By its roundneSs
and  firmneSs, the head may be diftinguifhed from any  other
part  ; the breech may be known by  the cleft between the buu
tocks, by  the parts of generation, and by (he difcharge of  the
meconium  ; though  the laft circumftance does not always hap-
pen even when the breech prefents, till the labour is far advan-
ced,  and Sometimes occurs likewife in presentations of  the
head.  The foot  may  be known by the heel and the want of a
thumb ; and  the hand by  its flatnefs, by the  thumb and  the
length of  the fingers.  In Some caSes  I have found the  hands
and the ieet lying together ; but this cannot create much em-
barraffment to an  intelligent practitioner ;  though  there is
reafon to believe that an error or miftake in judging a fuperior
to be an inferior extremity, lias Sometimes been produftive of
mifchief.   I do not mention the marks by which the back, belly. 
Il8           INTRODUCTION TO MIDWIFERY.
or fides might bediftinguilhed, becauSe thefe properly Speaking,
never conflitute the presenting part;  that is, though they may
Sometimes be felt, they never advance foremoft into the pelvis
in the commencement, at kaft, ot a labour.
                      SECTION III.

 ON THE MANAGEMENT  OF THE FIRST ORDER OF  PRETERNA-
                     TURAL LABOURS.

   Is the firft order of preternatural labours may- be included,
 the prefentation of the breech, of a hip, of the knees, and of one
 or both legs.
   When a labour is fo far advanced that the os uteri is fully
 dilated, if no part of the child can be felt, it will be prudent to
 watch carefully when the membranes break, as there is a chance
 that the prefentation  may be of Such a kind as may  require the^
 child to be immediately turned.   But if no part of the child can
 be  felt,  by a common  examination, after the membranes are
 broken, it will be justifiable to afcertain the presentation by the
 mtroduftion of the hand.  Should the head or inferior extremi-
 ties, be found to prefent, the h-uid may be withdrawn, and we
 may Suffer the labour to proceed without any further interpofi-
 tion ;  but if it fhould be that kind of presentation which requires
 the child to be turned, we Shall have an opportunity  of perform-
 ing the operation, before there is any  contraftion of the uterus,
 Sufficient to obflruft the delivery.
   In the firft order of preternatural labours, two very different
 methods of praftice have been recommended.   By the favour-
 ers ot  the firft  method, we  have been direfted, as Soon as the
 {irefentation was difcovered,  whatever might be the ftate of the
 abour, to dilate the parts, then to pafs the hand into the uterus,
 and to bring down the feet of the child.   Or if thefe were ori-
ginally in the vagina, to grafp them and extraft the child with
all poflible expedition,  making the  labour wholly artificial,
without waiting Sor  the  natural expanfion of the parts, or for
the efforts of the conftitution.  Would it not argue a want of
humanity, fay they, to leave the woman for many hours, perhaps
a whole day, or even a longer time, in pain and anxiety, when
we have the power of extrafting the child in a very ffiort Space
of time, by which the violence of the pain would  be leffened,
or its duration, at leaft,  very much Shortened ?  Others, on the
contrary, have confidered this praftice as  founded on a vulgar 
ON  PRETERNATURAL LABOURS.
1T9
and pernicious error, which makes no diftinftion between the
flownefs and danger of a  labour.  Thefe have  confidered the
prefentation ot the breech and inferior extremities as generally
Safe ;  and  have taught us,  that  fuch cafes  ought to be, and
with fecurity may, be left teethe efforts of the conftitution, no
kind ot affiftance being required, in the firft Stage of the labour ;
the mother at leaft,  certainly not  Suffering more than in a pre-
fentation* of the head, and the chance  of preferving the lite  of
the child, being  by this  proceeding, much better.  Of the
fuperior advantage  of thefe two methods, it is only poffible to
judge by the general event ot caSes of  this kind.  If this fhould
prove, which I believe is fcarcely to be doubted, that lefs injury
is done to the mother, and that there  is a better chance of lav-
ing the life of the child, by fuffering it to be expelled, than by
artificial delivery, there can  be no hefitation to which ot the
methods preference fhould be  given  ; for  the  charge ot want
of humanity  cannot be  properly laid  againft a. proceeding,-
which moft frequently terminates happily tor both.
„   From the manner of exprefling the directions for the intro-
duftion of the hand, for the  purpofe of bringing down the feet,
in prefentations ot the breech, or inferior extremities, we might
conclude that it was always  to  be done with much cafe.. But
ontrial it  is often  found impoffible, without the  exertion of
very great  force ; and when this is  done, or  if the feet were
originally in the vagina, though the firft part of the extraction
might be eafy, we fhould  in  the progrefs find an increafing dif-
ficulty, which would bring the life ot the child into great hazard.
The thighs would advance more flowly than the legs, and the
breech than  the thighs; there  would be fome delay with the
body, then with the fhoulders, and laftly, when the arms were
brought down,  with  the head.  Thefe little  difficulties and
embarraffments,  Separately  confidered, may not be of much
 confequence,  but collectively  they  occafion a compreffion of
 ihe funis, continuing long enough to bring the life of the child
into greater danger, if not to deftroy  it ;  and this  can  only be
 prevented by a hurry in the  extraftion of the child, whicli may
lacerate or do much injury to the parts of the mother.  If, on the
 contrary, we  fuffer the breech, efpecially with the legs turned
 upwards, to be expelled by the natural pains, the diftention of
 the parts  thereby  occafioned  is So ample,  that the  body and
 head follow immediately, or  are readily extrafted.   In cafes of
 the prefentation of the breech or inferior extremities, it is there-
 fore  now  eftablifhed as  a general  rule with men of the fir it 
120           INTRODUCTION TO  MIDWIFERY.
  abilities  and reputation, to fuffer the breech to be expelled by
  the pains, and then to give fuch affiftance as the exigencies ot
  the cafe may require.
    In every labour, in the progrefs of which we cannot feel the
  head  of  the child prefenting, or  do feel  any other part, the
  membranes being unbroken, we muft be particularly careful on
  no account  to break  them  prematurely, that  is, before the os
  Uteri is fully dilated ;  becaufe, whatever the  prefentation may
  be, the child is in no danger, till the waters are difcharged ;  and
  a natural opening or expanfion of the parts is always preferable
  to an artificial dilatation,  however carefully made.  But wdicn
  the membranes break fpontaneoufly before the os uteri is dilated,
  and we can  difcover the prefentation of the breech or inferior
  extremities,  it is proper to leave the  dilatation to be completed
  by the  natural  efforts, though it will be effefted flowly and
  more awkwardly,  than  if it was done  by the volume  of  the
  membranes  containing the  waters, or by the head of the child.
  The prefentation of the breech is  fometimes  fo untoward that
  the fcrotum and penis ot  the child intervene,  and are the parts'
  which are preffed upon the os uteri during its dilatation. In con-
  fequence ot  this preffure, which is in fome cafes unavoidable,
  thofe parts become prodigioufly tumefied, and when the child
  is  born,  appear in a  gangrenous ftate.  In a few inftances I
 have known a portion of the /kin of the fcrotum or prepuce
  flough  away, but  by  the affiduous  ufe of fomentations and
 cataplafms, farther mifchief has always been prevented.
   Though it may be proper, and is perfeftly  agreeable to the
 •moft refpeftable modern praftice, to leave the  child to be ex-
 pelled by the pains,  when the breech or inferior extremities
 prefent, unlefs the circumftances of the mother fhould require
 more Speedy affiftance : yet  this  refignation of  the  labour  is
 only to  be  underftood as proper, till the breech is  expelled
 through the external parts, giving time for their dilatation, and
 guarding  them with as much care as when the head prefents.
 For after that time, as there is great danger of the child being
 deftroyed by the compreffion of the funis, though perhaps of
 no long  continuance,  the labour  muft be accelerated bv the
 practitioner,  but  with fkill and judgment.   That compreffion
 is alfo to be leffened, or any other injury prevented, by draw-
 ing the Jums fomewhat lower down," in fuch a manner that it
 may never be on  the full ftretch.  In fome cafes, however, af-
 ter the expulfion of the breech, the  continuance of the pulSa-
'tion in theJunis very Satisfactorily  proves, that no compieffioa
 of importance has taken place ; the child of  courfe bein^ i.>
 bo danger, there is no occafion to haften the deliver/ 
               ON  PRETERNATURAL LABOURS.            121

    When the breech or inferior extremities have paffed through
 the external parts great attention is fo be given alfo to the pofi-
 tion which the child bears  with  regard to the mother.  What-
 ever that might be, the chilcl  would be  extrafted with equal
 eaSe till we  came to the  head  ; but if  the face were turned
 towards the pubes  of the  mother,  the head could not then be
 brought away, or its pofition conveniently changed, without
 much additional difficulty.  As Soon therefore as the breech
 is expelled, if the back ot the child be not turned towards the
 abdomen of the mother, it will be neceffary, that the praftition-
 er,  while he  is extrafting,  fhould give fuch an inclination to
 the body, that when it is wholly extrafted, the hind part of the
 head of the  child may be turned  towards the pubes, though
 not with a  fudden motion  or violence, left the child  fhould be
 thereby  injured  or deftroyed.   The directions given on this
 occafion are, that we fhould make  the turn beyond  the mere
 reduftion of the back of the child to the pubes, and then revert
 it to a certain degree, by what may be fuppofed equivalent to a
 quarter turn.   But Such rules being very complex,  are more
 apt to create  confufion than to be of ufe, and are not founded
 on praftical observation, but on an  erroneous opinion that the
 head of  the child could be extrafted  only or moft commodi-
 oufly, when the face of the child was turned toward the os
facrum of the mother.  Whereas it is now well  known, that
 the  head of the  child  will pafs through the pelvis, with one
 ear to the pubes and the other  to the facrum, or in different
 degrees  of  diagonal direction regarding the cavity, and that it
 is not found to proceed exafclly alike in any two labours.
   When the child is brought clown  as low as the fhoulders, it
 has  been efteemed by fome as a very injudicious praftice, to
 bring/lown the arms of the  child ; thefe being turned  along the
 head, preventing, in their  opinion, that contraftion of the os
 uteri, round the neck of the child, which would be an impedi-
 ment to its  complete  deliverance.  Others have confidered
 this ftep as abfolutely neceffary in all cafes, the arms, according
 to  them, occupying a portion of that  fpace,  which fhould be
 filled up by the head  only.   It the extra6tion  ot the head with
 the  arms turned  up,  be on trial  found tolerably eafy, there is
 clearly no occafion to bring them down ; but if the head fhould
 remain fixed in Such a manner as to refift the force which we
 think can be fafely or prudently exerted,  then  the arms ought
 to be bi ought down ; but very circumfpeftly, left they fhould
 be  fraftured or diflocated,  or  come  along with  a flirt, or fo
   Vol.  II.                 71 
122
ON  PRETERNATURAL  LABOURS.
fudden a motion as to endanger the laceration of the pennaum.
Nor is there afterwards found to have been any reafon for ap-
prehending inconvenience from the fpafmodic contraftion of
the cervix or os  uteri round the neck of the child ;  at leaft it
is not produced by this cauSe So commonly as by hurrying the
firft part of the delivery.
  When the arms are brought down,  fliould there be much
difficulty  in the  extraction  of the head, it will be of great ufe
to pafs the fore-finger of the left hand  into the  mouth ot the
child, and to prefs  down the jaw towards the breaft,  (but not
to pull by it) in order to change the pofition of the head, which
may be eafily done, and the extraftion be thereby much facili-
tated.   But ot  this difficulty we fhall Speak more fully when
we confider the inconveniencies produced in this kind ot labour,
by the diftortion of the pelvis.
   In the extraftion of the child, the body is converted  into a
lever or inftrument for that purpofe, and this  will aft in differ-
ent cafes, or different  periods  ot the fame  cafe, with greater
advantage, by changing the direftion in which it is ufed.  Ac-  •
cordingly in fome cafes,  greater progrefs  is made  by afting
alternately from  fide to fide, and in others  from the  pubes  to
the facrum, or in the oppofite direftion;  and that  way is to
be purfued, in which we  obtain the greateft advantage with
the leaft violence.   When the  head  is paffing through the ex-
ternal parts, thefe may be Supported  with the fingers or palm of
the left hand fpread over the perinceum, while we are extrafting
with the right.   As the head advances, tne body muft be turned ,
more and more towards the pubes, and we muft finifh the oper-
ation very deliberately, or the  parts will  be lacerated ; an evil
rendered  fometimes  by precipitation and imprudent manage-
ment, ot almoft  as much importance as the loSs of the child or
mother, occafioning, at leaft, great mifery and diftrefs through
the future part of the patient's life.
   Though children prefenting with the breech are  commonly
 expelled by the  efforts ot the parent, it  muft fometimes happen
 that thefe tail to produce their proper effeft, and the affiftance
of art is required.   But affiftance is not to be given till, by the
 failure of the efforts, it is proved tp be  abfolutely neceffary ;
that is, when having given full Scope and due time to the efforts,
 they are  proved to  be unequal to the expulfion of the child.
 Whenever artificial affiftance is given in  thefe caSes, it ought
 to be  perfeftly  confiftent with the fafety of the mother, and if
 poffible, with that of the child, which  muft be confidered and
 treated as if we were certain it  was, and would be born,  living. 
ON  PRETERNATURAL LABOURS.          123
 When therefore we are Satisfied and convinced that the mother
 is unable to expel her child preSenting with the breech, if the
 inferior extremities cannot  be readily brought down, it will be
 proper, by  hooking one or more fingers in the groin, to try
 whether we  cannot  give  fuch an addition to the force of the
 pains, as may be fufficient to extraft without injuring  it ; that
 is, either by hurting the neck, or joint ot the thigh bone, or by
 Separating  the  bones of which  the pelvis is then compofed.
 Should  this force,  though continued tor fome time, be proved
 unequal to the purpofe,  it will  be found expedient to pafs a
 garter,  a  piece of tape or ribband, over one  or both thighs,
 one  of  which is  ufually preffed  before the other, as  the cafe
 will  allow ; and then taking both the ends of  the ligature in
 the fain* hand,  we fhall have the opportunity of exerting great
 power, fhould it be required, with lefs  detriment to the mother
 or child than by any other means, with much  convenience at
 the fame time to ourSe-lves, and generally with SucceSs.  But it
 the breech fhould be So high, that the feercannot be brought
 down, nor  the ligature paffed,  or its power be  infufficien', of
 which I do not  recollect an inftance, and the neceffity of deli-
 vering the  mother fhould be urgent, then a blunt hook or the
 crotchet muft  be  fixed over the thigh or in the groin of the
 child, and  we muft manage as in  other cafes of extreme diffi-
 culty and danger ;  as the circumftances will allow, but perhaps
 without following  any general  rule, and without regard to the
 child.
   It  has been faid, that children prefenting with the breech are
 generally born alive, and fome writers have even confidered the
 prefentation of the inferior extremities as  natural, and  prefera-
 ble to that of the head ;  becaufe affiftance could be more readily
 given when it was required.  It  is true that the children will ♦ *
 ufually  be  born alive, it they  be Small,  or ot a common fize,
 and the true dimenfions, of the pelvis be unimpaired ; or if the
 prefentation occur to thofe, who have before had children, the
 parts yielding kindly and with facility according to the progrefs
 of the labour, and this be not by  any  caufe retarded or inter-
 rupted.   But if  it fhould  be a firft labour, and the children
 large, or Somewhat beyond the common  fize, and the labour
tardy, or require much affiftance  from  art, they will be more
 frequently  born dead, in confequence of fome cafual  but  de-
 ft ruftive preffure of the funis, before the breech is expelled,
or afterward ; and  with  regard to  reprefentation, that which is
moft common  is  certainly, for  that reafon, to be efieemed.'
 natural. 
124
INTRODUCTION TO MIDWIFERY.
  In all cafes, in which the child is expelled or extrafted by
the breech,  or  inferior  extremities,  the placenta  is ufually
managed without  difficulty  or- danger,  and it is  generally,
though not always, excluded more eafily, and in a fhorter time
than after a natural birth.
SECTION  IV.
ON  THE DISTINCTIONS OF THE SECOND  ORDER OF PRETERNA-
                     TURAL LABOURS.
  In the fecond order.of preternatural labours, the prefentation
of the ffioulder, or one or both arms, may be included ;  and
whichsoever of tl|eSe is the presenting part, there is a neceflity
of turning the child,  and delivering by the feet.   In the man-
agement of prefentations of this kind, there is always lefs diffi-
culty if both arms prefent, than if there fhould be but one arm ;
it will therefore be neceffary, to fpeak only of the prefentation
of a fingle arm.
  In ancient times it was the cuftom, in every kind of labour,
except thofe in which the  head originally prefented, to endea-
vour to return the part presenting, and to bring down the  head ;
and if this  were found  imprafticable, direftions were given to
bring the child away by  the feet, or in any manner its fituation
would allow, or the exigencies of the cafe might require.   But
we fearn from AEtius,  who lived probably about  the fith cen-
tury, that Philomenes, whofe writings, except thofe preServcd
by j£tius,  are now loft, discovered a method of turning and
delivering children by the feet, in all unnatural prefentations ;
and this method, with fome alterations and improvements in the
operation, has been praftifed ever fince his time, and confider-
ed as the only one, by which the child prefenting preternaturally
could be extrafted, and the life of the mother preferved.   But
many years ago it was my good fortune to difcover, that in Some
of the worft kinds  of preternatural labours, thofe  in which the
affiftance of art is Sometimes found  to be infufficient and often
unfafe, the  powers of the conftitution, if not impeded in their
operation, are  capable of expelling the child, with peifeft fafety
to the mother, and without any additional  danger  to the  child.
Of  the manner in which this delivery is accomplifhed by the
natural pains, we fhall Speak in it., proper place. 
ON  PRETERNATURAL LABOURS.
"5
  Though the neceflity for turning children and delivering by
the feet, in this  fecond order of preternatural labours, be uni-
veifally acknowledged, yet the circumftances of the women flit-
tering them are exceedingly different.   With the view of pre-
venting or leffening the embarraffment of the praftitioner, it is
requifite, therefore,  to make feveral diftinftions, and we will
fay, that it may be neceffary to turn tjie child.
  Firft, When the os uteri being fully  dilated,  and the mem-
branes unbroken, a  fuperior extremity is felt through them ;
or immediately upon  the rupture of the membranes and the
difcharge of the waters, before there is any return of the pains,
or any contraftion of the uterus  round the body ot the child.
  Secondly, When the membranes break in the beginning of
labour,  the os uteri being very  little dilated, perhaps fcarcely
in a  fufficient degree to allow a  hand or an arm of the child to
pafs through it, and but juft enough to difeover the kind of pre-
sentation. .
  Thirdly, When the  os uteri is fully dilated, the membranes
having  been long broken, and  the uterus ftrongly contracted
round the body of the child, which is elofely fixed at the Supe-
rior aperture of the pelvis.
  Fourthly, When under any of thefe circumftances, there is a
<*reat disproportion between the Size of the child and the dimen-
fions of the pelvis.
  Under each of thefe diftinftions, a variety of other objefts
may require the attention of the praftitioner, but of every one
of thefe it is impoffible to take notice in the  defcription ot any
ftated cafe, as no two  labours ever were in all points exaftly
Similar.
  In  the pradice of every art, fome advantages muft remain
beyond the power of any doftrine to  teach  or defcribe, all
rules  applying  to general, and  praftice to particular Cafes.
Thefe advantages can only be obtained by the cultivation of our
own minds, by  experience, and by the acquisition of that dex-
terity,  which  frequent exercife muft give to  our hands.


                      SECTION V.

  It is proper in the firft place, to Speak  of the method of turn-
ing children in  thofe cafes, which come under the firft diftinc-
tion, the management of them being more  eaSy and Simple, as
lhere is only one  objeft  which demands our care,  that is, to
change the pofition of the child. 
 126           INTRODUCTION TO  MIDWIFERY.

  Whenever there is a neceffity of turning the child, the patient
 is to be placed in the fame Situation as in a natural birth, upon her
 left fide, with her knees drawn up, acrofs the bed, and as near to
 the edge  of it as poffible.  There  have been many  different
 direftions and opinions refpefting the advantages of particular
 fituations, efpecially that of turning  the patient upon her knees.
 But as our aim, in the choice or preference of thefe, is merely
 to obtain the free and mo'ft convenient ufe of our own hands, the
 pofition of the child  remaining the  fame, however the woman
 may be  placed, the common Situation will generally be found
 moft  convenient.  Yet as that fituation which fuits one prac-
 titioner may be awkward to  another,, and as in the courle  of
 the operation changes may  be  expedient,  every praftitioner
 muft make them, when they appear neceffary to himSelf.  To
 many i* is more convenient to turn with  the leSt hand, than with
 the right ; and from the common pofition ot the child, the for-
 mer is often more commodious ;  but  every perfon  will,  of
 courfe, uSe that with which he can aft with moft dexterity and
 advantage.
  Though in the caSe we are now  fuppofing the os uteri may
 be  fully dilated, it is poffible, that the os externum may be in a
 rigid and contrafted ftate.  For the purpofe  of dilating this, it
 will then be neceffary with the fingers of the right hand, redu-
 ced into a conical form, to a6t with  a femirotatory motion, and
 with Some, degree ot prcflure upon  the  fides,  and towards the
periuceum.  The artificial dilatation  of all parts Should be flowly
 made,  and in imitation of the manner in which they  are natu-
 rally dilated ; and we are not to be  Satisfied with fuch  a degree
 of dilatation, as will barely admit the hand into the vagina, bt>-
 cauSe the contraftion round the wrift would, in Some cafes,  be
 a hinderance in the Subfequent parts of the operation.
  When the hand  is  palled through the os externum, it muft
 be condufted Slowly to the os uteri, which  we preSuine to  be
 fully or fufficiently dilated.
  If the membranes be unbroken, the hand may be condufted
 into the  uterus, and they will be eafily  ruptured  by  graSping
 them firmly, or hy perforating them with' a finger.  The hand
 muft then be carried very deliberately along the fides, thighs,
 and legs of the child, till we come to tlie feet.  If both the feet
fhould  be lying together, we muft grafp them in our hand ; t>ut
 if they be at a diftance from each other, we may commonly deli-
 ver with one foot without much additional  difficulty ;  though
as in fome particular pofitions we cannot always turn the child,
it it be large, by one foot,  it  is better to  make  it a general rule'
to bring down both feet together, when they are in our power. 
ON  PRETERNATURAL LABOURS.
I27
   Before we  begin to extract,  we muft examine the limbs we
 hold, and be affured we do not  miftake a hand for a foot.  The
 feet, being held firmly  in the hand, muft  then  be brought
 with a  waving motion flowly into the pelvis.   While we are
 withdrawing the hand, the waters of the ovum flow away, and
 the  uterus being emptied* by the evacuation of the  waters, and
 the  extraftion of the inferior extremities, we muft wait till it has
 contracted, and on the acceffion of  a  pain  the  feet muft be
 brought lower, till they are at length  cleared through the os ex-
 ternum.  The operation may then, in one fenfe, be Said to be
 completed, that is, what  was originally  a presentation of the
 arm, is now become that of the teet, which confidered as pri-
 mary, might have  been left to the efforts of the conftitution in
 the  manner before defcribed.  But  as no perfon who had un-
 dergone the operation  of turning a child, with the  expectation
 of a Speedy delivery,  would have patience to wait  lor the  ex-
 pulfion of the child by the natural pains, it is incumbent upon
 us to finifh the delivery, though there is no occafion for hurry ;
 and  violence would be equally unneceffary and improper.
   In the firft place then, obServing the direftion of the feet, and
 knowing if the toes of the child  be towards the abdomen ot th'e
 mother, that this pofition would be unfavourable when the head
 was  to  be extrafted,  we  muft  gradually turn the body of the
 child during its extraftion, in Such a manner that the back of
 the  child may be  placed towards the abdomen of the mother,
 before the head is brought into  the pelvis.  It was  before ob-
 served,  that this turn of the child has been defcribed with ufelefs
 intricacy, and  in a manner which can only Serve  to  confufe
 the praftitioner, who will reap all the  advantage to be gained by
 any  kind of turn, if  he remember in general, that if the back
 of the child be toward the.abdomen of the mother, the head wili
 pafs  more commodioufly than in any other direftion.   The opi-
 nion of the neceffity of changing the pofition of the child at this
 time has been  So ftrongly inculcated, and  So eagerlv purfued,
 that  I have more than once feen  it attempted with fuch a decree
 ot force, as muft have deftroyed, or done very  great injury to
 the child, had it been living ;  the operation  being evidently
 more dangerous, than the evil it  was intended to remove.   Nor
 is this the only cafe in midwifery, in which the means, recom-
 mended for the purpofe of preferving the life of the child, are
 utterly inconfiftent with its fafety.
   When the heels  or  back part of the'child are turned toward
the pubes, the  feet  wrapped up in a cloth are to be held firmly
about the ancles, when the pains  ccne on, we muft extraft in
* 
123
INTRODUCTION  TO MIDWiFERY.
 a Straight direction, or from fide to fide, or from the pubes to the
facrum ;  taking care that we do not by violence, or by too large
 a Sweep,  run  the  rifque of hurting the child, or of lacerating
 the  external parts of  the  mother.   In  the interval between
 the-pains  we muft reft, and in this manner proceed, affifling the
 efforts of the mother onlv at the time of her making them, and not
 rendering the delivery wholly artificial.   When the breech of
 the child  is arrived at and begins to diftend  the  external parts,
 we muft proceed yet more flowly, giving time for their dilatation,
 Supporting and favouring any part which may be immoderately
 diftended, and guiding the child in a proper direftion, by turn-
 ing  it towards the pubes as it advances.   The breech being ex-
 pelled,  the funis Soon appears, and a fmall portion of it muft be
 drawn forth to prevent its being upon the ftretch.   Then wrap-
 ping a cloth over the body of the child, which muft be held as
 clofcto the mother as it conveniently can, and calling for her
 voluntary exertions, the child is to be Speedily extrafted in the
 manner already defcribed*.
   When  both the arms are brought down, if that be neceffary,
 it will be  of fervice to fuffer the body of the  child to reft upon
 the  left arm of the operator, his hand being fpread under the
 breaft,  with a finger turned back over  each Shoulder.   His
 right hand is to be lard in a Similar manner over the fhoulders
 of the child, and thefe pofitions will give  him great avantage in
 the extraftion.   But if the head fhould not defcend, the opera-
 tor with  his thumbs condu6ted into the vigina may. prefs the
 head from the pubes to the facrum ;  or pafs the fore-finger of
 his left  hand into the mouth of the child, and extraft as was
 before  advifed,  being ftill careful of the  external parts, when
 the head is paffing through them.
   Proper  attention muft  be immediately paid to the child, and
of the management of the placenta we are to fpeak hereafter.


                      SECTION VI.

   In the fecond diftinftion it was  Suppofed, that together with
the prefentation of a fuperior extremity, there was at the time
of the rupture of the membranes, very little dilatation of the os
uteri, and  fome degree of contraftion of the uterus round the
body of the child.

  *  When the life of a child was endangered in this fituatio*.
Dr.  Pugh advifed the introduction  of an  air pipe  into ;']
■ acnth, but this I h we never ufed.
• 
ON PRETERNATURAL LABOURS.
l£9
   The directions generally given on thefe occafions are, that as
 foon as the prefentation is afcertained, the operator  fliould  fit
 down and dilate the os uteri Sufficiently to allow the introduftion
 of the hand, which fhould then be paffed with  care and exoedi-
 tion into the uterus, and the child turned.   But Some practiti-
 oners have judged it more proper, to wait till  the os uteri was
 dilated naturally, before any attempt is made to introduce the
 hand, and turn the child.   As in every cafe of the prefentation
 of the  fuperior extremities,  there is a neceffity of turning the
 child, the fooner  the hand can  be paffed for that purpofe, the
 more Safe and eafy in general will the operation  be, as there muft
 of courSe be lets  contraftion of the uterus round the-body  of
 the child.  But as  chere is fome hazard of doing mifchief by
 every artificial dilatation of the os uteri, I believe it is better  to
 wait for the natural dilatation ; at leaft every attempt to dilate
 by art fhould be made with great caution, and  only during the
 interval between the pains.  Yet we ought not to wait in thefe
 caSes, till there is  a complete  and abfolute dilatation of the os
 uteri; but always to confider it as Sufficiently dilated, when
 we preSume it will readily admit the hand, and then  the child
 fliould be turned without delay.
   If the external  parts be rigid and contracted, they muft be
 dilated, but without violence,  in  the manner before direfted*;
 and the hand, being paffed into the vagina, muft then be con-
 dufted  into the uterus, on that fide  of the pelvis where it  can
 be done with moft convenience ; becaufe that will lead moft
 readily to the feet of the child.  It is generally better to con-
 duft the hand between  the body of the child and the  pubes,
 than between it and the facrum, becaufe in thefe .prefentations
 the feet lie moft commonly towards the abdomen of the mother.
 In every cafe which comes under the prefent diftinftion, there
 is  Some degree of  contraftion of the uterus round the body ,oj£
 the child,  though trifling when compared with what occurs 'in
 the cafes to be defcribed under the next feftion.  If therefore
 we underftand and are able to perform the operation of turning
 the child, in the eafieft and moft difficult cafes, we fhall certainly
 be competent to the management of all the intermediate ones  ; '
there being in thefe no new rules,  which we  are required to
follow, but merely an accommodation pi rules.already known
to the exigencies of any individual cafe.
Vol. II.
S 
130 '
JN'TRODUCTION  TO MIDWIFERY.
                    SECTION VII.

  Under the third diftinftion, we are to prefume, that togetltfrr
with the prefentation of a Superior extremity, there is the worft
poffible fituation of the  child in all other refpefts ; that is, an
exceedingly clofe  contraction of the uterus round the body ot
the child, the membranes having  been long broken, and the
waters difcharged  ; to which may perhaps be added very ftrong
pains.
  In this cafe, fuppofing-the difficulty of turning the child as
great as it poffibly can be, it will follow, that there is no occa-
fion for/hurry or violence, as we can lofe nothing by taking time
to deliberate.   Before we proceed to the operation of turning,
it will be therefore proper to repeat our examination, when we
have confidered the cafe, in order  to prevent any error in the
firft decifion  we have made  upon the  fubjeft, and to afcertain
the precife pofition of the child ;  and to refleft alfo, whether by
Some previous management it may not be in our power, to lef-
fen the impediments to the operation, and the general  evils of
the patient's ftate.  In either ot thefe view's tKS"£ are only two
objefts, which can  engage  our attention ;  the  wrong  pofition
ot the child, and the ftrong  contraftion of the uterus round its
body. The  firft  of thefe,  in  the account given ot  the cafes
which came under the firft diftinftion,  was ftated to be of little
confequence ; that is to be  manageable without difficulty, and
to be commonly void of danger either  to the mother or child.
The principal inconvenience will then be produced by the con-
traftion of the uterus, which it muft be our duty to remove or
leffen, before we attempt to perform  the  operation of turning
 the child.
   The contraftion  of  the  uterus, under thefe circumftances,
may be o'f-three  kinds.   There is, firft," the continued  or per-
 manent contraftion, in  confequence of the waters having been
 long drained off, and which to a certain degree takes  place in
 all cafes, when there has been but little or no pain.  This may
 in faft be confidered as the  exercife of that inherent difpofition
 in the uterus, by which its efforts are made to recover its primi-
 tive fize and fituation, when any  cauSe of diftention is removed.
 There is,  Secondly, the occafional or extraordinary  contrac-
 tion of  the uterus, by which whatever is contained in its cavity 
ON  PRETERNATURAL LABOURS.
»3*
is ultimately  to be expelled, which returns at intervals, and is
fo conftantly  attended with pain, that the terms pain and aftion
are ufed fynonymoufly.  Thirdly, there is an irregular aftion
of the  whole or fome part of the  uterus, which is  fometimes
unfavourable to the  expulfion of its contents, which produces
effefts  according to its peculiarity, and this is called fpafmodic ;
a general term, not wrefted from its common meaning, but ap.
propriated  to every  kind of  morbid,  irregular, or  exceffive
aftion.  Now the difficulty and the danger, which  attend the
operation of turning a child, proceed either from the extraor-
dinary or irregular aftion ot the uterus ; and in order to avoid
thefe, as much as poffible, it will be proper to eftablifh  it- as a
general rule,  never to attempt the operation of turning the child,
while the patient has very ftrong pains.
  The confternation of friends, and the fufferings of the patient,
muft  neceffariiy raiSe  a fufpicion in her  mind, that there* is
Something unuSual and dreadful in her cafe,  and the Solicitude
thence arifing will increafe the unavoidable inconveniencies of
her fituation.  The prudent and, fteady conduft of the  prafti-
tioner  will, on fuch occafions,  very much contribute to remove
the fears of her attendants, and  to give a  compofure to the
mind of the patient,  which will be produftive of the moft hap-
py effefts.  If fhe fliould be much heated, it will be alfo proper
to take  away fome blood, and to direct an emollient clyfter.,
for the  purpofe of emptying the  redum, and of Softening and
Soothing the  parts, which are in a very irritable State.  Even
the time employed in thefe matters will give an opportunity for
quieting the violent agitation of the patient's mind.
  We are not at prefent in the poffeffion or knowledge  of any
fpecific medicine, upon  which we can depend, for fuppreffing
or moderating the aftion of the  uterus, when exerted unfa-
vourably, or at any improper time.   Almoft the only medicine
we  ever think of having recourfe to on Such occafions, is
opium  ; and  this, given in two or three times the uSual quan-
tity, will in many caSes ot this  kind anSwer our expectations;
though Sometimes, when given in a common doSe, it has a con-
trary effeft, and excites the uterus to ftronger aftion.  If the
opiate fhould  fail to quiet  the pains, and to compofe the pati-
ent, we muft  wait till the uterus is wearied, or ceafes to  aft oi
its own accord.   But if  the opiate fhould produce  the effeft
for which it was given, it will be in about twenty minutes after
its exhibition, when we are to confider  the calm or difpofition
to fleep, as affording us the moft favourable opportunity for
turning the child. 
ityi           INTRODUCTION TO MIDWIFERY.
  Throughout the operation it is neceffary to bear in our minds
the diftinftions made between the different  kinds ot aftion  ot
the uterus.  The hand muft be introduced with fufficient force
to overcome the continued or permanent contraction ot tho.
Uterus, or the dperation  could never be  performed ;  and the
fame may be obferved of  the irregular or Ipafmodic  aftion, but
with  pci Severance  rattier than violence.  But  if we* were
to attempt to  overcome  the extraordinary aftion, either  the
hand would be cramped,  and we fliould be unable to finifh the
operation ; or if we had  power fufficient to overcome the con-
traftion of the uterus, there would be the greateft hazard of its
being ruptured : the deduftion is therefore plain, that we ought
not to attempt  to introduce the  hand, while the  uterus is in
extraordinary aftion.
   By the examination of the child's hand  which prefents, we
fhall be able to diftinguifh whether it be  the right  or the left;
and, which is of  more confequence, by  its pofition, to which
part of the uterus the feet of the child are direfted.  For unlefs
the arm or body be  unnaturally  twilled, the  palm of the hand is
always turned towards the inferior extremities or fore parts of
the child.
   It is in no cafe neceffary, or in  any wife Serviceable, to Sepa-
rate the  arm of  the, child, previous to the introduction of the
hand of the operator.   In fome eaSes to which I have been
called, in which the arm had been Separated at the  fhoulder, I
have  found a great  inconvenience, there being much difficulty
in diftinguifhing between the lacerated fkin of  the child, and the
parts appertaining to the mother.  The presenting arm is never
an impediment ot any confequence in the opeiation, and there-
fore ought not to be regarded, or on any account removed.
   It  Sometimes happens, that  the introduftion of  our hand is
absolutely prevented by the fhoulder of the child, jammed at the
Superior aperture of the pelvis.  It will then  be neceffary,  to
paSs the forefinger and thumb of the right hand in  the form of
a crutch, into the armpit ot the child,  pufhing the fhoulder
towards the head and towards the fundus of the uterus, at the

   * Qui enim itrgentibus doloribvs, man us intus dare, vel
fcetum dihgere,  vel aliquod membrum replicare  audent,  vs
evemre potejt,  ut uterus rumpatur, metier que fulnta  morte
rapiatur, cujus partus pofi obitum in ventre reperiri Jolet.

              Platneri  Inftitutiones Chirurgicae, Pa^.  io*o. 
                ON PRETERNATURAL  LABOURS.          133

fame time  firmly and Steadily maintaining, the advantage we
gain as we proceed,  till we have  r-dfed  '! e  body fumciently,
to allow the admiffion of the hand into the uterus.
   When we begin to make our attempts to introduce the hand
into the  uterus, though the patient might be in a compofed
ftate, the irritation thereby occafioned will difturb her, and the
extraordinary action  of fhe uterus be  brought on, which will
be indicated by the eonfequent pain.   During the continuance
of this aftion and  pain, we muft  not proceed in our attempt,
but wait till they ceafe,  laying our  hand flattened in fuch a
manner,  that no injury my be done by  our  efforts, or by the
aftion of the uterus  itfelf, upon any  inequalities of the knuc-
kles.   When the  action  of the uterus ceafes, our attempts to
introduce our hand muft  be renewed, and fteadily continued,
till that aftion  returns, when we  muft again reft.  Thus pro-
ceeding, that  is, alternately retting and afting, we  fhall, by
repeated and fometimes long continued efforts, at length fafely
accomplifh the purpofe of conducting the hand fo far ipto the
uterus, that we ijh!1 be able to lay hold of the feet of the child.
In fome cafes our attempts to introduce the  hand aie very dis-
couraging,  as we  are Senfible of little or no  progrefs ;  but the
hurry  or violence are never to  be increafed on account of the
greatnefs of the difficulty.   We  muft. perfevere, and  be per-
Suaded, that prudent  attempts will not be fruitlefs, though they
immediately fail to  anfwer our expeftations ; as  each appar-
ently unprofitable attempt contributes at leaft to the efficacy of
a Succeeding one.
   The ftrongeft contraftion of the uterus is  fometimes at the
cervix, and when this is paffed, ample room is afforded for the
dif'covery ot the feet towards the fundus, without much trou-
ble.  But the contraftion is very irregular, being in feme cafes
in the  centre,  or uniform  thoughout ;  whilfl in others, the
 uterus is drawn into lines, as if a cord had been paffed round it
externally with great ftrength,  So as  even to be  painful to the
haiid.   In Some cafes the uterus is' alfo contrafted into a glo-
 bular, and in others into a longitudinal form.  Thefe different
 contractions render  Some difference in our condu6t  neceffary,
 but if we have a true general idea of the various  kinds of  con-
 tractions,  as before  defcribed, the little increafe or peculiarity
 ot difficulty will be  readily managed.   In.a globular contrac-
 tion of the uterus, when our hand has  paffed  beyond the cervix,
 there will be no trouble in coming at the feet, and the child will
 be turned  very  eafily ; but in the longitudinal contraftion, the
 feet being at a great dilLnce, there is  more difficulty, thong hit 
 134          INTRODUCTION TO MIDWIFERY.

is not always. nece(Tary  to go up to the fundus, for when  we
come to the knees, thefe being cautioufly bent, the legs and
feet will be brought down together.
   In whatever way we lay hold of the feet, we  muft examine
them before we begin to extraft ; for though one arm be in the
vagina, the other may be high up in the uterus, and miftaken
for a leg.   We muft alfo remember,  that it is neceffary to ex-
traft flowly : for if we Should attempt to hurry  the operation,
the feet may Slip out of our hand, and immediately recede to
thejundus of the uterus, or to the part from  which they were
brought, and  lay us  under the neceffity of returning with the
hand, to bring them  down again.  When we have laid hold of
the teet, if we proceed flowly, the child commonly turns with-
out much  difficulty.  But when the feet are  brought into the
pelvis, if  the turning of the child  be not perfefted, it will be
of great ufe to fix the noofe of a garter or ribband round one or
both ancles, which may  be  conveniently done by  forming it
upon  our  wrift, and  then Aiding it with the fingers of the left"
hand, over the right  hand containing the foot or feet, without
quitting our hold of them ; and dexterity in forming and fixing
this noofe may be of great ufe in the fubfequent parts ot the
operation.  When the noofe is fixed and drawn tight round
one or both the ancles, we may pull  by both the ends ot it with
either of our hands, at the fame timegrafping the feet and ex-
trafting with the other hand, till  they are brought through the
external orifice.  Should there be much difficulty in the oper-
ation, after the feet are brought low  into the vagina, we may
conclude,  that, it is occafioned by the body of the child being
fixed acrofs the  fuperior aperture ot the pelvis.  To remove
this impediment, it will be neceffary to take  the two ends of the
noofe into our right  hand,  and paffing the  finger and thumb
of the left in the  form of a crutch, in the armpit of the child, as
before defcribed, we  muft extraft  with our right hand, and at
the fame time raife the body of the child with the left, till the
child is difengaged, and there is Sufficient room for the entrance
of the hips into the pelvis.  There will then be no further diffi-
culty, and we muft deliver as  was diucfed  under the Firft Or-
der of Preternatural Labours.

                  .  SECTION VIIL

   In prefentations of the Superior extremities, when the waters
have been  long difcharged, and the fhoulder of the child is jam-
med at the Superior aperture ot the pfluis, it was  faid to be ex-
pedient and neceffary, to pafs the finger and thumb in the form 
ON  PRETERNATURAL LABOURS,
*35
  of a crutch, into the armpit of the child, in order to raife the
  body towards its head, and towards the Jundus of the uterus ;
  till it was fufficiently moved  out of our way to allow of the in-
  troduftion  of the hand into the  uterus.   But in fome cafes,
  when  we  are firft called, the fhoulder is fo far advanced into
  the pelvis,  and the action of the uterus is at the  fame time So
  ftrong, that it  is  impoffible to raife or move the  child, which  is
  So ftrongly impelled by the pains, as  to overcome all the  force
  we are able to exert.   This  impoffibility of turning  the  child
  has, to the  apprehenfion of all writers  and praftitioners, left the
  woman without any hope of relief.  But in a cafe of this  kind,
  which occurred  to me about twelve years ago,  I was fo fortu-
  nate as to obferve, though it was not  in my power to pafs my
  hand into the uterus to turn the child, that by the mere  effeft
  ot the aftion  of the  uterus, an evolution took place, and the
  child was expelled by the breech.
    Of  the  firft teftimonies*  that prove the poffibility of this
  evolution,  which I  have  called fpbntaneousT, the  public has
  long been  in poffeffion.  The cafes in which it  has happened
  are now  become fo numerous, and fupported not only by  many
  examples in my own praftice, but eftSblifhed by Such unexcep-
  tionable authority, in the praftice "of others, that  there is no lon-
'  ger any room to  doubt of the poffibility of its happening,  more
  than there is of the moft acknowledged faft in midwifery.  As to
  the manner in which this evolution takes place, I prefume, that
  after the long continued aftion of the  uterus, the body of the
  child is brought  into fuch a compafted State, as to receive the
  full  force of every returning aftion  The body in its doubled
  ftate, being too large to  pafs  through the pelvis, and the uterus
  prefling  upon its inferior extremities, which are the only parta
  capable of being moved, they are forced gradually lower,  mak-

    * See the London Medical journal, Vol.  V.  for 1785 ; and
  the Journal de  Me'decine de Pans,  our Avril  el Septem bre,
  1783,  and many cafes publiffedJince that time.

    + / ufed the  word fpontaneous, though to fome it appeared
  objedionable,  but I could not fix upon one better fuited to ex-
  plain my meaning.   I only intended by it to Jay, that the frits
  of effeds terminating in an ewlution  of the child were wholly
  independent oj the praditio/ier ;  but not that this was pro-
  cured from any impulfe or exertion in the body moved.  In the
 Jenje in which I ufe the  term fpontaneous, it  feems to it prop-:*
  according  to  its common ufe in medical, though perhaps r>A
 Jlridty in mechanical language. 
  J$6            introduction to midwifery.

  ing room as they are preffed down for the reception of Some
  other part into the cavity of the uterus which they have evacu-
  ated, till the body turning as it  were upon its own axis, the
  breech  of the child is expelled, as in an original prefentation of
  that part.  Nor hasthere been any thing uncommon in the fize
  or form of the pelvis  of thofe-women, to whom this cafe has
  happened, nor have the children been  fmall, or Softened by pu-
  trefaftion, becaufe one or more children have been in this  way
  born  alive*.   I believe, on the contrary, that a child of a com-
  mon  fize, living, or but lattly dead, in Such a ftate as to poffefs
  fome degree  of refilition, is the beft calculated for the expul-
  fion  in this manner.   Premature or very fmall children have
  often been expelled in a doubled ftate, whatever might be the
  original  prefentation, when the  pelvis was well- foirncd, or
  rather more capacious than  ordinary.
    Yet  the  knowledge of this faft,  however unqueftionably
  proved, does not free us from the neceffity and propriety of turn-
  ing children prefenting with the fuperior extremities, in every
  cafe in which that operation  can be performed with fafety to
  the mother, or give us a better chance of Saving the child.  Un-
  der fuch circumftances the inftruftions given by former writers,
  and the  obfervations  we have before made, muft  ftill be con-
  fidered  as proper to guide  our  conduft.   But  when we  are
  called to a patient witJi/a preternatural  labour, in which there is
  no room to.'hope for the preservation ot the child,  or in which
  we are aflured ot its  death, or when the operation of turning
  cannot be performed without violence  and  fome danger to the
 mother ;  then the knowledge of the probability of a fpontaneous
 evolution will Set our minds at eafe, and difengage us from the
 confideration of making any hafty attempts to perform a hazard-
 ous operation, from which no poffible good  can be derived, ex-
 cept that of extrafting a  dead child,  and  which at all events
 might be effefted by a method far more Safe to the mother.
   The time required for the Spontaneous evolution of the chfy,
 and the facility with which  it may be made, will depend upon
 a variety of circumftances, but chiefly upon  the fize of the
 child,  the aptitude of its pofition, the dimenfion of the pelvis,
 and the power exerted  by the uterus.  If the child be very large,
 or  much below  the common fize, the  flower I believe will  be

   * Dr. Garthfhore, Confultirg Phyfician  of the  Britifti Ly-
 .ng-in-HoJpital, informed me of a ccfe  of this kind, in which
 the child was born living ; and  <\lr.  Martineau,  an  eminent
furgeon at Norwhich informed mcoja-i-Ahcr. 
ON  PRETERNATURAL LABOURS.            137
 evolution, nor can it be made, at all without a ftrong aftion of
 the uterus.  It is poffible therefore, when we have condufted
 ourfelves on the ground of expeftation that the evolution would
 be made, that the pains may fall off, or be unequal to the effeft,
 and we  may  be  difappointed.  It might then  be apprehended,
 that the  difficulty of extrafting the child would be infinitely in-
 creafed.  But though the evolution was not perfected, I have
 hot found  this confequence ; for  the child,  though  not ex-
 pelled, has been brought into fuch a ftate, that I could after-
 wards pafs my hand with eaSe, and bring down its feet, though
 in an attempt to do this in the beginning of the labour I had
 been foiled.   In  owe cafe, in which the evolution did not* take
 place, I  could not bring down the  inferior extremities, but I
 had no difficulty  in fixing an inftrument upon  the curved part
 ot the body of the child, or in bringing it away with entire fafe-
 ty to the mother.  It was before prefumed, that the child was
 dead ; and  the Sole objeft was, to free the mother from her
 danger, and with her  fafety, no appearances ot  the child, how-
 ever difagreeable, are to be put in competition. In cafes  ot
 this kind another mode of praftice has been recommenced, that
 of feparating the head from the body,  with a blunt hook, or
 other convenient fate inftrument; but as I have never praftifed
 this method, I give the defcription of it in i note*.
   In the courfe  of my converfation and, correfpondence with
 Hiedical  friends,  I have  been informed of feveral inftances of
 women,  who have died undelivered, their children presenting
 with the arm, becaufe the practitioners were not able, by art
 or by force, to pafs the hand into the uterus, to turn  the child,
 and deliver  by the feet,  and it was not fpontaneoufly turned.
 Thefe cafes have  been mentioned to me as object:ions to the idea

   * Hoorneus fizp'e laudatus ad hue peculiar em novum, eumq ;
 breviorem modum, Joctum mortuum cum  brachio ardiffimi  in
 vagina uteri hcerente, invemt atque dejeripfit : qui in eo con-
Jiftit, ut quando ad pedes pervenirenequit, collum, utpote quod'
 injcetibus valde adhu - tenerum eft, vel fculpello a reliquo trunco
 rcfecct, vel unco  idoneo  quam cautiffime aujerat : hoc enun
jado vel fpohte moxprorumpit ex uterojaitus, vel tamen, dum
 brachium propendens attrahitur, quod medico tunc loco habenx
 infervit, quam jacillime excutitur : caput verodemde Jeorfim
 mox vel  manu, vel alul propojitis  artificiis, Ji  man jfi par urn
 effet, ejiciendum.
                              Heifter. Cap.  cli'j. feft. ix.
   Vol.  II.                   T            . 
I3S           IN IRODUCTION TO MIDWIFERY.
of a fpontaneous evolution, but, I apprehend, without reafon.
The evolution is Suppofed to be the confequence 'of the ftrong
and long-continued aftion of the uterus, uointerrupcd.  Now
the firft part of the operation of turning a child by art, confiftjf
almoft wholly in refilling this evolution ;  and if the attempts*
were perfeverecLrin, would be an abfolute bar to its taking place.
   To give a full explanation ot my opinion, I fhould fay, that
a woman in a ftate of nature, with her child prefcnting in any*
manner, would not die undelivered, if no affiftance were afforded
to her.   But if an equally healthful  woman lived in a  country
Somewhat civilized, in which the art of midwifery was in an im-
perfeft ftate, much would be thought requifite to be done, and
violence Supplying the place of knowledge and fkill, fhe might
perifli  from the  ungainly and rude exercife of art, rather than
from the neceffity of her cafe ; for by the attempt ot art the natu.
ral efforts would, in thefe cafes, be defeated.   In the moft per-
feft ftate of fociety, all juft and true  knowledge being founded
upon obfervation of the proceedings ot Nature, and all Sound
praftice upon the imitation, the praftitioner would return to the
primitive  ftate ; that is, he would  do nothing, unlefs it was
abfolutely neceffary for him to  aft, and  then he would aft in
imitation of Nature.  From  a retrofpeftive view of the prac-
 tice of midwifery in all former times, and in all countries, every
 intelligent perfon fees, and is ready to acknowledge, that there
 has been too officious an interpofition, and too great a readinefs
 to give affiftance in various ways, for the relief of many diffi-
 culties attending parturition, which are not only fully proved
to require no affiftance, but which are alfo now allowed to be
 furmountedina fafer and more effeftual way by the refources of
 the conftitution.   This fhould certainly put us upon our guard
 againft hafty determinations, upon what is poflible or otherwife,
 in any cafe ;  or upon the ufe of any means, which may be de-
 ftruftive to the child, or injurious to the mother*.

