THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID PUBUC HEALTH UBRABY Digitized by tine Internet Arciiive in 2008 with funding from IVIicrosoft Corporation littp://www.arcliive.org/details/compendioussysteOOdewericli COMPENDIOUS SYSTEM OP MIDWIFERY, CHIEFLY DESIGNED TO FACILITATE THE INQUIRIES OF THOSE WHO MAY BE PURSUING THIS BRANCH OF STUDY. UXUSTRATED BY OCCASIOKAIi CASKS. WITH MANY ENGRAVINGS. SIXTH EDITION, WITH ADDITIONS AND IMPROVEMENTS, BY WILLIAM P. DEWEES, M. D. ADJUNCT PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA ; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY ; MEMBER OF THE PHILADELPHIA MEDICAL SOCIETY ; OF THE ROYAL MEDICAL SOCIETY OF DENMARK, &-C. &-C. PHILADELPHIA : CAREY, LEA & BLANCHARD, CHESTNUT STREET 1833. EASTERN DISTRICT OF PENNSYLVANIA, to wit : BE IT REMEMBERED, That on the thirteenth day of (L. S.) January, in the fiftieth year of the indepenence of the United States of America. A. D.' 1826, Wilham P. Dewees, M. D. of the said District, hath deposited in this Office the Title of a Book the right where- of he claims as author in the words following to wit: "A Compendious System of Midwifery, chiefly designed to facilitate the In- " quiries of those who may be pursuing tliis branch of study. Illustrated by " occasional Cases. With tliirteen engi-avings. Second Edition, with Additions, " &c. By Wm. P, Dewees, M. D. Adjunct Professor of Midwifery in the Um- «' varsity of Pennsylvania, Member of the American Philosophical Society, "Sic. &c." In conformity to the act of Congress of the United States, entitled '« An act for the encouragement of learning, by securing the copies of maps, charts, and books, to tlie authors and proprietors of such copies, during the times therein mentioned," — And also to the act, entitled, " An act supplementary to an act, entitled, 'An act for the encovu-agement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such co- pies during the times therein mentioned,' and extending the benefits thereof to the Arts of designing, engraving, and etching, historical and other prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvatiia. PUBUC HEALTH TO G^eS® PHILIP S. PHYSICK, M. D. pnoFESson of anatomy in thf. university of Pennsylvania, f.tc. MY EARLY AND FAITHFUL FRIEND, THE SPLENDOUR OF WHOSE PROFESSIONAL REPUTATION IS ONLY EXCEEDED BY THE PURITY OF HIS PRIVATE CHARACTER, THIS VrORK, THE ItESULT OF MY INaUIRIES, OBSEUVATIONS, AND REFLECTIONS, ON AN IMPORTANT SUBJECT, IS AFFECTIONATFLY INSCRIBED, BY WM. P. DEWEES iviS752S4 CONTENTS, PAGE Introduction . . . • . . . 11 CHAPTER I. Sect. I. Of the Pelvis ....... 17 II. Of the Sacrum ...... 18 III. Of the Coccyx ....... 19 IV. Of the Ossalnnominata ..... 20 * V. Of the Separation of the Bones of the Pelvis . . .21 VI. Of the Deformity of the Pelvis .... 28 VII. Examination of the Pelvis . . . . .37 CHAPTER n. Ofthe Child's Head ....... 40 CHAPTER HI. Of the Genital Organs . . • . • . .44 Sect. I. Of the Internal Org-ans . ... . . 48 II. Of the Uterus and its Dependencies . . . .49 CHAPTER IV. Of the Efficient and Final Cause of the Menses ... 58 Sect. I. Of Lvmar Influence ...... 62 II. The General Plethora Doctrine .... 63 III. TojMcal Congestion ...... 65 IV. Final Cause "...... 68 CHAPTER V. Of Conception ........ 70 Sect. I. Graviditas in Uteri Substantia, or Graviditas Interstitialis . 72 CHAPTER VI. Of the Changes produced by Conception . • . .73 Sect. I. Tlie Membranes ...... 78 II. The Placenta . • • - .81 ni. Foetal Circulation ...... 83 IV. Of the Changes wliich take place in the Uterus from Impregna- tion . . . • • .85 CHAPTER Vn. Of the Developement of the Foetus ..... 89 CHAPTER VIII. Of the Action of the Uterus ..... CHAPTER IX. Of Displacements of the Uterus . , . ■ • 108 Sect. I. Of Prolapsus from Pregnancy .... JOS II. Retroversion of the Uterus . . • • 109 III. Ofthe Obliquities ofthe Uterus • .118 103 CONTENTS. CHAPTER X. Of the Term of Utero-Gcstation Cause of Labour . CHAPTER XT. CHAPTER XII. Of Labour ...••■ Sect. I. Of Rigors, &c. ..... II. Frequent inclinations to make water, Tenesmus, &c in. Affections of the Uterine System in particular a. Subsiding of the Abdominal Tumour b. Secretion of Mucus . c. Dilution of the Os Uteri . a. Contraction of the Longitudinal Fibres b. Contraction of the Circular Fibres c. Of the Simple Contraction . d. Of the Compound Contraction . e. Of the Tonic Contraction and its Effects /. Of the Spasmodic or Alternate Contraction, and its Effects CHAPTER Xm. The Manner in which the Os Uteri is opened CHAPTER Xn . Conduct during Labour . . • Sect. I. What may be necessary for the Child II. Unassisted Dehvery of the Placenta HI. Of Putting to Bed . IV. Of After-pams ... "V. Regimen during the Month, &c. VI. Of tl\e Lochia .... Excessive Lochia Vn. Attention necessarj' to the Child a. Of washing the Child b. The dressing of the Navel c. Purging off the Meconium, &c. . e?. Of the Retention of Urine . Vm. Of Food for the Child 128 147 169 169 170 172 172 172 174 175 176 176 177 177 178 180 185 190 197 198 198 205 209 210 213 213 213 214 216 218 CHAPTER XV. Of Natural, or Unassisted Labour 221 CHAPTER XVI. Of the Presentations of the Head Sect. I. First Presentation, and its Mechanism . II. Character and Mechanism of the Second Position m. Thu-d Position rV. Fourth Position V. < Fifth Position VI. Sixth Position 224 226 227 227 228 233 233 PART II. Of Labours, in which the child presents the Vertex, but rendered difficult or preternatural ....... 235 CONTEN'IVS. VII CHAPTEIl XVll. Causes of Prenatural Labours ...... 235 Sect. I. Of Flooding' ...... 236 II. Of Convulsions . . . • • .238 III. Of Syncopes . . . . • • . 238 IV. Of Hernia . . . . . . . 241 V. Of Obliquity of the Uterus .... 242 VI. Of Partial Contractions of the Uterus . . .242 VII. Of Compound Preg-nancy .... 247 VIII. Of Prolapsus of the Umbilical Cord, &c. . . . 248 IX. Of Too Short a Cord 248 X. Of the bad position of the Head, though the Vertex may pre- sent 249 a. Of the Bad Position of the Vertex . . 249 b. Of the Chin departing too early from the Breast . 250 c. Cases in which the Face Presents . . . 255 d. Presentations of the Head and Hand . . . 258 XI. Of Exhaustion ...... 260 XII. Of Hemorrhage from other parts than the Uterus . . 264 CHAPTER XVIII. Rules for Conducting a Preternatural Labour . . . 265 Sect. I. Position of the Woman for Turning .... 266 CHAPTER XIX. The Mode of Operating in Each Presentation of the Head . 272 Sect. I. First Presentation ...... 272 II. Second do. ...... 273 III. Third do. ...... . 273 IV. Fourth and Fifth do. .... . 274 V. Sixth do. ..... 275 PART III. Where it is necessary to use Instruments which do no injiuy to Mother or Child, .277 CHAPTER XX. Of the Forceps ...... 277 Sect. I. General rules for the use of the Forceps . . . 279 G, Of those which regard the Woman . 279 6. Of the Condition of the Uterus and Soft Parts . 280 c. Application, and mode of Action of the Forceps . 281 a. Of Compression ...... 292 h. Compression and Traction .... 294 d. Mode of Acting after Application . . 295 II. Recapitulation . . . . . . 296 III. General Observations upon the Forceps . . 298 CHAPTER XXI. Of the Specific Apphcation of the Forceps . . . . 300 Sect. I. a. Application in the First of these Positions . . . 301 II. h. Second .... 302 III. c. Third . . . .303 IV. £?. Fourth . . . 304 V. e. ■ Fifth . . .304 VI. /. Sixth .... 305 VII. g. Seventh . . .305 CONTENTS. CHAPTER XXII. Cieneral remarks on the Use of the Forceps, when the Head is above the Superior Strait ....... 306 CHAPTER XXin. * Of the Locked or Impacted Head ..... 308 Sect. I. Of the Causes, Signs, and Accidents of the Locked Head 309 n. Indications in the Locked Head .... 309 HI. Method of using the Forceps in the Locked Head . . 311 CHAPTER XXIV. Of the use of the Forceps in Face Presentations . . . 312 CHAPTER XXV. Of Presentations of the Breech ..... 3x5 Sect. I. Species of Breech Presentations .... 316 II. a. Mechanism of First Breech Presentations . . . 316 HI. b. Second do. . . . . 318 IV. c. Third do. . . . • ^^^ V. d. Fourth do. . 318 CHAPTER XXVI. Causes which may render Presentations of the Breech Preternatural 319 a. First degrees of Advancement .... 321 b. Second ditto ..... 322 c. Third ditto ..... 322 Sect. I. Position of the Child ..... 326 II. Size of the Breech . . • . • .325 III. Mode of bringing down the Feet in the first Breech Presenta- tions ....... 326 IV. Mode in Second Position of the Breech . . . 327 V. Third ditto ..... 327 VI. Fourth ditto . . . . 328 CHAPTER XXVII. On the use of the Forceps, when the body is delivered, and the head re- tained ....... 329 Sect. I. Cases proper for the Forceps .... 336 a. Mode of operating in First Case . . . 336 — Second do. . . . 338 CHAPTER XXVIH. Of the Presentations of the Feet ..... 338 Sect. I. Species of Feet Presentations .... 339 II. Preternatural Labours when Feet present . . 340 III. Mode of Acting in the First and Second Presentations . 341 IV. Third and Fourth do. . 343 CHAPTER XXIX. Presentations of t!ie Knees ...... 346 Sect. I. Causes which render Presentations of the Knees preternatural 347 II. Mode of Operating in Presentations of the Knees . . 348 CHAPTER XXX. Of Tedious Labour ...... 349 Sect. I. Of the M^ant of Contractile Force .... 350 II. Of Rigidity, &c. of the Soft Parts, as the cause of Tedious and pre- ternatural Labour ..... 353 CONTENTS. IX PARE Of the Species of Rigidity of the Os Uteri . . 360 Rigidity of the first Kind .... 360 V:ir. 1, . . . .360 2, . . . . 361 3, . . . . 361 III. Cicatrices, or other Imperfections arising- from Local Injuries, 364 Relative Rigidity . . ' . . ' . 370 IV. Tonic Rigidity; or Rigidity from the Premature Escape of the Waters ....... 371 Sect. V. and VI. Over-distension of tlie Uterus, and the Membranes too dense, as a cause of Tedious Labour . 373 CHAPTER XXXL Hsemorrhage from the situation of the Placenta over the mouth of the Ute- rus . ........ 376 Sect. I. Where the Uterus is but little opened, and is very rigid 389 II. When but little opened, but disposed to dilate . . 392 III. Opened to some extent, but very unyielding . . . 393 IV. Where opened to the same extent, but soft . . 394 V. Where fully dilated . . . . . .395 A case of fiital Haemorrhage at the Seventh Month of Utero- g-estation, from the Placenta being placed over the mouth of the Uterus, together with remarks upon it, and several other modes of treating Uterine Hemorrhage . . 406 VI. Causes of Uterine Inertia ..... 416 VII. Haemorrhage, before the Placenta is expelled . . 416 a, I. Where there is a partial separation, but the Uterus enjoy- ing some tonic power . . . .418 h. II. Where there is a partial separation, but the Uterus pos- sessing very little or no tonic power . . 419 c. III. Wliere thereis a partial separation of the placenta, while the remaining portion is too adlierent, and the Uterus contracts but feebly .... 423 d. IV. Where everything is as at III. except that the Uterus enjoys its full power .... 426 e. V. Where there is an entire or partial separation, but the Uterus in a state of exhaustion or syncope . 427 /. VI. Where there is either a pai-tial or complete separation of the placenta, and where the body and fundus ai-e in a state of Inertia, wliile the neck enjoys its tonic powers 430 Vm. Flooding after the expulsion of the Placenta . . 433 IX. On the means for preventing Flooding .... 435 CHAPTER XXXII. Of the Assisted delivery of the Placenta .... 439 Sect. I. Mode of Acting in Retention from want of Tonic Power . 440 II. Retention from too firm adherence .... 440 a. Mode of acting in this Case .... 441 III. Of the Delivery of the Encysted Placenta . . . 443 a. Mode of Operating in this Case .... 445 IV. On the enclosed and partially protruded Placenta . . 446 Mode of acting in each Case .... 448 V. Of tlie delivery of the Placenta, when the cord is broken, or is veiy feeble •■...., 449 a. The signs by which the Placenta may be detected . 450 b. Mode of acting in this case .... 450 CHAPTER XXXHI. Of Puerperal Convul-iions . . . _ 452 Cases ......... 457 CONTENTS. CHAPTER XXXIV. On the Inversion of the Uterus ...... 465 Cases ..... ... 486 CHAPTER XXXV. Of Twins, &:c. ....... 492 o. On the Management of the Placenta . . 502 CHAPTER XXXVI. Of Preternatural labours ...... 505 CHAPTER XXXVII. Of the Presentation of the Arm and Shoulder .... 506 Sect. L Of the Condition of the Uterus .... 512 II. Of the Situation of the Arm and Shoulder within the pelvis . 5t4 a. The Manner of Acting, jf the Child be living . 515 b. Of Spontaneous Evolution .... 516 c. Mode of Actijig, if tlie Child be dead . . 518 CHAPTER XXXVni. On Presentations, with the faUing down of the Umbilical Cord . . 523 CHAPTER XXXIX. Of the Rupture of the Uterus ..... 535 Gastj'otomy ...... 545 PART IV. On Deliveries performed bv Cutting Instruments, applied either to the Child or Motlier . ' . . - . . . 548 CHAPTER XL. Deformity of the Pelvis ....... 548 Sect. I. Of Turning in a Deformed Pelvis, as a means of saving the Child's Life 549 II. Of the Forceps in a Deformed Pelvis .... 551 III. Of Cephalotomy ...... 555 Observations, &c., on Elizabeth Sherwood's Case, as related by Dr. Osborn ...... 566 IV. Of the Cesarean Operation .... 572 a. Mode of performing it . . . . . 583 h. Treatment after the Operation . . . 589 V. On Premature Delivery ..... 592 VI. Section of the Pubes '.,... 600 Vn. Regimen ....... 608 CHAPTER XLI. Monstrosity and Accidental Deformity .... 613 CHAPTER XLH. Uncertainty of the Child's Death . . . . .614 CHAPTER XLHI. On the Secalc Cornutum, or Ergot ..... 615 INTRODUCTION. It has often been declared, that labour, being a natural act, ife did not require the interference of art for either its promotion, or its accomplishment; and, consequently, that when this becomes necessary, it only forms an exception to the rule. This view of the subject has had many followers; and has, from its influence, retarded, more perhaps than any other circumstance, the pro- gress of improvement in this most important branch of medical science. It so entirely comported with the theories of the fasti- dious admirers of nature; it so completely coincided with the feelings of those, whose supineness made them averse from in- quiry; so effectually apologized for ignorance; and so plausibl}'^ extenuated the evils arising from neglect, or the want of the proper and judicious application of skill, as to secure in its favour by far the greatest portion of the practitioners of Mid- wifery. Errors in premises must almost necessarily lead to errors in de- duction; hence, the too exclusive reliance on the powers of na- ture to overcome all the obstacles connected with parturition — hence the almost total disregard of the first, and most important principles in the art of midwifery ! These errors doubtlessly ori- ginated in ignorance; and were perhaps at first excusable from this cause: but how reprehensible do they become now, since the powers of nature are better calculated, and the resources of art better understood! In what light, then, should we view writers, who still inculcate such doctrines — teachers who make the whole art of midwifery consist, in doing nothing! Were the constitutional powers of the system, the physical conformation of the pelvis, and the size of the child's head, al- ways and undeviatingly the same; were the most favourable pre- sentation of the child, the best construction, and the most healthy play of the powers concerned in this operation, never to be as- sailed by accident, or complicated by disease — the opinions of those who contend for the supremacy of unassisted nature, would Xii INTRODUCTION. deserve much, and perhaps exclusive attention. But, it is too well known, that this never has, nor ever can, be the case; for the powers of nature must necessarily have their limits, and con- sequently the interference of art becomes sometimes absolutely necessary. I am very far from wishing to be understood, as advocating the indiscriminate interference of art during the progress of a healthy labour — it is the very reverse of my opinion, and of my practice ; I wish merely to insist, that nature is not competent to all exigencies. For in very many instances, when permitted to proceed without interruption, and is eventually able to effect her object, the sufferings of the patient, most probably, might have been ver}'- much abridged by the judicious interposition of skill. Of this, from long experience, I am entirely convinced. If this be true in the most healthy or practicable labour, how much more important does the judicious and timely application of adventitious aid become, when it is well known, that the devi- ations from healthy power and structure, are almost constant in their occurrence, and almost infinite in their variety. It is the knowledge of these aberrations, and the mode of obviating them when necessary, that emphatically declare midwifery to be a science — for it has, and must have, its principles; principles, that must not only be known in the abstract, but constantly employed; and it is the happy application of these fundamental rules, that makes one practitioner, superior to nnolher. I trust my last assertion will not be considered gratuitous; for if there be a difference in the skill of practitioners, which most certainly there is, it can only arise from a more perfect acquaint- ance with the rules which should govern; the extent of experi- ence; and the justness of deduction. But does not this declare there is something more to be learnt, than the bare exercise of patience? What practitioner has ever been eminentl}' successful, who has neglected the first principles of the art? He may be ex- tensively employed, and tolerably lucky, (for it is nothing more,) without a correct notion of either the structure of tiie pelvis, the mechanism of labour, or the powers of the uterus; but will ho be qualified to act where the first is faulty; the second obstructed; or the third impaired? will he not, in most instances where either of these conditions obtain, wait in vain for the all-sufficient exertions of nature? Experience, however necessary and important, is not alone suf- INTRODUCTION. Xlll ficient; a correct foundation must be laid, by the study of first principles; and with even these, the progress must be slow; since variety in labour, is so multiplied. It is only by a happy and well- balanced generalization, that the practitioner can arrive at prin- ciples; and it is but by judiciously acting upon these, that he can be extensivel}^ useful. I may safely appeal to the candour of al- most any practitioner, whether he has not admitted to himself, that had he been better acquainted with principles at a previous pe- riod of practice, he could have procured, in certain cases of labour, either a speedier termination of it, or a more fortunate is- sue — I am sure he will answer in the alFn-mative. Too much importance can easily be attached to experience alone; and though I consider it a sine qua non to the successful exercise of the profession, yet it becomes only decidedly useful in difficult cases, when it is based upon the fundamental principles of obstetrics. Without an acquaintance with these, every prac- titioner must act empirically; and this to the too frequent de- struction of human life. If he be ignorant of all that is essential to be known of the well-formed and diseased pelvis; or unac- quainted with the various ways the head may pass through it, he will be totally incompetent to act, when there is any material deviation from the healthy economy of labour. On the one hand, he may rashly suppose, there is no alternative but in the use of the crotchet, where a little address might have immediately re- lieved the patient by rectifying the error in presentation; and on the other, he may negligently and reprehensibly, wait for the successful operation of nature, until the patient expire. In making an estimate of the value of experience alone, I must admit that many pursue the safer plan in submitting the case to nature; for I confess that, in many cases of desperate appear- ances, she successfully overcomes the dangers that menace her; but this is only submitting to a choice of evils: while the well-in- structed practitioner would triumph over them by his skill, and spare nature this hazardous conflict. That in many instances we should be the silent observers of nature, is unhesitatingly acknow- ledged; but I must insist, and I am persuaded I shall be supported by every well-instructed accoucheur, that it requires no less judgment to determine when we should be so, than when it is proper to offer assistance, or to take the business entirely out of her hands. But the decisions of ignorance do not always result in an entire xiv INTRODUCTION. reliance upon the powers of nature; they sometimes, and this but too frequently, end in the contrary extreme — in these cases, there is, on the part of the practitioner, an overweening desire to aid her efforts; and his ill-directed endeavours, but too soon eventuate in a destructive subversion of her powers. To this we must attrib- ute the very many instances of injury that take place in the hands of the ill-instructed. Who has not witnessed a labour, which, had it been let alone, would have been but an ordinary one, as regards either duration or severity, converted into one of great hazard, and protracted duration? Can such mischievous igno- rance be too severely reprehended, or could it be too severely punished? What has he not to answer for, who shall permit a fellow creature to die, when a little address or knowledge might have saved her; or, what is perhaps still worse, who shall abso- lutely destroy her, by ill-judged and rude manoeuvres, under the specious pretence of relieving her, when the case should have been trusted to the powers of nature alone. Besides, the peculiar situation of our country, imposes a neces- sity upon every medical student, to become v.ell acquainted with the theory of midwifery; for every one almost must practice it, if he pursue the object for which he is educated. A change of manners within a few years, has resulted in the almost exclusive employment of the male practitioner. Tliis was mainly effected by a conviction, that the well-instructed physician is better cal- culated to avert danger, and surmount difficulties, than the igno- rant pretender: but how ill is this confidence repaid! a confidence which costs the female, so severe a struggle! Should they submit their welfare, nay their lives, to the ill-instructed practitioner, what security have they that they shall escape, without having entailed on them a permanent derangement of organ, or the per- petuation of a harassing, and loathsome disease? In whatever point of view we regard this subject, it must be highly interesting to the philosopher, and the philanthropist; shall it be less so, then, to the physician who should be both, and who is more immediately concerned in its influence? Shall it be a matter of indifference to him, who has almost the control of the future comfort and happiness of perhaps an extensive pop- ulation, and who shall become as it were, the arbiter of the lives of thousands? A man of very loose morality shudders at the idea of a single murder; yet an ignorant practitioner of mid- INTRODUCTION. XV wifery, may feel no " compunctious visitations of conscience" for a hundred, committed professionally, from ignorance. I hope to be credited when I declare, that the present work was not undertaken, without due deliberation upon the responsi- bility attached to such an enterprise: and that my aim most ho- nestly was, to be useful — 1 have endeavoured to make my expe- rience available to the interests of humanity; and, should I even fail to instruct, I feel a confidence, I shall not dangerously mis- lead. I have ventured to depart from common usage, in treating of the various objects belonging to my subject; but it is the method I have pursued for more than thirty years in teaching; and to me it appears the most natural. That is, to bring under one view all that may belong to any particular labour, or class of labours — whether natural, and to be trusted to the powers concerned in the operation ; or complicated, and requiring a departure from this rule; or when essentially bad. I make all the modes of treating it under the various circumstances which may affect it, follow each other without interruption. Generally speaking, I have followed Baudelocque's distribu- tion of subjects, but not rigorously; and to him I hold myself in- debted for nearly all I know: or, at least, his masterly manner of treating everything connected with this branch of medicine, has enabled me to comprehend at once, the seeming intricacies of obstetrics, and to profit by bed-side experience. I therefore can- not too earnestly recommend the study of his works to such prac- titioners, as well as the student of midwifery, who may not have profited already by his genius, and his long and well-tried ex-r perience. I occasionally, in the course of the present work, differ from this great man,; but when I do, it is doubtingly; and only when a careful examination of my own experience, has produced a con- viction, that it is correct so to do; accompanied, however, at the same time, by a regret, that I am forced to the alternative. I have added Plates, to represent the different positions of the head, that no embarrassment might follow from mere description. These I hope will prove as acceptable, as I am persuaded they will be useful. I have materially altered the arrangement of the present edi- tion, by removing from it all the Chapters which related to the diseases of women and children. My motive for this will be ob- XVI INTRODUCTION. vious, when it is recollected, I have written separate treatises on both these subjects, since the first publication of this system. I have also added several very important Chapters on subjects strictly obstetrical; together with several new plates, illustrative of the topics to which they have reference. In a word, I have attempted to make this present edition, deserving of the high pa- tronage this work continues to receive. COMPENDIOUS SYSTEM MIDWIFERY, CHAPTER I. Section I. — Of the Pelvis. 1. The complete knowledge of the pelvis, as well in its healthy as in its diseased state, is essentially necessary to the successful practice of midwifery. Had more attention been paid to acquiring an acquaintance with its natural, and its deranged dimensions by those who profess to practise this important branch of medicine, we should have had fewer instances of gross mistakes, and, of course, fewer victims. Without understanding the pelvis well, it is impossible that any one can safely give assistance where either the operation of turning, or the applica- tion of the forceps, is required, to terminate the labour; nor can the mechanisms of the various presentations be understood in their most simple forms, without a thorough knowledge of it. We hope then we shall be excused when we say, that no man should be trusted to practise obstetrics, who is ignorant of this important assemblage of bones. 2. The pelvis is that structure which is situated below the last lumbar vertebra, with which it is by one of its surfaces articulated ; and above the superior extremities of the thigh bones, with which it is connected, by means of the acetabula. It is composed, properly, but of four bones in the adult state, viz. on its posterior and inferior part, by tlie sacrum and coccyx ; and on the lateral inferior and anterior parts, by the ossa inno- minata. But in treating of this structure, it is useful and proper, 3 18 THE SACRUM. to consider its constituent parts, as eacii is composed of several others, to which appropriate divisions and names have been given; we shall therefore pursue this plan, as it has both pro- priety and utility to recommend it; and first, of Sect. II. — The Sacrum. 3. This bone has been sometimes called the false vertebrae, because it is a kind of continuation of the true; and because, in the foetal state, it may be divided into five portions. The union of these five pieces can readily be detected in adult age, b}^ four transverse seams. * Its general figure is triangular or pyramidal ; the base of which is upwards, and is connected to the last lumbar vertebra, by a cartilaginous intervention. The apex of the triangle or pyramid is below; and has the coccyx united to its extremity, by means of cartilage. It may be divided into four surfaces; namely, an anterior, posterior, and two lateral surfaces: its anterior surface is smooth and concave; while its posterior is very rough and convex; its anterior face is smooth, that no obstacles may be offered, or abrasions take place, by the passage of the child's head through the cavity of the pelvis; its posterior is studded with processes or eminences, to give greater security and surface to the various muscles that originate, and that are inserted on it; as also, to afford greater firmness of connexion to the many ligaments which aid in its union with the ossa inno- minata. Its lateral surfaces are rough or scabrous; and are covered in the recent subject with cartilage, by means of which they are united to corresponding surfaces, offered by the ilia. This bone is pierced on each side by four holes, which transmit the sacral nerves. There is also on its posterior portion, a canal, along which the spinal marrow is continued. 4. The manner in which the sacrum is set into the ossa inno- minata, is well calculated to give firmness and security to its • Velpcau speaks doubtingly of the number of pieces and lines in which the sacrum may be divided — why, we are at a loss to understand, as our impression is, that nature is uniform in tliis respect. He says, "sa face (the sacrum) anter- cure, plus ou moins concave, offre, au milieu, quatre on cinqfacettcs qiiadrangu- laires et uutant de Ugnes transversales." p. 3. Baudelocque makes but four lines, as it requii-es five pieces to give four lines when united. He makes but four holes for the transmission of the sacral nerves, whereas Velpeau makes five. It is true, that tlie upper portion of tlie coccyx unites witli tlie inferior portion of the sacrum, and thus forms an additional hole. In general, however, tliis is merely a notch in each of these bones, forming thus an imperfect foramen, for the transmission of the fifth nerve of the sacrum; but this hole is not proper i o the sacrum. THE COCCYX. 19 position; as it acts, in some measure, as a key-stone does to an arch: this arises from two peculiarities of form: the anterior part of this bone is broader than the posterior; consequently, enters like a wedge between the ossa innominata; this enables it to sustain without injury, any foi'ce that may operate from within, outwards: the superior portion is also broader than the inferior; and of course is placed precisely analogous to the key-stone of an arch, by which it is enabled to support the superincumbent weight of the body, &c. without yielding. We cannot fail to remark, how admirably this arrangement gives stability to the whole of the pelvic circle. 5. The union of the last lumbar vertebra with the base of the sacrum, is permitted to take, place in such a manner as to look over, and into, the superior opening of the pelvis, so as to form a promontory; and hence, it is called the projection or promon- tory of the sacrum. 6. The length of this bone is usually from four inches, to four and a half; its breadth is about four inches. Its thickness, if measured from the middle of its base anteriorly, to the extremity of the superior spinous tubercle on its posterior face, is very constantly two inches and a half; and we are informed by Bau- delocque,* that this measurement is so constant, that he did not find it vary a line in between thirty and forty pelves, the greater part of which were deformed. The concave form of this bone gives a hollowness to a greater part of its length; the depth of this in a well formed bone is about three quarters of an inch. Sect. III. — The Coccyx. 7. This appendage to the sacrum is also of a pyramidical form, and is about an inch and a quarter in length; like the sa- crum itself, it resembles an inverted pyramid; its bass being united with this bone by intervening cartilage: it is formed of three bony portions, whose connexion with each other is readi- ly observed by the transverse ridges which their union forms. Its connexion is such, as to permit of a regressive motion; es- pecially in the earlier parts of life. Lateral motion is prevented by the insertion into the sides of this bone, of the coccygaei muscles; of parts of the levatores ani; and portions of the sacro- sciatic ligaments. * System, page 18, par, 35. 20 THE OSSA INNOMINATA. Sect. IV. — The Ossa Innominata. 8. The other portions of the pelvis are made up of the ossa innominata; they constitute the lateral, anterior, and inferior parts of this cavity. Each of these is divided into three distinct bones by all the writers upon midwifery or anatomy; and there seems to be propriety in this separation; since they were origi- nally, or in the foetal state, distinctly marked as independent bones, though not so clearly defined, in adult life; and in the study of the pelvis, it will contribute to a more precise notion of its form and combinations. The os innominatum is then com- posed of the ilium, ischium, and pubis. 9. The iha form the highest lateral portions of the pelvis; and may with much propriety be considered as belonging to, and constituting a part of the abdomen, as well as of the pelvis pro- perly so called; the ilium is the largest of the bones now under consideration — its superior edge is nearly semicircular, and is almost always tipped with cartilage; this is called the spine of the ilium. It reaches down, and forms, with certain portions of the ischium and pubis, the acetabulum. The external surface of this bone is a little convex, and has been named dorsum; while its internal face is concave, and is called costa, or fossa of the ilium. There are four processes usually described as belonging to the ilium; namely, two anterior, and two posterior, spinous processes. 10. The broad, spreading part of this bone is divided from the lower portions, by a ridge which commences at its connexion with the sacrum; runs forward, and joins with a similar ridge, sent by the os pubis — this sliarp line marks the upper, from the lower boundary of the pelvis; and is called the linea ilio pectinea. 11. The ischium is the lowest of the three bones; and, like the ilium, forms a part of the acetabulum. From the posterior part of this bone, a sharp process runs backward, yet inclining towards the cavity of the pelvis, so as rather to diminish its ca- pacity; to this is attached, the internal sacro-sciatic ligaments; it then runs downward, and terminates in a tuber; into the in- side of which, the external sacro-sciatic ligament is affixed. From this tuber a bony process is reflected, which joins the os pubis. 12. The OS pubis is the smallest of the three bones which con- stitute the OS innominatum — its largest portion is employed in the formation of the acetabulum; it then diminishes in size; and stretches over, to meet a similar portion of the os pubis of the OF THE SEPARATION OF THE BONES OF THE PELVIS. 21 opposite side. It now becomes broader and thinner, and sends a branch downwards, to unite with the one reflected from the OS ischium. The mode of union of these bones is such, as to leave a considerable space between them, and this space is call- ed, foramen ovale, or foramen magnum ischii ;. which in the recent subject, is covered by a dense ligamentous membrane, and gives origin to the obturator muscles. Nerves and blood-vessels are transmitted through this membrane, by appropriate openings. 13. The ossa innominata are joined at their posterior, and central portions, to the sacrum, by rough corresponding surfaces; these are spread over by thin cartilage; and the union secured by strong appropriate ligaments. The anterior junction of these bones is called the symphysis of the ossa pubis; but the mode of union is different from that which connects their posterior por- tions — agreeably to Baudelocque, nature has paid much more attention to it, than to the other parts of the pelvis, by sending out, in addition to a proper quantity of cartilage, a number of short, but very strong ligaments, which give great security to the symphysis. Dr. Wm. Hunter has also given a very particular description of the mode of union of this symphysis, in the second volume of the Medical Observations and Inquiries. 14. As it is not in the power of everybody to consult, and study the pelvis from the natural one, it is thought important to give a figure of a healthy, well constructed one; that an idea may be formed of its general shape and connexions; and though not as satisfactory as the natural preparation, it will nevertheless give a pretty correct notion of it. (See Plates I. and II. ) Sect. V. — Of the Separation of the Bones of the Pelvis. 15. It would seem, from what occasionally occurs in practice, that the bones of the pelvis may separate, notwithstanding the especial care that nature has bestowed upon their union. This separation may take place in various degrees: from a simple relaxation of the connecting media, to an absolute separation. This accident may happen gradually; commencing almost with gestation, but not manifesting itself with much severity until after delivery; or it may occur suddenly during labour; or just when it is about to be finished. Fortunately for the female, it is a disease of rare occurrence; at least in this country; for we have met with but two decided cases of the kind in the course of our practice. 22 OF THE SEPARATION OP THE BONES OP THE PELVIS. 16. Were we to yield to popular belief, we should be obliged to grant, that nature had kindly studied the comfort and safety of the female, by endowing the ligaments and cartilages which connect the different portions of the pelvis with a capacity to yield to the impulses of labour, that the operation might not only be less severe, but safer. This opinion is coeval with medical record, and it has been sustained, not only by ingenious reasoning, but by an appeal to observation. The respectable names of Pineau and Pare are used in support of it among the more remote moderns; and Gardien, in our own time, yields to a belief of its advantage. While Baudelocque, Denman, &c. see nothing in this supposed provision, but misery to the female who may be the subject of it. 17. We may adduce the following reasons as conclusive against this relaxation being a natural provision — 1. It is certain, so far as can be determined by the dissection of women who had died during, or immediately after labour, that the symphyses were very rarely found to have yielded in the slightest degree. Baudelocque tells us, he sought for it twenty times in well- constructed pelves after laborious labours, as well as in distorted ones, without meeting with scarcely one, which could remove all doubts of its existence.* 2. That it is not more frequent in the distorted, than in the well-formed pelvis; now, were it an advantageous provision, it consequently should have been more certainly observed in the former. 3. Were it an arrangement of nature, the means do not seem adequate to the end; as it would require that the extremities of the ossa pubis should be separated one inch from each other, to gain two lines, or two- twelfths of an inch, in the antero-posterior diameter of the superior strait; an increase but very rarely sufficient to do good in a contracted pelvis; and unnecessary in a well-formed one ; as the latter is almost constantly larger than is absolutely neces- sary in ordinary labours. 4. That wherever it has been ascer- tained to have taken place even in a slight degree, it has never failed to create either temporary, or a permanent inconvenience; and, where extensive, the most serious evils, and even death, have followed. IS. Various causes have been assigned for this relaxation or separation of the pelvic bones: 1. Serous depositions in the * System, vol. i. pur. 55. OP THE SEPARATION OP THE BONES OP THE PELVIS. 23 cellular meshes, or interstices of the connecting media. 2, Tumefaction of the cartilaginous extremities of the ossa pubis. 3. The child in transitu acting like a wedge on the bony circle which bounds the upper strait. 4. Mechanical violences, as falls, blows, instrumental delivery, &c. 19. When mere relaxation exists, the symptoms, though pretty permanent, are not so violent, as when there is a separation. A painful tottering walk, with a greater or less inability to stand, and more especially on both feet with equal firmness, mark very certainly this condition of the pelvis; and this is sometimes detected even before labour. When it happens during labour, it is always attended with a painful sensation at the relaxed part, together with an inability to exercise the auxiliary powers con- cerned in this operation. This latter circumstance is worthy of notice; as it would seem to decide at once, that this yielding is not intended to benefit parturient women. When the injury is greater, and a real separation has taken place, it has been found, that it is by the destruction of the ligamentous tissue which connects the bones, and thus permits them to retire further from each other than mere relaxation would have done. When it is the symphysis of the pubes which suffers this accident, an entire separation of the cartilaginous epiphysis from the extremity of the OS pubis takes place; for agreeably to Baudelocque, no power is capable of breaking the ligamentous substance which connects these two bones. 20. When this last condition obtains, it is usually followed by a melancholy train of evils— pain, inflammation, suppuration, caries, gangrene, and death. 21. The mode of treatment of these evils is reduced to great simplicity, though far from equal certainty— the indications are: 1. To reduce the parts as nearly as possible to their natural po- sition, and to secure them thus as effectually as possible. 2. To obviate inflammation and its consequences, as far as may be practicable. 3. To relieve pain. 4. To give strength at a proper time to the system generally. . 22. The first indication must be fulfilled by the proper application of bandages; and we are of opinion, that the simple calico roller is as effectual as any of the more complicated machinery contrived for this purpose. It should be applied as high as the cristas of the ilia, and a little below the trochanters 24 OF THE SEPARATION OF THE BONES OF THE PELVIS. of the thio-hs — its length should be so ample, as to secure a num- ber of turns round the parts; and it should be drawn sufficiently tight to fulfil the object for which it is applied. The patient must be confined to a horizontal position, and employ her lower extremities as little as possible, at least in the beginning of the plan. 23. The second indication must be answered by blood-letting, leeching, or cupping; a very abstemious vegetable diet must be insisted on; and the most perfect quiet observed; the bowels should be kept free, but the effects of brisk purging must be doubtful — this plan should be persisted in, until fever is subdued; then the course may be changed as in any other case, to a more generous diet, or invigorating regimen. If it run on to suppura- tion, it must be treated throughout its consequences, as any other abscess should be. 24. The third indication must be fulfilled by the proper exhi- bition of opium, in its various forms. 25. The fourth must be complied with, by the judicious ad- ministration of tonics; as bark, sulphate of quinine, &c. &c. and by the daily use of the cold bath, where there are no contraindi- cations to render its use improper. 26. I believe I am justified in saying, that women may very effectually recover, when the symphyses have suffered from mere relaxation of their ligaments; but I fear we have but little reason to hope for an effectual cure, when the bones have been denuded of their cartilages, though the situation of the woman, by proper treatment, may be made comparatively comfortable. 27. As the derangements either of separation, or of relaxation, of the pelvic symphyses are of very rare occurrence, I hope I shall be excused, for giving at length the cases communicated by Dr. A. J. Nicholson, in " Vol. iv. p. 452, of the Transactions of the Association of Fellows and Licentiates of the King and Queen's College of Physicians, in Ireland. 28. Dr. N. says, " It appears from the extensive observations of the most eminent accoucheurs in Paris, Vienna, and Dublin, that this disease is of rare occurrence. In the following case, the woman, after a natural delivery, did well to the fourth day, when she complained of an inability of moving her limbs. 29. " On making inquiry, she informed me, that while at the fire she felt sick, and fell off the low seat on which she was sit- OP THE SEPARATION OF THE BONES OF THE PELVIS. 25 ting. The nurse tender had left her, and when she returned she found her fainting on the floor. When she recovered she was quite unable to afford herself any assistance. 30. " In the course of the fifth day she was seized with fre- quent rigours, so violent as to shake the entire bed; and she complained of excruciating pain at the end of the os pubis, and along the course of the left thigh. The fainting and rigours re- turned to such an excess, that I found it necessary to remain with her. Wine and other stimulants were given, which soon alleviated these distressing symptoms. Her stomach, however, was at times much disturbed; and she was tormented with noise in her ears, and constant sneezing, which greatly aggravated the pain at the pelvis. 31. "To relieve these unpleasant sensations, she took the black drop in large doses, which agreed extremely well with her. I at first tried opium, but it caused very unpleasant sensa- tions when she closed her eyes, and kept her in a constant state of terror. 32. " On putting the finger over the symphysis, at its edge cre- pitation was distinctly perceived; a tumour was also observed on each side of the sacrum on examining it particularly ; the tumour was hard and circumscribed, and about the size of a hazel-nut. 33. " Whenever she was moved, the pain was so agonizing, that she said they must be tearing her asunder. I communicated to the family my opinion, that the ossa pubis had separated, and requested a consultation. In the mean time, I ordered her to be kept in a state of rest, and applied a firm broad bandage around the pelvis, from which she experienced the greatest relief, and found herself more comfortable than any time since her con- finement. A solution of muriate of ammonia was applied to the tumours on the sacrum: they did not cause any considerable in- convenience, and were soon removed. 34. " For nearly six weeks she remained perfectly well in her health, and easy in her bed, except when she attempted to move or turn on either side, on which occasion she always suffered the most violent pain. She could stretch her feet downwards, but could not draw them up again; she found relief from leaning forwards, and placing her elbows on her knees; and when that position became irksome, she returned to her usual one on her back, when she always felt easy. About this time she men- 4 26 OF THE SEPARATION OF THE BONES OF THE PELVIS. struated, and though much benefit was expected from this cir- cumstance, yet no alteration took pltice in her complaint. 35. " A gentleman of considerable experience in midwifery, {Dr. Beatty,) saw her in about ten weeks from her confinement; and, after a very careful examination, we found the internal parts in their natural situation, and free from disease. The perinseum was not lacerated, nor was there the least appearance of injury about the external parts ; but on considering the seat of the pain, and the inability of moving her limbs, there could be no doubt that the symphysis of the ossa pubis had separated. The broad bandage was continued, with cold applications to the seat of the pain. A bandage, to keep the knees together, was also suggested by Dr. Beatty, and adopted. 36. " In the course of conversation, after it continued for five months, the circumstance was related to a medical friend, who stated that he had a case somewhat similar, though more aggra- vated, a few years before. 37. "In that instance it appeared that for several days before labour came on, she suffered much from pain and weakness in her back, and a total inability of moving herself, which caused her labour to be unusually severe, as she was unable to render herself any assistance. A crackling noise could be distinctly heard at several yards distance, and not only were the pelvis and sacrum separated, but the disease seemed to have extended to the functions of all the bones of the pelvis. 38. "Many medical men of eminence were consulted, and a variety of medicines were exhibited. Bark, wine, muriate of lime, carbonate of iron, tincture of iron, and every other remedy that could be thought of. At the end of seven months no improve- ment whatever had taken place, and her situation being truly deplorable, he determined on using the shower-bath, the good effects of which were soon apparent; for in a few weeks she was able to walk on crutches about the room, and in two months to go up stairs, which to a person so affected, was an operation of no little diificulty. In three months she was fully restored to the use of her limbs, and has had a living child after a tedious but natural birth. 39. " I immediately communicated the result of this case to my patient, who agreed to do willingly whatever I proposed. A partial shower-bath was contrived; and before the expiration of a month, not only great relief from pain, but much benefit OP THE SEPARATION OP THE BONES OP THE PELVIS. 27 was experienced; for she was once more able to pull on her stockings, and draw up her feet. 40. " About two months after, she expressed a great inclination to try to walk, which I have often since regretted was not agreed to. She continued, however, free from pain, and in good health until December, (just twelve months from her confinement,) when, contrary to my wish and opinion, she was moved to her husband's house, as she had been confined at her father's. 41. " She was put into a chaise, but whether from the motion of the carriage, or the confinement in which she was obliged to be in, during two hours, I cannot say, but all the unpleasant symptoms returned, accompanied with great pain, and the crackling of the pubis. 42. " At this period I gave up my attendance, as I did not ap- prove of the proceeding. She was put under the care of another practitioner, who, I understand, employed counter-extension, to keep, as he termed it, < the opposite sides of the pelvis in oppo- sition.' This was contrived by keeping her upper and lower extremities fastened to the bed-post; but it caused such jDain, that she refused to endure it any longer: and matters having become much worse, I was requested to renew my attendance. I found her quite resigned to her situation, but without any hopes of re- covery, to which she had so patiently looked forward. I per- suaded her to return to the constant use of the shower-bath and belt, both of which had been much neglected. 43. <'I visited her at Easter, and staid with her two days; and was satisfied from close observation, that she was in a fair way of recovery. She was playing with her child on the bed, and she turned herself in various directions without making any complaint; and her sister, who slept with her, told me that she had often turned on her side in her sleep, without experiencing any bad effect the next morning. I contrived a little carriage for her, in which she could lie lengthways, and which was easily wheeled about the garden. The delightful sensation she expe- rienced on once more breathing the fresh air, after being confined nearly eighteen months, may be readily conceived. A pair of crutches were procured, and directions given, if she should have any inclination to stand or walk, to allow her to make a trial. 44. '-1 had a letter from her about a month ago, in which she gave me the pleasing intelligence, that she had either walked, or shufiled half across the room, and felt no pain from the exertion; 28 OF DEFORMITY OF THE PELVIS. and every subsequent account confirms the pleasing prospect of her complete recovery." Sect. VI. — Of Deformity of the Pelvis. 45. Every departure from the healthy dimensions of a pelvis, either by excess or diminution, is considered a deformity — I shall therefore first state the admeasurements of the different por- tions of this cavity, as generally agreed upon by writers, before I proceed to the consideration of such alterations as may justly be considered as deformities. 46. The diameter which runs from the superior part of the symphysis of the pubes to the projection of the sacrum, in a well-formed pelvis, is rather more than four inches; while the one running from side to side, a little exceeds five inchesj and the one traversing the pelvis diagonally, from behind one of the acetabula to the union of the os innominatum with the sacrum, is nearly the same. The first of these is called the antero-posterior diameter, or small diameter of the superior strait; the second, the transversal or great diameter; and the third, the oblique, which is also properly considered the great diameter. At the inferior part of the pelvis, or the lower strait, the measurements are nearly the same, but reversed — that is, the great diameter of this strait runs from the inferior edge of the symphysis pubis, to the point of the coccyx, allowing for the regressive power of this bone, and is usually rather more than four inches. The small diameter of the lower strait, is from the tuber of one ischium, to that of the other; and is about four inches. From this it will be seen, that the great diameter of the lower strait, traverses the great diameter of the superior strait at right angles — this should be constantly borne in mind. 47. It must also be mentioned, that not only the diameters of the superior and inferior straits do not coincide, but, that their axes are also very different, owing principally to the curvature of the lumbar vertebrae, the promontory of the sacrum, and the retiring of this bone very considerably backwards. 48. The deviations from the standard measurement, are so numerous, that it would be almost impossible to enumerate them, were it even useful; I shall not therefore descend to such detail, as it would fatigue the memory, without benefiting the under- standing. I shall content myself with pointing out only such OF DEFORMITY OP THE PELVIS. 29 variations as shall be practically useful; or such as would require a difference in the mode of terminating the labour. 49. Deformities of the pelvis consist, first, in an access of size in the diameters of this cavity; and, secondly, in a defect of them. The first presents scarcely any obstacle that is not sur- mountable by common means; as a precipitation of the uterus within the pelvis during gestation is the chief evil, occasioning some inconvenience or embarrassment to the flow of urine, the alvine discharges, and the locomotion of the woman; during parturition, a too rapid labour, threatening the escape of the uterus with its contents, from the os externum; and after the birth of the child, giving rise to a profuse and alarming haemor- rhage, by the uterus being too suddenly emptied, by the hasty ex- pulsion of its contents. 50. The first of these inconveniences may be remedied by the application of a proper-sized pessary — the second may be in a great measure prevented by a judicious management of the case during labour: 1. By forbidding the woman to bear down during pain. 2. By opposing the too rapid escape of the child, by press- ing firmly against it with the fingers within the vagina, so as in some measure to counteract the influence of the pains, if the uterus be but in part dilated; and if fully dilated, by making a firm pressure agaiflst the perinseum with the extended hand, so as to allow of the more gradual passage of the head. The third, may be at least very much diminished, by brisk frictions upon the abdomen, immediately over the uterus; by a proper manage- ment of the placenta; and by the immediate exhibition of twenty grains of the powdered secale cornutuni. 51. That departure from the standard pelvis, (4G) which con- sists in a diminution of its principal diameters, is much more common, and much more serious in its consequences, than the one I have just considered: for the difficulties are increased in proportion almost to the deviation from the healthy proportions just enumerated. 52. The most common cause of the distortions of the pelvis, is rachitis in infancy and childhood; and of malacosteon, itj the more advanced periods of life. The former of these diseases hinders the proper consolidation of the bones; and thus exposes them to the influence of any pressure that they may be subject to, during its continuance. This being the case, it will be very readily understood how a pelvis shall receive injury while labour- 30 OP DEFORMITY OP THE PELVIS. ing under this disease; for on it is exerted, the weight of the body from above, when the child is either sitting or standing; this carries the projection of the sacrum still more forward; while the acetabula serve as fulcra to the lower extremities, when it is standing on its feet, and thus obliges the yielding bones to re- tire towards the sacrum; hence, in some extreme cases, the ap- proximation of these parts is such, as to leave but a very few lines of opening between them. 53. It rarely happens that every part of the pelvis is equally affected by rickets; and when it is not, the consequences will be different, both in degree, and in location. Sometimes, but one side will have suffered by this extraordinary disease; while the opposite shall be free from all complaint, and preserve its original healthy conformation — at others, it is still more partial, and only affects one small part of this cavity — while again, every portion of it seems to participate in the derangement; then the consequences become most lamentably serious. The upper strait is generally the most injured, and that almost constantly in the direction of its antero-posterior diameter ; leaving the transversal one as large, and'sometimeseven larger than usual; and the inferior strait sometimes without blemish. 54. When the inferior strait is defective, it is usually in the direction of its small diameter; this is affected by the approxi- mation of the tubers of the ischia. It may also be faulty in several other ways — 1. By the spine or spines of the ilia looking too much inward. 2. By the symphysis pubis being too salient. 3. By this symphysis being too long. 4. By the processes of the ossa pubis running down in too perpendicular a direction. The healthy depth and form of the pelvis may be injured in various ways — 1. By the sacrum being too strait. 2. By its having too great a curvature. 3. By the coccyx looking too much upwards. 4. By this bone losing its regressive motion, by being anchylosed with the sacrum. 55. But as every degree of deviation does not render labour impracticable by the natural agents of deliver)^ at full time, it will be well to fix the boundary, which the practitioners of Eu- rope of the greatest experience have affixed for it. It seems to be pretty generally conceded, that a labour cannot be successfully terminated, when there is less than three inches in the antero- posterior diameter of the superior strait. When a pelvis has three inches, or even three inches and a half in this diameter, OP DEFORMITY OF THE PELVIS. 31 the labour is rendered for the most part tedious, painful and uncertain.* We hear of some remarkable cases, however, of children being born alive, when there have been but two inches and three-quarters from the pubes to the sacrum; but these must constantly be regarded as exceptions to the general rule; and require, that it may take place, an unusual suppleness in the bones of the cranium. t See Baudelocque, &c. 56. I have appealed above to the experience of the European accoucheurs for the datum, that labour at full time is imprac- ticable, when there is less than three inches in the small diameter of the superior strait — I do this, because I believe, that the united experience of all the American practitioners, would not have led to a correct conclusion on the subject; as the occur- rence of deformity of pelvis in this country is so very rare, as never to have been even encountered by some practitioners of pretty extensive experience. And as far as regards my own, I must declare, that I have not met with extreme deformity in American women, three times in my life; and when it has occurred to such an extent, as to render labour impracticable by the natural powers, it has uniformly been with European women. J 57. Rickets, among the children in this country, is so rare, that practitioners of considerable practice have declared to me, they have not witnessed a case, — nor is this to be much won- dered at; since the remote causes of this disease are rarely present. Our population, even in our largest cities, is not crowded like those in many parts of Europe. That we have many poor, must be confessed; but even that poor enjoy com- paratively, a purity of air, and a wholesomeness of diet, unknown to many of the same class in Great Britain, or in many parts of the continent of Europe. Very little, indeed, of our population, live under ground, or very thickly crowded together. They are not impacted in confined manufactories, nor exposed to many * This can be easily understood, when it is recollected, that the ti-ansversal diameter of the child's head (82) very rarely can be reduced to less than three inches, with impunity; consequently when this diameter measures more than three inches, or the antero-posterior diameter of the pelvis measm-es ratlier less, the labour must always be protracted, and dang'erous to the child. t The French measure is rather more than the Eng-hsh; that is, the French inch is thu-teen lines English. A line is the twelfth of an inch ; consequently two inches three-quarters French, make three inches within a fraction, English. + In this I am happy to find myself supported by the testimony of Professor James, in a note affixed to his edition of Burns' Midwifery. Note k. p. 35. 32 OF DEFORMITY OF THE PELVIS. of their deleterious operations. It is a rare occurrence, if even our beggars do not I'egale themselves daily, on more or less of animal food; and certainly the population with us, which would correspond with the common manufacturers of Europe, are for the most part, sufficiently, nay, oftentimes, abundantly supplied with it; hence, our general exemption from rickets, and of course our freedom from its consequences. 58. I have said above, (53), that when a pelvis is injured in its proper proportions, it is almost always in the small diameter of the superior strait. Dr. Denman, however, declares it to be always in this diameter, when this strait is faulty, and never in the direction of the great one; but in this I must differ from this experienced and respectable practitioner; for it was my chance to meet with two instances of this kind in practice, as well as to be in possession of a natural pelvis, where the diameters at the upper strait are reversed. Besides, Baudelocque admits the fact, though he says it is very rare. 59. One of the cases alluded to above, occurred to me within a few years, and, as it is one of some interest from its rarity, I will relate it. On the 18th March, 182-4, at 9 o'clock, A. M. I was called to Mrs. , in labour with her seventh child. She had been complaining during the whole of the previous night, but the pains did not become efficient in her estimation, until about the time I was sent for — at this time the pains were very slow, but pretty forcing. Upon examining per vaginam, the os uteri was found but little dilated, much tumefied, but not rigid. As there was no immediate necessity for my presence, 1 took my leave, desiring the nurse to send immediately, should any change take place before my intended return. 1 saw her several times during the day, although no alteration had taken place, in either the force or frequency of her pains. At about 10 o'clock, P. M. of the same day, I was again summoned, in con- sequence, as the nurse said, of her having had several pains nearer each other and ^^ smarter.'''' Upon a second examination every- thing was found pretty much as it was in the morning — in the course of two hours more the pains became more frequent and urgent; and the os uteri was found more dilated, but still tumid; the head of the child still very high up, indeed, was scarcely to be felt. Two hours more were unprofitably employed, in the hope of the advancement of the head; thinking it probable that this. did not take place, because the membranes were entire, and ap- parently more than usually rigid, I ruptured them and gave OP DEFORMITY OF THE PELVIS. 33 issue to a very moderate quantity of liquor amnii — the head did not yet descend, as was hoped, though more within reach; and as the pains were now rather brisker, without manifestly advan- cing it, I was induced to examine into the cause of the delay more particularly. Upon a careful search being made as regarded the pelvis, it was found that the point of the cocc)'x looked very much up into the pelvis; and the projection of the sacrum could not be felt by the finger; it seemed to retire unusually far poste- riorly; the sides of the pelvis could be easily traced at the upper strait; and on the anterior portion of the pelvis, immediately behind the symphysis of the pubes, two fingers could be intro- duced with their breadth between it and the child's head. The head of the child was found to occupy completely the transversal diameter of the superior strait — it now occurred to me, that this was an instance of deformity, in which the transverse diameter was injured, and which of course produced an increase in the antero-posterior diameter ; and that the head being placed trans- versely above, could not enter the strait in that direction. With this in view, I introduced my hand, and placed the head in such a manner as to make the posterior fontanelle answer to the pubes, and the anterior to the sacrum, and then withdrew it. Twenty grains of the ergot were now given, with a hope that the pains would follow each other more quickly, as well as be ren- dered more powerful — but the first pain after this, made the head descend to the lower strait, and four more delivered it — there was a little delay with the shoulders, but they followed the second or third pain. 60. This lady, though tlie mother of six children previously, never had had an untoward accident from this peculiar conform- ation — but her labours she represented as having alwa3-s been very tedious and severe — four hours of extremely hard pains was the shortest period she had ever known, after she found herself what she called " to be in earnest." 61. During the existence of rickets, the child is constantly exposed to doing itself mischief by almost any position it may take; if it be placed on its feet, two powers are acting to this end; the weight of the body upon the sacrum from abov^e, and the pressure of the heads of the thigh bones upon the acetabula from below; producing either moderate or extreme deformity, as the disease may be more or less severe, or as the patient may be more or less disposed to exert its lower limbs. In sitting, the 5 34 OF DEFORMITY OP THE PELVIS. weight of the body is sustained by the tubers of the ischia, and the point of the sacrum ; hence the latter may become too much curved, and the former be made to injure the length of the pro- cesses of these bones, as well as those of the pubes, and thus do mischief to the arch formed by these bones. If carried in the arms too constantly, the whole of the lateral portions of the pelvis may become injured by the pressure of the nurse's arms. 62. To guard against these evils, Baudelocque* suggests a very important practical direction; which is, to keep the patient as much as possible in a horizontal posture, and to permit him to exercise his little limbs freely by sprawling upon a bed or mat- trass. 63. Injuries arising from malacosteon are more rare, but not less grievous than those from rickets — of the former 1 have never witnessed an instance. Mr. Burnst says the women of manufacturing towns are particularly obnoxious to it. It begins very soon after delivery, and very frequently during pregnancy- and is comparatively rare in women who do not bear children, and is always hurried in its progress by gestation. Hitherto, no remedy has been discovered capable of arresting its progress, or preventing its occurrence. He recommends to such women as are afflicted with it, to live " absque marlto." 64. The pelvis may also be injured by exostoses and tumours, which may give rise to either very difficult, or even impracticable labour — of the former I have witnessed but one case, and that occasioned a rupture of the uterus ;t of the latter I have never had the misfortune to meet with a single instance. They are occasioned in some instances by enlargements of the ovaria or glands; or they may consist of some adventitious substance within the pelvic cavity. They are said to be often movable when of the ovarian kind; and fixed generally when of the other. They are found to have but cellular attachments; and are of easy re- moval, by making an incision through the vagina, and evacuat- ing the contents of the tumour. There is a kind, however, which either adheres by a pedicle, or has a broad base; these can only be rem.oved by deep cutting, and are, for the most part, cartila- ginous. 65. Mr. Burns has laid down the following practical rules for * System, page 61, par. 92. f Principles of Midwifery. James' edition, p. 34. :}: See Essays on Subjects connected witlv Midwifery, by the Author, p. 75. OF DEFORMITY OF THE PELVIS. 35 the government of those, whose ill luck may put them in pos- session of such cases — 1st. "Whenever the tumour is movable, it should be pushed above the brim of the pelvis at the com- mencement of labour, and prevented from again descending be- fore the child." 66. 2d. " That we should never permit the lal)0ur to be long protracted, but early resort to the means of relief." 67. 3d. " As it is impossible to decide with certainty on the nature of the contents of many of these tumours, we should in all cases, where we cannot push them up, try the effects of punc- turing with a trocar. If the contents be fluid, we evacuate them more or less completely ; if solid, we find the canula, when with- drawn, empty, or filled with clotted blood; if fatty, or cheesy, the end of the tube retains a portion, and we are thus informed of its nature." GS. 4th. " When the size of the tumour cannot be sufficiently or considerably diminished by tapping, I am inclined, from the unfavourable result of cases where the perforator has been used, and from the severe and long-continued efforts which have been required to accomplish delivery, to recommend the extirpation of the tumour, rather than the use of the crotchet. There may, however, be situations where the incision ought to be made in the vagina; but these are rare. But extirpation cannot in any mode be proposed, if firm cohesions have been contracted be- tween the tumours and vagina or rectum." 69. 5th. "If the extensive connexions, extent, or nature of the tumour, or danger from heemorrhage, prohibit extirpation, or the patient will not submit to it, and it has been early ascer- tained that tapping is ineffectual, I deem it an imperative duty to urge the perforation of the head, or extraction of the child, as soon as the circumstances of the case will permit." 70. 6th. " Much and justly as the Caesarean operation is dreaded, it may with great propriety be made a question, whether in extreme cases, that would not be less painful, and less hazardous to the mother, than those truly appalling sufferings which are sometimes inflicted by the practitioner for a great length of time, when the crotchet is employed; whilst it would save the child, if alive at the time of interference. I am aware that it may be objected to this opinion, that in those cases, the tumour being softer than bone, the same injury will not be sustained, as if the soft parts had been pressed with equal force, and for the same 36 OF DEFORMITY OP THE PELVIS. time, against the bones of a contracted pelvis, and that, in point of fact, recovery has taken place, though the strength of two able practitioners were exerted and exhausted during several hours; but such an instance cannot establish the general safety of the practice." 71. 7th. " It is scarcely necessary for me to add, that there may be different degrees of encroachment, which admit of the safe and successful application of the forceps, and of this matter we judge by the size of the tumour, and the capacity of the pelvis."* 72. This subject is highly interesting to the accoucheur; and I would refer, for farther information, to the chapter from, which the above is derived; and where a number of important refer- ences are made, to various authorities for cases, illustrative of the views of the gentlemen into whose hands they fell. It is a matter of much moment, in the event of meeting with such a case, that we should be well acquainted with the best mode of treating it; for however rare such instances may be in this coun- try, they certainly may occur; and to be ignorant of the resources of the art upon such an occasion, would be a reprehensible want of information. In addition to the case related by Mr, Burns, we subjoin the following highly interesting as well as important operation, from Med. and Phys. Jour. Vol, 13th, p. 178, 73. " An account of two cases of tumours in the pelvis, grow- ing out of the sacro-sciatic ligament, one of which terminated fatally, and the other was cured by extracting the tumour through an incision made into the cavity of the pelvis, through the peri- tonaeum, by P, P, Drew, M. D. Fermoy, county of Cork. 74. ' of a living child." Fodere, Vol. 2. p. 183. •'In 1638, a woman was delivered of a child, one year and thirteen days after the death of her husband. She suffered with severe labour pains one month previously. The child's head was without fontanelles. The faculty of Leipsic declared it to be legitimate." Valentin's Pandects, Vol. 1. p. 142. "A man died on the 2d of December, 1687, after being eight days in ex- tremis,- 16th of October following, his wife was delivered of a son. The faculty of Geissen declared it to be legitimate." Ibid. "Le Seur was struck with apoplexy. May 14th, 1671, and died on the 16th. His wife had not been pregnant during the six years of their marriage. On the 11th of the succeechng September she declared herself pregnant, and on the 17th of April, 1672, (eleven months and four days after his illness,) she was deliver- ed of a son. The relatives of the husband contested its legitimacy, and obtained a decree in their favour, but on appealing to the parliament of Rouen, the cause was decided in favour of the widow, on the score of the goodness of character, and on the possibihty of protracted gestation. The following case is related by Heister : — A woman was delivered thirteen months after the death of her hus- band; the individuals interested, were about to contest the legitimacy of the child, but were deterred from it by the excellence of her character. So con- vinced was one Christopher Misnerus, who had acted as shopkeeper during her widowhood, that he married her shortly after, and had two children by her, and each of them was born after a gestation of thirteen months." " Duhgnac testified, that his wife with two children went thirteen months and an half, and with a third eleven months. La Cloture also gave an opinion in favour of the widow, and quoted several similar cases from his own observa- tion." " Charles , aged upwards of seventy -two years, married Renee, aged thu-ty years. They were married nearly four years without having issue. On the 7th of October, 1762, he was seized with fevei^ and violent oppression, which remained until his death. The last symptoms were so severe, that he was forced to sit in his bed, nor could he move without assistance. In addition to these, he was seized with dry gangrene of the leg on the 21st, and with this accumu- lation of disease he gradually sunk, and died on the 17th of November, aged seventy-six years. Renee had not slept in the chamber during his illness; but about three and a half months after his death she suggested that she was pregnant, and on the 3d of October, 1763, (within four days of a year since the illness of her husband, and ten months and seventeen days after his death,) she was delivered of a healthy, well-formed, and full-sized child. The opinion of I.ouis was asked in this case, and he declared the offispring was illegitimate." The above cases, notwithstanding Dr. Beck's scepticism, appear, (with the exception of the last,) to be well-attested instances of prolonged gestatioK. The 140 OF THE TERM OF UTERO-GESTATION. arisen in error, that scepticism must appear unavoidable," p. 298. ^'This reasoning," says Dr. Beck, "appears to me to carry great weight, and Mahon, in his chapter on this subject, adds several sensible remarks in confirmation of it. He observes, that 'if the doctrine be true, that the children of old people are longer in coming to maturity, it would have been confirmed by experience, which it is not.'" Now, we cannot perceive anything very profound in this observation; on the contrary, we think it is marked by much oversight — for it is contended, by the opposers of the doctrine of protracted gestation, that there is no absolute certainty of the moment at which conception takes place, as the stopping of the menses is not a guide; or, at what period the woman may quicken, as that differs in difterent women, and at difierent times in the same woman; consequently, there may be much error in their calculations; yet, with no better data, Mahon insists, "that if the doctrine be true, that the children of old people are longer in coming to maturity, it would have been con- firmed by experience." 359. We would ask, how could this have been confirmed by experience, if they would not rely upon the only data they could possess? For the same objections must attach to the means, and mode of calculation, in both instances; and if they be rejected in one case, they must in the other. first case, from Bartholin, is particularly in point, and well wortliy of considera- tion. To us, it appears a little sturdy on the part of Dr. Beck, not to have given a little more credit to the cases and authorities, he has so liberally quoted. Had he have done so, it might have saved the expression of contempt, for those who differ in opinion with him in tjjis point, contained in the following advice to them. " I recommend to those who intend embracing tlie doctrines of protract- ed gestation, an examination of the following case. If they can satisfy tlieir minds respecting it, all difficulties on this subject will vanish. The husband had been absent four years, at the end of which period, the wafe brought forth a child. She pleaded that her conception had taken place through the force of imagination alone — 'utmulierper fortem imaginationem putaverit, se in in- somniis rem habuisse cum marito, atque sic concepisse.' The parliament of Grenoble, to whom this case was referred, declared the offspring legitimate. " — Metzger, p. 416. Schkgel, Vol. 2, p. 148. Had Dr. Beck confined his ridicule to tlie above, and a few other cases, almost as preposterous and incredible, we should have been better pleased with his mode of treating this subject; for it is not into the truth of such stories that we mean to inquire ; nor from such vague testimony, that we mean to draw our inferences. OF THE TERM OP UTERO-GESTATION. 141 360. '< Grief also, and the depressing passions, are much relied upon, as possessing a delaying power; but certainly these are more apt to produce abortion, than protracted gestation." We do not know the fact, but we are persuaded from these last observa- tions, that Mahon was not an accoucheur of experience; for had he been extensively engaged in the practise of midwifery, he could not have failed to observe that ''grief and the depressing pas- sions," have " a delaying power;" and that they do not dispose to abortion. Passions and emotions of the mind, have this ten- dency when in excess; but " grief and the depressing passions," have not. On the contrary, it is in strict conformity with our experience in a considerable number of cases, that they have a delaying influence. 361. "That the menses in married women may be suppressed not only from disease, but from affections of the mind, or acci- dental causes, which do not immediately impair the health, while the increase of volume in the abdomen may originate from this, or from numerous other causes." 362. We have admitted, that the disappearance of the menses, is by no means to be exclusively relied upon; but when the stoppage shall correspond with the period of quickening, a pretty near estimate may be formed. And it may be proper to observe, that when the menstrual discharge fail in the married woman, hitherto healthy and regular, the presumption, that it is arrested by pregnancy, is strengthened ; especially, as when this happens from either disease, or "affections of the mind," it is rare for impregnation to take place during the continuance of the suppression. 363. "If this doctrine be allowed, how shall we distinguish a delayed child from one that is born at nine months; and by what means are we to detect fraud in such cases?" 364. With the difficulties which may be presented to the me- dical jurist by these cases, we have nothing to do. In our opi- nions, the fact of prolonged gestation is established beyOnd con- troversy ; and this being so, it rests with those who have the set- tlement of the question, to find out the respective marks, which may distinguish each case. 365. " Certainly, as far as we can judge from the narratives given, the infants born after protracted gestation, were not dis- tinguished for size, or other appearances of maturity." 142 OP THE TERM OP TJTERO-GESTATION. 366. This declaration is at least at variance with the opinions of Mauriceau, Lamotte, and Orfila ; as well as with that of Dr. Hopkins, who gave evidence in the Gardner Peerage cause. See " Minutes of the Medical Evidence," &c. by Dr. Lyall, p. 71. 367. And were " the infants born after protracted gestation not distinguished by size or other appearances," it would not militate in the slightest degree against the doctrine; as we are of opinion, that the tardy developement of the foetus, may be one of the causes of delayed gestation. 368. We were at one period opposed to the doctrine of pro- tracted gestation; for we had adopted that of the immutable na- ture of this operation, as regarded duration. But the case already- referred to, (321,) convinced us that the period of nine calendar months could certainly be exceeded by at least thirteen days. This led us to a careful investigation of the subject, and which has resulted in the entire belief, that the commonly fixed period may be extended from thirteen days to six weeks, under the influence of certain causes or peculiarities of consti- tution. 369. Nor do we feel disposed to abandon this opinion, by all the ridicule which has been heaped upon it ; nor from the appre- hension that our cherishing it will have the slightest tendency to subvert good morals, or to offer inducements to the wicked and designing, to practise upon either the credulity of husbands, or the good faith of friends. The checks to impositions of this kind, are both certain, and numerous ; and they would not fail to be employed against the attempt. 370. We have upon record several remarkable histories of modern date; in addition to those already noticed, which seem to establish beyond doubt, that human utero-gestation may very much exceed nine calendar months. And as they are not within general reach, it may be acceptable to the reader to have them presented. 371. Case I. A woman, aged twenty-seven years, though much emaciated and very weak, in the month of October, 1820, had all the symptoms of pregnancy. About the middle of the fifth month she began to feel the motions of the child, and at the end of the ninth felt the precursory pains of labour. The OF THE TERM OP UTERO-GESTATION. 143 surgeon, who was called, found the pains weak, and the os uteri not much dilated, though sufficiently so to allow him to feel that the vertex presented. In consequence of the extreme weakness of the patient, she was treated with permanent and diffusihle sti- muli, and with so much advantage, that at the end of six weeks she had regained the appearances of health, and had returned to her ordinary occupations. 372. A few days after the coming on of the pains, the motions of the child became weaker, and eventually ceased. The size of the belly diminished, and the child appeared turned to the left side. The menses appeared in the tenth month, and returned re- gularly afterwards. In December, 1821, Mr. Penker was called into consultation, and advised forcible delivery, which was not consented to. In Octobex, 1822, he found the os uteri above the symphysis pubis, inclined obliquely half an inch to the right side, with the fundus to the left. 373. The posterior surface of the uterus had descended so low in the pelvis, as not to be more than an inch and a half from the orifice of the vagina; and was not thicker than a double sheet of paper. The back and feet of the child could be felt through the abdomen. Such was the state of the patient in March, 1823, up to v/hich time, she had refused to submit to any operation. The relator of this case promises the sequel at some future time. 374. The translator of the above history has favoured us with the following remarks upon it. "Although this case is described as a uterine pregnancy, there are some circumstances connected with it, sufficient to suggest a doubt on that point. If not extra- uterine, there is every probability, that it is an instance of retro- version, continuing through the whole period of pregnancy, an occurrence often mistaken for the real extra-uterine case, as has been fully proved by Dr. Merriman in his ingenious essay on that subject." 375. It would have afforded us much pleasure, and perhaps equalinstruction had the 'translator" favoured us with the points of resemblance between this case and an extra-uterine concep- tion; or, between it and a "case of retroversion continuing through the whole period of pregnancy." For as regards our- selves, we do not see the slightest resemblance to either of his supposed cases. 144 OF THE TERM OF UTERO-GESTATION. 376. It could not have been an extra-uterine case, because we are distinctly told, that "the os uteri was not much dilated, though sufficiently so as to permit him, (the attendant,) to ascer- tain that the vertex presented." That settles this part of the question. 377. As regards its resemblance to a case of retroversion at full time, it is equally out of the question. 1st. Because up to the ninth month, there is no symptom recorded, that would lead to the suspicion that this accident had taken place. 2d. Because, up to this period, the os uteri is not said to have been out of its na- tural or ordinary situation; on the contrary, it is distinctly stated that the attendant was able to pass a finger into, and to determine it was a vertex presentation. 3d. Because there is no mention made of a tumour occupying the posterior and inferior portion of the pelvis; nor a single symptom to lead to the suspicion of such a case, even after the ninth month. 378. We are told that the patient had been " weak and much emaciated;" but was relieved of both, by the use of stimulants ; is it probable that stimulants would have improved the condi- tion of a patient who was labouring under a permanent retrover- sion of the uterus? The only circumstance in the history of this case which could lead to the supposition of its being one of re- troverted uterus, was, that Mr. Penker found the os uteri above the symphysis pubis; but this was twelve months after labour- pains had appeared and ceased, and nearly as long after the qui- escence, if not the death of the child. 379. Again, Mr. Penker speaks of iha jjoste7nor surface of the uterus being no thicker than a double sheet of paper. If it were a retroversion of the uterus, how could Mr. Penker have felt it? and especially as this part is represented to be so much stretched by the head of the child. For this part must be behind the vagina in a case of retroversion. Moreover, he expressly states, that the head of the child had descended very low in the pelvis, and but an inch and a half from the os externum. 380. Were this even admitted to be a case of retroversion, it could only have become so, after the death of the child, and after the belly had diminished in size. But to put this question to rest at once, we are told that " the back and feet of the child could be felt through the abdomen." Now, it is impossible that these circumstances could obtain, and be a case of retroversion at the OP THE TERM OF UTERO-OESTATION. 145 same time. Indeed we arc inclined to believe that Dr. Merri- man himself, in a siilisequent edition of his work, will not select this case, to support his hypothesis. See Essays on various subjects connected with Midwifery by the author; in which he has ventured to offer strictures, upon Dr. Merriman's opinion upon this point, p. 291. 381. Since the above was written, we have met with the his- tory of a case, so analogous to the one just related, and w^hich dissection proved to be a uterine pregnancy, as to leave no doubts upon our minds, that the case of Mr. Penker was one of a similar kind. This case is one of great interest; inasmuch, as it shows the very extraordinary indifference of the uterus at times to foreign bodies within its cavity, (for we must look upon the child and its appendages as such, after they have parted with their vitality,) after it has made unsuccessful attempts for their removal at the last period of utero-gestation. We will relate the case as concisely as will be consistent with its impor- tance. 382. Mrs. A. H. aged twxnty-nine years, became pregnant about the first of April, 1822. She was much afflicted at various periods of gestation, with spasms of the stomach and vomiting. She quickened at about the fourth month. After this period, her spasms, &c. were less severe; but new evils supervened; such as pains in the hips, loins, back, &c. About two weeks before the expected period of labour, she was attacked with the usual symp- toms of this process. These continued for ten hours, and then subsided; from this time no motion of the child was felt. 383. LS22 "March 1st. — She was attacked with phlegmasia alba dolens, in one limb. The disease having left this soon seized upon the other. During the first and second week of this attack, she had a discharge from the vagina, resembling the catamenia. At times this was fetid; the os uteri was closed; no portion of the child could be felt. The abdomen very tense." 384. " About the 20th of March, she began to recover; and soon was able to walk some distance without fatigue. From the 1st of April, convalescence was rapid. The tumefaction of the abdomen began to subside; she appeared to be as large as at the seventh month." 385. "June 10. — Catamenia; health good; further subsidence of the abdomen. November, 1823. — Nothing remarkable occur- 19 146 OP THE TERM OP UTERO-GESTATION. red up to this time. Abdomen nearly to its natural size. A small tumour of the shape and size of a child's head remains. Two weeks after the supposed death of the child, milk was secreted, and continued in small quantities until October." 386. "April 10th, 1824. — She was attacked with pain, vomit- ing, cough, &c. and continued in this way until the 24th of May, when she died." 387. Dissection. — " Upon opening the abdomen, the uterus was discovered to be very much thickened, and presented the appearance of having been inflamed, and to have suppurated. It adhered closely to all the surrounding parts, and organs. Anteri- orly, it was united intimately with the peritoneum, and in this way with the abdominal parietes. An incision was made through the anterior face of the uterus and a full grown fcetus was disco- vered." New England Journal, No. III. vol. XIV. 388. It would be difficult, perhaps, to find two cases so strongly resembling each other in most of their leading and material points, as these just related; and the latter, most satis- factorily proves, that a uterine pregnancy may continue very much beyond the ordinary period assigned for gestation. In this case, as well as the former, the material points were sub- stantially the same. 389. First. At the usual period for gestation to terminate, labour pains commenced, and continued unavailingly for some time. 390. Second. In neither case were the pains renewed, after the first attempt was made by the uterus to relieve itself; and the motion of the children ceased at about the same period. 391. Third. There was a regular return of the catamenia in both instances, some time after the cessation of pain, and in both, an amendment of health after this period, for a certain duration. 392. Fourth. In both instances, the abdomen gradually dimin- ished in size; but in one, a tumour resembling in feeling, and in size, a child's head, was perceived through the abdominal parie- tes; in the other the back and feet of the child were to be felt. 393. Now, in the latter case, there was full as much reason for considering it an instance of extra-uterine pregnancy, or a retro- version continuing until full time, as the other; and would have been so looked upon, perhaps, by the gentleman who translated the former case, had not dissection settled the point. CAUSE OP LABOUR. 147 394. How the first case may eventuate we can only conjec- ture; it may end with safety to the woman, should the uterus so far regain its natural susceptibilities and powers, as to throw its contents off per vias naturales; or inflammation may ensue, and the uterus discharge itself by ulceration ; or, in case the system is not able to institute this process, she may die, like the woman in case second, of inflammation, and general irritation of the sys- tem. 395. In our opinion, these cases offer irrefragable evidence, that the uterus may remain quiescent, for a long period after the ter- mination of the ninth month; and though we acknowledge them both to be extreme cases, they nevertheless prove the fact con- tended for. CHAPTER XI. CAUSE OF LABOUR. 396. Avicenna, centuries ago, declared that labour was a law of God, and that it came on at the appointed time. I would ask, has any hypothesis since that period, enlightened us more upon this subject, than the humble confession of this good old man? Ingenuity has attempted much upon this subject; but each sug- gestion has been displaced to give room to another, which like its predecessor was to be crowded out by some newer speculation. Thus Harvey and others supposed that the stirrings of the foetus itself contributed to the production of labour, and that it had much agency in its own deliverance ; but it had often been proved, that labour was sometimes prematurely induced by the death of the foetus; and that in many instances, delivery was more rapid; with a dead than with a living child. 397. Others have declared, that the desire of the foetus to have food, and to breathe, were the causes of the first contractions of the uterus; but the force of both these conjectures are completely destroyed by the argument just adduced. The liquor amnii it has been said, becomes acrid towards the latter period of gesta- 148 CAUSE OP LABOUR. tion, and by its stimulus forces the womb to labour. But, no such change in the quality of this fluid has ever been shown; and as it cannot come in contact with the immediate surface of the uterus, in consequence of the interposition of the membranes, no faith can be placed upon this conjecture, were it even proved, that the waters of the amnion had become acrid. 398. The explanation of Baudelocque is very much more plausible, and better supported. He makes it consist in a kind of mechanical necessity; he is of opinion that the body and fun- dus by their persevering, alternate contractions, especially after the sixth month, oblige the neck of the uterus to unfold; and the same agency, together with the weight of the child, constrain the OS uteri to open, and labour to take place. This hypothesis has some important facts to sustain it; for the action spoken of, really exists ; and after it has commenced, the neck of the uterus gradually expands ; and is eventually obliterated, and labour en- sues: but a number of facts, in which this change did not, nor could not take place, destroy much of the force of this ingenious suggestion — thus labour comes on spontaneously in some females at the seventh, and others at the eighth month of pregnancy, while others abort at certain periods, without any evident cause. 399. The latest explanation we have seen, is that of Mr. Power, which may be looked upon as a slight modification of that of Baudelocque's; both being strictly mechanical; and the agent, the wedge. Mr. Power says,* '' when the state of dilatation has proceeded so far that the os uteri is opened to the size of a shil- ling, or more, a portion of the adjoining membranes begin to be protruded through it; the effect of tb^e paroxysm now impels upon them a quantity of the liquor amnii, by which they become distended into a roundish tense bag, resembling a portion of a blown bladder, fdling up the orifice, and at the same time, pressing forcibly upon it, on the principle of a wedge, so as to promote the dilatation ; this, which is called the gathering of the waters, is of much utility in the process, as instead of the hard head of the child, it offers a soft, regular, and easy medium, by which the dilatation is effected. In proportion as it advances, the size of the membranous bag increases, until at length the os uteri is fully opened." • 'I'reatisc on Midwifery, &,c. p. 27. CAUSE OF LABOUR. 149 400. We will now examine this opinion a little in detail : First, It is stated, tliat ^^lohen the state of dilatation, has proceeded so far that the os uteri is ojiened to the size of a shilli7ig, or tnorcy a portion of the adjoining membranes begin to be pro- truded through it;'' S,'C. which membranes are eventually, by being impelled by the contractions of the uterus, to effect the complete dilatation. Secondly, that these distended membranes, "resembling a portion of a blown bladder, fdl up the orifice, and at the same time press forcibly upon it, ' on the principle of the ivedge,' so as to promote the dilatation." Third, It is de- clared, that the os uteri is filled up by the distended membranes. 401. It is evident at first sight, that the scheme proposed by Mr. Power, for the dilcitation of the os uteri, requires the agency of two distinct and widely differing powers for its completion, (though he acknowledges but one;) namely, one, which shall open the orifice "to the size of a shilling, or 77iore;" and a second, (which is entirely mechanical,) to complete the expansion; the latter consists of the distended membranes, which are to enter the os uteri on the principle of the wedge, and so promote the dilata- tion. 402. Now, from all that Mr. Power says after this exposition, of the manner in which the os uteri becomes expanded, it is evi- dent he intended, that a mechanical power should be considered as the sole, and efficient cause, of this phenomenon. This being the case, we would inquire, by what influence or power, was the OS uteri first dilated to ''the size of a shilling, or tnoreV It could not have been by the distended membranes; for Mr. P. de- clares that this does not take place until after this degree of open- ing has been effected. 403. Is it not then probable, that the uterus possesses some organic power by which it effects the opening of the os uteri, and which is totally independent of the mechanical influence of the distended membranes, since, a certain degree of dilatation takes place, without their agency? And if this be true in part, as is admitted by Mr. P., may it not be capable of effecting the entire expansion of this part? we certainly think so; and in our chapter "On Labour," in the section, treating of the manner in which the 03 uteri becomes opened, we have given our viev.'s upon this subject, and to which we beg to refer the reader. 404. Indeed, Mr. P. himself, immediately after declaring the necessity and eflicicncy of the distended ijiembranes to produce 150 CAUSE OF LABOUR. the dilatation of the os uteri, goes on to say, "in proportion as it advances, (the dilatation of the os uteri,) the size of the mem- branous bag increases, until at length the os uteri is fully open- ed." By this admission, the order of cause and effect are re- versed; above, we are told that the distended membranes enter the OS uteri after it is opened to the size of a shilling, or more, and on the principle of a wedge, effect its enlargement; imme- diately below we are informed, that the size of the membranous bag increases in proportion to the dilatation of the os uteri. 405. In the first instance, the extent of dilatation of the os uteri is in proportion to the size of " the roundish tense bag;" in the next, the size of the membranous bag, is commensurate with the expansion of the mouth of the uterus; now the mem- branous bag cannot be both active and passive at the same instant. 406. Besides, Mr. P. makes the uterus perform a work of su- pererogation in effecting the opening of its mouth. For agreeably to him, as we have shown above, the active agent in the produc- tion of this effect, is the mechanical influence of the distended membranes against the orifice of the womb in the time of pain; yet he informs us with a commendable candour, though not in- tended as a concession, "that as the paroxysm comes on, the ori- fice begins to acquire a tense and constricted feel, its internal rim becomes more perfectly circular, fixed and incapable of being moved laterally by the action of the finger." It is evident, there- fore, if Mr. P.'s explanation be the true one, that nature is at variance with herself; a circumstance that very few will admit, when she is performing the ordinary functions of the system, 407. Agreeably to this scheme, the fundus and body of the uterus contract with the effect of pressing the presenting part against the orificium uteri, that it may be expanded sufficiently to permit the child to pass; but this intention is effectually frustrated by the perverseness of the os uteri. For instead of yielding kindly to the impulse of the fundus and body, as we suppose it should do under such circumstances, it opposes their efforts, by becoming tense, and constricted, and thus, at once defeating the very object of the " parturient paroxysm." Now, we admit, that this really does take place; that it is continued for some time; and that it is attended by these very circumstances. But after a longer or shorter time, the orifice of the uterus is found dilated, and this CAUSE OF LABOUR. 151 without the mechanical aid of the distended membranes; for un- der the best condition of this part it is found fully expanded with- out the membranous bag (however tense this may be) engaging in its circle; consequently, witliout its being directly, and physi- cally acting within this circle, like a wedge. 408. It must be evident, if the distended membranes are to act upon the principle of the wedge, they must be, for this purpose, in complete possession of the uterine circle; and if placed thus, they must, (caeteris paribus,) stretch it quaqua versum, and thus tend to thicken the edges, by making them encroach upon the portions of the neck of the uterus, not dilated; but this never, or but very rarely, takes place.* Now it is familiarly known to almost every obstetric practitioner, that when the os uteri is about to yield in its kindest manner, that nearly the whole of that por- tion, which, in the unimpregnated state constitutes the neck, be- comes by the continuance of labour, thinner and thinner; and es- pecially at that part which constitutes its mouth, until at last it becomes so attenuated, and, as it were, so paralyzed, that it dis- continues its opposition, and fully dilates itself; and all this hap- pens without the agency of the membranes; or, (if they be rup- tured,) the presenting part engaging in the circle of its retiring edges ; unless it be after the os uteri has become fully dilated.t 409. Again, Mr, P. tells us, that the "parturient paroxysm" obliges the presenting part to approach nearer to the external orifice, with a degree of force which the finger is incapable of resisting, and by which the orifice is often seyisibly enlarged. A few lines above, and in the same paragraph, he declares, as we have just stated, that this part, in consequence of the paroxysm, "acquires a tense and constricted feel, its rim becomes more per- • See Chapter "On Labour." f That is, agreeably to our view of the subject, the circular fibres of the neck and mouth of the uterus, relax themselves, by a law of the uterus; and thus give to the longitudinal fibres the control: for by the conti-action of the latter, the uterus becomes shorter, and consequently will widen itself at its opening, by drawing the circidar fibres upwards. When this happens, the mouth of the uterus is drawn, or has a tendency to be drawn upwards, and the presenting part escapes from it — hence, after the complete expansion of the os uteri, its margin is often not to be found; but when it is not retracted, it advances before the head of the child; and though every way disposed to dilate fully, or yield to the pass- ing head, it often remains in that situation, so as to become a cause of tedious or difficult labour. Sec chapter on Tedious Labour. 152 €AUSE OP LABOUR. fectly circular, fixed, and incapable of being moved laterally by the action of the finger." 410. Notwithstanding these declarations, Mr. P. will have us believe, that the (generally) frail membranes, will overcome a re- sistance, which the united efforts of the body and fundus, and an introduced finger is incapable of; for the membranes efiect agreeably to him, the dilatation of the os uteri by their presence within its circle. Now, it must be evident, that they cannot do this, even according to his own showing, without exerting a force upon the uterine mouth, superior to the resistance with which this part maintains its contraction; and this is acknowledged by him to be more than equal to any degree of force, that the finger could exert in order to move it laterally.* Is it for a moment to be believed, that these membranes can exert such a degree of force? But to put this subject at rest; we have attempted to show, in the section above referred to, that the most entire dila- tation of the OS uteri takes place, without the intervention of the distended membranes, or even of the presenting part. And Mr. P. must have met with similar cases, in his own practice. 411. Having premised the above explanation, and the eSect of the "expulsive or parturient action," Mr. P. proceeds to the con- sideration of the nature and cause of the parturient action." Under this head, Mr. P. offers a new, and certainly, an ingenious hypothesis: which it becomes our duty to examine, lest it be too easily admitted as true. 412. Mr. P. commences his subject, by an unnecessary endea- vour to prove the muscularity of the uterus, and that its action is similar to that of other muscles. He next informs us, that this organ is liberally supplied with nerves from several sources; and, that the neck of the uterus is, in an especial manner, furnished with them; and hence the great sensibility, upon which he grounds his hypothesis. 413. He declares the uterus to be disposed to expel its contents during the whole term of utero-gestation, whenever a sufficient » We are not certain that we liave arrived at tlie exact meaning- of the word "laterally," as employed by Mr. P. We presume, however, that he intends to convey the idea, that the os uteri cannot be stretched by an introduced finger in that direction, during the "partiment paroxysm," or, in other words, that at this time it maintains its "constriction" with iin obstinacy, that is not to be sub- dued by any safe degree of force, tliat could be applied by the finger. CAUSE OF LABOUR. 153 exciting cause is applied; and that this disposition is inherent, and not adventitiously acquired during pregnancy. He then asks, "what is then the nature of that exciting cause, which in partu- rition determines the uterine muscles to these efforts at so exact a period?" p. 33. He contends that '< the exciting cause, al- though acting upon the susceptibility of the uterus to receive its impressions, does not appear innate in the uterus itself, but pro- bably consists of some principle, externally or mechanically ap- plied to it." p. 34. 414. He attempts to support these opinions, by ingeniously em- ploying analogies furnished by the actions of the rectum and bladder; and being thus strengthened, as he believes, he pro- ceeds to a more detailed exposition of the modus operandi of the causes which act upon these peculiar susceptibilities of the uterus. 415. '' It has been observed, that a regular series of change takes place in the cervix of the uterus during the latter months, which only becomes completed at the end of gestation, and im- mediately before the commencement of parturition. This change has been stated to consist of a gradual opening, or expansion of the cervix ; during the earlier parts of gestation, tlie uterine con- tents are at a distance from its orifice; but, as the expansion pro- ceeds, they gradually approximate; when it is completed, they are contiguous, and the process of expulsion soon succeeds. A strong analogy may be here observed, with the case of fajcal evacuation, in which a gradual progress takes place of the faecal contents to- wards the sphincter, and in which also the ready disposition to contract, is proportionate to that progress ; and is most perfect w^hen they are contiguous." In order to understand this analogy, we must relate Mr. P.'s notions of this act. He considers the rectum as a mere receptacle for the fasces, with which it becomes gradually filled; "the first portions of which enter the rectum, and occupy the farthest extremity," (that is, the upper portion of this gut,) « but as each successive portion is received, the former one is protruded forward by the impulse from behind, assisted by the contractile power of the part, until it eventually arrives at the anterior extremity or sphincter; in proportion, as the accumulation takes place at this point, a stimulating effect is produced upon it, the irritation of which is at length followed by 20 154 CAUSE OF LBOUR. the action of the muscular coat of the rectum, which presses for- cibly upon the faiccs, and expels them." p. 34. 41(). Between the illustration just given, and the exciting cause of labour as stated by Mr, P., we do not perceive the slightest analogy; nor can any exist if Mr. P.'s explanation be right, and for the following reasons: First, Because the relaxation of the sphincter ani which precedes the expulsion of the faeces, is an act of the will; for, from the constant tendency of the rectum to be- come distended, it requires, that the excrementitious part of the food should be occasionally carried off; and this is done when- ever the rectum is filled; for the irritation occasioned by its dis- tention advertises the individual of the necessity of its being emptied; he wills that this should take place; in obedience to which, the sphincter ani is relaxed ; the effect of expulsion fol- lows; and the rectum is relieved of its contents.* 417. Secondly, Because Mr. P. makes the opening of the os uteri to depend upon mechanical force, whereas the sphincter ani requires no such force, to call the auxiliary powers concern- ed in the discharge of the faices, into action. The " irritation" which calls the attention of the will, (if we may so term it,) to this act, does not necessarily i^eside in the rectum ; or rather on the verge of the sphincter ani ; for it is often seated in the sto- mach, more frequently in the bowels, and sometimes only in the imagination. 418. Thirdly, Because, we do not fmdthis " irritation" always produced, by the presence of a large quantity, of even indurated, (and as it would seem more highly stimulating from their me- chanical properties,) fasces ; as in constipation. 419. Fourthly, Because, some of the most violent, tormenting, and frequent discharges from the rectum, are not caused by the * It is true that the relaxation of the sphincter ani is not always in obedience to the will; and may, when this happens, be considered as mihtating against this objection; but this it surely does not do, under the point of view this sub- ject is examined — for when involuntarily discharges take jilace, the parts both directly and indirectly concerned in the operation, are labouring under disease: consequently, must not be looked upon as illustrative of a healtliy or normal action. The brain may be so disordered, that the will cannot act; or the sphincter may be somorl)idly irritable, as not to be under its control; or the actions associated with the irritations of the rectum may be so susceptible of impressions as to force the sphincter to obedience. CAUSE OF LABOUR. 155 presence of faeces in this gut; as in tenesmus, or dysentery; nor is distention necessary always to the relaxation of the sphincter ani; as we see in diarrhoea. 420. Fifthly, Because, Mr. P. makes the opening of the os uteri to consist in a mechanical stretching; but the opening of the sphincter ani, is a functional act; namely, the relaxation of a muscular band, and subject to the control of tlie will. 421. Sixthly, Because, Mr. P. confesses that there is a con- sciousness of the presence of some irritating substance applied to the sphincter; for, he says, "that during the earlier periods of accumulation, no disposition to expulsion is perceived ; and in the latter period, when the sensation of want of expulsion comes on, it is always referred to the sphincter." Now, it is known to everybody, that at neither the commencement of labour, nor dur- ing any period of its progress, is any sensation experienced at the sphincter of the uterus; nor can any woman will its relaxation or contraction. 422. The same arguments may be employed against his other analogy; namely, the filling of the bladder, and the extrusion of the urine, as it is founded upon the same principle, and derives support from similar phenomena. 423. Having first given Mr. P.'s views of the manner in which the OS uteri becomes expanded, we will proceed to examine the principles on which he predicates, " the nature and cause of par- turient action." 424. Mr. P. after briefly relating the order of changes in the developement of the uterus, up to the commencement of parturi- tion, says, "during the earlier months of pregnancy, the uterine contents are at a distance from its orifice; as the expansion pro- ceeds, they gradually approximate; when it is completed they are contiguous, and the process of expulsion soon succeeds. A strong analogy may be here observed with the case of faecal evacuation just noticed, in which a gradual progress takes place of the faecal contents towards the sphincter, and in which also the ready disposition to contract, is proportionate to that pro- gress; as is most perfect when they are contiguous; but the ana- logy does not rest here, as it may be shown that the nervous structure connected with their respective organs, are not only similar, but derived from the same origin, both being supplied with nerves from the hypogastric trunk, of which one division 156 CAUSE OF LABOUR. is expended upon the rectum and its sphincter, the other upon the uterus, and vagina. Is it not reasonable to suppose this similarity of structure to be attended with similarity of action, particularly when we do know, that their functions are, corres- pondent, viz. to exclude the contents of their respective or- gans.^" 425. <' We have hence strong analogy to prove that the con- tractions of the uterus are produced, in consequence of a certain impression excited by its contents upon its orifice. We shall in- quire how far circumstances, connected with the structure and actions of the uterus, confirm the position." 426. ''It has been admitted that different parts of the uterus are possessed of different states of sensibility, and that its orifice is most highly charged; upon whatever ground the admission has been founded, it is confirmed and illustrated by anatomical observation. We have seen it supplied with nerves from the renal plexus, the spermatics, and the hypogastric nerves; the two former, which are chiefly derived from the sympathetic plexus, supply the upper parts of the uterus, ovaria, &c. and may be considered as the chief media of their communications with the general system, or of their sympathetic actions; the latter, though not devoid of connection with the sympathetic nerves, is principally formed from the spinal nerves, which are more peculiarl}' nerves of motion; it may be considered the chief nerve of the uterus and vagina, upon every part of which the largest part of it is expended, the lesser one, as before noticed, supplying the rectum; it, however passes more directly and largely to the os tinea; and adjoining parts." 427. "It may hence be inferred, that the orifice of the uterus possesses a high state of nervous power, and consequently a pe- culiar function. It has also been observed that this part becomes little connected with utero-gestation until that oflice is complete, being previously removed to a determinate distance from the distending process. Is it not, therefore, reasonable to consider that its peculiar function, so far as it is connected with a high state of sensibility, is to give warning of the task of utero-gesta- tion being performed, and to be the medium of calling into ac- tion, the powers which are appointed to produce the expulsion of the now mature foetus?" p. 36, &c. 428. From wjjat has been just said, it appears that Mr. P. in- CAUSE or LABOUR. 157 sists upon the following positions or principles, as essential to the establishment of his hypothesis. 429. First, That the uterus is gradually developed; but not completely, until the last period of utero-gestation; that is, the neck of this organ is not effaced until that epoch. 430. Secondly, That the design of this arrangement is to keep the uterine contents at a distance from the os tincae. 431. Thirdly, That as gestation advances, the contents of the uterus, and the os tincae gradually approximate ; when completed they are in contact. 432. Fourthly, That there is a strong resemblance of nervous structure between the uterus and rectum. And that this corres- pondence in structure is to ensure a similarity of function ; name- ly, to " exclude the contents of their respective organs." 433. Fifthly, That the contractions of the uterus ai-e produced, in consequence of a certain impression excited by its contents upon its orifice. 434. Sixthly, That the different parts of the uterus "are pos- sessed of different states of sensibility, and that its orifice is most highly charged." 435. Seventhly, That as the orifice of the uterus possesses a high state of nervous power, it must necessarily have a peculiar function. 436. Eighthly, That the os uteri is but little connected with utero-gestation, until this is nearly completed, as the contents of the uterus are designedly removed from it. 437. Ninthly, That the os uteri, from its great sensibility, is in- tended to give notice, that the term of utero-gestation is com- pleted; and is the medium by which the fundus and body are called into action, that the foetus may be expelled. 438. Tenthly, That in proportion to the pressure exerted by the uterine contents upon the os uteri, will be the efficiency of the " parturient action," as is illustrated by malposition, &c. &c. 439. Eleventhly, That the cessation of contraction, in cases of ruptured uteri, is owing to the removal of the presenting part from the os uteri. 440. We trust we have faithfully given Mr. P.'s ideas on the subject in question, in the positions now laid down; we will there- fore proceed in order to their examination. 158 CAUSE OF LABOUR. 441. To positions first and second, we would observe, that though they are strictly true as regards arrangement, yet that this arrangement is not for the purposes declared by Mr. P. ; namely, that the uterine contents should be kept at a distance from the highly sensible os uteri, that the parturient action need not be pro- voked. See prop, sixth. 442. Now, it is a fact known to everybody, that the complete distension of the uterus is not essential to this end; since the ute- rus occasionally expels its contents at every period of gestation, from a variety of causes, which cannot in possibility act upon the sensitive os tincse as a mechanical irritant. The ergot has been known to produce abortion, as well as other substances; so have passions and emotions of the mind; as well as external mechani- cal injuries, as blows, falls, &:c. 443. In neither of these instances was it essential to the pro- duction of the parturient effort, that the uterus should have been fully developed, or that the os uteri should have been irritated by the presence of the foetus or embryo, (see prop, fifth and tenth;) yet the uterine contents were thrown off by the repeated contrac- tion of the fundus and body. 444. To proposition third, we may remark, that it proves no- thing, unless it can be shown, that the sensibility included in prop, sixth, is exclusively resident in the extreme external edge of the os tincse; for, if it be admitted that the nervous distribution is ex- tended over the whole of the neck of the uterus, (as is confirmed by anatomy,) premature labour should always take place so soon as this part is called upon to furnish room for the augmenting size of the foetus. 445. For immediately after the sixth month, the neck of the uterus is found to expand; and it continues to do so, until it is en- tirely effaced. If, then, the " parturient action" depend upon the application of the contents of the uterus to this highly sensible 2}art, (according to Mr. P.) namely, the neck of the uterus, why is not its sensibility so roused by this mechanical impression, as to call into action the parturient effort, and premature delivery take place? But we find it altogether otherwise in the ordinary arrangement of nature: for it is almost constantly found that the neck of the uterus passively suffers itself to be developed, to the last period of utero-gestation, without manifesting the slightest CAUSE OF LABOUR. 159 repugnance to the operation ; it must, therefore, be evident, tliat it would 1)6 otherwise, were Mr. P.'s hypothesis well sustained, since here the agent and capacity are constantly presented to each other.* 446. To proposition fourth, it is scarcely necessary to reply, since it also proves nothing. The stomach, the oesophagus, the alimentary canal, the gall-bladder, the vesiculse seminalis and pe- nis in the male, the vagina, all have muscular fibres, elastic mem- branes, blood-vessels, nerves, &c. like the uterus: yet they prove nothing, by their structure, in favour of the position of Mr. P. that the contractile powers of the body and fundus are called into action, as an original and natural function, in consequence, and by necessity of, an irritation produced on the mouth of the uterus, by the pressure of the contents of this organ, as declared in prop, fifth. 447. To proposition fifth, we must declare, that it is not sus- tained by any fact within our knowledge, as a natural and essen- tial arrangement. It would necessarily require that the extreme sensibility of the neck of the uterus should be confined to the ex- treme edge of the os tincae; [see answer to prop, third,] or that that portion of this organ, which, in its vacant state, as well as in a state of impregnation until the sixth month, called its neck, must acquire a new state of sensibility, the instant the full term of gestation is completed; which condition has neither been shown nor insisted on by Mr. P. For, if the whole neck were possessed of an equal degree of sensibility, premature labour must lake place soon after the sixth month, agreeably to the scheme of Mr. P.; since it is acknowledged by all accoucheurs of experience, that there is a constant nisus in the body and fundus; and which is favourable to the expansion of the neck, (par. 206.) • Mr. Power says, rather incorrectly, we think, that the " orifice of the uterus is but httle connected with utcro-gestation, until that office, (of utero-g-estation,) is complete;" [prop, eighth,] as we know that it must necessarily be involved in the developement of the neck, so soon as tliis pai-t is acted upon by the con- tractions of the body and fundus, as just stated. And if he shall insist, that "the higli state of nervous power," is confined to the mai-ginof the opening of the uterus, lie is bound to show some proof of it ; for so far he certainly has not. A bare assertion to tliis eflcct is not sufficient. 160 CAUSE OP LABOUR. 448. This being the case, it must be evident that the neck will be more or less irritated, (if it possessed this extreme sen- sibility^ by the contents of the uterus being forced constantly against it, by the contractions of the body and fundus; and, which we believe invariably takes place, at, or very soon after, the sixth month. 449. Besides, we have no evidence of the "high state of sen- sibility," spoken of in prop, sixth, by Mr. P. It certainly docs not exist agreeably to our experience, either before or during parturition as a natural condition of this part; for unless it be in a state of disease, either chronic or immediately produced by rude and improper management, we have no evidence of this state. We can with much safety say, we have touched the os uteri a thousand times, without the woman betraying the slight- est inconvenience or pain. 450. To prop, seventh, we can only say, that were this "high state of nervous power" admitted to exist, it would prove no- thing in favour of Mr. P.'s hypothesis, unless he can prove that the mouth of the uterus always obtains it at the moment that utero-gestation is finished. For if he cannot do this, and he insist, that it takes place during the progress of gestation, it would be certainly mischievous; as it must be acted upon very constantly by a variety of agents; and thus would " give warning of the task of utero-gestation being perfected," and that labour was about to ensue prematurely. 451. In prop, eighth, Mr. P. seems aware of the difficulty there would be to reconcile " this high state of sensibility" of the orifice of the uterus, with the unavoidable production of irritation from the presenting part, (did this condition really exist,) as gesta- tion advances, and especially after the sixth month. He therefore relies for support upon the mechanical arrangement, mentioned in one part of the proposition under consideration, by saying, that the orifice is " removed at a distance 'from the distending process." Now it must be well known to so experienced a prac- titioner as Mr. P. that labour ensues sometimes before the entire obliteration of the neck takes place; and that it does not neces- sarily ensue immediately after it is completely effaced; neither of which should happen in anything like the frequency, that we have occasion to observe it, were Mr. P.'s hypothesis well founded. Nay, the mouth of the uterus will sometimes be opened CAUSE OF LABOUR. 161 to some extent for days: indeed, even weeks now and then, with- out the "parturient eflbrt" declaring itself.* 452. The ninth proposition declares, that the great sensibility of the OS uteri is intended to notify the other portions of this or- gan, that the great business of gestation is fmished; and that they must now set into action the parturient powers to remove the product of this elaborate process. It must of necessity follow, that this high state of sensibility is a sine qua non to parturition; and that the entire developement of this portion of the uterus is a sine qua non to this sensibility; since Mr. P. affirms that this part is but little connected with utero-gestation until this office is complete, [prop, eight.] The facts detailed in the observations upon prop, eight, may be successfully employed against these views. 453. Besides, it is well known that labour comes on as prompt- ly, and as certainly, when the foetus dies before its full develope- ment, and consequently before "the task of utero-gestation is perfected," as when it lives to the full period; yet, in many cases this does not happen until the period of nine months have ex. pired. In these instances, so far is the neck of the uterus from being completely expanded, that a portion of it can be distinctly felt, if it be examined soon after the commencement of the pains. Indeed, the whole uterine bulk is oftentimes found diminished. How does the extreme sensibility of the os uteri perform its office in these cases? do they give warning that the term of gestation is completed ? 454. But more powerful objections may be raised against prop, tenth, and which will have a direct application to prop, ninth. If we understand Mr. P. rightly, and we would feel great reluct- ance to force his meaning, the following circumstances must combine, that labour may take place; first that an especial degree of sensibility must reside in the extreme edge of the os uteri; secondly, to make this sensibility available, the presenting part * "A friend, a practitioner and lecturer of some eminence, is positive that he has known repeated instances of spurious pains, in which the cervex uteri has not only been entirely obliterated, but the orifice sufficiently open to ad- mit a couple of fingers, and yet labour has been deferred for nearly a month afterwati'ds. Professor Hamilton used to mention cases in wliich, though the cervix uteri was obliterated, yetreal labour had not commenced." — Note by Dr. Lyall to minutes of the medical evidence given in the Gardner Peerage cause, p. 23. 21 162 CAUSE OF LABOUR. must press upon it; and thirdly, if this be of a minor kind, or not reo-ularly applied, the parturient action is less forcibly or speedily excited." p. 39. 455. The first circumstance we have endeavoured to prove, does not exist in the natural condition of the part interested; and if we have been successful in this attempt, it might look like a work of supererogation to offer objections to the second and third, as they depend, agreeably to Mr. P.'s statement, upon the first for their success or influence. 456. But let us suppose this exalted sensibility to exist; we shall soon see that it must be called into action if the pressure of the contents of the uterus be capable of doing so, in a vast majo- rity of cases, long before the 'ital part of the system, and as such had received both support and forbearance from it." p. 42. CAUSE OP LABOUR. 165 lion of this organ, that it instantly sets about expelling the body, be it what it may, that becomes foreign to it by losing its vitality. Thus it is with the decidua ; it loses its life because it cannot be maintained longer, agreeably to a law of nature; it is then expel- led, by the repeated efibrts of the uterus; and these efforts, are accompanied by pain. 467. In dysmenorrhoea, a similar process is instituted to dis- lodge the membrane or coagulum, produced within the uterus. Mr. P. might say with equal propriety, in this case, that the pain the woman experiences, "does not partake of the parturient effort, because the uterus in fact has nothing to expel ;" yet, in both instances, it extrudes by its action a foreign body. 468. If these facts, and the reasoning from them be admitted, the cause of pain at the end of nine months, (more or less,) in cases of extra-uterine conceptions, is accounted for; and conse- quently, the explanation of " the nature and causes of the partu- rient action," given by Mr. P. must fall to the ground; since, it may, nay, it is constantly produced in the cases alluded to, without either the condition of the os uteri insisted on by him, or the pre- sence of a child within it, both of which he considers as essential to the action in question. 46.9. The second position assumed by Mr. P. is, that the uterus may be urged to pain, by a translation of action from " the sur- rounding parts unconnected with this organ." We confess our- selves entirely ignorant of this change, as we have never witness- ed it; and are altogether at a loss to account for pain attacking the surrounding parts, under this particular form of conception ; and so uniformly, at ihe same period of gestation, in preference to the uterus itself, which everybody will admit, is more impli- cated in the progress, and consequences of this mode of gestation, (unless perhaps it be the very sac itself in which the foetus is concealed,) than any other portion of the neighbouring parts. Besides, metastasis is the translation of a morbid action: uterine contraction is normal. 470. The third position assumes an impossibility ; namely, that " the child may gravitate during the latter months, upon the cervical part of the uterus, which may have undergone some similar preparatory change, to what it experiences in utero-ges- tation, and thus produce certain actions of the uterus, by irritation of the cervix." 471. In cases of extra-uterine conceptions the seats of de- 166 CAUSE OF LABOUR. velopement are the ovarium, the tube, and the abdomen; and to these has lately been added a new one; namely, the sub- stance of the uterus itself. Now, if the foetus occupy either of the three first named places, it is impossible that it shall " gra- vitate during the latter months upon the cervical part of the uterus;" unless it be made to reach this part, by some process of ulceration, which it is scarcely worth while to anticipate, as in this case, it would not serve the purpose of Mr. P. The whole arrangement or anatomy of the parts, forbids the possibility of a foetus, enclosed in either of the viscera just named, from being so precipitated in the pelvic cavity, as to come in contact with the cervical part of the uterus. 472. Late pathological researches have discovered, that the foetus may be included in the proper substance of the uterus. But even this fact cannot be made subservient to the puiposes of Mr. P. He declares the possibility of the fostus so to gravitate, as to reach the cervical portion of the uterus, at the last months of utero-gestation; but, in the newly discovered species of extra- uterine conception, the period of gestation has hitherto been con- fined to the first few months, and has proved fatal in every in- stance so far known: consequently, qannot be looked upon as a support to Mr. P.'s conjecture, (see pars. 164, 165.) 473. It may be farther urged against proposition tenth, that the irritation caused by the presence of the presenting part, upon the <' highly sensitive os uteri," should be in proportion to the pres- sure it may exert upon it; now this is contradicted by the expe- rience of everyday. For there are no cases so uniformly slow, as those in which the membranes have given way early, and in which the presenting part "gravitates" so decidedly, "upon the cervical portion of the uterus." The tonic contraction of the uterus almost immediately ensues, after the rupture of the mem- branes ; by which, the presenting part is made to rest upon, and mechanically stretch the most depending part of the uterus, (the very situation contended for by Mr. P.) yet this condition may remain from a few hours to many days, without having this pe- riod invaded by pain. 474. Proposition eleventh says nothing more, than when the uterus is entirely empty, it ceases to contract ; this is but as it should be ; or the poor female, who has had her uterus once forced to contraction, would never have it to cease, did not a state of vacuity prove a guarantee against them. It is, there- CAUSE OF LABOUR. 167 fore, every way presumable, that in the case of a rupture of the uterus, when the fcjctus and sccundines have escaped from it, that this oi-gan would cease to contract, as no motive now remained for this function; to say nothing of the extreme state of exhaustion this accident uniformly produces, which of itself is capable of ar- resting uterine contraction. 475. Mr. P. says "the contractions of the os uteri may be ar- tificially excited by an irritation applied to the orifice, affording a proof that the cause presumed, is adequate to produce the effect attributed to it," p. 39. Admitted; but what does it prove in favour of Mr. P.'s hypothesis? nothing; especially, as Mr. P. will not declare it to be a natural state of function. Irritating the fauces will produce vomiting, and a dose of jalap will purge: but will anybody acknowledge either to be essential to the emptying of the stomach and bowels under the exercise of their natural or normal actions? 476. Mr. P. with a view of strengthening his conjecture, quotes a letter from his father. Dr. Power, of Litchfield. He com- mences his letter by saying, "that the parturient contraction does not happen in consequence of distention of the uterus after nine months pregnancy, but from some stimulus applied to the os uteri, may be inferred from the following case." 477. " A woman, forty years of age, the mother of many chil- dren, cqnsidered herself at the full period of utero-gestation, and experienced at that period a slight pain or two, after which she became free from any further efibrt for nearly three months; her situation exciting alarm, several medical gentlemen saw her, and declared, after examination per vaginam, that she was not with child, as they could feel no weight upon the os uteri, or variation of it, from what is found in the unimpregnated state. I saw her, and in a common examination as she lay upon the bed, found matters apparently as had been represented ; observing, however, the abdomen very large and pendulous, hanging down when in an erect posture almost to the knees. A friend of hers, a physi- cian of great eminence, who was present, was requested to stand above her on a chair, and to elevate as he stood, the pendulous belly with the assistance of a napkin ; an examination was made under these circumstances per vaginam, and I could feel now dis- tinctly the head of the child. A bandage was contrived with straps to her stays, by which the child was removed from its situation over the pubes; and in four or five days labour-pains 168 CAUSE OF LABOUR. came on, and she was delivered of an amazing large but still-born child." p. 40. 478. To this case it will be only necessary to observe, that there is not the slightest evidence of the agency of the present- ing part, in producing labour. For it is acknowledged that the patient was the mother of "many children;" and consequently liable from this cause to the anterior obliquity of the uterus; for it is by no means probable that this was the first instance of deviation; especially as it was so extreme as to reach nearly to the knees when the woman was standing. If it existed in her previous pregnancies, how did labour commence in them, if the aid given by Dr. Power was essential to this process, since it was not resorted to upon the former occasions? 479. Besides, Dr. P. acknowledges that four or five days elapsed before labour took place; if this be so, w^hat evidence is there that the head pressing against the os uteri was the cause of it? none whatever. It is much more probable if anything had an influence upon uterine contraction, that it was the change of position and the bandages ; as it is well known that external friction over the body and fundus will produce contraction, even when the uterus is in a state of inertia. Again, we have seen many cases of anterior obliquity, in neither of which was it ne- cessary to have recourse to the means employed by Dr. P. to provoke labour — it always came on spontaneously at the appoint- ed time. 169 CHAPTER XII. OP LABOUR. 480. Whatever uncertainty may exist as to the efficient cause of labour, we are taught by long experience, that about the fortieth week of gestation there is for the most part, a painful effiart made by the uterus to expel its contents; and this effort is called labour. This event rarely takes place so suddenly, or so silently, as not to present a very regular series of phenomena, which, from their universality, must be considered as constituting a part of this process ; and some of them perhaps must be looked upon as essential to its well performance. The appearances to which I allude may be divided, 1st, into those which affect the system at large ; as rigors, and a number of what are denominated nervous symptoms; 2d, into those which affect certain portions of the system independently of the uterine; as frequent inclination to make water, or a suppression of it, and tenesmus; 3d, into those which affect the uterus in particular; as the subsiding of the uterine globe; the secretion of mucus ; the dilatation of the mouth of the uterus, and its alternate contractions. Sect. I. — 1. Of Rigors, 4'C. 481. It is a very usual thing, especially with nervous women, to be seized with rigors of more or less severity, in the very com- mencement of the silent preparations for, or during the more evi- dent progress of the labour. These shiverings, or rather, trem- blings, are never attended with a reaction of the system ; and therefore, must not be considered as ushering in fever. These rigors would seem to be connected in somemanner with the dila- tation of the OS uteri; and occur most certainly, where this is ra- pidly performed. Nor do I at this moment recollect an instance of rigor taking place, where the os uteri was not more or less dilated. One of the most remarkable examples of this kind, I recollect to have witnessed, was with a lady, who awoke with a smart rigor from a sleep, and who every moment expected her labour to com- mence; the nurse became alarmed, and I was immediately sen^ for — when I arrived, I found her still trembling very severely, but had not experienced any symptom of labour — she assured me, 22 170 FREQUENT INCLINATION TO MAKE WATER, &C. that nothing was the matter with her, except, what I was wit- nessing; namely, an agitation of the whole body, which she could not, by any effort, control. It was an extremely cold night, and I had approached the fire; but I had not been there five mi- nutes before my patient exclaimed, she believed her labour was coming on; and this really was the case, and so rapidly, as not to give me time to place her in a proper situation for delivery ; she was delivered in less than five minutes from the time she first called my attention to her. 482. When these tremblings take place later in the process, I have always felt assured the mouth of the uterus was dilating or dilated. They sometimes occur immediately after labour. And, so far as I have witnessed, they have never been attended by the sensation of cold. Nor have I ever known them do the slightest injury: though the patient and her friends are oftentimes so much alarmed, as to commit an error, by giving stimulating or heating drinks; &c. — in a word they require no attention. 483. Besides the rigor I have just mentioned, we sometimes see a number of nervous, or hysterical symptoms, attend the progress of labour; especially, with the first child, if the process be rather slow — such as a disposition to cry, a sense of suffocation or choak- ing, palpitation of the heart, &c. ; all of which, however, are al- most sure to disappear so. soon as the labour becomes active, and the pains succeed each other quickly. Should they be violent, a little of the tincture of assafoctida, or Hoffman's anodyne liquor, may be advantageously administered. Under such circumstances, we should give the patient every reasonable assurance of a hap- py termination of her sufferings; and that there is nothing un- common in her situation. Sect. II. — 2. Frequent inclination to make Water, Tenes- mus, Sf-c. 484. The uterus even in the commencement of labour, if the fundus and body of this organ act healthily, is very often found so low in the pelvis, as to press upon some portion of the blad- der : but especially, upon the neck ; this pressure excites a fre- quent inclination to make water; in obeying which, the woman always suffers more or less inconvenience. Under such circum- stances, the urine is very frequently driven from the bladder in small quantities, by every contraction of the uterus ; this often leads the patient and her friends to believe that the liquor amnii FREQUENT INCLINATION TO MAKE WATER, &C. 171 is escaping. This I think, more frequently happens where the OS uteri opens reluctantly; and where the pains are pretty fre- quent and severe — it needs no application, unless the inclination cannot be obeyed, and it amount to retention; in such case, the catheter must be introduced; nor should this condition be sufler- ed to remain too long without being relieved by this instrument. This retention, so far as I have witnessed, never takes place but in protracted labours, and especially in such as may require arti- ficial means for their relief. It should ever be a rule to inquire frequently into the state of the bladder in all cases of tedious labour; and, should the patient have been several hours without passing urine, the catheter should be employed; and particularly, if there be no prospect that the labour will terminate speedily. Much present inconvenience, and sometimes lasting mischief, have arisen from the neglect of this precaution — I have seen this disposition continue for days after delivery, and relieved only by the occasional use of the catheter; I have known an opening take place between the urethra and the vagina by the part sloughing; and this in consequence of long pressure ; and witnessed an in- continency of urine from the same cause. 485. In a case of the latter kind, I was once consulted by my friend Dr. William Harris, in which entire relief was procured by the use of the tincture of cantharides. In this patient the sti- licidium of urine was so constant, as to lead to the suspicion there was an artificial opening from the urethra; but a careful exami- nation could detect no such state — I think this lady has had a child since that period without this accident being renew^ed ; but of this I am not certain. 486. It is not unfrequent, at the commencement of labour, for the bowels to be several times moved in pretty quick succession, accompanied with a strong effort or tenesmus; or this inclination may take place after the labour is advanced, from the mechanical pressure the rectum suffers from the loaded uterus completely occupying the vagina. In the first case, should there appear to be sufficient time to permit its operation, a full dose of castor oil will be sure to remove it — should there not be time, five-and- tvventy drops of laudanum will speedily quiet this inclination. In the last case we can offer no relief, unless the rectum be impacted with hardened faeces, which do not escape from it, even by the repeated pressure of the child's heud — when thus situated, an emollient injection will almost always procure relief. 172 OF THE SUBSIDING OP THE ABDOMINAL TUMOUR. Sect. III. — 3. Sjfections of the Uterine System in particular. 487. These last are of much more importance than those we have just been considering; and most of them may be looked upon as always accompanying every healthy labour, and may be divided into a. The subsiding of the abdominal tumour. b. The secretion of mucus. c. The dilatation of the os uteri. d. The alternate contractions of the uterus. • a.— Of the Subsiding of the Mdominal Tumour. 488. When the uterus and pelvis are in a healthy condition, the fundus, at the last period of utero-gestation, is found little or no higher than at the eighth month ; the reasons for this are, first, the constant tendency which the body and fundus have to contract after the seventh month, forces the uterine' contents lower into the pelvis ; and second, the effect of these contractions upon the neck of this organ, causes it to unfold, and thus furnishes additional room for the increasing fatus. In consequence of the develope- ment of the neck, the uterine contents must necessarily sink lower into the pelvis even without the agency of the contrac- tions just spoken of; but especially, when these take place in a healthy and natural manner. The existence of these contractions, can be ascertained, by the introduction of the finger into the os uteri, and placing its extremity gently against the membranes; when thus situated, they will be found to be alternately tense and relaxed* — the effect of these contractions will be the obliteration of the neck of the uterus, and eventually producing labour itself. 489. The sinking of the uterus into the pelvist has been just- ly considered a favourable circumstance ; as it would seem to de- clare two important facts: 1st. A healthy condition of the uterus itself; and 2nd. A healthy conformation of the pelvis, b. — The secretion of Mucus. 490. This important discharge almost always takes place, even before other symptoms declare labour to be at hand. Its forma- tion is the result of one of the numerous sympathies, to which the * Baudclocque. t The old women cull this falling. THE SECRETION OP MUCUS. 173 uterine system lays claim. It is always a welcome harbinger to the accoucheur, as it almost always foretells the condition of the parts, or ensures a favourable disposition in them to relax; and this disposition is, ceteris paribus, almost in proportion to the quantity secreted. When it does not appear in the beginning of labour, even where the pains are frequent and severe, we rarely find upon examination, that the labour has progressed much, or that the os uteri is well dilated. But if a quantity be quickly secreted, even very soon after we have made an examination, it will be found, that the orifice of the uterus has suddenly undergone a change, by being either perhaps well dila- ted, or easily dilatable — hence, we infer, it is in some way or other connected with, or instrumental to, this process. 491. This discharge is frequently tinged with blood; this co- lour is derived from the rupture of some small blood-vessels of the chorion, or perhaps of the placenta. When not tinged with blood, it much resembles the white of an egg. Dr. Denman calls it an increased secretion of the fluid natural of the parts; but to this it does not appear to bear the least resemblance — and if it be even furnished by the same vessels, it must be by an altered action of them. 492. The formation of this fluid answers two important ends; 1st. It lubricates the vagina, which permits the foetus to pass more easily ; 2d. It acts as topical depletion from the neck of the uterus, vagina, and peringeum; and thus facilitates their relaxa- tion. This last circumstance I consider to be the chief use of this discharge; for were it confined to the mere lubrication of the pas- sage, its utility would be much more limited than it is found to be; for this end could be answered very well by artificial means; but these it is well known are not adequate. 493. The writers on midwifery have too much limited the usefulness of this discharge; they look upon it as a mere lubricant; and they carefully caution against too frequent touching, lest, say they, it remove this substance from the vagina, and thus give rise to more friction between the child's head, and the soft parts of the mother: now, were this the only evil to be apprehend- ed by incautious or unnecessary touching, it could be easily re- medied by any mild unctuous substance; but, as I have just ob- served, it is well known, though not acknowledged, that this sub- stitute by no means answers the purpose for which I believe this discharge was instituted. 174 OF THE DILATATION OF THE OS UTERI. 494. By frequent and incautious touching, the glands furnish- ing this fluid are over-stimulated, nay, sometimes become in- flamed. In this case, the secretion ceases, and the parts become tender and swoln; especially, the mouth of the uterus, should it not be fully dilated; the pains are less frequent, and less pro- trusive; the woman is restless, and enjoys no calm in the intervals of the pains; fever is excited; headache, thirst, and a hot skin follow; in a word, a new condition of the system arises, and al- most suspends the business of labour. It would be in vain, under such circumstances, to offer a substitute for the absent mucus, by presenting to the parts any unctuous, or mucilaginous substance whatever — it can only be recalled by rest, and free blood-letting. To the latter, we must have immediate recourse, if we wish to subdue the unnecessarily provoked inflammation; and to restore the uterus to the re-enjoyment of its suspended powers — in many cases like those just mentioned, I have seen this remedy act with the certainty, and promptitude of a charm. 495. The disturbance excited throughout the system when the vaginal surface becomes inflamed, distinctly shows the important role this mucous secretion performs in the economy of labour; it demonstrates that it is instituted for a much higher purpose than merely to lubricate the parts: it shows clearly, that its form- ation is in some way or other connected with the dilatation of the OS uteri, and the relaxation of the perinaeum — let us beware then how we interrupt its formation, by rude and uncalled for handling. c. — Of the Dilatation of the Os Uteri. 496. All writers upon midwifery, make this important ope- ration the efiect of mechanical impulse, though many of them, at the same time, are forced to acknowledge, they have seen it dilate, where neither the distended membranes, nor any portion of the child has entered its circle, to efiect its opening by a wedge-like action. That the waters distending the membranes and the child itself, when powerfully impelled by uterine con- traction, may occasionally have an influence on this operation, I am not disposed to deny; but if this take place, it does not open this part either so kindly, or so effectually, as when this is achieved by the powers destined for this purpose. Before I oflTer a different explanation of this phenomenon, it will be necessary THE CONTRACTION OP LONOITUDINAL FIBRES. 175 to consider the different Idnd of contractions performed by the uterus; they arc 497. a. The contraction of the longitudinal fibres of this organ. b. The contraction of the circular fibres. c. The simple contraction. d. The compound contraction. e. The tonic contraction and its effects. f. The spasmodic, or alternate contraction, and its effects. «. — The Contraction of the Longitudinal Fibres. 498. By the longitudinal fibres of the uterus, I wish to signify those fibres upon the contraction of which the uterus is shortened from fundus to mouth, and which will be in proportion to the effort. The effect of this contraction is, to make the contents of the uterus approach its mouth; as this, from its organization, must necessarily be the least resisting part — this tendency will constantly be in proportion to the diminution of resistance,* and the force with whidi these fibres act. It will be perceived, that if the uterus be diminished in length, it will, necessarily, be in- creased in breadth, unless opposed by the circular fibres; or, in other words, the circular fibres would be put upon the stretch, until the diminished length be compensated, did they not resist this violence, by being stimulated to contraction, by the uterus becoming shorter from fundus to mouth by the contraction of the longitudinal fibres, asd which necessarily tend to distend the uterus in its transverse direction. But being thus excited to ac- tion, the two sets of fibres urge the contents of the uterus towards the least resisting part of itself, namely, the mouth; by which means the membranes become distended, and lengthened in the direction of the longitudinal axis of this viscus, nearly as much as this set of fibres shorten themselves. The action of the lon- gitudinal fibres is at right angles, with the circular; and has a * The duration of labour will therefore almost invariably depend upon the re- sistance of the circular fibres of the mouth of the uterus, (all things being equal.) It is evident to every experienced accouclieur, that the circular fibres constitu- ting the moutli of the uterus, have difi'erent degrees of disposition to relax, when acted upon by tlie contracting body and fundus; in some instances, the long- continued efforts of the body and fundus are required ere they yield; while in othei-s, contraction scarcely takes place before they give way, and permit the presenting part to j^ass freely ; nay, sometimes rapidly. 176 OF THE SIMPLE CONTRACTION. tendency to oppose, or overcome the disposition of the circular fibres to narrow the uterus in its transverse direction. b. — The Contraction of the Circular Fibres. 499. By the circular fibres I mean those which are arranged transversely from the mouth to the fundus, and which, by con- tracting, diminish the capacity of the uterus in the direction of the transverse diameter; and should they act alone, and the os uteri be closed, they would necessarily stretch the uterus in the direc- tion of its vertical, or longitudinal diameter. These fibres, as we have said, may be considered as running round the uterus, from the fundus to the termination of the neck; they have, as I shall attempt to prove presently, but an indirect agency in furthering the expulsion of the uterine contents; the action of the circular fibres, especially at the neck of the uterus, is almost in direct op- position to the longitudinal, and serves rather to retain than to expel the contents of the uterus. It is by the successful and uni- form contraction of these fibres, and especially those of the neck, that the woman is enabled to carry the produce of conception to the full period of utero-gestation. They may act independently, of the longitudinal fibres; or they may act with greater force, as I shall have occasion to remark by and by. c. — Of the Simple Contraction. 500. When either the longitudinal or circular fibres act alone, « the simple contraction" takes place. It may be asked what evi- dence have we that one set of fibres can act independently of the other? I answer, of this we have abundant proof in the contrac- tions which take place towards the latter period of gestation; and of which we are made sensible, by passing the finger, as already mentioned, (488,) within the os tincai, and placing its extremity against the membranes — a tense and relaxed condition of the membranes is perceived: this is owing to the longitudinal fibres acting alone, for did the circular act at the same time, it would be felt by the finger, by the edges of the os uteri stifiening or be- coming rigid; but this is not the case. On the other hand, we prove that the circular fibres may contract firmly, and for a long time, without the slightest co-operation of the longitudinal fibres, by the well known circumstance that when the waters have been discharged for some time, the uterus is found to embrace the body OP THE TONIC CONTRACTION AND ITS EFFECTS. 177 of the child firmly ; in this case it is evident that the circular fibres contract alone, as there is no effort to expel the child, as would be the case, did the longitudinal fibres exert an influence at the same time. d. — Of the Comj}ound Contraction. 501. This contraction is the effect of both sets of fibres acting simultaneously; this is proved by the mouth of the uterus at- tempting to close itself during the period of action, and by the head, or presenting part, evidently sinking lower, (though per- haps to rise again immediately,) in the pelvis. Now, these two circumstances could not happen at one and the same time, did not both sets of fibres contract together — it is this compound ac- tion, which attends the commencement of all healthy or regular labours. e. — Of the Tonic Contraction and its Effects. 502. The tonic contraction, or that contraction which tends to diminish the uterus in all directions, (250) cannot be called into action to any extent until the uterus is either in part, or altoge- ther deprived of its contents;* but if this happen even in a small degree, the whole of the fibres of which the uterus is composed, begin to shorten, or fold themselves up, and thus make the uterus accommodate itself to the quantity and almost the shape of its con- tents. In consequence of this, the direction, and perhaps, the size of the blood-vessels of this organ are changed; and though in no very sensible degree at first, or when its contents are but little diminished, yet it will be found, that the changes will bear an exact proportion to the evacuation from the uterus. It is this contraction which preserves the woman from fatal haemorrhage, when the placenta is either partially, or altogether detached; it serves also the important purpose of keeping the uterus in con- stant contact with its contents, and enables its fibres to act with more efficiency upon the body, to be expelled; it is also this con- traction which opposes the re-distention of the uterus; and so ob- * Whatever will weaken the force of the uterus, or diminish the quantity of jts contents, will permit, in that proportion, the tonic contraction of the uterus to take place, if this organ be in a healthy condition; even a less quantity of blood in tlie parietes, or a very partial dilatation of the os uteri, or the escape of a very small quantity of the liquor amnii, will do the same. 23 178 SPASMODIC OR ALTERNATE CONTRACTION, &C. stinately does it do this sometimes, that turning is rendered im- practicable. f, — Of the Sjjasmodic or Alternate Contraction, and its Effects. 503. This contraction is often called the spasmodic contrac- tion; but I prefer, as I have already observed, (254) the term alternate or periodical contraction; for it is not necessarily ac- companied with pain. 504. The cause of these contractions, like the contractions of every other muscle, must be a stimulus of some kind or other; I have already declared, (161) my ignorance, of the nature of the stimulus that excites the uterus to contraction, at the end of nine months; though we are very often enabled to detect it, before that period; for it is always found, that whatever can stimulate this organ to a certain degree, is capable of provoking its action: and if not interrupted by proper counter-agents, it goes on until the con- tents of the uterus are expelled. So much for the causes which may excite the uterus to action^ but what is it that gives these contrac- tions their alternate or periodical form? So far as I know, a solu- tion to this question has never been given; indeed, I am not cer- tain, it has ever been asked ; therefore if I fail to be satisfactory in the one about to be offered, it must be remembered I only hazard a conjecture; and it will but share the fate of thousands upon every subject, from the time of Hippocrates to the present mo- ment. 505. In order that a muscle may renew its contraction, it must be elongated by some antagonizing power, after it has become re- laxed; in almost every part of the body this power is at once dis- coverable; but, where, and in what resides, that which enables the uterus to repeat its efforts? I am of opinion this power de- pends upon its own structure, and economy — I shall now attempt to prove this. The uterus, by impregnation, becomes of course distended, in proportion as that process advances — it is, therefore, elongated, or its fibres put, to a certain extent, upon the stretch, and are thus enabled to contract, so soon as the appropriate sti- mulus be applied. What is the efiect of this contraction? An approximation of the uterine fibres; a compression of all its blood- vessels, with the immediate discharge of a large portion of blood from them into the general system: in consequence of this, the uterus becomes paler and the vessels empty, or nearly so. The blood escapes by means of this contraction quaquaversum; and SPASMODIC OR ALTERNATE CONTRACTION, &C. 179 to facilitate its departure, the anastomoses between the arteries and veins, are unusually frequent; and the latter vessels are not furnished with valves. 506. What is the effect of the subsequent relaxation? The fibres of the uterus become longer, straighter, and more easily- distensible; the large vessels and sinuses are less compressed, and consequently w^ill now permit the natural resiliency of their coats to act — while the influent blood will suddenly fill them, and thus restore the equilibrium which the previous contraction had destroyed — now, this rapid influx, will not only distend the empty vessels, but will also prove a powerful stimulus to the uterine fibres; and thus urge them to renew their contraction; and this will be repeated from time to time, until there be no farther ne- cessity for its continuance. This plethoric state of the uterus, if we may so term it, is proved by the heightened colour of its parietes. 507. I presume, when this contraction is best performed, it is chiefly by the exertion of the longitudinal fibres. 508. This opinion is founded upon the relative strength of the two sets of fibres. I believe that the longitudinal fibres, or those which by contracting shorten the uterus, are the stronger of the two ; and for the following reasons: 1st. Because, if they were of equal strength, delivery could not take place ; as the circular fibres by their contractions, would rather embrace and retain the child, than advance it; since, they tend to diminish the transverse diameter of the uterus; and consequently, their ac- tion is, as I have already observed, (498) at right angles with the action of the longitudinal fibres. 2d. When either the abso- lute, or relative strength of the circular fibres is increased by any cause whatever, labour does not advance ; therefore, the cir- cular fibres do not directly contribute to the expulsion of the child. 3. As the circular fibres do not, from the very nature of their action, contribute to the immediate propulsion of the child, as just declared, they must be considered inferior in powej. to the longitudinal fibres ; since, the child is expelled without their direct agency— therefore, the latter set of fibres has not only to move the child, but to overcome the resistance the former gives, by the direction of their action. We see this finely ex- emplified in those cases, where the waters have been discharged early, and the uterus closely embraces the child ; and where, by virtue of its tonic contraction, it even accommodates itself to the ISO THE MANNER IN WHICH THE OS UTERI IS OPENED. inequalities presented by the child's body ; in such instances, la- bour would be stationary, did not the longitudinal fibres possess greater power, than the circular. CHAPTER XIII. THE MANNER IN WHICH THE OS UTERI IS OPENED. 