    *  In America and Africa ihe native women, whom we may
 prejume to be healthy, "very Jeldom  die in labour, or  in confe-
  Jruence of it.  Properly leaking, they have no midwives.  The
  ame may be"objerved of the women in Lapland, and other nor-
 thern  countries.  Yet  the African women, when tranjplanted
 to the Weft-India colonies, not unjrequently  die.   They are
 attended by ignorant midwives.  In the Eaft-Iudies, the mid-
 wives of ihe country  are ignorant and dating, interfering
 perpetually,  and often in the moft  outrageous manner, with
 ifie women in labour,  many of whom die, or fuffer grievous 
ON  PRETERNATURAL LABOURS.
*39
   Now I am fpeaking of the fpontaneous evolution in prefenta-
 tions of the arm, it will  not be amifs to obferve, that feveral
 other  changes of the  pofition  of the  child take place, at the
 time o' birth, particularly the following, of which I have feen
 more than one inftance.   Having been called to women in the
 beginning of labour, and finding by  an exmJwtion, that" the
 head of the child prefented, I have left them for Several hours,
 till the firft changes were naturally made.   When  I have ex-
 amined them  on my rctrun, I have found the arm of the child
 prefenting, the head being departed out of my reach.  I do not
 know, that, any practical advantage is to be obtained by fhe
 knowledge of thefe caSes; but it is remarkable, that the acci-
 dent has  always happened  to women, who were deformed.
 Such cafes  However  fhould be recorded,  and  it is  poflible,
 that, Some time or other, the knowledge of them may be of ufe.
 It may lead to an explanation of one caufe at leaft of preterna-
 tural labours.

                      SECTION  IX.

   To  the preternatural prefentation  of the child, and the cir-
 cumftances before mentioned, there  may be added a distortion
 of the pelvis.  As there is no occafion to rcoeat the manage-
 ment,.which the other circumftances may require, we may con-
 fine our attention to the peculiar difficulties produced by the
 diftortion.'  Some disadvantage  mayariSe from this caufe in tie
 extraftion of any part of the child, but it will be trifling, if com-
 pared  with,  that which attends the extraftion of the head ; we
 may therefore be allowed to  fuppofe, that the whole of the child
 is born, except the head, which cannot be brought away in the
 ufual  manner, or by the means before advifed.  The  force,
 with which we endeavour to bring down the head ot the child,
 muft then be gradually increafed, till  we are convinced,  that  a
 greater degree is inconflftent with, the fafety of the child.

 complaints Jor- the remainder of their lives.   In England the
pradice of midwifery is extremely  reafonable,  and it  is a
 rare thing for women to die  in labour, or in confequence of it,
 unlefs when there is fome dangerous epedemic difeafe.  In France,
 the pradice of midwifery is more artifical, and there is, both
 in that and other countries  on  the continent, a  very reprehen-
fible fondnefs for inftruments and operations ;  we may there-
fore conclude, that ihe abufe of art produces more and greater
 evils, than arc occafioned by  all the imperjedions of nature. 
l^O           INTRODUCTION TO MIDWIFERY.
  The with to extraft the head ot the child fpecdily, is founded
on the apprehenfion, jultly entertained, that in this pofition the
life of the child is in the moft imminent danger, from the com-
preffion  of the Junis.  A vigorous pulfation in thejunis proves,
even  at  this time, that  the child  is not in any danger, and of
courSe gives us an opportunity of a6ling with deliberation.  But
fhould the pulfation, which was at firft lively and ftrong, gradu-
ally decline,  and then altogether ccaSe, the head muft be Spee-
dily extrafted, or the child will  be  inevitably loft, there being
no other way ot  removing the  compreffion, or of preferving
its life.
  The extraftion  of the head may then be attempted with  two
views, either, to faye the life of the child, or merely to free the
mother  from any  danger, which might arife from its detention.
When the firft is our aim, the force with which we extraft muft
be moderate, and  confiftent with the fafety of the child; it muft
be ex.-i ted in a proper direftion with regard to the pelvis ;  it
muft  be uniform  and commanded ; and if there be any pains,
it muft accompany them.  Should  the head defcend in ever fo
fmall  a degree, we muft not aft precipitately, and increafe the
force  in order to finiffi the delivery fuddenly ; but we muft pro-
ceed with circumSpeftion, or we fhall add to the danger which
the child is  already in, and run the rifque of doing  injury to
the mother ; tho%gh when the head begins to advance, there
is feldom much difficulty, the caufe ufully exifting at one par-
ticular part of the pelvis.   It  has been faid, that children have
been  Sometimes born alive, when the ftrongeft efforts, and thofe
continued for many hours, have .been made to extraft the  head
detained in this pofition.  But I have not been fo fortunate as to
meet  with any Such inftances, a fhort Space of  time having gene-
rally  been fufficient to fruftrate my hopes, and convince me that
the child was dead.  Though when the head has been detained
a confiderable time, a few cafes have terminated more favourably
than I could have expefted and I have been agreeably SurpriSed
with  the difcovery of fome faint figns of lite,  which, by the
affiduous and  careful ufe of the common  means, have  been,
improved, and  the life of the  child at length perfe6tly reco-
vered.
   But when we have abondonedallhope of preferving the child,
and have no other view but fimply that of extrafting the head,
we muft be particularly cautious, that through  our conduft
the mother does not Suffer either any immediate injury, or that
any foundation of mifchief be  laid, which may ffiew itfelf  at
 fome future time.  When we have in vain exerted all the force 
ON  PRETERNATURAL LABOURS.            14!
which we think reafonable and proper, and which, in'fome cafes,
muft be more than any circumftance would be thought to require,
it will  be expedient to reft, for the purpofe of gaining ail the
advantage to be obtained by the compreffion of the head.   On
this account, the mother will  aftually fuffer no more incon-
venience, than would have  been produced if the head had ori-
ginally prefented, and been locked in  the pelvis.   After wait-
ing*fome time, we muft renew our attemps to extraft, and thus
proceed, alternately  refting, and afting  with efficacy and refolu-
tion, and  if the  hold we may have of  the body or extremities
ot the child does not fuit, a  Silk handkerchief or other band may
be paffed  round its neck, and  this will be found a very handy
and convenient inftrument.
  The great impediment to the extraftion of the head of the
child exifts in  the  difproportion  between it  and'the pelvis.
Another of no little  confequence may be produced by the dislo-
cation of the neck, or the laceration of  the Skin, either of which.
would lead to the feparation of the body from the head ; an ac-
cident one would wifh to avoid, as it  would lay us under the
neceffity of ufing fome awkward inftrument, inftead of the body
of the child.  Either of thefe  inconveniencies is readily occa-
 fioned by the impatience or defpair  of the praftitioner, who is
 apt to twill the neck while he is extrafting, or to pull with a
fudden  motion,  inftead  of the  uniform one  before  recom-
mended.
   In thefe cafes of extreme difficulty, it  will always be of fervice,
and  often  Succeed  when other means  fail, if we conduft our
 thumbs between the head of the child  and the pubes, and prefs
the head forcibly towards the hollow of the facrum.  It would
 alfo be of fervice if we  were able to  pafs the finger into the
 mouth of the child, to change the pofition of the head ; but in
 the worft cafes this is impracticable, the head being obftrufted
 fo  high,  that the mouth  of the  child is  beyond our  reach.
 When thefe means  are not  in our power, or fail to anfwer our
 purpoSe,  it will be neceffary to leave the head  a yet longer
 time, that it may undergo  a greater degree of compreffion and
 accommodation to  the pelvis, and then to renew our attempts
 to extraft it.
   It muft be a very great difproportion between the head  of ._
 the child and the pelvis, which is able  to withftand this method
 of proceeding, if we perfevere in  it with prudence  and  ftea-
 dinefs ;  becaufe the  integuments of  the head Will burft,  or
 or the  bones be bent inwards in an  extraordinary degree, or
 even broken.   Sometimes, however,  a hemorrhage comes on, 
142
INTRODUCTION TO MIDWIFERY.
 or the fituation of the mother will not allow us to take So much
 time, or proceed So flowly, as is generally propoSed, and we are
 compelled to the uSe of Such means, as' promiSe a more Speedy
 completion of, the delivery.  Different kinds of Jorceps have
 been advifed for this purpofe,  but no inftrument of the fort
 ought to be ufed on Such occafions, becauSe the child is  dead ;
 and it would be impoffible but that the mother muft by their
 uSe undergo the chance of mifchief, without any equivalent
 advantage.   It  then  only remains that we  fhould leffen the
 head of the child, and the operation may be as eafily per£ -fined
 in this, as  in the natural prefentation of the head. In the de-
 fcription of this operation it was faid, that it clearly divided it-'
 Self into  three  parts  :  i.  perforation ; a.  evacuation of  the
 brain ;  and o. extraftion of the head.  It will not be poffible
 to make the perforation in the ufual place,  but we muft take
 that which offers itfelf moft conveniently.  We  may  recolleft
 that there is  a fmall fontanell behind each ear in  the head of a
foetus, which is  a convenient place for tie purpofe ; or it may'
 be done^it the  bafis of the cranium through the mouth ;  or in
 fhort, in any part where we can  fix and command the ufe  of the
 perforator, except perhaps the occipital bone, where we may cut
 the ligaments which join the neck to the head, and when we
 expefted to extraft, we  fhould leave the head behind.  When
 the perforation is made according to the rules before mentioned,
 and the brain evacuated,  the head  may be readily extrafted,
 either by pulling by  the body  of the child, or by inferting a
 crotchet in the opening made by the operator as in other  cafeJi
 But it will be fcarcely believed, how feldom this  operation is
 neceffary  under theSe circumftances, if we have not been in a
 hurry, but  have afted with prudence. Nor have I ever known
 any ill confequences follow the compreffion which the Soft
 parts undergo, between the head of the child,  and the fides of th©- '
pelvis, if proper attention were  afterwards  paid to the ftate of
the bladder and reel urn.
                      SECTION X.

  Though with cautious management the head of the child is
Seldom Separated from the neck, and though  with indifcretion it
could not often be produced, yet the poffibility ot the accident,
when there is great difproportion between the dimenfions of the
head and thofe of the pelvis, efpecially in the  cafe of a child fome
time dead, makes it neceffary fijr us to be prepared tor manage 
ON  PRETERNATURAL LABOURS.            143
ing th? cafe if  it fhould occur.  It has moreover been furmi*
fed, that  under peculiar circumftances it might be, eligiable to
feparate the head from the body, with the expeftation of extraft*
ing it  with more eafe*; but this, however juft  in theory will
not; I believe,, give us any advantage in praftice, efpecially
in cafes of diftortion of the pelvis ; at leaft fo the accident Seems
to have proved, when it has unavoidably happened.
  When the head of the child has been  left behind, the cafe
has  been  confidered as frightful, and, which is true, exceedingly
troublefome to manage, becaufe the pelvis might be  expefted
to be very Small  in proportion to the  Size of the head, except
in the  cafe of a putrid child ;  and becaufe it could not without
great difficulty be fixed in fuch a  manner, as to be conveniently
fubjefted to  the aftion of the inftruments, which it may  be
neceffary to ufe.  Of thefe there has certainly  been contrived
a fufficient number for the purpofe of almoft every cafe.  It is
neverthelefs evident  to  every practical man, that the  greater
part of them were the conceits of ingenious men in their clofets,
and either could not be applied, or  if applied, could not be of
any fervice in a cafe of real perplexity.
  The chief obftacle to the extraftion of the head, muft arife
from the disproportion between it and the cavity of the pelvis ;
and this difproportion can only be removed by leffening the Bulk
of the head.   It this were fixed firmly in the pelvis, there would
be no difficulty in making the perforation, or in any part of the "
operation, than  in a cafe in which the head originally prcSented ;
but fliould the head be difengaged, and  lying loofe at the Supe-
rior  aperture of the pelvis,  it  would  not  make due  refift-
ance to the point of the  perforator,  which would be apt to
Aide, we fhould be foiled in our attempt, and incur the hazard
of injuring the mother.  To avoid  thefe inconveniences and
mifchief, external preffure muft be made either  by the hands of
an afliftant, or  with a napkin preffed round  the abdomen with
fufficient firmnefs to keep the head fteadily fixed, and this be-
ing done, the operation of perforating and leffening the bulk of
the head  may  be performed  without any chance of  failure or
mifchief.  In the very few cafes of this kind to which I have
been called,  the  difficulty  has not except in one inftance, by
any means been equal to what I  expefted from the representa-
tion of different writers.  It is a cafe to be prevented or avoid*
ed, if  poffible ; but when it  does  occur, there is neither that
danger in the cafe, nor that difficulty  in  the operation, wbicr.
                                        *
                   *  See note, page 137.                   t 
 ,44           INTRODUCTION TO MIDWIFERY.

 ought to terrify a praftitioner who has common refolution, and
 who  gives himfelf time for a  little refleftion.  It is however
 Said, that in Some inftances every attempt to extraft the head has
 been  in vain, and the patients have been refigned to their fate ;
 of which there  is one inftance in Mauriceau, another in  Chap-   4
 man,  and fome  other writers.  Yet even in fome of thefe cafes,
 though the patients have moft frequently died, after a certain
 time,  the aftion of the uterus has  come  on, and at length ex-
 pelled the head; in one cafe, if I be not miftaken, fo late as the
 twentieth day after the accident had happened.   The degree of
 diftention of the uterus, occafioned by the mere head of a child,
 would not indeed be fo great, as to make us apprehend any fatal
confequences on that account; and if the uterus be in a healthy  ^
ftate,  a fubftance of that bulk and kind might be managed,  either
by common putrefaftion, reducing its fize and dividing it into
portions, or it might by repeated efforts be expelled, efpecially if
the pelvis were  of any reafonable fize.   Should the head of the
child  be  retained,  it is probable, that the placenta would alfo
remain, and the  two circumftances combined  would add to the
danger of each,  fo that the head never ought to be left, if  it can
poffibly be extrafted by any means not  abfolutely  injurious to
the patient. 
ANOMALOUS, OR  COMPLEX LABOURS.        1$$
       CHAPTER  XV.

        CLASS FOURTH.

ANOMALOUS, OR COMPLEX LABOURS.
                  FOUR ORDERS.

                     ORDER FIRST.

           Labours attended with Hemorrhage.

                    ORDER SECOND.

            Labours attended with Convulfions.

                     ORDER THIRD.

           Labours with two or more Children.

                    ORDER FOURTH.

Labours in which there is a defcent of the Funis Umbilicalis
               before any part of the child.
                     SECTION I.

                      ORDER FIRST.

           Labours attended with Hemorrhage.


XT is neceffary to premife, that no praftical advantage can be
derived  from the arrangement oi thefe labours into one clafs.
This is merely of ufe for the convenience of doftrine, anu to
prevent  multiplication of claffes ; fore there is not the le.ift
refemblance between the different orders of anomalous or com-
plex labours, which do not therefore admit of any general defi-
nition or charafter.
  Vol.  II.                 U 
14&           INTRODUCTION TO MIDWIFERY.
  Uterine hemorrhages, from different caufes, very frequently
occur  in  praftice, and  always  require  great attention ;  but
thofe, which we are about to confider in this place, are iuch as
depend upon  the ftates of pregnancy and parturition.  Thefe
have ever been efieemed as conftituting a very important part
of the praftice of midwifery, on account of the immediate and
great danger with which  they are often attended ; and becaufe
the fafety of the patient, in thefe  cafes, more frequently depends
upon the judgment and  fkill of  thofe under whofe care fhe.is
placed, than  in almoft any otb<*r circumftances.   The fubjeft
therefore demands to be treated with the utmoft circumSpeftion;
and  though much induftry hath been employed upon it, there is
reaSon to believe, thatthe knowledge of many things, of which
we are at prefent ignorant, is wanting for the perfeftion ot the
rules of praftice.  The knowledge however, which we do pof-
SeSs, it is incumbent upon us to place in the moft advantageous
point of view, that it may be converted to ufe ; that we may be
enabled to do what reafon and experience diftate to be neceffary
and proper;  that we may deteimine upon the time moft fuita-
ble  for afting ; and be warned moreover againft relying on fucji
 things as are ufelefs, or doing what is hurtful.
   The word hemorrhage  does not apply with propriety  to  all
 difcharges oi blood from the uterus, fome of thefe being natural
 or  falutary.  The  menftruous  discharge  is natural,  but  if  it
 fhould be exceffive in quantity, too frequent or  irregular in  its
 returns, or prolonged beyond its ufual time, it might  be called
 hemorrhage.  Every difcharge of blood which occurs during
 pregnancy, however fmall, may be called a hemorrhage, becaufe
 it is not  natural  at that  time.   The fame observation may be
 made of thofe discharges, which happen between the birth ot
 the child, and the expulfion of the placenta ;  and thefe are often
 profufe, and not unfrequently dangerous.  But the diScharges,
 which happen after the  expulfion of  the placenta, cannot be
 called  hemorrhages, unlefs they are  exceffive in their degree ;
 becaufe fome lofs of blood is  that time neceffary and natural.
 We may then  fay, that  all effufions ot blood, which are inordi-
 nate in quantity, or irregular in the time of their appearance,'may
 be  denominated hemorrhages ;  and thefe, which are the objefts
 of  our prefent confideration, may be divided into four kinds.
    1.  Thofe which occur in early pregnancy, or in abortions.
    2. Thofe which occur in advanced pregnancy, or at the full
 period of utero-geftation.
    3. Thofe which happen between the birth of the child and the
 expulfion of the placenta.                     ...
    4. Thofe which follow the expulfion of'the placenta. 
ANOMALOUS,  OR COMPLEX LABOURS.
H7
   Under one or other of thefe  diftinftions will be  included
 every kind of hemorrhage, which depends upon pregnancy or
 parturition ;  and this arrangement will not only convey a clear
 idea of the fubjeft, but be ot ufe alfo in praftice. Yet it is ne-
 ceffary to obServe, that there may be a combination of  the three
 laft kinds, or any two of them in the fame patient; but whether
 they  be feparate or combined, the  modes ot treatment may be
 accommodated to each cafe  with equal propriety and  advan-
 tage, as  far as it may be reducible to the general denomination.
   Greater accuracy is neverthelefs required in the description
 of what is meant by  early or advanced  pregnancy,  or we may
 entertain different notions of, and ufe  different  terms for, the
 fame thing.   Perhaps no precife line can bet'drawn for this pur-
 pofe, as contingent circumftances may caufe a variation  in differ-
 ent women ; yet the beft, which the nature of the fubjeft  admitsj is
 probably to be taken from time.  We will then fay that all expul-
 sions of the fetus, before the termination of the  fixth  month of
 pregnancy, may be called abortions*;  but all expu-lfions in the laft
 three months fhall be confidered as labours, premature or regular.
 There is a practical reaSon for this diftinftion. Before the termin-
 ation of the fixth month, thefe cafes, generally Speaking, neither
 require  nor allow of manual affiftance, but in the laft three
 months,  they admit  of manual affiftance, if it be  required,
 though not with equal eafe ; for the  longer the  time  which is
 wanting  to complete the  period of utero-geftation, the greater
 the difficulty will be which attends any operation, that  it may
 be neceffary to perforin.  It is alfo to be obferved, that expul-
 fions of the fatus fometimes happen fo critically, as to  render it
 an extremely difficult thing to decide, to which of the distinc-
 tions they ought to be preferred ;  and in thefe, if we knew any
 method of treatment between that enjoined for abortions, and at
 the full period, fuch tor inftance as punfturing or breaking the
 membranes containing the waters of the ovum, that would be moft
 eligible.   But on this, as well as many other occafions,  there is
 room to obferve, that whenevery doctrinal diftinftion  has been
 made, no abfolute rule can be formed  for the conduft of the
praftitioner, in every individual cafe which may occur, or in

  *  Fatus prematura ejedio.—Linnaeus.
  Sanguinis ex utero gravido prqftuvium, cumjcetu immaluro
vel molafubfequenti.—Vogel.
  Partus morbojus  et J'ymptomaticus.   Fatus ejiidur potius
quam paritur.—Harv. 
148           INTRODUCTION TO MIDWIFERY.
every poffible fituation in which a patient may be placed; but
he knowing in general what ought to be done, and what ought
to be avoided, muft ever be at liberty to exercife his own judg-
ment in the application.


                      SECTION II.

  It would be curious, and might be of fome utility in praftice,
to afcertain whether women, on account of their menftruation,
or their ereft pofition, or the ftrufture  of the ovum, or the pro-
cefs by which this is connefted to the uterus, or from any other
cauie,  are naturally more liable to abortions than animals ;  or
whether frequent abortion in women may not be confidered as
an attributive, either of habits Superinduced by modes ot educa-
tion or of living, or of accidents  which  might  be avoided.
There is  great room to lament  their frequent occurrence in
the more civilized, perhaps luxurious fcenes ©f life, and in thofe
con;*itutions that are extremely delicate, and which are indeed
hardly found equal  to the continuance of the human race.  Yet
in thofe Situations which might  be  preSumed to be moft  unfa-
vourable  to the Sex, among the lowe.ft  ranks of life, abortions,
except from violent external accidents, very rarely happen ;  fo
that there is good reafon for believing, that women in a ftate of
nature would not be more  liable to abortion than other  crea-
tures.  According to the opinions nevertheless of  many fyfte-
matice writers  on this Subjeft, every aftion in common life has
 been  affigned  as the cauSe  of  abortion : yet this  is rarely the
 cafe ; and in general that, about which the patient was em-
 ployed, when the firft Symptom appeared, is fixed upon as the
 particular cauSe,  though probably the was before  in fuch a
 ftate,  that abortion was inevitable.   But if this- opinion were
juft, then the event ought rather to be imputed to fome previ-
 ous indifpofition, or  the exceSs of fome actions, forgotten per-
 haps when abortion aftually takes place, than to the exercife of
 the body on common occafions.  Yet greater praftical benefit
 will  be  obtained, if we feek for  the  caufes of abortion in the
 general infirmity of the conftitution, or in fome particular ftate
 of the uterus, or its  appendages, than by imputing  it,to thefe
 accidents.  As far as the conftitution may  be altered, by the
 reduction ot  the general  ftrength, by exceffive irritability,
 by plethora or febrile  difpofition,  So as to  be unable to per-
 form its  functions,  or to perform them with eafe, proprie-
 ty, and  regularity,  we may  cfteem every caufe capable of 
           ANOMALOUS, OR COMPLEX LABOURS.         I49

producing  fuch a ftate, as a primary  caufe of  abortion.  It
does not, however, often happen, that  fimple  weaknefs is a
caufe of abortion ; tor women who prove with child, in very
weak and reduced ftates of the body, particularly in confump-
tions, in  which there is a great aptitude  to conceive, have, of
all women, the leaft difpofition to mifcarry ; yet  a ftate more
feeble and  more irritable could with difficulty be pointed out.
But  the weaknefs and irritability then are of a particular kind,
notarifing from, connefted with, or influencing the uterus, which
proceeds in the performance of its funftions, as regularly as if
the whole  conftitution was in a  ftate of perfeft health.  We
may hence conclude,, that either weaknefs or irritability  in
general is feldom a caufe of abortion ; but fome weaknefs or
imperfeftion originating in, or affefting the uterus or its appen-
dages ; or a peculiar  kind of  irritability, thence proceeding,
diftinguifhable enough in the female character, by a careful ob-
server, which createsimpatience ot mind and reftleffnefs of body;
in which every occurrence is"the parent ungrounded fear and So-
licitude, and every office 's performed with hurry and vexation.
iVs an abundance of acrimonious, or Some other humour, or Some
quality of the body, may transfer this ftate to the  mind,  fo the
mind often reverberates this ftate to the body, the continuance of
which will often prevent, or impede the regular performance of
any procefs.   It is therefore often fqund of as much importance,
to give  compofure and fteadineSs to the mind of a patient, by
leading her to hope and cheerful expeftation, by Soothing and
comfortable converfation,  as  it is to  administer  medicines to
the body.
   With refpeft to  the ftate of the uterus, the opinion origin-
ally entertained and ftill purfued,  as far as can be collected from
the  medicines ufually prefcribed, was, that it failed to perform
its office on account  of its exceffive lubricity, as if the ovum,
before loofely attached, flipped out of the uterus ; but this idea
will not bear examination, being  fupported neither by the rea-
 fon of the thing, nor by the  occurrences of praftice.  It is
 remarkable, that women, who are in the habit ot mifearrying,
 go on in a very promifing way  to a certain time, and then mif-
 carry, not once,  but  for a number ot times, in fpite of all the
 methods which can be contrived, and all the medicines which
 can be given ; So that befides the force ot habit, there is Some-
 times  reaSon to fufpeft, that the uterus is incapable  of diftend-
 ing beyond fitch a Size, before it affumes its difpofition to 0. i,
 and that it cannot  be quieted till it his excluded the ovum.
 What I am about to  fay will  not, I hope, be confti ued as giv_ 
15°           INTRODUCTION  TO MIDWIFERY.
 ing a licence  to an irregularity of conduft, which may otter*
 be juftly affigned as the  immediate caufe of abortion ;  or lead
 to the negligent ufe of thofe means which are likely to prevent
 it.  But from  the examination of many ova, after their expul-
 fion, it has appeared, that their longer retention could not have
 produced any advantage, the Jatus being decayed, or  having
 ceafed to grow long before it was expelled.   Or the ovum, has
 been in fuch a ftate, as to have become wholly unfit for  the
 purpofe which it was defigned to anfwer; So that if we could
 believe there was a general intelligence exifting in every part
 ot the body, we fhould Say, it was concluded in council, this
 ovum can never eorrie to perfection, and the fooner it is expelled
 the  better.   Nevertheless, in Some cafes,  the ovum, though
 extinguifhed, if the expreffion may be allowed, will remain  iu-
 offenfive in the uterus to  the period of legitimate pregnancy.
   Conception  probably depends upon the perfeft ftate ot one
 or both ovaria, and will therefore fometimes  take place, when
 the uterus is confideiably difeafed-  But the progrefs depends
 upon the ftate of the uterus, and chiefly upon that of the fundus ;
 for I have known  feveral inftances of women, who  had both
 excrefcences and induration about the os uteri, who have con-
 ceived and gone on to their full time without any material in-
 convenience.
   The  imperfections obfervable in ova are of different kinds,
 and  found occafionally in  every, part,  and there is ufually a
 confeiit  between the fatus and (hell of the ovum,  as the pla-
 centa part and  the  membranes  may be called, but not always.
 Foi examples have  occurred, in which/the fatus has  died be-
 fore the termination of the third  month,  yet the Shell being
 healthy has.increafed to a certain fize,  has remained till the ex-
 piration of the ninth month, and then been expelled, according
 to the genius and conftitution of the uterus, thoitgh frequently
 it has been found to have  undergone great changes, as, for in-
 ftance, in many cafes of hydatids.  But if the Shell becomes
 diSeaSed,  then the fatus being deprived of its nourishment is of
 courfe deftroyed, and both are expelled, as any other extraneous
body would be,  though not immediately on the acceffion  of the
mifchief.  There is  reafon to believe, that the part ofthe ovum
moft commonly  difeafed is not that which paffes from the ova-
rium, but that production  of the uterus, which is prepared for
the reception of the ovum after its paffage from the ovarium,
and which may be called the connefting membrane of  the
ovum.  When that procefs, by which  the two membranes are
cemented, goes on without interruption, I believe the connec- 
           ANOMALOUS,  OR COMPLEX LABOURS.         Xjl

tion is completed between the Sixth and tecnth week from the
time of conception.   But when an abortion is about to happenj
there is ufually  between this and the outer  membrane of the
ovum an effufion of blood, which infinuates itfelt through the
cellular membrane of the placenta, and between the membranes,
giving externally to the  whole  ovum a tumid and  unequal
appearance,  often not  unlike a lump of coagulated blood, for
which it has been  frequently miftaken.   It  is probable, that
either the connefting membrane is imperfeftly formed, or there
is fome difficuky, and a failure in the completion of the union
between it and the ovum  ; according to this opinion the caufes
ot abortions are generally to be fought for in the female only,
contrary  to what I formerly fufpefted.


                      SECTION III;

  All the«means which can be advifed with any proSpeft of
fuccefs, in the treatment of abortions, whether the caufe confift
in the conftitution or  fo, the uterus, may  be  confidered as
preventative or curative.   In either of thefe views we  muft
chiefly recur to the conftitution ; as in the firft  caSe,  it is the
great objeft of oar attention ; and in the fecond, as the princi-
pal  chance  of producing any falutary change in the  uterus is
through the  medium of the conftitution, on the improvement of
which our  fuccefs muft  ultimately depend.   Should  a Separa-
tion of the hufband from his  wife's  bed be  thought neceffarv,
it muft be chefly  fo about the period above mentioned, unlef3
when there have been frequent mifcarriages at any other precife
time, as that would always require particular attention.
  As women with different conftitutions and different ftates of
health are fubjeft to abortion, every mode of treatment muft be
accommodated *o the  conftitution ot each  patient, and to the
difeafe of which there may be any indication.  In plethoric and
febrile habits it may be proper,  to take  away a fmall quantity
of blood, fo«n after the fuppreffion of the menftruous difcharge,
and occasionally'afterwards ; to enjoin a fpare, or even a veget-
able diet, and to give  cooling medicines;  in fome habits, in
which the uterus may be  fuppofed unwilling to diftend beyond
a certain  degree, or where the degree of irritability is  extreme,
to  preScribe opiates in Small quantites  often repeated ; and
fometimes tepid bathing.   In debilitated and .languid  conftitu-
tions, a ftrengtheningdiet muft be allowed, and wine, efpecially
claret, in a larger quantity  than ordinary, at fuch tunes as the 
x«52            INTRODUCTION TO MIDWIFERY.
  patient may be more fenfible of depreffion, or the want of Sup-
  port.   Every kind of medicine, which promifes to give vigour
  and energy, will alfo be proper, as the cortex  cinchonae in any
  convenient  form, and preparations  of iron in the officinal or
  extemporaneous  forms, or mineral waters in fmall  quantities.
  The ffiower bath, dafhing cold water upon the loins,  the cold
  bath, Sea-bathing eSpecially, are pretty conftantly recommended,
  for the  general purpoSe of improving the health, not only in
  thofe who have a  difpofition to abortion, but in thofe alSo who
  are accuftomed to bring Sorth dead children, or who are prone
  to hemorrhages at the time of delivery; and  experience  has
  fhewn, that they may, in many caf^i, be  continued through the
  whole time of pregnancy with fafety  and advantage.   For the
  great purpofe of eftablithing permanent  ftrength in thofe,  who'
  have had long continued ill health, or who are in a habit of meet-
 ing with thefe untoward*accidents, nothing feems better calcu-
 lated, or is found to be more ufeful, than travelling;  not taking
 9. hafty journey, but wandering about by eafy  ftages, for many.
 months,  by  which the evils, that appertain to  the too refined
 Scenes of civilized life, are done away,  the mind  becomes footh-,
 ed *nd  compofed, and the corporal advantages  of a natural
 ftate are in fome meafure, acquired.
   When the health cannot be confirmed, fo as to enable the
 constitution to bear the common exigencies of life it has been
 thought advifable to remove patients from them, by  confining
 them occasionally to their houfe, to a floor, or a fingle room ;
 even to a horizontal pofition,  throughout pregnancy  ; at leaft
 till the period when they were  accuftomed to miScarry is paft,
 and the injunctions in this refpeft muft accord with the debili-
 tated or irritable ftate of the patient.  Some inftances  of advan-
 tage from this method I have known, particularly in  the early
 part of pregnancy.  But if we were  to  confider abortions as
 originally proceeding from weaknefs, or  too great a degree of
 irritability, confinement to a room, or any treatment by which
 both thofe evils  are likely to be encreafed, feems a ftrange me-
 thod  of  preventing mifchief ;  and from what  I have Seen of
 the general iffue  of fuch ftrift praftice, much conriot be faid in
 its favour, the event being  ufually deferred, but not hindered.
 In the management of  Some caSes  of this kind, I have thought
 mySelf entitled to credit, but I muft alfo.acknowledge, that L
 have been frequently disappointed , yet from  Some general im-
 provement of the  healthv or for fome reafon,  not obvious or
 eafy to difcover, the^patient, wearied with the fruitlefs attemps
©f art, and deferting all rules, has another time efcaped the abor-
 tion, which I  had before in vain attempted to prevent. 
ANOMALOUS,  OR COMPLEX LABOURS.         153
   With refpeft to that ftate ot the uterus itfelf, Which may be<
confidered as the caufe ot abortion, fhould there have been any
indication  from the difcharges  being irregular or protufe, if
they be of the fanguineous kind ; from their quality or degree,
if of  that kind which paffes under the general name of weak-
nefs ;  it is firft  to be  determined, whether they be Symptoms
indicating a certain ftate of general health, or any morbid dispo-
sition of the uterus.   Should they even be of the latter kind, it is
in general only by application to, and improvement of, the con-
ftitution at large, that we have the power of making any material-
alteration in the ftate of the uterus.  Something may however
be done by local applications  of  various kinds, efpecially by
injeftions,  but their aftivity  muft not be fuch  as to make too
quick an alteration,  by fuppreffing fuddenly  any kind of dif-
charge, to which the part itfelf, or the conftitution, may  have
been long accuftomed.   For it muft beobferved, that disagree-
able as theSe discharges are, their Sudden Suppreffion by the uSe
of powerful aftringents, often occafions very Serious or danger-
ous  diSeaSes ;  and Such discharges Seem to  be really of Secon-
dary ufe.   That is, if we fuppofc a certain ftate of the uterus,
the difcharge may be abfolutely neceffary for its relief, while it
remains in fuch a ftate, and the ftate is to be changed previous
to the  Suppreffion of the difcharge ; elfe, inftead of removing,
we fhall add to the exifting difeafe, or produce one of a different
and worfe kind. In fuch ftates of the uterus as difpoSe to abortion,
I  have feldom dared to advife anymore aftive application  than
the Bath or Buxton  Waters,  which  may be injefted into the
Vagina, in  the interval between the  two periods of  menftru-
ation, or even for a longer time.  I fay into the vagina, be-
caufe I do not approve ot daily or frequent attempts to intro-
duce  any inftrument within  the  os uteri, on this account, or
for the relief of any difeafe.   It muft however  be mentioned,
that fome have affured me, they have advifed the uSe of aftringent
injeftions, even thofe compofed of zincum vitriolatum, and other
medicines of that clafs, not only for the cure  of  weakening
difcharges, but with much advantage alfo in pregnancy, when
there was a propenfity to  abortion.

                      SECTION  IV.

  The circumftances attending abortions, and  the fymptoms
by which they are threatened or accompanied, are very unlike
in different  patients, as are indeed all the effefts arifing from
  Vol. II.                   V 
154           INTRODUCTION  TO MIDWIFERY.
Uterine  difturbance.  But there is generally pain in the back,
abdomen, and inferior extremities, with a fenfe ot weight and
weaknefs in the region of the uterus, frequent mifturition, and
a tenefmus ; but the moft certain  fign of an abortion is  a dif-
charge ot blood, which proves that fome part oi the ovum is al-
ready loofened from the uterus.
- When fuch difcharge  happens  during pregnancy, efpecially
at an early period, it has  been a received opinion, that abortion
was inevitable,  becaufe  it was prefumed, that the  feparation
which it proved could not be repaired.   It muft be allowed,
that under fuch circumftances there is always too much reafon,
to apprehend an abortion :  yet experience has  fully Shewn,
that  women, who  have  had  not one, but repeated  difcharges,
and fometimes to a profufe degree, with confiderable and regu*
lar pains, have  gone to  their full time, without any imperfect
tion in the  child,  or any detriment to the mother ; the pain
ceafing, and the loofened part, by fome operation beyond human
tkill, having been cemented and re-united to the uterus, which)
I prefume may take place in ten or twelve days after the  ceffa«
tion of the difcharge.    There Seems to be juft fo much chance
of preventing an abortion, when there has been a difcharge of
blood, as to make it worth while to ufe the common means for
that purpofe, and to keep the patient cool and compofed, which
muft in fuch cafes be the^general  aim, by, means fuited  to her
conftitution and any peculiarity in her fituation.
  There is an almoft endlefs variety in the manner, in which
abortion happens.   Some women abort with ffiarp and long
continued pains ;  others, wkh little or no pain, the ovum glid-
ing out of the  uterus almoft imperceptibly  ; fome with a pro-
fufe and alarming hemorrhage, others with very little difcharge.
In Some, the ovum has been Soon  and perfeftly expelled; in
others, after a long  time,  firft the child, then the placenta, whole,
or in fmall portions, or part of it diffolved.  But whatever
other pain or trouble may attend, the hemorrhage is the only
immediately alarming Symptom ; I Say immediately,  becaufe
every pra£titioner  muft  be convinced, that either abortions oc-
cafion local diSeaSes, or the time of abortion  is an era,  from
which we may date the commencement of Som^* dangerous dif-
eafes ot the uterus, or its appendages.   It has alfo been imagin-
ed, that the fafety  of the patient very much depended upon the
 complete and  Speedy  expulfion of the placenta;  and  when it
was retained, very active deobftruent medicines, as they were
 called,  were fuppofed to be neceffary and ftrenuoufly given for
 the purpofe of expelling it, left it  fhould hecome putrid, and 
ANOMALOUS,  OR COMPLEX LABOURS.
»<5S
 fome ot the putrefied parts be abforbed into the conftitution.  I
 believe the whole ot this fuppofition is groundiefs, having Seen
 many inftances of its being  expelled in  a very  putrid ftate at
 different periods of pregnancy, when the patient was in perfeft
 health ; and when the patient had a difeafe, the putridity of the
 placenta clearly Seemed the conSequence, not the cauSe, of the
 difeafe.  At all events, much lefs mifchief may be expefted
 from the retention of a  putrid placenta, than trom attempts to
 force it away by the medicines ufually given, or by manual affift-
 ance.
   The degree of hemorrhage  in abortions is not always  in pro-
 portion to the period  of pregnancy,  but it depends upon the
 difficulty  with which the ovum  may be expelled;  fometimes
 upon the caufe, and often upon fome peculiarity in the conftitu-
 tion, as happens in the menftruous difcharge.
   A notion of there being fomething  myfterious  in uterine he-
 morrhages, different from thofe from any other part of the body,
 has been entertained, and fuppofed to occafion the neceffity of
 a  peculiar treatment.   But it is  now agreed, that  the general
 principles, which guide us  in the treatment of hemorrhages
 from any othenpert of the body, are with equal propriety appli-
 cable to thofe from the  uterus.  We muft however recollect.,-
 that in uterine hemorrhages, depending on pregnancy, there is
 an additional circumftance, which we are ever to bear in mind;
 that they are ultimately to be fuppreffed by the  aftion of the
 uterus, contracting its  cavity into a lefs compafs, of  courfe
 leffening the  dimenfions of the veffels, and expelling whatever
 may be contained in its cavity ; and in this  view, uterine  he-
 morrhages  do  certainly differ from- thofe of any  other  pau of
 the body.
   Hemorrhages of all kinds are  moderated,  or wholly  flayed,
 by the formation ot coagula at the orifices of the open veffels ;
 or by the contraftion of the coats of the veffels themfelves, by
 which their orifices are leffened or clofed.  The latter of thefe
 effects being ftronger and more active in arteries than in  veins,
 may be a reafon for the  common observation, that hemorrhages
 from arteries, thou in an equal degree, are  fajfs dangerous than
 thofe from veins, in which the power of contraftion is wanting.
 It  has been proved by phyfiologifts, that both thefe effefts, that
is, the formation of coagula, and the contraftion of the veffels,.
 are favoured when the blood circulates moft flowly, as in faint-
ing' ;  not to mention, that the  quantity of blood loft in a given
time will depend upon  the rapidity or flownefs ot the ciicula-
•»n, as well as upon the fize  of the  veffel opened.   But in a. 
I£6           INTRODUCTION TO MIDWIFERY.
ftate.of taintnefs, which Speedily follows all prof ufe hemorrhages,
the three effefts are produced at the fame time, the blood circu-
lates more flowly, coagula are Sooner formed, and the veffels da
contraft more efficacioufly. During faintnef s, the advantage arif-
ing from the contraftion of the  uterus is likewife obtained ; tor
this afts, or makes its efforts to aft, in fleep, during faintnefs, and
Sometimes even after death.  Fainting may  then be confidered
as a remedy provided by nature for averting the immediate
danger of all hemorrhages, and to prevent their return.  Cor-
dials or ftimulants fhould not therefore be given  to thofe who
are faint from hemorrhages, till by the duration of the faintnefs
we conclude there has been.fufficient time to produce thofe ef-
fefts, which would prevent a renewal of the hemorrhage, or lef-
fen its danger if it fhould return ;  and then they are to be given
liberally, and repeated as often as the circumftances may re-
quire.
  The materia medica abounds with articles under the elafs of
aftringents, many of which  are  given indiferiminately in he-
morrhages and profufe difcharges of every kind ; nor does much
diftinftion feem to have been made between thoSe, which were
Sound ufeful in hemorrhages as applications, and thoSe which
were given  internally.  It has rather been concluded, that what
was found ufeful as an external application, would of courfe be
profitable if given internaUy.  It is however clear, thataftiingent
medicines, properly  So called, can have no immediate power o£
ftopping hemorrhages from the uterus, or any other part  of the
body, excepting the inteftinal canal; but that every medicine,
which flackens the circulation of the blood, becomes eventually
an aftringent.   If the patient therefore be plethoric or heated.
it may be proper to bleed in an incipient abortion accompanied
with an  hemorrhage ;  though  if fhe be reduced to a ftate of
great weaknefs, that operation  would be ufelefs and improper.
The Saline draughts with nitre,  or nitre alone ; or acids mineral
or vegetable, may be given as frequently  and in  as large  a
quantity as the ftomach can bear.  Even the naufea, which thefe
and other  medicines Sometimes produce,  has, by no forced
conftruftion, been confidered as an  artificial imitation of faint-
nefs, and found fervieeable,  and medicines have been  given
exprefsly for this purpofe ; the fafeft perhaps, and  not  leaft
effeftual, of which  is  ipecacuanha, in fmall quantities,  often
repeated, fo as to keep up a perpetual naufea.  Oil of turpen-
tine and the ceruffa  acetata in  proper dofes have been recom-
mended, and ceitainly are very powerful medicines in,hemor-
rhages, but they feem better foiled to thofe  which are.i&bttr.ai 
           ANOMALOUS), OR COMPLEX  LABOURS.         157

or of  long continuance, than  to  thofe which are  inftantly
protufe,  and dangerous.   When the difcharge  is  profufe,
cloths wet  in  cold vinegar  may be applied to  the  abdomen
and loins, and changed  when they grow warm.  In Italy and
other hot countries,  and fometimes  in this, it is a cuftom  to
fprinkle ice crufhed into fmall pieces over the body of the pati-
ent, who muft alfo be  expofed to and  Suffered to breathe the
cold air.  On  the  fame principle clyfters  of cold water have
been advifed.  In fhort, every application and medicine, aftu-
ally or potentially eold,  the coldeft water, even ice itfelf,  if it
can be procured, may be given and repeated with probable ad-
vantage, when  the exigency of thefe cafes requires very power-
ful affiftance.
   Injeftions of cold  or aftringent fluids into the vagina have
been recommended, as being of great fervice for the fuppreffion
of uterine  hemorrhages.  If we attempt to throw up the injec-
tions when the blood is flowing in full torrent, they will be im-
mediately rejefted ; and if they be ufed with the view of pre-
venting a return  ot the hemorrhage, which  has already ceafed,
it is rather  to be expected, by warning away the coaguta formed
and applied to the orifices of the veffels, that they would occa-
fion it.  The  principal good, that can  be derived from them,
probably is by their aftion upon the internal parts as a cold appli-
cation, and in this view ice has been introduced into the vagina.
Lefs objeftion  may perhaps be made, and equal or rather greater
advantage  will attend the introduftion of lint, or any  foft fub-
ftance, moiftened with fpirit of  wine or any aftringent liquor
into the vagina, which  may ferve the purpofe of forming coa-
gula, and applying them to the orifices of  the opened veffels.
But I have generally  been fatisfied with the application of a
cloth wet with cold  vinegar to the external parts, with fo firm
a preffure,  that the ftream 0/ blood fhould be inftantly retarded
or flopped.  This might have been originally done inftinftively,
to remove  the  immediate dread of the  hemorrhage, and to give
me a little  time to  refleft and determine how I fhould  proceed ;
but being perluaded that this  is of real utility, it is a cuftom with
me do it, in the firft inftance, in every alarming or dangerous
hemorrhage.
   Opiates  have been generally recommended as  of  principal
efficacy for the prevention of abortions, and in all cafer. of uter-
ine hemorrhage ;  but I Seldom  uSe them in the latter  fituation,
unlefs with a  view ot moderating any unnfual degree of pain,
or of quieting fome tumult which preceded, attended, or fol-
lowed the accident, and then in moderate dofes repeated accdrd. 
1^8          INTRODUCTION TO MIDWIFERY.
ing to the urgencv of the cafe ;  having reafoned  my.felt in*>
an opinion that they  do not, in  thefe  cafes, deServe the high
commendation which has been given them.   Some pain is  un-
avoidable and neceffary, for the exclufion ot the ovum out of the
cavity of the  uterus, whenever we have given up the hope of
preventing abortion.  The degree of pain proves the degree of
aftion railed for the purpofe, and  we Should confider how far
by leffening the pain we may leffen the aftion, and by leffening
that aftion, by which-the ovum would be expelled, whether we
contribute to the fuppreffion or continuance of the hemorrhage,
or to the more regular conduft of the abortion.
  It was faid, that no manual affiftance was required in the
management of abortions, and no rule  can  be  more generally
true ; yet there are fome exceptions.   When, for  inftance, a
woman who is mifcarrying, with a confiderable,  or an appar-
ently dangerous hemorrhage, is fo far  advanced  in  her preg-
nancy, that it may be difficult to decide  whether we  Should
deem it an abortion or a premature labour ;  it may not be  fafe
to rely' upon  the  ufe of thofe  means which were advifed for
hemorrhages  in general,  and yet the operation ot delivering
would be extremely difficult  and hazardous.  We may then
determine upon an intermediate method, which is to break the
membranes.  By the difcharge of  the waters ot the ovum, which
neceffariiy follows, the diftention of the uterus is leffened, of
courfe the fize of the open blood veffels, by  which the difcharge
had been made, is diminifhed, and the hemorrhage is abated or
fuppreffed.  In confequence alfo of the difcharge of the  waters,
the  uterus acquires a  difpofition  to aft, and an  ability to aft
with more energy, aud the whole bufinefs is Sooner completed.
At a more early period of pregnancy, when the hemorrhage is
profufe, liable to return, or of long continuance, on  examina-
tion  per vaginarrt, not otherwife thought neceffary, the ovum
will fometimes be found  hanging  in the os  uteri,  half or more
of it voided out of the cavity of the uterus,  yet enough remain-
ing to keep up the hemorrhage.   Then, by a little motion or
flight impulfe in different directions, it will fometimes be cleared
of the os uteri, and drop into the vagina.   But great caution
is to be ufed in  this operation, for if it be done with violence,
it may occafion an  increafe of the  hemorrhage, or be a caufe of
future mifchief.
  In  abortions, dreadful and alarming as they fometimes are, it
is a great comfort to know, that they are almoft univerfally void
of danger, either from  the hemorrhage,  or any  other account-
It is perhaps impoffible to explain  it, but the laft is undoubi- 
ANOMALOUS,  OR COMPLEX LABOURS.
*5$
edly true, that an equal lofs  of blood,  and with apparently
equal effefts, fhould, in abortions, if properly managed, and the
patient be  in good health when they take place, not occafion
any danger ; and yet at the full period  of uterogeftation be fo
dangerous, that one confiders the patient  who recovers as hav-
ing a lucky efcape.  It is wonderful alfo to obServe, how fome
women recover from the debility occafioned by hemorrhages in
abortions  ;  and how  long a time is often required for their
recovery  after the fame  circumftance in  advanced  pregnancy.
But though I reckon there  is little or no danger from mere
abortion, yet when the accident is in confequence of acute dif-
eafes, there is often extreme danger ; for  women abort becaufe
tbey are already  in great danger, and this is aggravated  by  the
abortion.   Without  a more accurate diftinftion we may ftill
form an erroneous prognoftic.   It has been faid, for example,
that women who mifcarry, or are delivered at the time of their
having  the fmall-pox, univerfally  die.  Now  if a pregnant
woman fhould, at any period of pregnancy, expel her  child in  the
commencement  of that difeafe, perhaps from the  viofence  of
the eruptive fever,  fhe may not only efcape the danger, but
go  through the  difeafe with as much regularity, as if fhe had
not mifcarried.   But if that period of the difeafe be paffed with-
out abortion, and the patient fhould go on to the time of  the
crifis, and  then  mifcarry,  the  general  prognoftic  will be too
true ; at leaft the death of the patient has followed in every cafe
ot this kind which I have Seen.   But fince the firft publication
ot theSe observations I have been informed of two cafes of early
abortion, which have proved fatal,  the firft, the patient became
paralytic immediately after the hemorrhage ;  but the death  ot
the fecond, though fhe was only in the feventh week of her preg-
nancy, feemed to be occafioned  merely by the hemorrhage, or
more probably by a convulfion.

                     SECTION V.