509. With these facts before us, I shall attempt the explana- tion of the dilatation of the os uteri. At the full period of utero- gestation, the process called labour must take place, that the womb may expel its contents; to this important end, its body and fundus must contract, while its neck must dilate— the question now is, how is the latter effected? During the whole period of gesta- tion, the lower part of the womb is kept closed by the contraction of the circular fibres: this condition must now be overcome by the exertions of the longitiidinal; therefore, these two sets of fibres may, without a strained comparison, be considered as antagoniz- ing powers. During gestation, at least until the seventh month, the longitudinal fibres yield much more willingly than the circular, to the distending force of the increasing ovum; this may be owing to their greater length, or their greater laxity; and hence, per- haps, the lengthened form of the uterus. This stretching must have a limit, or a maximum; and when this arrives, they will necessarily be stimulated to contraction; and this really takes place at this period, as I have several times declared, and at- tempted to prove, (488, 500. ) Now, the effect of this effort, which is almost constantly repeated after it is once commenced, is felt by (until now,) the passive neck of the uterus; and obliges it not only to support the action of the body and fundus, but also the weight of the child and waters; these joint powers make it unfold itself, and to become identified with the other portions of the uterus; so that, at full time, it forms a portion of that globe which is placed in the cavity of the pelvis; and its distinctive mark, or projec- tion, is lost in the uniform surface presented to the finger. 510. From the moment the neck begins to be operated upon, it begins to lose in thickness, and in length — and these changes com- mence at that part next to the body of the uterus; so that the THE MANNER IN WHICH THE OS UTERI IS OPENED. 181 extremity of the neck, or the os tinccc, is the last portion which is effaced. When the longitudinal fibres act, the circular become a little stretched, in consequence of the length of the uterus being diminished; and I have already said, (49S,) that the uterus can- not diminish in one direction while the membranes are entire, with- out increasing in another; and this must be the case so long as the mouth of the uterus remains shut; but this cannot be very long, as it is obliged to sustain the whole pressure of the contents of the body and fundus, and this in proportion to the power with which the longitudinal fibres may contract, as well as the force exerted by a part of the circular fibres, which are now called into action, by the contraction of the longitudinal distending them, until they themselves contract from this very stimulus. 511. This action and re-action, are reciprocated for some time; the longitudinal fibres shortening the uterus from fundus to mouth; while the circular attempts to resist the effect of their action, by contracting themselves, and thereby opposing the tendency to dis- tention in the transverse direction of this body — the effect of this compound action is, to direct the body to be moved towards that part which offers it the least resistance; and this is the small open- ing called the os uteri — the fibres which immediately surround this opening, and oppose its immediate dilatation, gradually be- come weakened by the superior strength, and persevering action of the longitudinal fibres; and after a struggle of more or less se- verity and duration, they are obliged to yield; and in their quies- cence, the dilatation of the os uteri consists. 512. In the whole of this arrangement, we see no necessity for the mechanical wedge-like agency of the membranes acting on the circle of the os uteri, which Dr. Denman* speaks of as im- portant to its dilatation — for every day's experience proves that the most perfect and speedy relaxation of the mouth of the uterus takes place, without any such influence. Indeed the doctor! seems to yield this point when he confesses that "in many cases the membranes break spontaneously long before this period (that of the OS uteri being wholly dilated,) without any material inconve- nience." 513. If it be asked, why are those labours in which the mem- branes give way early, always more tedious and painful, than those in which they are preserved? * Introduction, Francis's cd. p. 278. f Idem, p. 280. 182 THE MANNER IN WHICH THE OS UTERI IS OPENED. 514. I would answer, that this is not by any means always the case; and that when the membranes have yielded from their deli- cacy before the genuine expulsive action has commenced, the uterus may be said to be surprised, (if I may use the expression,) into contraction, before the natural stimulus is given. In conse- quence of this, the uterus is made to embrace the child closely, by virtue of its tonic power, and is sometimes, by this event thrown into irregular and painful contractions, by the unequal surface which the child's body presents to its internal surface — for the evacuation of the waters prevents the lower part of the uterus from being fully stretched by the contractions of the body and fundus; and by this means, retards the weakening of the circular fibres at this part; a circumstance of considerable moment to the dilatation of the os uteri. If an unusual degree of pain be excited by the premature escape of the waters, it is not because the mem- branes and waters fail in their v/edge-like agency to dilate it; but because the uterus is prematurely excited into action ; and of course, before all the terms of pregnancy have been complied ■vvith — as the waters, while retained, serve to ensure an equal dis- tention of that part of the uterus, which we have agreed to call in the unimpregnated state, its neck, and is the part which is to relax during labour, that the child may escape from the general cavity of this organ. 515. I am abundantly confirmed that this is the true explana- tion; for, by the fact, if the waters have not prematurely passed ofif ; or, in other words, if at the time of their escape, the uterus is prepared for the regular routine of labour, the mere circumstance of their evacuation, (cseteris paribus,) will neither materially re- tard the dilatation of the os uteri, nor necessarily create unusual delay to delivery — of this, we have additional proof from Dr. Den- man, as just quoted. But in this admission, let it be recollected, that I consider the waters as useful, by their equal pressure upon the lower part of the uterus, and by distending, and, at the same time, by the same agency, weakening, the circular fibres of this part; and thus indirectly favouring the dilatation of the mouth of the uterus. . 516. I may therefore, I believe, safely lay it down as a general rule, that the early spontaneous rupture of the membranes does not directly or necessarily produce a more painful or tedious la- bour, unless the uterus is from this cause immediately excited to contraction ; for should pain not follow very soon, or should the THE MANNER IN WHICH THE OS UTERI IS OPENED. 183 legitimate pains of labour have preceded this accident, the labour will, all things being equal, be as in ordinary cases; for I have many times seen patients, with whom the first intimation of labour being at hand, was a discharge of the liquor amnii; but this not instantly followed by pain; but when pain did come on, the labour was speedily finished — in these instances, the mouth of the uterus opened as speedily and as extensively, as though the membranes had not given way, and the waters had not discharged themselves. 517. Let any one who has made the attempt to penetrate the OS uteri when rigid, be asked, if a direct action on its edges by tl->e hand formed in a wedge-like shape, and the application of consi- derable force will always be sufficient to overcome the opposition of the circular fibres of the neck? He will answer, if he be candid, No; and will add, that the part would suffer laceration rather than yield to the force employed. Is it reasonable, then, to expect that a wedge formed by the smooth, and comparatively delicate membranes with the liquor amnii within them, will, as a mere mechanical power, however aided by a strongly contracting body and fundus, achieve more than the well-directed force of the hand as just stated?* Let any one familiar with the general manner in which the distended membranes offer themselves at the orifice of the uterus during pain be asked, if their presence and agency, at such a moment, presents to his mind, the idea of a mechanical power, attempting to overcome the resistance offered by the con- traction of the circular fibres? and, I am sure, he would unhesi- tatingly say. No. 518. When the os uteri does dilate, it is not by its edges being stretched mechanically — it is an absolute inability in the circular fibres to maintain a state of contraction, and, for the time being, may be considered as paralyzed, or excessively fatigued — or, per- haps, more properly speaking, it is the relaxation of a sphincter not subject to the control of the will. 519. I admit, that the os uteri is sometimes forced to open in a * Besides, every accoucheur knows, that in many instances of the most spee- dy and perfect dilatation of the os uteri, the membranes are too feeble to bear the slightest force. The mere touch of the finger will sometimes rupture them; and this at the moment the os uteri is yielding rapidly. Now, in such cases, the dilatation of the os uteri should cease, as soon as the membranes had yield- ed, if their presence were mechanically necessary to this end; especially, if a portion of the cliild have not engaged in the mouth of the uterus, to supply the place of the distended membranes. 184 THE MANNER IN WHICH THE OS UTERI IS OPENED. degree, by the membranes, or the presenting part engaging in its circle when these parts are strongly impelled by the contractions of the body and fundus; but, when this happens, the orifice does not present the same feel as when it dilates by the regular, and natural process? it is evidently perceived that it is reluctantly yielding to force, and is not obeying a law. 520. When labour is most easily, and naturally performed, there appears to be a tacit understanding, if we may be allowed the expression, between the longitudinal and circular fibres; the latter relax suddenly, and extensively; while the former, contract so silently, but so effectually, that we cannot discover the agencies by which this is effected — who has not witnessed the almost in- stantaneous opening of the os uteri? been sensible of the retraction of its edges over the child's head, and the delivery of the child follow almost at the same moment ? 521. To the explanation just given of "the manner in which the OS uteri becomes opened," it is objected, "that if a muscular part is suddenly extended, its contractile powers are brought into violent action; but let the part be extended graduall)^, as is, of course, the case where the extension depends upon the slowly in- creasing size of the ovum, and when it has arrived at its ' maxi- mum of stretching,' its antagonistic powers appear to be destroyed ; for contraction either does not take place at all, or very imper- fectly. It is well known that surgeons act upon this principle, when they have to overcome the obstinate contraction of muscles: they exhaust the powers of the part, by keeping up a gradual ex- tension."* 522. The objection just stated, is ingenious, but not valid: 1st, because there is no analogy between the inordinate stretching of a muscle not organized for this purpose, and the expansion of the uterus, to which this capacity is most amply given; 2d, that a pe- riod must arrive, in the stretching of even the common muscles, however gently performed, at which they would contract, and that violently, if permitted from the stimulus which "extension" must offer; and it is precisely so, with the uterus — its organization is such, as to support a great deal of distention, before it is, like the common muscle, stimulated to contraction; 3d, the bladder is gra- dually distended, by the percolating urine, until its parietes are put upon an easy stretch; it then gives warning, that it can no * Lond, Med. and Pbys. Jour, for August, p. 143. CONDUCT DURING LABOUR. 185 longer support this state with impunity; for the distention has ar- rived at its healthy '' maximum," and must not be carried farther; 4th, that were the bladder, or the uterus itself, suddenly stretched to the extent of their capacity, they would as certainly lose the power of contraction, as the muscles over which the surgeon exerts his control. CHAPTER XIV. CONDUCT DURING LABOUR. 523. In the management of labours much judgment and cau- tion are required, that a simple and natural case, may not be con- verted into a laborious, and dangerous one. Ill-directed measures will always have penalties attached to them; and it is only by taking a proper view of the nature of the labour, that it can be conducted to a happy issue. There is no one circumstance, that so largely and certainly contributes to divert nature from her proper course, as the persuasion that art can always benefit her — hence, the constant employment of ill-directed mancBuvres by an ignorant accoucheur, or midwife. And unfortunately for the interest of humanity, it requires more knowledge not tobeofficioiis than falls to the share of many of those, who pretend to practise midwifery. It is a vulgar prejudice, that great and constant be- nefit, can be derived from the agency of the accoucheur; es- pecially, during the active state of pain; and this feeling is but too often encouraged by the ignorant and the designing, to the injury of the patient, and to the disgrace of the profession. When all things are doing well, the active duties of the accoucheur, are limited indeed — it is but where the cojitrary obtain, that he can be said to be positively useful; but to discriminate between the two conditions, requires a thorough knowledge in what a healthy labour consists; and this can only be known with certainty, by him who is well-grounded in the principles of his professicm, and who has enjoyed an extensive, or, at least, a well-directed experience. 524. To conduct a labour with safety, the practitioner should 24 186 CONDUCT DURING LABOUR. be well acquainted with its phenomena; the order or succession of them; be able to decide, when certain of them are wanting, or when others are in excess; to estimate the relative or positive im- portance of such; ihe force or effect of each pain ; the necessity of preserving or of wasting the waters; the degree of resistance the OS uteri, or external parts may offer; the situation of the former, as regards the presenting part ; the certainty of the presentation, both generically and specifically ; the mode of rectifying any er- ror of presentation in proper time ; the capability of doing this with the greatest advantage to the patient and to the infant; and " though last, not least" in importance, he should be able to pur- sue a firm, candid, and feeling conduct throughout the whole scene, that he may not be betrayed into indiscretion, by the over- weening anxiety of the friends of the patient; that he may not lose the important moment to act, from an apprehension that blame may attach upon the disclosure of its necessity; and that the sufilsrer may derive every advantage his kindness and sympa- thy can aflTord. 525. That man is but little used to the exercise of the social virtues, who is ignorant of the influence, a kind and feeling con- duct has upon his suffering patient — to her, it almost atones for the want of skill or experience: and to deprive her of it, is with- holding a right for which nothing can compensate. 526. She is entitled to all the consolation a well-grounded as- surance of a happy termination of her sufferings can afford; and this must be offered to her from time to time, that she may profit by its encouraging influence; yet sbe must not be betrayed into false hopes, by an ill-judged promise of a speedy issue, when the period, from the very nature of the case, must be remote — no- thing perhaps is so destructive to confidence, as ill-requited pro- mises of this kind ; nothing so sickening to the heart, as " hope deferred." 527. The young practitioner especially, should be very sparing of promises; for it requires long experience to make them with any kind of certainty; and until he possess this, they should be evasively given, that sad disappointment may not ensue. For a woman will support herself with much firmness, where relief is believed to be certain, tliough it may be distant, while she would flag, under the failure of often repeated promises of speedy re- lief.* Her mind should be kept as free from anxiety as the nature * Denman. CONDUCT DURING LABOUU. 187 of hdf- siluMttm will permit; therefore, no conversation should be inthi1 ^<^(j_HiV tf^nt miglit for an instant excite her apprehensions — conversati'^on~"5hTTOitWje-xlieeiful^nd free from the idle dis- cussions of danger in similar situations; and it TnuB U afi.as _void of levity, as of gloom. "^ 528. To the well-bred gentleman, it would be almost an insult to say anything on the score of decency; but as errors may be un- consciously committed, it may be proper to suggest a few cau- tions upon this head that may be important to the welfare of the well-meaning, but inexperienced practitioner. 529. 1st. Let all communications to the patient of a deUcate nature, be conducted through the medium of a third person; the nurse when present, should always be that person ; in her ab- sence, an elderly friend. 530. 2d. Endeavour, by a general and well-chosen conversa- tion, to divert the patient's mind as much as possible from the purpose of your visit, when your services are not immediately required. 531. 3d. When your presence is not absolutely necessary in the sick room, be as little in it as will be consistent with your duty — by this you remove restraint; and abridge to appearance the period of your watching. 532. 4th. Should you judge it necessary to ascertain the situa- tion of your patient, let the proposition be made by a third per- son, as the nurse; let her declare the circumstances which lead you to believe it would be important; such as the length of time the patient has been in pain; the force and frequency of the pains; the evacuations of the waters, if it have taken place; and above all, the necessity of ascertaining the progress of the labour, and the nature of the presentation. 533. 5th. If, after you have made your examination, you should be importuned for your opinion of the nature of the pre- sentation, and the duration of the labour, do not commit your- self by any positive declaration, unless you are certain of the first, and pretty sure of the latter. 534. 6th. Before you proceed to the examination, let your patient be placed with the most scrupulous regard to delicacy, as the slightest exposure is never necessary; let the light be ex- cluded from the room by closing the shutters if it be day, and by the concealment of it, if it be night. So much for the regula- tion of the conduct of the accoucheur in his intercourse with his 188 CONDUCT DURING LABOUR. patient; but it is also important that we lay down some general rules by which he, and the patient shall be governed, during the progress of the labour. 535. 1st. The patient is to be forbidden everything which shall have a tendency to excite the system; she will therefore be prohibited wine or any other liquor; or even stimulating food. 536. 2d. She should be directed to keep as quiet as possible; and the preposterous custom of obliging her to walk the floor with a view to increase the pains when tardy, should be peremp- toril}^ forbidden. 537. 3d. Inquiry should be made as to the state of the bowels; costiveness should be removed by castor oil, magnesia, or any other mild cathartic, if there appears to be sufficient time for its operation; if not, let it be effected by a simple injection.* 538. 4th. Her dress should be such, as to require no alteration after delivery; therefore, her linen should be so placed, as to be out of danger of becoming wet from the discharges; her petti- coat should be without shoulder-straps, that it may be easily re- moved; and a bed gown should protect the upper part of her body. 539. 5th. The bed should be so arranged as to preserve it with certainty from the discharges; for this purpose a blanket should be folded several times, and placed beneath the under sheets at the part of the bed on which the woman will permanently lie; a sheet as often folded should be placed over the under sheet, so as to correspond with the blanket below ; on this the woman will be placed after delivery. 540. 6th. The woman will be placed for labour upon her left side, at the foot of the bed, in such a manner, as will enable her to fix her feet firmly against the bed-post; her hips within ten or twelve inches of the edge of the bed ; her knees bent, her body well flexed upon the thighs ; this position will bring the head and shoulders near the centre of the bed ; and pillows may be placed to raise them to a comfortable height — the part of the bed on which the patient is now placed, must, like the part on which she is permanently to rest, be secured by folded blankets placed over the under sheet. * A pint of warm watei", and a table spoonful of common salt is one of the best. CONDUCT DURING LABOUR. 189 541. 7th. When the patient is gibout to be placed for labour, the practitioner should withdraw, and leave this arrangement to the nurse ; she should be covered entirely, except her head ; if in winter, by a blanket or coverlet ; if in summer a sheet will be sufficient. 542. 8th. When about to make an examination, choose the time of a pain for this purpose, and to proceed to it with the most rigid observance of delicacy. To the very young practitioner it may be well to observe, that the chair on which he is about to sit, should be so placed that his right arm should be next to his pa- tient: if this be not attended to, his position will be both incon- venient and fatiguing. 543. 9th. Do not remain with the patient longer than the state of the labour may make it necessary. That is, if it be not well- advanced, time should be given for its farther progress ; but from time to time, it is well to ascertain its condition ; but beware of officious and unnecessary touching, for the reason we have else- where assigned. (494.) 544. 10th. Should the pains be efficient, and the os uteri well dilated, or even easily dilatable, and the membranes entire, let them be ruptured by the pressure of the finger against them, or, by cutting them with the nail of the introduced fmger. We are well aware that this direction is very far from being in conformity with the opinions of writers upon this subject; but we are sure, we have not adopted it upon slight grounds; nor proposed it, be- cause it might quadrate with preconceived notions. In directing it, we are certain that experience is altogether in its favour. And this should be done for the following reasons: first, because, when the mouth of the uterus is dilated, or even easily dilatable, the membranes have performed every duty they can perform ; secondly, that very often the advancement of the presenting part is retarded by the strength of the membranes, and the labour much protracted by it; thirdly, that very frequently the pains are increased both in force and frequency, and the labour much abridged by it; fourthly, it gives much greater security to the woman after delivery, by permitting the tonic contraction to take place before it is accomplished, and thus insuring a more speedy delivery of the placenta, and also very much lessening the risk of after-haemorrhage. 545. 11th, When the head is emerging from under the arch of the pubes, the perineal tumour should be carefully supported by 190 OP THE NECESSARY DUTIES TOWARDS THE CHILD. placing the palm of the left hand, with a cloth interposing against it, and retained there until the head is entirely freed from the vulva. 546. 12th. When the head is in this situation, it should not be meddled with; no effort should be made to withdraw the body of the child; its delivery should be trusted to the subsequent con- tractions of the uterus, that this organ need not be too suddenly emptied, and by this means, give rise to floding. Sect. I. — Of the Necessary Duties towards the Child. 547. Having conducted the labour to the delivery of the child, new duties immediately commence; the high importance of which, renders it proper, we should lay down some rules for their fulfilment. 548. The first great object after the delivery of the child, is to establish respiration; for the most part this takes place spon- taneously the instant it is in the world; indeed it very often cries, even forcibly, so soon as the head is protruded through the exter- nal parts. M. Baudelocque has communicated to the Academy of Sciences, a case of Labour, in which the waters being evacua- ted, the face of the child presented to the neck of the uterus, and the child uttered cries as strong as if it had been delivered. Ame- rican Journal of the Medical Sciences for May, 1831. p. 248. But if it fail to cry soon after delivery, attention should be imme- diately paid, that respiration may be established. The child may be born in one of the following conditions. 1st. Feeble, (but not entirely exhausted,) either by the delay in its delivery; by the compression of the cord; or from a delicacy of stamina; these several conditions may be attended by a pulsating cord, or one in which pulsation has ceased. 549. In cases in which the cord still pulsates, there is but little risk, so long as this action continues; and for the most part, all that is necessary is, to remove all impediments from the mouth of the child which may interrupt the passage of air to the lungs; or by dashing upon its body some cold spirits or brandy. This almost instantly makes it send forth cries, that are most welcome to the accoucheur, and are the reward of the suffering mother. But should there be no pulsation in the cord; the body flaccid ; and especially, if upon dividing the funis, only a drop or two of black blood issues from the cut, the case is desperate ; but not al- ways absolutely hopeless. OF THE NECESSARY DUTIES TOWARDS THE CHILD. 191 550. In this case we should, 1st, carefully remove any mucus that may be in the mouth, fauces, or upper part of the trachea, by wiping as far as we can reach with the little fmger armed with a piece of fine dry rag; 2d, endeavour to inflate the lungs of the child by forcing air into them from our own; this must be done by holding the nostrils and applying our mouth to that of the child, and forcibly expiring.* If we succeed in passing air into * M. Velpeau recommends this to be done by means of "a quill barrel, a female catheter, or any kind of canula, introduced into the moudi or nostrils, or by- blowing with the mouth directly into the air passages. The laryngeal tube in- vented by Chausier, having the advantage of pretty exactly filling the glottis when introduced into it, is better than the strait canula of Heroldt; but a simple giun elastic catheter, an instrument which can be got anyiuhere, is almost as con- venient: it is introduced through the mouth, as far as the bottom of the phai-ynx; then while it is passed inwards, the point may be bent with the httle finger, so as to compel it to enter into the larynx rather than the oesophagus; when fixed right, the nostrils and mouth of the fcEtus are closed, and the inflation com- menced. However, if it should be admitted that the experiments tried by Winslow, Heroldt, Schule, Viberg, Schmidt, and Beclard, incontestibly prove that the liquor amnii penetrates during intra-uterine life as far as the bronchia, it would be useful to fi-ee the trachea from it by suction or otherwise, previously to trying inflation ; but there is too much uncertainty upon this point for it to serve as a basis for any practice whatever." p. 564. Dr. Meig's translation. We rarely meet with an assemblage of directions or suggestions, that con- tain so little practical utility, as we do in the above quotations. First, the kind of instrument to be used upon such occasion is far from being satisfactory; for neither the quill, nor female catheter, nor any kind of canula, can be used with any prospect of success, unless one of its extremities pass into the trachea; and this requires no common adroitness, to render its location exact, or profitable. But if this difficulty be surmounted by one of tliese instruments, we are every way certain that violent irritation must ensue, especially from "the quill or any kind of canula," and this we fear without proportional advantage; for we doubt very much whether the lungs can be inflated by these means without the em- ployment of very many more precautions than are recommended by M. Vel- ]>eau. Besides, it would be proper to put every practitioner, but especially the young, in possession of means that can always be commanded, rather thai\ to make him rely upon instruments for this common purpose, that can rarely be procured; but at the loss of so much time that would be fatal to the child — for the loss of five minutes upon such occasions, most commonly seals its fate. For though the "gum elastic catheter may be got anywhere" (that is any- where in Paris) the child would often lose its life, were it required to be sent for out of the house; and in this country, nay even in this city, much time would be lost, were tliis instrument to be relied upon. The apphcation of the accou- cheur's mouth to that of the child, as we have just recommended, is the only means that can be depended upon for the inflation of the cliild's lungs. Second- ly; however M. V. may scout the idea of tlie trachea being at least partially filled with the Uquor amnii, and disregard the precaution of removing it, we do advance upon ow own proper experience, that it Is an accident by no means of 192 OP THE NECESSARY DUTIES TOWARDS THE CHILD. the child's lungs, which is easily known, by the elevation of the chest; and if the air we have thrown in, is not immediately re- turned, we must quickly expel it, by a gentle, but pretty firm pressure upon the thorax; 3d, by placing the child's mouth down- ward, and holding the body and hips higher than the head; at the same time gently shaking the child, so as to disengage any mucus that may be lodged in the trachea: and permitting it to flow from the mouth, by making this the depending'part* — then cautiously wiping the mouth as just directed; renew the infla- tions, and the suspensions alternately, until the mucus flow from the mouth ; by proceeding in this manner, I have often had the satisfaction of seeing the child restored, under very discouraging circumstances. It is every way worthy of remark, that owing to the tenacity of the fluid within the windpipe, we cannot at first force air into the lungs; but, by a little perseverance, we over- come this obstacle, and the mucus becomes sometimes so thinned, as to flow readily from the mouth, and at once relieves the child — this operation should never be neglected ; nor should it be too soon relinquished; especially, if we can excite a few pulsations in the heart and in the cord. Both of these should be carefully ex- amined after each inflation ; the pulsation of the heart is best uncommon occurrence; and that there is no such "uncertainty upon this point," as to render at all doubtful the practice necessary upon such occasions. For we do further aver it as our firm opinion and belief, that we have saved the lives of very many children by the plan recommended in our text. » We regret to find the following passage in Velpeau's directions for the treat- ment of children born in a state of asphyxia—'* there is no reason to believe, that it is either safe or useful to turn tlie child with its face downwards to force the matters contained in the. trachea to escape therefrom." We say we are sorry to observe the above opinion so peremptorily announced; as the authority of M. Velpeau might lead to the neglect of tliis highly important, and in some instances, this indispensable practice. I am every way persuaded, that I have preserved the lives of many children by this mode of management, which with- out it, would have been lost. And we are altogether as certain, that no possible injury can arise from the practice, unless it be from mal-adroitness in the hand- \mv of the child. We are also persuaded that it is vastly more efficacious, and to say the least, as safe, as the direction he gives immediately before for the same piu-pose, namely, to cleanse the mouth by a brush either dry, or dipped in salt and water, and indubitably more rational and efficient than the one that follows; to wit, "supposing the secundines are either wholly expelled, or on the point of being expelled, and that there should be some pulsation in the cord, I should not oljject to keeping them for some time in warm wine and water".'.' M. \'. has not told us however, how the wine and water is to be apphcd to the uiicx- pelled secundines. OF THE NECESSARY DUTIES TOWARDS THE CHILD. 193 detected by placing the ear immediately over its region; that of the cord, by pressing it between the thumb and finger, close to the umbilicus, 4th. By the frequent application of heated cloths; this should be attended to immediately, and persevered in until the last moment of hope. In the August No. of the Lond. Med. and Phys. Jour, we find the following notice, of a method to resus- citate still-born children, which, from the manner it is announced, seems to be considered as new by the editor; at this, we are not a little surprised as the plan has been recommended for many years by us, both in our public and private lectures, as well as in the first edition of this work. Many years' experience has con- firmed the efficacy of the method, though we lay no claim to the suggestion. We cannot pretend to say, at this moment, from whose recommendation we first employed it ; but we are certain, that it has been our method for nearly forty years ; and that we firmly believe we obtained it at second hand. But this is of no consequence. Its almost uniform success renders it valuable; and, if it be not generally known, (as would seem to be the case, from the position it occupies in a widely circulating, and highly useful journal,) it ought to be; especially, as agreeably to the authority about to be quoted, it has succeeded in some apparently hopeless cases. " Mr. J. Toogood, of London, has related some cases in which he has recovered infants apparently dead, after an unusual length of time. In one case, no efibrt was made to respire for thirty-five minutes ; in another, forty-five minutes had elapsed ; in a third, thirty minutes; and in a fourth, the mother's situation was so critical, that the child was not attended to for more than half an hour ; it had been wrapped in a cloth and removed to another room. An attempt was immediately made, and in twenty-five minutes signs of life were manifested ; and in fifteen more, the child breathed freely. Mr. T. has always succeeded in resuscita- ting infants who were living during the birth. He puts no con- fidence in the warm bath, in frictions, nor in pouring stimulants, but endeavours to imitate natural respiration, by placing a napkin over the mouth, pressing out the air from the chest afterwards. When a feeble attempt is made by the child to inspire, the infla- tion should be made quicker; and afterwards a little aq.ammonise or brandy, rubbed over the palm of the hand, and held over the mouth, during the inflation of air, will materially assist the re- covery. I much prefer dry warmth as an application to the 25 194 OF THE NECESSARY DUTIES TOWARDS THE CHILD- child's body, to the warm bath which is so much relied on in such cases; I think the latter decidedly injurious, though I can- not pretend to explain why.* Might not a properly constructed syringe be highly useful in removing the obstructing mucus? 551. When the child shows signs of returning life, it is gene- rally by a deep short sob; which may be repeated at longer or shorter intervals ; but when we think the interval too long, we should renew the inflations, &c. Should respiration be but feebly restored, we should carefully guard against anything like fatigue to the child; it should not on any consideration be disturbed, by dressing; on the contrary, it must be carefully placed in such a situation, as will permit the frequent renewal of the warm appli- cations, which are of primary consequence of the well-doing of the child. I have had more than once the mortification to see all my endeavours frustrated, by inattention to my directions upon this point, though given as impressively as I well knew how. 552. 2d. The ohikl may be born healthy and strong, with a brisk pulsation in the funis, yet not cry; because a mechanical obstruction from mucus prevents the ingress of air into the lungs. This mucus may be in the mouth or posterior fauces, or it may be in the trachea — if in the first, we may remove it entirely by a piece of fine rag upon the little finger, as just suggested; (550) if in the second, by suspending the child as just directed, which will seldom fail to give relief, by permitting the mucus to run from the mouth. I do not recollect an instance, where it was necessary to have recourse to inflation if the pulsation in the cord continued ; but if it stop before respiration be established, recourse must be had to inflation. When the child is about to make at- tempts to cry, I often enable it to succeed, by dashing its body with spirit or brandy as directed above. 553. 3d. The child, from being long delayed in the passage, or from having its neck tightly begirt with the cord, may be still- bornjt in this case its face will be black, or livid, and svvoln — the * Does the warm bath invite too much blood to the capillaries of the sui-face, and thus deprive the general circulation of a quantity that is essential to the well perfoi-mance of this process ? f Very little attention has been paid until lately to the pathological condition of children who die in astate of asphyxia in coming" into the world. It has now atti-acted the attention of the French pathologists, and some curious facts have presented themselves, especially as regards the state of the liver. Andi-alsays, "that a mechanical cause will sometimes produce a congestive state of the hver during the progress of a laboui-, and in those children who die in a state of as- OF THE NECESSARV DTTTTES TOWARDS THE CHILD. 195 arteries may have ceased to beat, or they may beat vigorously — in such cases, nothing can save the child from immediate death, but the instant abstraction of blood by cutting the cord — should the pulsation have ceased, we may sometimes still succeed in drawing some blood by forcing it from the cord, and then em- plojang inflations, &c. ; if pulsation continue, we must also ab- stract blood by cutting the cord — the quantity to be drawn must be regulated very much by its effects — when respiration is esta- blished, we need draw no more; but until some signs discover themselves of this being about to take place, we may abstract pretty freely, as this process most probably is interrupted by the congestive state of the brain, which can only be removed by pret- ty ample depletion. 554, When respiration is established either spontaneously, or by artificial means, we apply a ligature to the cord, provided pulsation has ceased in it; but not until then. The best ligature is a portion of a skein of fine thread; if this be not at hand, a piece of narrow tape or flat bobin will answer perfectly well — it should be applied an inch or an inch and a half from the um- bilicus, and should be drawn sufficiently, to make it securely tight — this precaution is necessary, as otherwise bleeding some- times ensues. We are aware, that it is considered a work of supererogation to apply a ligature to the cord, by some — but this precaution in our opinion should never be neglected; for it is not true as the advocates for this carelessness declare, that "after the child has breathed, and respiration is well established, the circu- lation in the umbilical arteries never returns ;" for we have re- peatedly witnessed the contrary. We have witnessed several nearly fatal instances of haemorrhagy from the umbilicus, where it has been thought that the vessels had been properly protected against this accident. And we find the following interesting case rdated by Mr. Waller, in the London Medical and Physical Journal for February, 1829, Vol. Ixi. No. 360. New Series, Vol. i. No. 32, p. 121. 555. "In one instance there was repeated haemorrhage from the umbilical cord, which so weakened the infant that it died in a few days. This, I apprehend, must have arisen from disease of phyxia, will cause a rupture of the hepatic vessels; and from excessive engorge- ment an effusion is found on the convex surface beneatli the investing mem- brane of the liver. And Billard has found blood effused into the abdomen, in con- sequence of this engorged state of this organ. 196 OF THE NECESSARY DUTIES TOWARDS THE CHILD. the arteries, as there was no less than six ligatures applied, arid by three different persons, (myself among the rest,) notwith- standing which, however, the bleeding recurred at intervals, and the blood was observed to issue not from the part at which the ligature was applied, but from the extremity of the funis." Is this not an instance of a constitutional disposition to hemor- rhage rather than one of diseased arteries? The cord should be cut by a pair of scissors,* half an inch at least beyond the liga- ture — it is never necessary to place two ligatures, except there be twins — indeed, it is best not to do so;t as the evacuation from the open extremity of the cord will yield two or three ounces of blood sometimes, which favours the contraction of the uterus, • Formerly many prejudices existed on the subject of cutting the navel; and even the instrument with which this should be performed. Alphonse Le Roy is, however, the only modern I know, who seriously recommends attention to this point. lie directs, that " we shoidd not cut the cord, but when the pulsa- tion in the cord has nearly ceased." And adds, that, " as regards the moderns, respecting the cutting of the cord, all is negligence or want of care. But among the ancients, it was an act that had its rules, nay even laws; and among cer- tain people, even now, much precaution is exercised." Tliat "the ancients never employed instruments made of iron to cut the um- bilical cord; for," adds he gravely, "it is very dangerous in tliis operation, to do so within the tropics. For if we apply a microscope to the cut portion of the cord, we shall find particles of the metal oxyded, or rusted; and these are more numerous between the tropics, tlian in other climates. These particles exert a deleterious effect upon the wounded cord, which in hot climates, is destruc- tive to the whole economy of the child." "It was," continues he, "with a view to .avoid these dangers, that Moses ordered circumcision to be performed with a sharp-edged stone. And tlie Jews in all countries, witliout understanding tlie reason which governed their law- giver, abide with great ex.actness to his precepts, and never employ Insti-uments made of iron or steel." — Medicine Matemelle, p. 6. and 7. It would be no ways difficult to perceive too much refined specul.ation in these opinions; and no ways difficult to account for Moses employing for tliis purpose a stone instead of iron ; and as easy to prove, tli.at in this and many coun- tries, a well-tempered knife is employed for the purposes of circumcision, in- stead of a rough-edged stone. We liave frequently seen tliis operation perform- ed, and it has always been with a knife of steel. Nor is it reasonable to sup- pose that Moses could have been aware of oxyded particles being left by the knife, even if it were a fact; as the microscope is necessary to their detection. j- "No harm can possibly arise from the application of two ligatures, and we consider it the safer practice." (Lond. Med. and Phys. Journ. Aug. p. 145.) I regret tliat the gentleman who honoured this woi-k with his notice, did not state wliy two ligatures were safer than one. An experience of more than forty years, has not furnished me with an instance, in wliich inconvenience has result- ed, wliere only one has been applied. THE UNASSISTED DELIVERY OV THE PLACENTA. 197 and the expulsion of the placenta — it favours the contraction of the uterus, by the vessels of the placenta emptying themselves, and thereby diminishing its bulk; this reduction proves a gene- ral and grateful stimulus to the uterus, and promotes its contrac- tion; this contraction acts upon the placenta, so as to disengage it from its surface, that it may be expelled, soon after the child is born. Sect. II. — The Unassisted Belivery of the Placenta. 556. After the child is separated from the mother, it is to be given to the nurse, and removed from the bed-side — the next duty is to deliver the placenta — but before this is attempted, we should first ascertain the condition of the uterus, by examining it through the parietes of the abdomen, by placing a hand over its region. This examination will discover this organ in one of two condi- tions: namely, contracted, or not contracted. If the first, the placenta may be delivered, provided it be loose in the vagina, by tightening the cord with the left hand, and tracing it with the fore-finger of the right to the placenta, which is to be hooked with the introduced finger, and gently drawn by the cord with the other hand, until it pass through the os externum — we should then grasp it with both hands, and give it several twirls, to twist the membranes, that they may be entirely withdrawn from -the uterus — the advantages of this proceeding are, Ave prevent a ter- rible stench; and occasionally, alarm; for we have known them, when about to escape from the vagina some days after delivery, lo excite great terror in the patient and her friends ; by their being mistaken for a falling down of the uterus. 557. When the placenta is delivered, it is to be carefully placed in a basin, or pot, and removed — the abdomen should again be examined; should the uterus be well contracted, which is easily determined by its hardness and size, we should entertain every reasonable hope, that everything is going on so far well ; but should the uterus be found flaccid, brisk frictions with the open hand, with the occasional grasping pressure of the fingers, should be instantly made. Should these be successful, the uterus vvill be found to harden gradually, as well as to diminish in size under the hand. At this moment, perhaps, there may be a sudden dis- charge of coagula from the vagina, accompanied by some pain, which very fi-equcntly alarms the inexperienced practitioner, and 198 OF AFTER-PAINS. renders him doubtful of the propriety of the plan he is pursuing; but so far from being alarmed at this circumstance, he should fe- licitate himself upon it ; as it is a proof that the uterus is con- tracting. These frictions should, however, be continued for some time; or until the uterus becomes very hard, and appears to be disposed to retire within the pelvic cavity. Sect. III.— Of Putting to Bed. 558. As the patient is usually delivered at a part of the bed distant from where she is to be permanently placed, the removal from one to the other, is familiarly called " putting the patient to bed." This operation consists of several details, w'hich are highly important to be wxll understood by the young practitioner; though the executive part does not strictly belong to him. " Put- ting to bed" consists, first, in the entire removal of all the wet things that may be about the woman, and substituting dry ones; second, in her being lifted or slid into the place where she is permanently to lie; third, in the application of a bandage over the abdomen, pinned as tightly as the patient can bear with comfort. 559. It may be asked, is every woman to be put to bed so soon as .she may be delivered? certainly not; the "putting to bed," must be governed by the following circumstances: first, if the patient be very much exhausted by the severity of the labour, by a previous flooding, or any other circumstance that may render her feeble or faint, she must not be removed until she recover some of her spent strength, should this require even several hours; second, should the patient, from her exertions during labour, or the heat of the weather, be in a perspiration, she should not be disturbed juntil this has gone ofi' entirely; third, should there be too great a discharge or flooding, the patient must not be moved, until this is much diminished or stopped. But if neither of these conditions present themselves, it is best to direct the patient to be put to bed immediately, as I am persuaded she will bear it better, than if suffered to remain any time. Sect. IV. — Of ^fter-pams. 5G0. Almost every woman, with the exception perhaps of the first child, is tormented with what are called "after-pains," these pains are produced by the renewal of the alternate contractions of OF AFTER-PAINS. 199 the uterus in consequence of coagula forming from time to time, within its cavity, and now being foreign bodies, efforts are made by the uterus to expel them. These coagula are formed by the blood flowing into the cavity of the uterus from the extremities of the vessels exposed by the separation of the placenta — and they will form in proportion as the uterus may be more or less disposed to contract ; therefore it is found, that the more this organ is closed by virtue of its tonic power, the fewer and milder will be the "after-pains:" hence these pains rarely occur with the first child, as the tonic power of the uterus is then more perfect, or less exhausted. There is a circumstance attending these pains, which deserves notice, though it may not be easily explained; which is, their almost uniform renewal, upon the application of the child to the breast, though they may have been suspended even for hours; and the aggravation of them, if they have not been interrupted. 561. These pains, by the old women, are considered useful, because they are almost always accompanied by the discharge of coagula, which they say must come away, and on this account they oftentimes refuse to give anything for their relief. But this doctrine, were it strictly acted upon, would subject the patient to most unnecessary tortures, sometimes for many days together — I have ever regarded after-pains as an evil of magnitude, and always endeavoured to prevent them as quickly as possible — they interrupt sleep, which is at this time of especial importance to the exhausted woman, as well as needlessly excruciate the body. 562. I generally prescribe camphor for their relief, and in the following form : R. Gum Camph. 3j. Sr. vin. rect. q. s. f. pulv. — Adde Pulv. G. Arab. 3ij. Sacch. alb. 3ij. Aq. font, ^vj— M. Of this, a table-spoonful is given every hour or two, or oftener, until the pains cease — or, I sometimes give ten grains of this substance finely powdered, every hour or two, mixed in a little syrup of any kind; this appears to answer nearly as well as the julep just mentioned. 563. The camphor, in two or three instances, has disagreed with the patient, though it relieved the pain. In these cases, it produced most distressing feelings: as head-ache and delirium; 200 OF AFTER-PAINS. but they soon disappeared upon desisting from it* — it has a de- cided advantage over opium; for in many instances it can be given where the opium is altogether improper, either from the state of the pulse, or idiosyncrasy ; besides, it more certainly gives relief. I think, however, that the relief is not quite so permanent as that procured by opium ; and therefore, we are sometimes obliged to re- peat it more frequently. Should the camphor fail to give relief, or constitutional peculiarity render it improper, vve must give the opium; provided, there be no circumstance of the system, as fever, which would make it inadmissible. I have in a few instances been obliged to let blood, from the high action of the arterial sys- tem, before I could venture upon the use of opium; but these cases are rare, though of high consequence to be well understood in practice. I have, however, given the camphor, where 1 dared not venture upon the opium; and this is important to know, as preparatory bleeding always excites alarm. 564. We often find patients who cannot use opium in any of its common forms, in consequence of its disagreeable after-ef- fects; such as severe head-ache, and distressing sickness of sto- mach.t But these consequences may very often be prevented by mixing the laudanum with vinegar instead of water; or using the acetated tincture of opium, or black drop. When used, it should be in such doses as will quickly make an impression upon the system— I therefore always begin with a dose of fifty or sixty drops, and repeat it every half hour or hour, until relief is pro- cured; if the black drop be made choice of, it should be given in half the quantities of the laudanum. If this plan be persisted in for a short time, it will certainly relieve the patient. % * In one case, the unpleasant symptoms were so excessive, as to oblige me to give .in emetic of ipecacuanha. As soon as the camphor was thrown up, the patient was relieved. But these are extremely rare cases; and were I to institute a comparison, I would say, that opium disagrees five tunes as often as camphor. + Dr. Hare has pointed out a method of freeing opium from its narcotine^ and laudanum is now prepared from the residue, with the great advantage of not producing any, or but in a very shght degree, the distressing effects of that made in the common way. We regai-d tliis, among tlie happiest and most im- portant discoveries of modern Chemistiy. 4: Until the « denarcotised laudanum," gets into general use, as it certainly will, the plan recommended in the text may be pursued with advantage. Dr. Physick informs me, that he is in the habit of using a few grains of the carbo- nate of soda or potash, with the same good effects. OP AFTER-PAINS. aOl 565. I have met with a few cases of a very distressing kind of after-pain, which I have not seen noticed by writers. It is a most severe and constant pain at the very extremity of the sacrum and coccyx; it begins the instant the child is born; and con- tinues with the most agonizing severity, until overcome by the rapid and liberal use of camphor and opium. It is declared by the patient, to be vastly more insupportable than the pains of labour; for it is as intense, as unceasing, 566. The first case of this kind I met with, occasioned me no little anxiety and perplexity, from its novelty and severity. It was the case of a young lady with her first child — it began most severely, the instant the child was born; and its intensity was such as to make me abandon the delivery of the after birth, to attempt the relief of my patient. I at first looked upon it as only a protracted after-pain, which I had not expected to encounter with a first child. I immediately gave a large dose of laudanum, and repeated it in fifteen minutes — and at the end of the second quarter of an hour, as there was no abatement of the sufiering, I again gave the laudanum — these doses procured no relief, in half an hour more; though, in the three portions exhibited, more than two hundred drops of this medicine were given, in the course of half an hour. I was obliged now to suspend the repetition of the laudanum from a fear of an excess in its exhibition; but, to amuse the patient, I gave her a few drops at a time, disguised by a little of the compound spirit of lavender, until an hour had passed. By this time the patient thought herself easier; but still suffered very severely — I now ventured upon another full dose of laudanum, and sat down to deliver the placenta: this was readily done, and it was found lying loose in the vagina; but its expulsion procured no abatement of sufiering — in a word, nearly five hundred drops of laudanum were administered, before complete relief was ob- tained. After she became easy, she had no subsequent return of this pain ; nor did she suffer in the least, from the use of so large a quantity of laudanum, in so short a period. 567. On the termination of her next labour, as she had most anxiously and fearfully anticipated, the same violent distress assailed her. I instantly gave her, at one dose, one hundred and twenty drops of laudanum; this was repeated in twenty minutes — in the mean time, the placenta was spontaneously discharged. This second dose afforded no relief; and I was then induced to administer the laudanum at short intervals, which, as before, 26 202 OF AFTER-PAINS. eventually overcame the pain — as happened on the former occa- sion, she suflered no return of this pain after it had once been subdued. 56S. On her third confinement, I was again distressed to find a recurrence of this terrible agony. I had however, from my former experience in her case, anticipated this event, and had at hand the following julep: 1^ Gum Camph. 3ii. Sp. vin. rect. q. s. f. pulv. — Adde Pulv. G. Arab. 3iii. Tinct. opii acetat. 3iiss. 01. Juniperi. gut. xx. Sacch. alb. q. s. Aq. font. 5vi, M. Of this, a large table-spoonful was given about fifteen minutes before I expected the child to be born, by way of making some impression before the pain should come on. The child was born rather within the period I had calculated; and, as on the two for- mer occasions, the pain commenced the instant it was in the world; another spoonful of the julep was immediately given, and this was followed by another in fifteen minutes more, which decidedly abated the severity of the pain; and I had the satisfac- tion of seeing it entirely conquered, in an hour from its commence- ment; a period less by one half than on the former occasions. The placenta came away without trouble, as it had always done before. I thought it evident, that the combination of camphor with the opium was highly beneficial; and, perhaps, they were aided by the oil of juniper, which I had frequently found very useful in controlling after-pains. On her fourthdelivery she was managed precisely as above related, and "with the same happy eflects. * 569. The second and third cases which fell under my notice, were treated with camphor julep, as above stated, and with the same happy results. Can this pain be considered as a modi- fication of after-pains? I am disposed to think not; as its com- mencement is too sudden, and its duration too uninterrupted; besides after this pain has ceased, the part no longer becomes the seat of pain, should after-pains follow. That strange variations in the seat of after-pains occasionally take place, I have witness- * This lady suffered in the same manner with her fifth and sixth cliildren. OP AFTER-PAINS. 203 ed; but in all the Aberrations I have observed, the change of seat did not alter the cliaracter of the pains — for they were all of the alternate kind, and as regular, as if they were seated in the uterus. One of the most remarkable I remember to have met with, was where the after-pains were located in the right knee; and this peculiarity in seat, obtained with every child this lady bore. 570. 1 am of opinion, however, that much may be done before the labour is finished, and immediately after, to abate the seve- rity, if not to prevent the occurrence of " after-pains." During labour; 1st. By rupturing the membranes whenever the mouth of the uterus is sufficiently dilated to permit the head to pass, that the tonic contraction, may immediately ensue; by this the follow- ing advantages result as regards the prevention of "after-pains:'* by the absence of the waters, the uterus is reduced in size, in pro- portion to the quantity discharged; this gives greater strength to this organ, and enables it to contract with more force; and con- sequently, will more certainly diminish the size of the vessels ex- posed by the separation of the placenta; as these, by pouring out blood, give rise to these "after-pains;" (193) again, it prevents the uterus from being too suddenly emptied; and thus inducing a state of atony in it — for it must be remembered, that "after-pains," are never more certain, nor ever more severe, than after a very quick labour. 2d. By permitting the uterus to finish the labour after the head is born ; in doing this, we have an assurance that the tonic contraction has regularly followed; as the uterus be- comes more and more empty ; for, were this not the case, the al- ternate contractions would be feeble and transitory, as always happens, when the shoulders are about to be hurried through the external parts and the uterus too suddenly emptied; in this case the tonic contraction of course is imperfect — consequently, the vessels exposed by the separation, and departure of the placenta, are not pressed upon by this power; and consequently blood is freely poured into the cavity of the uterus, where it coagulates, and obliges the uterus to throw it off by repeated contractions. 3d. After the delivery of the.child, we may do much by not at- tempting the delivery of the placenta until we have ensured the tonic contraction of the uterus, by frictions as before recommended, over the hypogastric region; and after its expulsion to repeat them, until the uterus seems to retire considerably within the pelvic cavity. Burton's success, (though I should be but little disposed to follow his practice,) in preventing ''after-pains" by the intro- 204 or AFTER-PAINS. duction of his hand to the fundus of the uterus, and kept there until he found this organ contracting upon it, depended precisely upon the principle I have been endeavouring to establish; namely, promoting as quickly and as certainly as possible, the tonic con- traction of the uterus. 571. It must, however, be admitted, that neither camphor nor opium is always successful in calming these distressing contrac- tions of the uterus; they sometimes persevere with great obsti- nacy, even after the faithful trial of both these remedies; while in other cases, no form of opium can be made to suit the peculiar idiosyncrasy of the patient, and to some the camphor is altogether disgusting. In such cases it may be highly useful to exhibit the hydrocyanic acid, as recommended by Dr. Von dem Busch, of Bremen. 572. As this is a new remedy in spasms of the uterus; and as its effects were highly satisfactory to Dr. Von dem Busch, I will subjoin the two cases related by him in Hufeland's Journal for September, 1826. 573. Case I. "Madame N. aged thirty-three years, was safely delivered in the morning of the 14th May, 1821. A short time however after she was put to bed, she was attacked with a violent vomiting, and severe after-pains. She was visited an hour after by her physician ; she had by this time vomited five times, a green, bitter substance like bile; the pulse was full and hard; the abdo- men tense, and tender to the touch; the skin hot, but the face not flushed ; tongue clean, and thirst great. The patient complained of pains in the uterus; and when they became very violent, they excited nausea and vomiting. The lochia was very sparing. Three drops of the hydrocyanic acid mixed in an ounce and an half of syrup was given by tea-spoonful every hour. In the evening the pulse had softened, the patient had vomited but twice; the abdo- men still painful to the touch; nausea continued, but the after- pains were much less frequent. The lochia returned in abundance during the night of the 14th, and the day of the 15th, after hav- ing repeated during the day the mixture; it was now given but once in three hours, as the pains had entirely disappeared. This lady lias been twice delivered since; in both she again suffered with after-pains, but not accompanied by vomiting; in both cases she was relieved by the same remedy." 574. Case II. "Madame S. a well-made robust woman, twenty- eight years of age, was always delivered safely, and without any THE REGIMEN DURING THE MONTH, &C. 205 thing unpleasant following her labours. But in her fourth delivery, the after-pains were so violent as to cause convulsions. The lochia were nearly suppressed ; the pulse full and hard ; the tongue clean, and the skin hot ; pressure on the hypogastrium increased the pains. Four drops of the hydrocyanic acid in two ounces of syrup were ordered ; of this a tea-spoonful was given every hour and a half. The pains subsided presently, and by the time the mixture was finished, they had ceased entirely ; in the mean time the lochia returned to their healthy condition.'^* Sect. V. — The Regimen During the Month, S,'C. 575. There is no vulgar error more replete with mischief, than that which supposes the woman to be in a state of great debility after delivery, and to require the most nourishing, and the most stimulating things to overcome it — hence the destructive use of ardent spirits, wine, cordials, spices, animal food, and broths, &c. &c during the whole period of confinement. We cannot too de- cidedly set our faces against such practices; and with a hope of preventing them, we should give to the nurse the most explicit directions, as well as the most positive injunctions, with regard to the regimen of the patient, before we leave the room; and we should see as far as may be in our power, that our instructions are carried rigidly into execution. 576. Should we have reason to suspect, or have positive evi- dence that they have been departed from, we should at once, with- out regard to the nurse's experience or respectability, tax her with this disobedience — for it must be recollected that the whole re- sponsibility lies with the physician; and if he do not support his instructions with proper firmness and dignity, and see them cor- rectly acted upon; if he pass in silence the improper conduct of the nurse, he will constantly and evermore have his directions infringed, and his skill and experience, be them what they may, rendered nugatory. 577. But to return to the regimen proper in the month; I de- sire that the patient ma7/ not have animal food, or broth from any animal substance; that she may take neither distilled nor fermented liquor; nor any stimulating tea "to dispel wind," or "to allay after-pains," or to "promote the lochia." I direct she should have gruel of oat meal, tapioca, sago, panada, mush * Revue Medicale, &.c. for April, 1827. 20G THE REGIMEN DURING THE MONTH. and milk, rice and milk, tea, coffee, or very thin chocolate. I permit to be seasoned with sugar, a little nutmeg, or lemon juice, any of the articles above enumerated, in which it would be proper to use them. I permit the use of toast-water, barley- water, molasses and water, or balm-tea as common drinks; or what is very often extremely grateful to them, apple-water — that is, a roasted apple or more, well beaten with water, and af- terwards strained. This diet is to be observed strictly until after the fifth day; or until the milk has been freely secreted, and is easily extracted — after this time, all things being right, she may be allowed the soft ends of four or five oysters, or a poached egg, a little chicken-water, beef-tea, or vegetable soup may fol- low, until about the tenth day: then, (nothing forbidding,) she may indulge in a little ale, or porter and water at her dinner ; and if requested, a table-spoonful of white wine may be added to the gruel, &c. This plan I persevere in until after the fifteenth day; at which time she generally may take some animal sub- stance, such as broiled or boiled chickens ; birds of almost any kind ; a piece of beef-steak, mutton-chop, &:c. 578. The child should be put to the breast, as soon as the mother is well-rested from the fatigue of labour; this is an im- portant direction ; and should not, without very strong reasons, be neglected: the advantages of this early application of the child to the breast, are; first, the child keeps the faculty, (if we may so term it,) of sucking, with which it is born; for if this direction be not attended to for several days, because, as they say, the mother has no milk, it will lose this faculty, and much trouble will be given to recall it — I have witnessed this consequence but too often; second, the child's mouth will by its gentle action upon the nipple, gradually stretch it, and accustom it to exten- sion, before the breasts become tender, and swelled with milk; third, by the nipple being stimulated by the child's sucking, an earlier secretion of milk takes place; fourth, the milk will be drawn off, nearly as fast as formed; which will prevent the pain so constantly arising from its accumulation, as well as the swell- ing, which is almost sure to follow its formation. This swell- ing, if it take place, shortens the nipple, and renders the extrac- tion of the milk more difficult; this increases the efforts of the child, by which means the external covering of this important little organ becomes irritated, and sore, to the great misery of the mother, and serious injury to the child; fifth, the early se- THE REGIMEN DURING THE MONTH. 207 creted milk possesses a purgative quality, by which the infant profits, by its assisting in carrying ofi' the meconium.* 579. It should be directed, that the room be constantly venti- lated; the curtains, if there be any, should always be open; and where we can command, we should forbid them altogether, in warm weather. They should never be drawn, because the woman sleeps, or with a view to protect her from a draught of air; for the woman can sleep without closed curtains; and can by other contrivances be protected against a current of air. She should have a plentiful change of cloths, that the lochia may not become offensive; and, after the third day, she should be per- mitted to wash the parts with warm water, two or three times a day — this last permission is a great comfort to a delicate woman; and should not under frivolous pretences, be denied her. 580. On the third day if the bowels have not been previously opened, the woman should take some mild purgative; castor oil is the best; but where this is disgusting, or should disagree, the calcined magnesia, the syrup of rhubarb, or a little senna tea, will answer extremely well. Should the " after-pains" be very obstinate, and not yield to the common remedies, the castor oil will be found to be the most useful purgative; and has this very decided advantage over every other, perhaps, that, in cases of great pain, laudanum can be administered, if it be judged proper to exhibit it, without interrupting the operation of the oil, though it may retard it a little. A strict attention should also be paid to the state of the bladder — we should never forget to inquire whether the patient has passed water; if she has not, we should immediately order such remedies as are best calculated to remove the difficulty— the most certain is sp. nitri. dul. (sp. »ther. nit.) in tea-spoonful doses, repeated every two hours, until relief be obtained; for, if this fail, it is more than probable no other diuretic will succeed; we are then under the necessity of em- * We are persuaded, that the "milk fever," as it is called, is nearly altog-e- ther of artificial origin, and can almost constantly be prevented. We have been always attentive to tliis subject, and an ample experience leads us irresistibly to this conclusion. In a practice of more than forty years, we have witnessed but two instances of inevitable '« milk fever," In both of these, every pains were taken to prevent the formation of this fever, but in neither did a severe anti- phlogistic treatment prevent it— in botl\ of these cases, the patients were ex- tremely prone to fever from very slight causes. We therefore cannot agree with Professor Dubois, that the " milk fever" is a legitimate traumatic fever occasioned by the separation of the placenta from tlie uterus. 208 THE REGIMEN DURING THE MONTH. ploying the catheter: nor should we delay its employment too long. I have seen much misery, and perhaps danger, in per- mitting the bladder to be too long distended. 581. The following is the mode of using this instrument — the patient must be placed at the side of the bed; the bed should be protected by a folded blanket being placed under her. The finger should be lubricated with a little sweet oil or lard, and the hand introduced under the bed-clothes, so as not to occasion the smallest exposure — the patient's knees must be drawn up, and the labia separated by the points of the fingers — search for the inferior edge of the symphysis pubis under which the urethra im- mediately runs — press this part gently with the point of the fin- ger, and the meatus urinarius will be for the most part, readily discovered — when found, keep the extremity of the finger upon it; then, with the other hand guide the catheter along it until it reach the orifice, and is inserted into it; press it gently back- wards and upwards, until it enter the bladder; and prevent the immediate issue of urine, by placing a finger upon its external ex- tremity until the vessel is handed, which is intended to receive it this is to be so placed, as to prevent the escape of the urine upon the bed — when all the water is discharged the instrument must be withdrawn. This operation must be repeated until the bladder regains its powers, and is capable of discharging its con- tents it sometimes becomes necessary to do this twice or thrice a day; but in general once will do.* • "If it were our only purpose, in such cases, to prevent the woman from suffering' pain from the suppression of urine, it is true that the use of the ca- theter once a day 'will generally do.' But we have a much more important objectin view,— to prevent the natural power of the bladder from being so far weakened by over distention, that a very considerable time may elapse before tlie patient is able to pass her urine. We have known the use of the catheter necessary for many weeks, in consequence of the contractile power of the blad- der having been lost, from the water not having at first been drawn off more than once in twenty-four houi-s. We differ then from our author, upon this pomt. The introduction of the catheter once a day, ought never to be considered sufficient." (Lo7id. Med. and Phys. Journ. Aug. 1825, p. 148.) The reviewer says that he and I differ upon the subject of the catheter — but we certainly do not : on the contrary, we perfectly agree. My practice ever has been, to draw off the urine, whenever distention was evident; did this require three or even four introductions of the catheter, in twenty -four hours. But more cases have occurred, where once a day was sufficient, than where a more frequent use of tlie catheter was necessary; nor have we ever witnessed a case, which required a continuance of this operation beyond a week. In Europe, this necessity is both more frequent, and much more urgent ; owing to the much greater frequency of contracted pelves, or tedious labours. OP THE LOCHIA. 209 Sect. VI. — Of the Lochia. 582. The discharges which take place from the uterus after delivery, arc called the "lochia" — they proceed from the extre- mities of the vessels exposed by the separation of the placenta; and will of course be in proportion to the extent of surface this mass may have occupied in the uterus; the number and size of the vessels concerned; and the degree of contraction the uterus may exert. Should the tonic contraction of the uterus be imperfectly performed, an hc-p.morrhage will be the consequence; but when more perfectly contracted, the discharge will not amount to a flooding; but would yield the lochia. Much con- sequence is attached to these discharges; the good old gossips of almost every country are of opinion that the freer they are produced, the better; and are always better pleased with a super- abundant, than with a sparing quantity — it is proper therefore, before we proceed farther, that wc determine the real nature of this evacuation. 583. As the uterus never contracts with so much force imme- diately after delivery, as to stop the mouths of all the exposed vessels, a quantity of blood must necessarily proceed from the extremities of such as are open ; and this quantity will be in pro- portion to their capacities, though perhaps these vessels are now much reduced in size; while on the other hand, the quantity dis- charged, will be constantly diminishing in the exact ratio of re- duction; it must therefore follow, there is no definite quantity to be evacuated, but will entirely depend upon the contingency, of the more or less perfect condition of the tonic power of the ute- rus. This being true, it must also follow, that the quantity dis- charged will differ in each individual, and in the same individual at each particular labour; consequently, there can be no rule upon the subject. The absolute use of this evacuation appears to be, to give the uterine vessels an opportunity to contract, by gra- dually relieving themselves of the engorgement to which they have long been subject from pregnancy, by pouring a part of their contents into the cavity of the uterus; and that, so soon as this engorgement is relieved, all the purposes of the evacuation are answered: for the extremities of the vessels, which open into the cavity of the uterus, cannot return the blood they contain into the circulation, as their anastomoses are destroyed, by their 27 210 LOCHIA, EXCESSIVE. terminations being opened; they therefore part with it, and thus form the lochia; and they will do this, until the tonic contraction is so perfect, as to shut up their exposed extremities — therefore, as a discharge, this evacuation is of no farther use, than to relieve the vessels of the uterus, and thus indirectly promote its contrac- tion — it may however, injure by its excess, because, it may pro- duce weakness; but cannot injure by its scantiness, when that is the effect of contraction, since this is an evidence of the most healthy condition of the uterus. a. — Lochia, Excessive. 584. As this discharge sometimes injures by its excess, and as that excess must necessarily result from a want of due contraction in the uterus, it follows as a consequence, that we always render an important service, when we can increase the tonic powers of the uterus, and thereby diminish the quantity of the lochia. I have for many years acted upon this principle, and have great reason to be satisfied with it. It is very unusual in my practice, to see the lochia too abundant; on the contrary, very little of this discharge is to be seen after the fifth day, and sometimes it is over sooner. I do not, however, say, that, in the cases just alluded to, there is an entire stoppage of the discharge; but that there is a very great abatement of it, both as regards quantity and intensity of colour. 585. The lochia, however, from various causes, will continue for a great length of time, nay, during the month, or even longer, to the injury of the patient; in such cases, I have made it a rule, to interfere whenever it has continued with any force beyond the tenth day. I have found this discharge sometimes kept up by a febrile condition of the system, occasioned perhaps by an impro- per consideration of the case by the friends of the patient, who could not imagine that any other cause than debility produced the discharge in question ; accordingly, wine, bark, and cordials were given, with a view to arrest it, and thus perpetuated the evil they intended to cure. In such cases there are pretty regu- lar febrile paroxysms, especially towards evening; a quick full pulse, with considerable heat of skin — the tongue furred, the bowels oftentimes much confined; a feeble state of stomach, or a whimsical appetite ; the sleep disturbed and unrefreshing; pain in the back, and an occasional discharge of coagula. In treating LOCHIA, EXCESSIVE. 211 this case we shall have much prejudice to overcome — for that fatal term ^^ clebilifij,^' which has slain its thousands, and its tens of thousands, is always employed against us; "the patient is so weak, she wants something to strengthen her," is the unceasing cry of friends upon such occasions; and, though they will reluc- tantly suhmit to your directions, they will rarely coincide with you as to their propriety. We must not, however, give up prin- ciples, to satisfy the crude notions of friends, upon a point so im- portant to the welfare of the patient; we must prescribe agreea- bly to the opinion we have formed of the nature of the case, after a due consideration of the symptoms, and condition of the vascu- 1 ar system. 586. In cases like these, wc cannot expect to abate the dis- charge, until we shall have subdued the febrile condition of the system; we are, therefore, to begin by taking a few ounces of blood, and opening the bowels freely, with any of the neutral salts, either alone or combined with magnesia; by confining the patient strictly to a vegetable or mild diet, and the entire pro- scription of wine or any other liquor, and all stimulating teas, such as chamomile, centaury, or mint. By forbidding all exer- cise, or even sitting up in severe cases; by placing the patient upon a mattrass, instead of a feather bed; by ordering the parts to be bathed with cool water, three or four times a day. After having bled and purged as just suggested, we may give from a grain and a half to two grains of the acetate of lead, every three or four hours. The following is the formula I generally employ for such purposes: — R. Sacch. Saturn. 3ij. Gum opii. gr. vi. Conserv. Rosar. q. s. M. f. pil. xxiv. 587. During the exhibition of the pills, the state of the bowels should be regarded; and should the febrile condition not be sub- dued by the evacuations already employed, we should again have recourse to the lancet. It will rarely happen that this state of circulation will not yield to this plan; indeed, the very omission of the improper articles which were before employed, will very much aid us in our endeavours. After the system is freed from fever, we shall find advantage in the employment of some gentle tonic; the elixir vitriol, in doses of fifteen or twenty drops, three or four times a day, in strong red-rose-leaf tea, properly sweet- 212 LOCHIA, EXCESSIVE. ened, is a very useful, as well as grateful remedy.* It must be observed, the acetate of lead may be suspended, if it does not con- siderably check the discharge in the course of five or six days; and should always be intermitted when the vitriolic acid is given. Should the complaint not yield to this plan in a reasonable time, I have seen much advantage from injections per vaginam, of the acetate of lead and water, a little warmed, and thrown up, three or four times a day; this should be made so as to have ten grains of the acetate to an ounce of water. 58S. At other times, the system seems to be rather prostrated by the profusion, or the long continuance of the discharge: when this is the case, the elix. vitriol., as above directed, should be given freely; the tincture or extract of rathana will also be found highly useful, as will sometimes the alum whey: the parts should be bathed as just directed: the patient should be kept quiet, as above suggested; and the injections be had immediate recourse to; this plan will generally prove quickly serviceable. 589. There is another condition of the lochia, which is not only very troublesome, but from its offensive smell extremely loath- some; this is where the coloured discharge has disappeared, but is succeeded by a profuse watery one, of a greenish colour; and from this circumstance is called by the old women the " Green water;" it is frequently so acrid as to excoriate the parts over which it flows; and always extremely offensive in smell. The woman is almost always much debilitated by this noisome evacu- ation ; and, in some few cases, I have seen a kind of hectic dispo- sition supervene. 590. The system almost always in these cases requires the use of tonics — the decoction of bark and the vitriol, should be freely given; and the patient allowed a generous diet, with either ale or porter, in moderate quantities at dinner. The parts should be frequently bathed with lukewarm water; and injections of strong chamomile tea, in which a piece of quick-lime has been slacked and permitted to settle, should be used per vaginam, four or five times a day — these injections, like all others I have directed for the vagina, should be a little warmed. This complaint, as far as I have observed, has always yielded to this plan of treatment. A chlo- * A pint of boiling water is to be poured on an half ounce of red rose leaves, and allowed to stand; strain, as wanted,- when cold — sweeten to taste, and g-ive a wine-glassful, with or without the elixir vitriol as may be judged most proper. If used without the vitriol, it may be given every two hours. OF WASHING THE CHILD. 213 ruret of lime or soda is also highly useful, and may be used per vagi nam three or four times a-day. 591. It may be thought incumbent on me to say something, oa that condition of the lochia, where this discharge is too sparing — but I have already said, I looJc upon this as a favourable sign in the ordinary course of things; when it exists as a symptom of another complaint, that complaint must alone be considered. Sect. VII. — Of the Mtentions necessary to the Child. 592. Hitherto we have been considering the attentions due to the mother, together with some of the most common complaints attendant upon delivery: I shall now say a few words upon the demands of the child. Under this head, I shall first direct its washing; 2d, dressing of its navel; 3d, the medicines proper to purge oflf the meconium; 4th, its food. a. — Of JVashing the Child. 593. The child's body, when first born, is almost always co- vered with a tenacious unctuous substance, which is rather trou- blesome to remove. It has been analyzed by Vauquelin and Buniva, and found most to resemble fat — they have not disco- vered anything which readily unites with it. It is, however, as- certained, that hog's lard answers better than anything else that we know of to detach this substance from the skin. When the lard has become well incorporated with this coating, it can be re- moved by strong warm soap-suds, and a piece of flannel, or sponge. It should be carefully taken off at the first washing, as it some- times encrusts, and excoriates the skin, when this is neglected. The child, during this process, should not be unnecessarily ex- posed — if it be cold weather, it should always be washed near the fire ; and should be carefully dried after the washing. Many nurses have a preposterous, and, as I believe, an injurious practice of using brandy or some other liquor, when they wash the child; and especially when they wash the head — this practice should be forbidden ; as I am persuaded that it has oftentimes been very in- jurious to the infant. After washing, the next thing to be attend- ed to is, b. — The Dressing of the Navel. 594. Much ceremony was formerly observed in the perform- ance of this office ; but it has now become a process of great oim- 214 PURGING OFF THE MECONIUM. • plicity, among the more enlightened part of the civilized world. It would be idle to enter into all the details suggested by igno- rance, or craft, for the due performance of navel-dressing. A variety of medicaments were, and in some places are still in use for this purpose; all of which, to say the least of them, are alto- gether unnecessary. The only necessity for applying anything to this part is, to prevent the dead navel-string from coming in contact with the skin of the child; it would therefore matter not, as regard the cord itself, if it were not touched by any dressing. Dress it as we may, it will always separate at the umbilicus; and our whole care should be to prevent this putrefying mass from excoriating the skin. Though the dressing of the navel is not strictly the accoucheur's province, nevertheless as it may be re- quired of him, he must not be ignorant upon a subject, to which the world at large, attaches so much consequences, however lightly he himself may think of it. 595. All that is necessary, is, to pass the remaining portion of the cord through a hole in the centre of a piece of linen rag, seven or eight inches in length, and about two and a half broad. After the cord has been passed through, it must be enveloped entirely by a bandage of ten inches long, and rather less than an inch broad, by passing it round, its whole length. The pierced piece of rag is placed lengthwise, as regards the child's body; on this the wrapped up cord is laid, with its extremity towards the breast of the child; the inferior portion of the first rag is then folded over it, and the whole secured by the belly-band; after this, the child is dressed as fancy directs, or as circumstances may force. c. — Purgiiig off the Meconium, 4*c. 596. The propriety of purging off the meconium is no longer doubted; especially, in hot climates. It has been found very much to lessen the mortality among the new-born children of the West Indies, and other similar climates, by preventing that very common, and but too often fatal disease, called the jaw-fall, or the trismus nacentium. This practice should never be neglect- ed, even in this country. It might be difficult to say exactly, of what the meconium is composed; but it would seem certain, that bile is one of its constituent parts, agreeably to the analysis of Vauquelin ; and the other, in part, is, the recrement of the secre- tion from the mucous membrane of the intestines; the finer parts PURGING OFF THE MECONIUM. 215 having been absorbed.* This substance is sometimes of very con- siderable tenacity, and a dark bottle-green; this colour is de- rived from the admixture of bile. 597. For the purpose of carrying off this substance, it is found that a little molasses and warm water is generally sufficient; I always order two or three tea-spoonsful to be given at once, and repeated from time to time, if the previous quantity be not suffi- cient — this rarely fails; especially, when aided by the early se- cretion of the mother's milk.,t Should this fail, the child becomes fretful and uneasy; and oftentimes will moan, or cry loudly; be- come sleepy; frequently start; and by its complainings, show it- self to be ill at ease. When we find this to be the case, we should inquire into the state of the evacuations; and if these have not been sufficiently liberal, which is easily determined by their con- tinuing to be tenacious and green, we should direct a small tea- spoonful of warm castor oil ; this must be repeated, should it not operate in a couple of hours; or a mild injection of warm milk • It would seem to be proved, by a case related by Dr. Rees (on Costiveness, p. 137.) on the authority of Mr. Hallam, that the meconium is a combination of the recrement of some digestion, perhaps bile, and a peculiar secretion from the intestines themselves, (but perhaps, especially of the colon) and not the remains of food taken in after birth, or as some have supposed, of nourishment received by the mouth dui-ing the stay of the foetus in utero. Mr. H. delivered a patient of a *' fine muscular, fat, and healthy child, which had an impervious oesopha- gus, so that no food ever passed into the stomach. The child Uved thirteen days; but was so wasted that its skin hung like a loose garment, and could be lapped and folded over its limbs. At first the child discharged the usual quantity of meconium from the bowels, and afterwards had, during eight days, one or two alvine discharges, in quantity, colour, and consistence, not distinguishable from the stools of children who took food in the usual manner. After the eighth day tlie faecal discharges became more scanty and less frequent, but they continued to the last." A similar case has just fallen under my own observation. A child was born with every external appearance of healthy conformation — but upon attempting to give it a little molasses and water it had nearly strangled. Upon looking into its mouth it was discovered, there was no vault to it; neither was there a ves- tige of soft pallet. It never swallowed a drop — indeed every attempt was fol- lowed by such terrible distress, by the fluid passing into the trachea, that the trial was abandoned. It lived however ten days — ^became extremely emaciated and very yellow; yet it passed the meconium freely; after which the evacua- tions were yellow. f This is an additional argument, for the early apf)lication of the cluld to the breast; since the first secretion of the breasts is of a purgative quality. This product is called " Colostrum." 216 OP THE RETENTION OP URINE. and water, with some molasses dissolved in it; will answer very well to aid the action of the oil. 598. I must earnestly protest against the use of any acrid pur- gative, for the purpose of carrying off the meconium — nurses and midwives are too apt to employ them, when this part of our duty is left to their discretion. I therefore make it a rule to point out the remedy to be employed, without permitting them the smallest latitude. Their ignorance frequently betrays them into indiscre- tions; and this sometimes to the absolute injury of the child. I have too frequently witnessed this, not to feel it a duty to inveigh most pointedly against it. 599. Dr. Buchan, in his pleasant and useful little work, "Ad- vice to jNTothers," relates an anecdote so much in point, that I am induced to quote it at length; "I was once sent for by an inti- mate friend, to look at a new born-infant, who appeared to be in great agony. I soon discovered the complaint was the belly-ache, caused by some injudicious purgative. As the midwife was pre- sent, I remonstrated with her on the rashness of thus tampering with an infant's delicate constitution. She replied, in a tone of self-sufficiency and surprise, 'Good God! Doctor, I only gave the proper medicine to carry away the economy.'''' I should have smiled at her affectation of medical cant," adds the Doctor, ''and her ridiculous attempt to catch the word 7neconiu7n, had not the serious mischief she had done repressed every motion of laugh- ter." A medical friend told me some time since, that he was called to a newly-born infant, which was dying in great agony from a dose of aloes, exhibited by the midwife. 600. There is oftentimes much mischief arising from over- purging newly-born infants; they therefore not only require very mild remedies, but proper doses of such remedies — and there is one rule by which these exhibitions should always be governed ; namely, that so soon as there is a change in the colour of the evacuations, all purgative medicines should instantly be withheld. d. — Of the Retention of Urine. 601 . It very frequently happens with newly-born children, that they do not pass their urine for many hours afterbirth; or so sparingly as to afford little or no relief; this creates a great deal of distress, and if not relieved by proper means, will sometimes occasion death. A very remarkable instance of this kind fell un- der the notice of my friend Dr. Parrish, and myself, which I will OP THK RETENTION OF UKINE. 217 give in detail. Mrs. was delivered of a healthy baby on the 15th June, 1822. On the 20th, in the evening, the child showed uneasiness, and on the 21st it cried violently, and continued to be much pained until the 25th. A variety of simple means were in- effectually used for the discharge of the urine, which had been either very sparing, or entirely suppressed, most probably from the 20th. On the morning of the 25th, at ten o'clock, we found the abdomen very much distended, even to the scrobiculus cor- dis; the skin shining, and the superficial veins very much en- larged. The child had several very sparing stools, of a very dark green colour: two tea-spoonsful of castor oil were given in the course of the morning. At half past one o'clock, P. M. Dr. Parrish introduced a small flexible catheter and drew off at one time eighteen ounces and a half of a straw-coloured urine. At seven o'clock of the same day, the child appeared perfectly reliev- ed; it slept soundly, and took nourishment freely; two more tea- spoonsful of castor oil had been given since the visit at noon, but without moving the bowels, nor did any water pass — as the child was easy, it was permitted to rest without disturbance. 602. From this time until it died, (on the 28th,) the water was regularly drawn off by the catheter; the child, however, gradu- ally declined from our first visit; and its mouth became very sore; leave was not obtained to examine it. 603. I have recorded this case for its great practical importance. I have seen several instances similar in their general appearances, and terminations; vv'hich gives me strong reason to believe, that these children may have died of a retention of urine, though I was assured that they had regularly passed water — such was the state- ment for awhile, in the case just related; and perhaps there may have been a small discharge, as always happens when the bladder becomes excessively distended. This often takes place in the adult, from the same cause; it is therefore a good rule to inquire into the state of the bladder, in all the complaints of very young children ; and we must not be too easily satisfied with the re- ports of the nurse upon this subject — I now make it my business, whenever I have any suspicion that the urine is not freely evacuated, to examine the abdomen of the child, especially if it be reported to be swelled. I carefully examine the region of the bladder, with a view to detect any distention of it, that I may take measures accordingly. I am disposed to believe, had the catheter been introduced twenty-four hours sooner, nay, perhaps 28 218 OF FOOD FOR THE CHILD. twelve, the infant, whose case is related above, might have been saved — but as there was a constant assurance that water passed, there was no suspicion of the state of the bladder.* 604. I suggest, as a matter of probability, that the cases I have witnessed of death in very young children, where the ab- domen has been much svvoln; the superficial veins passing over it much distended, and very conspicuous, were similar affec- tions of the bladder, though no such suspicion was entertained at the time. How far a distended belly, (indeed almost to transpa- rency,) with greatly enlarged veins, may serve to distinguish this state of the urinary organs in very young children, must be left to future observation. I felt it a duty to express this im- pression, with a hope it might awaken attention in those, whose province it is, to witness many cases of sickness; especially, in very young children. Sect. YWl.— Of Food for the Child. 605. The mother very rarely has her breasts furnished with milk, at the birth of the child; for the most part, there is an inter- val of several days, before it is supplied in sufficient quantity, to sustain the infant — it is therefore supposed, that the child would suffer severely, did it not receive nourishment by other means, until the mother is enabled to ^rom't/e for it. According- ly, an ample bowl is prepared by the nurse ; and the stomach of the child is crammed to regurgitation, with a tenacious paste, called pap, or panada. This is repeated with such mischievous indus- try, as to throw the poor infant into violent agony, unless its sto- mach revolt at the unmerciful invasion, and rejects it by a violent effort, and thus averts the impending mischief Nature seems to have endowed the stomachs of children with a discriminating * "The introduction of the catheter is spoken of, in the case of a child ten days old. We never have had occasion to employ the instrument at so early an age, and fear that its employment is more easily described on paper than carried into execution in practice, particularly in the male." {Lond. Med. and Phys. Journ. Aug. p. 149.) In a case similar to the one which gave rise to the above observation, it may be asked, what other resource does our art afford? I have not declared, nor even insinuated, that the catheter should be used upon slight occasions: but where the suppression is confirmed, and where every usual expedient has been resorted to, and has failed, should we suffer our patient to die, because the in- troduction of the catheter is difficult!' OP FOOD FOR THE CHILD. 219 power upon such occasions; and most happy it is for them that she has been thus kind ; for, were it otherwise, many would die in a few hours after birth, from absolute repletion. 606. It appears that the kind nurse has but one rule, by which she regulates the feeding of a newly-born child; which, is, to pour food down its throat until its stomach can hold no more; it is then permitted to rest a short time. But the delightful task of cramming, is again resumed; especially, if the poor babe cry ; it is now imagined to be again hungry, and again its feeble powers of digestion are unmercifully taxed. This addition of food, to the great surprise of the anxious nurse, does not quiet its complainings; and its uneasiness is now attributed to " wind;" and the unfortunate child is next obliged to swallow some stimulating tea, or liquor, until further distention, and perhaps intoxication, are added to the already almost bursting stomach. It is then rudely jolted on the knee, until a kind vomiting comes to its relief; or until the bowels, rapidly and profusely discharge their contents, or until convulsions close the scene. 607. Let us consider for a moment how small the stomach of a newly-born child is; and how little will put it upon an uneasy stretch — passive, during the whole period of utero-gestation,* • Dr. C. Lee has been making some interesting inquiries into the nature of the digestive process in the foetus while in utero, and upon which, he has come to the following conclusions; that, "there is a digestive process carried on in the upper intestines of the foetus, similar to that which takes place after birth : and that the nutrition and growth of the foetus, are chiefly, or, perhaps entirely, effected Intliis manner." He has ascertained, that "the stomach of the foetus, from three to nine months old, invariably contains a transparent mucus and acid fluid, but never the smallest admixture of albuminous or nutritious matter, while on the other hand, the upper half of the small intestines always contains a yel- lowish or orange-coloured pultaceous mass, which, in appearance, as well as chemical composition, resembles exactly the chyme of the adult; in a word, that it is nearly pui-e albumen. The contents of the lower half of the small Intestines, contain a much smaller proportion of albumen, than those of the upjier half, and the matters gradually assume more and more the characters of the contents of the large intestines, in proportion as the distance from the valve of the colon diminishes." A fluid resembling that contained in the duodenum, has been detected in the hepatic ducts of the foetus; from which it Is inferred, that the liver of the foetus secretes the nutritious matter. This conjecture appears to be strengthened, from the great comparative size of the Uver In the foetus; and that this organ has never been found wanting in any case of monstrosity yet examined. — Lond. Med. and Phys, Journal, for September, 1827. These facts show us how extremely small, and unused to distention, the sto- 220 OF FOOD FOR THE CHILD. and contracted to its minimum size; it is no sooner born than it is obliged to submit to be suddenly distended to almost giving way, from mistaken zeal. Can it then be a matter of surprise, that so many children are subject to pain, spasms, convulsions, and even death, a few days after they are born ? 608. What is the proper food for a child at this period? — or should it have any? There can be no objection to nourishment from time to time meted in proper quantities, and composed of proper materials. It must be recollected, that the nearer we follow nature in such cases, the nearer we approach to what is right; nature provides milk as early as circumstances will per- mit, and milk only — so, on our parts, we can imitate her provi- dence sufficiently near, to prevent mischief; and only milk should be given, until the mother herself be capable of furnish- ing adequate supplies. The article I am in the habit of recom- mending, is, cow's milk diluted with one-third water, with the addition of a little loaf sugar. Of this, the youngest child may take a few tea-spoonsful at a time, and this to be repeated as oc- casion may require. 609. The vulgar, judge of the nutritious quality of a sub- stance, principally by its density; hence, they are opposed to the simple food just recommended, because it does not possess this quality; and they insist upon improving it, by the addition of some farinaceous article, but by which it is sure to be deterio- ated: for almost all the children who partake of this improved substance, are sure to be afflicted with green and watery stools, if not with a full crop of aphthse. But, so soon as the mother is able to supply the demands of her infant, it should be con- fined to the product of her breasts; and to that alone; cseteris paribus. 610. Many of the preparations in use as nourishment for young children, cannot be too strongly condemned; such as crackers and water boiled together, and sweetened; or bread, water, and su- gar; than which nothing can be more ungenial to the infant sto- mach — for these masses begin to ferment the instant they are re- ceived into the stomach. Green and watery stools, amounting in fact to diarrhoea, colic, sour eructations, or throwing up their mach of the new-bom child is; and warn us to be cautious not to put it too suddenly upon the stretch. They put to flight, besides, the agency of the liquor amnii in foetal nutrition; and satisfactorily account for the recrement, called "meconium." ./< ON NATURAL OR UNASSISTED LABOUR. 221 milk strongly curdled, are almost the constant result of their em- ployment. Besides, we must object upon general principles, to the use of any substance, which needs to be made so warm as to require tempering for the child's mouth, by first entering that of the nurse. This is a horrible practice, and cannot be too severe- ly reprobated. The child is thus obliged to take into its ill-con- firmed stomach, food, not only improper in itself, but which has the addition of a rank saliva from the nurse's mouth. 611. Much care, we grant, must betaken in warming the food of the child, lest it be overheated, and its mouth made to pay the forfeit of the nurse's carelessness; but this can be done without any previous mouthing. CHAPTER XV. ON NATURAL OR UNASSISTED LABOUR. 612. The classification of labours is altogether arbitrary; scarce- ly two writers agreeing upon the same arrangement. The object of every classification, is to aid the memory by tracing analogies; to establish general rules from which particular ones may be de- duced, and for the convenience of description. Now these ends appear to be answered by almost any division that we may adopt, starting with some general definitions, and making everything, as far as may be, conform to the g3neralization. There cannot, there- fore, be any one employed which may not be liable, some to more, and others to fewer, exceptions. I have carefully considered them all — some I would reject for their learned parade, without cor- responding perspicuity; others, for their complication, and the want of harmony in their parts ; others, for their multiplied dis- tinctions without essential difierences; and others, for the incor- rectness of their definitions; experience being constantly at vari- ance with them. 613. The one in my estimation least liable to objection, is that of Baudelocque — I am persuaded that more correct practical no- tions can be collected by a proper study of his arrangement, than from any other; and I am also certain, that the younger practi- tioner well acquainted with his system, when placed at the bed- 222 ON NATURAL OR UNASSISTED LABOUR. side, will give a more correct view of any given case; will feel less embarrassment in deciding on the proper mode of treating that case, and will commit fewer mistakes in the absolute management of it, than from the study of any other classification. In my view it is as perfect as the nature of things will permit; and I therefore, from acting under it for many years, have adopted it. In pursuing this plan, I shall constantly feel that I am abridging the labour of the student; removing many of the difficulties of the young practitioner; and confirming the observations of the experienced."* 614. A number of circumstances must concur that a woman carry her child to the full period of utero-gestation, and then give birth to it with the least possible trouble and risk. To secure the first, she must be free from every cause capable of exciting the uterus to action ; or at least to that degree of action, that would terminate in labour. And, for the latter, there must be present in the uterus itself, a healthy disposition to action; and that dis- position manifested, previously to the commencement of labour, properly so called, by the subsiding of the uterus lower in the pel- vis; by a secretion of mucus ; by a kindly disposition in the circular fibres of the uterus to relax, that the longitudinal need not be fa- tigued by too long acting; and these contractions must be sufficient- ly powerful to make the child pass through the pelvis. There must also be a disposition in the external parts to yield, without the agency of much mechanical force; there must exist a proper pro- portion between the opening of the pelvis, and the diameter of the child's head ; and the latter must be well situated, that it may profit by the proper construction of the former; or, in other words, the great diameter of the child's head must constantly correspond with the great diameter of the pelvis. 615. As all the circumstances essential to an easy and natural labour cannot be commanded, it must follow, that there will con- stantly be deviations from it; and these deviations must be looked upon as so many exceptions to the several presentations, which Baudelocque makes necessary to a natural labour. Baudelocque considers every labour natural, in which the. woman might be de- livered without help; and makes such consist of four principal presentations; namely, 1st, the head ; 2d, the feet; 3d, the knees, 4th, the breech. • Though I have adopted Baudelocque's general arrangement, I have not rigorously confined myself to it. This will be readily perceived, from the manner in which I have treated the various presentations. ON NATURAL OR UNASSISTED LABOUR. 223 616. It would be reasonable to conclude, that the presentations which most frequently occur, are the most natural: now these are found to consist of, 1st, those cases in which the child presents the head ; 2d, those in which the breech offers ; 3d, those in which the feet offer ; 4th, those in which the knees offer.* Each of these genei-al presentations are subdivided and form varieties. 617. Baudelocque is censured by some for the detail he enters into when speaking of his general presentations, and his subdivi- sions of them ; but in this their censure is misapplied. Every prac- titioner who is well acquainted with the form and dimensions of the pelvis ; with the construction and various dimensions of the child's head ; and with the mechanism of each individual labour; will be so far from condemning him, that he will admit that no man can practise with entire success, or complete usefulness, without a thorough knowledge of them, I agree, that to certain practitioners it will not only appear useless, but burthensome — those, for instance, who commit the whole charge of the labour to the management of nature, provided the head present, and this no matter how; and as she is usually successful, never stop to in- quire whether they can aid her efforts, or abridge her toils : or those who consider the presentation of any one of the other parts above designated as essentially wrong ; and who will, in conse- quence, wrest from the hands of nature, a labour, to terminate it by force, when she was every way competent to its accomplish- ment. Against the cavilings of such practitioners, I do not think it worth the trouble to defend him. 618. As regards myself, 1 am willing to confess, for the know- ledge I possess upon the subject of midwifery, I am principally indebted to him: for to him do I owe the principles which ren- dered my experience profitable ; and could I induce others who engage in the practice of midwifery, to carefully study this great man's works, I should benefit society, by rendering practitioners so much the more competent to fulfil the duties they have under- taken to discharge. Entertaining such sentiments of the author I intend chiefly to follow, I shall not deem it necessary to apo- logize for my choice. • For the reason just assigned, I have changed the order of Baudelocque's arrangement of the presentations constituting *« natural labour." The fre- quency of the comparative occurrence of the several presentations named above, will I beUeve be found pretty constantly to stand in the order I have now placed them ; and this, in my estimation, should be taken as the rule of division. 224 ON THE PRESENTATIONS OF THE HEAD. 619. In speaking of the presentations of the head, I confine myself, like Baudelocque, to those portions of it designated by the name of the vertex or the posterior fontanelle, and to that of the anterior fontanelle; or in other words, the particular or spe- cific presentation, is always indicated by these portions of the cranium. And when neither of these offer, so as to characterize the presentation, the part most easy to touch in the pelvis will always be designated by its own name ; and all such will be con- sidered as deviations from the presentations of the head, properly so called. CHAPTER XVI. OP THE PRESENTATIONS OP THE HEAD. 620. The frequency with which the head presents, compared with any other part of the body, renders its various positions bet- ter known; and also entitles them to be considered as the most natural: yet even head presentations have essential difierences, as they are not all equally advantageous. Therefore each variety should be well studied ; its distinguishing marks well ascertained, and its mechanisms thoroughly comprehended. 621. These presentations will be divided into six varieties ; each of which has peculiar characteristics: — In the first presenta- tion, 7;o5/erior/on/«/iff//e is behind the left acetabulum, and the anterior before the right sacro-iliac symphysis ; the head, there- fore, is placed diagonally as regards the superior strait; so also is the case in the second, fourth, and fiflh. In the second presenta- tion, the posterior fontanalle is behind the right acetabulum, and the anterior before the left sacro-iliac symphysis. In the third, the posterior fontanelle is placed behind the symphysis pubis, and the anterior before the projection of the sacrum — in this, and in the sixth presentation, the great diameter of the child's head offers itself parallel with the small diameter of the superior strait. In the fourth, the anterior fontanelle is behind the left acetabulum, and ihe posterior before the right sacro-iliac symphysis. In the fifth, the anterior fontanelle is behind the right acetabulum, and the posterior before the left sacro-iliac symphysis. The sixth is the reverse of the third. 622. Some have objected to these divisions, 1st, as being per- THE FIRST PRESENTATION. 225 plexing to the memory; 2(], and this without conveying any es- sential practical information. To the first, it may be answered, that the whole of them can be learned, by pursuing the course I shall lay down, as quickly almost as they can be read; and the same observation will apply to all the other varieties of natural labour. 623. Let it be remembered; first, that the 1, 2, and 3 presen- tations of the head, are all represented by W\q posterior fontanelle; and the 4, 5, and 6, by the anterior fontanclh: second; that in describing these presentations, we constantly follow their nume- rical order: third; that we always commence with the left aceta- bulum; then go to the right acetabulum, and next to the symphy- sis pubis, whether it be the posterior fontanelle or the anterior, that is to be represented — this will make the first presentation have the posterior fontanelle behind the left acetabulum, the se- cond behind the right acetabulum, and the third behind the sym- physis pubis. Then, as I have just stated, the other three take their character from the anterior fontanelle, and follow precisely the same route, or order — of course, the fourth will have the an- terior fontanelle to the left acetabulum, the fifth to the right ace- tabulum, and the sixth to the symphysis pubis. 624. As regards the second objection, that " this division con- veys no essential practical information," I can only lament the imperfect knowledge of the objector of what is absolutely required of every one who attempts to pursue midwifery, if he cannot pro- fit, and that materially, by the divisions and distinctions of Baude- locque; for I maintain, that the excellence of one accoucheur over that of another, almost exclusively depends upon the accu- racy of his knowledge of the different presentations. 625. I have already earnestly recommended to the inexperi- enced practitioner, to study the different pi-esentations carefully; and to take the fontanelles, and not the ears, for his guide. (89) The vertex, therefore, will be distinguished from any other part, by its roundness, its firmness, its sutures, and its fontanelle. The particular position of the head relatively to the pelvis, (and this constitutes the species of presentation,) is only to be determined by the position of the fontanelles, and the direction of the su- tures; to determine this, however, it is only necessary to ascer- tain the situation of the fontanelles. 29 22G THE FIRST PRESENTATION. Sect. I. — Of the first Presentation, and its Mechanism. 626. In the first presentation, the posterior fontanelle places itself behind the left acetabulum, while the anterior offers before the right sacro-iliac junction: the sagital suture must, therefore, traverse the superior strait obliquely. For the position of the trunk and other parts of the child, I refer to plate V. and expla- nation, at the end of the volume. 627. The head of the child in this presentation offers itself in an oblique position as regards the superior strait; by the contrac- tions of the uterus the vertex is made to sink lower in the pelvis than any other portion of the head, and at the same time places the chin of the child upon its breast. The head descends in this state of anterior iiexion, in the axis of the superior strait,* until it is arrested by the sacro-ischiatic ligaments of the left side, the sacrum and perinseum. When the head arrives at this first part, it would remain stationary, did not its relations with the pelvis at the lower strait, change in such manner as to force the posterior fontanelle to offer itself to the arch of the pubes — in doing this, there is a slight twist or pivot-like motion executed at the ex- pense of the neck, which may be estimated at a sixth or eighth of a circle. During this change in the direction of the head, it must be recollected, that the trunk does not perform a similar movement. 628. In proportion as the head is urged forward, the lamboidal suture is to be more distinctly felt below the symphysis pubis; and if the head be not unusually large; the pelvis a little contracted; or the sacrum too straight; the centre of the occipital bone will be found to correspond with the symphysis pubis: but if either of these circumstances obtain, it will be perceived to answer to the leg of the left pubis, and ischium. At this moment, the chin of the child, which had hitherto been placed on its breast, begins to depart from it; the vertex advances and separates the external parts, by engaging under the pubes, and rises up towards the mons veneris; the inferior edge of the symphysis pubis answers as a kind of axis for the head to turn on ; in doing this, the head describes about a quarter of a circle backward. For the head, in * It must be borne in mind, that the head of the child never engages in tlie superior strait, in a perpendicular or vertical position; for this cannot happen, and coincide with the direction of the opening of tliis strait, since this is at an angle of about 30°, and consequently, the head must enter this opening at the same angle. SECOND AND THIRD POSITIONS. 227 issuing from the pelvis, obliges the chin to describe an extensive curve; passing successively over the whole of the central line of the sacrum, coccyx, and perinaeum; while the vertex itself passes through but a small space. So soon as the head has escaped through the external machinery, the face is found to turn almost always towards the right thigh. 629. The shoulders are now to deliver themselves; Avhlch they do in the following order — the right shoulder advances to- wards the pubes, while the left is placed before the sacrum, and is by the force of the pains made to descend lower and lower until its point issues from the bottom of the vulva, while the right is freeing itself from under the pubes. When the shoulders are delivered, the rest of the body follows immediately. 630. "By following," says Baudelocque, " step by step the course I have just traced from observation, it will appear, 1. That at all periods of labour, the head presents its smallest diameters to the pelvis, and that it passes through it, presenting only its smallest circumference. 2. That it executes three different mo- tions in its passage; that of flexion forward, in the first period; the pivot-like or rotatory motion in the second; and, lastly, that of flexion backward, at the time it disengages from under the pubes." Vol. I. p. 362. See Plate VI. Sect. II. — Of the Character and Mechanism of the Second Position. 631. The mechanism of the second position is precisely the same as that of the first, if we change the position of the vertex, and place it at the right acetabulum, instead of the left. In con- sequence of the right lateral obliquity of the uterus prevailing so often, and the rectum not passing immediately down the centre of the sacrum, and being occasionally impacted with hardened fgeces, this presentation is not quite as favourable as the first — but we rarely find in practice any essential difference between them ; for w^e may always controul the obliquity of the uterus, by placing the woman upon her left side; and can empty the rectum by an injection, as is my uniform practice, when I find things thus situated. See Plate VII. Sect. III. — Character and Mechanism of the Third Position. 632. In this presentation, the posterior fontanelle answers to 228 FOURTH POSITION. the symphysis pubis, and the anterior to the projection of the sacrum; and where a proper relation exists between the head and pelvis, this presentation is not attended with more difficulty perhaps than the two former positions; provided neither the right, nor the left lateral obliquities, carry the head from the centre of the pelvis; for the vertex will be found to descend be-r hind the symphysis pubis, while the chin will mount upwards, and place itself against the breast, as in the former cases; in con- sequence of this, the head will only present its perpendicular diameter to the small diameter of the upper strait; and when the vertex has arrived at the bottom of the pelvis, the occipital bone will be found to offer itself to the arch of the pubes, and will pass through the external parts as in the first and second presentations. The shoulders will now present, but there will be no certainty, whether it will be the right, or the left. See Plate VIII. Sect. IV. — Character and Mechanism of the Fourth Position. 633. This position is by no means so favourable, as either of those just described; for the forehead must come under the arch of the pubes, in consequence of the anterior fontanelle being to the left acetabulum, and the posterior to the right sacro-iliac symphy- sis. In order that the head may pass on, it must descend until a portion of the right parietal bone rests upon the inferior part of the sacrum; when there, the pivot-like motion mentioned (627) in the other presentations must take place, if everything go on well, and by the same mechanism. This motion, however, in this instance, is such, as to place the forehead under the arch of the pubes, by sliding along the left side ofthe pelvis. 634. In consequence of the forehead being placed under the arch of the pubes, the anterior fontanelle will be found in the middle ofthe arch, and the posterior above the point ofthe sacrum. The head being urged by the pains, descends still lower in the pelvis, and makes the posterior fontanelle pass over the coccyx and perinoeum, while the anterior and forehead, are confined, as it were, to the arch of the pubes. Indeed, it mounts a little be- hind the symphysis; as the anterior part of the head, has not the same relation to the arch, as the occipital region ; therefore, the anterior fontanelle becomes almost stationary, while the posterior continues to advance, and stretch the perinseum, which presently FOURTH POSITION. 229 slips over the occiput, and retires with its edge to the child's neck, and, like the same part when under the arch of the pubes in the former presentations, becomes the centre of motion, and permits the occipital region to turn backward towards the anus of the mother ; at the same time the face disengages itself from un- der the pubes. In this instance, as in the former, the chin is made to describe a curved line, but in a contrary direction. 635. So soon as the chin is liberated from the arch of the pubes, and appears without, the face of the child, by half a turn, places itself towards the left thigh of the mother; at the same time the shoulders descend, and the left is found under the pubes, while the right moves towards the sacrum, and is first disengaged from the vulva. See Plate IX. 636. This species of labour is necessarily more difficult, and painful than those we have just considered; and it oftentimes becomes extremely so, if the head be either relatively or posi- tively large for the pelvis. It requires, in some instances, many hours to accomplish a labour, that would have been speedily ter- minated, had either of the two first been the presentation; more especially, if resisting soft parts should be added, to the other diffi- culty. Baudelocque thinks that the right lateral obliquity would also increase the evil of this presentation; but this I believe can be surmounted, by placing the woman upon her left side. This labour is always of longer duration, than where the vertex pre- sents; and of course the woman's sufferings are increased, in pro- portion to the duration; now, as we almost always have it in our power to reduce both this, and the fifth, one to the second, and the other to the first, we should always do it, when nature does not do it for us. Nor is this change of position of the head, an ope- ration of the slightest difficulty to the accoucheur, nor does it cause the smallest pain to the patient; provided, advantage be taken of the proper conditions of the uterus, and head of the child, and the state of the labour. For the uterus must be well dilated, the membranes ruptured, the head occupying the lower strait, and the labour active. When these pre-requisites obtain, the point of the fore-finger must be placed against the edge of the sagital su- ture, either before or behind the anterior fontanelle ; and in the absence of pain, this part must be pressed towards the left sacro- iliac symphasis, and maintained there during the subsequent con- traction of the uterus. Should this first attempt fail in changing the position of the head, by bringing the posterior fontanelle to the 230 FOURTH POSITION. right acetabulum, the attempt must be repeated again and again until it succeed; which it will almost constantly do. 637. I consider a perfect knowledge of this presentation, (for it is far from being unfrequent,) a matter of high moment to the practitioner; and particularly so in this country, where the study of midwifery engages so much of the attention of the medi- cal student, and where every one almost, who enters upon the practice of physic, must also become a practitioner of obstetrics. So positive an advantage does a knowledge of this presentation, and the mode of reducing it, give one practitioner over the one who may be ignorant of it, that it enables the first to terminate a labour in as many minutes, as the other might be hours. 638. So decidedly useful is the knowledge of the fourth and fifth presentations, to the patient, that I hold that man incompe- tent to practise midwifery, in its best manner, v/ho cannot de- tect, and change this mal-position of the head, and thus abridge sometimes, by several hours, the misery and pain of his patient. I therefore hold Dr. Denman's* advice as unfriendly to the im- provement of midwifery, when he says, " When the membranes break, if the os uteri be fully dilated, the child, though resting at the superior aperture of the pelvis, either sinks by its own gravi- ty, if the woman be in an erect position,t or is propelled by the continuance of the same pain by which they were broken; or, af- ter a short respite, the action of the uterus returns, and the head of the child is brought so low in the pelvis, as to press upon the external parts; properly speaking, upon the internal surface of the perineum. In its passage through the pelvis, the head of the child which, at the superior aperture was placed with one ear to the ossa pubis, and the other to the sacrum, or with dif- ferent degrees of diagonal direction, undergoes various changes of position, by which it is adapted to the form of each part of the pelvis, with more or less readiness, according to its size, the de- gree of its ossification, and the force of the pains. With all these changes, whether produced easily or tediously , in one or many hours, the practitioner should on no account interfere, pro- vided the labour be naiuraV^ * Introduction, Francis's ed. p. 282. + Dr. Denman is certainly wrong', when he supposes that the child's head will sink into the cavity of the pelvis by its own gravity, if the woman be stand. ing; for, when she is erect, the head finds a resting-place on the anterior mar- gin of the pelvis. See note to par. 627. FOURTH POSITION. 231 639. Agreeably to this advice, we are not to interfere, though the head present in either tiie fourth, or the fifth presentation; though we can, by an opportune, and well-directed force, shorten the woman's sufi'erings perhaps many hours; especially with a first child; and this without offering the slightest violence to either mother or child. Nature, indeed, sometimes, though not suffi- ciently often, operates this change herself; and is this not suffi- cient to warrant the practitioner to imitate her? I have always done this since I first became sensible of its advantages; a period now, of more than thirty years, unless the labour has been too far advanced to permit a change, which has not been oftener than three times, during the whole of the period stated. In doing this, I am well assured that I was but performing a duty by shortening, as well as moderating the woman's sufferings — indeed, so convinced am I of the propriety and utility of this *' interference," that I should hold myself culpable did I neglect to take advantage of this important hint of nature. 640. The propriety of changing this and the fifth position of the head cannot be questioned, when a moment's- reflection is be- stowed upon its mechanism. Yet neither Dr. Denman, nor any of his friends, appear to have been acquainted with the proper mode of treating these cases. It is truly a matter of surprise, that they should have been unwilling to receive information from their neighbours upon this important point of obstetric prac- tice; for they certainly were in possession of the works of Baudelocque,* in which he so scientifically and successfully treats of this subject. It is tru£ that Dr. John Clarke, about the year 1800, seems to have accidentally caught a glimpse of the proper manner of conducting such labours. I say a " glimpse;" for it was but little more, as he confounds the fourth and fifth pre- sentations with the sixth; and does not appear to think or to know there is a difference in their natures or mechanism. He confesses that "chance first led him to the knowledge of the fact, that in some cases this position of the head can be remedied without subjecting the mother to any additional pain, or the child to any kind of danger." He adds, 'st mentioned; and where practicable, make the shoulders take the same course; the hand will point out the side to which the face must be turned; then finish the delivery, as if we had interfered with a first or second presentation. If we cannot change the shoulders by act- ing immediately upon them, we may give the proper turn by pulling for a little while upon the right leg, if the face is turned to the left side, and upon the left, if turned to the right side. Sect. IV. — Fourth and Fifth Presentations. 746. These presentations, in consequence of the forehead coming under the arch of the pubes, are always more painful and tedious, (creteris paribus,) than where the vertex offers to this part; but in a vvell-formed pelvis, unless some accident complicate the labour, we are seldom or never obliged to turn for these posi- tions alone. Should, however, any circumstance render it neces- sary, we may turn in these cases, with as much facility as if they were the first and second vertex presentations: and we conduct SIXTH PRESENTATION. 275 the process precisely in the same manner; that is, in the fourth, the rules for turning are exactly the same as has been already directed for the second presentation, and in the fifth it is con- ducted as if it were the first — it is important, in these cases, that the leg which offers under the pubes should be more acted upon than the other, that the breech may take a proper position in the superior strait. Sect. V. — Sixth Presentation. 747. I believe it best in this presentation to turn, if the head and pelvis have but their ordinary relations; and most certainly so, if the latter is a little contracted, or the head of more than ordinary size; provided we are called early, and can have the advantage of the opening of the membranes; or if they have been but recently discharged. If the head be small, it will come along without much difficulty; and if but very little smaller than the pelvis, advantages might be derived from turning the occiput from the projection of the sacrum, as recommended by Baude- locque, and as once practised by myself, (see 646;) but this pre- sentation so rarely occurs, that almost all I can say upon the best mode of treating it, is derived from analogy and reasoning. After the head has passed the superior strait, it can offer no greater difficulties than the fourth or fifth presentation; but like these, it may require the application of the forceps; for, if the waters be long drained ofi, and the uterus strongly contracted on the child, turning would be extremely difficult, if not impracticable; as happened in the case I mentioned, (646,) having succeeded, by turning the occiput. 748. When turning is attempted in this case, either hand may be employed at the option of the operator; the head must be seized as directed for the third presentation, and converted into the fourth or fifth. Baudelocque recommends it being reduced to the first or second; I sincerely believe this to be impracticable; I am certain it cannot be done if the waters have been long eva- cuated ; and if it have succeeded, it must be at the moment they have expended themselves, and while the head yet enjoyed free- dom at the superior strait. The turning must be finished, as if the head originally presented in either of these positions. 749. Having spoken of the modes of terminating preternatural labours where the hand alone was sufficient, I shall now proceed 276 SIXTH PRESENTATION. to the consideration of the forceps as a means, where the hand is not capable of performing it, or where it is not proper to employ- it — for this purpose, I shall commence with a general considera- tion of these instruments; and afterwards point out the modes of application, in each particular case; this will bring me to the third part of the work. PART III. WHERE IT IS NECESSARY TO USE INSTRUMENTS WHICH DO NO INJURY TO MOTHER OR CHILD. CHAPTER XX. OF THE FORCEPS. 750. I SHALL not unnecessarily consume time in tracing the history of these important, but too frequently abused instruments; nor point out the alterations which caprice, or the affectation of improvement, have imposed upon them — I shall merely declare my preference for the long French, or the Baudelocque forceps. An experience of many years, I think, justifies this choice; the election is neither hastily nor heedlessly made; I think I have duly weighed the merits of both the long and the short forceps, and the preponderance is in favour of the long. In making this choice, I had no theory to support; and therefore, had no preju- dices to overcome; my sole desire was to determine which of the two would best answer the ends for which they are designed — trials, often repeated, have led to the conclusion, that there is no situation of the head, which can be delivered by the short forceps, that cannot, with at least equal certainty and facility, be relieved by the long; but the converse of this does not obtain; for there are situations of the head, which cannot be relieved by the short forceps; but to which the long are every way competent; this, in my estimation, is conclusive. See Plate XIII. 751. I shall briefly state the objections, which experience has suggested, against the short forceps. For a number of years the short were the only forceps I employed: and I only abandoned them from a conviction of their inferiority to the long. First, they can only be employed with advantage, when the head oc- cupies the lower strait. Second, when it is required to deliver 278 OF THE FORCEPS. from the superior strait, or above it, neither their length, nor their form, will permit their application; we are then obliged to use the long; but the converse of this never happens.* Third, from the shape, and shortness of their handles, they become very- inconvenient to the operator; forbidding, from these causes, the application of a sufficient force, to overcome the resistance. Fourth, their mode of union is such, as to render them extremely inconvenient to the operator, and oftentimes very painful to the patient, by including while locking, either a portion of the soft parts, or some of the capilli of the pudendum; thus creating a great deal of pain. 752. It is however insisted, that the last objection can always be removed, by carefully passing the finger round the lock ; but this is a mistake — for it is in the act of locking that this inclusion takes place. Now, it is certain, that the locking of the instru- ments requires the use of both hands; consequently, we cannot pass a finger round the locking portion, so as to extricate the soft parts, or capilli, if included, or prevent them from insinuating themselves between the joint; as the hands, and of course, the fingers are otherwise employed at this moment. It is true, we may search for the included part, or parts, before we commence extracting; but to relieve the soft parts would require the sepa- ration of the blades to a certain extent, and this without any se- curity that it will not happen again, when the handles are again pressed together ; and the capilli can only be relieved with cer- tainty, by breaking them, which would be painful, or by cutting them, which is not altogether decent. 753. In favour of the long, I may state, that no one of these objections attaches to them; they can be used in any position, or distance of the head within the pelvis; that the form and length of their handles, give great and decided advantage to the opera- tor; rendering his exertions more effective, and much less fatigu- ing; their mode of union obviates the very serious objection urged against the short; (751) for they lock without the vulva, even • Dr. Davis seems to entertain similai" notions of the insufficiency of the short forceps in certain cases, and I shall avail myself of his observations on this point. He says, " What I wish at present to insist on, is the absolute un- suitableness of the instrument known in this country by the name of the short or common forceps, for the relief of cases of impaction, from disproportionate size of the foetal head within the pelvis, on account of a general deficiency of space within its cavity." — {Ekm, Oper, Med. p. 141.) RULES WHICH REGARD THE POSITION OP THE WOMAN. 279 when the head is high: and remote from it, in lower positions — besides, they unite in themselves the forceps, the lever, and the blunt hook. Sect. I. — General Rules for the Use of the Forceps. 754. We may divide the general rules for the use of forceps, into, a. Those which regard the position of the woman, b. Those which respect the uterus and soft parts, c. Those which refer to the application of the instruments, and their action on the child's head ; and d. The mode of acting, after they are applied. a. — Those ivhich Regard the Position of the Woman. 755. Position is every way important to the successful applica- tion of the forceps; but as regards the particular situation of the woman, there is a diversity of opinion, between the British, and Continental practitioners — and, indeed, the same may be said of the different accoucheurs in our own country ; this depends yery much upon the school in which they have been educated, or the authority they are in the habit of following. The British practi- tioner almost invariably directs the patient to be placed upon her side, with her hips near the edge of the bed ;* while the Conti- nental accoucheur, has her placed upon her back.t It is, perhaps, not very difficult to explain the cause of this difference — the Bri- tish praciitioner never, or but very rarely since the days of the well-instructed and judicious Smellie, attempts to deliver the head from the superior strait; while many of the Continental accouch- eurs do — in the first, the lateral position of the woman is perhaps as proper as any; but in the second, it would be impossible to deliver from the superior strait; now, as the position of the back enables the practitioner to deliver from any part of the pelvis, it should always, I think, be preferred ; especially as the relative situations of the head, and pelvis, will be better understood by the young practitioner ; for he will have the symphysis pubis as a mark, by which he can determine every other part of the pel- vis; this he cannot so exactly do, when the patient is on her side. 756. Therefore, when practicable, I would recommend she should be placed upon her back, as directed for turning (733, &.c.) both for convenience and safety. I say when practicable; for it * Denman, &c. | See Baudelocque, &c. 2S0 THE CONDITION OF THE UTERUS AND SOFT PARTS. is not always so ; since, in cases of extreme exhaustion, of flood- ing, of convulsions, &c. we sometimes cannot move the patient to be thus placed; but we can always turn her upon her side ; or if the head be very low, and the patient is on her back when inter- ference is necessary, she may remain so ; but when we can com- mand position, I repeat, I prefer placing the woman upon her back, with her perineum free over the edge of the bed. 757. Before we proceed to the use of the instruments, we should apprize the friends and the patient, of their necessity — it rarely happens, that tbe patient is alarmed at this alternative ; as a very short explanation of the mode of action of the forceps, always satisfies her ; for we have only to say, that the natural powers are insufficient ; that the situation of the child requires immediate relief, as its longer continuance in the passage might be fatal. But at the same time, we must not give any positive assurance of its safety by the operation; though its chance should be represented as increased. Cause her to think the instruments an artificial pair of hands, whose use is to clasp the head of the child, and thus promote its delivery; and she becomes at once reconciled to their employment. 758. We should take care, before we use the forceps, that the bladder be discharged of its urine, either by the catheter, or by a voluntary effort of the patient ; and that the rectum be unloaded by a simple injection, if it has not been emptied a short time be- fore ; also that the vagina, external parts, and instruments, be well lubricated with hog's lard, or soft pomatum; and the latter warm- ed by being placed in warm water.* b. — The condition of the Uterus and Soft Parts. 759. The forceps should never be employed, whatever may be the emergency, before the os uteri ■^.> sufficiently dilated, or readily dilatable, and the membranes ruptured. Were w^e to attempt their application before this period, we should do much mischief; if not altogether be foiled in our enterprise. We must, therefore, wait until this has taken place; but we should endeavour to pro- mote this condition by every means, which may be compatible with the existing situation of the woman. This may sometimes * In warming the forceps, care should be taken that the water isnottoo hot; it will be sufficiently warm, if the hand can just be borne in it. It is proper, even in warm weather, to observe the precaution of wai-ming the forceps. APPLICATION, AND MODE OF ACTION OP THE FOllCEPS. 281 be by blood-letting, as in convulsions, &c. or by laudanum, as in certain kinds of exhaustion, &c. but never by force. We are told that the application of the belladonna to the os uteri has been useful for this purpose; but of this I have no experietice. Chau- sier recommends the extract of the belladonna, with great confi- dence, in cases of rigidity of the os uteri. He causes it to be in- corporated with some soft ointment, and applied by means of a particular syringe to the circle of the uterine orifice. In half an hour, or in forty minutes at farthest, after its application, he de- clares, the orifice of the uterus becomes so much relaxed, as to offer no farther resistance to the efforts of the body of the fun- dus. — [Co)isiderdtions sur les Convulsions qui Attaquent, les Femmes Encientes, p. 22.)* 760. Should the membranes be entire at the time we are about to operate, we may very readily effect their rupture by artificial means; but this should not be done until the os uteri is in a proper condition for the operation. It would be desirable, that the ex- ternal parts should also be disposed to yield readily before we commence; but this is of much less importance than the relaxa- tion of the os uteri; for these may be dilated gradually by the in- struments, or made to yield by the application of lard or soft po- matum. c. — Jljii^Ucation^ and mode of Jlction of the Forceps. 761. The proper application of the forceps, in each situation of the head, has ever been considered as an achievement of difficulty. It requires a complete knowledge of the various divisions of the pelvis; an acquaintance with the construction of the child's head; and the mode of ascertaining its precise situation, in the cavity which contains it, &c.. It will also be necessary to the success of the operation, that the practitioner understands the construc- tion and mode of action of his instruments, and have by practice acquired some facility in placing them. It has been considered by Dr. Denman, as uncertain, whether the art of midwifery has been benefited, or injured, by the introduction of instruments into * Since writing the above, Dr. James and myself had a case of the most rigid OS uteri either had ever witnessed. In this case we ti-ied the belladonna, with- out the slightest advantage. We perhaps did not apply it as effectually as Chausier, as we were not in possession of his syringe for this purpose. Should another case occur in which I should think it advisable to employ this drug, I would introduce it by means of a sponge well saturated with the extract — pre- viously reducing its tenacity. 36 282 APPLICATION, AND MODE OF ACTION OP THE FORCEPS. its practice.* That much mischief has been done by the ill-judged, and worse-conducted application of the forceps, I have had reason to know; but the abuse or wrong use of a thing, by no means furnishes a logical conclusion against its proper use. Indeed were we to admit this reasoning in almost any concern of human life, we should have a most reduced catalogue of real benefits; and were it legitimate to urge it in the practice of physic, or surgery, we should scarcely dare to prescribe an article of the materia medica, or venture to employ a single instrument, of the very many we now consider essential to the exercise of these branches of medical science. Yet what practitioner would give up opium, camphor, mercury, bark, and a hundred other articles, because quacks, and ill-instructed people, have abused them, or even de- stroyed with them ? or who, in the practice of physic, would throw aside the trephine, the scalpel, the gorget, or the amputating knife, because either of these instruments in the hands of the un- skilful, might be mischievous? 762. Let those who are to practise midwifery, become well ac- quainted with its elements, before they commence it; then gra- dually proceed to the exercise of the more difficult operations connected with it, and the clamour against the use of forceps will in great measure cease, because, there will necessarily be less reason for complaint. A severe probation awaits an upright, and conscientious man, upon his introduction to the practice of mid- wifery; for, if he be such, it will be a long time before he will dare to flatter himself, that he can do that which is best for his patient: and until he can, he will not be satisfied with himself — but this very distrust will, very probably, lead him to cultivate his talents by constant reading, that he may keep pace with the improvements in his profession, and seek the aid of those better qualified than himself, when difficulty presents itself. 763. Much of the embarrassment, and it may be safely added, the risk, in the application of the forceps, might be obviated were every gentleman, during his medical studies, to prepare himself by the frequent application of these instruments upon the machine * I am convinced, that if the forceps be judiciously employed, the lives of ve- ry many children may be saved; and that the death of the mother would be a rare occurrence. Dr. Davis declares, •' In my own practice, as one of the phy- sicians to the Maternity Charity of London, which is beyond comparison, the most extensive obstetric institution in Europe, I have tlie satisfaction of being able to assert, that I have never incurred the misfortune of losing a motlier in consequence of a forceps operation." — {Elem. Oper. Mid. p. 274.) APPLICATION, AND MODE OP ACTION OF THE FORCEPS. 283 under all the various conditions the head may offer itself within the pelvis — but I am sorry to say, this mode of acquiring know- ledge, is not sufficiently appreciated by those, to whom it would be of the most direct, and essential service. There is a tact in every operation, which is indispensable to its well performance, and suc- cess; but this can only be acquired, by its frequent repetition — for what would be said of the surgeon, who expected to acquire a knowledge of the anatomy of the part upon which he was about to operate by dissecting the living fibre, for the first time in his life? or, who could expect a man to apply the forceps with skill, the first time he attempted it upon the living machine, without a previous exercise upon the artificial one? The same observations will apply to turning. 764. But it would be unfair to charge all the mischief which has followed the use of forceps, to the ignorance of those who have employed them; or to the action of the instrument itself — much is justly attributable to the views which many celebrated men have taken of their necessity, or utility, as well as to the rules they have laid down for their application. In many in- stances, the evils which appeared to follow their use really existed before they were employed ; but which might, I am persuaded, in many cases have been prevented, had a timely and judicious use been made of them. 765. The following case, which is every way in point, occur- red to me a short time since: A lady with her first child, felt slight pains for several hours before she thought it necessary to send for me. The pains when I first saw her were pretty fre- quent, but not very protrusive; the external parts rather rigid, the OS uteri not freely dilated, and the membranes were entire. After waiting two hours, the pains became more effective, and the head soon occupied the lower strait — two hours more were given, at the end of which time the vertex was about to emerge under the arch of the pubes, and the perineal tumour was formed. The pains now became more distant and less forcing; while the external parts remained rather rigid, but not obstinately so. The er- got was now given at three several times, but without producing the slightest increase of energy in the contractions of the uterus. I now proposed the forceps;— but their employment was obstinately resisted; and as no advantage whatever was derived from the delay, and as the perinaeum was very much, and permanently distended, 1 became uneasy, and represented as forcibly as I knew how, the 284 APPLICATION, AND MODE OP ACTION OP THE FORCEPS. necessity of immediate delivery by the forceps. I presented for the consideration of the patient, the advantages of immediate de- livery, and the probable consequences to both her child and her- self, if it were not complied with; but nothing could prevail upon her to submit; she however promised, that if she were not better in another hour, she would comply with my wishes. This hour like the six preceding, passed away without the hoped-for advan- tage. She now consented to submit to anything I judged proper for her relief. But I thought it proper before I applied the for- ceps, to state to the friends my fears, that serious consequences might follow from this long and unavailing delay, though the de- livery could be easily accomplished. I applied the instruments; and in less than fifteen minutes she was delivered, contrary to ex- pectation, of a living child ; and also contrary 'to expectation, the patient appeared to be very well, except that the catheter was employed two or three times for emptying the bladder. On the third day the urine was discharged by voluntary efforts, and every thing seemed to promise well, except a burning and benumbing pain that was felt at the extremity of the coccyx, and perinaeum: this increased so much as to require anodynes and warm poul- tices. About the eighth day, sloughing of the perineum com- menced, and proceeded down to the sphincter ani, and some dis- tance up the vagina. The parts have healed however more for- tunately than could at first have been expected; the perinseum almost alone having suffered; leaving the rectum safe, and the vagina without serious injury — the case now resembles a lacera- ted perinseum.* 766. Dr. Denman, more perhaps than any other man, is charge- able with perpetuating errors in the use of the forceps, because, he is considered the highest British authority upon the subject. In his attempt at precision, he has created confusion ; and, in his desire to generalize, he has made so many exceptions, that his Aphorisms are no longer rules. The necessity for using the for- ceps he has taken principally from the time the head has tarried at tlie lower strait or passage, and the condition of the woman ; with- out the slightest regard to circumstances, which may complicate the labour, or make a departure from the rule necessary to both mo- ther and child. His aversion to instruments made him restrict their powers to such narrow limits, as to render them scarcely * I have delivered this lady safely twice since the above case occurred. APPLICATION, AND BFODE OF ACTION OF THE FORCEPS. 285 subservient to the art ; and he reduced the cases proper for their application to so few, and so peculiar, that they are scarcely to be met with, that they iTiay be employed. 767. Thus we find that Dr. Denman's fourth Aphorism de- clares that "the intention in the use of forceps is, to preserve the lives of both mother and child:" thus far good ; but in the very next sentence he says, "but the necessity of using them must be decided by the circumstances of the mother only;" that is, as I understand it, and as I believe every body else, means, we are not to deliver with a view to save the child, unless something threaten the mother. Is not this sadly and improperly limiting the utility of the forceps? for what security have we, when danger assails the mother, that the child will not perish before we are, agree- ably to Dr. D., justified in delivering it? Let us again suppose that the body of the child is delivered, and that the head cannot be made to pass, either from the want of ordinary power on the part of the mother, or from the extraordinary size of the child's head as regards the pelvis; are we to permit the child to perish because there is no <' circumstance," that is, as I understand it, no danger threatening the mother, to authorize immediate deli- very by the forceps, though he just expressly declared their " intention" is to save the lives of both? 768. His fifth Aphorism declares, " it is meant when the for- ceps are used to supply with them the insufficiency, or the want of pains ;" here is a plain and positive direction, one that the common sense of mankind would at once agree to be sound and proper; one that would justify in the absence of sufficient, or ef- ficient pains, the employment of forceps to supply the deficiency of the natural powers ; but all this prudent and well-tested direc- tion is destroyed by the next member of the Aphorism; namely, " but so long as the pains continue, we have reason to hope they will produce their effect, and shall be justified in waiting. 769. In the Lend. Med. and Phys. Jour. Aug. 1825, p. 157, I am indirectly charged with misquoting Dr. D.'s fifth Aphorism, which I take this opportunity to disclaim. I quoted from an American republication of the Aphorisms, and agreeable to that, I find I am correct. My observations on these Aphorisms were made more than tv/enty years ago; and if there be a discrepancy in the two texts, it may have arisen from a subsequent change in Dr. D.'s opinion on this subject; as the reviewer quotes from the 286 APPLICATION, AND MODE OF ACTION OP THE FORCEPS. sixth edition.* The additional sentence, '^with any degree nf vi- gour,'''' ahers the matter little or none, in my opinion — " for with any degree of vigour," is extremely indefinite; for the degree of suffering may lead to the helief that force is always commensurate with pain; than which there can be but few greater mistakes; espe- cially in cases like those under consideration. For the cases in which the most suffering is endured, are those in which we find labours the slowest. Had the sentence read, "so long as the na- tural pains continue with vigour," the meaning would have been clear ; and it would have authorized the alternative of the forceps, when this was not the case. As it stands, even in the reviewer's quotation, I am persuaded, every inexperienced practitioner would feel himself justified in waiting too long. 770. I must still insist, that if this Aphorism have any mean- ing collectively, it forbids the use of the forceps so long as there are pains, however feeble or transitory these may be, or however insuflBcient for the end proposed — the value of pains must be esti- mated by their power upon the body to be moved, and not by the degree of suffering the woman may endure. But let it be recol- lected, that beside the risk the child runs by long delay in the passage, the soft parts of the mother are suffering from the long pressure of its head ; subjecting them to contusion, inflammation, sloughing, &c. and this to comply with a prejudice against the proper employment of the forceps. But let us attend to what Dr. Merriman, one of the most zealous admirers of Dr. Denman, says upon this subject. He was called to the aid of a midwife in a case where, " the vertex was actually protruding through the os ex- ternum," but where it was necessary to draw off the urine as the woman had passed none for many hours — this was done, but he says, " on passing my finger into the vagina, the vagina felt so excessively hot and burning, as convinced me that the delivery ought not to be trusted to the efforts of nature, but that the child must be removed with all proper expedition, or otherwise, there was great reason to apprehend that mortification and slough- ing of the vagina ivould ensue.'' He accordingly delivered her with the forceps. His conduct upon this occasion, leads him to the following reflection: " It is laid down as a rule in practice, and it is * On consulting the works of Dr. D. as edited by Dr. Francis, I find the Aphorism precisely as I have quoted it; and Dr. F. declares, he has publish- ed, from the last edition, corrected by the author. APPLICATION, AND MODE OF ACTION OP THE FORCEPS. 287 one of those rules which, being founded in reason and experience, ought not lightly to be deviated from, that the head of the child should be in a situation capable of being delivered by the forceps for at least six hours before they are had recourse to." " But a rigid observance of it in the case I have related, would have proved highly injurious, if not fatal, to the patient, as it is apparent, that a very high degree of inflammation in the vagina, and parts ad- jacent, was just upon the point of taking place; and had the head of the child been suffered to remain there much longer, so much inflammation must necessarily come on, as might have proved incontrollable." In this case the head was "down low in the pelvis," but two hours. (Edinb. Med. and Phys. Jour, for 1810.) 771. Dr. Davis also relates a case completely illustrative of the point I have attempted to enforce; namely, that the soft parts of the mother may, by the long delay of the child's head in the passage, suffer extensive, and irremediable mischief. In the case alluded to, the patient was eighteen hours in labour; and, "during no stage of this labour, could it be truly asserted, that there was not some progress made. " The child " effected its transit through the pelvis, certainly in the midst of such a tempest of struggles, as I think I have never witnessed on any other occasion." 772. "The patient died on the tenth day after delivery." "On inspecting the body after death," "the cause of it was dis- covered to have been a large abscess, which seemed to have im- plicated all the structures at the superior part of the cavity, and towards the left side of the pelvis, and of which the left ovarium, probably dangerously contused during labour, had all the appear- ance of being the nucleus." (Elem. Oper. Mid. p. 149.) 773. I may also add, that the head of the child itself suffers very severely from a long-continued pressure upon it; producing extensive extravasations under the scalp, as well as sometimes abscess of this part, as is said to have happened to a child that was delivered at the Royal Maternity Charity, after an unusually tedious and painful labour. Baudelocque gives an instance of the scalp sloughing, &c. Vol. III. p. 161. 774. In a word, experience satisfactorily proves, that much risk, both to mother and child, is constantly incurred, by the head resting too long upon the lining of the pelvis. Dr. Davis men- tions a case, (p. 156,) where, after a labour of this kind, '«the parietes of the vagina" were much swelled, and required blood- letting and leeching to subdue it. 775. It is merely intended, by what is just said, to justify the 288 APPLICATION, AND MODE OF ACTION OF THE FORCEPS, assertions I have made against Dr. Denman's reluctance to em- ploy the forceps, and not a critique uj^on his Aphorisms — I have offered this elsewhei'e. See "Essays on various Subjects con- nected with Midwifery," by the Author. 776. Dr. Osborn* carries this reluctance still farther; to a de- gree indeed I think reprehensible, as it seems to militate against the interests of society — but he has not done equal mischief with Dr. Denman; because Tiis authority was not equal. He requires, before the forceps are applied, that " the powers of life be exhaust- ed; all capacity for farther exertion to be at an end; and that the mind be as much depressed as the body; and would at length both sink together under the influence of such continued but un- availing struggles, unless rescued by means of art." 777. I v/ould ask with what prospect of success could art in- terfere under such a complication of evils? the woman might be delivered but what would be her after-condition, or that of the child ? — why one would be subjected to all the evils which a too long delayed delivery would produce, if not death; and the other, to almost inevitable destruction. 778. Besides, the objections against the forceps are founded upon an erroneous estimate of their tendency — that they have been misused I admit; and so has almost everything else; but that they have been productive of more good than evil, I am every way persuaded. As regards the child, there can be no hesitation ; and as they may have affected the mother, I am certain they have been highly beneficial. It is entirely within my recollection, when cases similar to those, now treated by the forceps, were re- lieved by the crotchet — the child a certain victim, and the mo- ther a probable. one. In the year 1794, I was sent for by a mid- wife, to a woman who had been six and thirty hours in severe labour with her first child; and she nearly forty years of age. Upon examination, the posterior fontanelle was found at the left foramen ovale; the pains had been violent and frequent, but were now feeble and transitory, making no impression upon the child. I introduced the catheter, and discharged a large quantity of wa- ter; then applied the forceps, and soon delivered the child. So soon as it was born it began to cry; and when liberated from the placenta, I handed it to the midwife, who received it with averted face, and streaming eyes. I inquired of her what had so affected her; she answered by pointing to the child, and saying, * Essays, p. 45. APPLICATION, AND MODE OP ACTION OP THE FORCEPS. 289 " who with any feeling could help it? a poor child to be alive with its head open !" As 1 did not understand her, I desired she would explain herself; this she did, by saying, '^she would not have cared so much, had it been killed outright; but to be wounded and alive, was truly shocking!" I still insisted upon further explana- tion, as I yet did not understand her, and at the same time un- covering the child, asked if she supposed it was hurt, and if she did she was much mistaken. She now examined the child; and to her utter astonishment, found it without blemish. She then told me, she would have sent for me long before, but for the hor- ror she had of having the child's head opened; which she assured me, had been the uniform practice upon such occasions, when- ever she had sent for a physician. The influence of this case up- on many of the midwives of this city, procured me many oppor- tunities of applying the forceps.