  Under this head will be included all the hemorrhages  which
occur in the three laft months of pregnancy,  becaufe from the
danger with which they are attended, they require, and from
the fituation of the patient, they allow of a Similar treatment when
required, though not with  equal facility.   Thefe hemorrhages
are occafioned, ift. by the attachment ot ihe placenta over the
os uteri ;  and this is difcovered by our being able to feel in a
common examination only a flefhy fubftance, without any part
of the membranes:  ad. by a  feparation ©t a part, ©r ot the 
i6o
INTRODUCTION  TO MIDWIFERY.
 whole placenta, which had been attached to any other part ot
 the uterus, and this is konwn by our being able to diftinguifh
 the membranes without any  fleffiy  fubftance.   This feparation
 may be cauSed either by the approach oflabour, dilating the os
 uteri, and of courfe Separating, in  proportion to the degree of
 dilatation, the placenta ; or by accidental violence, or by fome
 morbid aflfeftion of the uterus or placenta, and it  fometimes
 happens without our being able to affign any caufe, equal to
 the SuddenneSs and violence ot the effeft produced.
   Hemorrhages arifing from the firft cauSe have been confidered,
 and generally are more dangerous than  thofe from the  Second ;
 but thefe have nevertheless fometimes proved fatal. Hence in the
 eftimate  of the  danger of uterine hemorrhages at the  time of
 labour, it is neceffary  not only  to difcover the caufe, and to
 regard the quantity of blood  loft, but, above all other confider-
 ations, to attend to the effeft produced, which is infinitely greater
 in  one conftitution than in another, and varies  in all.  If any
 individual patient therefore be brought into a ftate of danger by
 the lofs of blood, great or  fmall, it feems incumbent upon us to
 put in praftice all the means in  our power for the removal oi
 the danger.   For any judgment formed upon the quantity  of
 blood  really or  apparently difcharged, will be liable to great
 errors, as concealment or accident may deceive us;  not  to
 mention that cafes fometimes occur, in which there may  be a
 greater quantity of blood loft, than can  be known, either by its
 being locked up in the uterus beyond the child, when the mem-
 branes are broken, or by being effufed into the ovum, when that
 has an appearauce  ot  being  whole.  This observation, of the
 neceffity of judging principally by the effeft of the lofs ot blood,
 deferves the moft ferious  refleftion, becufe, the time when we
 are to execute what reafon dictates, or experience authorizes us
 to do, will  chiefly depend  upon it.  It is alfo of great import-
 ance to recolle£t, that thofe hemorrhages are far more  danger-
 ous, in which an equal quantity of blood is loft fuddenly, or
 in a ffiort fpace of time, than  if it flows away flowly.  The im-
 mediate injury to the conftitution is greater in the former cafe,
 the veffels requiring Sometime to enable them to be accommodat-
 ed to the quantity of blood  remaining in them, in  order to carry
on the circulation.   A great and hidden lofs of blood alfo cre-
ates a fufpicion that the return of the hemorrhage is to be much
dreaded, becaufe if it fhould be equally protufe with that which
has already happened, it may occafion the death ot the patient,
before we have time to put in  praftice, or reap the advantage, of
what we fuppofe to be the  only method of removing the danger. 
            ANOMALOUS, OR COMPLEX LABOURS.        l6l
                         /
   In hemorrhages the danger is indicated by the weaknefs and
 quicknefs ot the pulfe, or by it* becoming and continuing im-
 perceptible ; by a general  paleneSs and coldneSs of the body,
 and by a ghaftly countenance ; by inquietude, or by»continual
 faintings; by a high and laborious rcfpiration, and by convul-
 fions.   The two laft are ufually mortal*Symptoms ; yet when
 patients are reduced to a certain ftate of weakneSs, they are liable
 to hyfteric affections refembling convulfions, that  arc equally
 alarming, but by no means So dangerous.
   When patients have Suffered much from lofs  of blood, they
 will often have a Sudden and violent  fit of vomiting; and fome-
 times under circumftances of fuch extreme debility, that I have
 fhrunk with apprehenfion, left they fhould have been deftroyed
 by a return or increaSe ot the hemorrhage, which I concluded
 was  inevitable after fo violent an effort.  But there is no reafon
 for this apprehenfion ;  for though the vomiting  may be confi-
 dered as a proof ot the injury which the conftitution had  Suf-
 fered by the hemorrhage, yet the aftion of  vomiting contributes
 to its Suppreffion,  and to the immediate relief of the patient ;
 perhaps by fome  revulfion, and certainly by  exciting  a more
 vigorous  aftion of the remaining  powers of the conftitution,
 as is proved by the amendment of the  pulfe, and of all other
 appearances immediately after the vomiting.
   A  tolerably juft opinion may be formed  of  the danger of
 uterine hemorrhages, in advanced  pregnancy, by the pain with
 which;they  are attended.  An equal hemorrhage without pain,
 is always raore dangerous than if the  pain be regular and acute,
 and the danger  is leffened as the  pain increafes.  In the moft
 dangerous hemorrhages, there is no  pain whatever,  or none of
 confequence, and  patients have  often  died, or been brought
 into the moft imminent danger,  that is, into Situations from
 which it was fcarcely poffible for  them to recover, whilft the
 praftitioner was waiting for the acceffion of the pains of labour.
 The reafon was before mentioned.   The pain proves the degree
 of the  action of the uterus, and the a£tion of the  uterus proves
 that the powers  of the conftitution are not exhaufted.  In very-
 bad cafes there is before delivery an  effort in  the uterus  to aft,
juft fuificfent to caufe a renewal of the hemorrhage ;  but imme-
 diately upon the difcharge of a gufli of blood, the effort, toge-
 ther  with the little pain attending, ceafes ;  and in this manner
 patients would fometimes proceed to  the moment  of their death,
 unlefs they were relieved by art.
Vol. II.                  W 
i6s
INTRODUCTION TO MIDWIFERY.
                       SECTION VI.

    Those hemorrhages, which are occafioned by the attachment
  of the placenta over th$ os uteri, are firft to be confidered, be-
  caufe they are attended with the greateft danger, and becaufe
  Some part of their treatment will apply in the other cafes to be
  defcribed.
    Though the placenta be attached "over the os  uteri, the wo-
  man ufually goes through the early part  of her pregnancy with-
  out any inconvenience, or any Symptom, at leaft  which denotes
  that circumftance.  But  when the  cervix of the uterus is dif-
  tended to a certain  degree, or  when the changes  previous to
  labour come on, there muft be a hemorrhage, becauSe Such dis-
  tention, or change,  will neceffariiy  Separate a part of the pla-
  centa.   This hemorrhage  is often, but not always, in proportion
  to the fpace of the  placenta attached over the os uteri, or to
  the  quantity feparated, for women  have fometimes been in as
 , great danger when the mere edge oi the placenta was fixed upon
 "the os uteri, as if the middle had been placed over it.
    When  hemorrhages from this caufe once come on, though
  all  women without, proper affiftance would not die,  they  are
  never  free from poffible  danger, till they are delivered.  As
  there is a  very doubtful  chance of the accomplifhment of the
  delivery by the pains of labour, and as experience has fully
  proved the infufficiency of all other methods, intended to fup-
  prefs the hemorrhage,  and how little  reliance ought to  be placed
  on  them, though they are always to be tried ; it is a praftice,
  eftablifhed by high and multiplied authority, and Sanctioned by
  fucceSs,  to deliver  women  by  art, in all caSes  of dangerous
  hemorrhage, without confiding in the refources of the conftitu-
  tion*.  This praftice  is no longer a matter of partial opinion,
  on  the propriety of which we may think ourfelves at liberty to
*  debate ;  it has for near two  centuries met the confent and ap-
   probation of every  praftitioner of judgment and reputation, in
   this and many other countries.
     There is much comfort in knowing and poffeffing a remedy,
   to  which we can recur, with a more thaa equal  chance ot fuc-
   cefs, in any cafe of great and imminent danger.  But though
   it fhould be allowed, that the artificial delivery  of the patient,
   in every cafe of dangerous hemorrhage,  in advanced pregnancy,
   is expedient and neceffary for the prefervation of the  life of the

      * See Mauriceau, and almoft every Jucceeding writer. 
ANOMALOUS,  OR COMPLEX LABOURS.        l6g
patient; and  though the  praftitioner,  who  fliould negleft it,
would be  very reprehenfible ; yet the neceffity, prefuming it
to arife Solely from the lofs of blood, or that expediency, which
conftitutes the authority for the operation,  and which is now
clear and diftinft  to another, may not appear to me.   Befides,
fhould the neceffity  be acknowledged,  and the praftice ap-
proved, there may be much difpute and  difference ot opinion
about the time when the operation ought to be performed.
  It would be ot great advantage in praftice,  it fome mark were
difcovered, or fome fymptom  obferved, which would indicate
the precife time  when women  with hemorrhages  of this kind
ought to be delivered.  But though we do not at prefent know
any fuch mark or fymptom, and the determination of the time
is to be made by the judgment of each  individual praftitioner,
we  may be permitted to ftate what v/e do know  in  the  moft
convincing point of view.
  Admitting then, in the firft place, that  women having ute-
rine hemorrhages from this caufe, in advanced pregnancy, are
not in fafety till they are delivered ;  that  the natural efforts are
generally  unequal to the expulfion  of the child ; that the he- j
morrhage can only be flayed by the evacuation ot the contents
ot the uterus, giving an opportunity to the  veffels to contraft
and to clofe ; that thefe Salutary  effefts  may  be  produced as
certainly by an artificial  extraftion, as by a natural expulfion
of the child ; and if it be moreover true, that the  operation,
though' performed before  it is  abfolutely neceffary, is no/ at-
tended with danger, if it be performed in  a proper manner, and
with due care ;  but that it the operation be delayed beyond the
proper time, it  will not anfwer  the  purpofe for which  it is
recommended ; we may from thefe premifes  conclude, that  a
woman under the circumftance of dangerous  hemorrhage ought
to be delivered by art, if  the natural efforts  be unequal to the
expulfion  of the  child ; :hat  it is better to deliver  too fooi  ,
than to delay the delivery a moment too long  ; and that in every
cafe of doubt, it is a proof ot wifdom to decide, and determiiie *
upon fpeedy delivery.
  If  however we were certain that the placenta was  attached
over the os uteri, it would  feldom be neceffary to deliver wo-
men on the firft appearance of the hemorrhage ;  yet  that  will
be fufficient to awaken our  apprehenfions, and fet us upon our
guard.  Nor does it often happen that  a fecond or even a third
diScharge obliges us to proceed to deliver immediately : becaufe
each return may not be in  Such a quantity, as by  its violence
or  continuance  to endanger the life of the  patient, or very 
164            INTRODUCTION TO MIDWIFERY.
much to reduce her  ftrength ; and  Such an interval may  p?fs
between the returns, as to give time and opportunity for repair-
ing the mifchief done by one lofs of blood, before the return
of another.   Nor is delivery by art neceffary, or ufually  pro-
per, when the hemorrhage is  abating.  There are cafes how-
ever, in which the quantity of blood loft, the SuddenneSs of the
difcharge, and the effeft produced, are fuch with one hemor-
rhage, as to  make it evidently unfafe to truft a return ; and
whenever the  countenance, and  other  appearances, indicate,
that the constitution is much impaired, by repeated, though not
profufe difcharges, the ftrength  is undermined,  and  danger
creeps on certainly, though infiduoufly.  For we may prefume,
that every conftitution is capable of bearing the lofe of a cer-
tain quantity  of blood, without the inftantaneous hazard of life,
and this will depend upon the general ftate of the body.  Now
the body may be reduced to fuch  a ftate, that there  is barely a
fufficient quantity  of blood, or of powers, to carry on the bu-
finef* of life,  upon a very nice balance ; and of courfe the addi-
tional lofs ot  a fmall  quantity may altogether deftroy the power
of living, and  the patient  die of the hemorrhage,  though the
quantity of blood  which fhall immediately precede  her death
may be fmall ; but unfortunately ffie was able to bear the lofs
of none.   We fliould therefore, though careful not to aft raffily
and unadvif'edly, not only be on our guard againft the effeft  ot
rapid and p. of ufe difcharges, but againft thofe  which are  pro-
ductive of as  much danger, on account of their returns, though
lefs in degree at any one time ; we fhould ever call to mind the
poffible evil of delay, and recolleft that there is little danger in a
premature  delivery,  if the operation be  performed with pru-
dence.
   Thofe who are young in praftice, or of timid  and anxious
difpofitions, often fuffer much Solicitude  from the apprehenfion
of danger, when it does not exift in thefe cafes, which, tor many
reafons, I confider as highly proper for a confultation, when it
can be procured.
   In Some cafes, in which it has been prefumed to  be neceffary
to deliver the patient on  account  of the  hemorrhage, the  parts
have  been in  Such a  ftate, that the operation  could not, it was
thought, be  performed with Safety.   Whenever the  cafe de-
mands the operation, on account of the danger of the hemor-
rhage, the ftate of the parts will always allow it to be performed
with fafety, though not with/equal facility  ; and though it may
often be ncceffaiy to determine Speedily  upon  the propriety of
the operation, this Should never be performed raffily, but always 
ANOMALOUS,  OR COMPLEX  LABOURS.         165
with the utmoft deliberation and flowneSs, even though it might
admit ot hafte.   For in hemorrhages a woman may perifh from
two errors in praftice ;  from delaying the operation too long,
and from the rude, violent, or improper manner, in  which it
may be performed.
  !S ifficieiit notice hath been taken of the  danger of precipi-
tating, as well as that of delaying  the delivery, in cafes of he-
morrhage.   With refpeft to the operation, the firft part, that is,
as far as relates to the pofition of the patient, the introduftion
of the hand, and the dilatation of the  os uteri, has been already
defcribed under preternatural prefentations.   When the os uteri
is with great caution fufficiently dilated,  to allow of the ready
admiffion of the  hand, and we come to the placenta  attached
over it, it is of  no confequence whether we begin to Separate
this  till we come to an edge, and go up on the  outfide of the
membranes, which may be ruptured at pleafure or whether we
perforate the fubftance ot the placenta, and conduft  the hand
direftly into the ovum, though by the  latter method there is
rather more danger ot  lofing the  child.   In either cafe, with-
out regard to the pofition of the child, we muft proceed to and
lay hc»d of its,  feet, carefully diftinguifhing that they are the
feet, before  we begin to extraft them.  Immediately on our be-
ginning  to  withdraw the hand, which  fhould be done with a
flow waving motion, the waters of the  ovum flow away ; and
while  they are flowing, we muft  withdraw the hand, grafping
the feet of the child, till by flow degrees thefe are brought into
the vagina.   We are afterwards to wait till the uterus contrafts,
and then gently  bring the feet through the external parts.   It is
not improbable but we may then have the powet of finiffiing the
operation very Speedily ; but though the child were extrafted,
if the uterus did not aft, and, as it were, follow the child, as
there would be a chance of the hemorrhage  returning, the child
fhould be withdrawn according to the degree of the contraftion
of the uterus,  which will be known either by the application
of the hand to the abdomen, or by the pain.  Nor is there any
occafion at this time for hurrying the delivery, as the hemor-
rhage ufually ceafes as foon as the child is turned, in confequence
of the compreffion made upon the orifices of the veffels, by the
inferior parts of the child, as well as by  the contraction  of the
uterus.  If the labour-pains be at all efficient at this time, it
would be proper to leave the breech of th«» child to be expelled
by them ; but if they be not fufficiently ftrong for this purpofe,
affiftance  muft be given, gently extrafting by the feet  only dur-
ing the continuance of a pain, not with force Sufficient to bring 
l66           INTRODUCTION TO MIDWIFERY.
it away, but with the view of aiding the feeble power exerted
by the pains, imitating alfo the pains in the manner of extraft-
ing.  When the breech of the child has paffed through the ex-
ternal parts, the delivery muft be haftened,  as there is then dan-
ger of the child being deftroyed by the preffure upon the funis.
Yet under fuch circumftances there is often a better chance of
preferving the child, by leaving it  to be wholly, or in a -great
meafure expelled, than  by extrafting it with violence, as hath
been before  obferved.
  When the child  is born, it the  operation  were flowly per-
formed, there  is  not ufually any  continuance 01 return  of the
hemorrhage, v.nlefs from the blood prcvioufly difcharged, and
locked up behind the body of the child ; but if the hemorrhage
fhould return,  the cafe muft be managed, as will be recom-
mended, when we fpeak ot a hemorrhage with a retained pla-
centa.  If there 'iv no hemorrhage, and the placenta be retained,
we  muft be  particularly cautious not to hurry  it away  ; but in
thefe cafes it is commonly expelled  with great eafe, and we have
leSs occafion to  be  felicitous, becaufe from  the part where it
was originally  attached, it more readily admits of affiftance  if
required.
  Should nothing uncommon happen in the delivery,  children
will often be born alive, in cafes of hemorrhage, which were
extremely dangerous to the mother ; and there have been many
inftances in which the delivery being too long  delayed, a  living
child  has  been extrafted, after  her death.  In all  cafes of
danger, thefe in particular, the fafety of the parent, and the pre-
servation ot the child, are events which give inexpreffible fatis-
faftion, and  adorn the reputation ot the praftitioner.


                    SECTION  VII.

  It  was  before obferved,  that thofe hemorrhages which are
occafioned by  the feparation ot a portion  or of the whole pla-
centa, originally attached to  any part of the uterus, except the
cs ute^i, were  not generally fo dangerous as thofe laft defcribed.
But if the feparation be extenfive and Sudden,  they will be
equally alarming, the real danger may be as great, and  the Same
method ot proceeding, that is, Speedy delivery by  art, may,
though not  So generally, be required.   The feparation may be
occafioned by  great violence from external  accidents  in the
latter parts of  pregnancy ; or in Some  intenSe  fit of fainting or
of  laughter  ; and fometimes the whole or a very large part of 
ANOMALOUS,  OR COMPLEX LABOURS.         167
the placenta will be feparated Suddenly,  without any  accident
or fymptom which could give warning  or apprehenfion,  that
fuch an event was to be dreaded.  The feparation of  the pla-
centa may then  happen previoufly to the commencement,  and
it is  not furprifing that  it fhould  fometimes occur during any
period, or ftage, of labour.
  When Sudden and violent difcharges of blood happen to wo-
men with child, in advanced pregnancy, from external  acci-
dents, it  the patient be kept in a cool and compofed ftate, the
difcharge  may  ceafe, and without any return, the patient may
go on to her full time, and be delivered by her natural pains, as
if no fuch accident had happened ; though the child will often
be ftillborn.  Sometimes however the hemorrhage will return,
or it may  cemmence in any ftage of a labour, and our conduft
muft be regulated by the degree and probable confequences of
it, and by the ftate of the labour when it was firft difcovered.
   If any  confiderable hemorrhage fhould  come on in the be-
ginning of a labour, or previous to it, and if the treatment muft
in any meafure depend  upon the caufe, it is neceffary in the
firft place that we  fhould decide whether the placenta be attached
over the  os uteri, or be caSually Separated.   Before there is
fome degree of dilatation ot the  os uteri, be the difcharge ever
fo protufe, and it may even at this time be exceffive, I do not
know  that it is always poffible to tell with certainty  whether
the placenta prefent  or not.  It  may  indeed be conjeftured,
that the placenta is there attached, by the cufhion-like feel of
the  cervix and lower parts of the uterus ; and when the os
uteri is Somewhat dilated, inftead of the membranes, the fleffiy
fubftance  of the placenta  may be diftinguifhed.  Yet every
praftitioner knows how very different the Slate of thefe parts is
in  the  beginning of  labour,  and how difficult  it muft be to
diftinguifh between a firm coagutum of blood and the placenta ;
not  to mention that fo fmall part of the placenta may be attach-
ed over the os uteri, that unlefs we could pafs the finger com-
pletely round the circle, which is fometimes almoft impoffible,
it could not be  difcovered.  Taking therefore into confideration
all the varieties occafioned  by either of'the  caufes of hemor-
rhage, and knowing that neither the performance of the  oper-
ation,  nor the event,  is materially different,  whatever may be
the  caufe,  provided the diScharge and its effeft are equal, we
muft be careful, that we are not deceived by attemps  to  make
too  nice diftinftions*.

   * See  an Effay on this Jubjed written by Mr. Rigby, an
able and experiencedJurgeon at Norwhich. 
l68           INTRODUCTION TO  MIDWIFERY.
     From a cafual or fpontaneous Separation of the placenta, not
  attached  over the os uteri, a  hemorrhage may happen in the
  beginning of labour,  when the os uteri, foi example, is not in
  any degree dilated ; or when it is dilated to a third-or half its
  extent, or any other degree.  If the difcharge fhould be fo great
  as to require Some prefent meafures for the relief of the patient,'
  the methods  before advifed muft be put in  praftice, and the
  common  affiftance for promoting the dilatation muft be given,
  till we can feel diftinftly the membranes  of the ovum, which are
  to be ruptured.  By the difcharge of the waters the diftention
  of the uterus will be leffened,  the fize  of the blood veffels  of
  courfe diminifhed, and the hemorrhage  in general  immediately
\ removed  or very much abated.  By the Suppreffion  or abate-
  ment of the hemorrhage, the aftion of  the uterus will be ren-
  dered Stronger, and the delivery often completed ina fhort Space
  of time without farther affiftance, efpecially if the  patient  have
  before had{ children.
    In  every cafe of  dangerous  or  confiderable  hemorrhage,
  when we can diftinguifh the membranes,  it therefore feems  to be
  right  and justifiable to puncture or rupture them, and to dif-
  charge the waters.
    But if  the hemorrhage fliould come on in the fecond ftage of
  the labour, that is, after the full dilatation  ot the os uteri, and the
  rupture of the membranes,  when the child's head has entered
  and in part defcended into the pelvis ;  if the difcharge  be of
  fufficient importance either to prevent the aftion of the uterus,
  or to bring the life ot the patient into hazard, by its  violence
  or continuance : then the affiftance given muft depend upon
  the progrefs which the  labour has made,  and the fituation of
  the child, whether it fhall be turned, as in preternatural presen-
  tations, or  delivered with the Jorceps or vedis ; or when nei-
  ther of thefe  is practicable, and the  exigency of the cafe jufti-
  fies the operation, by leffening the head of the child ; that  is,
  the life of the  parent muft at all events, it  poffible, be preferved ;
  but fuch  cafes are rare, and always  require accuracy of judg-
  ment, and the greateft circumfpeftion.
    Hemorrhages ot this  kind are alfo Sometimes combined with
  preternatural presentations of the child.   Then little more will
  be required,  than what may  be neceffary on account of the
  prefentation, except that it be  Sooner decided, and  more Spee-
  dily  performed;  remembering  ever,   that all  operations  in
  midwifery are intended to remove, leffen or prevent natural
  or adventitious danger, and not to  add to that which  before
  exiffed. 
            ANOMALOUS, OR COMPLEX LABOURS.         169

   This method ot proceeding, that of accelerating the labour by
 breaking the membranes, recommended in this kind of hemor-
 rhage,  feldom fails to anfwer the intention of moderating or
 fuppreffing the difcharge, and of promoting the labour in fuch
 a manner,  as to remove the danger.   The only inconvenience
 to be apprehended is, that if the hemorrhage Should  continue
 in fuch a  degree, as to occafion  the  neceffity of artificial
 delivery, the operation would  be rendered  more difficult on
 account of the previous difcharge of the waters.   But in reply
 to this  objeftion it  may be obferved, that if the  uterus fhould
 contraft round the body of the child, with fo much force as to
 prevent  the introduftion of the hand to turn the child with  fa-
 cility, that it will probably be expelled without any farther affift-
 ance, if we wait  patiently for the return of the pains, which we
 may  fafely  do when  the hemorrhage  is  flayed, or very much
 abated.  But if in common cafes there be not fufficient force
 exerted by the uterus for the expulfion ot the child, then there
 will be no  great difficulty in paffing the  hand into the uterus.
 It  muft* however be  acknowledged, that  this  is  fometimes
 amongft the cafes, for which no  precifc rule can be laid down,
 and in which the praftitioner muft aft according to his own
 eftimate of the danger and difficulty.


                     SECTION VIIL

   It is often a mortifying refleftion,  whilft we are conducting
 a patient through a labour rendered uncommonly tedious by the
 inaftivity or irregular aftion ot uterus, that we can forefee  af-
 ter the birth of the  child an unfavourable  feparation of the
placenta, which cannot be prevented.   All that art has diftated
 to be done  in this cafe is, to fuffer the  body of the child to be
 wholly expelled by the aftion of the uterus, after the head is
 born ; or in fome cafes rather to retard its final expulfion, than
 to ufe any  force or  hurry  in extrafting it, by which proceed-
 ing the lower parts of the cavity ot the uterus will  be reftrained
 from clofing before the Jundus aflumes its proper Share oi  ac-
tion.   Yet  no method, nor any dexterity will be fufficient in all
cafes to prevent, after the "birth of the child, a troublefome, and
fometimes  a, dangerous hemorrhage; the proper  management
of which often requires as acute an intelligence, and as  deter-
mined a conduft, as any  circumftance which relates  to  the
birth of the child.  As the powers of the uterus or of the con-
  Vol. II.                  X 
1/0
INTRODUCTION  TO MIDWIFERY.
ftitution  are fometimes not exerted, or fail to anfwer the pur-
pofe, and as no  woman can be properly or fafely left till  the
placenta  is excluded, it is neceffary to confider  this fubjeft in
a full and explicit manner.
   From a review of what has been faid on the management of
the placenta  by  Hippocrates, or in the writings contained in
his works, it does not appear to have been the general cuftom,
to divide the Junis before the placenta was expelled ; that if
this were retained beyond the common time, no means, or  but
very gentle ones, were ufed for the purpofe of bringing it away ;
and in cafes of its retention, it was ufual to introduce medicated
fubftances into the vagina, and to give hyfteric  medicines for
the purpofe of favouring its expulfion,  which might happen on
the fourth  or  fifth day, when it  was  in a putrid ftate.   The
introduftion of  the hand  into the  uterus for the purpofe of
bringing away a retained placenta, had  not  been advifed or
come into confideration, and fuch cafes would  probably very
Seldom occur.   Whether  this praftice were gradually altered,
or another haftily affumed, it is impoflible to Say ;  bur*it is  ex-
traordinary, that Celfus*, without expecting or relying upon
the natural efforts made to ejeft the placenta, of which he feems
indeed to have had an imperfeft knowledge, fhould have direft-
ed the practitioner to introduce his hand into the uterus,  im-
mediately after the birth ot the child, to bring the placenta away,
together  with any coagula, which might have been formed in the
cavity, of the uterus.   Thefe t\«o  contrary methods have, in
different  times and countries, been adopted and  recommended
by fucceeding  writers; but unfortunately; the praftice oiCelJus

   *■ Medicus  deinde finifira manu, leniter trohere  umbilicum
ita, ne  abrumpat,  dextraque cum fequi ufque  ad  eas, quas
fecundas vacant, quod velamentum infantis intus fuit :  hifque
ultimis  apptekenfisy venulas membranulafque  omnes,  eadem
ratione mann  didttcef&a<vutva?totumque illud extrahere, et,jt
quid intuspraterea concreti Janguinis remanet.

                                Celfus, Lib. vii. Chap. xxix.

    / may be permitted to obferve, that many of the popular
 opinions, on medical fubjeds, are now the fame inihis country,
 as thofe entertained by  the Roman writers.  It  is probable',
 that they were firft  introduced by  thofe pkyficians  and fur-
 geons who attended the Roman army  in Britain, and not ac-
 quired by the Jiudy oj their writings. 
            ANOMALOUS, OR  COMPLEX  LABOURS.         171

 prevailed  more univerfally.   The Arabians, though fond oi
 the ftudy ot medicine, feem rather to have preferved, than im-
 proved or extended the learning which they gained when they
 plundered the eaftern part of  the Roman Empire.  But in the
 fifteenth  century, which  may be confidered as the era  of the
 revival of learning, Pare' publifhed,  among many valuable
 works, obfervations on the praftice of Midwifery, under the
 title, of the Generation of Man.   Pare'*, who had an under-
 ftauding to fee, and to profit by the errors of others, feems defi-
 rous of avoiding all  extremes ; for with an injunction not to
 leave the placenta behind, he recommends, in ftrong and repeat-
 ed terms, the  neceflity of extreme caution, not to ufe violence,
 left we  would invert, or do other injury  to the' uterus ;  and
 there is no doubt,  but the opinion of fo eminent a man muft
 have had its influence upon the praftice and  writings of others,
 particularly of thofe of his own country.  In the latter end of
 the laft, and the beginning of this century, Ruyfcfi was in high
 reputation as an anatomift at   Amfterdam, and he was empow-
 ered by the magistrates to inSpeft and regulate the praftice of
 midwifery  throuhgout that city.   Ruyjch had great induftry
 and abilities ; and his purfuits in anatomy, and hi*  office, as
 prefident of the Obftetric  College, leading  him to the know-
 ledge of many bad confequences, which followed the common
 method of managing the placenta, particularly the inverfion of
 the uterus, he laboured the point with great  knowledge  and
 ingenuity in many  parts  ot bj}s works ; difcountenanced  the
 praftice, and forbad the placenta to be extrafted haftily, choof-
 ing clearly to run the hazard of the evils, which might follow
 the imperfections of nature, rather than of thofe which would
 be incurred by the harfh and violent methods then in ufet.  For

   * Not having the French edition ojTare, Itranfcribe the fol-
 lowing from the Latin tranflation.   Molli Jifieripoteft umbi-
 lici tradu ; quod Ji fie non licet, obfietrix oleo inundum ma-
 num, blande in uterum immittat, ducem Jecuta umbilicum, fic-
 que comprehenfas,fi adhuc hareant utero,  leniter hac et iliac
 concutiat, et Jic concuffas, leniter extrahat ; non autem vi-
 olentius'idjjfcal, ne una Jequens  uterus procidat.

   .t Prudentius ergo relinquereplacentam, donee natura hanc
Jeparat, aut donee laxata, magifque libera, manu evellere hanc
 detur, quam lethalifejlinatione occidere agram.   Putetne quis,
 boni quid contigiffetrucidata, mulieri, quod mortua fit fine pla-
 centa ? Qua cum ilia poterat vixiffe! Ruyjch. Adverf. Anat. Dec.
 Secunda.—So-mc allowance is to be made Jor the arguments oj 
-: 172
INTRODUCTION  TO MIDWIFERY.
   many years after the time of Ruyfch, the praftice of Celfus was
   followed in this  country, by fome even down to this time, but
   not  univerfally; tor in a large manufcript, written on the fub-
   jeft  of  midwifery  by Dr.  Percival Willoughby, Phyfician  at
   Derby,  in the time of the Civil War, a copy of which  came
   into my poffeffion by the kindnefs of my very able and intel-
   ligent  friend, Dr.  Kirkland,  there is  in this observation ;  the
   cfterbirthe oft comt~th ofitfelfe, yet it is not amiffe to qffift na-
*  ture for the producing  of it.   There bee fome midwiues, that
   never offer to fetch the after bir the, but Juffer nature to expell
   it, and their women have done well.  The practice of extrafting
   the placenta, immediately after the birth  of the child, was ne-
   vertheless Common in this country, which 1 am  certain muft
   often have produced both much immediate and future  mifchief.
   It was taught in the fecond fchool of midwifery  eftablifhed in
   London by Chapman in 1733 ; by Sir Richard Manningh&m,
   in the public eftabliffiment Set on foot for the purpofe of teach-
   ing  midwifery, in the St. Sames's Infirmary, in  the  year 1738 ;
   and by Smellie,  who I think came to London in the year  1742.
   Soon after this time, in 1746, Dr. William Hunter hegan to give
   Jcftiires in anatomy ; as an appendage to which,  he added a
   certain  number of leftures on the anatomy and  phyfiology of
   the  gravid uterus, interfperfed. with  many  praftical obferva-
   tions.   With a mind Compofed and finely turned for obferva-
   tion, with a judgment exceedingly correft, and  with unwearied
   application, Dr. Hunter foon acquired very high and deferved
   reputation ;  and the great charafter he eftablifhed in the prac-
   tice of midwifery, for which his perfon and manners were admir-
   ably well calculated, and in which he was foon and very much
   engaged, gave a more than ufual authority to what he advanced
   on, the  fubjeft.  * Being an affociate with Dr. Sandys for the
   care of the  lying-in department in the Middlefex Hofpital, he
   propqfed to Dr. Sandys, that  they fhould try the event ot leav-
   ing the  placenta  to be expelled by the aftion of  the uterus,
   "without attempting to give any affiftance.   After much confi-
   deration and fome delay, from the dread of cenfure, they agreed

          * This account I had from Dr. Hunter himfelf.

   Ruyfch, which  were intended to overfet the bad pradice of his
   time.   For if the placenta were to be left entirely to  nature in
   all  cafes, there  would not be wanting many examples of mif-
   chief and fatal confequences from the very method  which he
   recommends.                                          . 
ANOMALOUS,  OR COMPLEX LABOURS.
»73
upon the trial ;  and in the firft inftance, the placenta remained
twenty-four hours.   No  ill  confequence however followed ;
and the trials being repeated with fuccefs, it became a very fre-
quent, and  almoft general rule, to leave the placenta to be ex-
pelled without any affiftance.   Several untoward and fome fatal
accidents having followed this praftice, was altered  ; at leaft it
became neceffary to admit many exceptions ;  and after a variety
ot changes  and  observations, I believe we are at length arrived
at a ftate of praftice, with regard to the managemen of the pla^
centa, that will with difficulty be improved ; a praftice founded
on common SenSe  and observation, that  ihe placenta  ought to
be, and is  generally expelled by the  aftion of  the uterus,  in
the fame manner as the child ;  feeling ourfelves at liberty, and
called  upon to  affift, only when this  aftion is not equal^ to the
purpofe, or when a hemorrhage or other dangerous circum-
ftances demand our affiftance.
                     SECTION  IX.

  In  the courfe of ten  or twenty  minutes, or a longer time,
after the birth of the child,  Sooner or later, according to the
condition of the patient  at the time of her delivery, the aftion
of the uterus returns for the purpofe ot expelling the placenta
and membranes, which collectively have the common name of
Secundines, or afterbirth.  This aftion is indicated by pains, in
all refpefts like thoSe the patient had before the child  was born,
excepting their degree.  When  thefe pains come on, it is cuf-
tomary, to take hold of the funis, by which it we pull (lightly,
the evacuation of the placenta out of the aterus will be  for-
warded, without the rifle  of doing any kind of injury to the ute-
rus.  The placenta and membranes formed a complete lining
to the uterus : but the placenta  coming away firft, and then the
membranes, the whole is ufually expelled in an inverted ftate;
yet not always, as the feparation  of the placenta is in fome cafes
fo fpeedy, that  it drops  into the vagina, and pufhes the mem-
branes before it.  But though the placenta is generally expelled
in a ffiort time after the  birth of the child,  and with the return
ot a few pains, it is fometimes retained, on  account, iff. of the
inaftion of theuterus;  or ad.ot the irregular aftion ot the ute-
rus ; or 3d. of a fcirrhous adhefion ot the placenta to the uterus.
It may be retained beyond the uSual time, without any hemor-
rhage, but whenever there is a  discharge of blood, the whole
•r a  portion of it muft have been previoufly feparated ;  and 
174          INTRODUCTION TO  MIDWIFERY.
   the hemorrhage may continue, or increafe, or ceafe and return
   in thefe cafes, till the placenta is extrafted or expelled.  Every
   difcharge of blood  at this time, properly Speaking,  is  a  he-
   morrhage ;  but to this term, together with the other parts of the
   definition, we annex the idea of fuch a  lofs ot blood*, as,  by its
   continuance or degree, nny  be apprehended to  occafion dan-
   ger, which we are ever to bear in mind ;  or on every flight dif-
   charge of blood, we might be led to make unneceffary attempts
   to extraft the placenta.
    A very Strenuous, and long  continued exertion of all  the
   powers of the conftitution is often required for the expulfion of
   the child.  Thefe powers, though  generally adequate to this
   effeft fometimes fail before it is accomplished.  But experience
   having ffiewn, that difficulties, to our apprehenfion infurmount-
*   able, are very frequently overcome by the natural efforts, both
   reaSon  and  humanity  diScourage  all hafty determinations to.
   purfue Such meaSures, as  may affeft the Safety of the mother or
   the child..  But as there  is a leaven of imperfe£tion in all hu-
   man aftions, animal  as well as mora), we may fometimes be led,
   by the moft commendable motives,- to defer that affiftance, which
   any particular caSe may require, fo long, that after the  birth of
   the child, the patient may be in fuch an exhaufted ftate, and
   the uterus fo completely diveltedof all power of farther aftion,.
   that it is neither difpofed  nor able to feperate or ejeft  the pla-
   centa ;  and fhe is Scarcely able to fupport the neceffary confe-
   quences of her delivery.  The mere debility  of the patient is
   therefore often a powerful reefoii^why we ought  to wait,  with-
   out making any attempts  to haften the feparation or extraftion
   of the placenta ; as an immediate feparation, natural or artificial,
   would  render her Still more exhaufted and feeble, and greatly
   increafe the  danger arifing from that debility, which before ex-
   isted.   Sometimes alfo  when  a labour has gone on with greafc
   aftivity, there js, for a confiderable time, and from the moment
   of the expulfion of the  child, even  though the labour  may not
   have been very fatiguing  or flow, a total inaction of the uterusj
   for which no reafon can be affigned.  But if the time, which
   paffes between the birth of the  child and the  expulfion of the
  placenta, be employed in compofing the patient's mind, in
   cooling her when overheated, or in Supplying her with proper.
  • gordials when  much fatigued and wearied with the preceding
   circumftances, in Short, in reftoring her to her natural ftate, it,
   generally happens, and we may reafonably expeft the aftion of
   the uterus to return, and  make its efforts to throw off  the pla-
   centa in the ufual manner, though more time may be required* 
ANOMALOUS,  OR COMPLEX  LABOURS.
l75
But during this time of waiting for the aftion of the uterus to
return, fhould a hemorrhage come on, we muft apply ourfelves
to the ufe of thofe means, by which  the feparation and exclufion
of the placenta may be forwarded  ; there  being (in a cafe of
hemorrhage equally  urgent) as justifiable a reafon for  the  re-
moval ot die placenta, when  that is retained, as there  was for
the extraftion  of the child.  But  every difcharge of blood is
not a  fufficient reafon for  the introduftion  of the  hand, or  for
the artificial extraftion of the placenta, as fome loSs of blood
moft frequently   precedes, and always  accompanies both its
feparation and exclufion.  We muft therefore form a judgment
ot the neceffity of extrafting  the placenta, by the opinion we
entertain of the hemorrhage being So profuSe as to  endanger the
life ot the patient by its continuance or probable increafe.
Sometimes alfo coagula are difcharged in confidewble quantities,
which trom  iheir appearance may  be  fuSpefted  to  have been
formed  long before  labour, by an effufion of blood into  the
ovum, from the rupture of fome veffel which ran over the fur-
face of the placenta ; which coagula do not indicate any dan-
ger.  It is not exaftly in  order, but  it  muft  neverthelefs.be
obferved in this place, that when I have been attending women?
who were prone  to violent hemorrhages after  the birth of  the
child  in former labours, I have made it a rule to keep them in
an ereft pofition, till the waters were difcharged by the fponta-
neous 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 afted  more favourably,  the placenta came away
more naturally, and the quantity of blood loft was very much
diminished.
  When the placenta is not feparated or ejefted in due time af-
ter  the birth of the child, with or without a hemorrhage, means
muft be ufed for the  purpofe of its exclufion or extraftion.  If
there be no hemorrhage, or none of  importance, it is always bet-
ter  to wait than  to interfere, becaufe flight attempts to extraft
the placenta by pulling hy^he funis may be juft fufficient,  by
loofening  a portion of the placenta, to occafion or increafe a
hemorrhage} and  not equal to the extraftion of the placenta ;
and fuch conduft is a very frequent  caufe of a degree of hemor-
rhage, which may lay us under the neceffity of  introducing the
hand  into the uterus, in order to bring  away the placenta,
which operation might not otherwife have been required.  But
after a certain time, which is too  indefinite a term if we  were
authorifed to ufe one more precife, but certainly not within one
hour after the birth  of the child, unlefs we arc compelled  by 
          17^           INTRODUCTION TO MIDWIFERY.

         hemorrhage or  fome untoward  fymptom, gentle means are to
         be  ufed to favour its  exclufion : and the moft gentle mult
         be firft tried, as  by giving and frequently repeating fome aftually
         warm and temperate cordial, which may renew the  difpofition
         in the uterus to  aft ; by change of pofition, or by making a mo-
         derate preffure  with the expanded hand upon the abdomen to
         aid  the aftion of the uterus  ; or by pulling very moderately by
         the  funis, to try whether it  be difpofed to come away.  As the
         term moderate has  no precife meaning, and what I call violent,  a
         may by another  called moderate, we will fay that fo much force
         is on account to be ufed in pulling by the funis, as to incur the
         rifque of tearing it from the placenta, or ot inverting the uterus ;
         and that it is better to make it a general rule, to prefer the in-
         troduftion of the hand into the uterus, to feparate and bring the
         placenta away, than to incur the hazard of either of thofe acci-
         dents.  It is however to be obferved, that when the hand is in-
         troduced  for this  purpofe, there is not always a neceffity of
         afting ; for the  very irritation thereby occafioned will often
         excite the uterus to its natural aftion, and the placenta be both
       N (Separated  and expelled,  as  will be recollefted by every one
         accuftomed to this operation.  But the hand ought never, on
         any  account, to  be introduced into the uterus, except as a mat-
         ter of neceffity,  and then with the utmoft care and tendernefs ;
         and  when  introduced, fhould never be withdrawn, till the end
         for which it was introgpced  is, it  poffible, accomplished.
           In the writings, and in converfations on this fubjeft, the in-
         troduftion of the hand, for the purpofe of bringing away a re-
         tained placenta,  is often  mentioned as a flight thing ;  but I am
         perfuaded, that every perfon, who  attends to  the confequences
         of practice, will  think it  of  importance, that, if poffible, it  al-
         ways ought to be avoided.
           To promote the feparation and exclufion of the placenta, the
         application  of the  halt-clofed hand to the  abdomen, fo as to
         make a moderate preffure, is fometimes of ufe by aiding the
         uterus in its  contraftion  ; but this affiftance cannot be given
         in the  worft cafes, that is,  when the uterus is not at all con-
         tracted, or contracted irregularly.  The refpiration*ot the pati-
         ent has alfo an evident effeft  upon the uterus and placenta, of
         which we Shall be  fenfible, if we retain the funis in our hand,
         in the aft of expiration, when it defeends, and in the aft of in-
         spiration,  when it  is Somewhat retrafted.  By Supporting  the
^, •"•' ^ funis with juft So much force as will prevent its  retraftion in
         the aft of infpiration, we  fhall foon be  fenfible, that the funis  -
      ,  is lengthendid, which will prove that the placenta is deScend- 
ANOMALOUS, OR COMPLEX LABOURS.
*77
 ing; and the purpofe of extrafting the placenta  will be com-
 pleted, without the ufe  of any other means : but this method
 requires much time and attention.  Sometimes alfo the exclu-
 fion of a defcending placenta may be favoured by preffing it,
 with one finger carried along the funis, towards the facrum, in
 fuch a manner, as to bring down an edge inftead of the whole
 rriafs ;  but this is not the cafe of which we are Speaking.
   Ip all caSes ot dangerous hemorrhage,  when the placenta is
 retained,  it  was Said to be equally justifiable and neceffary to
 extraft the placenta, as it Was to deliver the woman of her child
 under the fame circumftances.   But this general rule requires
 explanation, and fome  fkill in the application.  When there is
 a prefent hemorrhage, fo important as by its violence or conti-
 nuance to threaten danger, the  placenta ought to be immedi-
 ately extrafted.  This is not an opinion, but a rule of praftice.
 But if there have already been a hemorrhage, fo protufe as to
 occafion danger, and the common confequences of lofs of blood,
 as fainting and the like, have already followed ;  the placenta
 ought not then to be  extrafted,  nor the patient disturbed,  nor
 any  change  made, till the is Somewhat revived from her extreme
 debility ;  as the danger would be thereby increafed, and  the
 patient die, during or immediately after the operation, as I have
 feen and known in too many inftances.   In other words,  the
 extraftion of the placenta is to be confidered as a remedy  for
 a prefent or an apprehended dangerous hemorrhage, but cannot
 remove the effefts of one which has already ceafed.
  In cafes alfo in which there is no hemorrhage, if the placenta
 be not ejefted, or if none or but very feeble efforts be made by
 the uterus for that  purpofe, a time will  come, when we muft
 determine upon its extraftion, or1  leave it behind ; and the latter
 bejng unfafe and unjuftifiable, the mere retention will be fuffi-
 cient authority for us to extraft it.   Upon this point there  can
 be no difpute, except as  to the time, and we will fay, leaving
 the matter at large, for the exercife of individual-judgment, that,
 if the placenta be not expelled at the end of four hours from
 the birth of the child,  it is  generally wife to determine upon
 extrafting it; and the determination ot choofing that time is, I
 believe, to be founded  on the opinion, that the  parts have  not
 clofed fince  the expulfion of the child.   I can however recol-
 1 eft many examples of a  retained placenta, without a hemor-
 rhage, to which I have been called at any time within twelve or
 even twenty-four hours after  the birth of the child, in which
the placenta  has been very eafily  managed, when the exigencies
of any cafe required it.
 Vol.  II.                   Y 
ljS           INTRODUCTION TO MIDWIFERY.
   In  this place it  is neceffary  to  make  another diftinftion.
 Though the placenta may be retained for many hours after the
 birth of the child, if we be convinced of fome degree  ot  def-
 cent, efpecially if we can feel  that part of  it into which  the
funis is inferted, we have no occafion to be alarmed, or to
 hurry  its  exclufion, unlefs there be an exifting hemorrhage.
 Then the  placenta may be fuffered to remain, till it is excluded
 by the aftion of the  uterus, or  as it defeends, the moft gentle
 affiftance  may be given  by pulling by the junis, to extraft it ;
 without any apprehenfion of danger, whether it be detained two,
 or even twenty-tour hours, becaufe we have at all times, under
 fuch circumftances, an eafy and certain command of it.


                     SECTION  X.

   Whenever  we have determined upon the  neceffity and pro-
 priety  of extrafting the placenta by art,  we muft proceed in
 this manner.   The  patient being placed in aeonvenient pofi-
 tion, as when we deliver with the Jorceps or vedis, and every
 thingin order,  the Junis, which is our guide, is to beheld with a
 moderate  degree ot tightnefs.   The external parts are ufually in
 fuch a ftate, as not to require much dilatation ; but if this fhould
 be neceffary, it muft be done tenderly, and  in the manner be-
 fore direfted with the right hand or left, as may be found moft
 convenient; as muft alfo the os or cervix of the uterus, fhould
 either be contrafted.   When the  hand is in the vagina, the
 Junis is to be flowly followed into the uterus, which though in a
 ftate of total inaftion before,  may then be irritated  to a fuffici-
 ent degree of aftion, to feparate and  expel the placenta, withou|
 any further affiftance on our part. But if the fpontaneous aftion
 of the uterus fhould not Come  on, we muft  proceed  with  the
 hand  to the placenta, which may  either adhere with its whole
 furface, or  it may be partly, or even wholly feparated and  lying
 loofe in the cavity of the uterus.  Should there be a  total  ad-
 hefion, we  muft Search  for the edge ot the placenta, on the out-
 fide of the membranes, cautioufly  diftinguiffiing  between  the
 placenta  and  the uterus.  When the edge of  the placenta is
 raifed, the  further the feparation muft be made  with the blunt
 ends of  the fingers, and the  clofer and firmer the adhefion, the
 flower the feparation ought to be made; hot proceeding rafhly,
 or affefting dexterity, but giving our heads time to guide  our
 hands, as if the operation were performed  under infpeftion.
 By flow  proceeding, and by  demurring a ffiort time if we meet 
ANOMALOUS, OR. COMPLEX  LABOURS.
m
 with more*than ordinary difficulty, the feparation will be per-
 fected ; or, when the greater portion is loofened,  if we grafp it
 Slightly in the hand, and bend it backwards, the remaining part
 will often peel from the uterus, without trouble ; but this re-
 quires much  caution.   Should the placenta  be found  partly
 feparated, we muft proceed in the Same manner.  But whether
 on the introduftion of the hand we found the placenta fepa-
 rated,  or whether it were neceffary to feparate it, we are not
 to extraft it  immediately, but to wait till the  uterus begins to
 contraft, and then to withdraw the hand including the placenta,
'more quickly or ffowly, according to the degree of contraftion ;
 for the hemorrhage may not be occafioned becaufe the placenta
 was retained, but becaufe its retention, or fome other  cauSe,
 hindered the contraftion of the uterus.   It there be no  aftion
 ot  the uterus whatever, it is of fervice to throw the fingers
 gently backwards againft the fides or Jundus  of the  uterus, to
 irritate  and bring on its aftion, previous to  our .withdrawing
 our hand.  But when the uterus is perceived to aft, then gently
 withdraw the hand, till the placenta is brought into the vagina.
 Whatever motive induced us tp introduce the haia} to feparate
 the placenta,  when it is brought into the vagina,  it ought to be
 fuffered to abide  there,  till the patients compofed, and  reco-
 vered from her fatigue;  and till the uterus has had time to con-
 traft in fuch  a manner,  as to prevent the return of the hemor-
 rhage, at  leaft in a dangerous way.   For many years I have
 made it a rule to leave the placenta, naturally or artificially fe-
 parated, to abide  in the vagina one hour, after it'- was voided
 out of the cavity ot the uterus ; and  I  am convinced by  this
 method, there is an infinitely lefs chance of an enfuing hemor-
 rhage, on its  coming or being brought away, and leSs aiterpain.
 For the blood difcharged in confequence of the feparation of
 the placenta  ufually forms into coagula, which are  collected
 into the membranes as in a net, and the uterus is left perteftly
 void of any thing, which can become the caufeof any confider-
 able pain.
   With regard to thofe cafes in which the placenta is retained
 by the irregular  aftion of  the uterus, there is generally fome
 degree of hemorrhage, and often a very protufe one ; though
 Sometimes there is no diScharge, or none o£-importance, only a
 retention of the placenta-beyond the common time of its expul-
 fion.   When all the parts of the uterus .aft with equivalent
 force at the fame time, the  united aftion contributes to the  ex-
 pulfion of whatever mayvbe contained in its cavity.  But if
 one part, the. inferior for inftance, fhould aft,  when the. other 
l8o            INTRODUCTION TO MIDWIFERY.
is  at reft, a  contrary effeft might  be produced.  Tke forms,
which the uterus may affume in conSequence ot this irregular
aftion, are innumerable, but the moft common is the longitudi-
nal, which is produced when all the  parts, except the fundus,
aft ;  or the hour-glaSs form, when the middle of the uterus only
afts, by which it is divided as  it were into  two chambers or
cavities.  When it was the cuftom to bring away the placenta
immediately after the birth of  the  child, three reafons  were
affigned for the praftice ; firft, that it was  a dead fubftance,
without any power like that which was fuppofed to be inherent
in the child ; Secondly, that it  was an extraneous maSs, wrfich
became* pernicious  every  moment it remained ; and  thirdly,
that if not immediately extrafted, it would be almoft impoffible to
bring it away, the os uteri clofing in fuch a manner, as abfolutely
to prevent the introduftion of the hand for  the purpofe of ex-
tracting it,   Thefe  opinions are proved to  be groundleSs, for
the placenta,, we  know,  may remain  many hours or feveral
days without doing  any mifchef to the uterus ;  and the opinion
of the os uteri clofing  fo  foon after the birth  of the  child is
without foundation, as that feldom or never happens :  what has
been efteemed the natural clofing ot the os uteri, being in  reali-
ty  an irregular contraftion or fpafm  of Some portion of the
cervix, from which we are affured no harm and little additional
difficulty can arife*.
   When the uterus, is contracted thus irregularly, as the pla-
centa cannot be expelled, it muft be extrafted, by art, whenever,
on account of a hemorrhage, or ot the time that is paft Since the
birth of  the child,  it  may be thought expedient or neceffary.
There is no way of judging of this kind or degree of contraftion,
unlefs by the uncertain  information we may  acquire by the
application of the hand to the abdomen, till  we introduce our
hand into the uterus.  Before this operation it is always proper
to try, whether the placenta may not be difpofed to come away
by any of the  gentle means before recommended.  On the fai-
lure of theSe,  and being  fully  convinced of the neceffity, the

   * Scire  enim eft poft natum infantem, in utero  nullum repe-
 rin tale os ut olim fuerat: fed ita bmnino fe res habet,  ut in
 burfa nummaria, qua. tons tranfmiffis contrida, rugojum os
Jormat ; laxatis autem hmc vinculis, ubique aque lata eft et ex-
panfa.   Ruyjch. Adverfi Anat. Dec.  Secunda.
   The tenth chapter of the fecond Decade is fait oj ufeful ob-
Jervations regarding the management of the placentaj given in
 very honeft and animated language. 
ANOMALOUS, OR COMPLEX LABOURS.
l8 I
hand muft be condufted in the manner before mentioned, till
we come to that part which is partially  contrafted, whether it
be at the cervix, or in the cavity of the uterus.   The hand muft
then be reduced into a conical torm, in the way  direfted for
the dilatation of the os uteri, or external orifice.   Should fhe
fpafm be in Such a degree, as to  make a perfeft clofure of the
uterus round the Junis, one finger muft be firft infinuated along
ihe Junis, and this being turned with a femirotary motion, will
foon make room tor a Second, and  fo on,  till all the fingers, in
a conical form, may be admitted.   The  dilatation is fometimes
to be made in oppofition to a very firm contraftion, yet it muft
be done fteadily and reSolutely, though not raffily or violently.
Before the hand is paffed beyond the contrafted part, this muft
be amply dilated, otherwife it will clip round the wrift, and im-
pede  the fubfequent  part of the operation.   When the con-
trafted part is amply dilated, the hand muft be  carried forwards
 into what may be called the upper chamber of the uterus, in
 which  the placenta is contained.  Whether this be feparated
 wholly or partially, or be yet adhering,  we muft proceed ac-
 cording to the method before mentioned.  Immediately upon
 the feparation of the placenta, the hand  containing it  is to be
 drawn out of the upper cavity, to that part ot  the uterus which
 was before fo clofely contrafted,  and held  there, till by  the
 preffure behind, we are Senfible of the  aftion  of the Jundus.
 The hand containing the placenta is then to be withdrawn by
 flow degrees, till it arrives  in the vagina, where the placenta
 may be Suffered to remain for one or feveral hours  ; or we may
 wait till it is wholly expelled by the pains, in order to avoid the
 hazard ot a  Subsequent hemorrhage.
    When the placenta is  either expelled  by  the  aftion oi the
 Uterus, or extrafted by art, it Should be a general rule to apply the
 hand to the abdomen aSterward, that we may be affured the ute-
 rus is not inverted ;  but this method is not always Satisfaftory,
 for in one cafe,  though the  volume of the uterus was felt, ap-
 parently contraft ing properly, the inverting uterus, as it reced-
 ed, was miftaken for a regular contraftion.
    The natural attachment of the placenta to the uterus  is of
 fuch a texture and kind, as very  readily to admit of feparation.
 But if that part  of the uterus, to which the placenta  adheres,
 fhould be in a Scirrhous or morbid ftate the placenta will partake
 of the difeafe.  On the examination of the placenta of different
 women, there are not unfrequently found morbid appearances,
 fome beiug difpofed to a putrid, others  to a fchirrhous  or carti-
 laginous  ftate ;  while in others there is a degree of oflification 
 *8.T           INTRODUCTION  TO MIDWIFERY.

 in the veffels, and fometimes perfeft concretions'.  The ad'ijpofir
 fubftance often found upon the placenta in  large quantities is
 not ot  any importance.  The difficulty of the feparatiort will?
 depend  partly upon the placenta itfelf, and partly upon the
 ftate of  the uterus.  When there is found, on the introduftion-
 of the hand into the uterus, an uncommonly firm adhefion ot the
placenta, a perfeft feparation  will  be  extremely  difficult, and*
 perhaps fometimes impoffible, without hazard of doing direct
 injury to the uterus..  There  is no Security in thefe cafes, but
 by taking time in the operation, confiding  chiefly in flow pro-
 ceeding, both for accomplifhing  our purpofe, and  avoiding;
 mifehief.  It has been  faid, that it is more juftifiable to leave
 a portion of the placenta behind, than to continue very  Strenu-
 ous efforts to bring the whole away, as thefe may give unbear-
 able pain, and become the caufe of immediate or  fubfequent
 injury.   It muft be acknowledged, that it is always a very defir-
 able thing,  to bring ^away the placenta  wholly  and perfeftly,
 not only tor the fatisfaftion of friends,  but for the real good and
 intereft  of the  patient..  Even the membranes fhould be man-
aged with caution, for  though a portion or the whole  of thefe
might be left without danger, they occafion afxztor in the dif-
 charges, and often fo much pain as to create a fufpicion of dif*
eafe.  But without meaning to give authority to negligence, or
 mifconduft, to rafhnefs, or violence,  we  may Suppofe a fitu-
ation, in which we- muft Submit to Some evil,.and in which all
that is in our power is, to choofe the leaft.  There  can then be
 no doubt, but that it is a leSs evil to leave a portion of the pla~
 centa behind, than to do any  pofitive  injury to the uterus, in
 driving to bring it away.  For it has been found, when a por-
 tion of the placenta was left  behind, that  the hemorrhage has
 ceaSed and not returned, and that this portion Sar  Sooner decay-
 ed, or was  more readily digefted or expelled,  than the whole.
I once  Saw an  inftance of a whole placenta-  retained till the
 fifteenth day after the birth of the  child,  and then expelled with
 little  Signs of putrefaftion except upon the membranes ; the
 whole Surface, which had adhered, exhibiting marks of a freffi
 feparation.   The recovery of this patient was very fortunate,
 for I  have  feen  feveral other  cafes of a Similar kind terminate
 fatally.   It is  a  conclufion generally made, though not always
 warranted, that, if a woman die with a portion of the placenta
 retained, her death ought to be attributed to it ; yet it fhould
 be confidered, that there may  have been  previous diSeaSe in the
 uterus,  and that the event may have been  really occafioned by
 violent, though unfuccefsful attempts to  bring it away, and not 
              ANOMALOUS,  OR COMPLEX LABOURS.       t$*

 %y the retention.  Sometimes the danger of thefe  cafes  is
 known to the praftitioner only, who is obliged to aft according
 to exigencies, for which he may  not be particularly prepared •
 but if he has before acquired a juft knowledge of the principles
 of the art, explain himfelf ingenuoufly, determine not rafhly
 and proceed flowly, he will not do any thing, for which he can
 be juftly blamed, and will generally be fuccefsful.
   The funis is commonly inferted about one third of its fpace
 from, or at the very edge of the placenta, fometimes in the
 centre, and now and then the veffels branch off before it reaches
 the placenta ; and the eaSe or difficulty, with which this may
 be brought away, Somewhat depends upon the infertion of the
funis.  The chance alfo of tearing the funis away  refts chiefly
 upon  the force ufed to extraft the placenta by it; yet if it be
 inferted fully into the placenta,  and be in a found ftate,  the
 force which it can bear is infinitely greater, than can be exerted
 Without the hazard of inverting or doing other injury to the
 uterus.  But if the funis be in a putrid ftate,  or if the veffeh
 branch dff too foon, it may be torn away with a very fmall de-
 gree of force, as in the latter cafe it can only fuftain what  a
 fingle branch of the veffels can bear.  Hence in a cautious ex-
 traftioivof the placenta, we are Sometime Senfible of a fudden
 yielding or jerk in the funis, which, if the fame force  be con-
 tinued, will be repeated, till at length  the funis comes unex-
 pectedly away, and  the placenta is left in the uterus, or in the
 vagina.   Great circumfpection and flow proceeding will ufu-
 ally prevent this accident; but if it ffiould happen ir> our own
 praftice, or we fliould be called to affift others, we muft deter-
 mine whether the  cafe will allow of farther waiting,  or whether
 there be a neceffity of bringing the placenta away immediately
 by mtroducing the hand into the  uterus.   If there fhould  be
 occafion, on account of hemorrhage or  any other untoward
 circumftance, for the latter method, which, if  confiftent with
 the fafety of the patient, ought always to be avoided, we may
 confider the inconveniencies produced by the want of the funis,
 which, when it remains,  Serves as a guide to  conduct the hand!
and helps moreover to keep the uterus Steady, and to bring down
the placenta when feparated.   The former of thefe will not be
of much confequence to a perfon accuftomed to the operation ;
and the latter will be leflened, if an  affiftant make a judicious
preffure upon  the  abdomen with both his hands.  Some difad -
vantage will  neceflarily arife from this accident,  we  ffiould
therefore be careful to avoid it when in our power ; but though
a little embarraffment may be occafioned even  when the pla. 
1&4           INTRODUCTION TO  MIDWIFERY.
 centa is  in the vagina, the importance of the disadvantages
 produced  by  the Separation of the funis has, I believe, gener-
 ally been over-rated.


                      SECTION XI.

   The hemorrhage,  vyhich follows the expulfion or extraction
 ot the placenta, may be  a continuation of that which came on
 before the birth of the child, or between  the birth of the child
 and the expulfion ot the  placenta ; or it  may be unconnected
 with either of thefe, but merely a confequence ot the feparation
 and exclufion of the placenta.   This has ufually been defcribed
 by  writers as an'immoderate flux  of the lochia, but  it is with
 more propriety arranged under the clafs of hemorrhages ;  and
 though generally not fo dangerous as either of the varieties laft
 defcribed, it is often alarming, and,  under particular circum-
 ftances, has fometimes proved fatal.
  The difcharge of blood which followed the feparation and exclu-
 fion of the placenta, varies in different women, being iqijfome very
 fmall, and in others there is, after every act of parturition, a difpo-
 fition to a very profufe hemorrhage, which Suddenly reduces the
 patient into a frightful ftate.  It is a popular opinion, that  the
 greater thefe difcharges are at  the  time of delivery,  the fafer
 women will be from the chance of difeafes during childbed ; and
 this  opinion very  much  leffens the terror of the bye-ftanders,
 when difcharges come on with, great profufion.   But  the prac-
titioner, who knows the poffible effect of  fudden and violent
hemorrhages at this time, efpecially in patients who were before,
much weakened, cannot feel at his eafe, though fupported by
the general experience of their being  feldom dangerous.  Nor
is the  opinion  true, that the  greater the difcharge,  the fafer
the patient will be; for whatever weakens the patient  extreme-
ly, muft render her more liable  to difeaSes  of various  kinds  in
 childbed.
  It has  often been a matter of great furprife to me, when I
have Teen a patient bear a fudden difcharge of what feemed an
 enormous quantity ot blood on the  coming away  of the pla-
 centa, without fainting, or fhewing any Signs of the  common
 confequences of great lofs ot blood ;  but it may be explained
 in this manner.   Should every drop of blood, which circulates
 iri the uterus, be difcharged in an inftant, it would be of no im-
 mediate confequence to the patient, the very exiftence of the
 uterus not  being neceflary lor her life.   When  all this  blood 
            ANOMALOUS, OR COMPLEX  LABOURS.         185

 is difcharged,  if the uterus fhould contract fpeedily,  fo that
 the veffels ffiould be reduced to a Small Size, there would not be a
 continuance or return of the hemorrhage, and the patient would
 exhibit no figns of fuffering from that which had happened.  But
 after the difcharge of the blood contained in the veffels of the
 uterus, as before ftated, if there fhould be no contraftion of the
 uterus, then the veffels remaining of the fame fize, and the com-
 munication between the body  and the uterus being preferved
 open,  as in pregnancy; the veffels of the uterus would be re-
 pleniffied from the conftitution, and the fame effeft would be
 produced in the patient, as if it were really loft.  Should this
 fecond quantity of blood Supplied to the uterus be discharged,
 and  another be claimed from the conftitution, then, according
 to the  quantity demanded, and the number of times the demand
 was  made, would of courfe be the danger of the patient.  In
 fome cafes the hemorrhage  does not follow the extraftion of
 the placenta immediately, but  comes on after a certain time ;
 and  then  it  may be fuppofed, that the communication between
 the body and the uterus was clofed, but not being  confirmed,
 was  opened again  by fome effort too foon made, or more vio-
 lent  than the  fituation  of  the patient  could endure.   Thefe
 circumftances point out very clearly the neceffity, in the man-
 agement  and for the prevention  of uterine hemorrhages, of
 ever remembering, that the danger attending them is leffened,
 and the Safety of the patient Secured only by a proper contrac-
 tion  of the uterus.   Hence in hemorrhages of this kind, how-
 ever vehement, the acceffion of uterine  pain immediately pro-
 claims, that  the danger is paffing, or is paft.
  With  refpeft to this  variety of  hemorrhage,  two things are
 to be  confidered ;  lft. by what  method  or means it  is to
 be prevented ;  2d.  how it fhall be remedied, when it does
 exift.
  When the hemorrhage depends  upon the imperfeft or irre-
 gular aftion of the uterus,  excited for the end of expelling the
placenta, it  may not be  in  our power to regulate thefe.  But
 as far as relates to the force ufed in the  feparation, or hurry in
 the  extraftion of the placenta we may always aft  reafonably
 and cafmly, and  proper conduft will generally infure fuccefs.
 It was before  advifed to leave the placenta in the vagina for
 one hour after its exclufion from the uterus, in common cafes,'
 unlefs  it were  Sooner expelled by the natural efforts.  Objec-
tions have been raifed to this, becaufe it confines the patient to
an uncomfortable  fituation for a long  time; and it has been
  Vol. II.                  Z 
i€6
INTRODUCTION  TO MIDWIFERY.
faid, that it was cruel to leave her friends under anxiety, ^'tn
the delivery incomplete,  when we have the power ot  readily
bringing the placenta away.   Now, if we are  Speaking ot a
cafe of real or prefumed danger,  the argument of uncomtorta-
blenefs is not to be put in competition with acondutt, on which
the increafe or diminution ot that danger may turn ; nor does
the cenfure of a good aftion make it degenerate into a crime,
or convert that, which is in its own nature honeft and  intelli-
gent, to cruelty.   On the  contrary, it may  be the height of
tendernefs, in me, to encourage the patient to bear a Small de-
gree of prefent pain or  inconvenience, by which her Safety  is
infured, rather than by  an officious interpofition to add to the
hazard,  by  complying  with the felicitation of  thofe, who are
not qualified to judge.   When the placenta is brought into the
vagina, we have then the abfolute command of  it at our plea-
Sure ; but the very eaSe, with which it could be brought away,
is often a good reafon why it ffiould be Suffered  to abide, as  it
proves,  that there is no natural contraftion of the parts for its-
exclufion otherwife it would be expelled without our affiftance.
In what other manner a placenta remaining in the vagina may
contribute  to the prevention of a hemorrhage, except that by,
the irritation made  upon the os uteri, it urges the uterus to aft,
it may be hard to  fay ; though I am convinced of the benefit
thence derived.  Nor have I, when attending patients who have
been prone  to a hemorrhage in former labours, been Satisfied
with leaving it in that fituation for one hour, but have prolonged
the time to two hours, or more, unleSs it fhould  be in the mean
while ejefted by the pains, which proving the increaSed aftion
of the uterus, would give an affurance of fafety.   Moreover,
after waiting fo long as  Seemed reaSonable and  proper, I with-
draw the placenta very gently, not increafing the  force on ac-
count of every little obftacle, bin demurring and  waiting lon-
ger.  Even after the placenta is wholly excluded,  if the mem-
branes flick, I wait yet longer, and proceed more flowly, know-
ing that a few minutes occafion a difference between the lofs  of
one, and feven or eight ounces of blood, which fometimes may
be of the utmoft importance ; nor, under thefe  circumftances,
pan any harm arife from delay.
   When we have the management, or are called to  cafes of pre-
ceding or prefent hemorrhage,  the placenta being extrafted, it
Should be an unfailing general rule to examine the patient, to be
fure that the uterus is not inverted ; or perhaps by flight irrita-
tioh about the os uteri,  to endeavour to bring on its aftion.
Then all the means before recommended for the fupprcffion  of 
ANOMALOUS,  OR COMPLEX LABOURS.         187
hemorrhages are to be put in praftice, fpeedily and ftrenuoufly;
and we are alSo to endeavour to promote the aftion of the uterus,
if at  reft, or to  Strengthen  it if feeble,  by moderate  preffure
upon the abdomen with a very cold hand.
   After the exclufion of the placenta, on the application of
the hand into the abdomen,  it is fometimes clear, from  the vol-
ume of the uterus, though contrafted, that there are large coa-
gula  contained in its cavity.   We have been direfted  by gen-
tle dilatation  ot the os uteri, to give  thefe an opportunity ot
coming away, or even to introduce the hand for this purpofe*,
as by their continuance, they were filppofed to keep up the dis-
tention of the uterus* and to occafion a continuance of the
hemorrhage, as well as other mifchief.  Of  any advantage faid
to be derived from this praftice I am veiy doubtful, or  whether.
it may not be  fufpefted to renew or increafe, rather than to Sup-
preSs the hemorrhage.   I have never attempted it,  nor even
troubled myfelf with the ftate of the uterus, unlefs it was invert-
ed, after the placenta, was brought away, but  have left what-
ever  coagula  it  contained, to be  expelled  by its own aftion.
Some have believed, that the hemorrhage was to be prevented,
by giving, without delay, after the birth of the child, two or
three glaffes of wine, or even a ftronger cordial, with a view
of bringing  on a fpeedy contraction of the  uterus, and I  have
really thought  fometimes with great fuccefs.
   The fainting which follows hemorrhages was confidered as
an effeft produced, or as a remedy provided  for their fuppref-
fion.   It was  alfo faid that the medicines given, or the means
ufed, did'Service, according to the degree of chillnefs they oc-
cafioned, and the flacknefs  of. the circulation which followed.
We were cautioned  not to remove this faintnefs by the exhi-
bition ot cordials, left with  the return ot the circulation, there
ffiould be a  renewal  ot ihe hemorrhage ; at leaft till  we had
given fufficient time  for the contraftion of the veffels and other
circumftances-to take place,  before the patient revived.   But
when the patient becomes cold, and there is apparently the moft
imminent danger of her dying, we muft prefume thoSe effefts
are produced,, or no longer regard them, but give  without de-
lay nourifhment and cordials in fmall quantities, very often
repeated, and  the patient muft be as it were  compelled  to live,
by the ftrenuous and conftant fupport we give.   Nor is the ex-
hibition of cordials to be confined to any particular quantity
er time, we are only  to be guided in both refpects by the con-
* See the quotation from Celfus, at page 170. 
lf$           INTRODUCTION  TO MIDWIFERY.
tinuance  of danger.  Wine, brandy properly diluted, or  any
domeftic  cordial, will be fuitable on thefe  terrible  eccahons,
and they  muft be made aftually warm.   In fome cafes, vola-
tiles have a good effeft, and the juhp. viiee of Bates, which is
compofed of warm wine and the yelks ot eggs, with the addition
of a few drops of oil ot cinnamon, has  proved an admirable
medicine.  Yet I muft confefs, that  the beft and  moft general
cordial is very cold air, at  leaft it is indifpenfably  neceffary ;
and the ftrongeft ftimulant in extreme caSes is,  to Sprinkle the
face repeatedly with cold water, which the patient, Senfible of
the benefit fhe receives, Would often require to be  done with
great earneftnels*.
  On  the fame ground on  which thefe medicines are advifed,
opiates, though in Some caSes they may prevent, were efieemed
improper, during the  continuance ot a  hemorrhage,  and  they
certainly ought not to be given too freely,  when the patient is
reduced to a ftate of gr^t  weaknefs.  Above  all,  fhe  is not
to be difturbed, or raifed  to an ereft pofition, but the Small
portion of  the principle of life is to be carefully hufbanded ;
and there is often a power of living in a quiefcent ftate,  or in a
recumbent pofition, when the patient would  be  deftroyed by
the leaft exertion, or by being raifed to an ereft pofition.  Whe-
ther an hour or a day be required for this purpofe, after a  pro-
tufe hemorrhage, the  patient ought not to be raifed, or even
moved, before ffie is quite  revived,  and then with the utmoft
care and circumfpeftion ; and  through want of attention  to this
matter, fudden death has fometimes happened, when we were
not Sufpicious of danger.    When immediate danger is no  lon-
ger apprehended, and  the patient has  been reduced to  a  very
low ftate, the views of praftice are changed, and it  will  not  be
prudent  to replenifh the emptied veffels too haftily, or to fti-
mulatethem to ftrong aftion.
   It is laftly to be obferved, that in the violent and pertinacious
head-acht, and othef  nervous complaints, which follow  pro-

   * Chapman mentions a compliment paid him by Sir Richard
Blackmore, in a cafe of this kind which Jhews great  accuracy
of diftindion.   If, faid Sir Richard, you  had ufed  UJs  cold
applications, this  patient  would have  diedjrom  the  lofs ot
blood  ; and ijyou had continued them longer, you would  have
extingvijhed the powers of  life.

     T Douleurs du tefteapresgrandes pertes dujan.j.
                                          Mauriceau, 
ANOMALOUS,  OR COMPLEX LABOURS.
fufe hemorrhages, and fometimes continue for many weeks, it
will be of great Service to procure two or three (tools everyday
previous to the exhibition of the bark, or other tonic medicines,
though the patient be pale and in a weak  ftate.  For the pre-
fent  relief of  head-ach, cold applications to the temples,  as
white of egg mixed with powdered bay fait, or crvxdejal ammo-
niac,  always keeping the legs and feet warm, will Sometimes
be of fervice, as will occafionally all  the nervous medicines in
common ufe.
  Theie obfervations I have written with great pleafure, hop-
ing they may be of fervice, and I may recommend the method
founded  on them  with Some  confidence, having in praftice
feen innumerable inftances of its good effefts, though the fub-
jeft yet admits of much improvement,


                     SECTION XII.
           ON TILE INVERSION OF THE UTERUS.

  The inverfion ot the uterus has been more than once men-
tioned, but the fubjeft is fo important, as to require  fome far-
ther confideration.
  In every cafe in which there was reafon to fufpeft this terri-
ble accident, efpecially when it had been found neceffary to
extraft the placenta by art, we were advifed to apply the hand
to the abdomen, for the purpofe ot trying whether the tumour
ot the contrafted uterus could be  felt, and if  there were any
remaining doubt, to examine per  vaginam.  When it is in-
verted,  inftead of feeling  through the integuments the con-
trafted uterus, there is a confiderable vacuity at the lower part
of the abdomen, which gives fufficient reafon to SuSpeft the
inverfion, and  the  latter examination proves it.  In one cafe
which  was under the care of a perfon, who  might have been
allowed to  be  a competent judge,  and expefted  to aft more
wifely, when he applied his hand to the abdomen, the receffion
ot the inverting uterus was miftaken tor its contraftion  ; and it
was aftually inverted,  though, he entertained no SuSpicion of
what had happened.
  The reafons advanced to prove the neceffity of afcertaining
the  inverfion are, i. that the patient may be  relieved from her
prefent danger, if there be a hemorrhage ;  2.  that a part of fo
much confequence may not be Suffered to remain in  that ftate, 
 I9^>           INTRODUCTION TO MIDWIFERY.

 even if there were no hemorrhage ;  3. that  if it were not foor>
 replaced, it could  not, after a  very fhort time, be reftored to-
 its proper fituation.
  . Whether the inverfion of the uterus be the firft caufe ot the
 hemorrhage, with which it is  almoft univerfally attended," or
 only a caufe ofr its continuance, or if there be no hemorrhage,
 the reafons for replacing it fpeedily would  be  of equal force.
 Not that all women would die though the uterus were inverted,
 but they would be in the greateft and  moft imminent danger.
 The impoffibility of replacing it, if not done foon after the ac-
 cident,has been proved in feveral cafes, to which I have been
 called, So early as within four hours, and the  difficulty will be
 increafed at the expiration of a longer  time.   Whenever an
 opinion is afked, or affiftance required in thofe cafes which may
 not improperly be called  chronic  inverfionsr it is  almoft of
 courfe, that the repofition fhould be  attempted  ; but I  have
 never fucceeded in any  one inftance,  though the trials  were
 made with all the  force I durft exert, and with whatever fkill
 and ingenuity I poffeffed ; and I remember  the fame complaint
 being made by the late Doftors  Hunter and Ford  ; fo that a
 reverfion of a  uterus, which has been long inverted, may be
 concluded to be impoffible.  It feems as if the  cervix of the
 uterus continued  to aft, or had foon afted in fuch a manner, as
 to gird the inverted uterus fo firmly, that it could not be moved ;.
 yet the  inverted Surfaces, though lying in conta6t, have not
 been found coalefced together, fo as to form one maf's, as has
 been SurmiSed.  All that art can do in Such  cafes, in which the
 patients  are commonly Subjeft to protuSe mucous discharges,
 or to frequent hemorrhages, but without  any unbearable pain,
 is to alleviate their Sufferings, to moderate Symptoms, and Some-
 times to Support the perpending uterus by a flat  peffary.   In
 a plate publifhed many years ago, there is an exaft representa-
 tion of an inverted uterus oi  long Handing, from a beautiful
 drawing, by Dr. R. Atkinjon.  -"
   Befide the complete inverfion  of the  uterus,  in  which the
fundus may be brought into the vagina,  or without the body,
 diffeftions have ffiewn, that there is what may be called a femi-
 inverfion, in which the fundus of the uterus has been bent in-
 wards, but not paffed  through  the os uteri; yet the caSe may
 have been wholly unknown during the life-time ot the patients-.
  This is accompanied with fymptoms like thofe of the  com-
 plete inverfion, and had it been difcovered, would have required,
 equal care, and the fame methods fo be ufed for replacing  it.
 Many years ago, in a cafe of retained placenta, I perfectly'well- 
ANOMALOUS,  OR COMPLEX LABOURS. *        191.
remember feeling a beginning  inverfion,- which was prevented
by firft reftoring the uterus to its place, and  then waiting a
ffiort time, before  I made any farther attempts to feparate or
bring down the placenta.
   With refpeft to the caufes of the inverfion,  it has generally
been attributed, Solely, to the force ufed in pulling by the Junis,
in order to bring away a retained placenta.  But there is rea-
fon to believe, that the uterus  has been inverted, when on ac-
count  of a hemorrhage,  or fome other urgent fymptom,  the
hand has been introduced into the uterus while in  a collap.fed
or wholly uucontrafted ftate, and the placenta being withdrawn
before it was perfeftly loofened  the jundus of the  uterus, has
unexpectedly followed, and  a  complete inverfion  been occa-
fioned. I have alfo been affured, that in fome  cafes there has?
been a fpontaneous inverfion ; that the accident happened, at
leaft, when no force, or none  capable ot producing the effeft,
had been ufed ;  and then it was imputed to the  fhortneSs of the.
junis, giving  the  difpofition  before the birth of the child ; or
to fome untoward aftion of the uterus.  But with this affurance,
or explanation, I do not feel quite Satisfied, becaufe  the degreegi
of force muft  always be vaguely eftimated ; though if a difpo-
fition to an inverfion be firft given by the force  ufed in pulling
by the Junis, it may be completed by the aftion of the uterus ;
or it the leaft  poffible degree  of  inverfion were given  by the
fhortened funis, it might certainly be completed by a very flight
additional force in pulling by the Junis.
   Uterine  hemorrhages  following the exclufion or extraftion
of  the placenta, though often apparently^dangerous, very fel-
dom prove fatal; yet now and  then  we hear of a patient dying
from this  caufe.  May it  not be SuSpefted,  that in Such caSes
there was an inverfion of the uterus, which together with he-
morrhage, is always attended with dreadful disturbance of the
whole nervous fyftem.   Whether the uterus  be inverted or
not, fhould therefore be afcertained by the methods before men-
tioned, in every  cafe of profufe uterine hemorrhage.
   Seeing then the caufes by which  an inverfion of the  uterus
may be occafioned, knowing  the immediate  danger  arifing
from it, and, as far as experience  has proved, that after a  cer-
tain time it cannot be  replaced, we fhall want no other induce-
ments to ufe all poffible care, to avoid doing two things, which
have not been uncommon in praftice, though it is evident, that
in  various ways they  muft be injurious; firft, pulling by the
funis prematurely, or violently,  to bring away the placenta ;
Secondly,  hafty  introductions  of the hand  for that purpofe. 
10*
INTRODUCTION TO MIDWIFERY.
 Should, notwithstanding all our care, a caSe of this kind occur
 in our own praftice, or fliould we be called to one, which had
 happened in that of any other perfon, we ffiould find  none, or
 very little difficulty, in reftoring the uterus to its  proper fitua-
 tion, if, which is of prime importance in every cafe ot difficulty
 or alarm, we maintained the compofure of our minds; if, pay-
 ing due regard to the ftate of the patient, we made our attempt
 without delay, but at the Same  time without violent, or precipi-
 tation.   The  only point of  praftice, which occurs to me,  as
 likely to raife any doubt of the conduft we ought to purfue,
 is, when together with an inverted uterus there is an adhering
placenta.  It would probably  then be right to fay, if the pla-
 centa be partly feparated, it will be proper to finiffi the fepara-
 tion,  before we attempt to  replace the uterus ; but  if the
placenta  ffiould wholly adhere, it will  be better to replace the
 uterus, before wo endeavour  to  feparate the placenta.   The
 ground of this opinion  is, that  while we  are Separating the
placenta, the cervix of the uterus is contrafting, and the diffi-
 culty of replacing  it  increasing,  which is a greater evil  by far
 than a retained placenta. 
ANOMALOUS,  OR COMPLEX LABOURS.
*93
CHAPTER  XVI.
ANOMALOUS,  OR COMPLEX LABOURS.
ORDER SECOND.
             Labours attended with Convulfions.


                      SECTION I.


 X he rules given by different  writers, for the management of
of labours attended with convulfions, Seem to have been founded
on leSs certain principles, and to have been leSs confirmed by ex-
perience, than thoSe which have been given for almoft any other
cafes  that occur.  Thefe rules have  neverthelefs led to two
methods of praftice, offered with fufficient confidence, though
diametrically oppofite to each other.   According to the  firft**,
which has been moft generally approved and followed, it was
deemed indifpenfably  neceffary, to deliver the patient by art,
as expeditioufly as poffible, to free her from the caufe  of her
impending danger.  But according to the fecond, it being pre-
fumed that the convulfions appertained to the labour as fymp-
toms, this, it natural in other refpe£ls, was to be Suffered to go
on without interpofition, as  if there  were no convulfioiist ;
while we were to be engaged in ufing the moft efficacious means

  * La convulfion eft un autre accident qui fait fouvent perirla
mere  et Venfant, aujfi bien que la perte de Jang, Ji lajemme
n'eft ires promptement Jecourue par Vaccouchement, qui eft le
milleur remede qu'on puiffe apporter a I'une et a Vautre.

                          Mauriceau, vol. i. chap. 28.

  t INaturcc partus, qued ccetoaraJanus,  relinqui potefl.
    ?*"Roederer.  Element. Art.  Objletric, Aphorijm. 670.
  Vol. II.                   A a 
194            INTRODUCTION TO MIDWIFERY.
for preventing their return,  or for leffening the effect,  which
might be produced by them.   Without fuccefs, Whatever has
been done or omitted, has occafionally been blamed or regret-
ted; and, in confultations on  cafes of this kind, I have gener-
ally obferved, that the perfon,  who advanced his opinion in the
moft confident manner, prevailed on the reft to acquiefce in his
Sentiments ; the records  of  experience having been thought
infufficient, or not fo duly weighed, as to Satisfy our  minds, or
to juftify our forming an irrefragable rule of praftice.
   The tnue puerperal  convulfions have not  been accurately
deScribed ; yet there are fome peculiarities in the fymptoms pre-
ceding their appearance, and in the convulfious, or the mariner
of their return, which diftinguiffi them from every kind of hy-
fteric fymptom, and from convulfions proceeding  from any
other caufe.  Together with  the  fymptoms  of the  epilepfy*,
which they very  much refemble, there is not unfrequently  a
Jtertor, which has been confidered as peculiar to the apoplexy ;
or the patients, in the intervals between the fits, are obftinately
comatofe.   With the foaming at the mouth there is alfo a fharp
hifping noife, produced by fixing the teeth, and by the fudden
motion  of the under lip, as  if attempts were made  to retraft
the faliva back  into  the mouth ; and by this noife  I  have
generally been able to difcover the ftate ot a patient in con-
vulfions, though fhe  was in another room.  The intervals be-
tween the  convulfions, which are of fhorter or longer duration
according to the advancement ot labour, evidently depend up-
on the aftion ot the  uterus, as will be proved merely by the
application of the hand to the abdomen ; and when they  abate,
the patients in fome caSes Seem as  if  they were awakened by
furprife, and  foon  recover the ufe of their  faculties ; but in
others, they lie in  the intervals in an infenfible ftate, as if they
 were truly apoplectic,  which they are not, though there have
been inftances of patients dying in the firft attack, when there
 was no token of labour, as far as could be judged by  the ftate of

    *  Epilepfia—Agitatio convulfiva  univcrfalis,   chronica,
 cum opprefjioneJen forum, exituque fpuma ex  ore.—Vogelius.
    Epilepfia—Mufculorum convulfio"cum fopore.—Cullen.
    Convulfio—Mufculorum contradio, clbnica, abnormis, citra
foporem.-—'Cullen.

          Spec. 2.     1. Idiopathica.
                      a. Symptomatica. 
ANOMALOUS,  OR COMPLEX LABOURS.         195
the os uteri*.   By the degree of the derangement in the inter-
vals between the convulfions, the danger of the patient is to be
eftimated, as well as by the violence of the fits, or by the fymp-
toms which preceded them.
   It will be convenient to arrange what I have to fay  farther  ♦
on this fubjeft, in the following order :  firft, to enumerate the
reputed caufes of convulfions ; Secondly, the Symptoms which
precede  their  appearance; thirdly,  the means of preventing
them ; fourthly, the treatment which may be requifite when
the patient  is  aftuajly in  convulfions ;  and, fiifthly, on  the
delivery  by art.

   * In the examination of many women who have died in con-
vlfions, I have never  Seen an inftance of effufion of blood in
the brain, though the veffels were extremely turgid, but it is
remarkable, that in all, the heart was found unufually flaccid,
and without a fingle drop of blood in  the auricles or ventricles;
and in  feveral  there inftantly appeared many large  livid fpots
on the extremites and  furface of the  body.   They all died  im-
mediately after the diafiote of the heart.

   A woman in lobour was put to bed, and made an effort to
change her fituation.   She died inftantly in the aft of moving;
but fhe had previoufly complained  of a piercing pain in her
bead, and lofs of fight.

   Another  was in Such a fituation, that the child was expefted
to be  born  the next pain.   She threw herSelt  back,  and died
inftantly.

   Another raifed herSelf in bed to take nouriffiment, about half
an hour atter delivery.  She fell back, and died immediately.
She was opened by Dr. Jenner ot Berkley.

   There was  no effufion  of blood  in the brain  or any other
part, in any oi  thefe ;  but the heart was found flaccid, perhaps
Somewhat enlarged, and not a drop of blood in either the auri-
cles or ventricles.  Yet the late Mr.  Hevfon informed me of a
cafe of convulfions, in which, on examination after death, he
found an effufion of blood, in a fmall quantity, on the furface
of the brain. 
196           INTRODUCTION TO MIDWIFERY.
                      SECTION II.                      ;  *
                                                         *■ f

        ON THE REPUTED CAUSES OF  CONVULSIONS.

  It is remarkable that puerperal convulfions occur fo rarely
in the country, that I have not been able to make fome very
intelligent men, ot  great experience, comprehendtthem, they
having never feen a fingle example.  The tew cafes, ot  which
I have been informed, out of this city, have happened in large
towns,  or among thofe who might  be reckoned in the  higher
ranks of life.   It has alfo been juftly obServed, that women are
far more liable to peurperal convulfions in certain years and Sea-
Sons, than in others.   We may therefore conclude, that a re-
mote  caufe of thefe convulfions is  to  be Sought  for in fome
change made in the conftitution, by the cuftoms and manner of
living in cities and large towns ; or in the particular influence
of the air ;  though there may  alfo be immediate  caufes capable
of producing thefe convulfions in any Situation.
  The female  conftitution becomes infinitely more irritable
than oifual in  confequence of the changes made in the  uterus
during pregnancy, every part  of the body readily participating
with the State ot the uterus.   This increafed irritability, when
not exceffive, and only affecting in one peculiar manner parts
not effential to the economy of the conftitution at large, is SoSar
from being injurious, that it proves eventually Salutary  to the
parent or child.  But we may  conclude, that in a conftitution
become unufually irritable from one  caufe, any additional caufe
of morbid  irritation may often excite different and more  vio-
lent effects, than if that conftitution had been at reft, before the
application ot the fecond  caufe.  It is therefore reafonable to
believe, and the faft  is proved by  the daily occurrences of
praftice, that  the constitution which a delicate mode  of  educa-
tion can fcarce fail  to give, ftill farther augmented by  habits
of indulgence, and the eager  purfuit of pleafure  in  advanced
age, renders  Such woman at  all times, and in  all Situations,
more liable to every  kind and degree  of nervous  affection ;
that the ftate  of pregnancy makes them ftill more difpofed to
the Same affe6lions, and from  flighter caufes to convulfions,
than thofe women are, who, by education, and habits of  living!
are S^foued, as it were, againft impreffions which  might affeft
either their minds or constitutions ;  for it is to  both thefe we
are to look for the caufes ot convulfions.
> 
ANOMALOUS,  OR COMPLEX  LABOURS.
l97
   That the ftate of the  mind  does  very often difpofe women
 to peurperal convulfions, and  other dangerous nervous  affec-
 tions, there are numerous proofs to be drawn from the hiftory
 ot praftice*.   This has  been more particularly obferved among
 thoSe  women, whoSe unfortunate Situations render pregnancy
 an evil inftead of a blefling ; for, from their feclufion and from
 a deprivation of the comforts of fociety, their fenfe of prefent'
 ill, or apprehenfion of future  diftrefs, fuch women are efpeci-
 ally fubjeft to convulfions at the time of labour, and to become
 maniacal after their delivery.  It has  alfo been obferved, that,
 Srom violent and Sudden impreffions on the mind, more gener-
 ally Srom terror than any other, pregnant women  have  either
 immediately had convulfions, or fallen into a ftate which  Shew-
 ed a great propenfity to them,  though they did not appear be-
 fore the acceffion ot labourt.  In fome  cafes  however, from a
 ftate of apparently  perfe6t health, the firft tendency  to labour
 has produced convulfions, which have continued till  the child
 was born, or after its birth ; though in other  cafes the convul-
 fions have been removed, and the  labour has proceeded with
 great  regularity.   But  there  is often reafon to fufpeft, that
 when convulfions have once appeared, they make  to themfelves
 new caufes of their return, as they have continued for  many
 hours, or even days, after delivery.   There is likewife reafon to
 think, that caufes, Seemingly too trifling to produce  convulfi-
 ons, have Sometimes been equal to the effeft ; as I recolleft two
 inftances of women who had convulfions at the time of labour,
 preceded by violent head-aches,  brought on, as it appeared, by
 the ufe of fome mercurial preparation mixed  with the powder
 ufed for their hair.
   But it is not only in weak and very nervous habits  that con-
 vulfions occur, as they fometimes happen in plethoric conftitu-

   *  There is a very inter efiing  hiftory of this in the Bible, i.
 Samuel, chapter iv.  and three remarkable circumjtances  are
 mentioned; firjl, the caufe, the violent agitation and dijirejs of
 the mother's mind; fecond,herfiate of infenfibility at the time
 of her delivery ; third, that the child was born living, though
 the mother died immediately after his  birth.

   + The carriage of a lady, who was going on a party of plea-
fur e, was broken down  ; fhe was near the time oj her lying-in,
 and was vary muchjrightened, though Jhe received no appar-
 ent injury.   When Jhe fell into  labour, this was preceded by
 convulfions, in which Jhe died undelivered. 
i98
INTRODUCTION TO MIDWIFERY.
tions, and are accompanied with a ftrong aftion ot the vafcular
Syftem in general,  or of Some particular part  of the  body ;
though I do not recolleft a cafe, which could be attributed Sole-
ly to this cauSe.   With Such  different conftitutions, and indi-
cations, Some with all the Symptoms of debility anddepreffion,
and others of plethora and fever, the method ot treatment muft
of courfe vary ;  and great judgment will be  required  to  Suit
the proper method, if that can be difcovered, both in the degree
and the extent to which it ought to be carried, to the ftate of
every individual patient.
   Befide the general  affections of the body, which may he fup-
pofed to give a difpofition to  convulfions, affections ot different
parts, as of the inteftinal canal or bladder, if they ffiould be too
much loaded or diftended, may have the fame power*.-  But in
the female conftitution the uterus is the great Source of morbid
irritability, and of courfe every caufe capable of difturbing  this
part beyond a certain degree, or in an unnatural manner, may
affeft  the whole frame, according to the kind an degree of the
original affection, or according to the previous  difpofition.
Yet all the parts of  the uterus do not appear equally liable to
be difturbed, for the  os uteri is evidently the moft irritable part,
even in a natural ftate, as well as when difturbed  by any mor-
bid or adventitious caufet.   Hence it appears in  pregnant wo-
men, on the firft tendency to labour, that the changes, which
that part undergoes, often occafion a variety of nervous fymp-
toms ; and that  thefe may be brought on,  increafed, or conti-
nued, if they before exifted, by artificial or imprudent dilatation
ot that part  in the courfe of labour, when it is ufually rigid ;
or with an increafed degree of irritability occafioned by inflam-
mation:}:.

   * Adfpafmodica,  qua ex uteri  vitio proveniunt,pathemata
concitanda,  non  opus femper erit, ut materia  corrupta et
vitiata utero inharens proximi et emmediate id effictat.
                            Hoffmann, de Mai. Hyfteric.
   t In a cafe of this kind, which was publijlied twenty-three
years ago, I obferved,  " When the os internum began to dilate,
I gently affijled  during cverv fit; but being Joon convinced,
that this  endeavour  brought on,  continued, or  increafed the
convulfions, I defifted, and left the work to Nature."
   % A  woman,  whofe cafe was communicated to me by Dr.
Mackenzie, though  the convulfions ceafed after delivery, died
on the fifth day of the puerperal fever.   In almoft every cafe of
eonvulfions that I havefeen, there was evidently, after delivery,
a greater or lefs degree of abdominal inflammation. 
1
ANOMALOUS,  OR COMPLEX LABOURS.
    It has been preSumed, that the preffure made by the expanded
 uterus upon the  def'cending blood veffels,  caufing a regurgita-
 tion of the blood to the fuperior parts of the body, to the head
 m particular, by overloading the veffels of the brain, produced
 convulfions.  This opinion applies to a caufe very general in-
 deed, and, if true, muft have had its effeft fo frequently as not
 to remain  in doubt.  But it was before obferved, that women
 of plethoric habits, were univerfally  leSs  Subjeft to  convul-
 fions of this kind than the feeble and irritable, that they fome-
 times firft  came on, or  continued with equal violence after the
 birth of the child, when this preSumed cauSe was removed.
    Women are  far more liable to  convulfions in firft than  in
 fubfequent labours, which is true  ; and then, it is Said, more
 frequently when the child is dead, than when it is living ; but
 this I cannot allow.  For when women have convulfions, the
 death of the  children ought generally to be efieemed rather an
 effeft than a caufe ; as they have often been delivered of living
 children while they were in convulfions ; or of dead, and even
 putrid  children, without any tendency  to convulfions.  Some
 women have alfo had convuifions in feveral fucceffive labours ;
 butk having had them in one, they  generally, by the  precau-
 tions taken,  or fome natural change,  efcape them  in  future.
 Laftly,  I was for many years perfuaded, that convulfions hap."
 pened  only when  the  head prefented ; but experience has
 proved,  that  they fometimes occur in preterntural prefenta-
 tions of the child.

                     SECTION III.

       ON  THE SIGNS WHICH PRECEDE CONVULSIONS.

   l.  Puerperal convulfions are often preceded for many
 hours, or tor feveral days, by a vacillation of the mind,  or with
 a flight delirium.
   2.  Swimming in the head, and other vertiginous complaints,
 in the latter part of pregnancy, or in women in labour, not un-
 Irequently  forbode convulfions.
  3.  Violent or piercing pain of the head, preceding or recur-
 ring with the pains of labour, with Similar figns ot a difturbance
 of the funftions of the brain, often denote convulfions*.

  * The lady of Captain  C. who was at the full period of
 uterogejlation, but  not  in labour, having  complained about
twelve hours of an excruciating pain in her head, coming on at
intervals, fell down dead as Jhe was walking acrofs the room. 
200           INTRODUCTION TO MIDWIFERY.
   4. When women in labour frequently complain of blindnefs;
 they are in danger of falling into convulfions.
   5. Convulfions are oSten preceded by violent pain or cramp
 at the ftomach.
   6. Convulfions preceded by violent pain or  cramp at the
 ftomach,  are  ufually more dangerous  than  thoSe, Which are
 preceded by affections of the brain only;  and they  fometimes
 caufe fudden death by  ftopping the aftion of the  heart.
   7. Women who have a  rigor on the returns of the pains of
 labour, are in fome danger of falling into convulfions*.
   8. Women in labour, who have great Swelling or f ulnefi? of the
 neck, joined with an enlargement of the features of the face, and
 a flaring or protrufion of the eyes, accompanied with an almoft
 irrefiftible difpofition to fleep, often fall into convulfions.
   g. I  have not known any woman, who had  frequent vomit-
 ings, in the time of labour,  fall into convulfions ;  nor do theSe
 often happen in difficult labours.   But  women will frequently
 have vomitings, after they  have been feized with convulfions,
 which afford fome relief.
   10. The danger of cafes attended with convulfions is not in-
 creafed by their frequent return, as thefe depend  upon the fre-
 quency of the aftion ot the uterus ;  nor always upon an increafe
 of the caufe of the convulfions ; but the increafing violence of
 the convulfions always denotes an increafe of danger.
   11. In our attendance on patients in convulfions, it may be
 often obferved, that the fpafms in the fucceeding fits, chiefly'
 and evidently affeft diftant parts, fometimes the head, at others
 the abdomen, fometimes the' lungs,  and at others the mufcfes of
 the throat ; and the immediate danger  may depend upon the
 effeft of the fpafm in any one individual fit, upon one partial-'
 Iar part.                                            v
   12. When patients are recovered from labours which were
 accompanied with convulfions, there will often  be a vacillation
 ot the mind, or fymptoms partly delirious and partly maniacal,
 for feveral days or weeks ; but from thefe they  always recover.
   13.  Women who had convulfions,  remain  wholly infenfi-

   * All rigors may be confidered as a degree of convulfion ;  but
 thefe happen in labours frequently, thougfcnot always, without
 any ill confequences. I faw ajeeble woman feized immediately
 after her delivery with a rigor, which, in fpite  of all the means
 that could be ufed, continued for twentyi-fivi "rnHntttes, and then'
ffie died.   Her labour  had been very jlow, but was perfedly
 natural.                                            J   J 
           ANOMALOUS,  OR COMPLEX LABOURS.         JOl

blc of all the circumftances  which paffed  from the time when
the firft fymptoms of the  convulfions appeared, to that when
they recover their faculties ;  nor can they  ever recolleft them.
   14. Thofe women, who when in labour, from the violent
pain in the  head and other Symptoms, Seem to be threatened
with convulfions, have often a flight bleeding  from the nofe;
but Seldom in Suffient quantity, to give perfeft relief, or to pre-
vent milchief.
SECTION IV.
        ON THE MEANS OF PREVENTING CONVULSIONS.