* 779. However strongly I may be impressed with the utility of the forceps, I should not feel myself warranted to use them as often as they appear to be in Great Britain, and on the continent of Europe. The frequency with which they have been employed, in some instances is really alarming; and I had like to have said • We are not alone in making a charge against such practitioners, as substi- tute the crotchet for the forceps, and with similar results from the mutilation. Mr. Dease states an instance, " where the child was miserably dragged alive in- to the world, with a great part of the brain evacuated." And Dr. Beatty adds, '• I can never forget a scene of horror to which I was a witness in the year 1800. I was called upon to see a very young lady, in labour of her first child, who was under the care of one of the oldest and most eminent practitioners in this city, (since dead) : her labour was most violent, which she bore with gi-eat im- patience and noise. The head had been down in the perinjeum (he said) seve- ral hours; I pi-oposed to give more time and an opiate, not doubting the pow- ers of nature, or to try the forceps, which he dechned, on account of its being her first child, and the apprehension he entertained of her being exhausted; and finally he opened the head. The operation, as it always does, excited extraor- dinary uterine action, and before it was well concluded, or the brain evacuated, so as to lessen the bulk of the head, the child was propelled into the world alive and crying. The old gentleman whose patient she was, was a person of very fine feelings, and the reader may imagine his sufTerings on viewing the effects of a rash and ill-judged operation; he declared no earthly consideration should ever induce him again to witness the application of the perforator." Dr. Beatty also remarks, " that similar instances had (he understood) occurred in tills city (Dublin) in one of which humanity prompted the accoucheur to plunge the child into a vessel of water, to put an end to its existence and cries." — Observations on the use of instruments in cases of difficult parturition and pro- tracted labour. By ,Tohn Beatty, M. D. &c. flhtblin Med. Trans, from John- son? s Mtdico-Chirur. Review, for July, 1831. J 37 290 APPLICATION, AND MODE OP ACTION OF THE FORCEPS, must have been too often unnecessary.* In my own proper prac- tice, I am persuaded I have not employed them oftener than once in three hundred and fifty cases ; though I have been under the necessity of using them very frequently in the practice of others. 780. I must not, however, be understood as reflecting upon any individual, by the last remark — my meaning will be properly un- derstood, when I state that some years ago, the practice of mid- wifery was very much in the hands of females. These females were not competent to the use of instruments; consequently, when they were necessary, others had to perform this duty for them ; it fell to my lot to do much of this business. By this means I have seen very many forceps cases, but the greater part of these did not belong to me as original cases. 781. But let me ask, what is to be feared from a proper appli- cation of the forceps? is their mode of action, when well direct- ed, such as to do injury to either mother or child? certainly not — then there is nothing to be apprehended from their structure, application, and mode of action, since necessarily, they neither cut nor contuse mother or child ; neither do they create unneces- sary pain, nor inordinately augment that which may be present ; but are truly calculated, in the language of Dr. Denman, to • The following statements upon the subject hi question, I extract from Dr. Davis's " Elements of Operative Midwifery." " It has been stated by Prof. Baer, (see Medecina Obstetrica, p. 443,) that the forceps have been used in the practice of an individual, or of individuals, whom, however, he has not chosen to name, in nearly one case out of every three la- bours. Prof Hag-en, of Berlin, delivered 39 women out of 350, or 1 in 9, with forceps. Prof. Niigele, of Heidelburg, reports, that in the practice of the lying- in institution of that city, for the year 1817 and 1818, he used the forceps once in 53 cases. Mr. Burns gives the proportion of Prof. Nagele, as "very much correspondhig with those of his own lists." In a statement of presentations at Le Maison d'Accouchments, between December, 1799, and May, 1809,flirnish- ed by the late M. Baudelocque, we have the proportion of forceps to the whole number of labours, as 1 in 353. Madame Boivin, 1 in 212. Madame Lachapelle, 1 in 166. At the Obsteti-ic School of Gottingen, 1 to between 18 and 19. At the University of Stockholm, 1 in every 100. Dr. Luders, 1 in 109. M. I.ob- stein, 20 times in 712 cases. Prof. Boer, of Vienna, once in 238 labours. In Dr. Clarke's Ab'stract of the Dubhn Lying-in Hospital registry, It is stated, tliatthe forceps were used 14 times in 10,387 cases." Dr. Davis considers the proportion of 1 in 53, which is approved by Prof. Burns, at least 400 per cent, too great; and is of opinion that the forceps are not required more than once in 300, or at most, 250 cases. Frcm the above statements, it evidently appears, that the forceps, in the hands of some practitioners, have been most wantonly used, and in those of some others, as improperly withheld. APPLICATION, AND MODE OF ACTION OF THE FORCEPS, 291 supply the insufficiency, or want of labour-pains; if this be so, and it is so admitted by Dr. D. himself, why should they be con- demned, because they may, like every sublunary good, be abused? 782. Let me endeavour to strengthen my case, by considering, 1st, their structure: 2d, their application: and 3d, their mode of action. 783. Their structure is such as to offer the greatest possible security to the child — the breadth of the clams being so great,* as to prevent any partial or injurious pressure; and the excavat- ed diameter between the blades, even when the handles are pressed pretty closely, will permit the transversal diameter of the head of a child of ordinary size to lie between them, without any or with very little inconvenience; the length and strength of their handles are such as to permit compression wherever that compression may be necessary. 784. The proper application of the forceps consists in their complete adaptation to the sides of the head of the child, or as nearly as may be over its ears — when fixed upon any other part of the head, it is but an exception. When placed as just sug- gested, the head is embraced in the direction of its oblique diame- ter, (82,) and the small diameter presents itself between the blades of the instrument. The advantages of this position of the forceps, are, 1st. That the head is seized in its smallest diameter; and this diameter is so little increased by the thickness of the in- strument, as to offer no additional difficulty to the delivery. In- deed it may be justly doubted, if the forceps increase the diame- ter in the least, as their thickness is lost by the yielding of the head of the child; for compression to a certain extent must al- ways be made during the operation of the instruments, and the united thickness of both blades does not exceed four or five lines. 2d. When the head requires to be compressed, the compression will be in the direction of the short diameter of the head, and will oblige the vertex to extend itself, (however little,) in the direc- tion of the oblique diameter; as its construction gives a tendency to that direction. 785. The proper application of the forceps farther consists in such a direction of its blades, as will permit their concave edges * Dr. Davis, (Elem. Oper. Mid.) thinks the bi'cadth of the French forceps is too narrow and proposes those of much gi-eater breadth. I have never found any inconvenience in the use of these instruments, which was exclusively charge- able to thia circumstance. 292 OF COMPRESSION. to come under the arch of the pubes, at the last period of labour — this rule is never to be violated. They must be placed exactly parallel upon the sides of the head, that they may lock; and it is ascertained that they are well placed, by their locking w^ithout the necessity of force. Should they not lock spontaneously, if we may use the expression, force must not be used to make them — for if it be employed for this purpose, it must necessarily be at the expense of the bones of the head, and, perhaps, the destruction of the child. If the handles do not readily join upon the intro- duction of the second blade, we may be certain one of them has a wrong direction; it must be ascertained which, and, by a judi- cious management of the one in fault, make it join, without force, its fellow.* 786. When the handles join kindly, we may be certain the blades are properly applied; and one of the greatest difficulties of the forceps is overcome.! The degree of compression to be applied must be determined by the size of the child's head; its suppleness; and the capacity of the pelvis — the less compression the head requires, the easier, and the more successful will be the operation. 787. The forceps have two modes of action; a. That of com- pression, in the first instance; h. and that of traction and com- pression, in the second. a. — Of Compression. 788. I have already stated, that when the forceps are well ap- plied, they traverse the head in the direction of its oblique dia- meter, or nearly so; and that the compression which it may suf- fer, is in the direction of its small diameter; now, as we cannot determine a. priori, the size of the head; the firmness of its bones; nor the resistance it will meet with in its passage, we cannot possibly calculate the force that will be necessary to reduce the head sufficiently to permit it to pass through the pelvis. I can, therefore only say, the less force it is necessary to exert, the less * Nothing more clearly points out the importance of an entire knowledge of the mechanism of labour; and the gi-eat necessity of learning to detect the ex- act position of the head within the pelvis by means of the sutures, than the diffi- culty an ignorant practitioner always finds in ascertaining, wliich of the blades of the forceps is in fault when they do not lock. f We may make one exception, however to this; namely, when the head is high in the pelvis, and the extremities of the forceps have only been applied upon a small portion of it; in this case the head is not embraced by these in- struments; it is only partially included, and they will consequently slip. OF COMPKESSION. 293 the head will suffer; and consequently, so far as this operation is directly concerned, the greater the chance will be of preserving the life of the child — and also, that the converse of this is equally true. Inattention to this latter fact, or a want of knowledge of it, has given rise to many of the objections which are urged against the forceps — for it has occasioned their application upon any por- tion of the head ; and the handles forced to lock, at the expense of the fracture of the skull;* it has occasioned them to be employ- ed, where there was so much disparity between the diameters of the head of the child and the pelvis, that it could only be deliver- ed, after the forceps had nearly broken down its texture; need I say what mischief would follow such displays of ignorance? the child dies by a species of murder; and the mother, especially, in the latter instance, is subjected to inflammation, gangrene, slough- ing, or even death. 789. It has been imagined, from the elongation which the head sometimes permits in long-protracted labours, that it would bear with impunity any compressing force, which might be applied; but this is an error; and an error of great magnitude; for by act- ing upon it, the benefits of the forceps have not only been under- valued, but really called in question. I must then, to prevent the perpetuation of this mistake, as far as may be in my power, de- clare, that the head will bear with safety but a moderate diminu- tion of its bulk, by the compressing force of the forceps; and of- tentimes, much less than is sometimes observed to take place, when the child has been delivered solely by the exertion of the natural powers; the reason of this is obvious; we cannot, by any contrivance of art, imitate this gradual, (though not always safe,) modification of the head; consequently, when it becomes reduced * I was once called upon to determine whether any thing- could be done for a newly-born child, which had been most unskilfaUy delivered by the forceps. — The frontal bone was severely indented by the edge of the forceps; and one eye entirely destroyed, by the extremity of the blade having been fixed upon it: yet it was born ahve. The case was of coui'se a helpless one; and the child fortunately died, in a few hours after its birth. I was once shown a blade of the forceps, which had been excessively bent, by an endeavour to make it lock. In this case, the forceps were exhibited in triumph, as a proof of tlie great diffi- culty the operator had to encounter, in effecting the delivery; and as additional evidence of this, he declared, that no strength was sufficient to deliver the head, as both his, (and he was a powerful man,) and that of an equally ignorant prac- titioner, were unavailingly exerted, alternately and collectively — he at last de- livered with the crotchet, after having experienced very great difficulty in withdrawing the bent blade of the forceps. 294 MODE OF ACTING AFTER APPLICATION. by a suddenly applied force, like that exerted by the forceps, it must be at the hazard of doing much injury, or it may be even fatal to the child.* 790. This fact limits the powers of the forceps more than is commonly supposed, even by those who employ them with the laudable hope of saving the lives of both mother and child; but who frequently experience disappointment, because not aware of it. The forceps, therefore, in the hands of those who consider them as a means by which a difficult labour may be terminated, but who apply them without rule, or without a knowledge of their mode of action, are nearly as fatal as the crotchet itself; be- cause they are regardless of the degree of compression they im- pose upon the head during its extraction.! It would seem, then from all experience to follow, that from a pelvis with less than three inches, or even three inches and a half in its small diame- ter, a child's head at full time cannot be made to pass with safety, by means of the forceps, unless there be an unusual degree of suppleness in the bones of the cranium; or the head itself unu- sually sniall. If these facts were more generally know-n, or more constantly kept in view, we should have fewer complaints against the forceps, because there would be fewer victims to their ill-di- rected power upon the head of the child, and fewer evils follow- ing their application upon the soft parts of the mother. b. — Compression and Traction. 791. It is in but very few cases that we can avoid a pretty constant compression, from the moment of their application upon the head of the child until its final delivery. With a view to diminish the permanency of this pressure as much as possible, I am in the habit of not tying the extremities of the handles, as is usually recommended, that I may after each tractive effort, per- mit the instruments to expand, as much as the elasticity of the • Dr. Davis, however asks, "whether in some particular circumstances It might not be found more ehg-ible to apply to the foetal head a certain required amount of compressing force, within a short time, artificially by means of the forceps than to await the result of a more gradual and proti-acted application of an ultimately equal degree offeree by tlie natm-al agents of pai-turition ?" — {Elem. Oper. Mid. p. 139.) f I have more than once witnessed the truth advanced here. I have seen the whole length or nearly the whole length of the frontal bone cut through, by one of the sharp edges of the forceps, by an effort to compress it; and at another, I have seen the parietal bone in the same wretched plight, from the same cause. MODE OP ACTING AFTER APPLICATION. 295 head, and the restricted capacity of the pelvis will permit. In this, I think there is decidedly an advantage to the child; and no possible injury can happen from it, to the mother. d. — Mode of Acting after A implication. 792. Each effort made to advance the head after the forceps have been applied, must be considered as a renewed compression, though the lateral pressure may be but very little increased; for in order that the head may advance, the curved extremities of the instruments must necessarily act at nearly right angles with their sides; consequently, the transverse diameter must be a little increased, or rather not so much diminished, as if the pressure were strictly and only lateral ; this consequently must, to a cer- tain extent, increase the difficulty of delivery; or in other words, increase the necessity of a stronger tractive force. This, how- ever, is in some measure, if not altogether obviated, by making each blade of the forceps act alternately as a lever in conducting the delivery; and this is the usual direction given for their em- ployment, without expressing the reason for it — hence, when the instruments are fixed, we act with much greater effect, by drawing from blade to blade, than if we continued the force in a direct line; for by making the handles describe a portion of a circle, by passing them from right to left, and the reverse, dur- ing the traction, we each time, (when the head is movable,) make a part of its side sink lower into the pelvis, and advance to- wards the external opening of the pelvis. 793. The extent of this motion of the handles must, at first be very small, especially if the head be high in the pelvis; or we shall be making fulcra of the soft and bony parts of the mo- ther at each effort, which must always be carefully avoided. As the head advances, we may enlarge the space through which the handles are to move, but it is never to be so extensive as to make the instruments press with much force against the bones, form- ing the arch of the pubes, and the external soft parts of the mo- ther. 794. The motion just spoken of, is at first horizontal, or very nearly so; but as the head advances, we are obliged to elevate the extremities of the instruments, and this in proportion, as it approaches the vulva, or as it is about to escape the external machinery; so that at the last moments, the extremities of the handles are laid nearly upon the abdomen of the mother. Dur- ing the operation, our tractive efforts should coincide with the 296 RECAPITULATION. action of the uterus, whenever that remains; when the uterus has ceased to act, we should permit as much time to elapse be- tween each exertion, as generally takes place between the pains at this period of labour, that we may not exhaust the woman; that we may secure the tonic contraction of the uterus, and that we may not make too suddenand too long continued compres- sion on the child's head. 795. It is by no me^ins unusual for the pains to cease after the application of the forceps; and we are obliged, in consequence, to perform the delivery without their aid — I am at a loss to ac- count for this; for it is contrary to what might reasonably be expected. When, however, they continue with even moderate force, I have been in the habit of disengaging the instruments, when the head is about to pass through the external parts, that these may be the better supported, and the risk of laceration di- minished. Should there be no pain, we are then constrained to continue our efforts, until the head is without. 796. In removing the forceps before the head is delivered, I am aware I am departing from high authority; for Dr. Denman lays it down as a rule that " in every case in which the forceps have been applied, they are not to be removed before the head is extracted, even though we might have little or no occasion for them." But notwithstanding this positive injunction, I am en- tirely persuaded, from experience, it is the safer practice, if we regard the integrity of the soft parts of the mother, worth pre- serving. Sect. II. — Recapitulation. 797. As I have dwelt upon the use of the forceps longer than I had intended, I shall sum up in a few words the principal points intended to be insisted on, or illustrated: 1st. That the long French forceps are preferable to the English short forceps, even for the unskilful; 2d. The best position for the woman is that recommended for turning; 3d. The bladder and rectum are to be emptied before the forceps are introduced ; the former by the catheter, when the woman cannot command the discharge; and the latter by an injection, if it has not been done Sj^onta- neously, a short time before; 4th. The patient and friends are always to be apprized of the necessity and propriety of the ope- ration before it is resorted to; 5th. The vagina, external parts, and the instruments, are to be coated, by fresh hog's lard, or soft pomatum and the instruments always warmed ; 6th. The for- RECAPITULATION. 297 ceps are never to be employed before the os uteri and external parts are relaxed; and the membranes ruptured; 7th. This relax- ation to be promoted by ihe best adapted means ; Sth. Should the uterus be in a proper condition for the operation, and the mem- branes at the same time entire, the latter must be ruptured, that the application of the forceps need not be delayed, when the case requires immediate interference ; 9th. When the circumstances of the case require the use of these instruments, the application should not be too long delayed, from an imaginary fear, that the woman might suffer from their use, or from an ill-grounded hope that the woman may deliver herself — we should, therefore, not permit her to be exhausted, or the child to perish, because feeble or inefficient pains attend, or because the head of the child has not been six hours in the passage; 10th. The blades of the for- ceps are always to be applied to the sides of the head — that is, over the ears of the child — when necessity, (Avhich is very rare,) obliges us to depart from this rule, it is but an exception to the rule; 11th. They must be applied so that their upper, or concave edges, will come under the arch of the pubes, at the last period of labour; 12th. Should the handles of the instruments not join with ease, we may be certain they are ill-applied; the cause of their not locking must be ascertained; and they are never to be joined by force; 13th. The head will not permit with safety, but a moderate approximation of its sides; therefore, when compres- sion is carried beyond this point, the destruction of the child is sure: 14th. With a view to prevent all unnecessary, and too long continued pressure upon the head of the child, the handles of the forceps should not be tied; but after each tractive effort, they must be permitted to expand themselves, by ceasing to press upon them; 15th. Each traction should be made from blade to blade; that each may act as a lever upon the head; 16th. The extent of the motion of the handles for this last purpose, must be regula- ted by the distance the head is from the external parts; for the less the head is advanced, the more circumscribed should be the motion ; and the reverse — this motion is at first nearly horizontal;* 17th. The external extremities of the instruments must be raised towards the abdomen of the mother, in proportion as the head ad- vances through the external parts; ISth. Should pains continue until the head has nearly passed through the external parts, the * That la, irom one thigh of tlie mother to the otlier. 38 29S GENERAL OKSERVATIOXS UPON THE FORCEPS. forceps may be removed; but if none attend, the delivery must be completed by the forceps. Sect. III. — General Observations upon the Forceps. 798. In delivering by means of the forceps, every attention should be paid to delicacy, and every care should be taken that the patient be not subjected to unnecessary pain; to fulfil the first, the patient should not be exposed; this cannot be necessary, even for the drawing off of the urine, should that be an essential pre- vious step. The operator must become familiar with the intro- duction of the instruments without the aid of sight, more especi- ally as this cannot serve hbn, and must, if employed, be highly offensive to the patient. He must perform his duty under cover; and the guide for his instrument must be the hand in which the instrument is not held — this, of course, will sometimes be the right, and at others the left — two or three fingers must be introduced so as to touch the child's head when at the lower strait, and the extremities of them must be insinuated under the edge of the os uteri if that is still down; and upon the plane thus formed by the fingers, the instruments must be conducted; with this precaution he shall give no unnecessary pain; since it will prevent the edge of the uterus from being included between the blade of the for- ceps and the head of the child. 799. Should the head of the child have escaped from the os uteri, he must pass the instruments in such a manner as shall con- duct their extremities under its edges ; this is done by keeping the point of the blade pretty firmly passed against the scalp of the child as it passes into the pelvis — should it, however, meet with any obstruction in its passage, the difficulty must be overcome by address, and not by force — it may be a fold of the scalp, or it may be the ear, by which the point of the instrument is arrested ; gen- tly depressing the handle of the instrument, or varying its direc- tion a little, will almost always surmount this difficulty. 800. Should much pain be experienced by an attempt to lock the blades when well applied, as regards their position, we may be pretty certain, a portion of the neck of the uterus is included in the grasp of the instruments — we must inquire on which side of the pelvis the-pain is felt, and withdraw the blade from it, and introduce it anew. Should cramps be induced, we may some- times relieve them by elevating or depressing the handles of ^le forceps. GENERAL OBSERVATIONS UPON THE FORCEPS, 299 801. The greatest care must be taken before we begin our traction, that no portion of the mother is included in the locking of the blades — this must be done by passing a finger entirely- round the place of union. This accident very rarely occurs in the use of the long forceps, unless the head is high in the pelvis — with the short it is frequent, even under the direction of the most care- ful operator; this forms, in my estimation, a very serious objection to their employment. I was once called to a poor woman who had had a considerable portion of the internal face of the right labium removed, by having been included in the joint of the short forceps. 802. When the instruments are properly adjusted, we should seize the hooked extremities with the right hand, and make them approach each other in the most gradual manner; and make no more compression than is absolutely necessary to secure a certain hold, or to enable the head to pass:* The left hand must be applied over the joint of the instruments, and in a manner that will per- mit the point of the index finger to touch the head of the child, which will enable him to determine the progress it makes. We commence the traction with a very small force, and gradually augment it to the extent we may judge necessary — we should finish the effort by gradually diminishing the force, until it comes to a state of rest; taking care, however, to maintain the advan- tage we have gained, by removing the pressure from the handles, and hooking two fingers in their curved extremities, and thus pre- vent the receding of the head. When we have indulged the ute- rus in a sufficient interval, or upon the accession of a pain, we are to apply our hands as just directed, and act as before. 803. As the head is about to pass through the external parts, the left hand must forsake the instruments, and apply itself firmly against the now distended perinaeum; and if there be sufficient power in the uterus to carry the head through the os externum, without farther aid of the forceps, they should be removed, as ad- vised; but if not, they must be suflered to finish the delivery. 804. When the head is without, the same care should be ex- ercised as was recommeiKled in a natural labour; that is, not to * When the pelvis is deformed, and tlie relation between it and tlie head of the child is very strict, we are obliged to depart from this rule, and apply a much stronger compressing force; as the diameter of the head must be a little diminislied, that it may pass — in this instance, the handles are to be brought to- gether, and secured by a garter or ribbon. 300 OF THE SPECIFIC APPLICATION OP THE FORCEPS. hurry the shoulders through the pelvis; that the tonic contraction, may certainly follow their expulsion. 805. It is frequently more convenient to stand to perform this operation than to sit; but a chair should be at hand, that we may use it after the head is delivered: we should order a sheet suffi- ciently folded, to be spread over our lap, that we may receive the child upon it, when the body is expelled. The funis must be cut at a proper time, and the rest of the delivery finished as on ordi- nary occasions. CHAPTER XXI. OF THE SPECIFIC APPLICATION OF THE FORCEPS. 806. Generally speaking, the difficulty of applying these in- struments is in proportion to the remoteness of the head from the inferior strait, and the facility of application, as the vertex, or forehead, may be near the arch of the pubes. It would be well, were it always practicable, or a subject of choice, that the young practitioner should commence with the most simple cases, and gradually advance to the more difficult positions of the head — but as this is impossible under the circumstance of ordinary practice, he should, while in his power, become in some measure familiar with the application of the forceps, by diligently practising upon the machine — indeed it would be highly advantageous to all who may be about to engage in obstetrical practice, to order a machine as an appendage to their instruments. By the use of this contriv- ance he can become well acquainted with every important pre- sentation, and at the same time render himself master of their re- spective mechanisms; he can familiarize himself to the application of instruments, and readily teach himself the routine of turning, &c. 807. I shall lay down the rules for the application of the for- ceps in every presentation as succinctly as the subject will permit, knowing from long observation, that nothing but a careful expe- rience with the living subject can ever make a man adroit in their use. I shall therefore commence with the most simple cases, and graduall}' advance to the more complicated and difficult. OF THE SPECIFIC APPLICATION OF THE FORCEPS. 301 808. The various ways which the head of the child lAay offer to the pelvis, when it may he necessary to terminate the labour by the forceps, are, 809. a. 1st. Where the vertex answers to the arch of the pubes, and the/orehcad to the sacrum. 810. b. 2d. The reverse of this, the ybreAe«c^ to the pubes, and vertex to the sacrum. 811. c. 3d. Where the ^-er^ear is behind the left foramen ovale, and ihe forehead to the right sacro-iliae symphysis. 812. d. 4th. Where the forehead is behind the left foramen ovale, and the vertex to the right sacro-iliac symphysis. 813. e. 5th. Where the vertex is behind the right foramen ovale, and \he forehead to the left sacro-iliac symphysis. 814. f. 6th. Where ihe forehead is behind the right foramen ovale, and the vertex to the left sacro-iliac symphysis. 815. g. 7th. Where the position of the head is directly trans- versal: 1st. Wliere the vertex answers to the left side of the pelvis; and 2d. Where it answers to the right. Sect. I. — a. 1st. Jipplication of the Forceps in the First of these Positions. 816. The woman about to be delivered with the forceps is con- stantly supposed to be placed upon her back, and every other cir- cumstance, arranged as already directed. 817. The first position in which we are to apply the forceps. Dr. Denman thinks can very rarely require them — this by no means comports with my experience; for I have very often been under the necessity of using them in this situation of the child's head; for any one of the causes which I have considered capable of complicating a labour, may happen at this period, as well as any other. What is there in this position which shall protect the woman against flooding, convulsions, exhaustion, &c. and ren- der immediate interference unnecessary.'' I can see nothing; for, though the labour is near its completion, it is not completed; and I am convinced, that in many cases both mother and child have suffered from the delay which Dr. Denman's repugnance to the employment of these instruments has created with the prac- titioners, who consider him the best authority. W^ere it neces- sary it would be easy to give examples to prove what I have just said. (See 765, 771, 772.) 302 OP THE SPECIFIC APPLICATION OP THE FORCEPS. 818. In this case, after duly preparing the forceps as ah'eady directed, we take hold of the male branch of the forceps with the left hand, and hold it as we would a pen when writing, while we introduce two or three fingers of the right hand into the vagina against the child's head, and under the edge of the uterus if prac- ticable ; we then hold the handle or blade nearly perpendicular, but inclining to the right side of the mother, and insinuate the extremity of the blade between the labia, and slide it along the fingers intended as a guide, until it reaches four or five inches within the pelvis; gradually depressing the handle as it advances, and as it embraces the head. It rarely happens that any diffi- culty is experienced in the introduction of this blade; its position, if properly applied, is strictly lateral ; its concave edge being un- der the arch of the pubes, the pivot will have a vertical position, while the handle will be sustained by the edge of the perinseum. The instrument must be retained in this position either by an as- sistant, or by placing it on the knee, while you prepare for the in- troduction of the other blade — this must be taken in the right hand, as directed for the other blade ; and must, like it, be con- ducted to its proper situation by two or three fingers of the left hand; when advanced as far within the pelvis as the first blade, the handle must be lowered and inclined towards the left thigh of the mother, until it crosses the first blade, and locks with it — if the instruments are properly applied, this will readily happen — the pivot will be vertical, and must be turned, that the blades may be secured in their position with each other — the handles are now to be seized, and the delivery conducted as already directed. Sect. II. — b. 2d. Jipjolication in the Second of these Positions. 819. This position, (810) is by no means as favourable for de- livery as the first, though not more difficult for the use of the for- ceps; the presence of the forehead under the pubes, as I have al- ready stated, (633) always renders it more diflicult for the woman to deliver herself; and sometimes is of itself a sufficient reason for the use of the forceps.* The application of the forceps, is, * Mrs. S., May 7tli, 1827, in !al)our with her second child; the presentation was the fifth, but could not be reduced to the first by any effort I could make, owing to the large size of the child's^head. After waiting unavailingly for sev- eral hours for the natural powers to effect the delivery, I was obliged to use the forceps. I have no doubt but the use of instruments would have been unneces- sary in this case, had the vertex have presented, as the pelvis was ample as or- OF THE SPECIFIC AFPLICATION OF THE TORCEPS. 303 however, precisely the same as in the one just described; we are only to observe, in finishing the labour, to permit the vertex to turn backward, as it is described to do when speaking of its me- chanism. Sect. III. — c. 3d. Application of the Forceps in the third of these Positions. 820. The application of the forceps in this situation (Sll) of the head is more difficult than in the two preceding; owing to the oblique manner in which it offers at the lower strait. It must assume this position before it can offer its vertex to the opening of the pelvis, but it may fail to make this necessary change, and thus render the labour difficult; or the causes which may complicate any labour may operate at the moment the head has arrived at the place designated, and thus render the use of the forceps indispensablei 821. When the forceps are to be used, the male blade must be passed to the left side of the pelvis at about the same distance as before directed; it will almost always pass along easily, after hav- ing spontaneously assumed a change of position; this change car- ries the handle a little toward the left thigh of the mother, and gives to the pivot an oblique position, instead of the vertical one before spoken of — after the first blade is adjusted, the other must be passed nearly opposite to it, but a little higher, and immedi- ately against the right leg of the pubes, and behind the right for- amen ovale; the handle must be made to incline like its fellow to the left thigh; and, if properly conducted, the blades will lock; but in a manner that will enable the pivot to preserve its look to- wards the left groin of the mother. 822. When the instruments are joined, we are directed by Baudelocque and others, to turn the vertex towards the arch of the pubes; but this is certainly not always necessary; for 1 have usually found, that this took place spontaneously as I continued dinary; the parts well relaxed; and the pains"frequent and powerful. As this child was of unusual dimensions, I will subjoin tlie measurement of several parts: 16 6-8 inches round the forehead and occiput. 19 1-2 " round the shoulders. 5 5-8 " round tlie arm below the elbow. The other parts of the body, proportionably large. I'he head of the child was lengthened considerably; but it recovered its shape in a few days. 304 OF THE SPECIFIC APPLICATION OF THE FORCEPS. the traction. I have no doubt but this is occasionally necessary;* especially, where the pelvis is rather narrow, or the head large, and when we find, after successive efibrts, the head does not fol- low the proper direction, we may turn the vertex towards the pubes, by gradually bringing the pivot to a vertical position — when this is done, this case is precisely like the first of these po- sitions, and the labour must be finished like it. 823. In several instances of this position, I have found it easier to introduce the second blade from below, pressing the handle of the first blade, pretty firmly against the perinaeum — that is, in- stead of having the handle high over the abdomen, to place it un- der the left thigh of the mother, and make the extremity of the blade penetrate from downward, upward; care must be taken not to place the female blade below the male, in this case. Sect. IV. — d. 4th. Apjjlications of the Forcejjs in the fourth of these Positions. 824. This position (812) unites the difficulty of the oblique situation mentioned just now, with the disadvantage of the fore- head under the arch of the pubes; and, though the application of the forceps is precisely the same as in the last described posi- tion, it will nevertheless be a more difficult operation, for the rea- son just stated. At the last period, when the head is escaping, the vertex must be suffered to turn backward, as in the second position. Sect. V. — e. 5th. JlpjjUcation of the Forcej)s in the fifth of these Positions. 825. This position (813) is of more difficult management than any of those I have yet described, owing to the necessity of plac- ing the male branch above; and obliging the female branch to be placed below^ — but these difficulties may be surmounted by gen- tleness and perseverance, and by a just knowledge of the posi- tion of the head. * Baudelocque tells us, that he has occasionally failed to establish the vertex under the arch of the pubes; and, in these cases, the head has passed through the inferior strait and external parts in a diagonal direction. I have witnessed this direction of the head in a number of instances, where the forceps were not employed; but it has only occurred to me once, when employing these instru- ments — when this happens, it is generally owing to the sacrum beuig too sti-aight. SPECIFIC APPLICATION OF T^E FORCEPS. 305 826. The male branch of the forceps must be conducted by the left hand behind the left foramen ovale; this must be done by passing the extremity of the blade upon two or three fingers im- mediately under the left leg of the pubes ; the handle of course must be depressed in proportion to the advancement of the blade, and made to incline towards the right thigh of the mother; and, when correctly adjusted, the pivot will take an oblique position, and look towards the right groin of the woman. The female blade must be introduced on the inferior part of the right side of the pelvis, and adjusted so as to correspond with the first intro- duced blade — the handles must then be locked, and seized by the left hand at the extremities of the blades; while the right will take hold over the pivot; a finger to be placed against the head of the child, as before directed. 827. It is not generally necessary to turn the vertex towards the pubes in this case, any more than when it was on the oppo- site side of the pelvis; this will take place as in the former case, by observing the proper direction, for the tractive forces. Sect. VI.— / 6th. Jipplication of the Forceps in the sixth of these Positions. 828. The relations of the head and pelvis in this case, (814) as regards diameters, are precisely the same as the one just de- scribed; and the forceps must be applied in the same manner. The same precaution must be taken at the final passage of the head through the external parts, to permit it to turn backward. Sect. VII. — g. 7th. Jipplication of the Forceps in the seventh of these Positions. 829. Dr. Denman, inhis Aphorisms, seems to acknowledge but one mode of applying the forceps, for the four last positions, and the one now under consideration; (815) and his directions for all, are only applicable to the last. This position of the head must be rare; at least I have encountered it but once, and it was re- lieved by one blade of the forceps acting upon the vertex, so as to aid the efforts of the uterus, (which were very strong,) in bringing it towards the symphysis pubis. 830. When the forceps are resolved on, and the vertex of the child is to the left side of the pelvis, the female branch of the for- ceps must be placed behind the symphysis pubis, and the male 39 306 GENERAL REMARf;S ON THE USE OF THE FORCEPS, &C. blade before the sacrum. The handles of the instruments should be made to incline towards the left side of the mother, that the vertex may descend rather more than the forehead. When the vertex is on the opposite side, the male branch must be inserted behind the pubes, and the female branch before the sacrum; the handles, in this case, must be inclined to the right thigh of the mother, for the reason just stated. CHAPTER XXII. GENERAL REMARKS ON THE USE OF THE FORCEPS, WHEN THE HEAD IS ABOVE THE SUPERIOR STRAIT. 831. Smellie appears to be the first who had either sufficient skill or hardihood, to apply the forceps when the head was free above the superior strait, and since his time he has had but few followers.* This, however, has not arisen so much from the con- templation of its dangers, as the consciousness of its difficulties. To employ the forceps with success under such circumstances, it is necessary that the operator be aware of all he may have to en- counter; as well as be skilled in their application, in the situa- tions we have just considered ; therefore it cannot be recommend- ed as a resource to inexperienced practitioners. 832. Baudelocque's observations upon this subject are so just and so important, that I must recommend them to the serious consideration of every gentleman who may intend to pursue the practice of midwifery. Fortunately, the necessity of operating with the forceps, while the head is in this situation, seldom occurs; especially, in this country, where almost the only apology for their use, namely, a narrow pelvis, is of but of very rare occurrence. • Dr. Davis, (Elem. Oper. Mid.) appears to have used the forceps when the head was above tlie superior strait; and recommends it with every apparent confidence, in sevei-al cases where immediate delivery may be necessary. This however, neither diminishes the difficulty, nor lessens the danger of these instru- ments, when awkwardly used. In his hands, the forceps may relieve the head from any situation in which it may be placed: but it must be recollected that few can boast of his experience, or adroitness. GENERAL REMARKS ON THE USE OF THE FORCEPS, &C. 307 I have been obliged to use Iheni but five times in this situation of the head, in more than forty years;* my experience, of course, in this necessity, is very limited. On this account especially, I refer to the high authority just mentioned, and forbear to give di- rections for their use. I believe, that the frequent mention of dif- ficult, dangerous, and rare operations, leads oftentimes to the un- necessary performance of them; not always so much from the necessity of the case, as the eclat which attends them, however unsuccessful. In surgery, I have known it to happen more than once: and once certainly, in midwifery. 833. When necessity obliges us to deliver when the head is si- tuated at the superior strait, it is much better to have recourse to the doubtful, but safer alternative of turning — for it will rarely happen, that this cannot be performed while the head remains free above the superior strait, even where the pelvis may be a little contracted, with at least as much safety to the child, and certainly more to the mother, t I should therefore earnestly re- commend to every unskilled practitioner, not to attempt this diffi- cult, nay, in such hands, dangerous operation. Even Smellie J him- self, the original projector of the use of the forceps at the superior strait, deprecates their employment at this part of the pelvis; he says, " a long pair of forceps may take such firm hold, that, with great force, and the strong purchase, the head may be delivered, (from the superior strait,) but such violence is commonly fatal to the woman, by causing such an inflammation, and perhaps lace- ration of the parts, as is attended with mortification. " In order," continues he, " to disable young practitioners from running such risks, and to free myself from the temptation of using too great * It is a little remarkable, that I was under tlie necessity lately of using' the forceps twice within ten days of each other, when the head was at the siif Jerior strait. t Dr. Davis proposes to dehver from the superior strait, under cfrcumstances not recognized by any other practitioner. He observes, " Ir profuse uterine haemorrhage, for instance, the orifice of the uterus being «-ipposed to be amply dilated, but the head of the child still at the brim of th^ pelvis, this method of treatment might sometimes very well deserve consit'eration, in comparison with dehvery by turning."— jEZem. Oper. Mid. p. 23.'?. I have already noticed this opinion of Dr. Davis, elicited by other considera- tions oftliis subject, at par. 657. I there suggested, and now repeat, that the use of the forceps under such circumstances, mustbe uncertain, if not danger- ous; and I must again declare, I tliink turning to be the proper operation, if necessary to have recourse to any. + Treatise, Vol. I. p. 221. 308 OF THE LOCKED OR IMPACTED HEAD. force, I have always used and recommended the forceps so short in the handles, that they cannot be used with such violence as will endanger the woman's life." From this it would appear, that even in the hands of one of the most expert accoucheurs, that ever lived, there was much danger attending delivery by the forceps, while the head remained at the superior strait. CHAPTER XXIII. OF THE LOCKED OR IMPACTED HEAD. 834. When the head has advanced some distance into the pel- vis, and cannot proceed farther, and when it is immovable, ex- cept upward in the pelvic cavity, it is then said to be locked or impacted. Baudelocque's account of this situation of the head, is by far the most lucid I have met with ; he most successfully com- bats the opinions of Levret and Rocderer upon the mechanism of this arrest of the head, and completely establishes his own doc-> trines upon this point. 1 have so rarely met with this situation of the head, that I feel almost altogether indebted to him for what I know upon the subject; 1 shall therefore adopt his account of this embarrassing case.* 835. He admits but one general species of locking, and that is where the head is fixed by two points of its surface diametrically opposite each other; this species he divides into two varieties; 1st, where the head is jammed with its greatest length between the pubes and sacrum; and, 2d, where its thickness cannot pass, owing to a narrowness of the pelvis; in the first case, it is the foreheaa ^and occiput which are in contact with the inner edge of the pelvis; u-ad in the second, it is the parietal protuberances — this latter is thernost rare. 836. Whenever Jie head becomes locked, it acquires the form of a wedge; Lamotte finely illustrates it, by comparing it to the keystone of an arch. * Madame Le Chapelle, Velpeau informs us, has never met with a case of locked head. INDICATIONS IN THE LOCKED HEAD. 309 Sect. I. — Of the Causes, Signs, and Occidents of the Locked Head. 837. Several causes must concur to produce the locked head; 1st, the long-continued and vehement action of the uterus, and the auxiliary powers of labour — therefore, this fixedness of the head never need be feared in a delicate woman, agreeably to Baudelocque; 2d, a disproportion between the pelvis and the head; this disproportion may depend upon the mal-situation of the head, upon its great size and solidity, or upon the deformity of the pelvis. 838. The immobility of the head is the pathognomonic sign of its being locked; but after it has become fixed, other symptoms arise, which, if they do not characterize this situation, are sure to accompany it — such as a swelling of the hairy scalp of the child, a thickening of the os uteri, an intumescence of the vagina, and external parts. These symptoms do not always declare a locked head, but a locked head is never without them. When the pelvis is so small that the head cannot engage in it, certain symptoms take place, which, agreeably to Lamotte and Roederer are some- times mistaken for the signs of a locked head. 839. A locked head is always serious to both mother and child; the mother it exposes to inflammation, sloughing, or gangrene ; and the child to almost certain death. 840. The whole of the soft parts of the mother become injured, by the long-continued and violent pressure which the child's head exerts upon them; the vagina, rectum, and urethra, sometimes receive irreparable injury. The bladder also suffers from the ac- cumulation of the urine, nor can it be relieved by the catheter, as the canal of the urethra is entirely obliterated. Sect. II. — Indications in the Locked Head. 841. The principal indication in the locked head, is the deli- very of the child. This is to be effected by thp forceps, in pre- ference to any other means, so long as the child is living; if its death be certain, the crotchet undoubtedly merits the preference. If we consult the older writers upon this subject, we shall find they all had recourse to the crotchet upon such occasions; and I am sorry to add, that too many living authors, as well as practi- tioners, are too fond of recommending or following their^xample. For, though the forceps do not always ensure safety to the child. 310 INDICATIONS IN THE LOCKED HEAD. they give it at least the best possible chance; they should, there- fore, always be preferred. In this country, this terrible case is certainly very rare; this is owing principally to the healthy con- struction of the pelves of our females. When it lakes place, it almost always arises from the bad positions of the head, and these positions must be either the third or sixth — now, these, as has al- ready been observed, are of extremely rare occurrence. 842. I especially recommend the reader to consult Baude- locque's very useful chapter upon this subject; he will find much excellent practical matter, besides the histories of several very interesting cases, which are of much more importance, particu- larly to the professed accoucheur. 843. The locked head is sometimes confounded with a head merely arrested in its progress; this stoppage may arise from, 1st. Whenever the head maintains its diagonal or transverse po- sition at the lower strait; 2d. When the chin departs from the breast too early in the labour ; 3d. When the lower strait is less than the ordinary size ; 4th. When the external and internal parts make much resistance. 844. For the removal of the first cause, we must bring the vertex towards the arch of the pubes ; by one blade of the for- ceps or by a lever ; this is not very difficult to perform ; I have succeeded in altering this position of the head by applying the extremity of the instrument upon the vertex, by passing it at the bottom and side of the pelvis, until it has passed under the head; we must then raise the edge of the blade, and insinuate it between the side of the pelvis and the vertex ; then, if the handle be press- ed against the perinzeum, its curve will be placed upon, or near the posterior fontanelle. When thus fixed, we must draw the instrument downward and forward during a pain, until we can move the vertex to its proper situation. When the head is thus changed, we may withdraw the vectis, and commit the rest to nature. 845. The mode of treating the second case has already been explained, (702, &c.) when speaking of this perverse situation of the head. When the arrest is owing to the smallness of the lower strait, as in the third, (843) the head must be extracted by the forceps, unless the defect be excessive; and if excessive and the child dead, the crotchet must be used ; but if living, Baude. locque proposes the Csesarean operation. If the external and inter- METHOD OP USING THE FORCEPS, &C. 311 nal parts, as in the fourth case, (843) offer the resistance, blood- letting will be the remedy. Sect. III. — Method of Using the Forceps in the Locked Head. 846. When the head is locked by its greatest diameter be- coming wedged in the small diameter of the superior strait, it is either by the vertex or the forehead being towards the pubes. In using the forceps for either of these situations, we must conduct them so that they shall apply themselves over the ears of the child, or to the sides of the head. They must be so arranged, that the concave edges must be towards the part which will eventually come under the arch of the pubes. When the head is embraced, we must endeavour to raise it up by a compound motion of the forceps; that is, by carrying the handles gently from side to side of the pelvis, and at the same time pushing the instruments upwards, so as to raise it from its bed. When this is done, the vertex or forehead must be turned towards the left side of the pelvis, if practicable; and when there, the motion we have already described must be given to the handles of the instru- ments, until either the vertex or forehead, as the case may be, is brought under the arch of the pubes. Baudelocqye directs the head to be turned as it is brought along, but I do not think this necessary; for when the head arrives at the inclined plane, form- ed by the sacro-ischiatic ligaments, it will turn towards the open- ing of the pelvis spontaneously. It must be recollected, in order that the instruments should be carried to such a height in the pelvis, that the handles must be kept well pressed against the perincEum. 847. When the head is locked by the small diameter becoming jammed in the small diameter of the superior strait; the vertex must answer to either the right or the left side of the pelvis, and the concave part of the instruments must look towards it; conse- quently there will be a choice of blade to be first introduced — if the vertex be to the left side, the male blade must be first, and the reverse. The head must be raised from out of the superior strait by the hand, and then the instruments must be directed over the sides of the head, and the traction must be in conformity with the axis of the upper strait; this direction is given by pressing the handles against the perinseum. 312 CHAPTER XXIV. OP THE USE OF THE FORCEPS IN FACE PRESENTATIONS. 848. In considering face presentations, I was inclined to re- strict their number to two, instead of four, as described by Bau- delocque — if I should not be correct in this reduction, I am at least sure, that the first and second of my arrangement, are by far the most frequent, and can safely say, I have never met with the third and fourth, though they were recognized by both Smel- lie and Baudelocque. Indeed the presentation of the face in any position is of very rare occurrence; I find I have met with it but ten times in more than ten thousand cases;* and upon consulting the table furnished by "I'Hospice de la Maternite de Paris," I find, that of 12,751 women delivered in that institution, there were but forty face presentations; and of that forty, but one of the first presentations of Baudelocque, and not one of the second; whereas of the third, there were twenty-two, and seventeen of my second. This is strong confirmation of the infrequency of the first and second positions of Baudelocque. 849. When a labour in which the face presents becomes com- plicated by any of the before enumerated causes; (651) or if it is rendered impracticable without the application of adventitious aid, from mere position; and that aid consist in the proper appli- cation of the hand, and it prove insufiicient for its accomplishment, we must resort to instrumental delivery — this will comprehend, the use of the vectis, the application of the forceps, or the em- ployment of the crotchet. 850. Of the mode of using the vectis I have already spoken ;t * It is a. little remarkable, that lately I met with two cases of face presenta- tion within a week of each other, and a third witliin tlu-ee months of these two; making- nearly half the number, I have ever encountered. f Raudelocque's method of using the lever in this case, ( System, Vol. HI. par. 1836,) appears to me to be defective, as I have already stated. I have, in a few instances, used as described before with the most decided advantage — but how far it may be successful as a general practice, I have yet to learn; for I .igain declare, my experience in face cases to be very limited; but it appears to me to USE OF THE FOKCEPS IN FACE PKESENTATIONS. 313 the forceps I consider of doubtful efficacy, not so much from the difficulty of application, as their mode of action in these particu- lar cases; though it would seem, Smellie had succeeded with them. I would, however, wish to be understood, in speaking of the use of these instruments, that I confine my* observations en- tirely to the two first presentations of the present arrangement,* or where the head is situated ti-ansversely in the pelvis. In such situations of the face, wc are told, by both Smellie, ai\d Baude- locque, " that we must use the forceps;" the latter declaring, that *' when we cannot rectify the relation of the face to the pelvis by the plan already advised, or without great danger to the mo- ther, because the head is strongly wedged, and the uterus con- tracted and closed upon the child," — " we must use the forceps to bring the head along in the attitude we find it in," because few- er inconveniences result from it to mother and child than Ironi any other method. 851. Should the forceps be determined on, we must apply them over the ears; that is, one blade behind the pubes, and the other before the sacrum; they must be so applied that the concave edges must look towards the hind head, which must be brought under the arch of the pubes, and not the chin, as directed by Smellie. 852. Should all the reasons exist for using the forceps, and their application not prove successful, I feel that this is one of the very few cases, where the application of the crotchet is justifiable for the preservation of the mother, however repugnant I may be to its use, or however revolting it may be in its consequences. 853. Having considered all the most frequent and better known presentations of the head, with the v^arious modes of conducting them when nature is sufficient to their accomplishment; the mode be more consonant witli the principle to be acted upon in such cases; which is to reduce the vertex, and elevate tlie chin. But agreeably to him, we must act forcibly upon the vertex, that it may "be sufficiently broug'lit down;" but we cannot bring the vertex down alone by his plan, as the face will descend with it by obeying the same impulse which moved the vertex. Now, this disadvantage is avoided by the plan I propose; namely, after fixing the vectis properly upon the occiput, we apply no more force to it than is sufficient to prevent it from rising in the pelvis, at the lime we are acting on the face, by applying two fingers immediately at the extremity of the nose, and upon the upper jaw. * The third and fourth are so rai-e, or rather their possibihty so doubtful, that I do not think it worth while to notice them farther than I have already done — those desirous of seeing all that can be said upon these positions, are referred to Smellie, and Baudelocque. 40 314 USE OF THE FORCEPS IN FACE PRESENTATIONS. of operating by the hand alone Avhen she is incompetent to this end, and the use of instruments when it becomes essential from this cause to employ them; I shall not consume the reader's time or patience by describing a variety of other presentations of this part as laid down by authors; first, because I never have seen them; and, second, because I believe if they really exist, they must all, or with very few exceptions, be treated by turning: as I shall direct for many other rare and perverse positions which the child's body may assume at the orifice of the uterus, 854. Nor shall I spend time in describing the form of the vectis, or its mode of application; because the one would be totally un- necessary without the other ; and I decline the latter, because I am not in the habit of using this instrument, except in rectifying bad positions of the head; and for this purpose I have always found one of the blades of the forceps sufficient. I consider the vectis inferior to the forceps, in power, safety, and convenience: and I am truly glad to perceive the change which has taken place in the public mind, since the accurate and elaborate analysis of its merits, by the judicious Baudelocque, has been before the public. 855. T am also pleased to find a change in Mr. Burns'* opinion upon the subject of the vectis; he says that a *' young practitioner shall be less apt to injure his patient, and less likely to be foiled, with the forceps than the vectis;" and particularly gratified that Dr. James, in a note to this paragraph, expresses the same belief. The latter gentleman's opinion, upon this and every other point connected with our subject, is highly valuable; especially in this country, where the opportunities to test the respective merits of these instruments can fall to the lot of no one who is not exten- sively, and for a long period, engaged in obstetrics; for the facility of labours among our females, owing to the almost entire exemp- tion from rickets, and other causes which render this process one of much more difficulty in Europe, give comparatively few oppor- tunities to decide upon their respective claims. 856. I have for many years felt the superiority of the forceps over the vectis; but was reluctant publicly to express it, from an apprehension that I might have mistaken my own mal-adroitness in using the latter, for an imperfection in the instrument itself; but strengthened by the opinion of Dr. James, I have no longer any hesitation upon this subject. * Principles, James's ed. 1823, Vol. I. p. 447. 315 CHAPTER XXV. PRESENTATIONS OP THE BREECH. 857. The presentation next in frequency is that of the breech, though not so arranged by Baudelocque; but as I before stated, I think it a good rule, to treat of labours in the order of their fre- quency. The breech may with great propriety be considered as a variety of natural labour; since, the woman most frequently is able to relieve herself, if we except perhaps, a first child; though the process may be longer, and more painful, than when the vertex presents in one of its best manners. And were I to insti- tute a comparison between the two, I should say it is not ordina- rily more painful than the fourth, or fifth vertex presentation. I think also, that this presentation is more favourable for the child, than either the feet or knees; especially, in first labours; though the operation, generally speaking, is slower; and perhaps more fatiguing to the mother. 858. The risk, in all the labours, whether natural or artificial, in which the child's body is first delivered, arises from the delay in the delivery of the head, and the compression of the umbilical cord. Now, the latter very frequently depends upon the former; and the former upon the bad position of the head as regards the pelvis; or from the rigidity of the external parts. This being the case, it is evident, that the risk from the delay of the head at the inferior strait in consequence of the want of dilatation of the ex- ternal parts, must be less in presentations of the breech, than in the presentations of the feet and knees; because, its bulk being nearly equal to that of the head, will by passing through those parts so effectually dilate them, as very much to diminish the risk of such delay. On this account, 1 think breech labours, csete- ris paribus, safer to the child than those of the feet or knees, though they are not generally so considered.* • Baudelocquef says, that "delivery may be generally performed as naturally when the child presents the breech, as when it offers the feet or knees; only that, cseteris paribus, it will be a little longer, and more difficult; because the child does not then form so regular and lengthened a wedge, as when the lower extremities are unfolded." I agree, tliat it may be "a Uttle longer and more difficult" to the mother; but, for the reasons above stated, I think it safer for the child, t System, Vol. I. par. 7&6. 316 MECHANISM OP THE FIRST 859. The presence of the breech at the orifice of the uterus, cannot be very well ascertained or distinguished, before the mem- branes are ruptured and the uterus pretty well dilated. Under proper circumstances it may be known, by its forming a large softish tumour in the pelvis, which wants the characters of the head, with which it is alone liable to be confounded; for it has neither the sutures, nor the hardness of this part; nor the rough- ness of the hairy scalp.* A deep groove is observed in the centre of this part, which, when traced, leads to the detection of the anus, and, the parts of generation. A discharge of meconium, af- ter the membranes have given way, tends to corroborate, but does not absolutely confirm the presence of the breech, t Sect. I. — Species of the Breech Presentations. 860. There are four principal manners in which the breech may present at the upper part of the pelvis; a, the first is where the lower part of the spine and sacrum offers to the left acetabu- lum, while its abdomen looks towards the right sacro-iliac sym- physis; by 2nd, where the back part of the child answers to the right acetabulum, and the belly to the left sacro-iliac junction; c, 3d, where the spine and sacrum are behind the symphysis pubis, and the belly towards the projection of the sacrum; d, 4th, the reverse of this. Sect. II. — a. Mechanism, of the First Presentotion of the Breech. 861. In this presentation Ihe oblique situation of the breech at the upper strait, is soon changed by the contraction of the uterus, into one almost strictly transversal; so that the spine will at one * It must, however, be confessed, that there is sometimes a great deal of difficulty in deciding whether the presentation be the head or the breech— the former, when veiy much swoln by becoming locked, may resemble the breech; and the latter, when very tumid, may have its principal signs so masked, as to render it doubtful whether it be breech or head. Baudelocquet tells us of an experienced practitioner, who mistook the breech for a locked head, and de- livered it with the forceps. In all cases of ambiguity, I have constantly made it a practice to introduce the hand, to ascertain the nature of the presentation whenever it becomes important to decide the point. f It is Levret, I think, who mentions a case in which there was a considera- ble dischai'ge of meconium, thongli the head presented; and I am certain of having met with one case, if not more, of a similar kind. \ System, Vol. I. par. 1251. PRESENTATION OP THE BREECH. 317 time be found behind the symphysis pubis; but soon after, the left hip or spine of the ilium, will be made to offer itself under the arch of these bones, while the right will be resting upon a part of the sacrum, and the inclined plane formed by the left sacro-ischiatic ligaments. The spine of tlie child will rest against the left leg of the pubes, and the hip which is under the arch will rise upwards, while the right will turn into the hollow of the sacrum, and tra- vel successively over the point of the coccyx and the face of the perinajum, to offer itself at the bottom of the vulva, that it may escape through the external parts; which presently it does, with the other portions of the breech, by rising by a slight bend of the spine towards the mons veneris. 862. When the breech has passed a sufficient distance through the OS externum, the legs of the child fall down; and the remain- ing portion of the body by the successive contractions of the ute- rus will be delivered by passing a little obliquely through the ex- ternal opening of the pelvis. When the armpits descend to the superior strait, there is a momentary interruption to the farther descent of the body of the child, occasioned by the size of the shoulders, and position of the arms ; but from the pliant disposi- tion of these parts, it is but temporary; for they are made to ac- commodate themselves to the shape of the pelvis, by the repeated contraction of the uterus. -The head now offers itself to the up- per opening of the pelvis, the occiput is behind the left acetabu- lum, and the face before the right sacro-iliac junction. The chin will descend sooner than the occiput, in consequence of its having been placed against the breast of the child. 863. As soon as the head clears the superior strait, the fore- head inclines towards the hollow of the sacrum, by the same pivot- like motion which it performs to place the vertex under the arch of the pubes, in vertex presentations. The nape of the neck will now be under the arch of the pubes, while the face will be Ivino- on the face of the perinseum. The chin will first escape from the vulva: the other parts of the face, and anterior part of the head, will successively follow; while the nape of the neck will execute a slight circular motion under the arch of the pubes. The arms are liberated, so soon almost as the shoulders arc pushed through the OS externum.* • It must be borne in mind, tliat a strictly natural delivery is here described — or in other ^\'ords, where no advcTititious aid is required. 318 SECOND, THIRD AND FOURTH Sect. III. — b. Mechanism of the Second Presentation of the Breech. 864. In this presentation, the mechanism is precisely the same as that of the first; on the part of the child we must only substi- tute the right hip, offering at the arch of the pubes, for the left, as in the first presentation; and, at the last period of the labour, the vertex or occiput will be placed at the right side of the pelvis instead of the left. On the part of the pelvis, it is the right aceta- bulum, behind which the breech offers, &c. Sect. IV. — c. Mechanism of the Third Presentation of the Breech. ^%^. In this presentation, the breech engages in the superior strait, with its greatest width parallel to its large or transverse diameter — the spine passes immediately behind the symphysis pubis; and it becomes a matter of some uncertainty, which hip will ofller under it; but whichever it may be, it passes through a little obliquely, as in the other presentations. Though in this position the face of the child looks directly to the projection of the sacrum, it seldom happens that the head becomes jammed with its greatest diameter, in the small diameter of the superior strait; it is therefore, almost always, found to place itself diagonally, and pass down in that direction, as in the two former presentations. 866. When the breech becomes free, the labour proceeds com- monly as has been described in the first or second positions, as it may be the left or the right hip which offers to the arch of the pubes. Sect. V. — d. Mechanism of the Fourth Presentation of the Breech. 867. The only difference in the mechanism of the third and fourth of these presentations, is, that instead of the face being placed below, as in the third, it is found to be looking up, which creates the only' peculiar diflicult}' in this case. The risk of the head engaging with its greatest length in the smaller diameter of the superior strait, is perhaps greater in this than in the third — but should this take place in either, difficulty might be created. The fourth presentation is decidedly a rare one — I have met with it but once ; and upon examining the retui'nsfrom "I'Hospicede PRESENTATIONS OF THE BREECH. 319 Ja Malernite," but one case is recorded in more than 12,000. When it occurs, and we have not lost the opportunity, we should always seek for the feet, and deliver by them. 868. I have already observed, that all the presentations of the breech are attended with slower, and more painful labours; and that the child very frequently suffers. This is especially the case where tlie labour has been improperly interfered with, either by rupturing the membranes unseasonably, or under the influence of false principles, seeking the feet, and causing the child to pass rapidly through the external parts, before they are properly re- laxed; in consequence of this, the head becomes wedged in the inferior strait. Then, under the direction of the same erroneous views, it is attempted to deliver it quickly, by making force sup- ply the place of address; and the child becomes the victim of this unnecessary, and ill-directed violence. 8G9. It must constantly be recollected, in all cases in which the head is the last part to be delivered, that when it offers itself to the OS externum, it is entirely from under the direct control of uterine action; the auxiliary, and voluntary powers alone have an influence on it at this period of labour; and though external force may, and almost always does become necessary to termi- nate the labour, it must always be made to co-operate with these powers, by soliciting the woman to exert them as amply as may be in her power. CHAPTER XXVI. CAUSES WHICH MAY RENDER PRESENTATIONS OF THE BREECH PRETERNATURAL. 870. The presentation of the breech, like any other presenta- tion, may be complicated by either of the accidents enumerated in par. 651, and must when thus complicated be interfered with, whenever such a combination may render the labour difficult or dangerous. 871. Besides the causes just alluded to, there n)ay be others connected with the child itself, which should cause us to aid in the delivery of the woman. But in the absence of such causes, 320 PRESENTATIONS OP THE BREECH. and especially, in a first labour, the process should be left to the powers of nature alone; or at least, until the breech is delivered. 872. I am aware that many respectable practitioners are in the habit of introducing the hand and bringing down the feet, in all cases of breech presentation; but I am abundantly convinced, that as a general rule, it saves the mother nothing, and that it is highly dangerous to the child. I am of opinion that this prac- tice is often the result of the classification of labours, as breech presentations are almost uniformly placed in the preternatural class ; it has, therefore, been too easily supposed that such cases always require extrinsic aid. May not this be one of the rea- sons, why so many children perish in this presentation? What the general practice in breech presentations may be in Great Britain, I am not prepared to say; but the result is extremely unfavourable; since Dr. Denman says, "I have considered one child in three of those born with these presentations, to be still- born." This proportion by no means coincides with my experi- ence in such cases; the average of living children would be con- siderably greater, though a number of my cases were second hand, and in which the first stages of labour had been very often ill conducted ; I, nevertheless, think Portal's proportion rather too little for France, where there must necessarily be very many faulty pelves to contend with, as he makes but twenty per cent, while Dr. Denman's is thirty-three— in this country, where we but very rarely meet with a deformity of pelvis; when there is not an excess of size in the breech ; and when the earlier stages of labour have not been disturbed, by ill-timed officiousness, or. an entire ignorance of the correct rationale of such cases, I am, I think, warranted in saying, that the number of still-born children from breech presentations, niight be reduced to very few. But the result of cases in which the breech, the knees, or the feet present, agreeably to the records of '■'■la Maternite,^^ is, that one child in eight perishes, which is again very much less than the proportions established by Denman and Portal and can per- haps only be satisfactorily accounted for, by supposing that in that institution a better treatment is established for these cases. Yet we confess on the other hand, that the proportion of still- born children in the same hospital, to those born alive is, judg- ing by my own experience, excessive; namely, one in thirty-two. In this counti-y, under favourable management we do not think there is one in fifty, if we select, as v/e think we should, only such PUESENTATIONS OF THE BREECH. 33). cases in which children die in the birth, and this we presume is the mode of calculation in Paris, as the comparison is instituted between the head, breech, feet, and knees, cases. This disparity, induced M. Baudelocque, nephew to the celebrated accoucheur, to inquire into the cause, which he declares to be always the same; namely, to the interruption of circulation between the mother and child, which constantly produces a sanguineous congestion, either in the brain or in the liver, and thus adopt- ing the opinions of Chausier, Madame Lachappelle and Duges. He does not agree with his uncle, that the stretching of the vertebral column, is a frequent cause (736) of death in other, than head presentations, and strengthens the general position, by the testimony of Mdme. Lachappelle, who declares she has seen children born alive, when so much force had been applied as to cause a cracking noise from the tearing of the ligament, of the cervical ligaments. But let us not be deceived upon this point, and be disposed to believe, that the severe stretching of the cer- vical vertebrae is free from danger to the child; on the contrary, we are certain, that if it be severe, it is always fatal to the child, though it may not be the only cause of its death. 873. But should any one of the accidents which may disturb a labour, assail a woman whose child is presenting the breech, we are justified in giving such assistance as the exigency of the case may demand. The kind of aid we are to give, will depend upon, 1st. a. The degree of advancement, or the part of the pelvis at which the breech may be at the time; 2d. b. The position of the child ; and 3d. c. The size of the breech. a. First degree of Advancement . 874. An accident threatening or endangering the life of the mo- ther, may, a, attack her in the very commencement of labour, and where the child is still at the superior strait; b, it may attack, when the breech is pretty low in the pelvis, but still included by the uterus; c, it may attack when the breech is at the lower strait, but escaped from the uterus. 875. a. This may happen when the uterus is well dilated, or easily dilatable, or when rigid; the membranes may be either entire or just ruptured, or ruptured a long time. 876. Should any circumstance render it necessary to deliver the woman when labour is but little advanced; the breech at the superior strait, or near it; the uterus dilated or dilatable; the 41 322 CAUSES RENDERING BREECH PRESENTATIONS membranes entire or just ruptured: we must without hesitation introduce the hand and bring down the feet, and finisli the deli- very as directed, when turning is employed for a vertex presen- tation. But should the uterus be still shut, or but little opened and rigid, nothing should tempt us to enter the uterus forcibly, with a view to bring down the feet and deliver; especially, if the membranes are entire ; as, under such circumstances, there must be a reasonable expectation that the uterus will soon dilate, at least sufficiently to pass the hand without violence. As I have constantly inculcated the impropriety of dilating the uterus by force, whenever the labour is complicated by any supervening accident, I must be understood to make no exception here in fa- vour of this presentation; therefore, when the uterus is rigid, and but little opened, we must treat Ihe case by temporising agreeably to the nature of the accident, until either the remedies, or the influence of the accident, or the powers of the uterus it- self, shall make such change as will render the attempt at bring- ing down the feet proper and safe. b. Second Degree of Advancement. Sn. b. It may attack when the breech is pretty low in the pelvis, but still included in the uterus; this may happen when the uterus is well dilated or easily dilatable, or when rigid and un- yielding; and when the membranes are entire or just ruptured; or when the waters have been drained off a long time, and the uterus is firmly embracing the body of the child. 878. In the first instance, or where the uterus is in a condition to transmit the hand without much force, the membranes entire, or the waters but lately passed off, we should bring down the feet as directed in the former instance, and finish the labour after the same manner. But should the os uteri be rigid, whether the membranes be entire or not, we must not force the mouth of the uterus, with a view to terminate the labour; but, as just suggest- ed, temporise, until the uterus will permit the hand to pass for this purpose, without difficulty; for it will rarely happen, even where the waters have long escaped, that we cannot pass the hand to the margin of the pelvis, and seize the feet, provided the proper hand be employed. c. Third Degree of Advancement. 879. c. It may attack when the breech is at the lower strait, but passed through the mouth of the uterus. This situation ne- PRETERNATURAL, AND MOBE OF TREATMENT. 323 cessarily presupposes the dilation of the uterus, and ahnost cer- tainly the escape of the waters. In this condition of the breech and uterus, we must not attempt to bring down the feet, unless the breech be very small, or the pelvis very ample, and the wo- man without pains, or at least efficient ones: for if they are pro- trusive, and under the circumstances just mentioned, they will deliver the breech in good time, or in such time as will prevent any serious inconvenience from the delay. But should the breech be large, and occupy the lower strait very strictly, we should not attempt to finish the labour by bringing down the feet. In this case, we must assist the passage of the breech, by acting, 1st, with the fingers; 2d, by the fillet; 3d, by the blunt hook or hooks. SSO. When the breech is very low in the pelvis, or so low that w^e can place a finger into the groin, we may, by the forces so ap- plied, aid the descent of the breech; especially, if the uterus by its contractions still powerfully co-operate with our exertions. Whenever attainable, we should prefer that groin which is most posterior to the arch of the pubes, when but one at a time can be operated on. If both groins can be reached, we may insinuate a finger of each hand into them, and have this double power to as- sist the breech to descend. 