  For the prevention of common accidents it appears reafon-
able and proper,  that women tar advanced in pregnancy fliould
avoid all irregularities in their manner of living, and every Sit-
uation where they may be under reftraint; or they will be liable
to many complaints and inconveniencies*.  At the time  of
labour  it is a rule generally  obferved, that their minds fhould
be kept compofed, their apprehenfions quieted,  their  prefent
Sufferings Soothed by  the tenderneSs of their friends and attend-
ants ; that they ffiould be encouraged with the hope of a happy
event, and that the knowledge of every thing which might agi-
tate or diftrefs them fhould be concealed.   But when any fym-
toms ot  difeafe appear,  befides  theSe precautions,  Such means,
as the confideration ot any particular cafe  may indicate to  be
neceflary, are to be uSed ; and no Symptoms can require more
attention than thofe, which have been recited as threatening con-
vulfions.
  Bleeding is known to leffen, in a very effeftual manner,  all
the  complaints in pregnancy which ariSe from uterine irritation,
and to  a certain degree,  in pregnant women,  from all  other
caufes,   It is therefore,  I may  fay, univerfally recommended
in ail caSes,  when theSe  convulfions exift, or are to be appre-
hended.  The  quantity  of blood  to  be  taken away,  and the
repetition of the operation may be feveral times required, muft
depend upon the ftrength of the patient and the violence of the

  * Gregarious animals when pregnant or giving Jack, choofc
a. place in the herd,  different from  what  they take  at ether
times.
  Vol. II-.                 B b 
20«
INTRODUCTION  TO MIDWIFERY.
Symptoms.  But as,  in Some caSes of this kind, there are alfo
tokens of general debility, and a great dread of the operation,
it will then be alfo neceffary, or preferable, efpecially when the
head is particularly affefted, to ufe local bleedings, by Scarifica-
tion and cupping at the nape of the neck, by the free and fre-
quent application of  leeches,  or by opening the jugular vein,
or fometimes by cutting the temporal artery; a thing fo eafily
done as not to deter us from the praftice, and fo efficacious as
to invite our doing it on many other occafions.
   When thefe fymptoms have been preceded or are accompanied
by others, which denote much difturbance of, or the lodgement
of any offenfive matter in the ftomach, emetics may be given
with Safety and advantage*.  In many affections ot the brain it
has been  thought that emetics afforded Singular  benefit; and
when thefe convulfions have been threatened, or exifted, pa-
tients have been fometimes wonderfully relieved by the opera-
tion of  an emetic.   Care is alfo  to be  taken to regulate the
ftate of the bowels, whether they be too much relaxed or con-
ftipated, efpecially in the latter condition.
   Towards the'conclufion of pregnancy fome women are fub-
jeft to violent cramps in various parts oi the abdomen,  or inte-
rior extremities,  together with complaints in  the head or fto-
mach.   Should not thefe be relieved by the cuftomary means,
the warm bath may be advifed,  and from its occafional ufe they
Will often find much benefit.
   Objeftions have been made to the frequent or habitual ufeofc
opiates for flight complaints in pregnant women ; and there is
much reafon to fufpeft,  that they fometimes, afting  perhaps
like fpirituous liquors, prove injurious to the child.  But thefe
objeftions do not anply to their  occafional ufe when they are
really neceffary.   Yet as, in very  large dofes,  opiates have
been  known to  produce convulfions, it feems better to give


   * A very Jliort time ago, a lady had many Jevere attacks oj
this violent pain in the head, in the tatter part of her pregnancy
this was conftantly relieved by the application oj leeches to her
temples,   When Jhe Jell into labour jhe became blind, and had
one convulfion.   Having great ficknej's at herjiomaeh, without
vomiting, I urgedher to irritate her throat with her finger, by
which meansJJie vomited five or fix times, and had no fit ajler-
zvajrds ; the blindnefs remained infome meafureJorfeveral days
after her delivery.  The child had been dead about a jortnight. 
ANOMALOUS,  OR COMPLEX LABOURS.
203
them in thefe cafes, in fmall quantities often repeated,  than in
a large dofe at one time*.
   Nervous  medicines of various kinds are ufualjy given on
theSe occafions, rather from cuftom, or with the intention of
procuring temporary  relief  than permanent  advantage ; and
they ought not  to be neglefted.   But,  on the whole it  appears
that in bleeding, andkeepingthe ftomach and bowels in a heal-
thy Slate, in giving opiates, and in the  occafional uSe of the
warm bath, we have the principal means which  medicine af-
fords, as far as can be judged either by reafon  or experience,
of  preventing puerperal convulfions, of infuring, in  general,
an  undifturbed  labour, and an uninterrupted recovery*.
   It may laftly be confidered, whether in cafes  of convulfiens-
exifting or threatened after delivery, efpecially  when there are
twins,  it might  not be  expedient and ufeful to make an uniform-
preffure by paffing a napkin round the body, as foon as it can
be conveniently done,  between the birth ot the firft and Second
child.

                      SECTION  V.


           ON  THE TREATMENT OF CONVULSIONS.

   From the attack of convulfions without any previous Symp-
toms, or from  the  want of attention to thofe  fymptoms, we
have much more frequently an opportunity of exercifing our
judgment in curing than in preventing convulfions.  TheSe, it
was before obferved, may come on in the beginning,  or in the
courSe of a labour; or, which  is more rare, though not lefs
dreadful, foon after the birth of  the child ; and fome difference
of  treatment may be requifite, according to the time of  their
appearance.  But, whenever they do come  on, the danger is

   * But'the late Dr. Hunter informed me of the cafe of a pa-
tient who had convulfions, preceded by violent pain at thejio-
riach.   On  the approach  of her next labour Jlie was  attacked
with the fame kind of pain.   She was immediately bled largely,
and took thirty drops of tmft.  opii, by which  the pain was
removed.   She was delivered after an eafy and natural labour.

  * Mirtieri ex partu  convulftone tentatae,  Si febris Succedat^
bonum eft..
                           Hippocra':, Lib. i. n: Merbis.. 
204
INTRODUCTION TO MIDWIFERY.
fo manifeft, and fo alarming, as to call for the immediate exer-
tion of all the powers of medicine for the relief of the patient.
* The firft and moft  obvious remedy in a cafe of fuch violent
agitation of the whole frame, and fuch obtufion or perverSion of
the mental faculties,  is, to take away a proper quantity of blood
from the arm ;  for the direft good, which may be expefted to be
gained by bleeding Speedily, as  well as  for  the prevention of
the mifchief,  which  might follow  the convulfions.  One co-
pious bleeding has  fometimes entirely removed the convulfions,
which have not returned after, as well as before delivery ;  but
fhould thefe continue  with equal force  for a  certain time, it
will be expedient,  for  the particular eafement  of the head, to
try the effeft of local bleedings.  Leeches are too flow in their
operation,  though  they may be lately applied,  and  affording
feme relief, ffiould  not be  neglefted, and  fcarification, with
cupping,  could not be done  without  much  difficulty ; fo
that  the  two  methods, moft  applicable and  adequate to the
urgency ot the cafe, are,  to open the temporal  artery, or the
jugular vein ;  and the  latter has certainly been found prefer-
able,  perhaps becaufe the blood is thereby difcharged with great-
er velocity*.   Objeftions are fometimes made to bleeding, left
there fhould be a  difficulty in  reitraining the blood while the
patient is  fo much difturbed ;  but  there is no hazard, and the
cafe  does not admit of delay.   The bleeding, from whatever
part the blood may be  drawn, is to be repeated according to the
effeft produced, the  ftrength of the patient, and the violence
or continuance of the convulfionsf.
   In the  courfe of a few hours, I have  by different operations
 feen  more than forty  ounces of blood taken  away with the
 happieft effect  ; and in a  bibour of long  duration, when the
 convulfions have  been fevere, at various times, not leSs  than
 fixtyor feventy ounces.

    *  For a patient, who was lying  in ajtatewhich  deprived me
 andfeveral phyficians  of all hope  of her recovery,  Dr. Rey-
 nolds propofed, that the jugular veins fiiould be opened.  Ihe
 good effeds were almoft infiantancous ; the patient  recovered,
 and  has Jiuqc  had many children.

    t  The late Dr. Bromfield informed me of a  cafe  of puerperal
 convulfions, Jor whith he had bled the patient withouc much
'benefit.  In the violence of fome  of her Jlruggles the  orifice
 opened, and a confiderable quantity of blood  was loft bfore
 the accident was dijeover :d ;  but  the  convulfions jrom  that
 time ceajed. 
           ANOMALOUS,  OR COMPLEX LABOURS.         205

  The ftate of the patient will feldom allow of the ufe of eme-
tics ;  but, when they could be given, and have produced their
effeft, they have procured much relief ; and the fame obferva*
tion may  be made of purgative medicines.   But the truth i?.
from  the moment the  convulfions come  on, the patients pften
lofe all power of Swallowing, even in the intervals, and we are
compelled  to relinquish  internal  medicines  altogether.   Yet
in Such cafes, clyfters,  if they can be made to  pafs, are ufually
given ;  but,  whether they were purgative in  the firft inftance,
or afterwards compofed with a due quantity of opium, of oil of
amber, the fetid gums, or other medicines of that kind, I can-
not fay that I ever faw any good produced by  them, at leaft
before the birth of the child ;  and  fometimes  they Seemed to
increaSe the irritability.
   On a Suppofition that the remote cauSeof theSe convulfions is
in the too great irritability of the conftitution at large, and the
immediate caufe in the excitement raiSed by Some new  ftimulant,
as the labour, or  the like, opium  in any convenient form has
been  freely  given, and  fometimes with evident advantage ;
though I have feen many cafes, in which it had no  power to
remove, or even to abate, this  difeafe.  From the exhibition ot
large  dofes, I have Seen the patient brought into a comatoSe ftate,
but the moment ffie was rouSed, the convulfions have returned
with  their  former violence.  Nor. has more  fatisfaftion been
obtained by  the various  nervous  medicines  commonly pre-
scribed ; even mufk,  often repeated  in large quantities, has
done  as little fervice as the reft.
   When the convulfions have  continued or increafed, notwith-
ftanding the bleeding and  the  ufe of all the  other reafonable
means which could be deviSed, the patient may be put into the
warm bath, in which She may remain a confiderable time, if the
convulfions be f'ufpended while ffie is in  it.  There have been
inftances ot women with convulfions, who have been freed from
them only during the time they were  in the bath ; and I have
heard of more cafes of their being aftually delivered in the bath,
without any  ill confequences, either  to the mother or child.
When a warm bath could not  be procured, or  while it was pre-
paring, I have direfted flannels wrung out of hot water, or any
Suitable fomentation,  to be applied over the  whole  uldomen,
and, I think, with advantage ;  and after the ufe of the fomenta-
tions  I have alfo advifed fome liniment made more toothing by
Me mixture ot opium, Such as equal parts of oil and tmclura
opn.
  Qn every principle, of removing the caufe of the convulfions, 
2o6            INTRODUCTION TO MIDWIFERY.
 of fubftitutingnew modes of irritation different from that which
 produced  the convulfions, ot preventing their ill effects, or oi
 abating that exquifite irritability which renders  patients  Sub-
 ject to them, almoft every roeaSure and method has at one time
 or other been tried.  Harvey* recommended the irritation oi the
 noSe in a comatoSc patient who was in labour, and gives an in-
 ftance  ot its fuccefs.   Many years ago I was led by accident to
 try the effeft ot Sprinkling ordafhing cold water in the face; and in
 Some caSes the benefit was beyond expeftation or belief + : but in
 other caSes,  in which I uSed this method with equal  care and
 affiduity, no good whatever was derived from it; nor has the ap-
 plication of finapifms to the feet, or bliftei s to various parts of the
 body, afforded any  advantage, except, perhaps, when the  con-
 vulfions had ceafed, and the patient remained comatofe,
   When all the means have been tried without SucceSs, and the
 convulfions remain,  with evident and extreme danger of the
 patient dying every time they return, we Shall, notwithftanding,

   * Exercitat.  de Partu.—Page 5^4,

   T 1  Subjoin the  following  cafe, to explain the manner of
 ufing the  cold v^ater.  To a patient in convulfions, who had
 been bled, and for  whom many other means had been fi uitleSsly
 uSed,  I determined to try the effeft  of cold water.  I fat dqwn
 by the bed fide with a  large bafon before me, and a bunch of
 feathers.  She had a writhing of the body, and other indications
 of pain evidently occafioned by the aftion of the uterus, before
 the convulfions  ;  and  when thoSe came on, I dafhed,  with
 Some force, the cold water in her face repeatedly, and prevented
 the convulfion.   The effeft was aftonifhing to the by-ftanders,
 and indeed to my Self.  On the return of the indications of pain
 I renewed the ufe of the cold water, and with equal fuccefs; and
 proceeded in this manner til) the patient was  delivered, which
 fhe was without any  more convulfions, except once when the
 water was neglefted.   The child was born living about fifteen
 hours  from the  time of my being called,  and the patient re-
 covered perfeft ly.
   I was much mortified to find, that I had not difcovered a cer-
 tain and Safe method of treating convulfions ; farther experi-
 ence  convincing me, that this  often failed.   It  is  however a
^ fate remedy ; and, though it may not always have fufficient
 efficacy to prevent or check convulfions, whoever tries this
 manner of ufing cold water will Soon be convinced, that it i;
 a very powerful  Stimulant. 
ANOMALOUS, OR COMPLEX  LABOURS.
ioy
be driven by neceffity to wait quietly for  the tenhination  of
the labour in a natural way,  hoping ffie may ftruggle through ;
or we Shall be obliged to leek further refources in the delivery
of the patient by art.  But this part of our fubjeft fhall be con-
iidered in the next Seftion.
SECTION  VI.
                 ON THE DELIVERY BY  ART.

  If it be neceffary to make diftinftions as to the time wheti
ronvulfions come on, with regard to the medicinal treatment, it
is infinitely more So as to the delivery of the patient by art.
We will  therefore confider,
  I. Whether delivery by ait be proper or juftifiable in the
beginning of a labour attended with convulfions.
  Women fometimes fall into convulfions before there is any
discoverable tendency to labour, when there is not the fmalleft
degree of dilatation or relaxation ot the os uteri, and when there
is no way ot judging that  it  will be labour, except from the
peculiarity of the convulfions, or the manner in which they re-
turn ; and by theSe they may in general be readily diftinguiffied
Irom thoSe proceeding from any  other cauSe.  In fome cafes
alfo, after a long continuance of the convulfions, the os uteri
has remained cloSed ; and then it has been preSumed, that they
were not, properly fpeaking, puerperal.  Yet, after a long delay,
it has ufually happened, that the dilatation both of the internal
and external parts has begun, and proceeded very rapidly ; fo
that, in a ffiort Space of time,  from no degree oi dilatation, the
os uteri  became unexpectedly,  but completely dilated,  when
all hopes of delivery had been  laid afide, and the very existence
of the labour had been denied*.
  When women have before had children, the infant and pla-
centa, have been Sometimes expelled with wonderful rapidity,
by the mere force of the convulfion  afting upon the uterus.
But even in  fuch cafes the Convulfions  may continue  with
equal danger after delivery.

  *  In a welt known cafe of this kind, the midwfe, prefuming
that it would  not be labour, left the  patient, who xvasjourcii
d*ad in the  morning, with her  chxld3 alfo '.had, l-yin* in tfo
bid. 
*o8         INTRODUCTION  TO MIDWIFERY.
   Now whether it  be proper and reafonable, that  attempts
 ffiould be made to deliver a  woman with  the  os uter\ in
 this ftate, and under Such circumftances in  general, muft ap-
 pear very dubious to thofe, who confider how much would then
 be required to be done by art.  But, if we farther refleft upon
 the event of the greater number of cafes of  women  who  have
 been delivered by art, under thefe,  and far more favourable cir-
 cumftances, the greater part of whom have foon died, their death
 being  apparently haftened by the operation, however carefully
 it might have been performed, we fhall be deterred from then
 propofingit ;  and, I think, be juftified in Sorming this general
 rule of praftice, fubjeft perhaps to fome exceptions, that  wo-
 men,  who fall into  convulfions in the beginning ot labour,
 Ought  not then to be delivered by art.
   I prefume, that, with all the affiftance which art enables us to
 give, or if the labour be refigncd to  nature without interpofition
 on our part, patients will Sometimes die in a deplorable man-
 ner*.   I alfo know that, if the patient Should  die when no at-
 tempts were made to deliver, that the omiffion is always regret-
 ted *. or, if fhe ffiould be delivered by art and die, that  the oper-
 ation is lamented.  Yet there muft  be a rule, ot conduft to be
 preferably-followed, and with few exceptions ; and this is to
 be made, not according to the timidity or boldnefs of the perfon
 under  whofe care the patient may be, nor according to the  im-
 patience or tendernefs of friends ;  but according to a judgment
 formed by a fenfe of duty, maturely weighing all  that the know-
 ledge ot a prefent cafe, or the experience of others,  has enabled
 us » colleftr.

         * —!— with  remorfclefs cruelty,
           Spoiled at once both fruit and tree.
           The haplefsbabe b fore his birth,
           Had burial, yet not laid in earth.

                          Milton's Elegy on the Marchionefs
                              of Winchejler.

   T  Dr. Rofs, who, forty years ago, was one of the phyficians
 of St. George's flofpital, was thejirfi perfon who had courage
to declare his  doubt  of the  propriety of fpeedy  delivery in all
cafe* ojpuerperal convulfions.   The observation on which thefe
doubts were founded was merely pradical, and the event of very
many cafes has fince confirmed tkejujiice of his obfervaiion,
both with rcfpecl to mothers and children. 
           ANOMALOUS, OR COMPLEX LABOURa.         209

   2. Though convulfions often happen  in  the beginning of
a labour, and continue to its termination, the firft ftage is, in
fome cafes, paffed over  without any unuSual  difturbance or
irregularity, and they come on in the fecond ftage of the labour,
when the fymptoms which ufually precede them did not appear,
or rather paffed without observation.   The propriety of deliv-
ering by art is then to be determined on other grounds than in
the|preceding ftatement, whether the convulfions have continued,
or commence at that time.  For, it it fhould be thought necef-
fary, to deliver by  art, this may frequently  be done without
any peculiar force upon  the  parts  concerned,  as the os uteri
will then either be dilated with the membranes,  whole or lately
broken, and the child  may be turned  without difficulty, and
fafely extrafted by the  feet; or the head will have defcended
fo low  into the pelvis, as  to allow  of the ufe of the forceps or
vedis ; or  things may be fo unhappily  circumftanced, as to
leave no other option of the mode of delivery,  but we may.be
compelled to leffen the bead of the child. Whichsoever of thefe
methods  may be thought neceffary, the rules before given for
the management ot  difficult  or preternatural labours, will be
fufficient guides tor our conduft : and before any  thing elfe is
dene,  the membranes  may  he ruptured, and the  waters  dif-
charged ; from which alone, in fome cafes,  much benefit has
been derived.   But, from a  review  of what has paffed in my
own  praftice, I  feel it neceffary to caution the operator againft
a forwardnefs to facrifice the regard due to the child in cafes of
convulfions, as many of thefe, with very unfavourable appear-
ances,  have terminated happily and  fafely both to  the  mother
and child ;  and  againft hurry in any operation, as he would
thereby leffen his chance of faving the child, and probably with
disadvantage to the mother ;  and no good can refult to Society,
or reputation accrue to the profeffion, from a praftice by which
neither of their  lives is  preferved.   Should the  convulfions
continue after the birth of the child,  the methods  before tried
muft be perfifted in, or new  ones adopted,  as the  ftate  of the
cafe may then require or allow ; and  under thefe circumftances
it will  often be  found preferable, to fatisfy ourfelves with giv
ing time, proceeding gently  and  circumSpeftly with  general
care, rather than to ufe inceffantly the  more aftive means, which
it has been fometimes neceffary to recommemi.
   With refpeft to thofe convulfions, which  firft appear after
the birth of the  child,  the exigence of the cafe mutt  govern
the treatment, and great attention is to be paid to the placenta,
   Vol.  II.                  C c 
210
INTRODUCTION  TO MIDWIFERY.
 which, I believe, fliould not then be haftily extrafted.  There
 is in theSe  an appearance  of ini'ant and  unexpe£ted danger.
 beyond what is  found in convulfions before  delivery, frightful
 as. they always are.   TheSe convulfions are preceded or accom-
 panied by the fame Symptoms as thofe, which come on the com-
 mencement or  courfe ot a labour  ; and  notwithftanding the
 delivery, they require and allow of  the Same means being uSed
 for the relief of the  patient, provided thefe are accommodated
 to her general ftrength and circumftances.    In convulfions
 which come on  after delivery, if women  efcape from the firft
 fit, there  is  a  great chance  of  their recovery;  but ffiould
 they remain comatofe, or whatever  their ftate may be, the par-
 ticular fymptoms are to be confidered, and, from all that has
 been  Said upon this Subjeft  at large, we Shall be at no lofs to
 difcover what may be applicable in any individual caSe of this
 kind.
   But there is yet room for much improvement in our know-
 ledge of the caufes, effefts,  and treatment  of  convulfions, deT
 pending on pregnancy and parturition.
   Before the conclusion of this fubjeft, it will not be amifs to
 fpeak of the fudden deaths  which Sometimes happen foon, or a
 considerable time after  delivery, when there was no apparent
 reafon for fufpefting fuch events.
   In every cafe of extreme debility, induced by any circum-
 Stance which might occur at the time of parturition, great cau-
 tion was generally recommended, that patients fhould not exert
 themfelves beyond their ftrength, or what they were able  to
 do with  eafe.  But from a review of thefe dreadful accidents,
 ot which, in the courfe of a long and extenfive praftice, I have
 feen and known too many inftances, I think they may be reduced
 under  the following heads.
 . Firft, when before delivery the  patients were fubjeft to fre-
 quent  returns of fpafm  or  cramp-like pains  in the  ftomach
 fpreading their influence to the heart, as is Shewn by  the tem-
 porary fufpenfion or  interruption of the circulation, indicated
 by the pulfe.  TheSe Symptoms are very apt to  return a Ster
delivery with increafed and  dieadful violence.
  Secondly,  when the patient is  very  much  reduced by lofs
of blood  at the time of delivery, the weaknefs therebv occa-
 sioned  remaining a long time afterwards.  In thefe cafes  on
making any extraordinary  exertion, the  patient is Suddenly
overcome,  and the powers  ot  the  conftitution are never able
from that time to recover vigour of  aftion  fufficient to Suftain
life. 
ANOMALOUS, OR COMPLEX  LABOURS.
211
  Thirdly, when without any adequate indication of the mif-
chief to be apprehended, a taintnefs and a difficulty of refpira-
tion  fuddenly  come on, and thefe increafing, the patient dies
unexpectedly.   This event is uSually preceded by her Spitting a
very Small quantity of blood, and on examining the body after
death an effufion ot  blood in the air veffels  of the lungs has
clearly fhewn the caufe.
  Fourthly, in cafes of extreme debility from other caufes, par-
ticularly m the edematofe fwelhng  of the leg, in which there
is often a furprifing degree ot weaknefs with much difturbed
aftion  of the whole frame, on the patient's making any effort
beyond her ftrength, and perhaps her inclination,  a fatal and
fudden faintnefs is fometimes  brought on before an  aftion to
which  ffie feemed competent  is completed,  and death feems
more inftantaneous under thefe than any other circumftances.
  With regard to the firft caufe of thefe deplorable events, with-
out waiting for the return ot the fpaSmj it  will be proper to
give Some very  warm cordial  immediately after delivery,, as
brandy alone or diluted, afting in the manner uSually praftifed,
when patients  are Suffering from the gout in the ftomach.  The
moft fuitable medicine is the confedio opiata, given and repeat-
ed in a full dole according to the exigencies ot the cafe.
  With regard to the fecond and third caufes, there is no way of
preventing their effefts fo reafonable, as by taking care not to fill
the veffels too haftily, by  very plentiful nourishment, from an
impatience to  reftore that ftrength which the patient has loft.
  And with refpeft to the fourth caufe, of which  I have  feen
three inftances, we are to be very circumfpeft, that we do not
permit, orperfuade patients to make much exertion, while they
are very weak, but leave them to aft  according to their  own
feelings and judgment.
  Thefe obfervations  will not  I fear be of much importance,
but  we may be truly faid to be ignorant, or to have a very  im-
perfect knowledge of this fubjeft, which deferves more accu-
rate obfervation, and greater confideration. 
2.1%            INTRODUCTION TO MIDWIFBRY.
CHAPTER  XVII.
ANOMALOUS,  OR COMPLEX  LABOURS.
ORDER THIRD,
Labours  with two or more Children.-
                      SECTION I.


 J, he common order of generation, or the continuance of the
particular  kind of animals, according to the properties of each
kind, is more frequently invaded by an extension than a failure
of the principle ;  inftances of  unufual  increafe being often
found both in animals and vegetables, though thefe inftances
occur more frequently in fome claffes than in others.
  With refpeft to generation, all animals may be divided  into
two  claffes, uniparient and multiparient.   Of the multiparient
the number of young produced at one birth feems to be inde-
finite and governed by accidental circumftances, as the frequent
intercourfe with the male, plenty or want of food, and perhaps
by the cafual fixture of the firft conception in the firft chamber
or partition of the uterus.  It very feldom however happens,
that  animals multiparient by nature bring forth only one Jatus
at a  birth  ; and perhaps the uniparient do not more frequently
bring forth more than one, though  in every fpecies there are
 exceptions to this  general rule.  As to the economy of this
 important end of the animal creation, it would probably be
 found,  that the female multiparient animals have no exclufive
 attachment to any individual male ;  but that the female unipa-
 rient have naturally fuch an attachment.
   In fome fpecies  oi  animajs, the propenfity to bring forth
 more than their common number ot young is greater than  in
 others ; ffieep, for inftance, more frequently than in  cows,  in
 thefe than in lions   Climate, and ftate or degree of civil zation, 
ANOMALOUS,  OR COMPLEX  LABOURS.
213
Seem to have  their influence in this reSpeft on human beings ;
for in the account of women admitted into the Middlefex Hof-
pital in this city, in 8636 births, there were only ninety-three
cafes of twins, and none of a greater number.  Of this num-
ber there were 3263 boys; 310 were ftill  born,  and of this
number 180 were boys ; and Somewhat more than half of the
twins were  boys.   But in  the  accounts  published  by  Dr.
Clerke of Dublin*, the number ot twins was in greater propor-
tion to the births, and there were  feveral examples of  three
children.
  It has been fuppofed, that there is a difpofition in certain
families to this multiplied generation,  which may be transferred
either by the male or female ; but if this be the cafe, there are
no tokens by which this difpofition would be fuSpefted, either
from the form, fize, ftrength, or other appearance.
  It is not  very ufual for women to  have twins, though thefe
are to common observation  more frequent  in particular years
than in others, and it  can  fcarcely be  doubted,  but there is
fome relation in thofe years between  the animal  and vegetable'
creation.  In the  courfe ot  more than thirty years I have met
with only one inftanoe of three children,  and never of  more.
I have been informed  ©f Several  cafes of four  children, and
there  have been publiffied a  few cafes of five children born at
one birth, but beyond this number there is no well authentica-
ted cafe upon record.
  The fize  ot children born at one birth is generally ina reverfe
proportion to their number,  as is alfo the probability  ot  their ,
being born alive, or continuing to live.  Twins are frequently
born living, and not much  beneath the fize of a fingle child;
fometimes  three have been born living, and been reared, but
not often ; and when there have been more, the chance of
all or any being preferved is very little.  With more  than two
children women feldom go on the full period of uterogeftation.
There muft ot neceflity be Somewhat  more  complex and fome-
times hazardous when there are two or more children  than in a
fingle birth, but he who underftandsthe proper management ot
a twin caSe will meet with no difficulty to embarraSs him, how
many chifdren Soever  there may  be; we fhall therefore  Speak
of all  births of this kind under the denomination  of twin cafes.

             *  See Philojophical Tranfadions. 
ei4
INTRODUCTION  TO MIDWIFERY.
SECTION IL
                 ON THE SIGNS OF TWINS.

   i. Women are faid to be always of a greater Size in the ad-
vanced ftate ut utcrogeftation when they are pregnant with twins,
than when they have a fingle child.   This is a very uncertain
Sign, and  popular  opinions being uSually founded on this cir-
cumftance only, are therefore far more frequently  fallacious
than true.   But if a woman be  unufually large  in  the early-
part of pregnancy, and increafe proportionably to the full pe-
riod, there is good reafon for fuipefting  fhe will have twins.'
But as the terms fize is  indefinite, and what one, not much
conveifant in Such matters, may confider as large, another may
confider as moderate, there can be no SurpriSe, it conjectures
on this Subjeft often prove to be erroneous.
  a. The abdomen of  all women with child is in general  uni-
formly diftended, without any inequality.  It fometimes how-
ever happens, that the tendons, which form what is called the
tinea alba, which  leads  tioin the navel to the middle ot the
offa pubis, being lets diftenfible than  the fides of  the abdomen,
which are mulcular, divide  the  abdomen as  it v.ere  into two
equal parts by a raphe or indentation  through its  inferior  part.
This preSumed  fign of twins is ,r, ancient as the time when the
human uterus,  like thaf of the quadrupeds, was fuppofed to
be divided into cornua,  a child being thought to be contained
in each horn.   But as the form of the human uterus is  now
well underftood, and known to be equally diftenfible by its  con-
tents, whatever the form of the abdomen may be,  unlets it be
conftrained by external means, even  leSs  regard  is paid to its
form than its degree of diftention,  when  we are judging whe-
ther it  be probable, that a woman is  pregnant with more than
one child.
   3. Women with child,  efpecially thofe who have before had
children, are Sometimes apprehenSive that they have twins,  from
a greater,  or Some uncommon motion they feel  durino" preg-
nancy.   Some  regard  muft at all  times be paid to tie  repi den-
tations of thoSe who have had experience, though they may be
ignorant of doftrines; yet I have Seldom found thefe opinions
verified by the event.
   a. In the  courfe ot a labour, Sooner or later, according to the 
           ANOMALOUS, OR  COMPLEX LABOURS.         2 1^

ftrength of the membranes' and of the  pains,  the waters of the
ovum are difcharged at once, by one large, or a repetition of lefs
difcharges, when there is only one child.   Mention is Some-
times made of a  fecond difcharge of water, before the  birth of
the child, as a Sign of twins.  This fecond  difcharge may be
occafioned by an imperfeft firft difcharge, or by water collefted
in a confiderable quantity  between  the membranes, on  the
rupture of the fecond membrane.  When  however a child  is
far advanced towards birth, a fudden difcharge of any confider-
able quantity ot water from a part beyond the child does create
a juft fufpicion of there being another  child, the membranes of
the Second breaking by the efforts made to expel the firft.
   5. Extreme flowneSs of a labour, which has been confidered
a fign of twins, may be produced by a variety of other caufes, as
we have often mentioned, and of courfe this muft be a verv un-
certain one.  It  is  true, when there are twins, the firft labour
is almoft  univerSally flow, and this flowneSs has been not un-
reasonably attributed to the great diftention  of the uterus.
   But our ignorance of the  number  of children of which  a
woman may  be  pregnant,  fortunately  does not lead to any er-
rors in praftice ; becaufe if we knew  with certainty that there
were twins, our conduft with regard to the birth ot the firft
child ffiould not  be altered.   It  would then be our duty, as at
all other times, to wait for the expul/ion of the firft child, if the
labour were natural, and any difference in praftice would only
relate to the Second  child.
   After the birth of a child, it was formerly the cuftom to in-
troduce  the hand into the uterus to bring  away  the placenta,
or any coagulated blood which might  be collefted in its cavitv,
and to afcertain  whether there were another child.  This prac-
tice has been tor many years juftly held both unneceffary and
pernicious, the placenta generally coming away  without any,
or with very little affiftance, and coagula being alfo Safely ex-
pelled without any or much difficulty ;  and the application ol
the hand to the abdomen giving full fatisfaftion as to the other
intention. By this method we can often tell diftinftly if there
be another child, and  its limbs, together with the different parts
ot the body, through the integuments ot the  abdomen ; but it is
generally by  its  degree ot diftention after the birth of the firft,
that we jiufee the»e is a fecond child.  But  on this principle  I
remember heing miflaken  in a cafe in which a voung woman
with her firft child  had an ajcttes during pregnancy ;  and the
error muft always be of that kind, to lead  us to believr there
are twins when  there are not, but can never f :T.u us f:> over- 
216            INTRODUCTION TO MIDWIFERY.
look the cafe, or to leave a child remaining in the uterus, which
through inattention or ignorance has fometimes haPPen^-   -
  In Twin cafes, priority of birth does not depend  on fuperior
ftrength, but on convenience ot pofition ;  that which is neareft
the  aperture ot the pelvis  muft firft be born,  whether  i  be
ftrong  or  weak, living or dead.  When one child is beyond
comparison ftrong, and the other feeble  it is not unufual  for
the  feeble one to  be  killed, apparently, by preffure,  though it
may not be expelled before  the full period ot uterogeftation ;
fo that one may come into the world fat  and full grown, and
the  other may be Small,  withered, and  comprefled.   lhi*
diffimilarity in Size and appearance was once confidered as a
proof of the obfolete  doftrine of fuperfetatton.
SECTION  III.
          ON  THE MANAGEMENT OF TWIN CASES.

  It is a canftant  rule, to keep patients, who have born one
child, ignorant of there being another, as long as it can poffibly
be done.                              .          i_-  i  i
  In far  the greater number of thofe twin cafes,  which have
occurred  to me in  praftice, while I have been waiting for the
circulation in the funis to ceafe, or employed in tying  it, or
waiting for a pain to exclude the placenta, the patient has com-
plained with more than ordinary eagernefs.  On  examination,
I have found the fecond child on the point ot being born, or
the membranes protruding with great firmnefs, fo that  inftant-
ly on their breaking, the patient  has been delivered with great
rapidity almoft before I had.time to give notice to the attendants,
to prepare for  its reception.   Of courfe, in labours like thefe,
nothing particular could be required to be done, as they termi-
nated with as little trouble, as if there had been  only  a fingle
child.  Our  intelligence and care can then only  be exercifed
on one or other ot thefe occafions.
   i. Whatever may be the prefentation of the firft child, and
whatever method it may be found  neceffary to purfue  for the
delivery of the patient, thefe are to  be precifcly the fame, and
there will be no greater difficulty, than it there were only a
Single  child.  One ciicumftance alone demands attention, that,
if the prefentation  of the  firft child  be  Such  as to  require he
chHd to be turned, when we have introduced our hand into the 
ANOMALOUS,  OR COMPLEX LABOURS.        217
 uterus, we muft be careful not to break the membranes of the
 fecond child, if they be yet whole ; or it we ffiould find them
 broken, we muft  take care to bring down the feet of the fame
 child.   In all other refpefts I think  I have found the turning
 of the child lefs difficult, when  there were  twins;  and if we
 have been  under the neceffity of turning the firft child, it will
 generally be expedient, to extraft or get the command of the
 fecond, by repaffing the hand into the uterus and bringing down
 its feet into the vagina.
   Should the  Second child prefent with the breech or inferior
 extremities, there  can be no  Solicitude about  the caSe.   We
 muft aft as was before advifed in fuch cafes, that is, we muft
 wait for the expulfion of the child by the natural efforts, if they
 be excited, or  be  equal  to the effeft, otherwife we muft give
 affiftance.
  The moft fortunate prefentation of the Second child in a twin
 caSe is certainly with the  inferior extremities, becufe it may in
 that pofition be born without injury or difficulty, and if affift-
 ance be required,  this may be  given with fafety and conveni-
 ence.
  In  cafes of  the  fecond child prefenting  with the  head, the
fame obfervations  will hold- good.  That is to fay,  the  child
 will probably  be expelled by the natural efforts ; or if farther
 affiftance be  requifite, the forceps or vedis may be conveni-
 ently ufed.  As to leffening the head ot the child, this oper-
 ation cannot poffibly be needful, if there were room for the firft
 child  to pafs without diminifhing its bulk ;  unlefs from fome
 very unufual circumftance, as a hemorrhage or convulfions,
 threatening immediate danger.
   2dly. When after the  birth  of the firft child there is a SuS-
 penfion of the pains of labour,  and no efforts are made to expel
 the fecond child.
  The procefs of the labour of  the fiift child will have its effeft
 on that of the fecond.  It we were compelled to make the firft
 labour artificial, it might be neceffary or expedient, to deliver
 the patient ot  her fecond  on the fame principle, unlefs the na-
 tural efforts fhould be efficacioufly made very Soon after  the
 birth of the firft child ; which  i^ not the ftatement I now wilh
 to make.  But when after the  birth of the firft child,  expelled
 in a reafonable time and by the natural efforts, from fome caufe
 which we cannot comprehend or counteraft, no efforts-whatever
 are m.s.de for the expulfion of the fecond child, the patient being
as much at her eafe as it  there had been no  previous labour ;
  Vol. II.                 D d 
 2l8 *         INTRODUCTION TO MIDWIFERY.

 this is a ftate of great Solicitude to every perfon careful of his
 patient, and of his own character, as he  muft know fhe will be
 in  fome  degree liable to unpleafant, and even to  dangerous
 fymptoms, till the fecond is alfo born, and the bufinefs com-
 pleted.  The rules of praftice have been on this fubjeft not
 only Various, but direftly oppofite.  By the  older writers we
 have been taught, that  it was neceffary and proper, if the fe-
 cond  labour  were not fpeedily finifhed, immediately after the
 firft, to extraft the fecond child, according to its pofition  or fi-
 tuation,  by properly adapted artificial means.  Others, on the
 contrary, averfe on every Safe occafion to the  interpofition of
 art, have adviSed  us to wait patiently, till the efforts to  expel
 the Second child  were renewed, unleSs  Some Symptom Should
 ariSe, which ffiould call for more Speedy affiftance.  The latter
 appears to be a more judicious principle on which to aft in
 general, and  it is  Supported by Some fafts under the eye and
 direftion  of  very able men, as well as by  many popular ac-
 counts ;  not  to mention the guard it provides againft the mif-
 conduft of thoSe, who may not be perfeftly  competent to give
 that affiftance,  which they prefume to be required.  Like all
 other general principles in praftice, it requires nice diftinftions
 to be  made in particular  cafes, otherwife the caufe of danger
 will fometimes creep on infiduoufly, and come by furprife. No
 perfon can objeft to waiting for a certain  time after the birth
 of the firft child, provided there be no preffing occafion for his
 interpofition, before he determines on the extraftion of  the fe-
 cond  child by art.   We can then only debate upon  the length
 of time which it may be expedient to wait ; and, as we fay with
 regard to the  placenta, it Shall neither be fo fliort as to run the
 rifk of injuring the patient by hurry or raffinefs, nor fo long as
 to increaSe the danger, ffiould any exift, nor the difficulty of
 delivering the patient, if we ffiould be at length obliged to uSe
.art for this purpofe.   Without regard to thofe who are fond of
 Speculative opinions, or the determination  of  thofe who are
 guided by praftice alone, I have concluded that  we may fafely,
 and ought to wait for four hours  at leaft after the birth of the
 firft child, before  we deliver the  patient by art of the fecond
 child ; if there be no particular caufe for delivering her  Sooner.
 By this  decifion we fhall  certainly  avoid  many unneceffary
 operations, without detriment to the patient, without increa^*
 ing our own difficulties, or hazarding our reputation.
  The proper management 'of the  patient after  the birth of the
 firft child  is very obvious.   There is no reaSon for alarming her
 fears,  but  the cafe  will terminate more favourably by keeping 
            ANOMALOUS, OR COMPLEX LABOURS.      •  210,

 her ignorant of the  circumftance, or if it be difcovered  by
 cheering her mind, and fhe will go  on  better and with more
 refolution, by being affured that affiftance fhall be given, if  ffie
 fhould not be delivered naturally before fome fixed time.
   3.  When a  hemorrhage, convulfions, or other  dangerous
 Symptoms  come on, or are threatened,  after the birth of  the
 firft, or before the birth of the fecond child.
   Though there may be many aberrations, every labour has its
 denomination from  the  moft important circumftance,  with
 which it is attended, and fuch circumftance principally governs
 the praftice, which it  may  be  neceffary to purfue.  Among
 thei'e, hemorrhages and convulfions ftand in the firft place, and,
 whatever may be the nature of a labour in other reSpefts, that
 mUft be of  fecondary confideration.   In twin cafes, however
 proper or expedient it might be to wait,  for a limited time,  for
 the natural expulfion of the fecond child, the appearance of
 convulfions, or hemorrhage, or other  dangerous fymptoms,
 would decide the matter, and put the propriety of waiting any
 longer out  of the queftion.   The  patient, if thefe  cannot  be
 removed by other means, muft be fpeedily delivered by art.
 But  I with to confine the term Jpeedy to the determination to
 deliver ; for under all  circumftances, the operation inftituted
 for extrafting the child, of whatever kind that may be, ought
 to be  performed deliberately, or we fhall add to the  danger
 which before exifted.  Whether  therefore  we be compelled
 by thefe dangerous appearances, or after waiting a fpecific time,
 four hours  for inftance, as  was before ftated, we have deter-
 mined on  the propriety of delivering the patient by art,  we
 muft  bear  in mind this rule, that we never ought to proceed
 with any  degree of  hurry or violence, if it  can poflibly  be'
 avoMed.  We muft never forget, that it is not the mere deli-
 very  of a  woman which is of value, but as this may be the
 means of freeing her from the immediate  clanger ffie is in, leav-
 ing her with the faireft chance of a perfeft recovery, at the fame
 time preferving, ffiould it be poffible, the life of the child..


                      SECTION IV.

    '    ON THE MANAGEMENT OF THE PLACENT/E.

   When there are twins, more difficulty is  expefted, but not
always found, in the management of the  placenta, than in the
cafe of a fingle child. 
220
INTRODUCTION  TO MIDWIFERY.
 . The two placenta are ufually  connefted together fo as to
form one mafs ;  but in Some cafes they  remain Single, except
where the  membranes cohere, and  are to be Succeffively ex-
tra£fed.                                         .
  The number of placenta, feparate or connefted, is  ufually
in proportion to the number ot children.   Some  deviations
from this obfervation have been recorded, a fingle placenta and
a fingle cord having been found in a cafe of twins, the latter of
which branched off into two, after it had departed to fome dif-
tance from the placenta*.
  When the placenta are feparate, that of the firft child ffiould
not be extrafted before the  birth  of the fecond child, as a dif-
charge of blood muft  neceffariiy  follow,  and perhaps a hemor-
rhage; though fometimes one placenta has been difcharged be-
fore the birth of the  fecond child, without any material lofs
of blood ; and in fome cafes of hemorrhage,  when there was
only one child, the placenta has been expelled before the child,
without any detriment.
  When the  placenta are  connefted,  they ufually remain per-
 fectly attached till after the  birth of the fecond child, otherwife
 there would be a hemorrhage.
  If there have been a neceffity of extrafting the fecond child
 by  art, it is commonly, but  not univerfally, neceffary to extraft
 the placenta alSo by art.
  But preluming that two  or more children have been expelled
 by  the natural efforts, and that there is no hemorrhage or other
 cauSe  ot alarm,  then  there appears, and aftually is, no more
 reaSon tor giving affiftance  to bring away the placenta, than if
 there had been only one child, but we  fafely may and ought to
 wait for the expulfion of the placenta  by the natural efforts, as
 in a fingle birth.
   When we do give affiftance, we muft  recolleft, that the two
 placenta ought to be extrafted together or in quick fucceffion,
 as the patient would not be freed from the hazard of her  fitua-
 tion, if any exifted, ffiould one  of them be retained.  When
 therefore we give affiftance in pulling  by the junis, we muft be
 careful, that each ffiall bear an equal fhare  ot the force we think
 it expedient  to  ufe.  Or  if it  fhould be  neceffary to extra6t.
 the placenta, by  introducing the  hand  into the uterus,  the
 hand is not to be withdrawn, till both the placenta are loof-


    In the Memoirs of the  Royal Academy there is an  ccount
  of a cafe of this  kind. 
           ANOMALOUS,  OR COMPLEX LABOURS.         221

ened and  ready  to come away.   The caSe will then require
precisely the Same conduft as that ot a fingle placenta, which
there  is no  occafion to repeat.
   The  uterine  difcharges  are more copious in a cafe of
twins,  than  in  that ot a fingle child, and they are in general
of longer continuance. 
222            INTRODUCTION TO MIDWIFERY,
CHAPTER  XVIII.
ANOMALOUS,  OR COMPLEX LABOURS.
ORDER FOURTH.
 On Labours in which there is a defcent of the Funis Umbilicalis
                before any part oj the Child.


                      SECTION I.


  JL m Junis  umbilicalis may be eafily diftinguiffied from any
 part of the child by its pulfation if the child be  living, and by
 its form and continuation, whether the child be living or dead.
 When a confiderable fold of the Junis drops through the exter-
 nal parts, the  attendants are very apprehenfive of danger from
 their ignorance of the part ;  but this alarm is foon removed
 by an explanation.
   Some incident  is generally affigned as  the caufe of this de-
 fcent of the junis ; but the rupture ot the membranes, with  a
 rapid difcharge of the  waters  of the ovum, efpecially  if they
 be exceffive in quantity, has been confidered as the moft uSual
 caufe.  This circumftance may Sometimes occafion thedeScent
 of the Jums,  but far lefs  frequently than has been imagined.
 For, before the rupture of the  membranes, the funis may  very
 often be diftinguiffied through them,  lying before the head, or
 prefenting part of the child, fo, that, whenever the membranes
 break, whatever might be the quantity ot water, or the manner
 of its difcharge, it would be impoffible, but that the Junis mult
 be the part which  firft defeends.  For this, with many other
 reafons, fo many cautions have been given to avoid breaking
the membranes; becaufe though  the funis were thus  Situate,
the child would not be  in danger, before the membranes were
broken.  It has alfo been obServed, that the defcent of thefunis
has happened to the fame woman in feveral Succeffive labours ; 
ANOMALOUS, OR COMPLEX  LABOURS.         223
So that, from the uncommon length of the junis, or from fome
other peculiar circumftance, fome women Seem to be particu-
larly liable to this accident.
   The defcent of the Junis,  makes little or no difference with
regard to the progrefs Or event of a labour,  as far as the moth-
er is concerned.   The danger thence arifing is wholly confined
to the Child.   All our attention,  and every meafure wepurSiie,
muft  then  relate to the prevention of  this danger, which can
ariSe only Srom the compreffion of the Junis, and the confequent
interruption or fuppreflion of the circulation of the blood be- '
tween the placenta, and child.
   All the affiftance  which  art has afforded  for this purpofe has
led to two points of praftice ; firft, in direfting us to return the
deScended Junis beyond the head,  or prefenting part of  the
child, whatever that may be ; in  drawing it to the fides,  where
it  might be out of the way of compreffion ; or, if thefe were
impracticable, to favour the continuance of the circulation, by »
preventing its expofure to the influence of the open air.  Se-
condly, by  paffing the hand into the uterus,  turning and deliver-
ing the child  by the feet, by which the labour was accelerated,
and the  danger from the compreffion of ihe Junis avoided.
   When the Junis has defcended, the  ftate of the child may be
precifely determined by the Junis itfelf.  If there be a pulfation
in it,  the child is certainly  living, though the  pulfation may
ceafe  during the continuance of a pain, and return in the inter-
vals ;  but,  if no pulfation can be perceived in the Junis,  the
child, we may be affured,  is already dead.   When the child is
dead,  all the efforts  of art muft be ufelefs  to it, and might be
injurious to the mother;  we muft therefore be  Satisfied, with
permitting  the labour  to proceed, as if the Junis had not  deS-
cended.  It is only  when the child Ts living, which, as we be-
fore obferved, will be proved  by the puliation of the Junis,
that any interpofition can either be required,  or be of  fervice ;
yet k is remarkable, that writers  on this fubjeft have inftituted
their direftions in general terms,  without regard to the ftate of
the child,  whether  living  or dead,  It is alfo to be obferved,
that the Same  direftions have been given under all the  various
circumftances,  in which the mother may be, though theSe are
Sometimes Such as to make  it impoffible for them to be followed,
without inducing fome danger to  the mother, or with any prof-
peft of advantage to  the child ;  but we fliall underftand tliis
fubjeft better by confideiing it in the following manner.
** 
.224      '     INTRODUCTION TO MIDWIFERY.
SECTION II.
 ON THE DESCENT OF THE FUNIS WHEN  THE OS UTERI IS BUT
                      LITTLE DILATED.

    Should the membranes break in the beginning of labour,
 more efpecially if it  be the firft,  when the os uteri is but little
 dilated, and the Junis defcend before the prefenting part of the
 child, this would probably periffi long before the os uteri be-
Vcame dilated, or acquired fuch a ftate of dilatability,  as  to al-
 low of the fate introduftion of the  hand,  ii we were difpofed
 to turn the child ; and before we had an  opportunity of  put-
 ing in praftice any of the methods for replacing the Junis.
 With this Statement ot the fituation oi the mother,  it appears to
 be more eligible, and, I believe,  it is generally confonant to the
 prefent praftice, rather to Submit quietly to the natural event
 of the cafe, than by  violent and ill-timed attempts to deliver the
 patient by art,  with very little hope of Saving the child,  and not
 without Some danger to the mother.


                      SECTION  III.
          WHEN THE OS  UTERI IS FULLY DILATED.

  The os uteri is underftood to be completely or  Sufficiently
dilated,  when it will allow "of the introduftion of the hand with-
out much force.  When  the membranes break in the advanced
ftate of a labour, ffiould thejunis be defcended before the child,
it will even then be neceffary, to confider the ftate of the child,
before we determine  on  the  meafures  we might find it fafe,
and think it reafonable, to purfue.   If the child ffiould be  dead,
we then certainly ought to refign the  labour to the natural  ef-
forts without any interpofition.  But,  if the  child be living,
and the prefenting part remain  high  up in the pelvis, efpeci-
ally if the pains have been flow and feeble, it will generally be
better to pafs the hand into the uterus,  to turn and  deliver  the
child  by the feet ; ufing, at the fame time, the precaution ot
carrying up the defcendcd/if«ij, that it may be out  of the way
of compreffion,  But  ii the head ffiould be fo far advanced in 
ANOMALOUS,  OR COMPLEX LABOURS.
225
 the pelvis, as in any confpicuous degree to render the turning
 of the child unfafe to the mother,  that is, if the child cannot be
 turned without the ufe of much force,  it may be proper to uSe
 our endeavours to preServe the child by other means, Such as by
 replacing the funis, or by accelerating the  labour in its preSent
 pofition.
   For the firft we have been direfted to  raife  the defcended
Junis beyond the prefenting part of the child, in the  abfcenc'e
 of a pain, as far as we can reach ; retaining it there  when the
 pains  come on,  till it ffiall abide above  the prefenting part of
 the child,  when we might prefume it was  in Safety.  But this
 method,  as far as I  know, is, on trial, feldom or never found
 to fucceed, for the Junis is ufually forced down again on the
 return of the pains; though the  fuccefs ot thefe  attempts will
 very much depend  upon the quantity of Junis  defcended,  or
 upon its being in a fingle fold, or in feveral convolutions, and
 whether it be on the fore part or fides of the pelvis, where it can
 be more commodioufly  managed.
   The late Dr. Mackenfie, than whom I have not known a man
 more intelligent in converfation, or more excellent in praftice,
 informed  me of another method which  he had tried.  Inftead
"of attempting to replace the defcended Ju-nis in the  common
 way,  he  brought down as much more of it  as would come  with
 eafe,  and then enclofed the whole mafs in a Small bag made of
 Soft leather, gently drawn together with a firing,  like the mouth
 of a purfe.  The whole of the defcended Junis, inclofed in this
 "bag,  was  conveniently returned,  and  remained beyond  the
 head of the child till this was expelled ; and the bag  contain-
 ing the junis having efcaped compreffion, the child  was born
 living.  But he  very  ingenuoufly told me, that he had after-
 wards  made  feveral  other trials  in the Same manner  without
 fuccefs.
   Many  years  ago Mr. Croft alfo informed me of a method,
 which he  had  fuccefsfully praftifed in thefe cafes.  When he
 had in vain attempted to replace the Junis in the  common way,
 he carried up the defcended part beyond the head, till he met
 with a limb of the child, fuppofe the leg or arm.  On this he
 fufpended the Junis, and  then withdrawing his  hand,  fuffered
 the labour to proceed in a natural way*. There may be much
 of accident in the fuccefs of thefe different methods, but I fliould

   * Mr.  Croft informed me,  that, be fide the two cafes pu biff.
 ed in the London Medical Journal for the year  1786, he has
 met with other cafes, in which he has been equally Incctfsjnl.
   Vol. II.                  K e 
226
INTRODUCTION TO MIDWIFERY.
 believe, whenever it may have been thought neceffary to intre-     j
 duce the hand into the uterus, that it would be found more ex-     ^
 pedient, to complete the bufineSs by turning the child,  and de-
 livering by the feet.
   With reSpeft to the acceleration of the labour, the means to
 be ufed muft depend upon various  circumftances, which we
 will confider in the next Seftion.


                     SECTION IV.

   i.It  is to be  obSerVed, that every child is not born dead,
 though the Jums had deScended, and no means  were uSed to
 free It from compreffion ; but it  muft evidently have  been in
 "the greateft jeopardy. The danger ot thefe cafes depends upon
 two circumftances ;  the time which may pafs when the Junis is
 com preffed before the expulfion  of the child;  and the degree
 of compreffion made  upon it, in confequence either of  the     i
 fmallnefs of the pelvis in proportion to the head of  the child,
 or of the refiftance of the foft parts, or of the untoward fitua-
 tion of the Junis.   The firft is beyond the power  of art to
 remedy :  the fecond will  depend upon the  ftate of  the parts,
 whether it be a firft child,  or whether the patient may have be-     5
 fore had one or  many children,  -which is accidental.  If the
Junis Should  have deScended  with a firft child, in  general, the
 more flowly  the  labour proceeds, the lefs will be the hazard
 from the  compreffion ; but,  unfortunately, the  children thus
 circumftanced wilK commonly perifh, though there is a bare
 poffibility of their efcaping ; and I have  been mortified, in
 fome inftances, with an affurance, in my  own mind, that a
 very few minutes delay in the expulfion of the child has been
 the caufe of the misfortune.   When theJunis defeends in thofe
 women, who have had many  children, there is little compara-
 tive refiftance made by the  Soft parts; and, by   exciting the
 pains to aft with more vigour, or by encouraging the patient
 to exert her efforts more ftrenuoufly  towards the  concluiion,
 the child will be  Sooner  expelled,  and its lite,   perhaps, be
 preferved. But  no attempts  to Save the child are on any ac-
 count  to  be made, but  Such as can be praftiSed  without the
 chance of injuring the mother.
   2. When the head of  the child prefents,  and has  advanced    4
 far into the pelvis, if the  pains be flow and ineffectual,  and the     <
 child living, it may be confidered whether,  without  hazard to     J
 the mother, we may not apply the Jorceps or vedis; and, by 
            ANOMALOUS,  OR COMPLEX LABOURS.         2*7

extrafting  the head  Sooner than there was reaSon to think it
would be expelled  by the natural pains, preServe the child.
With  regard to turning the child, and delivering by the feet
in thefe caSes, the operation can only be performed before the
head has defcended  far into the pelvis; though in fome inftan-
ces I have gone in this refpeft  beyond the common rules of the
art, and  have fucceeded in Saving the child.
   3. When there is a defcent ot the Junis, with-a preternatu-
ral presentation of the child, our «onduft muft have regard to
both thefe circumftances.
   Should the breech prefent, the cafe will very much refemble
the presentation of the head; that is, the  fame methods tor re-
placing the junis may be tried,  and with  rather a better chance
ot SucceSs.  If thefe fail, inftead of confidering the labour as
one of thofe, which  is to be rcfigned to  the natural efforts,  it
may be expedient at a proper time to bring down one or both
ot the interior extremities, taking care that the junis be not en-
tangled between the legs ot the infant ; and there are  few cafes
ot this kind, in which we may not conduce to the preservation
of the infant, by proceeding in this manner when the junis is
the prefenting part.
   Should the arm of the child prefent, and Such presentation be
complicated with a defcent ot  the funis,  very little difference
of conduft will be required ; becaufe,  for the firft reafon, we
ffiould determine to turn the child,  and deliver by the feet, and
the additional circumftance of  the defcended funis can require
nothing more to be  done.  Yet when the Seet ot the child are
brought down,  it  the pulSation of the arteries of the Jums be
lively or perceptible,  it may Sometimes admit of a debate whe-
ther it will be moft  proper to batten the delivery, efpecially if
the os uteri be not fufliciently  dilated; or to leave it to be ex-
pelled  by the returning pains.   In either cafe it will however
be right, to attempt to return the Junis within the os uteri, and,
if  it be in our power,  out of the way of compreffion.  The ge-
neral rules already given  for the  ufe ot the forceps and vedis,
and for the management of preternatural labours, make it un-
neceffary to enlarge on this part ot our Subject, in this place 
INTRODUCTION  TO MIDWIFERY.
SECTION V.«
                      ON MONSTERS.

  This fubjeft affords very little room  for praftical observa-
tions, becauSe the Symptoms in early pregnancy are not different
from thoSe in natural births ;  and becauSe the Jatus, whatever
be its ftrufture, is  uSually expelled eafily and  regularly at the
time ot  labour.  We might indeed  be  miftaken in our opi-
nion of a prefenting part: but as in any  cafe of real difficulty,
the needful inveftigation would diScover the nature ot the cafe ;
and as we fhould have little to confider but the Simple extraction
ot the monftrous Jatus, without injury to  the mother, the
general rules of praftice would be readily applied to every ex-
igence arifing from that cauSe.
   Several books have  been  profeffedly  written on monfters,
but the fubjeft,  inftead  of being confidered and cultivated as a
branch ot natural hiftory, or  as leading to phyfiological discov-
eries and explanations, has, by the manner ot  treating  it, been
rendered little more than a  theme of Superftitious wonder,  of
ridiculous falfchood, or of fenfeleSs curiofity.   The Same ob-
servation may be made on the cafes publiffied in almoft every
periodical work, and  on collections of monfters.  Yet lord
Bacon thought that a hiftory of monfters  was very much want-
ed for two purpofes ;  " firft, to correft the  partiality ot ax-
ioms and opinions, which are commonly formed on common
and familiar examples ; Secondly,  becauSe  from the  wonders
of nature is the neareft paffage to the wonders ot art ;  for it is
no more than by following, and as it were hounding nature in
her wanderings, to be  able to lead her  afterwards to  the fame
place."  The advantages which might be derived from  the
 purfuit of the firft intention are manifeft,  but thofe  from the
 fecond, Seem to be problematical.
   It is  probable that  monfters  might  be reduced into regu-
 lar orders or fyftems, as they all feem to be of one or other of
 the following kinds.
    1. Monfters from redundance, or multiplicity of parts.
    2. Monfters from deficiency or want  of parts.
    3.  Monfters  from confufion of parts.
    To  thefe  might perhaps be  added, without  impropriety,
 another, kind,  in which there is neither redundance, nor cfefi- 
            ANOMALOUS, OR COMPLEX LABOURS.        22§ -

ciency, nor confufion of parts, but an error of place, as in tranf-
pofitions ot the vfcera.   But children born with diSeafes, as
the hydrocephalus, or their effefts,  as in Some caSes of blind-
neSsvfrom previous inflammation,  cannot be properly  con-
sidered as monfters, though they are often fo denominated.
   Of the firft order there  may be two kinds, redundance  or
multiplicity of natural parts, as ot two heads and one body ;  ot
one head and two bodies ;  an  increafed number of limbs,  as
legs, arms, fingers, and toes ; or  excrcScences,, or additions to
parts,  ot no certain  form,  as thofe upon the  head, and other
parts  of the.body, and thefe are ufually more or lefs important?
according to their fize, or the part where they grow.   But as
fuch excrefeences, whatever may be their fize, have, Srom their
texture, a diSpofition to enlarge, and to affume a morbid aftion,
it is become an eftablifhed rule to extirpate them whenever it
can be done with Safety.
   2.  Of  monfters from deficiency or want  of parts, the in-
ftances are lefs frequent than thofe of the former  kind, as  of
the'brain  and back part of  the head ;  or of the whole head, as
in the acephalus ;  or of one eye,  as in the monoculus ; or the
lip and palate, as in the hare-lip ;  of one or both arms ; of the
iore-arm or hand ; of one or more fingers ; ot a portion, or of
the whole of the fpinal proceffes of the vertebra, as in the fpina
bifida ; of the incomplete formation of the fkin, moft frequent
at the navel, or fome part ot the obdomen ; of the penis, efpe-
cially of the prepuce ;  of one or  both ot the inferior extremi-
ties ;  of the heart  ; of the liver; fpleen,  or any of the abdo-
minal vijcera ; of the lower part ot the  redum, terminating
before it reaches the anus ;  and many others.
   3.  Monfters from confufion of parts, as when the whole body
is in one  mats (ufually called a mole), in which various parts
of  the child are found lying together in apparent  confufion ;
ot  parts adhering  together, as  of  the fingers  and toes ;  of the
redum,  as  in the  clofure ot the anus ; ot the vagina; of the
external or internal parts ot generation, as  in thole called her-
maphrodites ;  of  the two inferior extremities connefted toge-
ther and  terminating in a point ; of the  club foot: and many
others.
   As we are ignorant of the manner in which the primordial
parts  of a regular  conception are formed  and eftablifhed, and
in many reSpefts^  of the order in  which the various parts ot a
Jatus  are  unfoalded  or  enlarged, it is not furprifing that  we
fhould be ignorant alfo ot the manner in which monfters or irre-
gular births are generated or produced ; though it is probable 
230
INTRODUCTION  TO MIDWIFERY.
 that the laws by which thefe are governed, are as regular, both
 as to caufe and effeft, as in common or natural pnxhfetions.
 Formerly, and indeed till within thefe few years, it was a ge-
 nerally received opinion that monfters were not primordial  or
 aboriginal, but that they were caufed fubfequently, by the power
 of  the  imagination  of  the mother,  transferring the  imperfe
 tion of  fome  external  objeft,  or the mark of  fomething for
 which  ffie longed, with which  ffie  was not indulged, to the
 child of which fhe  was pregnant ; or by fome accident which
 happened to her during her pregnancy.  Such opinions, it  is
freafonable to think, were permitted to pafs current, in  order  to
 proteft pregnant  women from  all hazardous and difagreeable
 occupations, to fkreen  them from fevere labour, and  to pro-
 cure for them a  greater fhare  of indulgence and  tendernefs,
 than could be granted to them  in the common occurrences  of
 life.  The laws and cuftoms ot every civilized nation  have  in
 fome degree eftablifhed a perfuafion  that there was fomething
 Sacred in the perSon of a pregnant woman, and this  may  be
 right in feveral points of view ;  but thefe go a little way  towards
 juftifying the opinion of monfters being caufed  by the imagi-
 nation of the mother. The opinion has been difproved by com-
 mon obfervation, and by philofophy,  not perhaps by  pofitive
 proofs, but by many ftrong negative facts ; as the improbability
 of any  child being born perfeft, had fuch a power exifted ; the
 freedom of children from any blemifh, their mothers being  in
 fituations moft expofed to objefts likely to produce them ; the
 ignorance of the mother of any thing being  wrong in the child,
 till,  from information ot  the faft, the begins to recolleft every
 accident which happened during her pregnancy,  and afligns the
 worft or the moft plaufible as the caufe ; the orginazation and
 colour  ot  theSe adventitious  Subftances ; the frequent occur-
 rence of monfters in the brute creation, in which the power  of
 the  imagination cannot  be great ; and  the analogous  appear-
 ances in the vegetable  fyftem,  where it does not exift in anv
 degree.   Judging however from  appearances, accidents rnav
 perhaps be allowed to have confiderable influence  in the pro-
 duftion of monfters of Some kinds, either by actual injury upon
  arts, or by luppreffing  or  deranging the principle  of growth,
  ecaufe when an arm, for inftance, is wanting,  the rudiments
 of the deficient parts may generally be difcovered*.
  As to the explanation or correction of  axioms  framed on
 common and familiar examples, there are fome things of great

  *  See Blondell on the Power of the Imagination, &c. 
            ANOMALOUS, OR COMPLEX LABOURS.         231

importance too obvious to efcape notice.   When, for inftance
there has been a defeft ot brain, or even no head, there has been
found a fyftem  of nerves ;  when  the  heart has been wanting,
there has been a vafcular  fyftem, fufficient to carry on the cir-
culation of the blood ;  when there was neither liver nor fpleen,
the blood was equally red as in perfeft infants ; and an endlefs
number of circumftances as curious is to  be  found in the hif-
tory of monfters.   It appears, that phyfiology might be greatly
improved by a  clofe and accurate cultivation  ot this fubjeft,
and thut  an  able and diligent anatomift would  not only deteft
many modes and varieties of things, hitherto unobferved, but by
carefully rcgiftering his obfervations, he would at length be able
to form general conclufions, highly  important to Science, and
which would in an eminent degree increaSe his own reputation.


                      SECTION VI.
              ON THE EXTRAUTERINE FCETUS.

  The kind of extrauterine^fMi of  which it  is intended to
fpeak in this place is not occafioned by a rupture of the uterus,
but by a failure of that part of the procefs of conception, when
the impregnated ovum, inftead of returning through one ot the
fallopian rubes into the uterus, is either detained in one of thofe
tubes, or, not being received into them, drops into the cavity
of the abdomen, where it muft  abide.   In thefe cafes, wher-
ever the mifplaced ovum may be lodged, the external Surface
adheres, and forming a  placenta, acquires  fufficient nouiiffi-
ment to bring the child to perteftion.  But though  it be  well
ascertained, that this muft be the order of proceeding when an
extrauterineyi^w^ acquires any  confiderable fize, it is not un-
reafonable to think,  that an ovum may  mifcarry in its tranfition
from the ovarium, and often  remain without increafe in the part
which receives it, as a Simple extraneous body.
  When- ihe period of uterogeftation is in thefe cafes  complet-
ed, or Sooner, there is a general difturbance, Similar in many
reSpefts to that of natural labour  ; which continues till the child
is dead, when the tumult is  for the  prefent  appeafed, and the
conftitution is at reft.  But after Sometime, either on account
of undue prelfure made by the bulk  ot the child  on Some
part not  able  to bear it,  without being excited to Some  new
and  extraordinary aftion, or from other caufes, frefh but  tin- 
 232           INTRODUCTION TO MIDWIFERY.

 availing efforts are  made.  Or as in the cafe of any other ex-
 traneous and offending body, a common procefs is  eftablifhed,
 which beginning with inflammation, and producing adhefion to
 the neighbouring parts, an opening  is ultimately made into
 fome part of the inteftines or vagina, or through the integuments
 of the abdomen,  by which the indiffoluble parts of the child
 are at length expelled.   In many cafes however, when the
 fatus has been lodged in one ot  the fallopian tubes, this  has
 burft at various  periods, and the patient has been  fpeedily,
 though not immediately,  deftroyed.  But in feme cafes the ex-
 trauterine Jatus, enveloped in its own, or fome adventitious
 membrane,  or covered with a ftony concretion, has remained
 harmlefs, except from its bulk, for  the  reft of the  patient's
 life*,
   Various opinions have been entertained refpefting the Situa-
 tion of the extrauterine/ar/MJ.   It  was commonly believed that
 it niight be placed in any part of the cavity of the abdomen,
 though many  afferted that it was  moft generally detained  in
 one of the  fallopian tubes*.  In fupport of this latter opinion
 many fafts  might be  adduced, and I was inclined  to give my
 affent; but from fome cafes which have fince occurred, I ra-
 ther believe, that the fatus when extrauterine is not univerfally,
 though moft frequently, lodged in one ot the fallopian tubes.
   Many circumftances in the animal economy are proved, or
 rendered probable, by thefe cafes.
   1. That impregnation  takes  place in the ovarium, but is per-
 fefted in the uterus.
*  2. That though the fatus be extrauterine, the  uterus be-
 comes confiderably  enlarged, and performs its proper office by
 providing the efflorefcent or deciduous membrane for the recep-
 tion of the ovum.
   3. That the fame fymptoms are produced in the early part
 of pregnancy, whether the child be contained in the cavity of
 the uterus, or be extrauterine.
   4. That though the child be placed in one of the  fallopian
 tubes, or in the cavity of the  abdomen, a placenta is formed,
 different indeed in Structure, but capable of fupplyintf*the child
 with fufficient nouriffiment to bring it  to,perfection ;'which
 tends to prove, that the  uterus does not perform its office by
 any fpecific aftion or quality.

              * See Colledion oj Engravings.
t See Opera omnia Anatomica, Diemerbroeck, page 135.
1 
ANOMALOUS, OR COMPLEX  LABOURS.
2SJ
   5. That the difpofition to labour  comes on, before or at the
completion of the period of uterogeftation, which Shews that it
is not excited  by diftention, or any  faculty of  the uterus, but
by fome flat? or quality of the child.
   6. that fo imall a cavity or canal as is that of a fallopian tube
is capable  of being gradually diftended  to fuch a hze, as to
contain a Jatus of the growth of five or fix months, or Some-
times even nine months, without burfting ; though in Several  1
cafes  the fallopian tube  which contained  the  child has been
found rent open, the death of the patient being thereby Speedily
occafioned, though the caufe had not been Sufpefted.
   7. That the merxfcs ceaSe during the time of geftation fo long
as the child is living.
   8. That the  menjes return in due  time after the death of the
child, though this may not be expelled ; unlefs the conftitution
be very much impaired.
   In  the records of medicine there is a very great number of
examples of the extrauterine fatus,  in  all of  which there mav
be obferved fome Similarity of circumftances, though in Several
of them there areioany and great varieties,  depending perhaps
upon Some caSual Situation of the  child, or Some peculiarity in
the conftitution of the patient.,   Few  praftical remarks have
been made upon the fubjeft, which  can be ufeful to thofe, who
are in the way  of meeting with cafes of this kind.  Nor has the
order ot the procefs, when the extrauterine fatus  comes to be
voided, been defcribed with much accuracy.   I therefore wifh
to obferve, that in every cafe of this  kind,  which I  have Seen,
there has been Sometimes great danger, and in all ot them much
pain and Suffering, which it is our duty to avert, or to alleviate,
according to the indications. When  the procefs by which an ex-
trauterihe/atfa.r is to be evacuated commences, it may Soon be dis-
covered, whether the effort will be made by the inteftines or vagi-
na,ox through the integuments of the  abdomen. It by the former,
the whole procefs is to be left without any, or as little moleftation
as poffible onour part, to  the natural aftion ot the conftitution  ;
for though we might apparently accelerate the procefs, and pro- •
cure perhaps a little temporary relief, we ought to be careful not
to difturb or interrupt the proceedings ot  nature already eftab-
lifhed, which  art can  in theSe  cafes, as in many others, very
imperfectly imitate.  But if an abfcefs ffiould be formed in the
fide or any part of the abdomen,  and through  the fubfequent
opening any part of the child fhould be evacuated, it will then
U  expedient to forward the exclufion of the remaining parts,
   Vu.II.                 Ft 
-*34
INTRODUCTION  TO MIDWIFERY.
-either by enlarging the opening, or by giving fuch other affift-
 ance, as forgery is very competent to afford.
   When the extrauterine jatus is evacuated by the inteftines
■or vagina, after the patient has endured  all the confequences
 of an abfcefs formed  in very  tender parts, there is firft dif-
 charged a large  quantity of offenfive purulent matter ; then the
 fame kind of matter mingled with hair or membranous fubftance;
then the fmall bones of the Jatus  ; and laftly the larger bones,
the moft difficult to be excluded of  which are the bones of the
 cranium, and the larger bones of the limbs; and if any of thefe
 ffiould happen  to lie  athwart the  opening in the  imeftine or
 vagina, their difcharge may fometimes be favoured by chang-
 ing  their  pofition.  When all the  bones are  evacuated,  the
 affefted parts gradually recover from the injury they have fuf-
 tained without  any remaining miSchief, and the patient ufually
enjoys as perieft health, as if no fuch accident had happened. 
ANOMALOUS, OR COMPLEX LABOURS,
*3&
CHAPTER  XIX.
ON"  THE MANAGEMENT OF WOMEN IN CHILDBED..
SECTION I.
In the eourSe of the obfervations  which have been made  on
various parts of  the praftice of midwifery, occafion hath  fre-
quently been taken, to mark and to confider thofe refources of
the conftitution, by which prefent evils were remedied,  and
Future danger prevented.   ThefevreSources are So conSpicuous
in all  circumftances attending parturition,  and So generally
found  adequate to the effeft, that, notwithftanding the  long
train of difficulties  and  diforders we have enumerated, it is a
popular, and I believe a true remark, that the moft healthful
parts of the  lives of women is that, in which they are employed
m bearing and nurfing children.   As it is however proved, that
thofe procefles, which are apparently oS little importance to
the conftitution,  do Sometimes become the cauSes  of difeafe,
So  it  might be expefted, that  thoSe,  which are  of  great
importance,  ffiould,  though generally exempt from  danger, in
particular  caSes become thV cauSes  of peculiar accidents  and
difeafes.  The laws  of a religion founded on principles oi the
moft active  benevolence,  the feelings of humanity, and  the
common interefts of  Society,  will not Suffer us to be indolent-
Speftators of  the diftreffes  or our fellow creatures, from what-
ever caufe they may arife.   But in the Situation which we are
now confidering, the paflions of men are deeply interefted,-there
is more than common tendernefs mixed with our concern for
thoSe who fuffer on theSe occafions,  and the mind is not at theSe
times prepared for untoward events.  Much induftry hath there-
fore been ufed for difcovery and eftablifhment of fome method,.
bv which women might be  condufted through  the ftate ot child-
bed with the leaft hazard  of exciting thofe difeafes, to Which
their  ftate was Suppofed to render  them peculiarly liable ; or
that veiv great pains fliould have  been taken to difeover the Sa-
feft and moil efficacious me*hod of curing thofe difeafes, when 
•2.^6            INTRODUCTION TO MIDWIFERY.

they aftually exifted.  The intentions of all may have been
commendable, but as the diicv.iions given tor both thefe pnr-
poSes have been various and contradictor)',  it n  proper  to in-
quire into the principles, on which Such  oppofite praftice has
been advifed.   We mav then fix  upon that,  which Seems moft
reafonable, or has been  found molt fucceSstul.
   From the MoSaic law we learn,  that,  in the ftate of childbed,
women were obliged, for a  certain time, to live Scperate from
the world,  and were exempted from the cares and Solicitudes of
life.  Whatever was  the  principle  of  this law, whether if
were eftablifhed  from motives of religion  or manners, the time
thus allotted gave to the womenthe privilege and opportunity of
repairing their own health and ftrength,  and of dedicating them-
felves with uninterrupted attention to the  careot their children.
   By the earlieft writers  in  medicine we  arc tatight, that the
treatment moft proper for women in childbed  was that, which is
now termed antiphlogiftic.   Without entering upon a minute
detail,  it is Sufficient to obServe, that, in the purSuit  of this
method,  we  were generally directed to confine,  for a  certain
number  ot days,  every patient lately delivered,- to the lame
ftrift regimen,  as if ffie aftually had an inflammatory fever, or
had received a wound of the moft dangerous kind*.
   This abfolute reftraint from every cultoriiarv indulgence,  and
confignment to a regimen  appropriate to the bed of ffeknefs,
was a mode of ffiewing tendernefs, of the propriety of which it
muft have been difficult to perf'uade the majority of people,
who felt themfelves at their eafe,  and in perfeft  health.   For
this was not pretended to be neceffary with a view to remove
any prefent evil,  but to prevent a danger which might never
o;-cur.   As no general method of proceeding could poffibly Se-
cure the well-doing of every  patient, the failure of this ftrift
regimen in any individual cafe was brought forward as an argu-
ment ot its general impropriety : in faft,  though this  plan
might be a!ways,rigoroufly  enjoined ; it  appears to have been
feldom exaftly followed.
   The  propolal of allowing a diet more  plentiful in quantity,
and more cord 1J in quality, was  founded on the preSumed ne-
ceflifv of guarding againft the confequences of that weaknefs,
which was thought  to be occafioned  by  the circumftances at-
tending  child-birth.  Then was  recommended the cuftom of
Supplying  to the conftitution thofe deficiencies,  which might
be occafioned by the uterine difcharges,  with plentiful living ;
* See Celfus. 
ANOMALOUS, OK COMPLEX  LABOURS.
*9T
 fcr.d Caudle was difpenfed with an unfparing hand, to remedy
 every temporary inconvenience.  ConSent is Seldom refuSed to
 that medical advice,' which is agreeably to the will of patients,
 or the partiality ot friends ; and'this regimen was of courfe rea-
 dily adopted, and long maintained its influence.
   •A confideration of tliefe two different methods of proceeding
 will explain all that lias been faid by different writers,  on the
 doftrine and praftice of low and generous living in childbed.
 J here have been  alfo recommended ina  few  inftances, other
 methods of  treatment mftituted according to the fancies or
 opinions of phyficians who have applied themfelves to this fub-
 jeft, but of 'hefe I fhall  only mention two.
   1. It had been  obferved, that fevers of any kind were Sel-
 dom terminated  without an increafed perfpiration,  or  a pro-
 fuSe fweating.  A fallacious  inference was then  drawn, that
 the  fame procefs,  by which the conftitution was freed  from a
 difeafe, would, before the formation ot  Such diScaSe, be  the
 moft likely method of preventing it.  On this ground the cuf-
 tom of  keeping women  in a ftate of con Rant perfpiration for a
 certain  number of days  after their delivery by warm  drinks.
 hot  rooms, and diaphoretic  medicines, was eftablifhed ; and
 the  greater the degree to  which it was carried, and the longer it
 was continued, the greater Security was preSumed  to be oiven
 to the patients from the apprehended difeafes.  Many inconve.
 niences followed  this method  of proceeding,  efpecially  by
 checking the natural  difcharges, in  interrupting the Secretion
 of the milk, by reducing the ftrength, and incre'afing the irrita-
 bility of the patient.  But the praftice was long purSued,  nei-
 ther common fenfe, nor experience, having power to extirpate
 deep-rooted prejudice.
   2. It  was by Some believed,  that a  woman lately delivered
 ought to be treated, as if fhe had been injured  by a concuflion
 or violent brnif'e of Some internal part ; and that the means to
 be advifed  for the relief of prefent inconveniencies, as well as
the prevention of  future mifchief,  were Such as might be pro-
 per under Similar circumftances from any  other caufe.  There
 is  no occafion to recapitulate all  the means' recommended upon
this  principle; but  it may  be obferved,  that Jpermacett, the
 moft popular medicine given to women in childbed at the pre-
 fent  time,   was originally advifed,  Ivcaufe it was efieemed of
Sovereign efficacy in the cjfe of an internal bruiSe.
   It is remarkable, that  the different  and oppofite modes of
treatment have been enjoined to women in  childbed, univerSal-
ly,  without any difcrimi.union of  peculiarity  of conftitution, 
2g8           INTRODUCTION TO MIDWIFERY.

former habits of living, difpofition to certain  difeafe;, or thr
kind of  labour  which  the patient  might have endured;  and
without due regard to the heat or coldnefs of  the  climate, or
the feaSon oi  the  year  when the patient might be confined.
General as the regulations were, all, that was SuppoSed neceffa-
to be done, was to follow one or other of  thefe  injunction*
implicitly; and  whenever a difeafe arc Se,  it was attributed, ot-
ten erroneoufly, and Sometimes very unjuflly,  to Some irregu-
larity or deviation  from theSe.
   It has been often obferved, that a ftate of pregnancy was an
altered, but not  a morbid ftate.  The fame obServatioti may be
made with equal propreity and truth of a woman in aftual la-
bour ;  and it may be extended to women in the ftate of childbed,
which, though fometimes accompanied with difeafes, cannot
Seriouflv  be fufpefted  to be of  neceffity the  caufe of them.
One moment's confideration, and the flighteft view of the per-
fectly Sale termination of labours  in general, and of the happy
recoveiy of the mafs ot women from childbed,  under infinitely
various circumftances,  muft convince us ot the contrary.   Be-
fore we therefore fix upon this or that method ot treatment,  it is
worth our trouble  to enquire, whether it be neceffary  to eftab-
lifh any peculiar method.
   When a woman is recently delivered, the attending circum-
flances, as the difcharge of the waters, the  exclufion of the
child and of the plcuenta, together with  the lochial difcharge,
commonly reduce  her to the ftate ot a  perfon,  who has  had a.
protufe evacuation ot any other  kind.  The great efforts ffie
may probably have made, in the courfe of even a natural la-
hour, muft alfo considerably increafe this change in her confti-
tution.   From what caufes  does this change ariSe ? from  that
emptinefs and fatigue confequent to vehemently increafed action.
Is it poffible to fix any better method of treatment, than wlrat
w<idd be efieemed  right and proper under the Same circumftan-
ces from any other caufe ?  That is, to  give  her  Suitable it -
frefhment,  and leave her to  repofe.  Judging  from events we
certainly cannot, and after feeing much pra6tice and trying va-
rious methods, not  onh immediately after delivery, but  through
the courfe of childbed,  I am fuilv perfuaded, that  laying afide
all refined Speculation, thofe patients wii! tare *be belt,  and re-
cover moft certainly and Speedily, by  whori t'jje leaft change
from their  former  habits is  made.  Some difference ot  treat-
ment muft of courfe be required for the  dciicarc and the rebuff,
for the nervous and the plethoric,  when there has been a Ion"
and difficult, or a  ffiort and eafy labour, ina h:,< or a cold  cli-. 
             ANOMALOUS, OR COMPLEX  LABOURS.        2<^

 mate, in Summer or in winter,  and in the Same climate,  under
 particular fituations and circumftances.   TheSe muft of  courfe
 be left to the judgment  ot the medical attendant.   But when
 no particular reaSon, which demands a contrary treatment, exifts,
 I am convinced, that the  general principle of making as little
 -change as poflible from their former habits and cuftoms,  either
 in diet, or in any other  refpeft,  will heft anfwer his expecta-
 tions.  In the colder climates, fome extraordinary care feems to
 be employed in guarding againft  the evils and  inconveniencies
 to be dreaded from  cold ;  but in Africa the women immediate-
 ly walks into the adjoining river, for the purpofe of purifying
 herfelf and her infant from the confequences of her delivery.
   Some years ago it was a general cultom, to bind the abdomen
 very tight immediately after  delivery, with the view of aiding
 the contraftion of the integuments,  and oi preferving the fhape
 of the patient.   In  fome  countries,  India in particular,  this is
 praftifed to a degree, that one cannot think of without  fhud-
 dering  at the mifchief, which muft of  neceflity be very often
 occafioned.   In this country the praftice has been  very  much
 difcountenanced as ufelefs and pernicious, and  it  is now  whol-
 ly, or nearly laid afide,  till  five  or fix  days  after delivery ;
 when a broad  band,  daily but very gradually drawn a little
 tighter, may be applied   not only without injury,  but with
 Some advantage.
   One of the firft, and not an uncommon confequence of de-
 livery,  is faintnefs.   This may proceed from any  ot thefe cauS-
 es, lofs of blood, fatigue ot the labour, fudden emptying of the
 abdomen, and its confequent changes, or  from great agitation
 of mind.  The method to be purfued, when it arifes from the
 firft caufe,  has been fully confidered when we fpoke of uterine
 hemorrhages; and when it proceeds from other  caufes, wine or
 fome temperate cordial is to be given, and the patient is to  be
 kept perfeftly undifturbed, till ffie recovers.   From the  dread
 of any accident happening,  I have long made it a general rule.
 to wait with every patient  for an  hour after her delivery, not
 choofing to put confidence in thofe,  who may  not be well ac-
 quainted with what is neceffary to be done  on extraordinary oc-
 cafions, ffiould they ariSe.
   Sometimes, but very rarely indeed, one ot the lab-a -becomes
 Suddenly and enormoufly enlarged, either toward* the conciu
 fion of labour, or immediately after  delivery, trom  an effuho..
ot blood in the cellular membrane of that part, and in a ffiou
fpace of time after  the appearance  ot the accident,  ih^* Skin
burft*  from  the vfeb-cc  of  the  diftention.  This comply::it 
«4<3
INTRODUCTION TO MIDWIFERY.
-■was firft defcribed by Dr.  Macbride* of Dublin, in the  year
 1766, and fince that time, I have been called to three inftances.
 It occafions very great pain, bur one moft important part of it
 is the Surprife it occafions, and the alarm it gives, when it is not
 we'll underftobd.   But I  believe it  is void of danger,  not hav-
 ing Seen or heard of any  dangerous confequences  from it, or
 ever found  any thing  neceffary to be done, but  to wrap  the
 tumefied part in a flannel wrung out of warm water and vine-
 gar, and on the difcharge of the Coagula, which fliould  not be
 haftened, to drefs  the litte fore with  feme Soft linament.  It is
 lemarkable, that the labium always burfts on the infide, as  if it
 were merely from mechanical  diftention ;  and  as  ihe pain  is
 fometimes violent, and the patient full ot apprehenfion, it will
 be expedient to give a proper dofe of the  tindura  opn in fome
 cordjfil.   I have alfo feew one cafe ot a Similar kind produced bv
 external injury, in a perfon who had never been pregnant, and
 this yielded to the like treatment.
   Few women paSs through the ftate of  childbed without  Suf-
 fering more or lefs pain in the abdomen, and this, may arife
 from various caufes.
   1.  From coagula of  blood formed and  retained in the cavity
 of uterus* ; or according to the opinion ot fome, bv the fhrink-
 ing of the uterus to it  its proper fize.  In the uterine dischar-
 ges conSequent to delivery, there  is a general order, but with
 an  endleSs variety, depending upon the conftitution ot the pa-
 tient, the circumftances  which attended  the delivery, and the
 local ftate of the partst.  A proper knowledge of thefe may be
 readily acquired ; and when coagula are formed, as above ftated,
 the pains thereby occafioned, which are  called afterpams, are
 uSually according to the fize of the coagula. and the difficulty
 with which they are excluded.   Thefe pains come on foon after

   * Medical objtrvations, London,  Vol. V.—See aljo  Medi-
 cal Commentaries, Edinburgh No.  xxi.         >

   t Cum uteri cervix  pojt partum  Jefe modice contrahit, et
propterce fanguims grumi  cum>, difficult ate aliqua prodeuat,
 dolorefquejaciunt, quos ahf,::rices  nojlra enixus pqfteros (aj-
 terthroes) uocant, &c.—S <j Harvey, page 567.

   | Per lochi  emanat  prirno Janguis purus, poftea Janiofus,
 recentis  carnis-lotura, fimilh,  deinde  ichor oj us—idea que per
 excreta depwrptrae aut  jamtate difcrimine Jlatui/nus.
                            Harvey, Exercitatio dc i;-.rtu. 
ANOMALOUS,  OR COMPLEX LABOURS.        241
delivery, and they return, though with longer intervals and leSs
in degree,  in the manner of thofe of labour, excluding in due
time whatever coagula might remain in the cavity ot the uterus.
Women have feldom pains from this caufe with firft children,
and they are fuppofed to have them in proportion to the number
of children they have had, which is generally true.   Very much
of this pain may however depend on the manner in which the
placenta and  membranes were brought away, for  if that  were
done witl| violence, or in a hurry, the uterus will be left in a
very irritable ftate, and there will generally be formed a fuccef-
fion ot large coagula ; whereas  if we had waited for their ex-
clufion  by  the natural aftion of the uterus, or given only very
gentle affiftance, the  cavity  of this would have been gradually
diminifhed  as the placenta defcended, and of courfe have pre-
vented either the effufion of fo much blood, or the formation of
fuch large coagula.
  The fufferings of women  from thefe pains are fometimes very
great, though they prove eventually falutary, and, it we had it
in our power, ffiould not be fuppreffed, till the end for which
they are excited is anfwered.   They  may however be  fafely
moderated by warm applications to the abdomen, and when ex-
tremely violent by fmall dofes  of  the tindura  opii, though
much unjuftifiable  clamour hath  been raifed againft the ufe  of
this medicine  for women in childbed. It will alfo be of fervice,
as foon as it can  with propriety be done after delivery, to pro-
cure one or more ftools,  by an injeftion or fome lenient medi-
cine.  The freedom from danger prevents all folicitude on this
account, and  we know, when the uterus is cleared, pains from
this caufe will ufually ceafe  within twenty-four hours after de-
livery.
  2. When the  abdomen has been greatly diftended, the inte-
guments, even before delivery, will be tender and  often Slightly
inflamed, and the tendernefs may be increaSed by the labour,
and continue  after delivery.  A warm flannel well Sprinkled
with any kind of  fpirit applied over the whole abdomen, and
occasionally renewecf, is the only thing I have found it necef*
fary to employ for this complaint.
  3. From wind in the  bowels.
  On the exclufion of the contents of the uterus, a confiderable
change immediately  takes place in the pofition of many parti
contained in the abdomen, and from many others the accuftom-
ed preffure or fupport, which they received during pregnancy,
is wholly taken away.  A greater freedom being given t»  every
  Vol. II.                 Gg 
■'■■i'-i           INTRODUCTION TO MIDWIFERY.

part, the change for the prefent gives the fame uneafy fenfation,
as wind pent up or rolling in the bowels, though in a ffiort time it
is generally removed by the accommodation of the parts to their
new ftate.  Should there afterward be reafon to attribute the pain
in the abdomen, with which a woman may be troubled, to this
caufe, inftead of giving ftrong aromatic or heating medicines,
it will be proper to procure one or more ftools by an injeftion,
or fome lenient purgative, the moft efficacious and excellent  of
which is that in common ufe, prepared in the following manner.

  R. Kali  tartarifat. vel natri tartarifat.  vel  magnefiae vitrio-
       latae,
       Syrup, rofae,  a  a unciam dimidiam,
       Infus.  fenae tartarifat. uncias quatuor,
       Tinft.  ejuSd. drachmas Sex. M.
Capiat cochlearia iij. vel iv. ampla primum, et  poll tres  horai
     cochlearia duo Secundis horis, donee  alvus Soluta erit.

  After the operation of the medicine an opiate in any proper
vehicle  may be given,  and the patient will  be  freed from the
complaint.
  4. FVom  SpaSm.
  After delivery the uterus  itSelf, or its appendages, or any  of
the contents of the abdomen,  may be affefted from this caufe,
with pain varying in degree, but fometimes  extremely fevere.
This may often be relieved by lightly rubbing the abdomen with
a warm hand, or with fome anodyne embrocation,  or the appli-
cation of warm flannels wrung out of fome fpirituous fomenta-
tion.  If thefe fail, recourfe muft be  had to tindura opii, at
leaft to opium in fome  form, given in fuitable dofes, according
to the degree of pain, and'repeated as may be neceffary.   Spaf-
modic pains of the abdomen very otten refemble  thofe arifing
from inflammation, and in fome cafes I confider  it as one of the
moft difficult things  in  the praftice of medicine,  to discriminate
them.   In very irritable habits the difficulty  is much increafed,
as fuch. are extremely liable to  painful  fpafms, to have their
pulfe quickened, heat exeited, and the whole frame difturbed
in a manner very like to what happens in true fever or-tnflam-
mation, yet all the disturbance may often be fpeedily quieted
by  a proper opiate.
   $.  From inflammation.
,   This leads us to the  confideration of that difeafe now gener-
ally called.the puerperal fever; not becaufe it is peculiar  to
the ftate »f childbed, but becaufe it is the  moft common fpecies 
            ANOMALOUS, OR COMPLEX  LABOURS.         2 4 ]

 oi fever, to which puerperal women are fubjeft, and certainly
 occafions the death ot much the greater part of thofe women,
 who die in childbed.  This has been defcribed by the ancient
 as well as  modern writers, with perfpicuity fufficient to diftin-
 guiffi it, but the methods  propofed for the cure have been lefs
 SatisSaftory.  Evident disadvantage hath ariSen from its having
 been attributed to a variety of  caufes, and from  the  different
 opinions entertained with refpeft to the  nature and qualities of
 the difeafe, from the fufpicions entertained, that the peculiar
''ftate of the patient required peculiar management, and from
 its having been defcribed  under fuch various  appellations.
 It has  been reprefented by fome writers, as entirely owing its
 exiftence to the undue  Secretion or  Subsequent  depofition of
 the milk, and therefore denominated the milk fever; by others,
 to a fuppreffion of the lochia,  and called by that name ;  while
 others have defcribed it as the miliary fever.  Some again have
 confidered this difeafe not as a fever, but as an inflammation or
 ulceration of the uterus* ; while  others have contended, that
 the  inflammation was wholly  confined to  the  omentum, the
 peritonaum, or the inteftines, and that the uterus was not any-
 wife concerned.  A contrariety of opinion of more importance,
 was produced by the interpretation of the word eryfipelas, which
 was probably given  by  the ancients to this  difeafe, without
 any intention to denote a fpecific kind of inflammation ; yet the
 early ufe oi this term  was of fufficient confequence to bind
 thofe,  who attended  to the nicer diftinftions in nofology, to a
 particular mode of praftice according to the  momenclature*.
 With fuch different notions regarding the caufes ot this difeafe,
 we might  expeft, that the treatment  ivould be different ; and as
 it was  contradiftory, we may prefume;  that it muft often have
 been hurtful.   There is undoubtedly much difficulty in forming
 a juft  idea of a very complicated difeafe, and in proportion to
 the difficulty,  every attempt to make accurate diftinftions is
 deferving of commendation.   But however fymptoms may vary
 from affeftions of particular parts, or in particular conftitutions,

   *  Uterus a placenta Jeparatione, pracibue violenta, excoria-
 tur, tanquam ulcus ingens internum, lochiorum liberiore ema-
 natione deturgitur et mundificatur.  Ideoque per  excreta de
 puerperajamtate aut dijcrimineJtatuimus.
                                         Harv.  page ,556.

   t Si mulieri pregnanti fiat  in utero eryfipelas, lathale eft.
                                             Hippocrates. 
244            INTRODUCTION  TO MIDWIFERY.
there  is but one effential nature of the difeafe ;  and if we have
a true notion of this, we have lefs reafon to be felicitous about the
caufe, or the determination of the part originally or principally af-
fefted. For a Similar treatment  may be enjoined with equal pro-
priety for an inflammation ot the uterus, omentum peritonaum,
or inteftines, or perhaps any ot the contents ot  the abdomen ;
provided a fever is produced, and  the influence ot  the difeafe,
originally local, be extended to the  conftitution.   It is however
obfervable, that inflammation  of the  uterus is far lefs danger-
ous than an equal degree of inflammation of any of the vifcera
of the abdomen, efpecially in the ftate ot childbed ;  becaufe the
uterus readily admits of a return of the lochial difcharge,  which
always affords relief, and fometimes cures the difeaSe.  But in
inflammations  ot any of the  contents  of the cavity which has
no vent  or outlet,  the effefts of  the inflammation become an
addition to the exifting difeaSe, or  a cauSe ot a new difeaSe.
   The knowledge of the caufes of this difeafe, whether occafional
or immediate, will be ot Service rather in enabling us to prevent
it, than in leading us  to the  cure when it is formed ; for if a
patient be brought into a certain ftate, the peculiar caufe of that
ftate  will not demand any material difference in the  treatment
 direfted for her relief.   There is but too much reafon to lament,
 that inconfiderate proceeding, and the want of common care,
 frequently give rife to the puerperal fever.   But independently
 of the changes occafioned in  the  conftitution by  particular
 modes of  living, women,  with a  view to parturition, will not
 bear a  comparifon with other creatures*.  The ereft pofition
 ot the body, the different  ftrufture of the uterus and placenta,
 and the paffions, though neceffary, and perfeftly adapted to the
 rank in which Providence hath placed mankind,  become per-
 manent cauSes of much pain,  and  eventually produce inconve-
 niencies, and  fometimes danger;  and for thefe  reaSons women
 are alSo Subjeft to So great a number of complaints  during preg-
 nancy, from which all other creatures are  exempt.   Some of
 thefe complaints, the retroverfion of the uterus for  example,
 are dangerous  in their own nature, while others indicate  or pro-
 duce a difpofition to  difeafes, not formed in the conftitution till
 after delivery ; and the inflammatory appearance, fo often ob-
 ferved in the blood of pregnant women, may perhaps be juftly

   ■* Mulieribus prat cateris animalibus  hac   contingunt, et
 prafertim ddicatis,  vitamque  umbratilem  et  mollem  degere
 qffuetis ; ut et us qua tenera valetudinis Junt,  et facile in mor-
 pbs  labuntur.   Harv.  Exercitat,  de Partu. 
            ANOMALOUS,  OR COMPLEX LABOURS.        245

efieemed a mark of a ftate particularly difpofed to fever.  Some
habits are naturally liable to difeafes of the bowels, proceeding
from an excefs in the  quantity, or an alteration in the quality
ot the bile, and fuch may derive a new and temporary caufe of
them from irritation, and from the difturbed Secretions of the
vijcera, from  the preffure  of the  enlarging uterus, or by the
labour.   Nor is it improbable, but that, by the fudden removal
ot this preffure at the time ot delivefy, a greater proportion of
fluids, than circulates even in a natural ftate, may ruffi  upon
fome particular part,  and from a very flight  obftruftion caufe a
local  plethora.  Imprudent management at the time of labour,
efpecially rude treatment of the os uteri,  and a violent or hafty
feparation of the  placenta, will often give rife  to this difeafe.
In Short, every caufe, capable of producing either local inflam-
mation  or fever under any circumftances, will at this time be
followed by worfe effefts;  and any disturbance raiSed in the
conftitution will,  after delivery, be invited  as it  were to  parts
already in a very irritable ftate, from the violence which they
have lb lately undergone.
   It is natural tor women, eSpecially with their firft children, to
have flow and painful labours, which they will generally bear with
refolution, and,  if not mifmanaged,  without danger.  Inftead
therefore of hurrying and deranging the order ot a labour, which
is always improper, and fometimes injurious, under the falfe and
ill-judged notion of freeing the woman from  her mifery, we
ffiould confider, that the bufinefs was intended to proceed flow-
ly, and ffiould  be left entirely to the aftion oi the uterus, and
and the efforts ot the  conftitution*.  When there are devia-
tions from the regular courfe of labours, the ufefulnefs of mid-