851. Should the force just directed, be too feeble for the pur- pose ; or too fatiguing to the operator, he may substitute the fil- let with very great advantage. Baudelocque* makes a disparaging mention of this power; he says, "its application is so difficult, that it is with a sort of repugnance that he reckons it among the resources of art." That it is sometimes difficult in its application, I readily admit ; but it is by no means impracticable, when the breech occupies the lower strait. If the passing of the fillet be attempted when the breech is pretty remote from the os exter- num, we may certainly be foiled ; but this is not a case proper for this instrument; for it can only be used when the point of the finger can command the groin. 852. This fillet should consist of a piece of silk riband of an inch and a quarter or half wide, and at least two feet and a half long. When doubled, the point of the forefinger must be placed in the centre of the fold and kept tight upon it, by drawing k sufficiently with the other hand — the parts of the woman and * System, par. 1267. 324 CAUSES RENDERING BREECH PRESENTATIONS the fillet should both be imbued with lard or sweet oil, and the riband then passed into the vagina by the point of the finger, and conducted over the hip, and into the groin towards the parts of generation of the child, as far as the point of the finger can reach; the finger is then to be retracted a little, that it may ga- ther upon its point another fold or fillet, which it also carries forward as far as it can reach; and this to be repeated for seveiral times, until the folds so multiply in the groin as to move each other forward, so as to appear at the other extremity of it — when there, it may be drawn down by the forefinger of the other hand, introduced, after the first is withdrawn from the vagina; or it may be hooked, as proposed by Baudelocque, and as 1 have myself practised, by a hook, made extemporaneously, of a piece of pret- ty stiff wire. 8S3. When the fold of the fillet is seized by the finger and thumb, or hooked by the instrument just mentioned, we are to take hold of one of the outer extremities of it with one hand, while we draw the other end through the groin, by gaining suc- cessive portions of it. When the fillet is thus made single in the groin, we take hold of both extremities of the riband, and secure a good hold by passing it several times round some of the fingers. We then co-operate with the pains if there be any, by pulling in the direction of the axis of the lower strait, until the breech is re- lieved from the pelvis. But if the pains have ceased, we draw at intervals; at the same time, we solicit the co-operation of the patient. 884. But should we not be able to pass the fillet, because the breech is too remote from the finger; or, because the breech is very large, and firmly impacted in the pelvis, we must then at- tempt assistance, by employing the blunt hook, or hooks. I have found, more than once, the hook at the extremities of the French forceps answer extremely well, as Baudelocque long since sug- gested. But that they may be employed with advantage, they must stand very nearly at right angles with their stems; for if they are too much depressed, they cannot be introduced into the groins; for this reason I would advise every gentleman who may adopt these instruments, to attend to this circumstance at the time he is purchasing them. 885. The mode of using the blunt hook, is by first placing the point of the forefinger upon the groove which leads to the groin: then pass the handle of the forcep into the vagina, with the point PRETERNATURAL, AND MODE OF TREAT^MENT. 325 of the hook looking upward or towards the point of the inserted finger, until it comes in contact with it; then, by altering the position of the hook, and making it take the place of the finger, by a gentle pressure, it may be placed in the groin; when thus placed, we must aid the descent of the breech by pulling at the external extremity of the instrument in the direction of the axis of that part of the pelvis through which the breech is to pass. 886. Baudelocque proposes blunt hooks to join something like tlie forceps for this operation ; but this I do not think necessary; for when both groins can be commanded, and it is essential from the nature of the difficulties attending the labour to act upon both of them at the same time, both handles of the forceps, I am of opinion may be employed advantageously, without being united — but I confess this to be conjecture; for I have had no experience of it. 887. When the breech is situated obliquely at the lower strait, w^e should apply the force whenever practicable, to the groin wliich offers to the sacro-iliac symphysis, or side of the sacrum; as this hip should advance faster than the other, that it may ar- rive at tlie bottom of the vulva to escape through the os exter- num. When placed transversely, we may act upon either, or both groins, until the breech is about to pass under the arch of the pubes — when there, we should endeavour to depress one of the groins, that the ilium may come under the arch, instead of the sacrum and spine, unless it does so spontaneously. Sect. I. — 1. Position of the Child. 888. The child may present so untowardly at the superior strait, in consequence of a severe obliquity of the uterus, as to be unable to engage in it. In such case, one of the hips may only present itself to the opening of the pelvis; of course the la- bour, if not rectified by changing the position of the woman, will be very tedious and painful, or even dangerous. This situation of the hip will, of itself, offer great embarrassment to the woman delivering herself; and often render it proper that we inter- fere without delay; but when this position is attended with either of the accidents heretofore enumerated, it becomes indis- pensable that we bring down the feet; provided, the conditions on the part of the uterus just mentioned, do not render that ope- ration improper. 889. Should the breech present in the fourth position, and this 326 CAUSES RENDEUTNG BREECH PRESENTATIONS be ascertained immediately after the rupture of the membranes, it would I believe, always be best to bring down the feet; pro- vided, the uterus be sufficiently relaxed to permit the hand to pass without difficulty ; but should this presentation be complica- ted by any accident, it will become absolutely necessary; but it must be under the provisions just stated. Sect. II. — 2. Size of the Breech. 890. The breech may be absolutely, or relatively large as re- gards the pelvis ; in either case, the same difficulties will be ex- perienced. If the labour be left to itself, it may consume so much of the w^oman's strength as to render her situation pre- carious without recourse be had to adventitious aid. This case may be complicated by any of the accidents already enumerated; or its difficulties may be increased, by being a fourth presenta- tion. 891. When sufficient time has been given, without advantage to the labour; and the cause of the delay satisfactorily ascertain- ed, we should interpose and save the patient much unavailing pain. The nature of the assistance to be given must depend; 1st, upon the condition of the uterus, and the degreeof advancement of the breech; and 2d, whether it be still contained, or has escaped, from the mouth of the uterus. In the first case we must bring down the feet so soon as the uterus will permit; and in the se- cond also, provided, the breech is still within the uterus; and the waters but recently drained off; but if it has escaped from the orifice of the uterus, we must employ the fingers, the fdlet, or the blunt hook, as may appear expedient. Sect. III. — The Mode of bringing doivn the Feet, in the First Presentation of the Breech. 892. The success of this operation very much depends upon -the choice of the hand to be employed. The rule on this subject is extremely simple — the hand, the palm of which will answer to the anterior parts of the child, is always to be used. In this presentation then, the left hand will be the proper one for bring- ing down the feet. It must be introduced with due attention to the rules already laid down, when speaking of turning, and pass- ed upward before the right sacro-iliac symphysis, until it can grasp the breech — which must be raised, and carried into the left iHac- fosse. We must then search for the feet, by tracing the posterior PRETERNATURAL, AND MODE OF TREATMENT. 327 part of the thighs and legs, until we arriveat them; they must be seized as before directed, and brought down. 893. If but one foot can be obtained, we may attempt the de- livery, by acting upon it alone; but when practicable, it is best to search for the other, unless it will require too much force. It will rarely happen if the breech be small, that much diiliculty will be experienced in doing this; but this is precisely the case in which we can almost always succeed, by applying the force to one. When delivering by^^one foot only, we should be very mind- ful of the direction in which we act upon it — we should al- ways direct our force so as to carry the leg towards the retained one, lest we fracture or dislocate the thigh; and, when the folded leg begins to appear, we may assist it by acting with a finger on the groin. When the breech is without, we must con- duct the body along, until the other leg and foot falls down of itself. 894. When the breech is still within the uterus, and occupies the lower strait, we can very often, should the necessity of the case require it, gain the feet, and enable us to expedite the la- bour; provided the waters have not been too long drained off; the pains feeble; and if the breech is not of an unusual size. But if the breech has passed the os uteri, we must not think of this expedient — when thus situated, the fingers, the fillet, or the blunt hook, must be our aids. Sect. YV.— The Mode in the Second Presentation of the Breech. 895. A proper choice of the hand must be made in this pre- sentation, as well as in the preceding — when the emergency of the case requires bringing the feet down, we must make use of the right hand instead of the left, and conduct the rest of the ope- ration in every respect as just directed. If but one foot can be obtained, we must proceed with it to finish the labour; but al- ways recollecting the conditions which would render this partial action safe and proper. (893) Should the breech, however, have escaped from the mouth of the uterus, it would be highly improper to pass up the hand with a view to bring down the feet — the aids just indicated (879) must then be resorted to. Sect. Y .— The Mode in the Third Presentation of the Breech. 896. The spine of the child, in this presentation, is to the sym- physis pubis, and the abdomen to the projection of the sacrum — 328 CAUSES RENDERING BREECH PRESENTATIONS, &C. this position is less favourable than the first and second, owing to the risk of having the head to engage with its greatest length pa- rallel to the small diameter of the superior strait; this, however, is not a necessary consequence of this presentation, as we have already observed. 897. In this presentation, either hand may be used. When required to act, the hand must take a firm hold of the breech, as directed for the raising of the head, and carry it forward and upward, over the pubes, and then pass the hand along the legs, until the feet can be reached; they must now be brought down, as heretofore directed; only observing, when the feet are entirely without, to turn the breech so as to make the body have an ob- lique position as regards the pelvis. Sect. VI.— The Mode in the Fourth Presentation of the Breech. 898. I have already remarked how very rare this presenta- tion is; but when it does occur, there can be no doubt of the pro- priety, if called to the case in proper time, of always searching for the feet. In this presentation, either hand may be used, as mentioned for the third; only observing, that the breech, in this case, if possible, must be carried to one of the iliac fossae; to the right, if we use the right hand, and the reverse, that the body may enter the superior strait obliquely, so as to give the chance to the face to turn from the pubes — after this, we search for the feet, and bring them down as directed. When the breech is without, we must attempt to give an oblique position to the body, if it has not already acquired it. It does not necessarily follow, however, that this case will be attended with more difficulty than those just spoken of; as the child may be very small, or the pelvis very ample. In either instance the woman would be ena- bled to deliver herself 899. It may be proper to observe, that all breech cases are to be subject to the rules I have endeavoured to inculcate for the safety of the uterus: 1st. That no severity of accident can justify forcing a passage into the uterus, with an intention of gaining the feet when the os uteri is unyielding. 2d. That ^vhen the breech is very large, the waters long drained off, the uterus firmly contract- ed on the body of the child, and much force would be required, (whatever address the accoucheur may possess,) the feet must not be sought for ; but the labour must be terminated by the other agents already indicated. (879) 3d. But when the uterus is in THE USE OP THE FORCEPS, &C. 329 proper condition, and the membranes just ruptured, or the con- tractions not severe, though the waters may have escaped some time, we should lose no time by temporizing, when the accident is of a nature to render interference important to mother and child. CHAPTER XXVII. THE USE OF THE FORCEPS WHEN THE BODY OF THE CHILD IS DE- LIVERED, AND THE HEAD RETAINED. 900. The risk the child always runs when its body is deliver- ed first, is so great, as to make us look upon such labours as hazardous, whether the necessity for this consideration be natural- ly or artificially created. I have already adverted to this; but it may still be useful to repeat, that the danger to the child arises, 1st. From the severe extension to which the cervical vertebrae may be liable, when it is necessary to employ force for the deliverance of the head; 2d. The almost inevitable compression of the cord, if th«e head be large, either positively or relatively, as it will be caught almost necessarily between the head and pelvis, or if it be tightly stretched, by its passing between the legs of the child, and we are unable to relieve it, &c. These causes pretty con- stantly operate, where the head is the last part to be delivered, unless the pelvis be very ample, or the head small, and the exter- nal parts disposed to yield readily, and the mechanism of this part of the labour well understood. The mode, by which the remote causes just enumerated effect the death of the child is not so clearly understood at this moment as it should be, considering its import- ance; and this seems to be admitted on all hands, and will, we trust, elicit farther inquiry. MM. Baudelocque (nephew to the celebrated accoucheur) and Hervey de Chegoin, have offered some valuable observations, in " a Report on two new proposi- tions by M. Baudelocque, junior, for preserving the life of the foetus when it presents the breech, feet, or knees, made to the Royal Academy of Medicine by M. Hervey de Chegoin." We think these observations so deserving of being more gene- rally known, that we attach them to our text. And we farther 42 330 THE USE OP THE FORCEPS think, that their value is increased, by the observations of Dr. Hodge of our city, who has prepared the paper for the '< Ameri- can Journal of Medical Sciences for February, 1833, page 463. "It being generally acknowledged, that the child during partu- rition is much more endangered when it presents the ^^elvic than the cephalic extremity of the foetal ellipse, the question as to the nature and cause of this difference is of importance. M. Baude- locque, Jr. in a late communication to the Royal Academy of Medicine, maintains that the cause of death in pelvic presenta- tions is alidays the same, viz. the interruption of the circulation from the mother to the child^ and that the effects of this inter- ruption d^YQ always the same, viz. a sanguineous congestion in the brain and liver, with or without effusion at the bass of the brain. He considers, therefore, the asphyxia and the apoplexy of new- born infants, to be two degrees of the same state, there being in both, sanguine congestion of the brain and other interior organs. " The cause of the interruption of the circulation between mother and child, he refers exclusively to pressure on the cord by the body, but especially by the head of the child in the pelvis. " Founded on these views, he recommends two modes of pro- cedure in cases where the head is retained after the delivery of the body; and the child's life thus jeopardized. He proposes to divide the umbilical cord, and allow it to bleed; and then to ex- cite respiration immediately, even while the head may be in utero. For this last object, he suggests the use of a long silver canula, with numerous perforations, by means of which atmospheric air may penetrate into the uterus, and also of a shorter canula which may, when requisite, be introduced into the mouth of the foetus. In eleven infants, presenting the feet, the umbilical cord was di- vided as soon as the pulsations became feeble, and before the head was delivered; the children were born alive. In three cases, the division of the cord was not made, and the children were born dead. The attempt to excite respiration was not made in either of the above cases; but M. Baudelocque conceives it may some- times be requisite. It may well however be doubted, whether respiration can possibly occur when the head is fixed, as the case supposes, in the superior strait of the pelvis. But that respiration may, under peculiar circumstances, occur, and even cries be eli- cited while the child is in utero, a point hitherto much disputed and generally denied, seems to be proved by an experiment of M. Baudelocque. In the case of a face presentation, after having WHEN THE BODY OP THE CHILD IS DELIVERED, &C. 331 punctured the membranes, he passed a canula into the mouth of the child, and inflated the lungs. lie and his assistants, M. Mar- tin, a physician, and Madame Chaumonot, a midwife, distinctly- heard, for the space of a minute, the respiratory noise. The infant was eventually delivered alive by means of the forceps. " Giving all confidence to the facts reported by M. Baudelocque, it would seem that in some cases at least, it would be useful to divide the umbilical cord before the delivery of the head, to re- lieve congestion, and to prevent effusion and death. But, can these cases be always ascertained? may not the child perish from the loss of blood, owing to the time required for the delivery of the head? and especially is it necessary to inquire whether, as M. Baudelocque supposes, this congestion always exists? or whether on the contrary, it be not often true that the child is already in a state of anemia, where the loss of a small quantity of blood would be necessarily fatal? The questions also arise whether other causes may not be operative in the destruction of the foetus, independent of interruption of the placental circulation; and whether such interruption depends on the pressure of cord as has been usually supposed; or on some other circumstance, connect- ed with pelvic presentations? ^'M. Hervey de Chegoin, in a report to the Academy, on the communication of M. Baudelocque, has noticed several of the above questions; and expressed his doubts on many of the posi- tions assumed by the author of the essay. " In presentations of the inferior extremities, and of course in the operation of version by the feet, do not foetuses often perish in consequence of the force applied by the accoucheur, rather than by pressure on the cord? M. Baudelocque and Madame Lachapelle would say, no ; because they have met with cases where great force had been exercised, even to the tearing of the vertebral ligaments, and yet the child has survived. The report- er however doubts the legitimacy of the deduction, when the re- sults of cases in which little or no traction has been exercised, are compared with those in which much force had been employed. Certainly few can doubt the injurious effects of traction on the lower extremities and body, in cases where the head is retained, and the consequent danger to which the child is exposed; espe- cially when, as is not unfrequently the case, from ignorance or inattention, the neck is also twisted. The only wonder which can be excited is, that all do not perish under this management. 332 THE USE OP THE FORCEPS Hence, as the effect of traction, when the head is entering or en- gaged in, the superior strait, is almost always injurious by causing the head to present unfavourably, the practice, however general or sanctioned by authority, should be abandoned; no force of any amount should, at this stage of the operation at least, be applied to the trunk of the infant; but, if any resistance be required, it should be judiciously directed to the head itself. " There can be no doubt that M. Baudelocque is in error in referring the interruption of the circulation between the mother and child, in all cases to pressure on the cord alone; for as the reporter remarks, in pelvic presentations generally, after the trunk is delivered, the uterus has so contracted that a separation of the placenta from the uterus is very frequently effected; and in some cases, especially where the head has descended into the excavation, the uterus may be emptied not only of the child, but also of the placenta. In all such cases, death must soon occur from the cessation of the placental functions, independently of pressure on the cord. " What is the result of compression of the cord? M. Baude- locque contends that in all cases the result is plethora, whence apoplectic congestion and effusion as demonstrated by dissection. But, says the reporter, this is a surprising assertion; for if the pressure be made equally on the vein and on the arteries of the cord, the foetus it is true no longer sends blood to the mother; but also no longer receives any from the mother by the umbilical vein. The exit of blood is prevented, but the supply is also cut off; therefore there can be no increased quantity. M. Chegoin however carries this argument much further, and contends, that as the circulation of blood in the vein is effected only by the agency of capillary vessels, while the passage of blood through the umbilical arteries is facilitated by the contractions of the foetal heart, it follovvs that when the vessels of the cord are equally pressed upon, the course of blood may be arrested in the vein but not in the arteries where the momentum is greater; in other words, that the exit of blood is continued while the supply is ar- rested. Hence, the foetus, instead of being plethoric, may actually perish for the want of blood, and this condition, M. Chegoin in- timates, would be more likely to ensue when the placenta was separated from the parietes of the uterus. This apparently spe- cious theory is supported by the well known fact, that children are born presenting externally very different appearances under WHEN THE BODY OP THE CHILD IS DELIVERED, &C. 333 the circumstances now contemplated. In some, the child is livid and swelled, particularly on the head, neck, and chest; the cord is large and tense, and on being cut, the blood issues with much impetus. In others, the infant is pale and exhausted, its limbs flaccid, features contracted, cord small and pallid, and when di- vided furnishing little or no blood. The former is regarded as a state of apoplexy; the latter as a state of anemia, of syncope, or asphyxia. " We must however dissent from the idea of actual plethora or anemia in those cases where death suddenly occurs, the mother and child having been previously in a natural and healthy condi- tion. Independent of many facts which might be adduced in opposition to these theories, both opinions seem to be predicated on an erroneous view of the foetal circulation: viz. that the blood of the foetus passes indirectly by means of the umbilical arteries and maternal veins to the mother, and the blood of the mother indirectly by maternal arteries and the umbilical vein to the child; so that blood might be lost by the child from its arteries when the supply by the vein was arrested, v^hence anemia; or, that the supply might be continued from the mother while the exit by the arteries of the cord was diminished or suspended, whence plethora. But we thought that these views had been abandoned by good physiologists. There is satisfactory proof that there is no direct or indirect communication between the blood of the mother and that of the child. The latter forms its own blood in utero out of materials furnished by the parent, as certainly as the chick forms its own blood in ovo, out of materials there provided. The blood from the umbilical arteries of the child passes to the radicles of the umbilical vein, and not those of the maternal ves- sels, and hence any variety of pressure on the arteries or vein of the cord can have but a comparatively trifling influence on the quantity of blood at any time in the body of the foetus. " If therefore neither plethora nor anemia be the cause of death when pressure is made on the cord, whence the source of mis- chief? Very many have referred it to the simple interruption of the circulation, but this is not sufficient, as death occurs too sud- denly to admit of this explanation; and moreover, the anatomical structure of the foetus is such as to allow a perfect circulation of blood even if the cord be completely obstructed. The injury therefore must be referred to some other source, and as this death occurs suddenly, and is usually accompanied with great venous 334 THE USE OF THE FORCEPS congestion, and may be prevented by establishing at once the respiratory process, it may be referred to the suspension of the purifying influence of the placenta on the blood, the placenta act- ing as lungs to the foetus — how is unknown. Hence, as conges- tion of venous blood follows the suspension of the respiratory pro- cess, congestion follows the suspension of the placental influence, and may be succeeded by the efilision of blood as testified by Eaudelocque and others. It is difficult however to account for the opposite condition of the foetus, or to specify the particular circumstances which produce a state of congesf^Dn or syncope. There are wanting a very careful observation and collation of facts on this subject. But if it be true that children are born some- times in the one, and sometimes in the other condition, the prac- tice of dividing the cord in all cases of delay must be very dan- gerous, even should future experience confirm the recommenda- tion of M. Baudelocque in cases where congestion can be demon- strated to exist. " Again: should the hypothesis of the author be correct, that in all cases of asphyxia of new-born infants, there is congestion of some internal organ and often efiusion, yet the practice he re- commends must be injurious, as the general circulatory system is depressed and emptied. The local congestion, in such cases, will not justify general depletion. Infants are often recovered from this state, not by depletory measures to which none resort, but by internal and external stimuli which sympathetically excite the respiration and circulation. " It is a difiicult matter to determine, by external appearances, the precise condition of the internal organs in this asphyxiated condition of new-born infants. Baudelocque insists that conges- tion always exists, and often efiusion, and appeals to his dissec- tions where such changes were invariably perceived; but the condition of the organs after death, as regards their vascular ful- ness, is no certain index of their state before death; and, as infants born in this state of asphyxia are frequently preserved by judi- cious and persevering efibrts, we must conclude that such conges- tion and eff'usion either do not exist, or that they are less injuri- ous than usually supposed; and moreover, that stimulating, not depletory measures are suitable in such supposed cases of con- gestion. " As to the apoplectic state above described, all will unite in the importance of evacuating the blood — a practice commonly WHEN THE BODY OP THE CHILD IS DELIVERED, &C. 335 resorted to and which may be employed as M. Baiidelocque re- commends, even before the delivery of the head. An additional remark however is of importance, that this depletion should be followed up by stimuli to the surface, nostrils, rectum, &c., as in cases of asphyxia; for the actions of the heart and arteries are feeble, and the surface cold in these apoplectic cases evincing depression of arterial action with the fulness and turgescence of the venous system. Hence while we empty the veins, the blood should be determined to the arterial system, that the natural ac- tions may be fully re-established. "On the whole, we agree with the reporter, M. Chegoin, that death in pelvic presentations is not simply the result of pressure on the cord, but may also ensue from other causes, as injury to the spinal marrow, detachment of the placenta, &c. ; that general plethora does not exist when such interruption occurs; neither, we would add, is there any deficiency of blood in the foetus; and that in a practical point of view, the states of asphyxia and apo- plexy are so far different, that in one the loss of blood would be injurious, but in the other highly useful. We believe however that these cases are so far of the same character, that in both, the arterial circulation is depressed; of course, the phenomena of or- ganic life diminished. The one condition may be regarded as a sinTple state of asphyxia, the other as asphyxia with venous con- gestion of the vital viscera; the one requiring simple but appro- priate stimulation, the other in addition, evacuation of venous blood, to relieve oppression and facilitate reaction of the heart and arteries." 901. These considerations early engaged the attention of Smel- lie; and the result of his deliberations was, the practicability of applying the forceps with success in such cases. Accordingly, he has left upon record his method of employing them, and the suc- cess attending it. He has been followed by De Leurie, Baude- locque, and others. I am every way disposed to do justice to the merit of this application of the forceps; and consider it as a real improvement in the art, whenever their application is guided by experience, or their employment properly limited. 902. It will be readily admitted, by all who have attempted the application of these instruments, with a view to relieve the head when the body was delivered, that it is attended with no inconsiderable difficulty, even in the most simple of the cases in which the^may be required; how much more, then, when the 336 CASES PROPER FOR THE FORCEPS. head is remote from the inferior, and perhaps tightly wedged in the superior strait; in both of which cases the use of these in- struments is recommended. 1 did not succeed in the two or three instances in which I employed them, under the circumstances de- scribed by Smellie and Baudelocque, and as represented by the former in his 35th, and by the latter in his 14th plate. I will not say that their application is impracticable 'because I failed; espe- cially as both Smellie and Baudelocque declare they have suc- ceeded; but there are several serious difficulties to oppose their application which I will endeavour to point out: 1st. When the head of the child is at the superior strait, and engaged with its greatest length between the pubes and sacrum, or even when the forehead and vertex offer to the sides of the pelvis; as the axis of this strait is so much in advance of the inferior, that it seems al- most impossible that the perinseum could be pressed so far back, as to permit the forceps to correspond with it, that they may se- curely grasp the head;* 2d. That if the head be even grasped by the forceps, it must be in the direction, or very nearly so, of the perpendicular diameter of the child's head, instead of the oblique; a circumstance of great consequence to the success of the operation; 3d. This advantageous position of the head for the use of these instruments, may lead to the belief that they are well placed, be- cause their handles unite without difficulty; whereas, they but very partially embrace the head; and if an effort be made to ex- tract they will most probably slip, and the uterus, vagina, or bladder, be severely injured. Sect. I. — Cases j)Toper for the Forceps. 903. From these considerations, I would confine the use of the forceps, in the cases under consideration, to two situations of the head, and those at the inferior strait, a. The first when the ver- tex is behind the symphysis of the pubes, and the face resting on the face of the perinaeum; b. The second when the forehead is be- hind the symphysis, and the vertex lying towards the hollow of the sacrum. a. Mode of Operating in the First Case. 904. It rarely happens that the forceps are indicated in this * This will be readily understood, when it is recollected, that the direction of the opening of the superior strait, is at an angle of about 30°, and conse- quently, its axis, and that of the inferior strait, do not coincide. CASES PROPER FOR THE FORCEPS. 337 situation of the head, since, when it arrives here, it may be al- most always delivered by soliciting the voluntary powers of the woman; by depressing the chin; and by a judicious force exerted upon the trunk. But at this moment, the woman may be attacked by some accident; or the head may be very large, or the pelvis narrow; the cord may be in danger of compression; the woman may be too feeble to make any effort to relieve her- self, and it might require too much force for the safety of the child, to attempt its deliverance by the body alone, yet the wel- fare of it may require immediate delivery. 905. When the circumstances of the case will most probably be improved by the use of these instruments, we should apply them, if at hand, witliout loss of time,* in the following manner; the body of the child must be carefully wrapped up in a cloth, and carried over the mons veneris, as far as it can be done, without injury to its neck, and supported there by a careful and judicious assistant; the chin of the child should be depressed,and the male branch of the forceps be passed to the left side of the pelvis de- pressing the handle pretty suddenly against the perinaium; this must be more or less, as we may find it necessary to make the blade conform as much as possible to the oblique diameter of the head; when this is arranged, the handle must be sustained until the other blade is passed on the opposite side of the pelvis, and made to correspond with its fellow — the handles must now be locked, and drawn in such direction at one and the same time, as shall tend to disengage the vertex from behind the pubes, and at the same instant raise the face along the perinseum, until the chin and other parts of the face successively pass through the os ex- ternum. * It might on some accounts be proper to be provided with these instruments, whenever we have leisure to send for them, in all such cases as we cannot de- cide positively that they will not be necessary. I was once made very happy by having them with me, when sent for to the aid of a midwife. The patient was pretty far advanced in life before slie married; she had lost three children previously, and was now in labour with a breech presentation. The child was very lai-ge, and required the fillet — the breech I deUvered, the body followed, and no difficulty was experienced until the head was stopped at the inferior sti-ait, hi consequence of its size. I employed as much force as I dared, and the woman, exerted herself powerfully; but the head, though well situated, could not be made to pass. I was very anxious about the life of the child, and the poor mother begged that I might save it at any expense of pain to herself, as she •' had lost all her poor babes before." 1 determined to try the forceps, as I had brought them with me, and did with tlie happiest effect. 43 338 OF THE PKESENTATIONS OF THE FEET. b. Mode of Operating in the Second Case. 906. The only difference in the mode of operating in this case from the first, (905) is, that the body of the child must be carried backward, and gradually depressed as the head disengages back- ward.* CHAPTER XXVIII. OF THE PRESENTATIONS OF THE FEET. 907. The presentations next in the order of frequency, are those of the feet; these presentations are with propriety ranked among the natural labours, because the woman is enabled to de- liver herself. Baudelocque says that ''those labours in which the child presents the feet, considered as natural, are not the most advantageous; but as preternatural, they must be esteemed the easiest and the most favourable." In this I cannot exactly coin- cide, at least as far as regards the safety of the child, which, in my opinion, ought always to enter into the calculation; for its welfare must be looked upon as constituting at least a part of what is to be understood by the words "most favourable." I have elsewhere, (858) assigned my reasons for this. 908. Had not the erroneous principle been so often inculcated, and still more frequently acted upon, " that in presentations of the feet, not to deliver the woman as speedily as possible, was to exercise a cruelty towards her, by permitting her to endure hours of pain, when it was in our power to relieve her in a very short time, by exerting a force by the feet, which would speedily de- liver the body," we should have had fewer instances to complain of injuries sustained by the mother, and fewer occasions to lament the death of the child. 909. It should be held as a fundamental principle in this va- riety of labour, and all the others enumerated under the title of natural, that they must be considered as such in the true sense of the word, at least until the uterus is dilated, and the membranes * Baudelocque advises the forceps in these cases, when the child is dead, in- stead of the crotchet. SPECIES OP FEET PRESENTATIONS. 339 are ruptured, and after these have taken place, only to consider them as preternatural, or labours requiring assistance, when they are complicated by accidents, or when their progress is retarded b}^ causes existing in the uterus itself, or from the position of the child. Under such circumstances, we are not only justified in aiding the woman in her struggles, but it becomes a duty to do so, in the best and most efficient manner, the case will admit. But to do this with the greatest advantage to both mother and child, requires a thorough knowledge of the mechanisms of these labours, as well as considerable address to fulfil the various indi- cations, their different positions create; that the former need not suffer from the effects of ignorant rashness, or the latter fall a vic- tim to it. 910. The presentations of the feet are readily distinguished from all others, by there being no other parts of the child which resemble them; the hands alone bear any analogy; but from them they are easily told by the projecting heels, the short toes, and especially by the absence of the thumb. Baudelocque, whom I shall follow, has divided presentations of the feet into four species — the distinguishing marks of each being derived from the part of the pelvis to which the heels and toes are directed ; according- ly four species are made. Sect. I. — Species of Feet Presentations. 911. In the first presentation, the heels are a little anterior to the left acetabulum, and the toes are directed towards the right sacro-iliac symphysis; the breast and face are above and over it, while the back is placed to the anterior and left lateral part of the uterus. It may, perhaps, be proper to remark, that in these presentations, the feet and legs do not hang loose or dangle in the pelvis, but, on the contrary, the thighs are flexed against the abdomen, the legs folded against the thighs, while the heels are almost always placed against the breech, or are in its immediate vicinity. 1 thought it best to state this, that the difficulty which is sometimes experienced in bringing down the feet, may be bet- ter comprehended. It must be also borne in mind, that both do not always present at the same time, and that they are so movable in the pelvis oftentimes, that it is more difficult to locate their exact position, than to distinguish it is the feet, that are pre- senting. 912. In the second presentation, the heels are behind the right acetabulum, or a little forward; the toes look toward the 340 rUESENTATIONS OP THE FEET. left sacro-iliac symphysis; while the breast and face are above and over it; the back is placed to the right anterior portion of the uterus. 913. In the third presentation, the heels are to the symphysis pubis, and the toes toward the sacrum; the back is placed to the anterior part of the uterus, while the breast and face look to- wards the lumbar column. 914. In the fourth presentation, the position of the child is exactly reversed; the heels are to the sacrum, and the toes to the pubes; the back towards the lumbar column, and the breast and face are turned towards the anterior part of the uterus. 915. Nature seems to have been particular in the arrangements of the presentations of the breech, feet, and knees, by making the numerical order of each resolve themselves into one general position, so soon as the legs are without; so that the most favour- able situation, or the first presentation of the breech, of the feet, and the knees, have each of them the legs in precisely the same situation when delivered: so true is this, that did we not arrive before this happened, we could not tell with which of these presentations the labour commenced — the same may be said of all the rest. We are, therefore, much indebted to Baude- locque, for his ingenious and natural arrangement of these labours. It is also remarkable, that the frequency or infrequency of each of these different species of natural labour, should be with few exceptions, in the order of their numerical succession: thus, the first presentations of the breech, feet, and knees, are more fre- quent than the second; the second more frequent than the third; and this third more frequent than the fourth, &c. 916. Why is it that we meet w^ith more presentations of the feet in premature deliveries, than in those at full time? or, is it only coincidence? Sect. II. — Preternatural Labours in which the Child pre- sents the Feet. 917. The causes which may render a labour preternatural, in which the child presents the feet, may be any of those already enumerated; (G51) or it may depend upon some irregular and inefficient action of the uterus, or the mere position of the child itself. Should either of these accidental causes, complicate a labour in which the child presents the feet, we must consider it a sufficient reason for interfering with its progress ; and we must FIRST AND SECOND PRESENTATIONS, 341 expedite the delivery by bringing down the feet; the mode, how- ever, of doing this will depend upon the particular presentation we may have to contend with. 918. From the position which the feet almost always assumes in these presentations, it will be readily perceived, that one can- not well descend without the other, and that it is the width of the breech, thighs, and legs, which offer together at the superior strait; hence, they will sometimes become jammed, at this part, and the feet, or a foot, will cease to advance, and as this may happen, and the difficulties of the labour arising from this may be increased, by some one of the accidents already enumerated (651) they give sufficient reason, for manual interference. Or the uterus may, from any of the causes we have already ack- nowledged to be capable of such effect, be incompetent -to force the parts down to the bottom of the pelvis, though no embarrass- ment be created by position. Or the fourth presentation itself may be considered as essentially bad, and require our interfer- ence. 919. Under either of these circumstances, we are obliged to convert an otherwise natural, into a preternatural labour. It will be constantly kept in mind, when taking hold of the feet is recommended, it is always supposed that the membranes have been ruptured, and the os uteri dilated, as has been uniformly been inculcated for every operation of the kind. It may be re- marked here, that there will be some difference in the mode of acting in footling cases, arising from the circumstance of presen- tation, or of one or both feet being within reach; but these will be illustrated as we proceed. We will repeat, lest it be forgot- ten, that the woman is supposed to bo constantly placed upon her back, as recommended for all cases of preternatural labours. Sect. III. — Mode of acting in the First and Second Presen- tations of the Feet. 920. It has already been remarked, that, in both these presenta- tions, when the feet are without the vulva, that the mecha?iism, is the first and second breech presentations; therefore I shall only point out the mode of treating the labour until that period; for, afterwards, everything must be conducted as directed for those presentations. 921. When it is agreed that there is a necessity to expedite the labour, it must be done by introducing the hand into the va- 342 FIRST AND SECOND PRESENTATIONS. gina, if the feet still remain at the superior strait; if this be the case, we pass the hand until we can by a proper grasp possess ourselves of them: and, when secured, we draw them downward; but, if this require more force than it would be prudent to exert, we must desist, and act upon the breech, by gently raising it upwards, this will almost always permit the feet to fall down; or, at all events, enable us to proceed with them through the pelvis. Should but one foot ofier, we may act upon it, and often- times successfully, when the child is small compared with the size of the pelvis; but if it come reluctantly, and evidently re- quiring a considerable degree of force to bring it along, we should cease to act upon it, and search for the other foot. 922. When the second foot is accessible, it is always best to make it descend with the first; and not merely push it up that it may unfold itself along the abdomen of the child. But let it be recollected, when we are obliged to search for the second foot, it is a matter of consequence to make a proper choice of hand; for it may be resting on the margin of the pelvis, or it may be un- folded and high up in the uterus; therefore, in either case, the facility of the operation will very much depend upon the hand that is employed — this I well know from experience. The rule in these cases is precisely the same as for the breech cases of the same numerical denominations; namely, the left hand for the first, and the right hand for the second presentation, &.c. 923. The reasons wherefore I prefer having both feet to act upon in these cases are, — first, we can exert the necessary force to much greater advantage by acting with both; second, we run much less risk of doing injury to the limbs; for if we act by one alone, we may chance to hurt it by the force not being divided; third, we can give a better direction to the body as it descends; when it is necessary to efiect any change upon its course. 924. The only difference in the mode of acting in the second presentation and the first, is the necessary choice of hand — in every other respect the mechanism is the same. 925. Should more than two feet be found in the passage, as in twin cases, we must be careful to select those which belong to the same child; this sometimes creates more difficulty than would at first be imagined; for simply selecting a right and left foot, by no means proves they belong to the same body; and if they should not, much inconvenience may be experienced. It is true, this circumstance will rarely occur, as it seldom happens that the THIRD AND FOURTH PRESENTATIONS. 343 membranes of both give way at the same time, or before one of the children is delivered; yet it happens sufficiently often to make the caution necessary. An instance of this kind occurred to me some years ago; for in attempting to bring down two feet, (properly selected, as I supposed.) where there were three, I got a foot of each of the children ; I discovered my mistake, how- ever, sufficiently early to enable me to pass up my hand, and select the proper foot, but not without some difficulty. Sect. IV. — Method of Acting in the Third and Fourth Pre- sentations of the Feet. 926. Were I permitted to draw a conclusion from my own ex- perience, or take for fact what is stated in the register of " I'Hos- pice de Maternite," cither of these presentations would be found to be extremely rare, and especially the last. Of the third pre- sentation, I find but three instances recorded in nearly thirteen thousand cases, in the practice of that institution, and of the fourth but one. In examining my own practice, I find two of the third, and but one of the fourth presentation. 927. The third presentation is not so replete with inconvenien- ces as the fourth, nor so uniformly fatal to the child; yet they are sufficiently so, to make us fear when it occurs, especially, if the forehead does not spontaneously turn from the projection of the sacrum, and place itself before the sacro-iliac symphysis of one side or other of the pelvis that the head may descend in a diagonal situation to the lower strait — when it arrives at this place, and in this direction, it will rarely happen that the face cannot be made to apply itself to the perinseum at the last period of labour. 928. Should this favourable disposition of the head, however, not take place spontaneously, it points out what should be done to make the labour more advantageous to both mother and child. Should we have charge of the case sufficiently early, that is, be- fore the feet have descended, and when the membranes have but lately yielded, we may dispose the head to turn to one side, by making the body observe an oblique position in its descent, by turning the toes to one side of the pelvis. Indeed, this would seem to be almost the only period at which we could pretend, with any certainty of success, to do this, by any manoeuvre per- formed on the body of the child; for after it is either in part, or wholly delivered, they would be almost nugatory. 344 THIRD AND FOURTH PRESENTATIONS. 929. We are directed by most writers who have mentioned this, and the fourth presentation, to attempt this change, by giving an extensive twist to the body. Thus La Motte, Levret, and Smel- lie, advise this motion to be made, by turning the child's body, under the expectation that the head and face will obey the im- pulse, without seeming to recollect that in these cases the head is not very movable in the pelvic cavity, especially when the waters have been long drained off; and that to change it would require much more force than can be safely exerted, or a much more extensive twist of the child's neck than would be compatible with its safety. 930. When the body is delivered, and the shoulders have de- scended sufficiently low to permit it, we should immediately ascertain whether the position of the head be correct or not — should its position be favourable, we proceed with the labour, as had been already directed for the breech; should it not, we must endeavour to rectify it, by acting upon the face so soon as the shoulders have been cautiously delivered; that is, without having exerted a force upon them, sufficient to jam the head in a bad direction at the superior strait. 931. Should the head be jammed in the superior strait, by any ill-directed force, it must be relieved as quickly as possible, if we expect to preserve the child — this must be done, by passing the hand under the head at the bottom of the pelvis, and gently rais- ing it, so as to lift the vertex from behind the pubes, and at the same time turn the face to one side. The side to which the face must be turned, will depend, first, upon the inclination it may have to either the right or left side; choosing that always to which it most tends; and, second, upon the hand which may be employed to rectify the position, when no inclination toward one side or the other is observed ; if the right hand be used, it will be easiest, ceteris paribus, to turn it towards the left, and the reverse. 932. Before, however, this reduction is attempted, it will be well to have the body of the child carefully raised by an assistant, towards the abdomen of the mother, that the hand may be intro- duced with more certainty and facility; care being taken in doing this, that the head is not drawn down, by the body being carried up. When the position of the head is adjusted, we must act as has been directed in such cases for the breech. 933. In the fourth presentation, we can scarcely expect to im- THIRD AND FOURTH PRESENTATIONS. 345 prove its position, unless we are very early with the patient; that is, immediately after the yielding of the membranes, and liave, at the same time, the os uteri sufficiently dilated to enable the child to obey the direction we mean it should take. Unless we can take advantage of this period to move the face toward one of the sides of the pelvis, I am disposed to believe that very little can be done until the shoulders are without — except indeed the head be small compared with the pelvis; in this case, there is very little necessity for assistance, as it will pass, face upward, under the arch of the pubes, without much difficulty. 934. When the shoulders are without, I am sure it will some- times succeed, to turn the face towards one of the foramina ova- lia; the occiput by this change, will descend a little, and offer it- self towards one of the tubers of the ischia, or a little obliquely as regards the lower strait; and may, by a well-directed force, aided by the voluntary contributions of the mother, be made to escape in this diagonal position. 935. I would always recommend to the young practitioner, in cases of such very doubtful issue to the child, and more especially, in the fourth presentation, to advertise the friends of the patient, of the risk the child must inevitably run in its delivery, that no exorbitant hopes may be entertained of its eventual safety. 936. There will be, of course, the same propriety in using the forceps in any of these cases, as was expressed for their employ- ment in breech cases. 44 346 CHAPTER XXIX. PIIESENTATIONS OP THE KNEES. 937. The presentation of the knees are very rare indeed; and 1 might perhaps have passed them over in silence, without incur- ring much censure for the omission. But I have chosen to notice them, because they are rare; and because they are sometimes em- barrassing to the young practitioner; for I well recollect my own trepidation, when called to a case of this kind in the very com- mencement of my practical career. To add to my embarrass- ment, I was called to the assistance of a midwife, who could not well have been more ignorant of what was proper to be done than myself. I will not pretend at this time to designate the particu- lar presentations of the knees, as I knew nothing about their pre- sentations at that time ; I only recollect, that I reasoned in the following manner upon the subject: — "If the feet were without, I should feel little or no difficulty in the case, as 1 once attended a labour of this kind successfully ; and it cannot be very danger- ous to pass the hand to them, since they must be in the neigh- bourhood of the knees." With these reflections, I passed a hand into the vagina, and tracing the legs, soon obtained the feet, which I had the good luck to bring along, by accidentally, (for so it was, as I had no principles to direct me,) disengaging the knees from the margin of the pelvis, against which I now know they must have butted, and terminated the labour successfully to both mother and child, but with severe agony to myself. 938. These presentations are more unusual than any I have hitherto considered ; not occurring oftener, perhaps, than once in a thousand or more times. They are less favourable than any of the presentations I have classed as natural; and agreeably to Baudelocque, they may present in four ways: 939. In the first presentation of them, the legs are to the left side of the mother, and the thighs to the right. 940. In the second, the legs to the right, and the thighs to the left. 941. In the third, the legs under the arch of the pubes, and the thigh towards the sacrum. PRESENTATIONS OP THE KNEES, 347 942. In the fourth, we find a reverse of the third. 943. The mechanism of these labours are precisely the same as those of the feet; for the latter must be quickly developed, if the labour proceed; and then they are reduced to footling cases. 944. The knees may be distinguished, when together, by their similarity, and the roundness of the bony angles they form. When but one presents, which is most commonly the case, it is not so easy; but we may trace the leg, and find by this means the foot, which puts the matter out of doubt. Sect. I. — Causes which may render Presentations of the Knees preteymatural. 945. Until the membranes be ruptured, and the uterus pro- perly dilated, a presentation of the knees, if the presentation can be discovered before that period, is to be treated as has been di- rected for the breech or the feet. 946. Baudelocque directs that we should not search for the feet in these presentations, unless the labour be complicated by some accident; but the difficulties which a woman almost always experiences in delivering herself in these cases, are such as to render it, I think, the better practice always to bring down the feet; especially in the earlier part of the labour, when neither force is required, nor inconvenience hazarded, b}'^ the proceeding. I once witnessed a case, where many hours of severe suffering had been endured, from a presentation of the knees, without its hav- ing made the smallest progress, after the first hour or two: the breech and knees had progressed together in such a manner as to completely occupy the pelvis; several pretty severe attempts had been made by the midwife, as she herself declared, to make the knees descend, by acting upon them to the serious injury of the child. After this period, I was requested to visit the patient. I found the presentation to be the first; but the breech had de- scended so much as to carry the knees against the right sacro- iliac symphysis, and thus prevented the farther progress of the labour. I introduced the right hand, and with some exertion was enabled to raise the breech sufficiently to permit the feet to fall down near fo the os externum; the knees were then readily removed from their position, and the delivery speedily effected. 947. Now, as there is no security that the breech will not de- scend in proportion to the advancement of the knees, and if it 348 PRESENTATIONS OF THE KNEES. do, the knees will almost certainly be arrested against some por- tion of the pelvis, in which case the contractions of the uterus and the efforts of the woman, are almost sure to be unavailing, though continued for hours, I think it always best to bring down the feet and knees, by pushing up the breech, whether the case be free from, or complicated by any of the accidents already men- tioned ; unless the os uteri is sufficiently dilated, and the feet are found to unfold, or the knees to advance; in this case we may trust the labour to nature. Sect. II. — Mode of Operating hi Presentations of the Knees. 948. When we attempt the relief of the woman in such cases, we should commence as early as the state of the uterus will per- mit, and especially when it may be either the third or fourth po- sition; in either of which we should experience all the inconve- niences which are found in the third and fourth presentations of breech and feet, with the contingency of the knees stopping in their progress; and this, at a time when it might be either dif- ficult or dangerous to attempt making the changes upon the direction of the body, so important to the safe delivery of the head. 949. Baudelocque recommends pushing up the knees when we attempt their reduction ; but, so far as I am capable of compar- ing the two methods, I think acting upon the breech is the bet- ter plan. 950. He also advises the employment of the fillet, or blunt hook, for the delivery of the knees — I confess I have tried nei- ther — but it appears to me they cannot in every position of the knees be employed with advantage; but in one I think they may aid, (that is, the fourth,) when these parts have descended low in the pelvis ; as then the direction necessary to the delivering them will be the one, and the only one, we can give them by either fillet or blunt hook. The proper hand must be employed, when we attempt to raise the breech, or we may fail in the attempt to liberate the feet and knees — in the first presentation, we must use the right hand ; in the second, the left ; and in the third and fourth, either. 349 CHAPTER XXX. OP TEDIOUS LABOUR, 951. Many causes have been assigned for tedious labour; some of which, are sufficiently evident; while others are extremely obscure, if not altogether inscrutable. The causes have been divided into constitutional and local; both of which unquestion- abl}^ may exist; but the former is much more rare than the latter. The general, or constitutional causes, appear to consist almost exclusively in passions, or emotions of the mind; or at least, to some peculiar condition of the sensorium commune, and nervous system. Thus, we see the uterine action rendered feeble and transitory for many hours together, or suspended from half an hour to a number of days, from the influence of some unexpected or distressing intelligence; or sometimes, even the presence of a strange accoucheur (259) or midwife, will have the same effect. 952. The state of the muscular system, appears to have but little influence upon uterine contraction; for when it exists in its most healthy condition it by no means ensures the best efforts of the uterus ; nor does a state of almost exhaustion, necessarily interrupt the regular and successful play of this organ. 953. Nay, we may go farther and declare, that the functions of the uterus are, in very many instances, never more rapidly, or'successfully performed, than when the powers of the muscular system are below the natural standard of health, or even indeed, when they are much reduced. Thus, in the last stages of fever, or of phthisis pulmonalis; or in a word, any other exhausting disease, the uterus at the proper time, is almost sure to discharge its contents, not only with rapidity, but almost without pain. Here, the relaxed condition of the soft parts immediately con- cerned in the act of delivery, cease to oppose the contraction of the fundus and body of the uterus; and this organ itself seems to be so economical of its powers, as not to suffer their waste, even when all the other muscles of the body are rapidly yielding them. Here, the os uteri gives way, with instant and seeming willing- ness, to uterine contraction, and will not oppose by obstinacy as in most cases, the passage of the child, and render labour tedious. 350 OF THE WANT OF CONTRACTILE FORCE. 954. In general, the condition of the os uteri, (casteris paribus) may be looked upon as one of the surest guides to determine the duration of labour; and hence, when it is not disposed to yield, it becomes the most common cause of tedious labour; and hence, we may learn why the local cause or causes, are much more fre- quent in their operation than the constitutional. Among these we may especially reckon — 1. A want of contractile force of the uterine fibre.* 2. A rigid condition of the soft parts concerned in labour; es- pecially, the mouth of the uterus itself. t 3. Cicatrices, or other imperfections, arising from injuries done to the parts concerned. J 4. A premature escape of the liquor amnii. 5. Over-distention of the uterus, producing torpor or inertia of this organ, aad too dense a condition of the membranes. § Of these we shall treat pretty fully, and illustrate the opera- tions of each cause, by appropriate examples. Sect. I. — Of the tvant of Contractile Force. 955. This is a condition of the uterus, and not an extremely unfrequent one, in which neither of the other enumerated causes are present, and for which it would be very difficult to assign the true one. It may, however, arise from some original defect of the uterine fibre, as it is occasionally found to be habitual with some women ; or it may follow the over-action of this organ. In the cases under consideration, we have not to contend with any unfavourable condition of the soft parts: for the defect seems to be seated in the uterine fibre itself. And it is in such cases, that the ergot or secale cornutum, has been found so highly useful. See Chapter on Ergot. 956. I shall relate a few cases, by way of illustration, of each of the conditions of the uterus just named. a. Where the powers of the uterus were partly exhausted by long-continued action. * See Chapter on Ergot. f See Section on Rigidity as a cause of Tedious Labour. + See Section III. § See Sections V. and VL OF THE WANT OF CONTRACTILE FORCE. 351 Case First. 1817, Dec. 21st. I was requested to visit Mrs. , in con- sultation. She had been in labour sixteen hours, with a first child, and was twenty-eight years of age. The waters had discharged themselves early in the labour: the pains had been, up to a certain period, strong and frequent; the head had passed the OS uteri, and every expectation was entertained, for some time, that the labour would have terminated promptly: but in this the medical attendant, and the friends of the patient, vvere disappointed. The head occupied the inferior strait, and the vertex was ap- plied nearly fair to the arch of the pubes. For some time the pains continued to be frequent, but feeble; but eventually, they nearly subsided altogether; after waiting, with things in this condition for six hours, without the smallest advantage, I was requested to visit the patient. I found the lady sufiering much from a generally spread pain over the abdomen; some fever; great restlessness; pains nearly gone, and very inefficient; and the head about to emerge from under the pubes. I soon perceived that the uterine forces were totally inadequate to depress the parietal protuberances below the tubers of the ischia. We however waited twenty minutes more to ascertain the absolute power of the pains, and during each, attempted to aid it, in the adaptation of the vertex to the arch of the pubes; that is, I assisted to turn the face ex- actly into the hollow of the sacrum. By this change in the po- sition of the head, some advantage was gained, as it necessarily diminished resistance; but it did not enable the uterus to accom- plish the labour. By this time the patient could hardly be said to have pains. I now proposed to give our patient twenty grains of ergot: this was acceded to, and it was administered to her immediately. This first dose of the ergot evidently roused the dormant powers of the uterus; and a second, of the like quantity, enabled it to expel a very large healthy child. Case Second. 1818, May 30th. 1 was called at eight o'clock, P. M. to Mrs. 352 OF THE WANT OF CONTRACTILE FORCE. , the mother of several children; she was constitutionally de- licate and nervous. Her pains were weak, and returned only at long intervals, sometimes not recurring oftener than once an hour. On the 31st, at eight o'clock, A. M. I made an examination for the first time; found the os uteri dilated pretty considerably, and very yielding; pains still very slow. During a pain I gently stretched the mouth of the uterus, with a hope it might excite a stronger action in the body and fundus, but without advantage. As the parts were all favourably disposed, I ruptured the mem- branes: this also failed to excite contractions of a better quality. At two o'clock, P. M. I gave twenty grains of the secale cornu- tum, and repeated it in fifteen minutes: pains now succeeded each other so rapidly and forcibly as to deliver the child safely in fifteen minutes more. No case can better decide the influence and specific action of the secale cornutum than the one just related. It most striking- ly exhibits the superiority of this drug over the rupturing of the membranes, though this operation is one which often succeeds. We are aware that the practice of rupturing the membranes is condemned by some, under almost any circumstance; but, in doing this, I had in expectation, first, that by taking off the distending cause from the uterus, it would assume its usual pow- ers, as not unfrequently happens when the waters are removed, by the unequal surface presented by the child, proving a stimu- lus to this organ; and, secondly, and particularly, that the tonic contraction would so certainly take place, as to secure my patient against a subsequent hasmorrhage. b. Where a want of power in the longitudinal fibres of the ute- rus appeared to be the cause of the delay of delivery. Case Third. 1819, May 26th. I was called to Mrs. , in labour with her sixth child. She was attacked with pain twenty-four hours be- fore; they had augmented gradually, but were very irregular in their recurrence, though very severe. The os uteri was found pretty fully dilated; the head of the child was at the superior strait, and resting upon the pubes, in consequence of a pretty ex- tensive anterior obliquity of the uterus. Things continued in this posture until two o'clock, P. M. of the 27th. I now ruptured the membranes hoping it might increase the contractions of the ute- RIGIDITY, &C. OF THE SOFT PARTS. 353 rus, or give them more efficacy; for though the pains were very severe as regards sensation, they manifested very little propulsive power. The rupturing of the membranes was not followed by the slight- est advantage; I therefore determined on giving the ergot; a scruple dose was accordingly given. It may be proper to remark, that, up to this moment, the head had not advanced a line. In fifteen minutes after the ergot was given, the pains became pow- erfully propulsive; and in a quarter of an hour more, my patient was safely delivered of a fine healthy boy. 957. This case, like many others, decidedly shows the influence of ergot upon the uterus; but perhaps it declares, in an especial manner, its power over the action of the longitudinal fibres of this viscus; which, as I have already observed, (508) have the greater agency in expelling the child. My reasons for thinking so are, first, because there were pains, even violent ones, from the com- mencement of the labour, until the very period of exhibiting the ergot, without the child being forwarded by them in the slightest degree; second, because the rupturing of the membranes, a plan generally successful in increasing pain, failed ; third, because the labour was terminated very soon after the character of the pains was changed, by the exhibition of the ergot — or, in other words, by the longitudinal fibres being stimulated to a healthy and effec- tive action. Sect. II. — Of Rigidity, S,^c. of the Soft Parts, as a cause of Tedious and Preternatii^ral Labour. 958. Writers upon midwifery have but y^xy imperfectly con- sidered the rigidity of the soft parts as a cause of difficult or tedi- ous labour — some indeed do not mention it, and others do so, merely en passant, without proposing any specific treatment for its relief. It is so common a case, that every practitioner must have met with it; yet it has failed to make a proper impression, because time and severe suffering have eventually overcome it, though not always with safety to either mother or child. 959. A rigid condition of the soft parts may, with much pro- priety, be considered the most frequent of the causes of a tedious labour; especially as every woman may be subject to it, as well as every variety of presentation, be complicated with it. It may, perhaps, be difficult to define by words, the precise condition of 45 354 KIGIDITY, &C. OF THE SOFT PARTS. parts, said to be rigid. But by tbis term we would wish to con- vey the idea, that certain of the soft parts concerned in labour, as the OS uteri, peringeum, &c. offer an unusual resistance to the efforts which the fundus and body of the uterus make to expel their contents; and it is in this sense only, we employ this term in this place. 960. From this explanation, it seems to follow, that such a con- dition of the mouth of the uterus and the external parts may ex- ist, as will resist for a longer time than natural, (all other things being equal,) the expulsive efforts of the fundus and body of this organ; so we presume, that in these very cases, had no such re- sistance from the parts been present, that a lesser degree of force, and a shorter continuance of contractions, would have effected the delivery. 961. The condition of the soft parts under consideration arises perhaps, in a failure of reciprocity of sympathy in the several parts concerned in labour. For in fault of this good understand- ing, if we may so term it, the ordinary, and essential changes for an easy delivery do not take place; or in other words, to employ the language of Mr. Hunter, the stimulus of relaxation is not given, or is not obeyed. This want of consent, however, does not necessarily imply a morbid condition of the parts concerned; though it must in many instances, have such an origin. Thus there may be no morbid condition of the os uteri, though it re- sists for a longer time than usual the efforts of the fundus and body, ■ when these parts have been prematurely excited to action; for in this case, all the terms of utero-gestation have not been complied with. While on the other hand, when the uterine developement is perfect, and the soft parts resist the efforts of the body and fun- dus for an unnatural period, the presumption is, that some mor- bid cause may be operating, so as to change the nature of the sympathies by which these parts are governed at such times. 962. For, in the ordinary course of a healthy labour, the mouth of the uterus opens by some secret agency; or at least without any apparent force; and when this takes place, the efforts of the body and fundus, are rendered as effective as prompt, in termi- nating the labour; but when this does not happen in the order just stated, the os uteri, (all things being otherwise equal,) is then said, in popular language, to be rigid. 963. In labours of the latter kind, there is an unnatural resist- ance to be overcome; and to effect this, unfortunately, mechani- RIGIDITY, &C. OF THE SOFT PARTS. 355 cal and other equally improper means are resorted to; which so far from fulfilling the intention in view, oftentimes increases the evil, and converts an otherways safe labour, (were it properly managed,) into one of great danger; or at least, into one of great tediousness, and difficulty. In such cases, and with such conse- quences, it is at once evident, that a wrong principle governs the attendant; for he attempts to overcome the resistance, by increas- ing the force of the body and fundus; or, by forcing open the resisting os uteri by mechanical means. 964. The first he attempts, by the exhibition of stimuli of one kind or other, until the system is urged to the formation of fever; or to fulfil the other, he stretches the mouth of the uterus so rude- ly, or so repeatedly, as to produce in it an incipient, or perhaps a very active inflammation. By such means, he defeats the opera- tions of nature, which would have been most safely performed, if they had, by a well-regulated plan, been permitted so to do. For, restofbody; tranquillity of mind; the abstraction of stimuli; the loss of blood; free bowels; and not allowing the soft parts to be disturbed, by ill-timed and officious touching, or ill-conceived ma- nual aid at the mouth of the uterus, have in a thousand instances, overcome every difficulty presented by simple rigidity. 965. Many of the errors committed in the treatment of the cases of tedious labour from rigidity, have arisen from the popular belief, that the dilatation of the os uteri is effected by the mechani- cal agency of the child, and the distended membranes; and conse- quently, that this part is in a degree subject to the laws which govern impelled bodies. Two very important mistakes arise from this view of the subject; first, it prescribes a definite time for the dilatation of the os uteri; for it seems to be assumed, that the contractions of the body and fundus, must, in a given time, force open this part, by the repeated shocks it receives, from the foetus being urged so often against it. 966. Hence we find Mr. Burns declaring " if the labour be go- ing on all the time but slowly, it is a good general rule to effect the dilatation of the os uteri within ten or twelve hours at farthest from the commencement of regular labour." This position is fol- lowed by the necessary directions for the fulfilment of this inten. tion by mechanical means; and though we acknowledge the mode pointed out for this purpose, and the conditions necessary to ren- der them profitable, are as well guarded as the assumption of the principle will permit, yet we must declare our unfeigned aversioB 356 RIGIPITV, &C. OF THE SOFT PARTS. to the practice; for we are every way certain that it can be done with advantage in but very few instances, even by the skilful ; and never, without the risk of much mischief, by the unskilful or inexperienced practitioner. 967. When the os uteri remains unyielding for a long time, it is an evidence that the natural processes, which so beautifully, kindly, and safely effect this change, have from some cause or other been interrupted. And though mechanical force may be made to usurp the organic function, it nevertheless will always be at the expense of the health, or even the integrity, (be this more or less,) of that portion of the uterus to which force is applied. 968. So well assured am I of this fact, that I never employ force to open the os uteri. Nor do I hold the argument, "that no mis- chief has been seen to follow this plan," of the slightest weight; as we have it not in our power at the moment, to determine satis- factorily, any consequence, but the proximate, or immediate effect of the violence; which may be, and most probably is, but slight, or even unappreciable at the instant it is committed. But can we with any certainty declare, that many of the severe and danger- ous chronic affections of the neck of the uterus, do not owe their origin to this cause? 969. There are but three situations of the os uteri with which we should ever interfere; namely, first. When this part does not coincide with the direction of the uterine forces, and the axis of the vagina. In this case, labour may become very tedious, for the want of a correspondence of axes; I therefore attempt to es- tablish them, as directed in cases of obliquity of the uterus. See section on the Obliquities of the Uterus, p. 115. 970. But I never attempt even the slight change here spoken of, until the os uteri is yielding, and at the same time dilated, to the size of a dollar, and the pains in pretty full force. By this method, not the slightest violence is committed ; nor is even pain excited. 971. Second. When the pains are powerfully protrusive, and the OS uteri, though pretty amply dilated, yet not sufficiently so to permit the parietal protuberances to pass freely through it. In this case, much time and suffering are very often saved, by run- ning the extremity of the finger round the margin of the os uteri, and gently stretching it. For in many instances, if we gain an increase of half an inch in the diameter of this part, it is all that is required, to enable the head to pass it. RIGIDITY, &C, OF THE SOFT TARTS. 357 972. Third. When the head is detained by the anterior portion of the uterus being in advance of it, and holding it, as it were, in a sling. In this case, that portion of the neck of the uterus, which is placed before the head, is obliged to sustain the whole force of the uterine efforts; in consequence of which it becomes not only severely stretched, but it very effectually op])oses the advancement of the presenting part, and gives rise to much un- necessary delay, as well as very much augmenting the sufferings of the patient. 973. This case is one of very frequent occurrence: and women who have ample pelves, and especially those who have had several children, and are liable to the anterior obliquity of the uterus, are more particularly obnoxious to it. I do not know that any writer has noticed this cause of tedious labour; and though this cannot, strictly speaking, be considered as an instance ofrigidjty, it nevertheless has all the effects of that condition, as it creates delay, by a portion of one of the soft parts opposing the passage of the head; and may, therefore, with much propriety, be consi- dered under the present head of our subject. 974. We are every way satisfied from long observation, that this situation of the uterus, and of the head of the child, is one of the most common causes of delay when everything else is fa- vourably disposed, that occurs in practice; at least in this coun- try. Whether this be so in Europe, where the remote causes, namely, large pelves, are not so general, we are unprepared to say; but we are certain, that the frequency of this relation of the head of the child, and the anterior portion of the uterus in this country, renders such labours more tedious by hours, than they would be, if no such interposition of the neck of the uterus took place. 975. It is true, that the remora which the neck of the uterus offers to the passage of the head when down before it, never of itself creates a serious difficulty; the evil chiefly consists in a painful and an unnecessary delay; but as the case is always manageable, when it is proper to offer aid, it is certainly right to correct this deviation from a strictly healthy labour, as early as circumstances will permit. 976. The proper time to act is, when the hand occupies the inferior strait and vagina, completely; when the pains are active; and when the os uteri is sufficiently dilated to permit the head to 358 RIGIDITY, &C. OF THE SOFT PARTS. pass, if the axis of the head, and that of the os uteri, were coin- cident. 977. To relieve the head from this state of embarrassment, we must draw the prolapsed edge of the os uteri by the point of the finger in the absence of pain, towards the symphysis pubis, and maintain it there, until a pain comes on. At this moment, the point of the finger is to be placed against the edge of the uterus, which is to be pushed upwards between the head of the child and the pubes. Should we be able to carry the prolapsed portion of the uterus above the advancing portion of the head, the former will suddenly withdraw itself from the finger; the vertex will apply itself to the arch of the pubes, aud the labour terminate al- most immediately. 