   * Increpandae Junt  obftetices, praefertini juniores temera-
riae ;  quae, cum parturientes prae dolore ejulare opemque ej-
Jlagitare audiunt, ne imperitae velparum fatagentes videantur,
manus oleis  obhnendo,  locaque muliebria dijiendendo,  mire
tumultuantur ; porredfque  potwnibus medicatis, Jaculta-
tem  expultricem  irritant ; atque  morae  debitae  impatientes,
dum accelarare  ac facilitare partum cupiunt,  eundem  re-
tardant potius  et pervertunt,  efficiuntque non  naturalem et
•difficilem.—Melius prqfedo cum pauperculis res agitur, if que
quaefurtim gravidae Jadae clanculum pariunt nullius obfle-
tricis advocata  epera : quanto enim diutius partum retinent
et rnorantur, tanto jacilius etjacilius rem expediunt.
Harv.  Exercitatio de Partu. 
246            INTRODUCTION TO MIDWIFERY.
 wifery «v an art, and the Skill and judgment of the praftitioner,
 will be ihewn, in deciding which of thefe require the affiftance
 of art, and  in choofing the fafeft and the beft  means of giving
 relief.
   There is not throughout nature an operation more wonderful
 than the  aft of parturition, and  there is little  reafon to be fur-
 prifed at  the bad confequences which fometimes follow an al-
 teration fo important, thotfgh this alteration is natural.  Judg-
 ing from Speculative principles, they might be expefted to oc-
 cur  more frequently ; and,  though they are  often occafioned
 by bad management, they cannot always be avoided under the
 moft promising circumftances, and with the greateft care.
  When a woman is delivered, it  Seems neceffary to make a
 moderate and  uniform compreffion upon the abdomen,  but
 binding it tight is certainly improper, and the  general abuSe of
 bandages, as was before obferved, has induced me to forbid ital-
 getber till the feventh or eighth day after delivery.   Women
 are certainly not fo often attacked with this fever, after difficult
 labours,  becaufe of the particular care with which  they are
 then managed, whereas after eafy ones they are more unguarded.
  The time when women are chiefly fubjeft to this fever, is un-
 certain.  There are not wanting inftances in  which it has been
 evidently forming before delivery, or during  labour, or at any
 intermediate time for feveral weeks  afterward ;  but the Sooner
 trom the time ot delivery the patient is attacked, if in an equal
 degree, the greater is the attendant danger.  But the moft fre-
 quent time of its appearing  is on the third  or fourth  day after
 delivery, when the patient, is feized with a Shivering  fit, from
 the violence and duration of which  we may generally eftimate
 the danger of the fucceeding diSeaSe.   In Some caSes however
 there has been no cold or Shivering  fit,  or none  which was ob-
 fervable ; and in others, the ffiivering fit in the ftate of child-
 bed has not been followed with thofe fymptoms which were to
 be apprehended.  Before the Shivering fit, the patients have
 been much debilitated, and  complained of wandering pains in
 the abdomen, which very Soon became fixed in the hypogaftric
 region, where a  Swelling or SulneSs with exquifite tenderneSs
 Soon enfue.   As the difeafe  advances the whole abdomen be-
 comes affefted and tumefied, fometimes nearly to its Size before
 delivery, the woman herSelf  being fenfible ot and defcribing its
 progrefs.  She alfo feels great pain in the  back, hips, and Some-
times in  one or both legs,  and other parts affefted  in uterine
 complaints.  She can fcarcely lie in  any other pofition than on
her back, or on one fide, with her body incurvated, and if the 
ANOMALOUS,  OR COMPLEX  LABOURS.
 difeafe be confined to the uterus, the feat of the pain Seems to
 be changed when ffie alters her  pofition.   There is uSually ei-
 ther vomiting ot green or yellow bitter matter, or a  naufea and
 loathing oi the ftomach, with an offenfive tafte in the mouth.
 An inftantaneous change  both  in the quantity and appearance
 ot the  lochia takes place, and Sometimes,  though rarely  they
 are wholly  Suppreffed.  The milk, it Secreted, recedes,' or is
 diminiffied, and the tafte with the appearance are much altered
 The urine is  voided  oSten, with pain, and in Small  quantities'
 and is remarkably turbid.   A tcneSmus or frequent ftools come
 on, and from the general difturbance  it  is  often maniteft, that
 all the contents of the pelvis are at once affefted by the difeafe
 The tongue becomes dry, though Sometimes it remains moift
 and is covered with a thick brown fur ;  but as the  difeafe ad-
 vances  its appearance  varies, and in fome dangerous caSes it has
 been little changed.   The patient immediately  entertains the
 ftrongeft apprehenfions ot her danger, and uSually labours un-
 der vaft anxiety, her countenance bearing indubitable marks ot
 great fuffering both in body and mind.
   The progrefs ot this difeafe is fometimes extremely rapid  ef-
 pecially in unfavorable feafons and hot climates.  Inftances have
 occurred, in which women have died within twenty-four hours
 of the  firft  attack; and I  have feen a few, who never  grew
 warm after the rigor.   In fome, death has  followed quite un-
 expectedly,  either from  inattention,  or from the fcarcely per-
 ceptible, but infidious progreSs  of the difeafe, the indications
 not having been at all  proportinate to the danger.   In other ca-
 fes the ffiivering fit is fucceeded by heat,, thii ft, and other fympl
 toms, according  to the courfe obferved in other fevers ; but
 the pain which originated in the abdomen, joined with thefe  is
 to be efieemed the pathognomonic or chief Sign of this  difeaSe.
 It Seems neceffary to enumerate all the Symptoms, which com-
 monly,  though not exclufively,  attend this  Sever," and not in
 any individual  patient; yet  caSes will occur  in  praftice, in
 which there will be much variation, depending on the degree oS
 difeaSe, the part affefted, the conftitution of the  patient,  and
 the period aSter delivery when the Sever makes its appearance.
   The puISe has almoft invariably in this  diSeaSe  an unufual
 quickneSs Srom the beginning.  It has often  that ftrength  and
 vibration obServed in disorders ot  the moft inflammatory kind
in robuft conftitutions; and yet  is fometimes exceedingly  See-
 ble and  quick, beyond what  might be expefted Srom the con-
curring circumftances.  The latter is to be  reckoned  among
the moft dangerous figns, proving perhaps,  that there is a great 
248
INTRODUCTION TO MIDWIFERY.
 degree of difeafe,  and that the powers ot  the conftitution are
 unable to Struggle with it, or to bear the operatoin oi the medi-
 cines,  which might be*neceffary for its relief.  There is much
 variation in the fubfequent ftages,  but there is fcarcely a worfe
 omen,  than a very  weak and accelerated pulfe, even though the
 other fymptoms may feem to be abated.  But this quickneSs oi
 the pulSe, if not attended with other figns of inflammation or
 fever, is not to be confidered as indicating danger, becauSe ve-
 ry irritable patients have Sometimes in childbed a very quck
 pulSe, unaccompanied with any other dangerous Symptom.
   The figns  of inflammation, joined with thofe of extreme ir-
 rjtibility, continue for a few days,  when thofe of putridity ap-
 pear, fooner  perhaps in this than in moft other difeafes,  which
 are originally of the truly inflammatory kind.  The teeth very
 early colleft  a brown adhefive Jordes,  and all kinds ot food and
 drink are naufeated, except fuch  as are agreeable from their
 coldnefs  or  fharpnefs.   A Singultus attends,  every return of
 which affefts the abdomen in the moft paintul manner.   Pete-
 chia or vibices are often  found  in unwholefome fituations,  and
 in Some conftitutions  of the air, at a very early period of the
 difeafe, and there are frequently miliary eruptions; but the lat-
 ter is rather a confequence of the method of  treatment, than oi
 the difeafe, for they do not afford that  relief, which often  fol-
 lows their appearance in true eruptive fevers.
   The bowels are in general very much difturbed, and in fome
 cafes aloofenefs takes  place immediately upon the acceffion, in
 others three  or four days after,  or  not till the laft ftage ot  the
 difeafe ; but it  very feldom fails to attend, nor can it be remov-
 ed  without the greateft difficulty as well as danger, before the
 difeafe is terminated.   The ftools often come away involuntari-
 ly, being always preceded by an increafe  of pain, and  every
 evacuation gives momentary relief.   They are  uncommonly
 fetid, of a green or dark  brown colour, and working like yeft.
 It is alfo remarkable that after the long continuance of the loofe-
 nefs,  when the patient  has taken little or no Solid nourishment
large and hard lumps of excrement will be fometimes difcharg-
ed which one  might fufpeft to have been confined in the bowels
for a long time before delivery.   With regard however to this
fymptom, it is very neceffary to obferve, that great diftuFban-
ces of the bowels are frequently occafioned by mere irritation,
in delicate conftitutions, which are  foon removed by the  well-
timed exhibition of  fome cordial opiate.
  There is a peculiarity in this fever,  which I believe has not
been obferved or mentioned.  It is an eryfipelatofe tumour of 
ANOMALOUS,  OR COMPLEX LABOURS.
24d
 a dufky red colour, on  the knuckles, wrifts, elbows,  knees,
 or ancles, about the fize ot a  fluffing, and fometimes  larger.
 This is almoft univerfally a mortal  Sign, and on the inSpeftion
 of thofe who have died  with  this  appearance, the difeafe has
 been found to have affefted principally the "uterus or its append
 dages.
   When this fever commences foon after delivery, and conr
 tinues its progrefs with violence for a few days, our hopes of
 a favourable  event will often be difappointed,  and the impendr
 ing  danger  may ufually be  foretold by  the  uninterrupted
 progrefs of the  fymptoms,  and by returns of the rigor.   An
 early derangement ot the faculties  of  the mind is always a ve-
 ry threatening fymptom.  A looSeneSs immediately Succeeding
 the attack, though  in  one SenSe it  may indicate the degree of
 difeaSe, always  contributes to its abatement, and Sometimes
 proves critical; as does likewiSe a Spontaneous vomiting, Some-
 times even towards the laft ftage, when all hopes of recovery
 were abandoned.  The protufe Sweat, which follows the ffiiver-
 ing fit,  has very often been completely critical.  In fome there
 has been a tranflation of the difeafe  to the extremities,  where
 the part has inflamed, and a large abfcefs has been formed ; a
 fimilar  abfcefs has alfo in fome caSes been formed on one fide
 of the  abdomen, which  has been  healed by  the moft  fimple
 treatment.  Freffi eruptions ot the lochia are always a favour-
 able fymptom,  and are to be reckoned among the moft certain
 figns ot amendment.   A fubfidence oi the abdomen, after co-
 pious ftools,  and with a moift Skin,  is a fortunate alteration for
 the patient;  but that circumftances, without evacuations, and
 a dry fkin, threatens the utmoft danger.  In the moft fevere de-
 grees of this  difeafe, which have refitted all the means  of re-
 lief in the early ftage,  thofe who have efcaped, feem to have
 owed their fafety to the  vomiting  before mentioned, or to a
 conftitution happily  ftrong  enough to bear the long continu-
 ance of the loofeneSs, by which the effefts of  the difeafe were
 gradually drained away.
   Of an uncommon cafe of the abfcefs above mentioned it
 will not be fuperfluousto add the following account.
   On June the  10th,  1798, a lady had been delivered  of a
 dead child, between the Seventh and eighth month of her preg-
 nancy,  when ffie fuffered very acute pain in the extraftion ot
the placenta,  which was thought neceffary.   For feveral days
 previous to her delivery ffie had a confiderable degree of  fever,
and much general uneafinefs over the abdomen, for which ffie
 was bled, and took fome cooling and quiet medicines.  On th*
   Vol. II.                H h 
250           INTRODUCTION TO  MIDWIFERY.
12th, (the Second day after her delivery),  ffie had a ftrong and
violent rigor, fucceeded by a  very fevere  pain in her left fide,
near the fpine of the ilium,  and  fever, which continued tor
feveral days, when  her milk, (before fecteted) entirely difap-
peared.
  Though  the  painand fever  were abated,  they never en-
tirely left her ; and after another rigor on the 19th, with an in-
creafe of tever and  pain in the part firft  affefted, her friends
were alarmed, and a phyfician of eminence  was defired to See
her.  He.  preScribed what the Situation and circumftances of
the patient Seemed to require, and ffie  was much relieved.—
There were,  however,  frequent  exacerbations ot tever; the
pain oi  which fhe originally complained never entirely left her,
and was fometimes violent.  It was  now perceived ffie had no
power to move  her left leg or thigh, and ffie herfelf was fenfi-
ble of a deep-feated fwelling on the lift  fide of  the abdomen,
though it could not  be difcovered by her  attendants.   A  blif-
ter was  applied to the whole of the pained fide, and after fome
farther  attendance,   the phyfician  withdrew,  recommending
her to go into the country, and encouraging her to hope,  that,
as ffie recovered her ftrength, her complaints would leave her.
She was alfo advifed to ufe as much exerciSe as ffie could, and
accordingly attempted every  day to walk with a crutch, and
the help oi hernurSe ; but every attempt gave her excruciating
pain, and ffie was daily fenfible of lofing, inftead of gaining
ftrength.
   I firft faw her on the 28th of July.  As there was evident
fulnefs  on the  left fide of the  abdomen,  with much pain on
preffure, lofs of appetite,  and other fymptoms of fever, from
fome degree of which ffie  was, in faft, very entirely free,  I di-
refted three  or  four leeches to be applied to the part affefted,
and to be repeated every other day,  and fuch medicines as were
likely to abate the fever, to keep the bowels gently open, and
to  .moderate the pain.  She  was fomewhat relieved by thefe
means,  and as ffie was very week, I tried the bark, and fome
other tonic  medicines,  Srom  which ffie did not apparently re-
ceive any benefit.   From the contraftion and wafting oi the
limb, and from the  other circumftances before recited, think-
ing it probable that an abfceSs had begun  to be formed in  Some
part  of the cavity of the  abdomen,  I requefted to have a con-
futation, and Dr. Baillie was called in.   After a mature deli-
beration on  all the preceding  circumftances, and the prefent
 ftate of the patient,  it Seemed moft reafonable to think, that  an
 abSceSs was forming in the pjoas muScle.   Small doSesof cicuta 
             ANOMALOUS,  OR COMPLEX LABOURS.        2J1

  in the faline draughts  were preScribed, and a Soft plafter with
  opium was applied to the fide ; the caSe of the patient Seeming to
  admit ot little other relief  than Some alleviation of her Suffering.
  In the middle of Auguft ffie returned to her houSe in town, not
  in any reSpeft amended in her general health, and ffie  Suffered
  more from her local complaints.
   In a few days after her arrival in town,  the pain being much
  increafed, ffie went into the warm bath, and on the  following
  day ffie was  fuddenly relieved by discharging  a very large quan-
  tity of purulent matter, mixed with her urine.  This was con-
  fidered as a proof that an abfcefs had  been formed, and dif-
  charged  into the  bladder,  probably  by  means of an adhefiorj
  which had taken  place, and a fubfequent  communication be-
  tween this and the part firft affefted.
   She continued  to go into the warm bath for a few days, but
  SuSpefting that ffie was weakened,   and  feeling  herSelf very
  much fatigued by it, ffie  relinquifhed  it altogether.   At this
  time her medicines were changed for fome  of the milder  turpen-
  tines, in  fmall dofes ; and,  fhe ftill Suffering  confiderable pain,
  opiates were given, and repeated as the caSe required.
   When there was the greateft quantity of purulent matter dis-
 charged with the urine, and Sometimes I think there could
 not have  been lefs than four ounces  at a Single evacuation, ffie
 Suffered the leaft pain ;  but when there was a  SuSpenfion of the
 difcharge, the pain was  always moft fevere.
   In-the beginning of September, a  fwelling of a confiderable
 fize,  with an evident fluctuation in it,  was difcovered on the
 infide ot the thigh, without any appearance of inflammation or
 rednefs of the fkin, as if the fluftuating matter had been formed
 there ; and,  by a careful examination, the courfe by which the
 fluid had defcended from the groin to the  thigh, could  be rea-
 dily traced.  The fwelling  gradually defcended till it came very
 near the ham, varying in fize, according to the pofition of the
 limb and body, and the patient thought ffie could diftinftly per-
 ceive both the defcent and rife ot the fluid.
   The night fweats, and other heftic  fymptoms, were now ex-
 treme ; but, after a  trial of the bark, and other  medicines of
 that clafs, which difagreed,  ffie for many weeks took no medi-
 cine whatever, except fmall dofes of opium, when  the pain was
 violent, and fome gentle laxatives, when ffie was coftive. She
 was allowed to drink porter at her meals, ..and at any other time,
 without reftraint,  when the wiffied for it, and always confidered
herfelf not only fupported,  but very much  retreffied by its ufe.
  In Oftober ffie  kept her bed altogether, unable to move, or 
2j2            INTRODUCTION TO MIDWIFERY.
help herfelf in any pofition, and frequently  fuffering much
pain.   I then propofed a confultation with Mr. Cline, the fur-
geon of the family,  to confider of the propriety or expediency
of making an opening in the tumour in the thigh, and by giving
ijt an inferior vent, to prevent  the matter from returning into
the abdomen.  Mr. Cline did  not  then think it juftifiable, to
make an opening in the tumour, and I readily acquiefced in
his opinion.
   At the latter end of this month, ffie was reduced to a  ftate of
extreme weaknefs, and exceedingly emaciated, but her appe-
tite, which had never entirely left her, now began to improve.
J'he tumour in the thigh daily leffened, and Soon disappeared al-
together ; as did the  Quantity  of matter  difcharged  with the
urine,  till that alSo entirely qeafed.   In November fhe frequent-
ly voided Smajl quantities of blood with  her ftools, and at the
fatter end of that month her health and ftrength were considera-
bly improved.  There was alfo about this time a return of fome
power of moving her limb ; ffie foon became able to walk with
crutches, the infirm leg bejng Supported  in a ftirrup ; and fhe
had a return of the menfes,  which had not before appeared fince
 the time of her delivery.
   On the 20th December ffie was lifted into the coach for the
 benefit of taking the air,  and her health  might at this time be
 laid to be restored, as ffie had no complaint,  and though weak
 and emaciated, wasevery day fenfible ot  amendment.
   In the beginning of the year  ffie again proved with child,  and
 went on to the. full period of pregnancy,   when ffie was fafely
 delivered of a healthy boy ;  having recovered before the time
 of her delivery the perfeft ufe of her limb.  She now walks and
 performs all the offices of Ufe with her  accuftomed eafe, and
 nas n<j£ the leaft, remaining token of the complaint from which
 ffie had So Severely Suffered.
    The fwelling and tenderneSs of Some  part of the abdomen,
 joined with a fever, were mentioned as the pathognomonic Symp-
 toms  of this diSeaSe.  ljut as  thefe parts are. often affefted hy
 the greatncfs of the diftention during pregnancy, hy after-pains,
 by flatulence, and by fpafms,  as well as inflammation,  we may
 be alarmed without reafon, and mistaken in giving the. name of
  a difeafe, which does not exift, tp complaints of  infinitely ^e.fs
  confequence.  On this principle  we may  account  for* the
  flight manner in. wnicfi Some have mentioned the pueperal fever,
  while others have recommended methods of treatment foreign to
  its nature,  and inadequate to its cuje.  But wjth attention, this
  fever may be readily diftinguiffied from all qthe* complaints,  tp
t' 
ANOMALOUS,  OR COMPLEX LABOURS.
*5$'
which it bears any refemblance.  Violent fpafmodic affeftions
of the uterus coming on  foon after delivery, and extending
their influence to various parts of the abdomen, if accompanied
with great quicknefs ot  the pulfe,  may give apprehenfions oi
this Sever, though they will be almoft immediately relieved, by
a fomentation to the abdomen, and the proper ufe of opiates.
After-pains  approach neareft  to thofe pains of the abdomen,
which attend it; but though thefe are fometimes attended with
great tendernefs of the abdomen, the intervals of perfeft free-
dom from pain, which are never obferved in this  tever,  not-
withftanding there may be confiderable exacerbations, and the
regularity with which, in after-pains, all other circumftances
proceed, will be evident and fufficient diftinftions.
   About the time when this fever  moft frequently appears, ef-
pecially in its worft form, a difturbance is raifed in the confti-
tution by the Secretion of the  milk. The confent between the
uterus and breafts is of fo intimate a nature, that it is fcarcely
poffible for them to be affefted Separately, as the tranfition of the
humours from one to the other abundantly demonftrates.  But
though this difeafe has been very often imputed to the milk, the
fuppofition  is probably groundlefs  ; for if this Secretion be not
 interrupted  in its natural courSe, the  inconveniencies  arifing
 from it, though they  may be troublefome, will not  be attended
 with any  danger.   But thoSe  who are unwilling or unable to
 give Suck, or to whom Suckling may on Some other account be
 improper,  are liable to various complaints, from which nurfes
 are free,  In fuch cafes, 1 have found no method of preventing
 fo effeftually the  ill confequences likely to enSue, as  by pro-
 curing ffools before the fecretion is completed, and for  fome
 days afterward with regularity.   Should inflammations come on,
 and abfceffes be  formed  in the breafts, they are always much
 lamented,   and confidered as proofs  of mifmanagement; but
 there is great reafon to conclude, that they fometimes prevent
 more grievous and dangerous complaints, and that they could by
 no care have been obviated.   It is remarkable, that not one fn-
 itance has been obferved of any woman, who had an abfcefs in
 the breaft, being attacked with this fever ; nor of one  who in
 confequence of herJahourfnad fuch an affection of the bladder,
 as to occafion a fuppreffion of the  urine.  At another period of
 kfe, when  the  difpofition to  cancerous  difeafes exifts  in the.
 conftitution, their fixing upon the uterus or breafts feems to be
 merely owing to  fome accidental caufe.
    A difeafe in which the fymptoms  come on with violence,
 proceed, with rapidity, and oi which the event has fo often been 
254
INTRODUCTION  TO MIDWIFERY.
 fatal, cannot fail to alarm every man folicitous for the welfare
 of his patients, or who has a due regard of his own charafter ;
 and under circumftances fo peculiarly diftreffing  as are thoSe
 of women in childbed, humanity would urge us to  exert our
 abilities for their relief with zeal and tenderneSs.
   We ffiould in the firft place endeavour to  fhorten the rigor,
 by hot applications to the extremities, and by giving  warm di-
 luents  in  Small  quantities  often repeated.  A conviftion  of
 the neceflity of Speedily removing the rigor, has induced Some
 to give very aftive  cordials for this purpofe ; but as  the hot
 fit which Succeeds will in Some meafure depend upon the means
 uSed, it does not Seem proper to give Spirituous liquors, unleSs
 they  are well diluted.
   Bleeding has been advifed in the  beginning of violent dif-
 eafes, with the intention ot fuppreffing the difeafe, of alleviat-
 ing the Symptoms, or of rendering the  operation of the medi-
 cines, which were afterwards to  be given, more fafe and effec-
 tual.   For the cure of the fever now  under confideration, fome
 have placed their whole confidence in the early and free ufe of
 this  remedy, while  others have expreffed more than ordinary
 fears and apprehenfions with reSpeft to it*.   Perhaps it may
 be impoffible to form a rule of praftice fo general as to preclude
 the neceffity of  leaving much  to difcretion ; for the treatment
 of patients  differing in conftitution, though  labouring under
 the fame difeaSe, muft vary, or the worft conSequences will in-
 eviatably SoIIoflr.
   In the early  part of my own praftice, I had much doubt
 of the propriety of bleeding indiscriminately for the cure of this
 difeafe. and I was long ot opinion, that it was not the moft na-
 tural, Safe, or effeftual  remedy.   I confidered, that Spontaneous
 hemorrhages were Seldom critical in this diSeaSe ;  I SuSpefted,
 that women in childbed Suftained bleeding worSe, than in almoft
 any other fituation ; and from  fome deteft in the remedy,  or
 fome  error in the application, I otten found myfelf disappointed

   * Equidem de fanguinis miffione multum  controvertitur;
 nonnulli enim venam pturies tundendam effe arbitrantur, dum
 cateri vel minimam Janguinis detradionem  averfantur.-----
 And  afterwards----Hac praxis)  enim docet phlebotomiam,
 haud nifi cafu  urgentiori et fumma cautela  effe celebrandam,
pro rerum conditione.  Caterum multa de hac  relepid et dilu-
 cide tradita,pr.oJlant apud Jcriptores, qua tamen inter praxim
 implicatiffuna deprehenduntur.
                     Lieutaud.  SynopS. Univ. Pra. Med. 
ANOMALOUS,  OR COMPLEX LABOURS.
26o
 in my hopes and expeftations, when I relied upon it.   It Seem-
 ed alSo an observation of importance, that thofe women, who
 had loft much  blood at the time of delivery, were more liable
 to this  difeaSe, and that it was*more  commonly fatal to them.
 The confequences alSo of erring by the too free ufe of the lan-
 cet Seemed more to be dreaded, becauSe they were harder to be
 repaired,  than thoSe  which  might ariSe from an  oppofite con-
 duft.
   But  I  am now convinced by manifold experience, that my
 reafoning was  fallacious, and  my fears groundleSs ; and that
 what I  had confidered as proofs of the infufficiency or impro-
 priety of bleeding in the true puerperal fever ought  in reality to
 be attributed to the neglect, of performing it in an effeftual man-
 ner, at  the very beginning  of the difeafe.  In fhort, if the firft
 ftage be fuffered to pafs unheeded, bleeding will  certainly then
 be injurious, the opportunity having  been loft ; and the phyfi-
 cian afterwards called in, however great his talents may be, will
 too often have the mortification of being a fpeftator  of mifchief,
 which he cannot then remedy, and of an event, which he can
 only deplore.
   It is in general abfolutely neceffary to bleed in the beginning
 of the puerperal tever, and we may then avail ourfelves of the
 advantage which this operation affords, with equal fafety and
^p#opriety as in  any ©ther inflammatory difeafe, under other cir-
 cumftances.  With  refpeft to the quantity of blood drawn, we
 are to be  guided by the conftitution ot the patient, and the vio-
 lence of the  fymptoms, being cautious not to err  by bleeding
 unneceffarily, or in  taking away too  large a quantity.   But if
 benefit ffiould be derived from the firft operation, and the vio-
 lence  of  the difeafe  fhould require it, we ffiall be juftified in
 repeating it at ffiort  intervals ,  not with a  view of  moderating
 or retarding the progrefs of the inflammation, but if poffibleJW
 wholly fuppreffing it.  For when the fever has remained for
 a very few days, the  putrid fymptoms advance very rapidly, and
 its continuance depends upon  caufes, which bleeding cannot
 remove, and will certainly increafe.   When the attack is vio-
 lent, and the conftitution feeble, it is  always  more fate and ex-
 peditioufly ferviceable, to draw blood  by fcarification and cup-
 ping, or by the application of eight  or ten, or even a greater
 number of leeches to that  part oi the abdomen, which appears
 to be principally affefted.  In  fome  countries  the application
 of leeches to  the hemorrhoidal  veins has been confidered as
 more effeftual in this difeafe, than any other mode of bleeding.
 I muft acknowledge, that the  advantages, which I have often 
256           INTRODUCTION  TO MIDWIFERY.
 Seen  derived from local bleeding, have given me the greateft
 fatisfaftion and pleafure.
   But though women, who have had profufe uterine hemor-
 rhages at  the time ot delivery, are particularly liable to the
 puerperal fever from this or fome contingent reafon; and though
 it is Seldom removed by Spontaneous hemorrhages, yet theSe are
 Sometimes critical.  The Sollowing caSe, which was communi-
 cated to  me by Dr. JoSeph Denman, of whom, he  is endeared
 to me by  fentiments of efteem and regard more clofely than by
 fraternal affeftion, might be allowed to fpeak in terms of high
 approbation, is an example ot this kind.
   "- I was called in the middle of the night to go ten miles- to a
 woman, whofe placenta had been retained many hours after the
 birth  of the child.   The want of courage to withftand Solicita-
 tion, and the diftance from me, were my reafons for undertaking
 to feparate it.   The placenta adhered Strongly, but the fepara-
 tion was made very gently, and without  any confiderable he-
 morrhage. On the third day,  the patient was feized with  a
 fhivering and fever which continued all night.  From this ffie
 was relieved by* fo large a difcharge of blood  from the uterus,
 that I was again Sent tor on that account.  There was  no  fwel-
 ling of the abdomen, but great tenderneSs, much  pain in the
 head, conftant  thirft,  a little delirium, and ffie had no Stools.
 An increafe of fever every evening, and the fame profufe dif-
 charge every  forenoon, continued for ten  days.  She took oc-
 casionally teftaceous  powders with rhubarb, Saline mixtures,
 tinfture of rofes, infufion of bark, and  fome  dofes of opium.
 She at length recovered."
   The hemorrhages feem in this cafe to have been abfolutely
 critical, and my own  praftice hath fupplied me with inftances
 oia fimilar kind in different ftages ot this fever, and many more
 have proved the great advantage of returning or tree fanguine-
 ous lochial difcharges.  Yet in thefe cafes  I had fufficient rea-
 fon to prefume, that the difeafe had not only  originated in the
 uterus, but was confined there, without extending to the abdo-
minal vijcera.
   Having finifhed thefe obfervations on the ufe and advantages
of bleeding, I beg leave to repeat, that when the puerperal  fever
oi a true inflammatory nature exifts, I feel  affured I am right in
the opinion I  have advanced refpefting bleeding.   But as it is
fometimes extremely difficult to diftingufh between this  fever
and complaints  proceeding  from mere  irritability, which far#
more  frequently occur, efpecially in very dilicate habits ; and"
as all the complaints arifing  Srom irritability would at this time 
ANOMALOUS,  OR COMPLEX LABOURS.       2£J
 be increafed by  bleeding, and rendered dangerous by a repeti-
 tion of it; I recommend in the ftrongeft terms, that we fhould be
 accurate in our diftinftions before we determine on a plan on
 the purfuit of which'the  good of our patient may fo effentially
 depend.
   When the attack of this fever is violent, a vomiting of bili-
 ous matter  attends, there is often a multiplicity ot ftools, and
 the commencement is fometimes  not unlike a moderate degree
 ot  the cholera morbus.   It  has  been an almoft univerfal rule
 in  praftice, in  other diSeaSes, to forward thefe  evident inten-
 tions of nature, at leaft not haftily to obftruft or fupprefs them ;
 but in this, different meafures have been purfued.  It has been
 objefted, that a woman  lately delivered has Suffered too much
 from her labour, to bear with fafety  a method  ot proceeding,
 found ufeful in other fevers with  the fame indications;  or that
 the parts affefted would be too much agitated by the operation
 of  an emetic.  It has alfo been conjeftured, that the vomiting
 and uneafineSs  of  the ftomach ought to be afcribed to uterine
 irritation alone, and are hyfteric fymptoms  in the common ac-
 ceptation of the word, and therefore not likely to be  relieved by
 encouragement.   But if  in thefe  cafes we confider  the appear-
 ance of the matter difcharged, the great relief which the patient
 immediately  receives from the evacuation, and  the advantages
 which are found to refult from it in the courfe of  the difeaSe,
 it Seems  impoffible  tg fix upon  circumftances, which more
 ftrongly indicate the neceffity of giving an emetic.  Affent has
 been given to an opinion,: that the vomiting of porraceous mat-
 ter when an hyfteric fymptom, does not require evacuations ;
 yet even in fuch cafes it may be fufpefted, thatthe  porraceous
 matter,-by its irritation upon the ftomach, is the materia morbi,
 which occafions or increaSesithe Spafms, and that the difcharge
 fhould not be flopped, while it is preternatural.   It would be
 difficult to imagine  a Situation, in which medicines of any kind
 were likely to do much fervice, when the ftomach is oppreffed
 with* vitiated humours.
  But however unfatisfaftory thefe reaSons may be, experience
 will Support me in  afferting, that, when  Such complaints ac-
 company the beginning of this difeafe, or occur during its pro-
greSs, we ffiall loSe an opportunity of doing much  fervice,  if
we  be deterred from giving a vomit;  and that the operation is
not only perfeftly free from danger, but certainly anfwers ma-
ny other good purpoSes befides that of cleaning the ftomach.  It
is nevertheless to be obferved, that an emetic was in this cafe
firft advifed, chiefly for the relief of a fymptom, without any
  Vol- II.                  I i 
2.58           INTRODUCTION'  TO MIDWIFERY.
 expeftation of thereby curing the difeafe.  Yet there are advo-
 cates fo Strenuous for the ufe of emetics in this difeaSe, as to re-
 commend the repetition of them everyday, and who have affert-
 ed, that they are the moft powerful medicines for the abfolute
 cure  of" the puerperal 'ever.  To  the merit of having firft re-
 commended this praftice I am  not entitled, becauSe my firft
 giving  them was accidental, and perhaps I  am not yet fully
 competent to judge of  it; yet experience has  in many-CaSes
 proved to me, that emetics may not only be given,  but frequent-
 ly repeated in this difeaSe, with very great advantage.
   I may in this place be  permitted to make a digreffion, for
 the purpoSe oS  obfervingi that it appears, from  the  records of
 medicine, that two  different opinions were very early enter-
 tained refpefting the treatment of  fevers in general.  The firft
 and moft prevalent of thefe was, that every fever was a procefs
 efTablifhed  by the powers  of the conftitution, for the purpoSe
 of altering and aflimilating, or of Separating and rejefting Some
 offending matter ; or changing one ftate of the body into ano-
 ther,  better fitted for the performance ot its funftions.  The
 procefs  was defined by the term generally, though not properly,
 traniJated fermentation ; by which the ancients underftood the
 different ftates of bodies, whilft they were in the aft of chang-
 ing into Some new form  or ftate, or  the procefs by which they
 were  changed ;  and not vinous,'acetous, or any other fermen-
 tation, according to the modern diftinftion  of this term.  As
 this procefs in fevers was expefted to be ultimately falutary,  it
 Could not,  according  to this opinion,  be difturbed without
 mifchief;  unlefs, on account of violence, irregularity, or fome
 extraordinary deviation  from its ufual courfe,  it  might be
 judged neceffary, to moderate it when too violent, to encour-
age it when too remits, or to obviate accidental fymptoms.
  The fecond opinion was, that in a fever excited by any caufe,
 the body was in a ftate adverfeto its wellbeing, and perhaps in-
 confitent with  life ; and that the fever ought therefore to be
 fubdued by'the expeditious ufe of all Such means;1 as  were like-
 ly to remove the cauSe,  or to appeafe the action of the powers
of the conftitution ;  or,  by weakening the powers themfelves,
to reduce the body  into fuch a ftate,  that it ffiould be unable to
 continue or maintain what might be called the feverifh procefs.''
  The marks ot thefe opinions  may be readily  difcovered'to
pervade every Syftem of fevers, and every method of treatment,
which have been offered to our confideration, or recommended
 tor our  guide, even down to the prefent time.  There is no
 doubt but that the knowledge of both thefe opinions  will occa- 
            ANOMALOUS.,  OR COMPLEX LABOURS.        259

fionally be found ot much  ufe in praftice, if we be not led  to
extremes.  But the knowledge of a difeafe, or of a method  ot
treatment, is of infinitely lefs value than the faculty ot applying
it, and confiitutes in-taft a Small fhare of the excellence of a
phyfician. -He, by discovering the part principally affefted,
and by weighing its importance to the conftitution ; the nature
of the difeafe, its prefent ftate and probable confequences ; and
by  taking into confideration all the colateral circumftances,
will clear his mind,from perplexity and error,  and form  a rule
for his own conduft far beyond the influence or power ot any
doftrine.
  But in the treatment of the puerperal fever the difficulty has
been much increafed,  on  account of the  very great caution,
which, for reafons before affigned,. was judged neceffary.  It
was alSo faid, that by  regulating the puerperal difcharges,  all
the difeafes incident to women in childbed wer*e to be prevent-
ed, or moft naturally cured ; and  all evacuations, by  which
theSe  were likely to be interrupted or Suppreffed, were for-
bidden.  In fhort,  in this,ftate there was a fufpicion  ot  Some-
thing-Sacred or myfterious, with which we were not authorized
to interfere ; and neither common fenfe nor observation had Suf-
ficient efficacy, to control thofe impreffions,  which originated
in Speculation  and prejudice, and which are now fully  proved
to have been without foundation.             '
  Many years ago, after muchjembarraffment and repeated dis-
appointments in the treatment of this fever in the  cuftomary
way,  I gave the powder, which was recommended by, and has
acquired much reputation under the  Sanction ot  the late Dr.
James, and Sometimes.the following medicine ; and I was foon
Senfible of ,the good effefts.

   ft. Antimon. tartarifat.  gr. ij.
       Chel. cancror. pp.  9 ii.  intime mijeeantur.

   Of a powder thus prepared, after bleeding, and, if thought
neceffary, the exhibition ot a clyfter, I have given from three
to ten grains, repeating it as circumftances required.
   Should the firft dofe produce  no  fenfible evacuations,  for on
thefe only we are to rely,  an increafed quantity muft be given
at the end of two hours, and we muft proceed in this manner,
till the end we wifh be obtained.
   But if the firft dofe fhould occafion a. vomiting, purging or
profufe fweat, we muft wait tor the good effeft ot thefe opera- 
26o           INTRODUCTION TO MIDWIFERY.
tions ;  and we ffiall then be able to judge oi^he propriety .of re-
peating the powder.
  But when the evacuations are concluded, if  any alarming
fymptoms fhould remain,  we need not hefitate to give the pow-
der in the fame quantity  as was  firft ufed, though an equal
quantity is not often  neceffary, if the firft dofe  have operated
properly.   We cannot reafenably expeft,,that a difeaSe, which
exhibits Such  evident marks of danger,  fhould.inftantly ceafe,
even if the principal part of the caufe ffiould be removed,  or of
the effeft be abated.  Yet we muft be careful not to rely So far
upon an abatement of the fymptoms, as  wholly  to cfefift  from
purfuing the  method, which produced the abatement; for no
difeafe is more liable  to returns,  which are generally more vio-
lent than  the firft attack, and with accumulated danger.  It
muft alfo  be obferved, that as the certainty of the cure often
depends upon the [due repetition ot the, powder,  the cuftom of
giving this, or any other medicine, at  ftated hours, is never
eligible, and Sometimes improper.
  If a  ficknefs, loathing of the ftomach, or offenfive tafte in the
mouth, attend the commencement of the  difeafe,, this medicine
feldom fails to occafion vomiting, and therpatient, with a coun-
tenance Strongly expreffive of the benefit jhe has received, will
atteft the advantage of the methpc^purfued.  Nor does the me-
dicine  often fail to procure copious ftools, which are uncom-
monly  fetid,  and, as  was  before obferved, in the loofe ones,
lumps  ot  hardened faces are intermixed.  Their appearance
ffiould in Some meafure guide us with refpCft to the continu-
ance of the evacuations,  in proportion  to ■whicfy ihe abdomen
becomes  eaSy and Subfides, and the  other Symptoms become
more  favourable.  The urine is Soon voided with more  eafe,
and in  larger  quantities, a moifture of thefkin or profufe fweat
Succeeds, and the  lochia, which, were before brown or  pale,
fetid, and  in fmall quantities, increafe and become Sanguineous.
But we are to remember,  that.the Small quantity*of the lochia
is never to be efieemed indicatory of difeaSe, independently oi
other appearances,  becauSe with  refpeft  to quantity they evi-
dently  vary in every conftitution.               -  ,.
  At the Same time that we avail ourSelvs of the advantage to
be obtained from the ufe of theantimonial powder, we muft not
negleft the ufe of thofe means, wjjich contribute  to procure
immediate eafe or relief to the patient.   Emollient clyfters in
cafes attended with violent pain, efpecially if preceded or ac-
companied with coftivene&> are neceffary and proper.   Clyf- 
           ANOMALOUS, OR COMPLEX  LABOURS.         u6<

ters have alfo been efieemed  of more importance than merely
as the  readieft meant; ot promoting  ftools, or as a temporary
fomentation to the bowels ;  tor Some phyficians ot great expe-
rience  have thought  they were able to  remove a great part of
the cauSe, or  to prevent'the continuance of the dileafe, by di-
refting them  to be adminiftered fo frequently, that they were
at length returned  without any mixture of faces.   Fomenta-
tions, or vapour-bathing, or even the  warm bath, may fome-
times be ttfed with advantage;  but I think a folded  v/arm flan-
nel, well- fprinkled with- brandy, and occasionally renewed, is
one of the beft and moft comfortable applications.  When the
pain is confined to one part of the abdomen, or remains after
the abatement ot the  fever, if not removed by leeches, a blister-
ing plafter, applied directly to the part,  may always be recom-
mended  with Safety, arid will fometimes do much Service.
Plentiful dilution being abSolutely neceffary, the patient ffiould
be carefully Supplied with proper drink, in Small quantities of-
ten repeated.   The moft palatable, and generally the beft, is
chicken water,  or very weak beef tea ; or, if objeftions be
made to thefe, barley water, thin gruel, milk and water, whey,
and tea of almoft any kind, may be drunk  at pleafure.
   In this manner I treated the  wife of a foldier in the guards,
whom I attended July  1, 1767, in a Safe, but tedious labour.
She was oS a very ftrong habit of body, and upwards ot thirty
years of age.   About thirty-fix hours after the birth of the child
ihe was feized  with  a violent fhivering,  followed  with fevere
pains  in the  abdomen and loins,  and within a few  hours from
the attack of  the diforder, became nearly as big as ffie had been
before delivery.   On the third I gave her four grains ot the an-
timonial powder before mentioned, and finding no fenfible ef-
feft:, I repeated in the  fame  quantity  after  two hours.  She
pukpd twice, and had Seventeen  ftools, like yeft in appearance,
within fix hours atter the repetition ot the powder.   When the
operation of the medicine ceafed, the abdomen had almoft whol-
ly fubfided, and the tenderneSs and  fever much  abated.  As
{he was much fatigued, I gave her a cordial draught, with a few
drops  ot tinfture of  opium.   She  had  fome quiet  fleep in the  N
night and Sweated  proiufely.  There did not appear any neceS-
fity ot repeating the  powder, and fhe recovered perSeftly, with-
out taking any other  medicine except Some Saline draughts, and
afterward the decoftion of bark twice everyday.
   The event of this  cafe, and of fome others which occurred to
me about the fame time, was very  flattering.   I preSumed, that
I had at length discovered a method of treating this fever, aui 
262         INTRODUCTION  TO MIDWIFERY.
a medicine which would Seldom fail to anfwer the moft fanguine
expectations.  But further experience has convinced me, that
without previous or  even repeated  bleeding in fome cafes,
when the  inflammatory Symptoms are violent,  this medicine
will often fail to Subdue the fever, and that it is fometimes uncer-
tain in its operation.   It is perhaps to be reckoned a mong the
figns  of an unfavourable  termination  of the difeafe, when the
medicine in proper quantities produces  110 fenfible effetts.   I
am however permaded, that if we have an opportunity of giVA
ing it foon after the acceffion of the  difeaSe, it  will  often ^
the moft effential Service,  and  that too much cannot well be Said
in favour  of this method.   And it  is above all things  to be
wiffied, that phyficians had  the  early care of patients in this
difeafe'; forthediffeftions of thofe, who have died, have proved,
that very terrible mifchief is  produced-  in various  parts  with
amazing celerity.  In a very great number ot patients,'whom
I have had an opportunity of examining, all or  fome of the
following appearances" were  obferved.   The uterus, or its ap-
pendages,  were in a ftate of inflammation ;-or fometimes one
or both of the ovaria  of a livid colour, and altered in their tex-
tuie, as it  mortified   The general  fubftance ot  the uterus was
loofe and Spongy, and it was leSs contrafted, than it ought to
have been Since  the time of delivery.  The os^vteri,  and that
part  ot the uterus to which the placenta adhered, were difco-
loured, and  had  a Sloughy appearance.  Small  abfeeffes  were
Sometimes found in the fubftance of  the uterus, or in the cel-
lular  membrane, which  connects it to the neighbouring  parts.
The bladder was inflamed.  The omentum was, very thin, ir-
regularly  fpread, and in a ftate  oi inflammation.   The  intef-
tines  were inflamed chiefly in the peritoneal coat,  adhering lb
each other, and  much inflated.   Inflammatory exfiidation, and
Serum extravafated in the cavity ot the abdomen, have been
found in various quantities ; but thefe  were in a  lefs degree,
when the  patient had laboured under a  long  continued  purg-
ing.    In the cavity of the abdomen were  likewife  found  la^gjq
flakes of  coagulable  lymph,  which  have been^often miftaken
for curdled milk,  or for diffolved portion* offcthe omentum.
It muft indeed be acknowledged, that the information acquired
in this Search has not  afforded any praftical advantage, equal to
the care or affiduity, with which  it has been  made. .What we
have been able to learn has chiefly proved, that various parts are
affefted in different fubjefts ; that when the difeaSe lias con-
tinued with violence  for a tfew days, fits effefts^ will generally
be beyond the reach of medicine, and that if the patient fhould 
ANOMALOUS,  OR COMPLEX  LABOURS.
z6y
  fortunately recover, her recovery will depend  upon  circum-
  ftances,  which the'phyfician cannot without great uncertainty
  and difficulty command*.
    In the  lefs violent degrees of this difeafe, and more dilicate
  conftitutions, it will be neceffary to purfue the fame inten-
  tions, though  with  leSs aftivity.  In Such caSes,  after  local
  bleeding with leeches or otherwife, as  may be moft convenient,
  and giving a proper dofe of ipecacuanha, or waffiing the ffo-
  rnach with an infufion of chamomile flowers, more lenient me-
  dicines muft  be preScribed.   But they muft be  Such as will
  produce  a certain and Speedy effeft, for  after the operation oi
  an emetic* if ftools be not procured, we ffiall negleft the means,
  and lofe the opportunity, ot doing moft  effeftual  fervice ; for
  without them the relief  obtained  will  not' be permanent.   An
  emollient clyfter may be firft injefted, to remove any hardened
 fac& from, the lower part ot the redum ;  and  the antimonial
  powder in  fmall dofes, or the faline draughts with a due  pro-
  portitSpof the natron or the kali tartarifatum, or with rhubarb,
  or the following draught may be given every third or fourth
  hour :                   v-

          R.   Natri tartarifat.
               Mannas opt. da 5ii.
               Intuf. Senna*, aq. ment. Sat. da si.
               Tinft. cardamom, gut. xxx. M.  '

 Or two ounces of magnefia vitriolata may be diffolved in a pint
 of thin gruel, and one or two large Spoonfuls given every hour,
 tBl  due evacuations are  obtained; and this midicine has been
 found to anfwer the  intention, when  aparently  more pleafant
 medicines could not be retained.
   In every cafe of  difeafe, which requires Speedy and repeated
 evacuations for its  relief, particularly if attended with violent
 jjnin, it is  neceffary to  give a refpite  to  the  conftitution, by
 which it may be enabled to exert its own  powers, or "recover
 from the fatigue of the  operations themfelves.   For this pur-
 pofe opiates are wifely preferibed, when the operations are con-
 cluded. But opiates  being given for the purpoSe of eafincr

   * We have been told, that, in the diffedions ojjome who are
faid to have died of this difeafe, no appearances of inflamma-
 tion have been difcovered ; but I JJiouldfuJped, that injuch
 cajes miftakes had been  committed as to ihe nature oj the dif-
 eafe, and probably in its treatment. 
«64            INTRODUCTION  TO MIDWIFERY.
 pain, or of quieting Some agitation, if they be not  given  in a
 fufficient quantity to produce the intended effefts, are ufelefi*;
 for it is by their  effefts we are to judge ot the propriety or
 advantage ot their ufe.  In fome cafes alfo, which were accorrf-
 panied  with violent pain at the commencement, it has been
 found neceffary, to give a large dofe ot  tindura opii, imme-
 diately  after the  firft  bleeding, without waiting for any other
 evacuations, by which  the progrefs of the difeafe will be retard-
 ed.  Nor is there ever occafion  to hefitate upon the ufe or re-
 petition of an opiate  at any period of this difeaSe,' when the
 violence  of the pain requires it  ; though the pain may origin-
 ally be  a conSequence  of the difeafe, jt becomes after a certain
 time  a powerful caufe  of its continuance and increaSe.
   In trie inferior degrees ot  this difeafe, after bleeding once,
 either with the  lancet, or,  which is generally preferable, by
 the application of leeches to the  part, if thjfm gift*'neceffary, and
 the exhibition of an emetic, which can  feldom  be difpefifed
 with, we ffiall find the  Simple method of exhibiting/an opening
 draught for the purpofe of procuring four or five ftools every
 day, and an opiate every evening,r^roduce the moft  happy ef-
 fefts.   But it is not poffible for me to exprefs my Sentiments of
 the advantage,  which  may  be  Sometimes procured  by daily
 purging, So clearly  as by  the relation of the following cafe,
 winch was lately under my care.                   &
   The wife of an eminent tradefman was brought to bed of a
 living child, after a very tedious and difficult labour.    She was
 of a corpulent but  relaxed habit, and this was her firft  child.
 About Sour hours after  her delivery ffie was Seized with a purg-
 ing, and the ftools, which were of a dark colour and exceedingly
 cfFenfive,'foon afterwards came away involuntarily.   I faw her
 enrly  the  following  morning, November 22d.  She had con-
 stant but not exquifite pain" in the abdomen, which was  tumefied ;
 her Skin was hot, her pulfe  quick,  and ffie w?s thirfty.  Hav-
 ing voided \io urine I introduced the catheter, applied a flannel
 well fprinklcd 'with  brandy to' the. lower part of the abdomen,
pnd ordered an opening draught of the kind before mentioned.
She had proper evacuations by ftools all day, and in  the even-
ino-'fook an opiate.  On the 23d I found, that the purging con-
tinued, and  there was-  little  alteration in the other fymptoms.
The'opening draught was repeated in the morning, and the opi-
ate  at  bed-time.  On the 24th I was informed ffie hac* got fome
rcfrefhing fleep  in the night".   The*pain in the bojwgls and fe-
verifh'fymptoms were  abated1;? but  the ftools, which were yet
very fetid, came away invoIuntarij^£»» Both the draughts were 
             ANOMALOUS, OR COMPLEX LABOURS.         26^

  repeated  as on the preceding day.  On the 2,5th, though the
  ftools conlinigjd to come away without her confent, the abdomen
  had fob Sided, and the tenderneSs was almoft gone.   On the 27th
  the purging ceafed,  and ffie  recovered without the  repetition
  of the medicines.  I was under the neceffity ot drawing off'her
  urine twice every day, till the eleventh after her delivery, when
  ffie was able to  void it  without any affiftance.   But it is not
  to a fingle.cafe that I ffiould have occafion to appeal in a matter
  of So much conSequence.  A long and SucceSsful praftice hath
  convinced me, that the,  purging, which often attends this dif-
  eaSe, is not only Salutary, but frequently critical, and inftead of
  being Supprefled, that it ought to a certain degree to beencou-
  ra@N^  Nor would it be difficult for me to recolleft many cafes,
  in which  fatal confequences have Speedily followed imprudent
  attempts to flop the evacuations*.
    As the  difeafe paffes into its more  advanced ftages, it becomes
  more complicated and dangerous,  and there is a neceffity of
  being  very circumfpeft  in our endeavours   to give  relief.
  Bleeding, unlefs  by fcarification, or the application of leeches
  to the abdomen or hemorrhoidal veffels,  will  very Seldom be
  proper.at  this  time ; and if direfted, or repeated, Srom the en-
  couragement which  the inflammatory appearance of the blood
  may afford, will generally batten the fate of the patient, by re-
  ducing  the ftrength in a much greater degree, than it can abate
  the difeaSe ; as. I  have Seen  in many inftances oS this and other
  kinds of fever.   It muft therefore  be  omitted,  or  preScribed

    * Thefe remarks  on the neceffity  of procuring Jlools are to
 be confidered as applicable only before the patient is reduced to
 a Jtate of great  debility, or perhaps in fevers occafioned by
 local inflammation  of fome of the  contents of the abdomen.
 Experience has proved, that, in the advanced ftate of fevers of
 the typhus clafs,  cofiivenefs is the  moft favourable Jymptom.
 Sydenham takes particular notice of this in his  mojt excellent
 treatije on the fever of 1661 ; and in a principal kofpital of
 this city, it is an  ejlabliffed rule, never to promote Jiools, or
 any  weakening evacuation, in fevers of tins clafs,  after the
fourth day.  But in  the advancedjlate  of thefe f vers, cofiive-
 nefs, for a great number of  days, not only prevents an increafe
 of the debility, but  is the moft promifing Jymptom of a hap-
py termination oj the difeafe.   It deferves to be particularly
 noticed,  whether patients, in the advancedjlate of thefe fevers,
 ever die  while* the-bowels are conftipated.
   Vol.  II.  :                 K k 
266
INTRODUCTION TO MIDWIFERY.
with the greateft caution.  But if the ftomach  or bowels be
much difturbed, and an emetic were not given  in the  begin-
ning, one may be given at almoft any period of the difeaSe with
fafety and  advantage.  Or if there be no loofnefs, and ftools
have been procured fparingly through the courfe oi the difeafe,
the general method of cure may be purfued, if the ftate of the
parts firft affefted ffiould  require it, allowing  for the reduced
ftrength of the patient.   The frequent injeftion of gently pur-
gative or emollient clyfters wiH be extremely  proper, and lax-
ative medicines of the kind before mentioned ; not omitting  to
give opiates to procure temporary eafe, or neglefting the ufe of
fuch diet and general regimen, as will Support the ftrength of the
patient.
   But when the ftools are very frequent or  involuntary, and
all appearances threaten imminent danger, we muft be cautious,
that our attempts to  cure the difeafe are  confiftent with the
ftate of the  patient, though Something-muft be hazarded  for her
relief.   Clyfters ot chicken water, or flour and water boiled to
a  proper confiftence, or of  a decoftion of linfeed;* often're-
peated, then conflitute a very important part of the cure,  by
wafhing off fome part of the offending matter,  which ftimulates
the bowels  to frequent evacuations, and by afting as a fomenta-
tion.   But if great Care be not taken in their adminiftration, the
patient will fuffer intolerable pain on account of the tenderneSs
ot the uterus, which  I fuppofe to be the part principally affeft-
ed, at leaft in which the difeafe moft  commonly originates, and
of the influence of which this part never fails to partake.
   At this time it will alfo be ufeful, to give very  fmall dofes of
ipecacuanha mixed with the  opiate as a  diaphoretic,  or the
pulv. ipecacuanha compofitus, either in fome cooling vehicle,
as the Saline draughts, of with cordials, as the fituation of the
patient may require.   But  if the  ftomach  or  bowels fhould be
much difturbed  in the advanced ftage, or  if any new caufe ot
disturbance ffiould occur,  the ipecacuanha may even then  be
given fometimes in fuch a quantity, that it may aft as an  emetic.
The white decoftion with a large  proportion of gum arabic, or
the  common  emulfion with  Spiritus  aetheris  nitrofi,  makes at
this time a proper  and agreeable drink.  IS the ftrertgth of the
patient ffiould fink, and great  faintnefs come on,  a  neceffary
quantity of fome cordial and wine muft be given  in the  interval
"between the  draughts.-  I have alfo  often in this Stage given
camphor in fubftarice^in julap, or in the form ot emulfion, but
have generally been  obliged to discontinue its ufe,  becaufe it
 foon became difgufting to the  palate, and offeftfive to the fto- 
ANOMALOUS,  OR COMPLEX LABOURS.        267
jfcach ;  nor have I ever found  that advantage  from -.the ufe of
champor, which Some have taught us to expeft in this difeaSe,
though in many inftances the camphor mixture has appeared to
be an agreeable cordial, and to moderate pain.
  Under the  moft deplorable circumftances, we ought never to
defifl from ufing our endeavours with affiduity, to relieve and
efctrica$e the  tick from the imminent danger they are in, both
from principles of humanity and prudence ;  for they will Some-
times recover very  unexpectedly, when every prognoftic  is
againft them.  Something  always remains  to be done, which
may be ot ufe, or contribute to their  comfort ; either with the
view o£- obviating troublefome or  painful fymptoms ; or of
Supporting, by means adapted to their ftate, their ftrength ; or
oi promoting  Some obftriifted Secretion,  eSpecially  by regulat-
ing the ftate of the bowels.   On Such occafions I have among
other things been induced;to try clyfters oi various kinds, emol-
lient,  anodyne,  and antiputreScent, particularly of  ftrong
decoftions ot Peruvian bark :  but the event obliges me to ac-
knowledge, that I have not obServed much advantage from them,
beyond what  may be derived from the domeftic ones, which are
in common ufe.
  Nor has the bark, though given in different ftages of the dif-
eaSe, with remiflions tolerably /diftinft, anSwered the intention
as a  febrifuge ;  though in a few cafes, in which the intermif-
fions were complete, it- has  fucceeded.   As a fupporter of the
general ftrength of the,conftitution, the bark has been  likewife
found of lefs  fervice than might have been expefted ;  becaufe
oi the difturbed <and very irritable ftate of the bowels, which it
tends to increafe.  Inftead of this medicine, the colomba root,
in powder or infufion, has  been  given  every fourth or Sixth
hour, or the common ^.bitter infufion. prepared with cold water,
and  joined with  fome aromatic ;  or a  ftrong infufion ot cha-
momile flowers,  with the addition of a few cloves ; and fome-
times the following medicine, efpecially when thehiceup has
been troublefome : '
A
         R  Spir. zetheris yitriolici 3ii.
             Aqu. pura:, vel menth. fativ.  Bviij.
             Sacchar.'- pur. q. s.  fiat  miftura, cujus  fumat
             aegra uncjias duas, tertia vel quarta quaque hora.