97.8. It sometimes, however, requires several trials of this kind before they may succeed: but the attempt must not be abandoned because it fail a few times: for the principle is a correct one; and should be acted upon perseveringly, should perseverance be necessary. We have everything to gain, if we succeed: and nothing to lose, if it fail; a disappointment, by the by, which can- not well happen, if the process for the restoration of the prolapsed part be properly condu^.ted. 979. We are convinced that we have seen very many labours, shortened by hours, by acting, as just proposed, for such cases. It would be extremely difficult to determine, a priori, the dura- tion of a labour of this kind, if left to itself; as the resistance which the margin of the uterus offers to the head, will for a long time be more than equal to the power of the uterine forces ; con- sequently, the labour becomes stationary, and will continue to be so, until the margin of the uterus is obliged to yield, by its losing a part of its power from attenuation, or perhaps by tearing, 980. Nobody estimates the general rule, "to let a labour alone that is advancing well, and is natural in its general relations," more highly than we do — we look upon it as a most wholesome restraint when acted upon; and is everyway calculated to dimi- nish ignorant and mischievous officiousness. But this rule, like every other general rule, has its exceptions; and we may be even accused of violating it unnecessarily, when we make the cases under consideration exceptions; but we should feel but little con- cern upon this head, if the charge be even preferred against us as we are certain that we are justified in making them, from an ample experience. RIGIDITY, &C. OF THE SOFT PAUTS. 359 981. Many, nay, perhaps everybody, (for we have said that we did not know that this case had been noticed,) will condemn what we have said upon this subject, and consider our directions as unnecessary, if not mischievous, because they have never had recourse to them, but have permitted the uterus to perform this duty unaided; therefore they say nature is competent to the work, and when she is competent, she is not to be interfered with. Were this rule rigidly acted up to, there would be an end to im- provement, not only in the obstetric art, but in the whole range of practical medicine. Our experience, however, teaches us not to heed this sweeping, indiscriminate rule; for it is not sound practice to permit nature to struggle through difficulties merely because it is supposed she can struggle through them; and to leave it for some time a moot point, whether or not the case will eventuate in safety, when aid, as certain, as safe, is always at command. Nor does this application of the finger ever pro- duce pain or other inconvenience, if properly and gently ma- naged. 982. Besides, much delay is sometimes experienced from this dropping down of the anterior portion of the uterus, by inter- rupting the pivot-like motion of the head, (627,) from completing itself ; especially, when the head occupies pretty strictly the in- ferior strait. In this case the posterior fontanelle will remain for a long time stationary behind one of the foramina ovalia; for its advancement towards the arch of the pubes is prevented by the prolapsed portion of the uterus interfering with the motion just mentioned, by embracing too strictly the advancing part of the head. 983. But the pivot-like motion of the head is almost always restored the instant we succeed in passing the depending portion of the uterus above the head of the child by the point of the fin- ger, as directed above. 984. The several situations of the os uteri just described, are the only ones I ever interfere with. For should it be thick and rigid, though pretty well opened, I never have recourse to me- chanical means for its farther enlargement ; I depend upon more time, or upon the therapeutical means to be named presently. 985. But let us now consider the rigidity of the os uteri, as a cause of tedious labour ; we will treat of its several varieties, i4;s consequences, and mode of treatment. 360 SPECIES OF RIGIDITY. Of the Species of Rigidity of the Os Uteri. 986. First, it may arise in the mouth or neck of the uterus, from the circular fibres of these parts maintaining their power in- ordinately long; but not inflamed. 987. Second, this condition may be attended with inflamma- tion. 988. Third, it may arise from previous injury done the parts, either by mechanical violence, or inflammation, and its conse- quences. 989. Fourth, it may happen from a relative cause;' as the disproportionate powers between the longitudinal and circular fibres. 990. Fifth, it may proceed from the too powerful exercise of the tonic contraction of the uterus, especially of the fundus and body. Rigidity of the First Kind. 991. This species may be divided into three varieties; viz. 1st, when the subject is very young; 2d, where she is advanced be- yond the twenty -fifth year; and, 3d, where the uterus is prema- turely excited into action. Vai\ 1. 992. In this variety the soft parts are found to yield very of- ten with great reluctance; and thus making this labour extremely tedious and painful; it would seem to arise from the incomplete developement of the uterus — but each of the species and varieties will be best explained, by apj)ropriate cases. Case First. " Miss V. aged fourteen years and a half, was taken in labour January 14, 1790. She had been in pain thirty-six hours, before I saw her; that is, she complained for that period, though the pains were not very severe; about twelve hours before I visited her, the waters were discharged; the mouth of the uterus was but very little opened, and the external parts not favourably dis- posed; the pains were now very severe, and the head was press- ed pretty deep into the pelvis: she was extremely costive, and SPECIES OF KIGIDITY. 361 had passed no urine for many hours; an injection was ordered, which operated very freely; the catheter was introduced, and nearly a quart of water was drawn off — she was much relieved by these discharges. An hour was given, in hope that a favour- able change might take place in her labour. There was but very little heat in the vagina, for she had been rarely touched. She had, however, by the advice of her midwife, been placed over water, and fumigated with burning onion-shells, but to no purpose. I now bled her fifteen ounces; this produced some little change in the mouth of the uterus, but not sufficient to permit the head to pass, as it contracted and stiffened with each pain. In an hour more she was again bled fifteen ounces; this produced sickness of stomach, which was my signal for stopping. Upon examination now, the parts were found sufficiently dilated; there was a tem- porary suspension of the pains, but ihey soon returned, and were of competent force, and much more tolerable — the labour was soon after terminated. Var. 2. — Or ivhere the Subject is not young, but with her' first Child. 993. The same general phenomena present themselves in this variety as in the first, but this case is generally rather more ob- stinate. Case Second. 1798, February 17th, Mrs. , aged forty, in labour with her first child; she had been long in labour previously to my seeing her, and had suflered much — her pains were in quick succession; the waters were still undischarged; the uterus opened to about the size of a quarter dollar; its edges very firm; no disposition in the external parts to relax — she was bled largely, (40 ounces) and was delivered in half an hour after. Var. 3. — Or luhere the Uterus is prematurely called into Ac- tion. 994. This may happen at any period of gestation, or in any subject; but I am only now considering those cases where this takes place at the last period. It would in this variety be highly 46 362 SPECIES OF UIGIDITY. useful to distinguish it from the two just mentioned; as in the be- ginning it requires very different treatment. .The following marks may serve to detect it: 1st. The unexpended portion of the neck of the uterus may sometimes be perceived by the touch, as at the eighth month or a little after; 2d, the os uteri is rigid, during, and in the absence of pain ; 3d, the pains are more irregular in their accessions and in their continuance ; 4th, no secretion of mucus, nor disposition in the perinseum to relax ; 5th, no subsi- ding of the abdominal tumour; and the knowledge of some violent mental excitement, or muscular exertion having preceded the onset of pain. 995. Should these pains however be suffered to proceed with- out interruption, it will eventuate in a painful and tedious labour — it therefore should be our first care to appease uterine contrac- tion, by remedies suited to the condition of the patient — blood- letting should be premised, if the pulse merely j3er7nit it, and without declaring its absolute necessity; especially, as the case may require repeated and large doses, sometimes, of laudanum. Rest should be strictly enjoined ; the bowels should be opened by mild laxatives, if costive; this should be followed by injections of laudanum and water, pro re nata — the diet should be mild, and in small quantities. By this kind of treatment we may very often have it in our power to interrupt this disagreeable anticipation of labour, as the following case, among many others, shows. Case Third. 1790, January 29th, Mrs. M. L. , aged twenty, pregnant of her first child, after standing all day at the ironing-table, was seized with pretty regular pains. There was no subsiding of the abdominal tumour; no secretion of mucus; the os tincae not en- tirely obliterated. There was very little tension of the membranes during a pain; from these circumstances I was disposed to believe the uterus had been prematurely excited to action. She was or- dered to lose twelve ounces of blood; to keep quiet, and receive an enema of a gill of water, and a tea-spoonful of laudanum — paip soon subsided; she went a fortnight longer, and her labour prb- ceeded kindly, and was not of long duration. 996. In cases similar to the above, much mismanagement fre- quently takes place; especially, when the patient is under the care of an ignorant midwife, who supposes the attending pains SPECIES OF RIGIDITY. 3G3 can only proceed from a commenced labour: particularly, if the reckoning of the patient be nearly expired; she is of course fre- quently and oftentimes rudely handled ; the uterus irritated, and the whole system stimulated by improper drinks or remedies, with a view to hasten the labour as it is called — the following case is in point. Case Fourth. 1790, August 11th, Mrs. C. pregnant with her third child, aged twenty-eight, after a severe fright, was attacked with pains; as her midwife was engaged at the time she was sent for, I was called on. From her being disappointed in her midwife she be- came very much alarmed, and her pains ceased for six hours. At the expiration of this period they returned, and the midwife ar- rived soon after; she examined her and found nothing like labour. She gave her a large dose of laudanum, which not easing her, was repeated in two hours more. Her pains became more violent; she had much fever, attended with delirium. I was now sent for a second time; upon examining the patient, the uterus appeared evidently to have been forced into contrac- tions by the fright, and these perpetuated by the improper con- duct of the midwife; but things were now in such a situation, that it would have been in vain to have attempted stopping the progress of the labour. The mouth of the uterus was thick and hard, and opened to about the size of half a dollar. As there was so much fever, I thought proper to bleed and purge her ; these had a good effect, as her fever and delirium were diminished, but the mouth of the uterus was firm, and not augmented in size since she was exami- ned before, (six hours;) she was again bled pretty largely, the delirium went off entirely, the uterus opened, and she was deliv- ered in less than an hour. 997. Had not this patient been bled very liberally, there is every reason to believe her labour would have had a serious ter- mination — she lost in the two bleedings about fifty ounces of blood. This case serves as a contrast to the one just before re- lated ; as I believe the bleeding which preceded the anodyne enema, enabled the latter to produce its beneficial effects ; and I am also of opinion, that had a bleeding been premised in this case, the patient would have suffered much less, and gone some time longer. 364 CICATRICES, &C. FROM LOCAL /nJURIES. 998. I think it an important rule in the farther arrangement of these labours, when pain cannot be suspended by the means pointed out alx)ve, to abstract stimuli of every kind, as much as possible ; to have the bowels well opened; and then to allow the circular fibres of the mouth of the uterus to be a little fatigued, before we employ a larger or sufficient bleeding to effect the far- ther dilatation. We -may easily know when they begin to be fa- tigued, by their readily yielding when the finger attempts to stretch it in the absence of pain. Bleeding alone sometimes quiets this premature motion of the uterus. Sect. III. — Cicatrices or other Imjoerfections arising frotn Local Injuries. 999. It was not until the year 1796 that I learnt the value and certainty of blood-letting in cases of local injur)^ from inflamma- tion, or from a solution of continuity in the soft parts concerned in labour, where in healing they became contracted, and other- wise severely injured, though I had so frequently experienced its value in cases where they had obstinately refused to yield to the common agents of delivery, when in the natural condition. The long continued pressure of the child's head during its pas- sage; the ill-judged use, and the worse directed application of instruments; and the reprehensible neglect of the perin^eum when much distended — have given rise to more or less grievous injuries of these parts. These accidents will retard delivery in propor- tion to their extent ; and if some oppose but a trifling resistance to the passage of the child, there are others, from their severity and extent, which may render it impossible without adventitious aid. 1000. Cutting instruments have been not only considered as justifiably employed in such cases, but deemed absolutely essen- tial for the termination of the labour,* in many instances where bridles, indurations, and cicatrices have deranged the natural or- der of these parts, or so disturbed their natural functions, as to render them no longer subservient to their proper uses — hence the necessity of means so severe as the scalpel or bistoury for the relief of the mother and child. 1001. I trust, however, this terrible alternative is no longer, or at least, not so frequently necessary as heretofore; since, it is * Baudelocque, &c. CICATRICES, &c. ruo:\r local injuries. 365 found, in some of the most distressing and extensive injuries of this kind, to yield in a very short time to the relaxing influence of a copious bleeding. To show the certainty of this reme- dy, even under the most unpromising circumstances, I will relate several cases where it was employed with the happiest effects. Case First. 1796, June, I was called to Mrs. T , in labour with her second child. When I arrived, I received the following account of the case from the midwife: "Mrs. T has been in labour sixteen hours; the waters discharged six; the mouth of the womb is but little opened; and, when in pain, the os externum seems to close up; the child is as high as ever, though many things have been given to force the labour. She has passed no water for twelve hours, and she is very costive." I found her very feverish; complaining of great heat in her ab- domen, and violent pain in her head. On examining per vagi- nam, I found, as the midwife had stated, that the os tineas was but little dilated; its edges very rigid and hot — as was the whole tract of the vagina; the rectum much distended with faeces, and the bladder by urine. The head of the child was still above the brim of the superior strait; but its situation could not be exactly determined, as the os uteri was not sufficiently opened for the purpose. She was bled immediately, to the amount of twelve or fourteen ounces, and an injection was thrown up, which procured two stools and a discharge of urine. Upon examination, I found the mouth of the uterus more dilated; and I was enabled to deter- mine, that the presentation was a perfectly natural one ; and the head lower in the pelvis. The pains were very powerful; the head at length cleared the upper strait, and the vertex was about to turn under the arch of the pubes, but completely enveloped in the uterus — during a pain, the perinaeum was much distended ; the OS externum, instead of yielding to the impulsive force of the uterus, rather closed, so that two fingers could not be retained at once. A seam, or cicatrice, formed a kind of barrier in the vagi- na; and the head in consequence, was thrown to the right side of the inferior strait; where the parts were so extremely stretched, 366 CICATRICES, &C. FROM LOCAL INJURIES. that I feared at each pain, the head would burst through them, in spite of every exertion to the contrary.* From the oblique situation of the head with respect to the va- gina, the OS externum, instead of answering to the axis of the inferior strait, was mounted up directly to the pubes; conse- quently the right side of the vagina, perinseum, and rectum, had to support the greater part of the force exerted by the uterus and its auxiliary powers. In order to counteract their influence, I supported the external parts with my hands; and made, during each pain, a strong pressure against the head; directing the wo- man at the same time to suspend her voluntary powers, as much as possible. Six hours were spent in this manner without advantage; the OS uteri still rigid, hot, and but partially dilated; the os externum not disposed to yield, and the cicatrix as firm as ever. The head advanced, notwithstanding my efforts to prevent it; so that the vertex, covered with the uterus had partly emerged from under the arch of the pubes. At this period it was extremely difficult to touch the mouth of the uterus; as it had receded towards the .sacrum, in proportion as the vertex had descended. The soft parts were very hot and dry; and I began to enter- tain serious apprehensions for the patient. I was ten miles from the city, and no one was near, on whose judgment I could rely. In this dilemma I had neai'ly resolved to divide the parts; believ- ing it preferable to permitting the head to force its way through them; which I began to consider as inevitable; when fortunate- ly Dr. Physick's case of luxated humerus occurred to me. This determined me to try the effects of bleeding, ad deliquium ani- mi. I represented to the friends of the patient, the danger of her case; the ^05.s/6/e result of the bleeding; and the inevitable one did it not succeed. They agreed to the trial. I had the patient placed on her feet, while the midwife firmly sup- • The cicatrix just spoken of, was formed by the heahng up of an extensive laceration which tlie patient sufTcrcd in her former labour. It ran from the in- ferior termination of the left labium, to about tiie termination of the sacrum. I judged of the extent of the injury, by the cicatrix; and tliis could be traced to this point. Conversing upon this case, some time after, with the practitioner who had delivered her before, he confirmed my supposition. It was a long time before the wound healed; and the woman's health suffered much from the excessive and long-continued discharge; but fi-om this she recovered: and was when I was called to her, apparently in robust health. She was about twenty- iwo years of age; of short stature, and rigid fibre. i CICATRICES, &C. FROM LOCAL INJURIES. 367 ported the perina^um, &c, A vein was opened; and allowed to bleed, until she fainted. '' She was now placed on her side in the bed. On examining her, everything appeared better; the external parts were perfectly soft and yielding; and the os uteri pretty fully dilated ; but no pains succeeded, during the time I thought proper to wait; (which was half an hour, the patient continuing very faint all this time ;) the parts being now in a proper situation for delivery, I introduced the forceps; and delivered a living, and healthy child. The parts yielded very readily without lacera- tion; and the woman had a rapid recovery. 1002. As cases of the kind I am now considering, are highly interesting; both from the extent of injury done to the parts, and their rarity, I trust I shall be excused for detailing another; especially, as the mode of treating them is as certain, as it is novel, t Case Second. On the 12th September, 1798, 1 was requested to visit the wife of Samuel G., in consultation with Dr. Jones. I was informed by the doctor, that Mrs. G. had been in labour sixteen hours; the waters evacuated themselves early; her pains were frequent and * The quantity of blood drawn was upwards of two quarts. \ Dr. Davles gives the credit of large bleedings In pai-tiu-itlon to the late Dr. Rush. 1 feel that I am entitled to whatever praise or blame may attach to this practice. But this has been long since ceded to me by that gentleman, with all that frankness and liberality which so constantly characterized him. But Dr. Davles does not appear to understand the ch'cumstances under which this prac- tice Is recommended. I Infer this from his observations on the use of blood-let- ting, where rigidity is a cause of difficulty. "For my own part," says he, "lean see no good reason for bleeding pro- spectively, or In anticipation of a mere possibility, which miglitor might not be realized by the event. To say the least of such a practice, it would appear to be a most unnecessary encroachment upon the ordiniuy dispositions of nature in the affairs of a function which she usually performs very safely and satisfactorily without any such Interference." — Elem. of Oper. Mid, p. 89. This passage would lead to the conclusion that I recommend, (for It Is not Dr. Rush,) this operation previously to any appearance of the necessity; which is far from being the case. This opinion Is strengthened by what Immediately follows; "Bleeding on the other hand, as a j-cmedy or a corrective of an actu- ally existing rigidity of the soft parts, whetlier or not accompanied by more than ordinary constitutional excitement, is a power of great and unquestionable val- ue." p. 90. Now this is conceding all that I have ever contended for in the use of this remedy. 368 CICATRICES, &C. FROM LOCAL INJURIES. strong ; but there was not the least disposition in the soft parts to dilate* I examined the patient, and found the os externum scarcely large enough to admit the finger, and mounted against the sym- physis pul)is, in consequence of the perinseum being very much distended by the head of the child. The os uteri was rigid, and but little opened; a kind of bridle, or small column of flesh ran from the inferior edge of the symphysis pubis, and lost itself in the perinseum below ; against this the head was firmly pressed. The head was situated naturally; and so far advanced, that the vertex was about to emerge from under the arch of the pubes, covered with the uterus; and had been in this situation six hours previous to my visit. All that had been done during this period, was the occasional exhibition of laudanum, with a steady pressure against the perinajum, to prevent the head escaping through it. In this situation of things what was to be done? My ingenious and much lamented friend. Dr. Elihu Smith, of New York, upon the receipt of the history of the case just re- lated, suggested the trial of an infusion of tobacco in similar cases, as a substitute for such extensive bleeding; affirming the effects were very like those produced by copious blood-letting; such as nausea, vomiting, syncope, and relaxation. I was pleased with the idea; and determined to employ it the first opportunity — the case under consideration I believed to be as favourable a one as could well occur; I accordingly proposed the tobacco infusion to Dr. Jones, who cheerfully consented to its trial. A strong infusion of tobacco, after several inefiectual attempts, was thrown up the rectum; it produced great sickness, vomiting, and fainting; but the desired relaxation did not take place — we waited some time longer, with no better success. In the course of an hour, or an hour and a half, the more distressing effects of * This patient like the one whose case has just been related, had also suffei-- ed a laceration of great extent; the parts, after a considerable lapse of time, liealed; but so unfortunately, as almost entirely to obliterate the vag-ina. I was called upon for advice; the woman's situation was truly distressing; the pas- sage, or vagina, was so much contracted, as not to exceed In size a common writing quill; the parts extremely callous; and a continual and profuse dis- charge of acrid, fcrtid pus, kept her in a constant state of misery, and ill-healtli. My friend, Dr. Physick, was also consulted at the same time: by a persevering use of sponge tents, &.c. the parts became sufficiently dilated to admit Imper- fectly the venereal congress; soon after, she became pregnant; and the conse- quences of this pregnancy, furnish the above case. CICATRICES, &C. FROM LOCAL INJUUIES. 3G9 the infusion wore off; but resolved to give the remedy every chance in our power, wc prevailed on the patient, with some difficulty, to consent to another trial of it; its effects were the same as before — great distress, without the smallest benefit; the parts remaining as rigid as before its exhibition. Supposing the bridle just spoken of, might have some influence on the developement of the parts, I divided it, but without any evident good. We now proposed the remedy that had so com- ])letely succeeded in the former case — namely, bleeding nearly to tainting; to this the patient consented. We placed the patient on her feet, taking care to have the perinaeum guarded, during the operation. Upon taking away about ten ounces of blood, she be- came very faint;* she was immediately laid upon the bed; and the most complete relaxation had taken place; the forceps were applied, and our patient was delivered in a few minutes of a fine healthy girl. The mother v.'as comfortably put to bed; and everything went on in the ordinary way until the sixth day; at which time, she was seized with a violent cholera morbus, and convulsions, (to which complaints she was subject,) and died in twelve hours. This case, notwithstanding its unfortunate termination, fully establishes the influence of blood-letting in this very distressing kind of rigidity; and jjroves its action to be different from that of tobacco; though the latter produces sickness, vomiting, and syncope. I do not think the slightest blame can attach to the bleeding; as the woman was very well unto the sixth day; when diseases to which she was subject, supervened, and carried her ofi'. Case Third. On the 26th September, 1800, I was called, in consultation with Dr. Ruan, to a woman in labour. She had been twelve or fourteen hours in travail with her second child. t The pains were frequent and strong; the waters had been discharged some time; the head was fiivourably situated, and completely occupied the vagina; the perinseal tumour large; the os externum, which did not exceed in size a fmger ring, admitted the finger with some difficulty, in the absence of pain; during a pain it would be * The subject of this case was a delicate woman, and wont to become very faint upon the loss of a little blood. f Witli the first she had suffered an extensive laceration of the perinaeum. 47 370 RELATIVE RIGIDITY. thrown up against the inferior edge of the symphysis pubis, so as not to admit the finger, or permit it to remain, if it had been pre- viously introduced. Externally, a large cicatrix was found to run to the very verge of the anus ; internally, it could be traced farther. This seam prevented the unfolding of the external parts so effectually, that the repeated efforts of the uterus for several hours were insufficient to make them yield , though the head had been closely applied to them for that period. The patient was a strong healthy woman — considerable fever — the pulse strong, frequent, and hard. I proposed bleeding ad deliquium, to which Dr. Ruan consented. A vein was opened immediately, and we took away about fourteen ounces of blood; but as the pains were very rapid, we were obliged to draw it while she was in a recumbent posture ; no disposition to syncope was manifested. This quantity, however, had some effect, as there was evidently a disposition in the parts to relax, and an abate- ment of the severity and frequency of the pains. A second bleed- ing was determined upon, and to perform it while the patient was in an erect position. We effected this with some difficulty, but upon taking five and twenty or thirty ounces of blood more, she fainted — she was laid on the bed, and in a few minutes was de- livered by the forceps, of a fine healthy boy — the patient reco- vered rapidly, without accident. About three years after, I again delivered the same person by the same means. Relative Rigidity. 1003. I have maintained that not only the different parts of the uterus into which it is usually divided, may act separately and independently of each other, but that even the different sets of fibres of which it is composed may do the same; hence that pecu- liar rigidity 1 have denominated "relative;" by this we are to understand that the circular fibres act with a force superior to the longitudinal. This may happen from the latter losing a portion of their strength, which will necessarily give to the circular a re- lative superiority of force; or it may happen that the circular fibres from some cause or other, may have an increase of power, which will of course, make the longitudinal relatively weaker. Whichever way it may take place, the result is the same, for the labour will become stationary. 1004. This case may be known by labour coming on kindly, but after a certain period, gradually diminishing in force, by the TONIC RIGIDITY. dn mouth of the uterus having a disposition to dilate; by its thicken- ing; by the presenting part not protruding during a pain; by pain extending itself OA'er the whole abdomen; by a sense of suffoca- tion; by a hard, full, depressed pulse; by the irregularity of the pains, both in force and frequency — the mouth of the uterus in this case cannot open agreeably to the order of nature, as the fibres destined to keep it shut, are relatively stronger than those intended to open it. 1005. In consequence of this transfer, or peculiar disposition of the power, the longitudinal fibres contract more feebly and tran- sitorily; the mouth of the uterus does not dilate, though not pre- ternaturally rigid; the abdominal tumour does not continue to sub- side; there is a secretion of m.ucus, and a disposition in the exter- nal parts to relax; but the os uteri cannot dilate until the longi- tudinal fibres have shaken off their torpor, or in other words, not until the cause of this torpor is removed; when this is done, they resume their healthy contractions, and the labour, for the most part, is quickljr terminated. Case. Mrs. W , June 10th, 1S05, was taken in labour with her tenth child: her pains began smartly, but soon ceased almost en- tirely — she continued in this situation from ten o'clock in tiie eve- ning until six the next morning; at this time I was called; I found her with nearly all the symptoms above enumerated ; she was bled twenty ounces; pains came on immediately, and she was quickly delivered. Sect, IV. — To7iic Rigidity; or Rigidity from the Premature Escape of the Waters. 1006, This only takes place after the waters have been a long time discharged — the tonic contraction of the uterus then becomes powerful, and its force will be in proportion to the healthy dispo- sition of ibis organ; and the time which may have elapsed since the waters were drained off. I have already remarked upon this disposition of the uterus when freed from its contents, and stated its high and important uses, to the woman at the time, (251 ;) I have also referred to the inconveniences to v/hich it sometimes gives rise, when speaking of the causes of preternatural labours, and given a case illustrative of it. (678) Cases of this kind have 372 TONIC RIGIDITV. frequently occurred to me; but in some I have been obliged to turn after bleeding, (which was impossible before,) and in one or two others I have been obliged to use the forceps. 1007. There is a kind of rigidity, or, more properly speaking, a cartilaginous or scirrhous condition of the neck or mouth of the uterus, which is so confirmed and indurated, as not to yield to the powers of the body and fundus, nor to blood-letting, however far it may be carried. These cases, fortunately, are very rare; so rare, indeed, that I have never met with an instance of the kind. They are, however, recognized by Baudelocque and other writers. 1008. Baudelocque says of them: "Sometimes the pad which constitutes the neck of the uterus, in the latter periods of preg- nancy, and in time of labour, is hard, scirrhous, incapable of any extension or dilatation, so as entirely to hinder the exit of the child. After a convenient delay to ascertain that the efforts of nature cannot overcome the resistance, and the administration of proper methods to relax it, it must be cut in several places, as some prac- titioners have done. These incisions are preferable to rents which might take place in it, and have never been attended with the same consequences. They must be made more or less extensive, according to the pad, which is callous: but always so much so, that the orifice may afterwards open sufficiently."* 1009. The success of this plan has been verified, in this coun- try, as the case of Dr. Thomas Archer most satisfactorily proves. Dr. A. was called to a woman in the thirtieth year of her age, and in labour with her first child. The os uteri was found to be very little opened, "and forming a thick cartilaginous ring, which nei- ther yielded to nor was softened by the pains." After ordering a bleeding to some extent, to be purged, &c. he took his leave, and left her to the midwife who had charge of her. He did not see this patient again until late in the following day. Soon after his arrival, the uterus, loaded with its contents, was pushed through the OS externum. The child was dead he thought, beyond doubt, and had most probably been so for ten days. As the case appeared to him hopeless, and as it was not in his power to procure a con- sultation, he resolved on making incisions in the mouth of the uterus; he accordingly, by means of a common lancet, made three cuts in the uterine circle; one anterior, one posterior, and one la- terally. The incisiens were each about two inches long. The * Vol. III. p. 205. OVER-BISTENTION OV THE UTERUS. 373 pains, though not strong at this time, were sulEcient, however, to expel the child almost instantaneously. The woman was put to bed, and no unpleasant symptom followed.* 1010. In addition to this case, and as confirmatory of its suc- cess, we may mention those of Moscati. A woman whose os uteri had suffered from a previous labour, was found at the time of her second, to be so restricted and dense as to require an ope- ration. This was performed by making several incisions in the circle of the os uteri, which dilated after a time sufficiently, and without farther injury, to permit the child to pass — this operation was repeated upon another occasion on the same vvoman with similar success. This method Moscati thinks better than that recommended by Smellie, and appears to consider it original. t But the above case will show that Dr. Archer had performed this very operation long before, and with equal advantage. Sect. V. and VI. — Over-distent ion of the Uterus^ and the Memhranes too Dense, as a Cause of Tedious Labour. 1011. In many cases of this kind, a well-directed interference may very much abridge the duration of suffering; but when and how to interfere, with success, can only he known, by those who possess correct principles, and have had long experience. Thus Mr. Burns telis us, and to the success and truth of which we can bear ample testimony, " that in many cases a very moderate resistance, retards the expulsive process, and renders the pains irregular or inefficient. And I know by experience that the membranes may be so tough as not readily to give way, and in this case the pains become less effective, and the labour is protract- ed till they be opened. Whenever the resistance is removed, the pains become brisk and forcing." 1012. Of cases of this kind, we have seen many; but one of the most remarkable happened in September, 1826. Mrs. — , at the full period of her pregnancy, as she calculated, was attack- ed on the eighteenth of August, with severe alternate pains, which caused me to be sent for. These pains were excessively severe; bu-t without either force or regularity. There was no secretion of mucus, nor was the os uteri dilated, though soft, and the whole of the inferior portion of the uterus was excessively distended and • Med. and Phys. Jour. Vol. I. p. 157. t See Bidletine Universal, &c. No. 6, July, 1827. 374 OVER-DISTENTION OP THE UTERUS. very thin. After waiting several hours, not the least alteration was observed, though the pains had continued with much severity. I ordered a gill of water and a drachm of laudanum to be given as an enema. This application completely tranquillized the pains for many hours; they however returned, with as much violence the day following; and were again relieved by the same remedy; nor did they return until the 21st of September, nearly five weeks from the first attack. 1013. This second attack was every way similar to the first, with the addition of an acute pain in the right side, which was augmented by coughing, or a full inspiration. Twelve ounces of blood were drawn ; the bowels freely opened by epsom salts and calcined magnesia; and the diet and drink restricted to barley- water. The condition of the uterus was very much the same as it was when examined on the 18th of August. The bleeding and purging afforded much relief, by removing the pain from the side; but there was no abatement of the uterine action, or pain; for such it certainly was, as the whole uterine globe was found firmly contracted or hardened at each pain. The laudanum ene- ma was repeated with the previous good effect, and my patient remained quiet until the day but one following, namely, the 23d, when there was again a renewal of the previous symptoms, which were again removed by bleeding, purging and laudanum. On the 24th, the same sufferings were endured, and relieved as be- fore. On the 25th, my patient was again seized at the hour with the same symptoms, together with great feebleness, and almost constant disposition to syncope. The pains were occasionally se- vere, but far apart; not at all protrusive; and each was followed by nearly complete syncope. 1014. The situation of my patient seemed now to call for some efficient relief, or she must succumb. As the uterus was very thin and much stretched, and the os uteri was pliant, though not -dilated beyond three-quarters of an inch, I thouglit it would be best to rupture the membranes, and give an opportunity to the uterus to contract, and, as I believed, remove tlie disposition to syncope; this was accordingly done; and it gave issue to an im- mense quantity of liquor amnii. My patient received immediate benefit from this operation ; the sensation of distention was re- lieved, and the faintness was instantly removed. In about half an hour, the pains became efficient, and the os uteri began to di- late ; and in about an hour and a half, my patient was safely de- OVER-DISTENTION OF THE UTEKUS. 375 livered of a large male child. No aflcr-inconvenicnce was expe- rienced. 1015. This case is remarkable for the numerous unsuccessful efforts the uterus made to disembarrass itself, and the severe suf- ferings the patient underwent during these efforts; and may with as much certainty as almost any with which I am acquaint- ed be looked upon as a protracted case of gestation.* The pa- tient considered her term as having fully expired on the 18th of August; the period at which pains first manifested themselves; and as far as the usual, mode of reckoning, and the complete de- velopement of the uterus at that time can be relied on, incline us to the belief, that she was correct; and that she really had ar- rived at ten months and a week, complete, when delivery took place. 1016. I can anticipate nothing, even at this moment, but a dis- astrous issue, had I neglected to rupture the membranes; as several very distressing, as well as alarming symptoms, had be- gun to show themselves; such as a cold, clammy skin ; a small, frequent pulse; laborious breathing, and great proneness to syn- cope ; all of which were instantly removed by taking off the dis- tention of the uterus, by giving an opportunitj^ for the liquor am- nii to escape by rupturing the membranes. This case must not be confounded with the Hydroamnios or a dropsy of the ovum one of the few diseases to which -it is liable. It is almost always caused, as far as my experience goes, by a latent venereal taint on the side most frequently of the father, and this, for reasons that will immediately present themselves. In these cases the woman rarely goes to the full period of utero-gestation — for the foetus is sometimes expelled as early as the sixth month, and rarely goes beyond the beginning of the eighth. It is usually found to be dead, or so weak as to die very soon after birth. In some instances the liquor amnii is so abundant as to give the woman the appearance of being at the full time, though she may not have exceeded the seventh month. We have had several such patients under our care — in one of these seven dead children were delivered in as many consecutive pregnancies. This case, with several similar, the uterus, &c. were restored to the healthy performance of their duties, by mercury, and sarsaparilla, in the unimpregnated interval. * See Chapter " On the Term of Utero-Gestation." 376 CHAPTER XXXI. IliEMORRHAGE FROM THE SITUATION OF THE PLACENTA OVER THE MOUTH OF THE UTERUS. 1017. I SHALL confine my observations on the subject of uterine haemorrhage in this place, to the " unavoidable species" and to those discharges of blood which follow the birth of the child; and will refer my reader for an account of such as precede delivery, but in which, the placenta is not situated over the mouth of the uterus, to my work on the Diseases of Females. 1018. The first evidence of the placenta being over the mouth of the uterus, may declare itself so early as between the sixth and seventh months of utero-gestation. At this time, the neck of the uterus begins to unfold itself for the more complete accom- modation of the foetus — in consequence of which, a small portion of the placenta will sometimes be separated from the uterus; this of course will be followed by a discharge of blood, commen- surate with the extent of the lesion, and the size of the vessels involved in the separation. 1019. This discharge may sometimes by proper management be made to cease, and not to return until the uterus and placenta are again forced to separate — then, another slight hsemorrhage ensues, which may also cease ; and not be renewed perhaps until the last period of pregnancy; or there may be, as happens some- times, a constant stillicidium of a bloody sanies until the last pe- riod of gestation. Dr. Rigby, who is considered the highest au- thority upon this subject, seems not to have bestowed as much attention to the condition of the patient before the full period of utero-gestation, as he did to the consequences after that time had arrived, or he would not have held the doubtful language he did when speaking of the " time and manner" in which the "acci- dental" and the unavoidable h&morrhage came on ; he says ^^ probably that which is occasioned by the placenta being fixed to the OS uteri, will, for the most part, not come on till the full term of parturition, when the uterus begins to dilate from the approach of labour; which is contrary to the account I have just given, (1018, 1019,) as well as to the experience of almost all the wri- UNAVOIDABLE IliEMORRH AGE. 377 ters* upon this subject. Besides, the very economy of the uterus makes the account 1 have given of this accident, correct. 1020. It must not, however, be supposed I insist, that the wo- man will necessarili/ be subject to these anticipating discharges; I only wish to be understood, that she is tmavoidabbj liable to them, from the mechanism, of uterine expansion. The oblitera- tion of the neck of the uterus is not purely a mechanical operation; for it unquestionably suffers an organic developement at the same time ; and much will depend, as regards the appearance of hae- morrhage before the full period of utero-gestation, whether the me- chanical or physiological process shall prevail. Thus, if the neck of the uterus be mechanically operated upon, and made to yield faster than the organic developement can follow, a portion of the placenta will be detached, and a discharge of blood will follow. When this takes place, the orifice of the uterus will be found thinner than usual; and the os uteri rather more open; and this happens perhaps more frequently than otherways, if my observations be correct; that is, I have witnessed more cases of women who have had anticipating discharges of blood, than those who were exempt from them. 1021. I am aware this does not correspond with the cases given us by Dr. Rigby — agreeably to his records, nearly two to one had no previous discharge. While Baudelocque tells us, that the dis- charge "sometimes appears as early as the sixth month: some- times not until the ninth, or even till the approach of labour; but generally , from the seventh to the eighth month." When it does not appear before the full period of utero-gestation, it must be owing lo the growth of the placenta keeping pace with the or- ganic developement of the neck of the uterus; or in other words, where the mechanical agency is inferior to the physiological coun- teraction. When this condition obtains, the neck of the uterus is larger, and its parietes thicker than common; indeed it has been thought by Duparque, that it is not entirely developed even at full time under such circumstances, and that it is on this account that the haemorrhage does not appear until the approach of la- bour. For he appears to believe in cases of the implantation of the placenta over the mouth of the uterus, that the neck of this organ does not develope itself as in ordinary cases of pregnancy; and endeavours to prove this, by saying, he opened the body of * See Leroux, Kok, Baudelocque, Denman, Burns, &.c. 48 378 UNAVOIDABLE HiEMORRHAGE. a woman who was in her ninth month; the neck of the uterus was very thick, and projected four lines; that he introduced his fin- ger with difficulty in the opening, and experienced the like resist- ance when he attempted to pass it from the cavity of the uterus outwards. Now this proves nothing more, than in that case, the developement was not complete; which certainly cannot establish the fact he wishes to prove, namely, that in all cases of unavoid- able haemorrhages, the neck of the uterus is less expanded, than when the placenta is attached to some other portion of this organ than the neck.* 1022. It is not difficult to believe, that the neck of the uterus in the cases under consideration, is found sometimes thicker than it ordinarily is, at full time; because, in most instances of pla- cental presentation, we believe, that haemorrhage takes place be- fore the exact period of gestation is completed. Our reasons for thinking so, are, 1st That in common cases, which arrive to their full term, but where the placenta is attached elsewhere than to the mouth, the mouth of the uterus is found to be a flat, plain surface; and either altogether closed, or but little opened, and the edges constituting it, thin. 2d, Because, this species of haemorrhage, is seldom attended with pain in its commencement; and sometimes not at all; which would hardly be the case, were the uterus completely developed ; and the flooding be the conse- quence of an entire developement, and the absolute commence- ment of labour. 1023. Therefore, when the full time arrives, the woman may be surprised by a sudden, and an alarming issue of blood, without the smallest premonition — for it sometimes makes its approach so silently and so rapidly, that the patient may be attacked in the midst of her domestic duties, or while in the enjoyment of company. At other times it is preceded by slight and distant pains ;t and when this is the case, the discharge, for the most * .Tourn. Gen. de Med. Vol. 29. j- Wlien this species of flooding' is accompanied by pain, it will in general be found that the waste is neither so sudden nor so profuse, as when none attends; though each contraction of the uterus augnncnts, for the time being-, the he- morrhage. It must, however, be observed, tiiat in proportion to the discharg-e, will be, (cseteris paribus,) the diminution of the uterine force — and hence the infrequency of natural deliveries in this kind of flooding*. Indeed the pain seems almost to cease; or, in other words, the contractions cease almost as soon as they commence; for a certain fulness of blood in the uterine vessels, seems essential to healthy contraction. UNAVOIDABLE HAEMORRHAGE. 379 part is neither so sudden, nor so alarmingly extensive; for hse- morrliagc is never so overwhelming nor appalling, as when the OS uteri siientl}^ and rapidly jaelds, and in an instant exposes a thousand bleeding vessels.* 1024. The blood flows in an almost unceasing stream, till the woman becomes much weakened and faint; coagula may then form, and a temporary truce ensue, but this in general is treach- erous, and of short duration; especially, if pains attend; for the coagula which had partially arrested the haemorrhage are now driven away by the contractions of the uterus, or by the opera- tion of some other cause, as accidental as unavoidable, and the discharge is renewed with perhaps even increased violence; and in this way may things proceed, until the patient is either ex- hausted by the waste of blood, or is relieved by the judicious and successful interposition of art. 1025. When the disciiarge is so excessive and sudden as I have just described it to he, no time should be lost before it is ascer- tained whether the flooding proceeds from a separation of a por- tion of the placenta remotely situated from the os uteri, or from this mass being placed over it— the symptoms which designate these different situations, though perhaps pretty strongly marked, are nevertheless not sufficiently accurate, to render a more certain and decided examination unnecessary, 102G. We should, therefore, upon such occasions, always exa- mine the mouth of the uterus with great care. In conducting this, the finger merely introduced into the vagina, will rarely in- form us with sufficient accuracy ; the hand should be conducted into this canal that the utmost freedom may be given to this im- portant examination. A proper moment, however, should be chosen for this purpose, that no evil may result from the opera- tion ; for I have just remarked, that a suspension of the discharge is sometimes eflfected by a coagulum within the vagina or mouth of the uterus, which being removed in making the examination, may renew the flooding; while the blood is flowing is therefore the time to make this attempt. 1027. When the hand has possession of the vagina, a finger * This circumstance, however, rarely obtains, but where the woman has ar- rived at, or very near, the full term, and where she has been teased by some previous discharge. May not the pretty constant, though inconsiderable dis- charge just noticed, contribute to this sudden dilation of the os uteri, by acting as a uniform local depletion? 380 UNAVOIDABLE HEMORRHAGE. must be carried within the os uteri ; it should then carefully and with certainty, determine the nature of the substance presented to it ; if it be the placenta it can be distinguished from a coagu- lum, (the only thing to which it has any resemblance,) by the following characters: 1st, The placenta always presents to the touch the sensation of a fibrous structure of pretty considerable firmness. 2d. When this is pressed upon by the extremity of the finger, a sensation of tearing an organized mass is excited. 3d. It being much firmer in its consistence, and offering more resistance to the play of the finger within it, than a coagulum. 4th. Its not escaping from the finger, when its substance is in some measure broken down by the pressure and free movement of it — it can never be mistaken for the membranes. 1028. In a case of such importance, we should neither permit a false humanity, nor a false delicacy to get the better of an im- perious duty; for upon the early knowledge of the species of flood- ing, the woman's life may unquestionably depend. We should, therefore, without reserve, state to the friends of the patient, our opinion of the nature and tendency of her case, and the import- ance of ascertaining it, by a proper examination. This will al- most always be acquiesced in; and, if it be properly conducted, it will neither excite severity of pain, nor wound the most fasti- dious delicacy. The hand for the most part, from the relaxation consequent upon a continued discharge, will pass without much difficulty; or it may be made to do so, by proper lubrication. 1029. It is true, indeed, with a first child, and at an incomplete period of utero-gestation, there may be some difficulty in pass- ing the hand, if the discharge has not been pretty abundant — but in this case, the examinat on is not so immediately important; should it, however, be so, from the excess of the haemorrhage, the parts will then be found almost always sufficiently yielding to permit the passage of the hand without much difficulty. The directions just given for ascertaining the particular nature of the haemorrhage, I am persuaded should never be neglected, as an attention to them will save a vast expenditure of blood in all cases, and in some life itself. 1030. Having ascertained it to be a placental presentation, the condition of the mouth of the uterus should next be carefully ex- amined — the degree of opening, and its disposition or indisposi- tion to dilate, should be marked, for on this much depends. It will be found in one of the following situations: 1st, but little UNAVOIDABLE ItiEMORRHAGE. 381 opened and very rigid; 2d, but little opened, yet disposed to di- late; 3d, opened to some extent, but very unyielding; 4th, opened to the same extent, but soft; 5th, fully dilated. 1031. The nature of the case being thus ascertained, the mode of treatment is next to be considered. This will necessarily be much influenced by the particular condition of the woman, and the period at which the discharge may show itself, and its quan- tity make interference necessary. 1 have already noticed, that when the placenta is situated over the mouth of the uterus, slight discharges of blood may take place after the sixth month, as a consequence of the economy of the uterus (1018) at this period; when these are moderate, they may, for the most part, be arrest- ed by the means usually employed for flooding, when the pla- centa is not placed over the mouth of the uterus ; they should therefore be put into immediate requisition, and the patient placed under the strictest injunctions of obedience, and conformity to directions. 1032. For a discharge of blood at this period is always to be looked upon as liable to extreme augmentation; and we should never lose the suspicion, that it may arise from the peculiar si- tuation of the placenta. We have no certain means by which the ^'accidental" may at this time be distinguished from the "una- voidable," unless it be by a careful examination — but this is never necessary so long as the flooding is moderate. I think however, I have observed in the " unavoidable," that the flow of blood is more sudden and copious in a given time; and that it is more fluid and florid than in the "accidental." In the com- mencement, the "unavoidable" is never accompanied by coa- gula; and when pain attends, the discharge is always increased at each contraction. But in cases demanding precision, these marks cannot be relied upon. From the proximity of the bleed- ing vessels to the os externum, the blood will issue so quickly from them, as to appear both more fluid and more florid, than in the "accidental" species; for in the "accidental," the blood may escape remotely from the os uteri, and be obliged to travel slowly through the meshes of the connecting medium oftlie ovum and uterus; and hence will appear less florid and fluid, and be more disposed to coagulate than in tlie "unavoidable." 1033. But coagula will form in the " unavoidable," when the discharge is about to cease, either by proper treatment, or by the mere efforts of nature, and it is in this way that a stop is put to farther waste. 382 UNAVOIDABLE HEMORRHAGE. 1034. As we cannot determine the situation of the placenta without much pain and force, before the full period, when the flooding is moderate, it may always be well to treat both kinds as if they were cases of placental presentations; as in doing so we shall be erring on the safe side. We should insist upon the most perfect tranquillity, and a constant confinement to the hori- zontal position whenever practicable. Blood at this period may be taken from the arm, if the arterial force be too great; cold applications should be resorted to; and the sugar of lead be ex- hibited in suificient doses, either by the mouth or by enemata as already advised. Kok and others recommend cold astringent injections into the vagina: of the utility of these I have much doubt — at least, I have never been tempted to employ them. 1 rarely pay any attention to the state of the bowels, unless they be very costive — then a mild, warm injection of molasses and water, or soap and water, will be every way sufficient. I am thoroughly convinced that much mischief is sometimes done by the exhibition of even the very mildest purgatives; and the reason will be immediately obvious, when we consider the ef- fects of them, I have frequently permitted my patients, under treatment for uterine haemorrhage, to be five or six days withuot a discharge from the bowels; and when I thought it necessary to stir them, it has been, for the most part, by means of mild in- jections. 1035. Kok also advises the introduction of some substance, such as lint or rags, into the vagina, well imbued with a fluid styptic, such as a strong solution of alum, or of wine in which alum is dissolved. I should place more reliance upon this latter means than upon the former; as it would in some measure act as a tampon, and serve as o. point cP apjnii iov coagula to form upon ; for at last we must have these form, if the haimorrhage stop with out having done much mischief. 1036. I have advised bleeding when the pulse is active ; Kok says, this is useless, if not injurious, in this kind of flooding. In this I cannot agree with him; and for the following reasons : — 1st. Under any kind of active haemorrhage, when the pulse is vi- gorous, the taking away blood from the arm has uniformly been found useful, by producing contraction by unloading the vessels t^D a certain extent; and more especially, in diminishing the ve- locity of the blood within them. 2dly. As, at the period we are UNAVOIDABLE HEMORRHAGE. 383 speaking of, we cannot decide with certainty without manifest vio- lence, from the contingencies just mentioned, that the discharge is from the pecuhar location of the placenta, we may act, as far as the bleeding is concerned, as if it were an " accidental" hoBmor- rhage; especially, as the blood detracted will not seriously weak- en the woman, and as there is a strong probability that it may be arrested until the last period of pregnancy by proper applica- tions and treatment. 3dly. That at this period the haemon-hage is for the most part owing to a mechanical separation of a portion of the placenta; but which will not generally be renewed for some time, as the separated vessels, and the other connecting me- dia, possess considerable elasticity; therefore, time will be given for the formation of coagula, provided the proper means be pur- sued to favour their production; among which we must reckon bleeding. 4thly. If the discharge be not produced by external violence, or any other cause which will certainly excite the action of the uterus, there is a strong probability, that it will cease for the time being; unless it be improperly treated, or unnecessarily provoked. 1037. Should the body and fundus of the uterus be excited into action from any cause, at this period; and the discharge be rather the eflect of such contractions, than the natural and unavoidable stretching of the neck of this organ, we have great reason to fear, that we shall not be able to suspend these efforts, so as to enable the woman to go the full term of gestation. But should we ever have this intention in view, as it may sometimes be happily ful- fdled; and if it be not, it is decidedly the most proper mode of treating the complaint. 1038. In such cases, vve should endeavour as quickly as pos- sible to interrupt uterine contraction ; for this purpose, we should bleed under the restrictions just mentioned; we should exhibit the sugar of lead with laudanum, as frequently as the exigencies of the case may require; and by enemata, I thmk, is much the most prompt and eiFicacious mode of administering them. From a scruple to half a drachm of this salt, with a drachm of lauda- num, and a gill of water, may be thrown up the rectum every hour, or more seldom, as occasion may call for them. All the auxiliary plans I have already recommended should be put in re- quisition, and their full adoption rigidily enforced. 1039. Should these means moderate the discharge, and the blood be found disposed to coagulate; and if at the same time 384 UNAVOIDABLE HJEMORRHAGE. uterine contractions have ceased, or even considerably diminished, we may be encouraged to persevere in the use of these remedies, and entertain an expectation of uhimate success. The intro- duction of a moderate sized tampon of sponge at this time, as a mevejwint d'appui, is highly useful; for, without some such support, the coagulamay be discharged, and the haemorrhage renewed. 1040. The artificial support for coagula, which I have recom- mended above, (1039) is of more consequence than we would at finst imagine. It permits the thinner parts of the blood to escape through the meshes of the sponge, by which means the coagula are rendered more firm and tenacious; besides diminishing, by a counter action, the influence of the vis a tergo, which is con- stantly operating to throw them off. 1041. I am aware, that some rely upon the coagula without the tampon; and I must admit, that they have occasionally been sufficient to save the woman's life; a case of this kind, is related by Leroux;* but he expressly declai-es they are not to be relied upon. The sudden movement of the woman's body, for even necessary purposes; uterine contraction; the escape of the wa- ters, &c. may all serve to disturb the coagulum which has arrest- ed the hemorrhage. But the most important use of the tampon under these circumstances, remains to be mentioned ; which is, that it causes the coagulation of the blood, merely by presenting a surface favourable to this change, long before this disposition would spontaneously show itself; for in general, this effect is not produced, but when the woman is much exhausted, or by the ra- ther tardy, though successful influence, or the remedies previously employed. t 1042. Should our endeavours, however, fail to arrest the dis- charge, we should, without farther loss of time, ascertain the con- dition of the OS uteri, and then j^roceed precisely as if the woman had arrived at her full time when the haemorrhage commenced ; for it will now be found that the cases are reduced exactly to the same condition, and will require the same niode of management; of which I shall speak more at large presently. 1043. A woman may escape these anticipating discharges un- til she complete her full term; but at this time it, will be seen that * Observations, p. 258. f Mr. Burns assures us, he never saw a case which required delivery during the first paroxysm, if a proper treatment had been adopted. — {Principles of Midwifery, 5th. ed. p. 323.) UNAVOIDABLE HAEMORRHAGE. 385 the uterus cannot expel its contents without necessarily exposing the patient to the most imminent risk. So alarmingly profuse^ and so decidedly dangerous are these discharges in some instances' that a few minutes are sufficient to exhaust the strength, or to deprive the woman of life. 1044. I once witnessed a case in which there was discharged from the uterus, in the course of about fifteen minutes, a full half gallon of blood; and was sent for in another instance, where the woman had expired before my arrival, though there had not, as the midwife assured me, more than half an hour passed from the commencement of the flooding to its fatal termination. These are, however, extreme cases ; yet they show how suddenly and certainly, they may be fatal. It is confessed, on all hands, that no accident attendant upon conception is equally menacing as the unavoidable hasmorrhage; and it also emphatically declares to the physician, that much depends upon him that it shall not be very often fatal. It is one of those extraordinary cases, in which nature does less for the preservation of the individual, than almost any other. 1045. This does not arise so much from want of exertion on the part of nature, if I may so term it, as from the almost entire incompatibility of giving birth to the child, and protecting the woman against flooding, at one and the same time. Yet we learn, from such authority as cannot be doubted, that the woman, left entirely to herself, vvill not always perish. The means, however, which nature employs to procure this immunity offer neither a useful practical hint, nor the smallest inducement to imitate her; for they are so entirely contingent, and sometimes so long with- held, that the woman from her great exhaustion, can scarcely be said to profit by the interposition. 1046. Baudelocque* says, the woman may be preserved '' when the orifice is fully dilated, and the mass separate entirely from it, and be so far removed from one side, that the membranes may pre- sent. The membranes may then tear spontaneously, and delivery be performed naturally, if the woman, notwithstanding her loss of blood, still preserves sufficient strength, as has sometimes hap- pened." Leroux,t by the formation of coagula, and the sponta- neous action of the uterus. Smellie,^ to the entire separation of * System of Midwifery, Vol. II. par. 986. \ Observations, &c. p. 306. \ Midwifery, Vol. II. Col. 18, No. 3. Cases, No. 3, 4, 5, 6, 7. 49 386 UNAVOIDABLE H-EMOKRHAGE. the placenta, rupture of the membranes, and the placenta being first delivered, &c, &c. 1047. From this it would appear that in some rare instances the woman has been saved by the natural agents efiecting the delivery before she vvas too much exhausted; but we do not pro- fit by the knowledge of the manner in which this was performed. It is therefore, now completely established, that the only chance the woman has for life, is by a u^ell-timed and well-conducted delivery in every case, (cseteris 2Juribus,j of placental presenta- tion. 1048. Though it be universally admitted that there is but one mode of proceeding in the case we are now considering; yet it is not so generally conceded that the success of that mode es- sentially requires that the delivery be properly timed, and as pro- perly conducted. All who have written upon this subject, seem to agree in one of the positions; namely, that delivery is abso- lutely necessary; but many, and indeed I may add too many, have been regardless of the conditions which serve to render this operation availing. 1049. The success of the operation of turning for the relief of this species of haemorrhage, must depend upon its being perform- ed under the proper conditions of the mouth of the uterus. We have already insisted on this when treating of " turning," there- fore shall not repeat here the rules we laid down as essential to success, whenever this operation is performed. 1050. The time when we shall attempt delivery is of the greatest moment, and deserves particular investigation. Dr. Den- man says, " it would be of great advantage in practice, if some mark were discovered, or some symptom observed, which would indicate the precise time when women with hasmorrhagesof this kind ought to be delivered;" but declares, "we do not at present know any such mark." Yet almost immediately after decides, that " whenever the case dem.ands the operation, on account of the danger of the hasmorrhage, the state of the parts will on this account always allow it to be performed with safety, though not with equal facility." 1051. If this be true, we are certainly in possession of what Dr. D. thought so great a desideratum — for if the parts be in condition to turn with safety, it is certainly all that is required, when " the danger of the haemorrhage demands the operation." For if the parts permit turning without risk, they must be in a UNAVOIDABLE HAEMORRHAGE. 387 dilated or a dilatable state, and tliis is all that is, or can be re- quired when the condition of the flooding " demands the opera- tion." Then we have a rule which is never failing, when this condition of the parts obtains, if it be true that this can always be done with safety, if not with equal facility. 1052. Now, it is of importance to inquire whether turning can always be performed with safety when the parts are in a condi- tion to permit it; for upon this much depends. It would seem, agreeably to this position, that the whole risk the woman runs in these cases, arises from the " state of the parts," opposing the in- troduction of the hand; and when they do not, that turning may then be performed with safety — experience, however, constant- ly contradicts this unqualified opinion, for the woman may be so far reduced that she may expire before the operation is com- pleted, or very quickly after.* 1053. Besides, the manner in which we find the opinion slated by Dr. D. would lead to the persuasion, that so long as the os uteri was not opened, there could be no danger, whatever might be the quantity discharged, than which nothing can be more unfounded. For it is a well-known fact, that the powers of the uterus may be so far impaired as not to perform this office, even at the last mo- ment of existence. In this I am supported by Rigby,t who de- clares, that were " this rule invariably adhered to, in some cases, it would be attended with danger, as we might wait for the open- ing of the uterus till it was too late to relieve the woman by turn- ing the child." 1054. This will be very readily understood, when it is recol- lected, that the opening of the uterus mainly depends upon the longitudinal fibres acquiring the mastery of the circular; but when the uterus is so far exhausted of contractile power as to remain passive, or nearly so, we shall always find the os uteri closed, (un- less previously distended by an exertion of its powers,) though it may be most easily dilutable. I may perhaps even acquiesce in the explanation of Dr. RigbyJ upon this subject, who supposes * of tliis we have ample proof, in cases 58, 81, 82, 89, 98, &c, of Rig-by, in each of which the condition of the parts easily permitted turning, but not with safety. But I am cleai-ly to be understood that I attach no censure to the ope- ration; for I am of opinion it was the only thing that coidd be done to give the woman a chance — and I liave no doubt, it was properly performed. But these cases goto prove the incorrectness of tlie position I am now examining. f Essay, 6th ed. p. 40. i: Essay, 6th cd. p. 40. 388 UNAVOIDABLE HEMORRHAGE. that the position of the placenta may serve to keep the uterus closed, by surrounding its mouth, by the attachment of its fibres to this part, which is now perfectly passive and unresisting — this is both ingenious and probable. 1055. I must now make a distinction of great practical import- ance, that has never, ^o far as I know, been pointed out; which, if it be just, (and my experience gives me every reason to believe it is,) will in some measure serve to reconcile the conflicting opin- ions of writers upon the subject of the time when it would be invariably proper to attempt the relief of the patient by turning — it is simply this, that there is a most material difierence between the dilatation of the os uteri, or even its dilatability, when efiected by the natural povv^ers of this organ, and that passive or quiescent condition, which results from the langour of death. 1056. Tiie one is the result of its organization, when its powers are not too much impaired or prostrated by disease; while the other is a syncope, if I may so term it, produced, when these powers are exhausted by an excessive waste of blood. This dis- tinction must constantly be kept in view; for on it depends the rational mode of treating this formidable complaint: for if it be not, we prescribe both uncertainly and empirically. An attention to the one, leads us to husband with the utmost care the strength and vigour of the patient; while the other makes us regardless, if not prodigal of it; the one is almost always crowned by success; the other leads almost constantly to a doubtful issue. 1057. We can readily account, with this distinction in view, for the difference of success in the operation of turning. When performed after the dilatation of the uterus has been effected by the natural agents, it has perhaps almost always been attended by the much desired issue; but when performed after the flacci- dity of approaching death had ceased to make it difficult, it too often has been followed by the loss of the patient. Under this impression, I should say, that when the os uteri was either dilated or rendered dilatable by the operations of this organ; and before the strength of the patient was materially impaired, that then, and then only, was the desirable time to operate ; but if circum- stances prevent advantage being taken of the proper moment, and nothing but a choice of difficulties remain, we should cer- tainly attempt to snatch the woman from her impending fate; but this should be under the cautions already suggested. 1058. 1 will attempt to put this subject in a clearer point of UNAVOIDABLE II.T.:\rORKHAGE. 389 view, by considering what ought to be attempted for the relief of the patient under each of the conditions of the uterus pointed out above; (1030) and which necessarily comprehends every state of which it is at this time susceptible. Sect. I. — 1. TF/iere the Uterus is but little opened, and is very rigid. 1059. In the condition of the uterus here designated, all the evils which can attend the forcing of a rigid os uteri, would take place by an attempt to deliver; it should therefore not be thought of Indeed, this has ever been a subject of great embarrassment to writers upon this subject; and makes them in many instances at variance with themselves; or they give their directions so ob- scurely, and so hesitatingly as to confound the judgment of the young practitioner.* It has given rise to two modes of proceed- ing, each of which is equally wrong. 1060. The first is to force the uterus, however rigid, provided a finger can be introduced. I have already said much upon this plan, and shall only add in proof of it a quotation from Dr. Rigbyt everyway illustrative of the impropriety of this outrageous prac- tice. J "In recommending early delivery, I think it right, how- ever, to express a caution against the premature introduction of the hand, and the too forcible dilatation of the os uteri, before it is sufficiently relaxed by pain or discharge, for it is undoubtedly very certain that the turning may be performed too soon, as well as too late, and that the consequences of the one may be as de- structive to the patient as the other. I am particularly led to observe this, as I have lately been informed from very good autho- rity, (namely, a gentleman to whom one of the cases occurred,) * For an instance of this kind, I may cite even Mr, Burns himself — he tells us, in one sentence, "if the hremorrhage have been or continues to be consider- able, we must not wait until tlie os uteri be much dilated, as we tlius reduce the woman to great danger, and diminish the chance of recovery." A few lines farther in the same page, he says " a prudent practitioner will not violently open up the OS utei-i, but will use the plug.''- A little further on, he declares, "he, (a prudent practitioner,) will not allow his patient to lose much blood, or have many attacks; he will deliver her immediately, for we know that whenever that is necessary, that it is easy, the os uteri yielding to his cautious endea- vours." — (Princip. 5th. ed. p. 324.) f Essay on Uterine Hemorrhage, 5th ed. p. 40. + See Chapters " On the causes, which may render anatural, a preternatural Labour^" and "onTui'ning." 390 UNAVOIDABLE HEMORRHAGE. of three unhappy instances of an error of this sort, which hap- pened some years ago to three surgeons of estabhshed reputation, who, from the success they had met with in deHvering several who were reduced to the last extremity, were encouraged to at- tempt it where but very little blood had been lost, in hopes that their patients' constitutions would suffer less injury, and their re- covery be more speedy; which, till the experiment was made, was a very reasonable supposition — the women died, and they seemed convinced that their deaths were owing to the violence of being delivered too soon, and not to the loss of blood, or any other cause." 1061. The other is, to permit the flooding to proceed until the woman shall be so much exhausted as to render the uterus pliant. Dr. Denman, as I have just noticed, supposed that when danger created a necessity for delivery, that then, from the loss of blood, the uterus would permit it with safety. Dr. Rigby says, that when the uterus contracts firmly round the fingers, we should desist from any attempt to deliver, and wait till the part be more relaxed by pain or discharge; and adds, "as an encou- ragement, that we may safely suffer a woman to lose more blood, the contraction may certainly be looked upon as a proof that there still remains a considerable portion of animal strength, and that she has not been so much affected by the loss as we before imagined." 1062. I cannot recommend this plan, though it be the advice of the first authority upon this subject. I am convinced, from both reason and experience, that it is seldom or never necessary; and is perhaps always injurious. To save the woman an ounce of blood, is a duty: to save her forty, or perhaps much more, is still a greater one. To follow, then, the speculation of Dr. Den- man, or the advice of Dr. Rigby, would be widely departing from these duties. 1 do not, I cannot adopt either. 1063. What is essentially important to be done in this case? 1st. To save as much and as quickly as we can, the farther ex- penditure' of blood. 2d. To obtain, as soon as the natural powers will effect it, the dilatation or dilatability of the uterus. 3d. To deliver then with as much speed as is consistent with the welfare of both mother and child. 1064. The first and second of these indications are, as far as I have witnessed for the last thirty years, readily complied with b}^ ihe use of the tampon, and the other auxiliary remedies. If they UNAVOIDiVBLE HiEMORRHAGE. 391 be instantly had recourse to, the discharge will almost immedi- ately abate; or in a short time be so diminished as to give no immediate concern. By this means we not only staunch the hae- morrhage, but gain most important time; for during this truce, the natural agents of delivery will effect the desired relaxation of the OS uteri. 1065. This plan, I believe, originated with Leroux; and has been adopted with entire success by myself for many years past. It has also the sanction of Mr. John Burns, who recommends it by saying, "a prudent practitioner will not violently open the os uteri at an early period, but will use the plug, until the os uteri become soft and dilatable." It is true, Gardien thinks the plug will do harm, by exciting the uterus, and thus increase the sepa- ration of the placenta — but this is theory; it is not consonant with experience. 1066. The following case, selected from several of a similar kind, will place in a clear point of view the promptness and effi- cacy of this plan. Mrs. , while looking out of her window, was suddenly surprised by a profuse discharge of blood from the vagina. Before I arrived, though near at hand, more than half a gallon of blood was expended upon the floor and in a pot. The patient was upon the bed, pale, feeble, and excessively alarmed. I examined her immediately, and found the uterus rigid, and the placenta presenting. She had no pain; nor had she any, previous to the irruption of blood. The discharge was very profuse and exhausting; but as the os uteri was undilated, and rigid, I intro- duced the tampon, and secured it within the vagina by a com- press upon the external labia with a T-bandage. The flooding ceased immediately, and there was nothing passed the os exter- num but some of the thinner parts of the blood. After the tam- pon had been applied about four hours, pains commenced pretty briskly, and in about two hours more, they were of considerable force, so much so as to press against the external compress with some violence. I now removed the tampon; and the os uteri was found sufficiently dilated to allow the hand to pass with entire freedom; and the delivery was quickly efiected, with safety to both mother and child. 1067. For the successful fulfdment of the third, and last indi- cation, it is necessary that the jiractitioner should be well ac- quainted with the condition of the uterus, at the moment he is about to commence the operation; that is, he should know how 392 UNAVOIDABLE HiEMORRHAGE. far he may rely upon its co-operation, or how far it may be capa- ble of that degree of contraction which shall secure the woman against a farther loss of blood. This can only be presumed, from taking into view the quantity of blood lost; the debility or ex- haustion it has occasioned ; and the degree of force the uterus may exert, at each return "of pain. 1068. If it be found, that the quantity of blood is not excessive; if the degree of exhaustion be not alarming; and if, above all, the uterus manifest considerable vigour; the delivery may be ac- complished in much shorter time, and with much greater promise of success, (especiaUy to the child,) than if the contrary of these obtain — in the latter case, the delivery must be conducted with the utmost caution, that the uterus may noi be too suddenly emp- tied, and augment the danger to both mother and child. I shall again advert to this subject, when I come to describe the manner of conducting the operation of turning, or effecting the delivery in such cases. Sect. II. — 2. When but little opened, but disposed to dilate. 1069. In this situation of the uterus, but few obstacles to turn- ing or delivery will present themselves; since, if the necessity of the case require the operation, the great objection to it is in some measure removed; for this disposition to yield to a moderate force, will secure the woman against an excessive loss of blood, by taking advantage of it, and effecting the delivery in proper time. 1070. But it must be recollected, that though the uterus may be disposed to yield, with even a moderate force, to a certain ex- tent, if it be slowly and judiciously applied, yet it ma}^ refuse to relax beyond this, or to such a degree as would not embarrass the operation; nor can it sometimes be made to yield more, unless a dangerous or reprehensible force be applied.