  In. other cafes ather or  Ifoffman's mineral anodyne liquor
has been given ; but they.have often proved leSs agreeable to
the ftomach, and I believe uoj. more efficacious, than the Jpiri- 
268           INTRODUCTION TO MIDWIFERY.
 tus atheris  nitrofi, which I have Substituted  for  them,  and
 given with great freedom and advantage.  It  was  before ob-
 ferved, that the hiccup was  frequently an  indication ot * col-
 lection of oflenfive humours in the ftomach, and has generally
 preceded the Spontaneous vomiting,  which in  the worft ftate
 has fometimes proved critical ; though  the fame Symptom is
 alSo not feldom a proof of the progrefs oi the difeaSe, and a Sign
 of the utmoft danger.                           \r
   In the courSe of the difeafe, when the abdomen had been much
 diftended,  notwithftanding  the  evacuations, I  have  recom-
 rat.ided  the application of  the cataplajma cumini  inoiftened
 with brandy ; and fometimes direfted' clyfters compofed of
 eledarium e baccis lauri, or a Solution of afafiatida in fimple
 peppermint water ; and wiffi I was juftified "n fpeaking more
 highly in their praife ; but they are  among the things which
 have occurred  to me, when I  have fcarcely' known  what^o
 propofe.
   I have rarely attempted to  injeft medicines of any kind into
 the vagina or uterus, though from a confideration of the1 pro-
 bable ftate oi the parts, and of the  fetid humours difcharged, it
 is  reafonable to'think, that  emollient or gently detergent in-
jeftions might fometimes "be ufeful.  But  the helplefs ftate  of
 the patient is Such, as to render the operation itfelt very trou-
 blefome ;  and if they be advifed,  great caution  will be necef-
 fary both in their compofition and  adminiftration ; but fomen-
 tations to the external parts have,  I think,  fometimes afforded
 comfort, and been ot fervice.
   TheSe are all the obfervations I have made, and the opinions
 I have entertained on the puerperal fever in  its fimple ftate ;
 that is, confidering it as a difeaSe, originally, of the truly  inflam-
 matory kind, affefting one or  more  of the parts contained in  the
 abdomen,  extending its  influence over the  whole conftitution,
 and fpeedily affuming a putrid form with  m0re or  lefs viru-
 lence, according to its degree and  treatment during the inflam-
 matory  ftate.   But when putrid  diSeaSes'are epidemic*,  the

   * The firjl account I have  met with of apuerperal epedemic
 is in Peu.   It appeared in the year 1664, in the H'otel-Dieu,
 at Paris.   In this account there  are fome very  curious¥B0fer.
 vations.   In this country we have very reprehenfibly  neglected,
 to prejerve any regjler oj the times, when fuch fevers have
prevailed.  ' But in the year 1788, an  account of a puerperal
 epidemic was publiftied by  my  ingenious  friend Dr. John
 Clarke, according to itstippedrO^e ih one ofyh$kofpitals' in
 this city, and, in fome inftances, in private preBicc. 
           ANOMALOUS,  OR COMPLEX LABOURS.        269

puerperal- fever  may, at  ,the commencement,  partake oi the
reigning difeaSe  ^varying only in the affeftion of the  parts
concerned in parturition), as the histories of the plague, in this
and other countries, have  Sufficiently proved.  .-This  diSeafe
may alSo be  combined with a phrenSy or  peripneumony, with
fymptoms multiplied and varying according to the combina-
tions.  Then our principal  attention muft ot courfe be paid to
the moft urgent difeaSe or Symptom ; but the event oi Such ca-
Ses muft be more dangerous, on account of the number and im-
portance of the parts concerned.
   There is another confequence of an epidemic, or even a Spo-
radic puerperal fever, on which it would be criminal to be  fi-
lent.  This is the contagious nature of thefe fevers ; it having
been long fufpefted, and being now fully proved, that they may
be, and often have been conveyed by midwives or  nurfes,
from>  one patient to another.  This faft explains  the reafon,
why, perSons, praftifing for  many years with the moft enviable
fuccefs, have at one or more periods of their lives, without any
change in the principles oi  their praftice, met with a number
of unfortunate cafes; when perhaps an  adjoining neighbour-
hood has been entirely free from fuch difeafes.  Of this I have
known many inftances, and have repeatedly feen it the cauSe of
the moft painful diftrefs,  and fevereft refleftions.  Nor ffiould
this Subjeft remain a barren fpeculation, but, according to the
value Set upon reputation, teach thofe, who are engaged in the
praftice of midwifery, the impropriety of their  attending pati-
ents in fevers and other dangerous dijfeafes, if it  can poffibly be
avoided ; and to ufe every precaution,  that they do  not carry
contagion from  one patient to another.  The  nature and the
power ot  contagion feem not to be perfeftly underftood, and
it may exift  in many difeafes, in which it has not yet been fuf-
pefted.  The Subject; is therefore deferving of the moft Serious
inveftigation.


                    SECTION II.
                         MANIA.

  Amidst the great variety of complaints to which women in
childbed are liable, there is none fo diftreffing as that aberration
of the mental faculties, which fometimes, though happily very
rarely, we  have an opportunity  of obfei ving.   This diforder 
1JO            INTRODUCTION TO MIDWIFERY.

has fometimes ffiewn  itfelf immediately on women becoming
pregnant,  in  others when the  time of  labour approached, in
others during the ftate of childbed, apparently  occafioned,by
fome  extraordinary disturbance or peculiar irritation of  the
uterus.   In fome  cafes it has, however, been evidently cau-
fed by  irritation of another kind; as  when the breafts have
been inflamed, or an abfcefs has been formed, and at the time of
firft fuckling or weaning the child, Seven or eight months after
delivery ;  but in every cafe, the diforder has been, occafioned
by an uncommon irritation of  one ot thefe parts, fpreading its
influence to the brain, though without any reference to former
difpofition or habits, acquired or hereditary.  Speaking of con-
vulfions, it was faid, that pregnant  women labouring under any
diftrefs of mind  from the peculiar  circumftances of their Situa-
tion were liable to them:  and the Same observation may '• be
made of this diforder ; tor if the nervous fyftem be  once  dif-
turbed to a certain degree, or in any particular manner, the kind
of diforder thereby produced may  be accidental ; and the fame
cauSe, which ffiall in one perSon produce convulfions or paraly-
tic affigftions, fhall  in another produce the diforder offW-hich
we are fpeaking, either  ot the melancholic, or violent kind.
In the fame manner patients, who have long fuffered from  in-
termiting fevers, have in fome feafons been difpofed to maniacal
diforders*.                    '
  AlmoSt all the difeafes of women in childbed were formerly
attributed to  two caufes, the interruption of the lochial  dis-
charges, and the milk ; the latter of which was fuppofed to have,
when imperfeftly fecreted a pernicious influence upon the con-
ftitution in general, or on Some part in particular.  Hence  the
name of the milk fever, the adema ladeum, or the edematoSe
Swelling  of the leg, and in;general ,of all iwellings  or abfeeffes
formed in any part ot the body foon after delivery ; and  this
aberration of the mind is, for the fame reafon, called by nofolo-
gifts,  the mania ladea.  I do  not, however, kqpw, whether
there beany real  difference in this  diforder when it happens to
women in childbed, or under  other circumftances, or in  the
fymptoms attending it; Saving, as, that ftate is conftantjy chang-
ing fo as women depart  from the time of delivery, there is,al-
ways a chance of amendment  from every degree of change.
Perhaps for this reafon, this diforder,  in fome .inftances, ceafes
in twenty-four hours, and in others, it continues only for a few
days, in fome a few weeks, and in others  for Several months.

                     * See Sydenham. 
ANOMALOUS,  OR COMPLEX LABOURS.
27J
 But the  inftances of  its  continuing more than  fix months are
 very rare ; and there is fearcepy one to be found, who did not
 ultimately recover.   It has been  afferted in very  unqualified
 terms, that women, who  become  maniacal in  childbed, always
 recover.  This opinion, I prefume, extends only thus  far, that
 if they live, they always  recover  their  faculties, the diftemper
 proceeding from diforderedj functions and not from any organic
 difeafe'but; I have  Seen Several women die during their ma-
 niacal ftate, and  not  long  after the acceffion  of the diforder.
 Their death has Sometimes  appeared to be owing merely to the
 vehemence and continuance of their exertions."
  The time when this diforder appears is different, in fome ca-
 Ses a few days after delivery, in  others about a  fortnight or lon-
 ger,  in the manner before mentioned.  All women foon after
 delivery  are either more irritated,  or more fubjeft to irritation,
 than they perhaps are at any other time ; and hence,  chiefly,
 ard?etlie neceffary cuftom of keeping them quiet, and Secludin*
them, for a certain time, Srom the  chance of meeting with Such
 occurrences as might difturb them.  1 have  known more than
 one inftance of a lying-m  woman  ina  very irritable ftate,  but
 with perteft compofure of mind,  becoming at once derano-ed
 by fome fright or mifchief apprehended to herfelf or child,°or
 from Some diSmal ftory related to her; who might have efcaped, .
 had ffie been managed with circurhSpeftion.   It is impoffible to
 deScribe  how much of the prevention and  cure of thefe com-
 plaints depends on the judicious conduft, and proper manners
 of the attendants.
  As to the delineation or hiftory of maniacal diforders, under
 any circumftance, this does not feem neceffary, if it were prac-
 ticable ;  becaufe the name does not depend on a Symptom, or
 a fingle aft, unleSs  it were an outrageous  one  indeed ;  but of-
 ten upon the construction  of general and unufual conduft, va-
 rying in degree and outward form in every individual  patient.
 For thefe  reafons it is not furprifing, that in  Some cafes there
 ffiould be a difference of opinion as to the aftual exiftence of
the diforder, even among men ot  experience ; or that, on  the
 firft interview, it is otten impoffible to give an opinion, which
 could be fupported.  The difficulty of  deciding is alfo very
much increaSed, by the ^difference in the conduft of the patient
 at particular times ;  for even in very bad cafes there are gener-
 ally lucid intervals, or areafonablencfs except on certain fubjefts,
 when', the" diforder would not  be  fufpefted.   Yet it we  once
 conclude a patient to be maniacal, which we were unwilling to
 fuSpeft, and ftill  lefs willing to announce, a review of the   re- 
 27a           INTRODUCTION TO MIDWIFERY.

 ceding circumftances commonly exhibits pretty clear proofs of
 the gradual progrcflion of the diforder.
   On the attack of every complaint of this kind, from the ex-
 ertions ot the patient, and the tumultuous derangement of her
 mind, the pulfe becomes extremely quick, the general heat of
 the body is increafed, and there are in moft cafes the common
 fymptoms of fever, though  mania has  been defined a delirium
 without fever.   Nor, when  cafes become chronic, is there ever
 a time,* when  they are to be  Seen  without more or leSs of what
 might be called fever, efpecially in and after fits of outrage.
   Though there is Sufficient difference in the  general appear-
 ance of the patient in thefe diforders, to make it evident on the
 attack, that it is not, properly  fpeaking, feve%. Something like
 the  fame method of  treatment has  been judged neceffary.  It
 was formerly  the  cuftom, to enjoin the  ufe of very powerful
 medicines, and  very fevere treatment, for maniacal  patients,
 and among other  things copious bleedings.   But for women
 reduced in their ftrength  by the circumftances of childbed, more
 gentle proceedings are requisite.  Bleeding, it advifed in any
 degree, muft be performed  with  a Sparing hand ; for if there
 be a faft, of which I am  affured, it  is, that copious bleedings
 are  extremely prejudicial ;  not  abating  the diforder  even for
 the prefent, and, if the patient furvive, increafing and render-
 ing  it more deeply rooted and permanent afterwards.   Gener-
 ally fpeaking,  they fhould therefore be altogether omitted.  It
 is alfo becaufe they  increafe rihe prefent irritation, and have
 been found ultimately to do no  fervice, that blifters are Seldom
 recommended in thefe caSes.  The refiftance, which is often
 unwifely made  to  the harmleSs  wiffies  and inclinations of the
 patient, frequently becomes  a caufe of violent  outrage,  as has
 alfo been obServed in fevers attended with delirium.
   The intentions in the uSe oS medicines are, to remove all fev-
 erifh diSpofition, whether original or Symptomatic, and to leffen
 at the Same time the exceffive irritation.  For  theSe purpoSes
 it is ufual, to give the Saline draughts,  with a Suitable quantity
 of Syrup of white poppies, or a tew drops of laudanum, repeated
 as the cafe may require.  The Secretions being generally much
 interrupted, especially thoSe by the bowels, thefe muft be pro-
 moted by the occafional uSe of clyfters,  or of common  purgprnr
 mixture, fometimes by fmall dofes of calomel, fo as to procure
two motions.regularly  every day ; and in this ftate of the difor-
der no other medicines feem to be required.        4
   Immdiately on the attack, with many other alterations of the
 countenance, efpecially oi the eyes, eafijy obferved. but which 
ANOMALOUS, OR COMPLEX LABOURS.        873
 eannot be defcribed, the Skin has often a yellow tinge, and fome*
 times there is a complete jaundice.   It is then thought requifit*
 to give an emetic, not with the view of curing the diforder,
 but of relieving the fvmptom, and of  regulating the conftitu*
 tion, and this  muft  be  our guide  in all  medicinal treatment %
 for I believe the idea of any  medicine having the power of in-
 fluencing the  mind, except  by producing certain effefts upon
 the body, is wholly abandoned.
    In the more advanced and fettled ftate of the diforder,. there
 has been but one view, that is to abate irritability, though very
 different means have been ufed for this purpofe. In cafes of
 great  depreffion  of the fpirits, or  what  has gone under the
 general  name  of melancholy, gentle emetics have been much
 advifed, and I  think with great advantage, ever)-  other or every
 third day ;  and at the intermediate times,  nervous medicines,
 fuch as  the fpirit. at her   vitriol,  comp., confed. Dumccrat.,
 or the fetid gums; efpecially  the gum ammoniac and camphor,
 which Dr. Kinneir  recommended many years ago in ftronger
 terms than  experience  will juftify.  On occafional returns of
 great  preturbation and  violence, we muft recur  to the method
 ufed on the firft attack.
    Opiates  have been given  with two  intentions.  Some have
 merely  purpofed  to Soothe and moderate  the violence of the
 difturbance by the frequent repetition  of fmall dofes.   Others
 have aimed by the more liberal ufe of opium often repeated to
 fupprefs the irritability altogether.   As far as I can judge, the
 former method is tar preferable to the latter ; and I think there
 can be no doubt, but that opiates in large dofes, inftead of di-
 miniffiing,  add in no fmall  degree to the irritability, which be-
 fore exifted.   A phyfician of very great eminence obferved to
 me, that opium almoft univerfally excited difturbance, before it
 exerted its  quieting powers, but  that  other narcotics, cicuta
 for inftance, immediately afted by their peculiar quality, with-
 out raifing any previous difturbance.
    Among  many  other medjcines,  which have been recom-
 mended in the advanced ftages of  this diforder, it would  have
m been extraordinary,  if fome  of the preparations  of quickfilvef
* had not been  tried  ; and of thefe  calomel has had the prefer*
 ence.  It was  the favourite medicine in maniacal cafes, as long
 as I remember any  thing of  the profeffion.  By fome all  pre-
 parations of quickfilver have been thought to increafe, and by
 others to leffen irritability,  but the explanation of the opera-
 tions  of medicines  has very little forwarded the improvement
    Vol. II,                h I 
274           INTRODUCTION TO MIDWIFERY.
of the art; and I am not clear, whether the praftice of medi-
cine may not, even at this time, be juftly confidered as empiri-
cal, the excellence of the art chiefly depending on the fagacity
and judgment of each perfon who prattifes it, and not on any
fixed principles.
  Calomel has  ufually in thefe cafes been given as an altera-
tive, in dofes too fmall to produce any immediately evident ef-
feft, but repeated fo often as to make very material alterations
in the conftitution.  Sometimes it has alfo been given as an ac-
tive purge, the operation of it being fuppofed more efficacious
than that oi any other medicine of this clafs.   The caufes of
mania, or the effefts produced by it,  fpeaking of the diforder
at large, as has  been proved by the diffeftion of dead bodies,
may be widely different, and for thefe different medicines may
be neceffary and proper.  But in that fpecies of which we are
now fpeaking, it is not fuppofed, that any difeafe exifts in any
of the conftituent parts  of the body, but that it wholly proceeds
from difturbed aftion of the nervous fyftem ; and that we ffiall
probably fucceed the beft, not by aiming to cure a difeafe which
does not exift, or which is beyond the power of phytic,  with
very attive medicines, but by obviating Symptoms, which may,
in this cafe at leaft,  be faid to conflitute the difeafe.
  Throughout the courfe of the complaint ftrift regularity of
the nonnaturals is to be eftablifhed, fuch as the times of going
to, and rifing from bed, exercife, employment, if poflible times
of taking food,  kinds of food, and the like ;  and  above all  care
is ever to be taken,  that the patients,  in their fits of rage, be
prevented from doing mifchiei to themfelves or others.  From
a ftrift regulation of thefe matters, and from the eftabliffiment
of a mild, but firm and vigilant authority, it is probable, as much
advantage may be derived, as irom any medicine.


                      SECTION III.

  Of every complaint, to which women in  childbed  are lia-
ble, and which may require medical affiftance, it is not necef-
fary or poffible  here to take notice.  I  have therefore confined
myfelf to thofe, which feem of  the greateft confideration either
from their frequency or importance.   Of this kind is the puer-
peral  fwelling oi the inferior extremities, as it  may not  im-
properly be called.   This difeafe has been long ago and oiten
Mentioned by the French writers, moft commonly under the
name «f /' enfiure dcsjtmkcs ct dcs cuiffcs de Ufcmme accou* 
             ANOMALOUS, OR COMPLEX LABOURS.       2J$

cke'e ;  or that of, depot du lait, from its fuppofed caufe ; but
often with fo little accuracy, as to  make it difficult  to diftin-
guiffi,  what kind of fwelling they meant to defcribe.  By the
Germans it is uSually called the adema ledeum.   Though the
diSeaSe has  frequently occurred in this country, and has been
long underftood in praftice, the firft treatife upon it was pub-
lished by Mr.  Charles White oi Manchefter,  and foon after
another by Mr. Trye of Gloucefter.  As  might be expefted
from  men  oi their  abilities  and  eminence,  in each of their
works there are many things  deferving attention ; but as the
fubjeft  yet  requires farther inveftigation,  with regard to its
caufe, its hiftory, and method of treatment,  I ffiall offer the re-
fult of Such observations and opinions, as have occurred to me
on this diSeaSe.
  The puerperal fwelling oi the inferior extremities does not
feem to depend upon the kind of labour the patient may have
had, as it indiscriminately happens alter thoSe which were eaSy,
and thoSe which were difficult ; or on any  evident peculiarity
of the  conftitution, the corpulent and the thin, the feeble and
the ftrong, being equally  liable to it ; or on rank in life,  as the
rich and poor are alike fubjeft to it ; or on any mode of treat-
ment in the ftate of childbed.   Nor does any appearance during
pregnancy denote a difpofition to it, the fwelling of the inferior
extremities at that time  being a totally different complaint ;
but the whole difeafe feems to arife from  fome circumftance,
that occurs  aiter the delivery of the patient.   It is alfo remark-
able, which is a Satisfactory reply to thoSe who have attributed
this fwelling to the depofition oi the milk, that it has happened
to thofe who had an  abundance, or thofe who had a Scarcity of
milk ; to thofe who  did, or thofe who did not give fuck ; and
fometimes, though rarely, in  abortions, when no milk was Se-
ereted.
   Before the appearance oi any fwelling, or any fenfe oi pain
in the limb about to  be affefted, women become very irritable,
and grevioufly depreffed  in their Spirits, without any  apparent-
ly fufficient reafon, complaining only of tranfient pains  in the
region oi the uterus, and from thefe only the approach of the
difeafe has  frequently been foretold.  Atter a fliort time they
are feized, often very'fuddenly, with an extremely acute pain in
the calf of the leg,  extending to the infide of the heel,  and then,
obierving the courfe ot  the lymphatics, ftretching up to the
ham, along the internal part of the thigh to the groin, occasion-
ing a flight forenefs over the the  lower part of the  abdomen.
Then alfo the inguinal glands are affefted, fometimes the external 
S76           INTRODUCTION TO MIDWIFERY.
which are perceptibly enlarged, indurated, and.painful, and fome*.
times the internal, or both, and probably alfo, judging from the
fymptoms, thofe which lie at the bifurcation ot the veffels at the
loins. Except that I have not obServed the limb to be diScolourea\
or the lymphatics inflamed, and marking their courSebv aredneffc.
of the Skin (which we provincially call the anguiffi vein), the
firft  effefts of this difeafe very  much refcmble  thofe, which
would attend the abSorption of fome poifonous matter from the
lower part of the limb.  The whole  furface of the  fwelled
limb becomes infufferably tender to the flighteft touch or pref-
fure, efpecially in thofe parts where the glands are Seated ; yet,
without any  other  apparent change,  except that the fkin is
gloffy and of a deadly palenefs ; and a certain degree ot pale-
neSs, not unlike that of a chlorotic or dropfical perfon, is Spread
over the countenance and whole body, every vein Seeming  to
be Scantily Supplied with blood.   When the pain has continued
about twenty-four hours, the limb begins to Swell,  and the
pain is uSually abated in proportion to the  increaSe of the Swel-
ling  ; but from  the moment of the attack, all power of acting
with the limb is loft, every attempt to move it giving great tor-.
ture, and  a difpofition to faint.  There  are, however,  many
varieties in the  manner, in which the difeaSe commenceth, as
well as in its degree and progreSs ;  but the glands and lympha-
tics ot the limb are  evidently the parts firft and principally af-
fefted.  In fome cafes the accefs of  the difeaSe is flower, and
the fymptoms  leSs  violent, hefitating, as it were, whether it
fhould be formed or  not.   In  thefe the  pain is  not only lefs
fevere, but diffufed over the limb, inftead  of being fixed on
particular parts, and the fwelling fcarce  fufficient to draw at-
tention.
  This difeafe happens at no precjfe time after delivery, as it has
come on at any period, from the fifth or fixth day, to the third or
even fourth week, but moft commonly, I think, between the
fifth and twelfth day.  Whenever it does appear,  the whole
conftitution is fpeedily and greatly affefted by it.  The pulfe
\s extremely  quick and generally ieeble, the heat of the body
is much increafed, the tongue is  white and clammy,  and the
countenance pale and dejected ; the urine, which is voided in
fmall quantities, is  thick and of a muddy colour, unlike what
I have obferved in any other difeafe, the muddinefs gradually
leffening as the  difeafe abates ;  the patient is coftive, the faces;
being oi a pale  colour and clayey confidence; and the uterine
difcharges, whatever their quantity may be, have an offenfive
fmel!, and unnatural appearance. Jt is however to be obServed, 
ANOMALOUS,  OR COMPLEX LABOURS.        9yj
that this fmell and appearance do not always continue through
the courSe of the diSeaSe, but on inquiry will be found to have
exifted at, or fome days before, its commencement.
  Either or both  the  legs  may be  affefted together or fuc-
cefliely.  When the latter is the cafe,  the diSeaSe having re-
mained for a certain time in one leg, and the  fymptoms being
abated, the other has been fuddenly and unexpectedly feized.
Then the  fymptoms have recurred with equal violence, and
gone through a Similar courSe,  But thepatietlt having efcaped_
the danger before apprehended, though difconcerted, bears the
fecond attack, even if it be more fevere, better than ffie did the
firft.  Should  the  fecond  leg become  affefted, it is not by  a
tranflation of the difeafe from one limb to the other, the leg firft
affefted remaining  in the fame  ftate, and obferving the Same
progrefs as before the affeftion of the fecond.   When only one
leg is affe£ted there are, in fome cafes, occafional exacerbations
of the difeaSe,  after apparemjy confiderable amendment ; and
theSe  may render it neceffary to change the order of treatment,
or even to return to that which  was proper at the commence-
ment.
   After eight  or ten days continuance, according to its lenity
or violence, the more urgent fymptoms of this difeafe begin to
abate, but in many cafes very flowly ; the debility and oppref-
lion Sometimes remaining for feveral weeks, as the conftitution
is naturally more inert or  vigorous.  Though  all the other
Symptoms be removed, the Swelling may,  and  generally does
remain tor many weeks, or even months, and in Some very bad
caSes, the limb has never been reduced to its  primitive fize, or
recovered its wonted powers of agility and firmnefs, during the
patient's life.
   The conftitution feems  to be very much difturbed and en-
feebled at the beginning of the difeafe, and unequal to the due
performance oi its common  funftions, yet after a certain time
it feems to become local;  for the patients recover their health,
and often menftruate regularly ; but even this change has fel-
dom  afforded the expefted relief to the affefted limb.
   Though this difeafe often creates much and great alarm to the
patient and her friends, and always occafions  much pain and
Suffering, yet on the whole  it may be faid, that it is not dan-
 gerous.  I do not mean, nor ffiould I be juftified in faying, that
 it was never attended with danger ;  h?ving been informed  of
 feveral cafes,  and Seen one,  which proved fatal, where no other
 cauSe of the  patient's  death could be affigned  or  fufpefted.
 But  on the retrofpeft it appeared, that this might poffibly have 
878           INTRODUCTION TO MIDWIFERY.
been avoided* if more regard had been paid to the representa-
tions of the feelings of the patients ;  ior they were urged, at
leaft encouraged, to exert themfelves beyond their abilities and
inclinations, and funk immediately atter,  or  while they were
making fome great effort.
  From this defcription of the difeafe, the inguinal and neigh-
bouring glands feem to be the parts firft affefted, and the fubfe-
quent fwelling of the  limb to be  evidently occafioned by the
blocking up of atl paffage for the lymph through thoSe glands.
The pain  and  extreme  Sorenefs  oi  the limb,  which  are al-
ways Somewhat abated wlfen the  fwelling comes on, appear to
be  incidental,  and to be produced by the  diftention  oi the
lymphatic veffels ; fo that the Swelling Seems to prove that
thoSe, which were before over diftended,  are relieved, either
by the burfting ot fome, allowing the effufion oi lymph into
the cellular membrane ; or a Series of veffels of fmall  dimen-
fions are enlarged, by which thofe lymphatics, which  before
fuffered from  extreme  diftention, together  with the parts on
which thev made compreffion, are eafed.
  But it remains to be proved how it comes to pafs, that thefe
glands are originally affefted ; and this I ffiould endeavour to
explain by preSuming,  that, as the lymphatic veffels  of the
uterus and vagina are very much increafed in fize during preg-
nancy, they are more capable of abforbing any fluid, which
may come into contaft with their orifices ; and ii any fluid not
confonant in its qualities with that, which they  were by nature
intended to Convey, were to be admitted and condufted to the
gland, to which any particular lymphatic may lead, a morbid
affeftion of the gland might be produced, which would occa-
fion all the fucceeding mifchief.  Whether the internal  or ex-
ternal inguinal glands, or thofe at the head of the tnteps, or
any other, were affefted, will depend on the courfe of the lym-
phatic, which  had taken up the offending matter.
  It was before obferved, that the uterine difcharges have an
offenfive fmell, and unufual appearance.  Now it has been prov-
ed, that the moft healthy fluids of the body, perfeftly innocent
and unoffending to the part where they were  fecreted, may aft
as means ot great and morbid irritation, it transferred to a part
not originally  deftined to receive them ; that is, they may aft
in fome degree as poifons.   But in the prefent cafe,  the fecre-
tion being of a morbid  kind, as  far as can be judged by fmell
and appearance, the malignity of  its effefts may be aggravated.
I therefore feel Satisfied, that the  abSorption of  vitiated  matter
from  the uterus is the caufe of the fwelling of the inguinal 
          ANOMALOUS, OR  COMPLEX LABOURS.         279

glands.   Farther, if this abforbed matter  had not  been inter-
rupted by the gland, and thus prevented from fpreading over
the whole body, this difeafe would have  been infinitely more
dangerous; and this opinion is ftrengthened, not only by the
common confequences of acknowledged poifons when abforbed,
but by many Similar complaints frequently  met with in praftice :
as in the fwelling of the inferior extremities in men, when the
proftrate gland is affefted ;  in one or both legs, when the uterus
is difeafed ;  in the arm, when the axillary  glands are enlarged ;
and in many other cafes.   But the  changes in the  uterine dif-
charges,  which precede this diSeaSe, are not, it is apprehended,
like the changes produced by  the  retention  ot coagula, or of
fmall portions of the placenta or membranes, but they are con-
fequent to an unhealthy ftate or morbid aftion of the uterus.
  Having formed this opinion of the  caufe of this difeafe, and
reafoning by  analogy of its effefts, in the method of the treat-
ment, without aiming to cure the  difeafe  in the  firft inftance,
I take the fymptoms  for my guide', and endeavour to relieve
thefe by all the means in my power.   As the fenfe of extreme
weaknefs, and exeeffive irritability, are the moft prominent and
diftreffing, the patient is to be well fupported by  cordial me-
dicines, and  by a liberal  ufe of  Jvine ; not reftraining her to
any precife quantity, but leaving her  at liberty to judge what
that fhall be,  by the degree of depreffion which ffie Seels.  O-
piates are alSo to be given, to abate and Soothe the general irri-
tability of the habit, and together with theSe, Such medicines
as promote the Secretion by the  {kin and kidneys.  Por thefe
purpoSes I uSually give the following  draught.

     R   Aq. ammon.  acetat. j$fs.
       Syrup, papaver. alb.
       Spir.  nuc.  mof. a 511".
       Aq. ment.  Sat.
       —purae. a 3Ss. M. f. hauftus  quarta  vel Sexta quaque
         hora  fumendus.

   Should this fail  to moderate the fufferings of the patient,  a
few drops of tinfl. opii  may be occafionally  added to the
draughts, efpecially to ,that taken at bed-time, and the quanti-
ty of ammonia acetata  may be increafed, or pure  ammonia
may be given in fome cafes oi great depreffion.
   Perhaps the beft application to the Swelled limb is a liniment
compofed of one drachm oi camphor diffolved in an ounce of
oil oi olives  ; or fome of the cxpreffed oil of  mace  Softened 
&8o            INTRODUCTION TO MIDWIFERY.
down to a proper confiftence with a  fufficient quantity of oil
of almonds ;  and to either of thefe may be added from five to
ten grains  ot powdered opium.  The moft painful parts, or
the whole limb,  may be gently anointed with a fmall quantity
of thefe every night and morning, and afterwards covered with
a fmall  quantity of  thefe every night and morning, and after-
wards covered with  a loofe flannel.  By fuch means, fome re-
lief is ufually obtained,  though not  much permanent benefit ;
and they are preferable,  I think,  either to fpiritnous or to hot
fomentations, which,  without producing more advantage, are
apt to bring on profufe Sweating,  and great faintnefs.
  In  this ftage  of the  difeaSe, local  bleedings with  leeches,
and blifters applied  to the enlarged glands, have been  recom-
mended, as effeftual means of fpeedily curing the difeaSe by
removing the glandular obftruftion.   But if  my  opinion of
the caufe of the difeafe be juft, the hafty difperfion of the fwel-
ling of the glands,  if it could be effefted, though it might lef-
fen or wholly remove the fwelling of the limb,  would ultimate-
ly prove a very great  difadvantage,  by  allowing  the abfor-
bed virus  to efcape; and this pervading the  whole body, a
difeaSe primarily local would become  a general one of the moft
dangerous kind.   In the cafe of poifonous matter of any kind
abforded by a flight wound or abrafion ot the (kin of the hand
or fingers,  (an accident to which furgeons are particularly lia-
ble in their  diffeftions  and  operations),  the fwelling  of  the
neareft or fome  gland,  which cuts off the communication  be-
tween  the limb and the  body,  leads to the Security oi  the pa-
tient.   But if active and effeftual means be ufed to remove the
fwelling of the gland, the abSorded virus paffes  into the confti-
tution, and the  patient will probably be deftroyed.   It  was by
an error of this kind we loft Mr. Hewfon the celebrated anato-
mift, when he was  rifing into eminence, and many other de-
Serving  men, whom I recolleft, and  with whoSe caSes I was
well acquainted.
  With regard to the ftate of the bowels, though we are to be
circumfpe6t in preventing the inconveniencies of conftipation,
it is never  advifable to  purge, in  tnis  ftage  of the difeafe.
Their regular courfe may be obtained by the occafional  ufe  of
magnefia  vitriolata, or  any other  medicine of   the kind,
which will anfwer the purpofe,  and is leaft likely to difturb  the
ftomach.  Clyfters are not eligible, becaufe the change of po-
f.'.ion, which  they require, is  often  extremely difficult  and
painful.
  The great tumult  raifed on the firft  attack of the difeafe  be* 
 *         ANOMALOUS,  OR COMPLEX LABOURS.         s8l

ip.g appeafed, the quantity of wine and opiates may be leffened,
or they may be leSs frequently given; but in this we are to be
guided by the degree of  debility and  irritation  that lemains.
As a preventative* alSo, when the difeafe is threatened, a gene-
rous diet and wine are to be allowed, if the appetite of the pa-
tient will allow her to take nourishment.
  When the conftitution  is, according to the old mode of ex-
prefBon,  fortified, and the health Somewhat reftored, the fwel-
ling of the leg is to  be confidered rather as of a chronic, than
of an acute kind,  and all  reafonable endeavours may be ufed,
to difperfe it,  I have then given  the decodum cinchona or
cafcarilla,  with  a falinc draught, or the kali vitriolatum, or
magriefia vitriolata, or a  ftrong infufion of burnt fponge, two
or three times .a day,  and every night at bed time, half a grain,
or a grain of calomel, with br without anopiate.   In fome ca-
fes  I have ttiought  it more eligible to give  from three to  five
grains of calomel twice a week, with a purging, draught on the
following morning,- and fome of the draughts before mentioned
on the intermediate  days.   In other cafes the cryftalsof tartar
have been liberally giverrin any convenient form; or the cicuta.
with a decoftion of Jurf"a, arid various other things ufually ad-
vifed on  Similar occafions ; and whenever there  was much re-
mainingweaknefs, fome preparation ofciron, astheferrum vitrio-.
latum or  ammoniacle in fuitable dofes have been of much fervice.
  Then  alfo it is neceffary to fupport the  fwelled limb by a
flight flannel bandage drawn gradually tighter,  and to ufe dif-
ferent applications,  fuch  as the volatile liniment, or one com-
pofed of three  parts of  linimentum faponis, and  one part of
tindur,  cantharidum, and fometimes fmall quantities  of the
unguentufn  hydrargyri.   The frequent application  ot  fmall
bliffers to different parts of the limb  has been then  ftrongly ad-
vifed, and in many  caSes  with evident advantage.   Electricity
has been tried, but  of its real benefits I am  not compe:ent to
judge.    Certainly many  patients have-been much relieved by
perfeverirtg in the ufe or  warm fea bathing ; and ihey are to be
encouraged, but  with Some caution, to ufe exercife, otherwife
the deSuetudc will endanger their being crippled.   It may  laft-
ly be obServed, though Some women have been afflifted with this
Swelling  of one or other of the inferior extremities in feveral
fucceffive labours, in general they, who have had it in one la-
bour, are not more liable to it in  Subsequent ones, and are
Sometimes  relieved during their confinemet from the  confe-
quences  of a former attack.  And here I muft conclude.
FINIS, 
         INDEX

              TO

THE SECOND VOLUME.  '
A.
AaDOMEN, coldnefs of
.... binding the
.   .   .   . pain in, after delivery
.   .   .   . integuments of, tender J
.   .   .   . abfcefs in
Abortion      -
.   .   . treatment of
.   .   . circumftances attending
.   ,   . not often dangerous
Adhefions oi the vagina
After pains, caufes and treatment of
Age, advanced, caufe oi rigidity
Amulets       -      ^   -
Antimonial powder     -      •
Arm prefenting
Attachment of the placenta over the os uteri
B.
Bladder, ftone in the
Bleeding, women in labour
.  .   .  . in convulfions
Boom
Bowels, wind in
Breafts, flaccidity of
Catheters
Cawl, what
m	J	Page.
-	-	77
9	*39>	246
-	-	242
1 inflamed	-	243
• m	-	s6i
* M	-	M7
-	*«5i	. M7
•	-	x«53
-	•	158
•» •	-	38
•	-	240
•	-	18
•	-	48
•	-	*59
-	-	124
ds uteri	m	l53
. «.	„	34
*	-	H
•	•	204
•	-	64
•	-	241
m		77
m	—	34
'	(note) 8	
 
                          INDEX-
                                                   Page*
 Cefarean operation          -          -          -   103
       .   .  .  .  . method of performing          -   112
 Chamberlens         -        -        -             63
 Child, firft          -        -        -         -   17
       . bead of, uncommonly large, or too much offified   27
       . want of motion of the       -       -       -79
       . dead, figns  of        -        -         -   77
       .   .  . equivocal figns of         -        -    82
       . caufes oii death of        -        -           83
       . method of turning         -         -           134
       . evolution oi       -        -       -           138,
 Childbed, management of women in        -           235
-Cicatrices, in the vagina         -         -       / -   37
 Clyfters, utility oi         •         -       -       -    6
 Coldnefs of the abdomen        -        -        -   77
 Confumptive women          -         -              13
 Conftitution, weaknefs of       .".'..   "       "   l2
 .   .... wanting Sufficient irritability         -   i£
 Convulfions, puerperal         -         -              194
 ........defcription of       •       -   195
 ........caufes of                       196
 Convulfions, puerperal, figns  of         -         -   199
 ,.......method of preventing         -   201
 .   .   •   .  .  .   .   . treatment ot         -      (-   203
 ......  ,   .   . manner of delivering ir*       -   207

                           D,

 De Bruyn         -         -         -             63
 Deformity, general, effefts of        -                   17
 Delivery  by means of inftruments        -             ,55
 .   .   .  . management of women after       -       -   336
 Difficult labours         -                             1
'Difcharge, fcetor and ill appearance o£       -           80
 .   .   .   . of meconium      -      -                ib.
"DifeaSe, head enlarged by        -                  -   28
 Diftortion of the pelvis         -         -             t^
 Douglas,  Dr.  his account of ruptured uterus-         -   45

                            E,

 Edematofe fwelling of the head      »       -           8i
 Emetics in convulfions         -         -         -   205
 Emphyfema of the head        -        -         -   8i
 Enlargement oi the ovaria         ^4      -           40 
                         INDEX.
                                                    Page."
Eryfipelatofe tumour on the knuckles, wrifts, &c.     -    249
Evacuation of the meconium        -        -       -Ho
.  .  .   .  of the brain         -         -         -     88
Evolution of the child          -         -             138
Excrefcences oi the os uteri        -        -        -     35
Experience, method ot improving by                -      2
External parts, rigidity of         -                      23
Extraftion of the head        -       -       -            89
Extrauterine foetus          -      -       -           231

                            F.

Face inclined towards the pubes      -       -      -     29
.  .  . prefentation of                                    30
Fainting after hemorrhage         -         -            187
.....delivery.         -         -         • -    239
Fever,  preventing  the  proper aftion of the uterus in
  parturition         -         -                       14
      .  puerperal         -         -                   242
Fillet, account and  defcription  of         -         --    30
Fcetor in the  apartment of the patient                     79
      .  of the difcharges        *•   ■  ,                 80
Foetus, extrauterine         -      -       -  .      -    231
Forceps, various kinds oi         -                      57
        general  observations on          -          -     54
        rules tor applying         -                     ,57
         .   .  Sor ufing when applied        -            58
        application of, under various circumftances  -     61
        compared with the veftis         -         -     6j
      umbilicalis, fhortnefs of        «.      -           10
          .  .  .  divifion of         -       -       -11
              .  torn from the placenta      -          176
            .  .  defcent ot before the child         • -    222
Funis
                           G.

General deformity, effefts of                             17

                           H.

Head of the child, compreffion oi       -                 ib.
.......uncommonly  large, or too much
  offified         -         -                           27
.......difeafed         -       -       -     28
Head oi the child prefcnting with the arms      -      -     31 
                          INDEX.
                                                    Page.
 ......on leffening the         -              73
 ......edema and emphyfema of                81
 .   .   .  .  *  . operation of leffening       -      -    85
 ......extradting of the         -              89
 ......Separation of from the body         -   142
 ......left        -      .       .          243
 Head-ach after hemorrhage         -        -          188
 Hemorrhage depending on  pregnancy and parturition   146
 .....in abortion         -              ,  -   148
            . treatment of       -       -        -   151
 .....in advanced pregnancy        -       -   159
 .....danger of                   -              tb.
 .....ii om attachment of the placenta over the
   os uteri          -                   -          _   162
 .....danger of delay in      -       -          ib*
 .....manner of delivering  in       -       -   165
 .....from feparation of the placenta         -   166
 .....when (the  placenta is retained         *    ib.
 .....when the placenta is expelled or extrafted   184
 .   .   .  .  .as connefted with puerperal fever      -   2$6

                             1.

 Irritability, deleft of               -               •    ij
         . excefs of               -                   107
 HI appearance of the difcharges      -      -       -    80
 Inflammation, local      -        -       -        -    14
 .....ot the uterus  •                            244
 Inftruments, general reflections on      -       «     -    ,54
 .....uSed in leffening the head       -      -    85

                            L.

 Labium, tumefaftion of                                240
 Labours, difficult,,difinition of      -      -       -     1
 ......orders of          -                      3
 •*.....from inert or irregular aftion of the >
   uterus         -       -        _       _        -   ih.
 .  •  .  ,   .   . attended with fever       -        -    14
 ......from extreme rigidity      •       -    21
......"*from difproportion         -        -    25
......from difeafes of the foft parts        -    32
•......general obfervations on                 43
.  .  .  premature         -         m      m       -   95
.  .  .  preternatural       «      ~       .,        -   11,5 
                          LND£X.

 .......diftinftions of        -             ii£
 .   .  . with hemorrhage         -        -              145
    .  . with convulfions      -       -      -      ~  '  103
 .'.,.. two or more children        -          -    212
 .....a defcent of the funis        -         -    2,24
 Leg, fwelling ot         -         -                    275
 Leffening the head         -       -       -       "73
 Lives, comparifon o£          -          -              74

                           M.
                                        t  ■
 Mania leftea        -..--„          -    260
 Mechanical weight of the uterus       -                 7B
 Meconium,  evacuation of     -.       -      -      -    80
 Membranes, rigidity  of        '«.         -                7
 .....too edrly rupture of         -          -    19
 Milk, receffion of        -        -        m        .77
 Mind, its influence  on labours       -      *       -    16
 Monfters         -          -      -  N             .    228

                           o.     '

 Os uteri, oblique pofition of           '    -        m    20
 .  .  .   . extreme rigidity of       -      -            21
 .  .  .   .  excrefcences of        - ■        -        -    35
 . " .  .   . manner of dilating        •                  129
 Operation, Cefarean       -                       48,  103
 .......method of performing     -      -    112
 Ovaria, enlargement ot        -         -              40

 '   -                      P.

 Palfyn       -         -      -       -                 63
 Paffions, influence of, on parturition          _  -     _    16
 Pain in hemorrhage, a favourable Symptom      -     -    161
 Pelvis, original SmallneSs oi        -        .         -    24
 .  .  .  diftortion of       -      -       .         25,   139
 Perforation of the head       -              4-87
Plaoenta, manner of its Separation and exclufion       -  "  173
.  ,   ,  retention ot                                   17c
 ,  .   .  mode of extrafting       -                 .    178
   .  .  funis feparated from       -       _       -    183
Prefentation of the inferior extremities       -       -115
 ......arm         -         -          -    13a
Preternatural, labours          -          -          .    11(j 
INDEX,
*...».. figns of
*......firft order of
......  . fecond  order of
Pubes, face inclined towards the
Puerperal  fever
♦  .   .  .   .  treatment of
.  «...  diffeftions of

                           R.

Rhonhuyfen
Rigidity, labours rendered difficult by
•  .   .  of the os uteri
      .  of the external parts
Rupture, too early, ot membranes
.  .   ,  ot the  uterus

                           S.

Signs oi a dead child
.  .   .  .  convulfions
»  .   .  .  twins
Smallnefs, original,  of the pelvis
Spafm after delivery
Stone in the bladder
Steatomatofe tumours
Suppreffion of urine
Symphyfis, feftion of

                           T.

Titfing "
Tumours,  fteatomatofe
Turning, method of         -
Twins, figns of
.  .   . manner of delivering
»  .   . management of the placentae

                           U.

Urine, Suppreffion of
Uterus, infufficient  aftion of  -
Uterus, too great diftention of
.  .   . partial aftion of
   ,   . rupture of
 .  .   . mechanical weight'of 
                        INDEX,      -
                                                  Page.
     . cqntraftion of        -       -                I29
     , on medicines for moderating the action ot     -    131
     . introduftion of the hand  into      -        -    *75
     . irregular action of        -      -             ,79
     . inverfion ot        -      -       "          ,°9
     . inflammation of     -      -       ~      -    242

                          V.

Vagina, cicatrices in      -       *      -  ^.    *     37
»  .  . adhefions of      -      -       ~       "3"
Veftis, hiftory and defcription of              -          63
*  .   . different kinds of  < .      -        -             65
*  .   . comparifon of with the forceps       - .          6j
.  .  . manner  of ufing      -       -                 7°
Vomiting in hemorrhages  often beneficial       -    -   161

                          W.

Waters imperfeft difcharge of                            9
WeakneSs ot conftitution       -      -       ~    "    12
Wind in the bowels      -                       -   24*
Women,  consumptive       -       -                  *3
 .  .  .  management of in childbed      ,   -          235
EMD OF  INDEX TO THE SECOND VOLUME, 
 
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