* 1071. In a case of this kind, we should gain time by the em- ployment of the tampon, as directed above, and not subject the woman to unnecessary risk, by attempting to overcome the re- sistance of the uterus by violence; and it must also be recollected, that, in cases like these; cases so replete with risk, we are to devote ourselves to the best interests of our patients — they should never be subjected to the chance of a fatal haemorrhage, by our '" Leroiix, Mariceau, Rigby, &.c. UNAVOIDABLE HAEMORRHAGE. 393 leaving them even for a short time; for neither the plea of other engagements, nor a persuasion tliey can receive no injury during a short interval of absence, can justify our withdrawing ourselves from them; I could cite a number of instances in support of this, were such confirmation necessary. If it be judged proper to em- ploy the tampon, we should wait patiently for its effects; but we should wait at the bedside^ or near the patient that we may take immediate advantage of any favourable change in the condition of the parts, for which we were so anxiously looking; or guard against any unfavourable contingency, that might suddenly or un- expectedly arise. 1072. Sometimes, indeed, the os uteri appears entirely closed, though at the same time it is easily dilatable; this case should not be confounded with the one just considered: for here the woman may be readily delivered, as far as the condition of the mouth of the uterus is concerned, should the urgency of the case require it. This situation of the uterus, for the most part, only takes place when the woman is nearly exhausted, and its powers so far im- paired, that the agents for the absolute dilatation of its orifice are incapable of the efibrt. Should we wait for the expansion of the OS uteri in such instances, we should wait in vain; and per- haps even be made witnesses of the death of the patient.* Sect. III. — 3. Opened to some extent, but very unyielding. 1073. Were we to consult authors upon the point of practice in this condition of the uterus, we should find too m.any sanc- tioning forced delivery. I might employ the arguments here, that I have already used against any violence being committed upon an unyielding uterus; for it may sustain as much injury in the condition supposed here, as in the instances I have been con- sidering; for if the opening be insufficient to permit the hand to pass without the employment of force, it will certainly be insuffi- cient to allow the foetus to pass without using much more; it should, therefore, be considered full as ineligible to operate in this case, as in the two I have just noticed. 1074. Besides, there is less excuse for being precipitate in this case; since, the desired relaxation will most probably soon ensue, as the OS uteri has already yielded to some extent; therefore, by giving it a little more time; and by employing the tampon, the delivery may be accomplished without either violence or risk. * See llig-by on Uterine Hemorrhage. 50 394 UNAVOIDABLE HEMORRHAGE. 1075. Had we no command of the hsemorrhage, we perhaps might be justified in the employment of force; as it would then be a dernier resource; but as we can certainly control the dis- charge by the tampon, we should be inexcusable to attempt de- livery, until it has been properly tried, and it had failed. 1076. But let not this case be confounded with the condition next to be mentioned. For when it is ascertained that the ute- rus though opened to some extent, is, notwithstanding, very un- yielding, a young practitioner may, in the confusion and embar- rassment created by the exigency of the case, easily run into the error, that this case must be treated as the one about to be con- sidered. To avoid this error, he should carefully examine the condition of the os uteri, by placing, or rather hooking a finger within it, and drawing the edge towards him: if it readily yield, he may be pretty certain it will stretch by a well-directed force within its circle. 1077. But, in conducting this examination, I must caution him against a mistake he may readily make, if he be not put upon his guard; which is this — he may mistake the movement of the whole OS uteri, for a portion of it; but this error may without difficulty be corrected, by deliberately performing the examina- tion, and attending strictly to the following marks — if a rigid os uteri be drawn, say towards the pubes, its edge under which the finger is placed, will retain its rigid feel; and if the finger be made to pass round the whole of its circle, it will be found to be uniformly stiff and round, and not any, or very little enlarged by the effort made upon it — but, on the other hand, if the os uteri be dilatable beyond the size we suppose it to be by the touch, it will be found soft; and will yield without difficulty to the effort made to stretch it: and if the finger be then allowed to pass round it, it will be perceived to be of a lengthened shape, and to have been entirely obedient to the force employed to draw it forward. Sect. IV. — 4. TV here opened to the same extent, but soft. 1078. I have just declared an error may be committed by an inexperienced or timid practitioner in this condition of the uterus; and have pointed out the method by which it may be instantly corrected; it therefore behoves him not to neglect to entirely satisfy himself, as to the situation of the os uteri, before he finally makes up his opinion on the proper mode of practice. UNAVOIDABLE HEMORRHAGE. 395 1079. A careless or ill-conducted examination, may in this in- stance lead to the loss of the patient; for, by mistaking the abso- lute diameter of the uterus for Xhe possible, he may delay opera- ting so long, as to render it totally unavailing; for I perfectly agree with Dr. Rigby,* that however important it may be as a general rule, that the uterus must be opened to the size of a shilling, or a half crown, before any attempt is made to introduce the hand; yet if this rule be rigidly enforced, "it would in some cases be attended with danger, as we might wait for the opening till it was too late to relieve the woman by turning; and for this reason it seems right we should be sometimes as much influenced by the os uteri being in a state capable of dilatation without vio- lence, as by its being nearly open."t In my directions for the management of cases in the second condition of the uterus, I noticed this situation of this organ, and remarked that it usually occurred when the woman had flooded to excess — but I have known at least two exceptions to this. Sect. V. — 5. Where fully dilated. 1080. When a case presents itself with this condition of the uterus, there can be no hesitation about the proper mode of pro- ceeding, if the exigencies require instant interference; for in this case all objection is removed to the operation of turning, so far as any mechanical injury to the uterus is to be feared — but this is a rare case; and when it does occur, it seems to happen but under the following circumstances: — 1st. In those women who are wont to have very rapid and very easy labours. 2dly. Where the edge of the placenta extends over the os uteri, and where, in conse- quence of this, the hsemorrhage has not been sufficient to seriously injure the contractile powers of the uterus, though rather profuse. 3dly. Where the pains have been so rapid and powerful, as to suddenly dilate the os uteri, and cause the head to carry the pla- centa some distance before it. 1081. In the first case, (1080) the haemorrhage will be of the most profuse and alarming kind; and if the woman be not very quickly aided, she will most probably die — this happened with the poor woman who died before I got to her assistance — in this situation of things not a moment is to be lost; turning must be in- stantly had recourse to. * Rig-by, p. 42. f 11^'^. P* 43. 396 UNAVOIDABLE H^IMORRHAGE. 1082. In the second instance, the discharge, though perhaps very free, is never so overwhelming as in the first ; for the edge of the placenta may be passed over the os uteri but a small dis- tance; the flooding will of course be in proportion as this may be more or less extensive — in these cases the membranes may even present, rupture spontaneously, and thus save the woman: here the natural agents may accomplish the delivery — but more of this by and by. 1083. In the third case, the flooding will be perhaps, for a pe- riod, as alarming, and for the time of its continuance, as profuse as in the first — but the uterus acting promptly and vigorously, the head of the child is made to press so effectively upon the mouths of the bleeding vessels, as to arrest the haemorrhage.* In this instance we must act according to circumstances; if we see the patient during the time of her profuse flooding, we should not he- sitate a moment to deliver, even though the pains be brisk; for it is entirely contingent that the discharge will be stopped by the intervention of the head. But should we not see the patient until, by the progress of the head, the bleeding is arrested, we should not interfere ; but commit the case to nature. 1084. It has been recommended by some, to rupture the mem- branes, in the expectation of stopping the haemorrhage, as fre- quently happens when the placenta is not fixed at the mouth of the uterus — but this should never be done; especially, before the uterus is well dilated, or easily dilatable, and for the following rea- sons: — 1st. Because they cannot be reached without great diffi- culty, in some instances, and in these cases, when they are reach- ed, it is either by piercing the centre of the mass, or separating a portion of the placenta, and thus increasing the extent of the bleeding surface. 2dly. When they are pierced, and the waters evacuated, it will very rarely stop the haemorrhage. 3dly. When it does not do this, we are sure to have the difliculties of turning increased. 4thly. Should the flooding for the moment cease af- ter the discharge of the waters, it is sure to return as the pains increase, and as the uterus expands. The only exceptions to these rules, are the cases just mentioned above, where the mem- branes present themselves in part. (1082.) 1085. Baudelocque assures us he has seen but one case, where the haemorrhage ceased after the discharge of the waters; and in * Baudelocque, Leroux, 8iC. UNAVOIDABLE HJaMORRHAGE. 397 that case the placenta was first delivered by a midwife, and the head of the child was made to press so firmly on the mouths of the bleeding vessels as to stop the haemorrhage.* 1086. It may be inquired, what plan of relief is to be pursued in placental presentations, when they happen at or near the sixth month? These, when they occur, are truly embarrassing cases; as, for the most part, the uterus is not sufficiently enlarged to ad- mit the hand to turn, and the haemorrhage is sometimes very alarming; the great risk in this situation of things, arises from the want of disposition in the os uteri to dilate; and, before this is accomplished, the woman sometimes succumbs from the unre- stained flow of blood. 1087. But women in this situation, even when unaided, do not necessarily die; nature being now and then competent to the task of delivery. t I may remark, as a general rule, and as a consola- tory circumstance, that nature, if not interrupted, or when the best chance is given her, will almost always effect the expulsion of the ovum, previously to, or soon after the sixth month, without the manual interference of the accoucheur — for the most part, then, in such eases, our attention should be directed to the dimi- nution of the haemorrhage, by such palliatives as we have con- stantly in our power; among these the tampon stands foremost. 1088. This remedy should be employed early in such cases, as it will, by proper management, save a prodigious expenditure of blood; and we gain by its application, important time; time that is essential to the successful delivery of the foetus — for by the tampon the woman's strength is preserved; pain is permitted to increase ; and eventually, though tardily, the os uteri is dilat- ed; the placenta and foetus thrown off; and the flooding almost immediately controlled. Other means should be advised, such as cold applications and the free use of the acetate of lead; but above all, if the uterus be disposed to dilate, the secale cornutum. These may powerfully aid the general intentions, and render the operation of the tampon more certain. 1089. Mauriceau and others attempted the relief of the wo- man by manual exertion under such circumstances ; but I should, neither from the history of their cases, nor my own experience, be tempted to recommend their plan. I am persuaded, that the temporizing mode I have just suggested, is the proper one to pur- * System, Vol. II. pai-. 982. f Rigby, Leroux, &c. 398 UNAVOIDABLE HEMORRHAGE. sue — Leroux long since adopted this method, and I have for many years but trod in his footsteps; and it is but just and proper to add, I have had abundant reason to be satisfied. Besides, in this opinion all the best writers concur. 1090. Dr. Rigby, though by no means confident of the efficacy of the tampon, confesses, in the cases I am now considering, it might be used with propriety. Had he put this plan in execu- tion, I am persuaded he would have been satisfied with its effects, and would unquestionably have prevented his giving the hazard- ous advice, "to wait for relaxation," by permitting the patient to flood, until the collapse almost of death should effect it. 1091. Experience has often convinced me, that the relaxation of the OS tincae, so desirable in the cases I am now considering, will be as certainly achieved by time, as by this excessive expen- diture of blood; and this time may be procured by the iiiter- ruption of the flooding hy \he id^m-^Qu. When we effect this, we assuredly gain a great deal — strength is saved, by saving much blood: and the woman's future safety is almost insured; for as a general rule we may declare, that when no violence is committed upon the uterus by an attempt at forced delivery, the only thing to be apprehended, is the consequences of the haemor- rhage. 1092. When the woman is farther advanced, say at the se- venth month, artificial delivery may most generally be effected,* provided we do not destroy the advantages this more advanced period gives us, by improper treatment; — for instance, by rup- turing the membranes, and the consequent discharge of the waters; this should therefore be especially guarded against. An attention to this point in these cases, is more important than at the full period; notwithstanding the advice of some accoucheurs to the contrary. 1093. It now only remains to describe the mode of effecting the delivery, when it is judged proper it shall be performed. In doing this, we can give only general directions for placing the woman, as we cannot, from extreme weakness, or from other causes, always command the most proper or convenient; it may nevertheless be well when we have a control over circumstances, to point out that which in our opinion is best — that disposition of the woman's body, which will give us the most entire com- * Leroux, Rigby, &.c. UNAVOIDABLE HJEMORRHAGE. 399 mand of the uterus and its contents, will certainly be the most convenient for the accoucheur, and also the safest for the woman, and this position is upon the back ; as has already been directed. (732, &c.) 1094. Many accoucheurs, and especially the British, recom- mend the patient to be placed upon the side ; I have ever found this position less convenient than the one just suggested ; and have therefore always adopted it, where the situation of the wo- man would permit a choice, without injury. The advantages of this position are first, we may employ either hand as may be most convenient to the practitioner, without changing the situation of the patient. Secondly, we always have one hand at liberty to co-operate with the introduced one, by placing it upon the abdo- men. Thirdly, we can pass the hand more readily in the axis of the superior strait, by having the perinaeum free over the edge of the bed. Fourthly, we can regulate the discharge of the liquor amnii, ad libitum, a matter sometimes of great moment.* But it must be remembered, we are never to attempt to procure these advantages by moving the patient, when that movement would be injurious to her: therefore, when she is very weak or faint, we must operate as well as we can in the position we find her; this is sometimes very awkward and inconvenient, but these are of no consideration, when her life, perhaps, is to be put in competition with our ease. For the most part, there is not much to be appre- hended from merely changing the woman from her back, should she be lying upon it, to her side: but a greater change might be very mischievous: we are therefore frequently obliged to do this before we can operate, as it would be almost impossible to turn, when the patient's back and hips are at some distance from the edge of the bed.t 1095. Should circumstances, or choice induce me to deliver from the side, I always give a preference to the left, provided an election can be made. The hips should be drawn near to the * Dr. Ryan,t seems a little surprized at this direction, and asks, "how can this fluid escape, if the wrist or arm fills the vagina?" It cannot, if the arm should literally fill the vagina— but it never does so, strictly, agreeably to my own experience, but what the liquor amnii would escape, if the membranes be pierced near the os uteri. But this precaution is recommended only in the unavoidable haemorrhage. f We must always remember to have pressure made upon the abdomen by a judicious assistant, when we deliver the woman upon the side; as we cannot in this position, as when she is upon her back, perform it ourselves. i Manual of Midwifery, 3d Vol. 400 UNAVOIDABLE HAEMORRHAGE. edge of the bed, and made as salient almost as may be, by the flexion of the body, and the drawing up of the knees. In this position the left hand is to be used, as with the right it would be very difficult to operate, owing to the axis of the superior strait being very much in advance. If, on the right side, the right hand should be employed, and for the reason just stated. 1096. The woman being properly placed, (if in our power;) the hand should be gradually and gently introduced into the va- gina, and then into the mouth of the uterus, separating the pla- centa and membranes from it as it advances towards the, fundus — when arrived there, the membranes should be broken by press- ing firmly against them; but the waters should not be permitted to escape but at our pleasure. 1097. We can command this almost always, as our arm fills up the OS externum, and prevents it passing out — from time to time some is permitted to escape by pressing the arm firmly against one side of the vagina, until a sufficient quantity has been evacuated; the object of this gradual discharge of the waters is at once ob- vious; it prevents the uterus from falling into a state of atony, by its being too suddenly deprived of them. The feet are now to be seized, and the body made to descend by drawing them down to the superior strait. We should now allow a little time for the uterus to contract; when we are assured that it has done so, either by pains declaring themselves by the child advancing farther into the pelvis without our exertion, or by the firm and hardened feel of the uterus through the parietes of the abdomen, vve may most safely proceed to finish the delivery. 1098. But should the woman be very much exhausted before we commence our operations, we should use additional caution in the delivery — it must be very slowly performed, and we should have, at each step of the progress, assurances, if possible, that the uterus has not lost, or rather that it possesses, sufficient contractility to render the completion of the operation eventually safe, if performed with due and necessary care. 1099. We are advised by some, to pierce the placenta by the hand; but this should never be done; especially, as it is impossi- ble to assign one single good reason for the practice, and there are several very strong ones against it. 1st. In attempting this, much important time is lost, as the flooding unabatedly, if not increasingly goes on. 2dly. In this attempt we are obliged to force against the membranes, so as to carry or urge the whole pla- TJNAVOIDABLK H^^iMOitUHAGE. 401 centary mass towards the fundus of the uterus, by which means, the separation of it from the neck is increased, and consequently the flooding augmented. 3dly. When the liand has even pene- trated the cavity of the uterus through the placenta, the hole which is made is no greater than itself; and, consequently, much too small for the ffi^tus to pass through, unless we force an en- largement; and this can only be done by the child during its passage. 4thly. As the hole made by the body of the child is not sufficiently large for the arms and head to pass through at the same time, they will consequently be arrested, and if force be applied to overcome the resistance, it will almost always separate the whole of the placenta from its connection with the uterus,* 5thly. That when this is done, it never fails to increase the dis- charge; besides adding the bulk of the placenta to that of the arms and head of the child. 6thly. When the placenta is pierced, we augment the risk of the child; for in making the opening, we may destroy some of the large umbilical veins, and thus permit the child to die from haemorrhage. t J 7thly. By this method, we in- crease the chance of an atony of the uterus, as the discharge of the liquor amnii is not under due control. Sthly. That it is sometimes impossible to penetrate the placenta; especially when its centre answers to the centre of the os uteri; in this case much time is lost, that may be very important to the woman. § 1100. It is a mistake to suppose we produce a greater separa- tion of the placenta Vy^hen we pass the hand between it and the uterus, than when we pierce the placenta. But if it were true, it would be no objection to the method I advocate, since both uterus and placenta are pretty firmly compressed by the arm in its passage to the fundus, and the bleeding by this means re- strained; and as this is the only objection which is raised against the method recommended, I shall consider it as completely an- swered by what is now said. 1101. Should the placenta not be found entirely detached from the uterus after the birth of the child, we should give a little time for it to separate spontaneously; and we must endeavour to pro- • Baudelocque. -{- Baudelocque. + Dr. Denman confesses, though he recommends the searching- for an edge of the placenta, and penetrating it, that, in performing the latter "there is ra- ther more danger of loosing the chM."—3Iidwifcrt/, Francis's ed. p. 484. § Dr. Rigby admits this, and declares he has "more tlian once found it." p. 64. 51 402 UNAVOIDABLE H^MORRHAGK. mote this by friction upon the abdomen over the uterus, unless the flooding continues to be violent ; it will then be proper to pass up the hand and separate it, for it may be the bulk of the placenta which keeps up the hEemorrhage; by preventing the uterus from closing sufficiently upon the bleeding vessels. 1102. Before I proceed farther, it may be well to inquire into Dr. Rigby's opinion concerning the nature of the uterine vessels, which I am content to call arteries. He says, "the uterine ves- sels differ very materially from arteries, and particularly in hav- ing no such power of contraction within themselves, their con- traction and dilatation being absolutely dependent upon the state of the uterus. In the unimpregnated state they are so small as scarcely to be discovered; but they are well known to increase when the uterus receives the ovum, and to grow in exact pro- portion to its gravidity; and when by the complete distention of it, they have acquired their utmost magnitude, their diameters cannot be lessened until the womb, being again emptied, closes them by the contraction of its whole capacity, and restores them to their original size." 1103. There is no one circumstance in this history that would lead me to reject the idea, that a part of the uterine vessels are arteries, and for the following reasons: 1st, the spermatic and hypogastric arteries furnish the uterus with these vessels; and it is well known that they increase in proportion as gestation ad- vances; consequently, vessels which all agree are arteries, enlarge, and in almost the same degree as those within the substance of the uterus, which are but continuations of them; 2d, no physical difference has ever been discovered between them. 1104. These two circumstances I consider in themselves as conclusive of the identity of the uterine, and the spermatic and hypogastric arteries. If not so, why should these vessels enlarge in proportion to each other? And why should the spermatic and hypogastric arteries contract when delivery has taken place, with- out being dependent for this effect upon the " contraction of the uterus?" Now let us see what would really present itself, were Dr. R.'s opinion substantially true; he declares, in the unim- pregnated state of the uterus, that these vessels " are so small as scarcely to be perceived." Now, how should this happen if they possessed no contractile power within themselves? The mere contraction of the uterus could not alter their real capacity; it could only change their form by strongly compressing them; UNAVOIDABLE HAEMORRHAGE. 403 therefore, if what he supposes were even true, they should con- stantly present to us the shape of flattened cylinders or puckered tubes; but the contrary of all this appears when we cut into the substance of the uterus, for we then find that, though the vessels are '' so small as scarcely to be perceived," yet those we do see, constantly present to us a circular form. 1105. That they do not contract during pregnancy, or imme- diately after delivery, as closely as arteries in many other parts of the body do, I admit; not because they do not possess con- tractibiiity in an equal degree with these, but because they can- not exert it to the same extent, in consequence of their peculiar connection with the general substance of the uterus — they are ever}'^ way surrounded by, and connected with, cellular mem- brane,* which will permit them to lessen themselves but to a cer- tain degree, so long as the muscular fibres of the uterus remain in an uncontracted state, and for this plain reason, that the sum of their power or disposition to shut themselves up, is inferior to the power which keeps them in some measure upon the stretch. But that they do diminish in size to a certain degree, after being ex- posed by a separation of a portion of the placenta during preg- nancy, I have no doubt, as the cellular membrane by which they are surrounded, will from its elasticity,! permit them to do so, and thus contribute to the suppression of haemorrhage. 1106. We must regard the uterus during gestation, as in a state of coercion— every part and portion of it sooner or later is put upon the stretch; consequently, the vessels entering into its sub- stance must enlarge with it, or put the cellular membrane, by which they are surrounded upon the stretch; but as there is a * I am not wishing to be understood, that there is anything peculiar in the uterine arteries being- surrounded with cellular membrane; for this we know obtains wherever there are arteries — I merely wish to insinuate an opinion, that they have positively less freedom than the arteries in the other parts of the bo- dy, by Ijeing more closely tied by their connecting media, and tliat, as I shall immediately say, for very important uses: and that they have relatively less, would appear evident, when we reflect on the immense increase they suffer du- ring gestation; and though they may contract very considerably, yet it may be insufficient to stop their bleeding without the co-operating contraction of the muscular fibres, for the reason I shall presently assign. Levret makes the pro- portion of the unlmpregnated uterus, to that of the impregnated, to be as eleven and a half to one. Now, if the arteries augment, (as it is reasonable to suppose they do,) in the same proportion, it will be seen how much their calibers must be reduced, before their contraction alone can stoj) haemorrhage. I Bichat, Anatom. Gen. 404 UNAVOIBABLE HiEMORRHAGE, most important intention to be fulfilled by their enlargement,they are found to augment in a ratio correspondent to the distention of the uterus; and they are not only made to yield in proportion to the increased demand for blood; but are also kept in that state by its constant influx, to supply the exigencies of the uterus in a state of gravidity. 1107. This condition of the uterine vessels, then, has two causes contributing to the same end — namely, the unfolding and separa- ting of the fibres constituting the proper substance of this organ, and the constantly increasing tide of blood which flows within it: the first, if it does not directly administer to the enlargement of these vessels, will, to a certain extent, favour it, by taking off that restraint which a state of contraction imposes upon them, and thus make them more certainly obedient to the impulses of the spermatics and hypogastrics — the vis a tergo, of these vessels, may be considered as essentially contributing to their distention. Hence we can no longer recognize the almost imperceptible ves- sels of the unimpregnated, in the large canals, if we may so term them, in the advanced impregnated uterus. 1108. Let us now suppose the supply to the uterine vessels to be cut off by any means whatever, and we make a section of the uterus near, or at the full time of gestation, and while yet' occu- pied by the ovum — what will this section discover to us? One of two things certainly — either the vessels small and contracted, or still patulus and large. If in the first situation, Dr. Rigby's opin- ion of their nature, is at once proved to be unfounded; if in the latter, will it not confirm the notion I entertain, that they are kept in this situation by force, as above suggested? (1105) If this be true, will not the same cause produce the same effect, when the uterus is emptied of its contents, but remains in a flaccid and uncontracted state? And will not the same consequences follow from tlie same cause in both instances, namely, a discharge of blood from the separation of the whole, or a part of the placenta?* * I might also insist, that, should tlie uterine vessels be found large and pat- ulous when the flaccid uterus was cut into, that it would not confii-m Dr. R. 's ophiion, should the explanation just offered be admitted; as it might be a rea- sonable conjecture to suppose that a cause capable of producing an atony of the muscular fibres of the uterus, might also be capable of rendering- the uterine ai-teries passive; and consequently, this uncontracted condition of them would tend to prove that this was really the case, rather than that they had been en- dowed with the power of self-diminution. UNAVOIDABLE H^.MORRIIAGE. 405 1109. If these statements be true, (and I sincerely believe them to be substantially correct,) it will follow, that the uterine arteries cannot contract sufficiently to stop haemorrhage, however emi- nently they may possess contractibilit}^, so long as the muscular fibres of the uterus are in an uncontracted state; because their pe- culiar connexion with them, will necessarily prevent it — and far- ther, I believe, that this kind of union highly contributes to the safety of the patient, after the expulsion of the foetus, by enabling it, or perhaps I may say inducing it to contract, to throw off the placenta, and prevent after hsemorrhage, 1110. They perform this valuable end by lessening themselves, and obliging, in a certain degree, the muscular fibres to follow them — and this contraction proves an extensive and congenial stimulus, and is, for the most part successfully exerted to this end — but, should the muscular fibres of the uterus be indisposed, or unable, from the operation of any suflicient cause to manifest a contractile power, haemorrhage must necessarily ensue. For the arterial extremities, which are exposed by the separation of the placenta, will and must remain open, not because they do not possess the faculty of contraction, but because it cannot be suc- cessfully exerted, for the reasons I have already assigned — there- fore, that haemorrhage may cease, it is necessary to ensure the co-operation of the contractile fibres of the uterus,- and to make them obedient to this end, is the great aim of all our exertions. 1111. From a review of the inquiry I have just made, it will be evident, that as far as regards effects, there is but little differ- ence between Dr. Rigby and myself; but much, as regards struc- ture and function — my object, in this attempt, is the removal of error, and not the expectation of any great practical advantage, though I am persuaded some benefit may be derived from these considerations, in the cure of haemorrhages of this kind — for, upon the notion of the uncontractibility of the uterine arteries, Dr. R. condemns the use of that class of medicines called astringents; and from the use of which, I have frequently found advantage; for the sugar of lead must be admitted to be an astringent; and in cases of flooding, one of no conimon power — in the modus ope- randi of this medicine I may be mistaken, but I cannot be in its effects. There may be many other substances belonging to this class which may be equally, or even more efficacious upon trial; but we shall be deterred from employing them if we subscribe to the opinion of Dr. Rigby, that the uterine arteries, " cannot contract of themselves. " 406 UNAVOIDABLE HEMORRHAGE. 1112. The unavoidable, and haemorrhage after the birth of the child, are every way so interesting from their frequency, and danger, that we feel ourselves justified in offering every novel suggestion that presents itself to our reading, or to our observa- tion. We do this for two reasons; first, to put our readers in pos- session of the viewsof other practitioners; and secondly, that we may have an opportunity to offer our remarks upon the opinions, and suggestions of others, when such suggestions do not appear to us either very practicable, or very useful. With these objects in view, we shall relate what we have collected since the second edition of this work went to press, upon these important points. ^' Jl Case of Fatal Hsemorrhage at the seventh month of Utero- gestation, from the placenta being placed over the mouth of the Uterus, together with remarks upon it, and several other modes of treating Uterine Hsemorrhage. " 1113. In this case it is stated that the patient lost three pints ofblood; she became faint: pulseninety and firm; os uteri admit- ted the point of tlie finger, but nothing unusual could be discover- ed. Rest, cold, opium, and sulphuric acid, were prescribed. Pro- fuse hfcrnorrhage followed after some hours, probably eight, as the medicines were directed every four hours, and it was after the third dose a profuse haemorrhage followed. But before Dr. James, the narrator, could arrive, the woman was in a dying state. 1114. Finding a large portion of the placenta in the vagina, and the os uteri fully dilated, he endeavoured to thrust his finger through the weakest edge of the placenta; but failing in this at- tempt, he perforated the centre of this mass, seized the feet of the child, and brought them into the vagina. A pain came on, but was not repeated; and as haemorrhage followed, the child was ex- tracted by mechanical means. Contraction of the uterus was so- licited by the introduction of the hand; pressure was made upon the abdominal aorta to lessen the extent of the heart's circulation, but all to no purpose. '' Life was gone."* 1115. The history of this case gives rise to the following sug- gestions. First. It appears extraordinary, that " nothing unusual could be discovered by the touch;" or, in other words, that the placenta could not be detected upon examination, as the os uteri * North Amer. Med. and Sm-g. Journ. No. 5, p. 203, from the Lond. Med. Kep. for September, 1826. i UNAVOIDABLE HiEMORRHAGE. 407 admitted the point of the finger; especially, as this mass must have been within reach, if a search had been made, as I have recom- mended, (1026) by the introduction of the hand into the vagina, instead of the finger alone. It may therefore be proper to insist again upon this being done, whenever the degree of flooding ren- ders it desirable to determine whether the hasmorrhage be of the accidental, or of the unavoidable kind; and this must be the case always when the discharge is very profuse. 1116. Second. That a patient, who had lost " three pints of blood," and was" faint," should be trusted to the powers of opium, acids, &c. and the practitioner to feel so much confidence in them, as to leave her for eight hours to their sole influence. In this case the patient should have been narrovsdy watched, and the tampon should have been introduced. (1071.) 1117. Third. It is evident from the statement that artificial de- livery could have been performed, most probably, a long time before it was, as upon the return of Dr. James, '«a large portion of the placenta was found protruding through a fully dilated os uteri;" consequently, precious time was unnecessarily lost, and the danger of the patient augmented. Ills. Fourth. That the efforts of the practitioner to procure the contraction of the uterus should not have been confined to the in- troduction of the hand alone. Brisk frictions should have been made upon the abdominal parietes; and the ergot, or sugar of lead, should have been given, before any attempt was made to deliver the child; nor should time liave been lost in the attempt to pierce any portion or part of the placenta; the hand should have been immediately passed between the uterus and the membranes; the latter of which, would have been easily broken, and this witliout the loss of a moment of time. 1119. Fifth. No kind of reliance can be placed upon the at- tempt to diminish the "extent of the heart's circulation," by pressing the aorta; for the tonic contraction of the uterus is alto- gether independent of the general or local circulation of the blood. Besides we do not think it possible to obliterate this enormous vessel by any means yet contrived; the pressure of the hand is certainly incompetent to such an effect; and if more rude means be employed, the parts interposing between the compressing power and spine may suffer severely — the attempt moreover, is but losing precious time. But let us suppose, that the circulation in the aorta is temporarily suspended; will this secure the patient 408 UNAVOIDABLE HEMORRHAGE. against the renewal of the flooding when the pressure is removed? Certainly it will not; unless the uterus has spontaneously con- tracted ; and if it be contracted, there can be no necessity for pressure upon the aorta. 1120. It may, however, be said that we may gain time by this plan, and thus give a greater opportunity for the uterus to con- tract. This is vastly more specious than solid, for by directing our attention to the pressure upon the aorta, we prevent the em- ployment of friction upon the abdomen, which is much more im- portant. Besides, the uterus is always found in such cases in one of two conditions; namely, either entirely flaccid, or very par- tially contracted. If in the first, it must be included between the means employed for the external pressure, and the spine; con- sequently, it may be severely injured by a force that is equal to stopping the circulation in the aorta. If in the second, it will be found, that no force, which can be safely applied, will compress the aorta successfully, through the abdominal and uterine pa- rietes; for it must be borne in mind, that the uterus in either of the supposed cases, will be above the umbilicus; and consequently will interfere with the attempt at pressure. 1121. With the same object in view. Dr. James also recom- mends the use of tourniquets to the extremities; we fear this plan, like the one just noticed, will be found equally unavailing, even supposing the proper instruments to be at hand. Of a simi- lar character is the proposal of Dr. Mojon to throw into the um- bilical vein, after having expressed from it as much of the blood it contains as is practicable, as great a quantity of acidulated water as it will receive by means of a syringe. He declares this to have succeeded: and requests others to repeat it. He says it required to be pushed with both force and promptitude. He thinks that the sensation of cold which the uterus perceives when cold liquor is injected, favourably promotes the separation of the placenta.* 1122. The notice we have of this new method of relieving the placenta in cases of hcemorrhagy is very imperfect ; for we are not informed of the condition of the uterus previously to the in- jection of the acidulated water; whether it was in a slate of in- ertia; or whether it was owing to an unusual obstinacy of adhe- sion; or whether any attempt had been previously made to ar- * Revue Medicate, &c. for June, 1826, p. 502. UNAVOIDABLE HiEMOKRHAGE. 409 rest tiie discharge, and it had failed. For we must declare, that merely to save the introduction of the hand, as he avows, is hy no means sufficient to seduce a well-instructed accoucheur to depart from a method which has been successful for centuries, and which, in general, is not attended by either difficulty or dan- ger. Besides, it may well be questioned,whether the liquid em- ployed by Dr. Mojon had any agency in relieving the placenta from its adhesion; as we well know that this mass is often very suddenly thrown off without any interference. Moreover it can only be useful in such cases, (if it ever be useful,) as are attended with a jxirtial sejuiration of the placenta;* a condition, we are bold to say, neither Dr. Mojon or any other man, can determine with certainty without the introduction of the hand if it be essen- tial that this point shall be determined ; and if this be necessary, as we believe it would Ix;, the hand had much better perform its duty, while it has possession of the uterine cavity, than to be withdrawn to aid in the injection of a cold acidulated water. 1123. Again, all the pains just noticed, necessarily suppose, that all the mechanical agents necessary to fulfd the indica- tions, (and we see these are sufficiently varied,) are at hand, and can be called into requisition, sur le chamjj; for these cases admit of no delay when extreme; and it is only when extreme, that they are proposed, or can be proper ; were these methods to be adopt- ed into general practice, it would require constantly a serious load of metal for the poor accoucheur to cai'ry into the bed-room of his patient,t or run the risk of losing his patient, if these are the only means to be relied on. 1124. We should place also under the same ban, the lately re- ne\yed expedient of " transfusion." We do not hesitate to credit the accounts of women not dying when this scheme has been re- sorted to; but we very much doubt whether the patient would have died had it been withheld. We believe this principally on the following grounds: — first, because women bear excessive * The reason of tliis is at once obvious; for should the placenta be separat- ed altogether, the liquid cannot be so applied to the uterine surface, as to make this organ perceive the impression of cold, and induce it to contract. Besides, it seems admitted, that it is by the uterus perceiving u sensation of cold, that it is induced to contract; now it is well known that this can be accomphshed in a much more simple plan; namely, by applying cold water or ice to tlie abdo- men, or introducing the latter into the cavity of the organ. t Dr. Slop's bag would have been very much too small, ample as it was, for so much ingenious machinery. 52 410 UNAVOIDABLE HEMORRHAGE, losses of blood without death following ; second, because the quan- tity of blood transmitted to the alien veins does not appear suffi- cient to prevent death, since but a very few ounces have been declared to answer; third, because the additional quantity of blood, though it increases by so much the stock of the patient, it does not necessarily or contingently promote the tonic contrac- tion of the uterus, without which, all " appliances and means to boot," will be found unavailing; fourth, because we have never yet met with a case in which the dormant powers of the uterus could not be roused into successful action, if means were timely employed; were of a suitable kind; and were proper!)' applied. All these plans appear to us to savour too much of the improve- ments of Sir Abel Handy.* 1125. The cases related by Mr. Waller, are as strongly mark- ed as any perhaps that have met the public eye; yet to us they are by no means conclusive. We can find in Rigby, Leroux, La Motte, JNIauriceau, «Scc. &e. cases equally formidable, where recoveries took place without this means. And if we dared to enforce the above opinion by observations of our own, we could certainly relate a number of cases, where the subjects of them were reduced to as great extremity as those furnished by Mr. W'aller — we shall however only refer to the one related in a sub- sequent part of this article; though many equally formidable, and equally successful, could be furnished. 1126. There appears to be excited, at the present time, a pas- sion for novelty in the treatment of uterine haemorrhage; but no remedy or means that has hitherto reached our knowledge, ap- pears to have any decided efficacy in themselves, in arresting this discharge. Both thei'apeutical and mechanical agents are anx- iously sought after; and each inventor of a new mode of fulfilling an old, and never to be deserted principle, vaunts his supposed improvement with a confidence that almost bids defiance to scep- * Handy, Jr. demands, after Sir Abel has set the house on fire by his expe- viiTieiits, " Wliat is to be done? Where's your famous preparation for extin- guishing flames?" " Sir Abel. It is not mixed." "Handy, Jr. Where's your fire escape?" " Sir Abel. It IS not fixed." "Handy, Jr. Where's yom- fire engine?" "Sir Mel. 'Tis on the road." — {Speed the plough.) UNAVOIDAKLF, HiRMOnnHAOE. 411 ticism, until trial is made of its boasted powers — it is then found to have no superiority over the remedial agents already known, and heretofore relied upon. In all these attempts it appears to be forgotten, that the only indication in a threatening haemorrhage after the delivery of the child, is to procure the tonic contraction of the uterus; yet, some of the means had recourse to, are but ill calculated for this end. Of this kind, is " transfusion;" the " fdl- ing of the uterus with rags;" " the compression of the aorta;" ''injecting the umbilical vein," &c. &c. And the therapeutical means, such as the introduction of vinegar, or the acid of lemons, have no other power perhaps upon the flaccid uterus, than as a kind of vehicle to the mechanical agents, if we may so express it; and a variety of these can unquestionably be employed with at least equal success without their assistance. Yet we hold it pro- per to lay before the inexperienced practitioner all the means which have of late challenged the attention of the medical pub- lic. Therefore, with this impression upon us, we shall relate several other schemes, on which the changes have been rung with much complacency in our various periodical Journals. 1127. Messrs. Gorat, Evrat, &c. propose the immediate appli- cation of the citric aid to the internal surface of the uterus, with a view to arrest haemorrhage after delivery. They describe this method in the following terms: they strip a lemon of its skin, and having cut one end of it, they carry it into the uterus, and then express the juice on the sides of the cavity. They allow the decorticated lemon to remain, until the irritation produced by the juice, and this foreign body, excites the uterus to contraction which, constringing the tissue of that organ, stops the hemor- rhage, and the lemon is expelled with the coagulum formed about it.* 112S. This is one of the late improvements in the treatment of this formidable complaint, and to which we have just alluded. It will be in most instances, in this country at least, in the same predicament as several of the means we have already noticed — rarely at hand when required. It will also be seen, that from the mode of its application it acts but as a mechanical stimulant upon the uterus; and we are disposed to believe in no manner superior, or more certain than the naked hand, so very many * Anderson's Quarterly Journal, Vol. II. No. VI. p. 298. Revue Medicate &.C. &c. &c. 412 UNAVOIDABLE HJEMORRHAGE. years recommentled. For in an hremorrliage that would require manual interference, Ave are of opinion that the small quantity of acid which could be expressed within the uterus, would be so ef- fectually and suddenly diluted by influent blood, as to render its powers altogether nugatory. Now we know from experience, that the very presence of a foreign body within the cavity of the uterus, and this passed perhaps even somewhat rudely over its surface, will cause it to contract, and thus arrest the discharge; and this mechanical influence has been acknowledged for more than a century. For we perfectly disclaim all efiects from the acid; and for the reason just stated:* and we cannot but regard the suggestion of M. Gorat, &c. as one of those determined at- tempts at novelty which a little subsequent experience will cure. 1129, A woman aged thirty -two, was taken in labour with her first child, on the 12th of February, 1825. The pains soon ceased, and on the 15th, M. Bedel, physician at Schirmack, was consult- ed, who speedily delivered her with the forceps of a dead child. The haemorrhage was so considerable as to render the immediate removal of the placenta necessary; but the uterus did not con- tract, and the bleeding continued, together with tremblings, syn- cope, cold sweats, &c- Irritation on the internal surface of the uterus, cold water to the abdomen, injections into the uterus of cold water and vinegar, were unavailing. 1130. Plugging the vagina, and also the uterus, were now re- sorted to, as the only remaining means of safety. The uterus was filled with pieces of rags, for fear the patient could not sus- tain the loss of blood necessary to fill the cavity; while a methodic compression was at the same time made upon the abdomen. The * In addition to what we have urged above, against the agency of the acid producing any effect from its own properties, it may be added, that in such hse- morrhages as occur before the entire separation of the placenta, the whole, or very near the whole, of the internal surface of the uterus, is still lined by the membranes; and consequently the acid cannot be placed in contact with the uterine fibre: therefore, if any effect follow the introduction of the lemon under such cu-cunistanccs, it must proceed from its mechanical irritation, aided by that of the hand. Besides, the author of this method of treating uterine haemori'hage, lays stress upon the sudden ejection of the citric acid by the pressui-e of the hand; but Chaussier tells us, in pressing a lemon cut as directed, and squeezed very tightly, it will not throw out its liquor in streams as stated by the inven- tor. At all events, it is no improvement upon tlie sponge and strong vinegar, Jong since recommended for the same purpose. UNAVOIDABLE HiEMORKHAGE. 413 haemorrhnge was immediately arrested, and soon after reaction ensued. 1131. On the 16th, JNIr. Bedel removed the plugs from the ute- rus cautiously and successively : and had the pleasure to find the ute- rus to contract regularly after each removal. The lochial discharge continued: but there was no secretion of milk. The patient re- covered slowly.* 1132. This is another instance of attempting to arrest an alarm- ing uterine haemorrhage in a new way ; but it more strong- ly recommends itself to us than some others, from its having suc- ceeded in the instance in which it was tried, and from the sim- plicity of its plan, and the certainty of the materials to operate with being almost always at hand. But we cannot help feeling surprised, that we do not find an instance, among those we have recorded, in Vv'hich well-directed and properly continued fric- tions over the region of the uterus have been instituted; a means, which has ever, in our hands, proved certain in restoring the lost energy of the uterus. Nor is there any case related, within our knowledge, out of this country, in which the acetate of lead has been given in proper doses; nor in which the ergot had been recoursed to, until very lately, though the success of these drugs in uterine haemorrhage have been frequently proclaimed in the periodical journals of this country for at least the last eight years. 1133. Nor are we less surprised at the misapprehension, which almost constantly seems to prevail, as regards the use of the tam- pon in the cases under consideration; for it is to the ill-timed application of this remedy, that we must attach its want of suc- cess. Leroux does not propose this plan as certain of success in floodings which follow the expulsion of the placenta; though he declares he has succeeded sometimes with it in such cases. Its great value is in floodings before impregnation; before the uterus is emptied, when it is impregnated; and when this organ will contract, after labouj- is terminated. 1134. In entering upon this part of our subject, it will be im- portant to the consideration, that we say a few words upon the changes effected in the uterus itself, by the delivery of the child, and the expulsion of the placenta. • Bulletin Universal, for January, 1826, from the Gazette de Sante, for De- cember, 1825. 414 UNAVOIDABLE HiRMORRIIAGE. 1135. I regard the uterus as a hollow muscle; and, like the other hollow muscles, has no separate or independent antago- nizing form; but has, like them, a compensating one, arising from its own organization or structure;* and also, like all the muscles of this kind, when not distended by some distracting force, will contract by virtue of some power of its own, and upon the healthy disposition of this kind in the uterus does the wel- fare of the woman depend, in every instance of child-birth or abortion. 1136. I shall not stop to inquire, as its consideration is not im- mediately involved in the present investigation, whether this is a legitimate muscular contraction, or the exertion of that power, common to many organic, as well as inorganic substances, termed elasticity. My own opinion, however, is decidedly made up, that the efforts the uterus makes to expel its contents, and to close it- self after it has performed this office, is by virtue of a genuine muscular contraction. 1137. In the performances of these offices, two distinct powers are concerned. One shows itself by a constant disposition to lessen the cavity of the uterus, whenever it may be put upon the stretch; or at least, whenever the cause is removed, that placed it in that condition. The other declares itself by alternate contrajction, which is, perhaps, only an exalted degree of the same power, • I say, that the uterus has, like the heart, and perhaps all other hollow mus- cles, an antagonizing power within itself, and this by its own organization. I shall attempt to pro^e this, by stating, that in consequence of that contraction, which we call the alternate contraction of the uterus, having taken place, a considera- ble portion of the blood which at that moment occupied the uterus, is driven quaqud versum into the general system; a facility for which is derived from the frequent anastomoses of the arteries and veins, and by the latter not having valves. This is pi-oved by the diminished thickness of the uterine parietes, and by the whole surface of this organ becoming paler at the moment of contraction. This state of things continues until tliis effort has ceased — so soon as this hap- pens, (which may be longer or shorter, according to the power wliich governs the contraction, and the state perhaps of the musciJar fibres of the uterus itself,) the vessels which had just been deprived of a portion of their contents by the contraction, will at the moment of relaxation be but imperfectly filled, and even a genuine vacuum may be induced; but, so soon as the restraint imposed upon the whole of the uterine vessels by this contraction is taken off; the blood will instantly rush into them, to restore the disturbed equilibrium, and thus again distend these vessels; which distention will prove a stimidus to the uterine fi- bres, and thus induce a new conti-action : and in this way would I account for 'the alternate pains of labour. UNAVOIDABLE IliEMOUKHAGE. 415 when urged by stimuli, as in child-birth, abortion, or from any other circumstances which may require its interference, to expel a foreign body from its cavity. 1138. The first of the powers just noticed, has been termed " tonic contraction;" and the second "spasmodic contraction," from its being usually, though not necessarily, attended with pain. This Tatter, it must be remembered, cannot take place without the former having preceded it: though the former can happen without the latter.* (251, 252.) 1139. Now the economy of the uterus, in its healthy condition is such, that it immediately exerts its tonic force to close upon, and to accommodate itself to the exact size and shape of such contents — thus, soon as the liquor amnii is discharged, the ute- rus instantly diminishes its size, by virtue of this tonic power, and this in the exact proportion to the quantity of water displaced; and so plastic is this power, that it makes the parietes of the ute- rus assume the inequalities presented by the surface of the child; and, when the child is delivered, it reduces itself so much as to compress the placenta, and force it from its attachment; and eventually expels it from its cavity; when this is achieved, it goes on reducing itself, until it interrupts, in a great measure, the sup- ply of blood from the spcrmatics and hjqiogastrics; closes almost completely the mouths of the vessels exposed by a separation of the placenta, and thus prevents any inordinate flow of blood. 1140. From this it appears, that the safety of the woman de- pends almost entirely upon the healthy exercise of the power just termed the "tonic contraction;" and on the contrary, that the risk she may run in giving birth to her child, is in exact propor- tion to the diminished force of this power; of course, the prevent- ing and stopping of floodings, will depend upon recalling it when absent, or upon augmenting it when deficient. 1141. The tonic power of the uterus may be feeble, or altogether wanting — it may be lost in every portion of the uterus, or only in a part; thus the fundus may possess it, and it may be absent from the body and neck; this may give rise to the diversion of the ute- rus — the fundus and neck may be deprived of it, while the body may enjoy it — this may occasion the hour-glass contraction; the body and fundus may be exhausted of it, while the neck retains * See Essay on the means of lessening- pain in certain cases of labour, &c. by the author. 416 HEMORRHAGE, REFORE it — this may produce the concealed hremorrhage. The body and fundus may be firmly contracted, while the neck of the uterus may be flaccid — this may occasion flooding, if the placenta has been attacked in that vicinity. Sect. VL — 6. Causes of Uterine Inertia. 1142. The remote causes of uterine inertia are said by Leroux and others to be — 1st. A general morbid condition of the body, as tendency to scurvy, &c. 2d. Long illness. 3d, A depraved condi- tion of the circulating mass. 4th. Unusual laxity of fibre, as in leucophlegmatic habits, &c. 5th. Over-distention, from an excess of liquor amnii. Gth. Strong emotions or passions of the mind. 7th. A long protracted labour. 8th. A previous haemorrhage. 9th. Le- sions in the proper substance of the uterus itself 1143. But the condition of the tonic power is far from being always regulated by the contingent situation of the general sys- tem; we cannot infer its absence from the debilitated state of the body at large; nor can we calculate upon its presence with cer- tainty, because every other function is carried on vigorously — this is a fact well known to every practical accoucher, and should teach us this highly important caution; to act as if this power were, or easily might be expended, and to consider no woman safe from the casualty of its exhaustion, until we are assured to the contrary by a careful examination. 1 1 44. Fortunately for the patient, as well as for the practitioner, this power, when weakened, nay, even to excess, may almost al- ways be recalled by proper means, and is almost certainly obe- dient to the judicious use of appropriate stimuli; but upon the time and manner of this application much will be shown presently. Sect. VII. — 7. Of Hxmorr/iagc before the Plnecnta is expelled. 1145. We are now to consider hajmorrhage as it may occur, before the placenta is expelled. It must be recollected that a flooding cannot happen, but when the placenta is in part, or wholly separated from the uterus; and that this separation has been efiected in the cases we arc now to speak of, by uterine contraction; unless a sufficiently powerful mechanical cause had been previously offered. For so long as the placenta preserves its continuity entire with the uterus, no flooding can ensue, THE PLACENTA IS EXPELLED. 417 should this viscus be even in a stale of complete atOny or exhaus- tion.* 1146. As there is considerable variety in these cases, it will be well for the sake of perspicuity to consider them under the fol- lowing heads: a. 1st. Where there is a partial separation of the placenta, but the uterus enjoying some tonic power. b. 2d. Where there is a partial separation, but the uterus pos- sessing very little or no tonic power. c. 3d. Where there is a partial separation of the placenta, while the remaining portion is too adherent, and the uterus con- tracts but feebly. * Unless some mechanical violence has been done to the uterus, either from external impression, or from some incautious manoeuvre performed within its cavit}^, as in the act of turning-, or tlie injudicious use of instruments, the placenta will preserve its connection with the uterus until disturbed by uterine contrac- tions; and consequently there will be an exemption from flooding, until this takes place; but this connection may be destroyed in a moment, by the causes just stated, aud an hemorrhage as quickly follow. Since writing the above note, an interesting case has occurred, which com- pletely proves my position. Mrs. , on the 23d of March, 1823, was taken, at her full period, with slight pains, and the other marks of approaching labour. Soon after these had manifested themselves, she was seized with violent vomit- ing', and considerble hemorrhage: there was an almost constant effort in the uterus to throw off its contents, togetlier with an occasional increase of pain. I was now sent for, and found the patient as above stated. The vomiting re- turned from time to time; and whenever it did so, there was an Increase of the heemorrhage; and tliis also occurred when the alternate pains were on, which gave rise to a suspicion that it was a placental presentation. I ordered the pa- tient to her bed; and upon examination, the membranes were found protruding, and the child rapidly advancing. I ruptured the membranes immediately, and the hemori-hage- was instantly suspended: in a few minutes more the child was expeUed, but still-born, Tiie navel-string was cut, but not a di"op of blood is- sued from either portion of it. Every effort was unavaillngly made to resusci- tate the child. The placenta was found loose in the vagina, and, upon examin- ing its surface, it was found covered over its whole extent, witli a thin black co- agulum; an evidence it had been entirely separated, and the child made to perish in consequence. The uterus appeai-ed to contract well, and everything was promising, for an hoiu"; at the expiration of this time, the uterus relaxed, and a profuse discharge instantly took place. When I arrived, (for I had taken my leave,) tlie patient was very faint, extremely sick at stomach, and very restless, wliich necessarily augmented the discharge. I immediately commenc- ed pretty brisk frictions upon the abdomen — the uterus soon contracted, and did not again relax. Two grains of opium were ordered every two hours, until the patient should become tranquil. On the following morning she was found much recruited, and had no unpleasant symptom afterwai-ds. 53 418 HiEMORRHAGE, BEFORE d. 4th. Where everything is as -at 3d, except that the uterus enjoys its full power. e, 5th. Where there is an entire or partial separation, but the uterus in a state of exhaustion or syncope. /.' 6th. Where there is either a partial or complete separation of the placenta, and where the body and fundus are in a state of inertia; while the neck enjoys its tonic power. a. I. — Where, there is a partial separatioji of the Placenta, but the Uterus enjoying some tonic j)Ower. 1147. In this case the last efforts of the uterus to expel the child may have occasioned a partial separation of the placenta, and of course there will be a greater or less discharge of blood: 1st. As the exposed surface may be large or small. 2d. As the contractile power of this organ may be more or less perfect. 3d. As the circulation of the blood may be more or less hurried. 1148. In almost every instance after the birth of the child, we find a quantity of blood issue from the vagina; but the young practitioner must not look upon this as an hemorrhage, unless it continue some time and has an evident effect upon the pulse.* In this case, he is immediately to attempt to arrest it, by solicit- ing an inci-eased contraction of the uterus, by pretty briskly passing his hand over the region of the uterus, and from time to time attempting, as it were, to grasp the uterus by closing his fingers upon it. 1149. By proceeding in this manner, he will almost instantly find the uterus harden under his hand; a coagulum of a greater or less size will escape from the os externum; a slight pain may- come on, and the placenta may be thrown down into the vagina. When this contraction takes place, as it almost alwaj-s does, when the woman has not been too much exhausted either by a long-protracted labour, or by disease, the discharge of blood is quickly put a stop to; the uterus diminishes much in size, and retires almost within the pelvic cavity, while the placenta is en- * Some women will bear a much greater loss of blood than others; and, therefore, we are to decide upon the propriety of interference, from the effect which tills loss has upon the system, ratlier than from the quantity which has been expended. If w"e do iiot attend to this rule, we shall interfere unneces- sarily where the powers of the system are everyway competent to the ex- igencies; and in other cases we may delay assistance so long as to render it unavailing. THE PLACENTA IS EXPELLED. 419 tirely detached from the uterus, or it may even be expelled from the vagina. This is, perhaps, the most simple case of flooding that can occur, and I believe it never requires any other manage- ment than frictions upon the abdomen; its termination may not always be so sudden as I have now stated, but it is sure to take place in a very short time, and as fortunately as I have described it to do. b. II. — Where there is a partial separation, but the Uterus 2J0ssessing very little or no tonic jjower. 1150. In this case, the same cause may produce the same ef- fects as in I. : but the uterus may be in a very different condition; here there will not only be a discharge of blood in proportion to the surface exposed by the separation ofthe placenta and the state of the circulation, but also a continuance of it, commensu- rate with the atonic condition of the uterus. 1151. This state may continue for a longer or a shorter time according to the force of the remote cause which induced the atonic state ofthe uterus, or as it may be of easy, or of difficult removal. 1152. In this, like every other case of flooding at this period, we should endeavour as quickly as possible, 1st. To remove the cause which induced the atonic state of the uterus, wherever it is evident and practicable. 2d. To excite, as soon as may be, uterine contraction. It will be readily perceived, that we can- not control some of the remote causes of inertia just enumera- ted, and therefore, our chief attention should be directed to the fulfdment of the second; and this should be immediately attempt- ed by frictions upon the abdomen, as above directed. On fric- tions I have the greatest reliance; and I never fail to employ them, with a view to promote contraction, whether there be haemorrhage or not, provided the uterine globe be not felt firm upon the application of the hand to the abdomen immediately after the child is removed from the mother; and wben there is a flooding, I chiefly rely upon them, to restore the energy of the uterus; and in this I never have been disappointed — its in- fluence is as prompt as it is efficacious; indeed, I consider fric- tions as indispensable, let whatever other means be emploj^cd. 1153. I have never had the misfortune to meet with a uterus that w^as altogether insensible to this mechanical stimulus; nor to lose a patient from the immediate loss of blood; and I can with 420 HiEMORRHAGE, BEFORE great truth affirm, that this simple plan has constantly appeared to me to be the chief agent in arresting the most formidable flood- ings of the kind I am now considering. The external face of the uterus, when acted upon by the hand through the abdomnial parietes, appears to me to be equally sensible to stimuli of the mechanical kind, as ^he internal surface; and it certainly offers facilities and advantages that the cavity does not: — 1st. It is always accessible to be acted upon ; 2d. No risk is run by very freely stimulating it with the extremities of the fingers ; 3d. It excites very little, or no pain, if judiciously managed; 4th. No fear is to be apprehended of increasing the discharge, which is not always the case, when the hand is employed within the uterine cavity ; 5th. No danger of inducing inflammation or other injury as may happen by the introduction of the hand. 1154. The attempt to arrest haemorrhage, by reviving the powers of the uterus is not new — it was long since recommended by a Mons. Basse* an accoucheur of Paris, whose method, though I do not exactly follow it, I will give in his own words. " II ne faut que porter les deux mains sur la region hypogastrique, et comprimer mollement le corps de la matrice par un mouvement tantot circulaire, tantfit de droite a gauche, de gauche a droite, de haut en has et de has en haut. Tons ces differens mouvemens sont absolument necessaires, a cause des differens plans de fibres que s'entrecroisent et forment une espece de reseau." 1155. I have just observed, that I do not exactly follow his method ; though the effect is precisely the same — one hand is all that is necessary, or that can be conveniently employed; and if this be industriously and properly used, I am persuaded that it will rarely fail. I must, however, in justice to myself declare, I was in the habit of employing this method long before I was aware it had been previously recommended by M. Dasse. 1156. When we have adopted this method we are to take care we do not abandon it too soon ; for it is not sufficient that we pro- cure the contraction of the uterus; we must maintain it in this condition for some time, and this by the continuance of the fric- tion. And I would at this time caution the inexperienced prac- titioner, against a very natural cause of alarm; when almost at the instant he feels the uterus hardening and diminishing under his hand, he hears very distinctly a considerable discharge of coa- * Joui-nal des Savan's d'Aout, 1792, p. 47'4. THE PLACENTA IS EXPELLED. 421 gula and fluid pass from the vagina; and at the same moment he finds the uterus retiring as it were from under his hand. 1157. This discharge is but the effect of the contraction induc- ed by his manoeuvres upon the external surface of the uterus, and must be regarded as a favourable omen, as it assures us that the uterus is about to regain its powers. Perseverance is now all-im- portant; the frictions are to be continued until he has sufficient evidence of the permanency of the contraction, by noting that the uterus no longer relaxes itself, as it did most probably at the com- mencement of his operations. 1158. Should this plan, however, not succeed in detaching the placenta, and stopping the flooding, we are, secondl3'-,.to deliver the placenta by the introduction of the hand within the cavity of the uterus, as this mass must now be considered as the cause of the continuance of the hsemorrhage, by preventing the uterus from contracting sufficiently to shut up the mouths of the bleeding ves- sels. It will be found either partially or entirely detached ; if in the first condition, we insinuate carefully the fingers behind the loose portion of the placenta, and gently separate the adhering part ; we then grasp the mass in the hand, and rotate it several times against the internal face of the uterus, with a view of more certainly procuring subsequent contraction; nor must the hand be withdrawn until this is perceived — should the uterus, however, be found to contract firmly upon the hand immediately after it has effected the separation of the placenta, it may be gradually, but never suddenly withdrawn.* 1159. If the placenta be found detached from the uterus, it must be withdrawn ; but the same precautions should first be practised. We must not, however, consider the patient free from all risk, because the placenta is extracted ; we should ex- amine the condition of the uterus, by again placing the hand upon the abdomen; if it be well contracted, it will be found hard and about to sink within the pelvic cavity, which will give us strong grounds to believe, that the woman is about to do well; but if, on the contrary, the uterus is found large and not very firm, we have every reason to fear there will be a renewal of the flooding, and the frictions must again be had recourse to, 11 GO, It must be confessed, however, that the young practi- * If the utei'us reg-ain its wonted powers, the hand, with the placentaiy mass, will be expelled almost immediately from its cavity^ but even when this effect is perceived, the hand sliould not be permitted to leave it too suddenly. 422 HJEMORRHAGE, BEFORE tioner may not be able, without some further directions, to detect the flaccid condition of the uterus, though he may be ver}^ able to perceive a contracted one — I shall, therefore, state, that when the uterus is not contracted, the whole abdomen appears equally soft and pliant — if the extremities of the fingers be pressed back- ward from the pubes, no hard unyielding tumour is perceived; and if he inquire into the state of the discharges from the vagina, he will find them, if not profuse, more abundant than they should be — when all these circumstances combine, he may be certain the uterus is in a state of inertia ; and he will soon be convinced of this, after he has commenced the friction upon the abdomen, (and which should be immediately done,) by finding it to harden, sometimes suddenl}^, at others gradually, under his hand, and pre- sently retire, when well-conditioned, into the pelvis, or at least the fundus will be found below the umbilicus. 1161. In all cases of severe flooding of this kind, I am in the habit of directing the nurse, or any intelligent woman, to renew these frictions from time to time for an hour or two after my de- parture, and more especially should there be a return of dis- charge, that no evil may arise until I can again attend to the patient. 1162. 3d. I think it best to call in every aid in such cases that may be at command; and 1 frequently exhibit a few grains of the sugar of lead, with a pretty full dose of opium; repeating the former v.'ith a diminished dose of the latter, every fifteen minutes or half hour, until I am pretty well assured it will be no longer necessary in such crowded doses — I however do not give up the use of acetate of lead, unless the stomach be very sick, for at least twelve hours, though 1 diminish the quantity. In alarming cases, I first exhibit from five to ten grains at a dose, unless contra-in- dicated by the state of the stomach; but when the necessity is less, I reduce it two grains every one, two or three hours, as the case may require. Should much pain attend, I give laudanum or opium until it is relieved or much subdued. The ergot, in twenty-grain doses, every twenty minutes, should be given in this case; and late experience seems to declare it preferable to the acetate of lead, and I now employ it alone. 1163. It is not unusual, where the woman has sustained consi- derable loss of blood, for the stomach to become much deranged — vomiting or great nausea, is almost always an attendant upon it ; and when either takes place, it becomes very fatiguing and distressing to (lie patient. If she vomit, the exertion is so severe THE PLACENTA IS EXPELLED. 423 as sometimes to exhaust her ahnost to syncope; and during this act, there is almost always a greater or less discharge of blood, which at this moment can be but ill spared — if it be sickness of stomach, it renders the patient so wretched, that she cannot rest quiet for a moment together in one position; she therefore tosses about from place to place, until she is almost spent — I dread this latter condition more than an occasional effort to vomit, as it seems to interrupt the tonic contraction of the uterus, by the influence which nausea is wont to exert over all muscular power, as well as to induce immediate exhaustion, by producing unceasing jacti- tation. Nothing tranquillizes the stomach under these circum- stances, so far as I have observed, like opium in the solid form — a newly prepared pill of two grains of the opium, with a very small portion of soap, to facilitate its solution in the stomach, should be given every hour or two, until the vomiting ceases, or the stomach becomes reconciled. 1 have foimd a sinapism over the region'of the stomach of great service, and should be resorted to if neces- sary. 1164. Should the discharge be too abundant after the expulsion of the placenta, though not amounting to a flooding, it should be moderated by the use of the sugar of lead, or ergot; the most effec- tual mode of exhibiting the former, is a watery solution of it with laudanum in form of an enema, unless the woman be too weak to have it administered in this manner. The best formula, we be- lieve for the injection, is the following: R. Acetate plumb. 3j. Tinct. Thebiac. gut. Ix. Aq. font, tepid. 5ij. M. pro enema, and the ergot in powder, may be given in ten-grain doses every half-hour, until four or five doses are taken, c. Ill, — Where there is a partial separation of the Placenta, while the remaini7ig jjortion is too adherent, and the Uterus contracts but feebly. 1165. A flooding maybe excessive under the circumstances mentioned in this variety, and considerable time may be lost in vainly soliciting the extrusion of the placenta by frictions upon the abdomen, and efforts exercised upon the cord,* before it is * Whenever an attempt is made to deliver the placenta by force being applied to the cord, great care should be taken that it be not so great as to separate the fu'^is from tliis mass; for if tliis occui-, it would be most probably necessary to 424 IIJEMORRHAGE, BEFORE suspected that this mass may be too adherent — it is fortunately but of rare occurrence, but its management on that account should be the better defined. 1166. We cannot know with certainty, if this complication ex- ist, until the hand be pressed into the uterus, and a proper exami- nation made of the condition of the placenta; for this case, as far as regards common symptoms, resembles almost every variety of retained placenta, and nothing but a strict search can justify its being pronounced a case of adherent placenta. This excuse, I am aware, is frequently employed to justify the introduction of the hand into the uterus, to bring away the after-birth by force, when it required but a little more time, or a little more address, to be delivered by the natural agents. We frequently hear young practitioners boast of the difficulties they have encountered in delivering the placenta; but we rarely meet with an experienced one, who complains of the same thing. 1167. In this country, I believe, that the adherent placenta is of very rare occurrence; while in Great Britain, or rather perhaps London, it is comparatively frequent, agreeably to the testimony of Dr. Ramsbotham.* 1168. There is something remarkable in the occurrence of this condition of the placenta, for which we do not pretend to account. For we cannot well suppose, that a practitioner of so much ex- perience as Dr. Ramsbotham, and one who seems to possess so much talent for observation, can have mistaken the nature of the cases he describes, as " too adherent placentas." In this country, at least so far as my own experience will justify the remark, this diseased condition of the placenta is extremely rare; not having met with more than two or three cases in more than forty years. It would also appear to be of very rare occurrence in some part of Germany, as a Dr. Seiter declares he had not met with a sin- gle case, " d'adherence anormale entrele placenta et I'uterus," in a practice of twenty years. The cases supposed to be of this kind, have been simply instances of the hour-glass contraction, (placente enchatonne.)t inti'oduce the hand, which sometuTies creates to the young practitioner a g-ood deal of embarrassment, as the placenta is not easily distinguished from the inter- nal face of the uterus itself. — See Section on the m.ode of delivering the placenta when the cord is ruptured. * Practical Observations on Midwifery, page 80, American edition. f Sicbold's" Joui-nal de I'Art des Accouchements," See. as quoted in "Bul- letin des Sciences Medicalcs," No. I.Jan. 1827, p. 83. THE PLACENTA IS EXPELLED. 425 1169. This condition of the placenta may be suspected, when the uterus continues large, though prett)?^ firmly contracted; when there is a constant issue of blood, and that florid; when the pla- centa is not within reach of the finger; and when, after a gentle force is applied to the cord, it is found to retract, as if an elastic string had been stretched. When the quantity of blood expended from the vagina would render manual interference necessary; and more especially, when frictions, the exhibition of the sugar of lead, and other " appliances," have failed to stop the discharge, or to expel the placenta, the hand should be introduced, and the separated portion of the placenta sought for. From this part the hand should take the direction of the adhering portion, and if it appear that it would require considerable force to destroy its con- nection with the uterus, every attempt to detach it should be in- stantly desisted from, and only the piece or pieces found loose, or not adhering, should be removed; the remaining part must be trusted to the efforts of nature. 1170. There will necessarily be a difference both in degree, as well as in the extent of the adhesion in individual cases — white some may be only rather more strict than is usual, others will seem to have the substance of the placenta identified with that of the uterus — and, while a small portion only may be too adherent in one case, a large one may be so situated in another. But in every instance, where there is a separated portion, there will be a dis- charge of blood from the vagina, either fluid or coagulated; and that, in proportion to its accumulation, or the activity of the ute- rine fibres. These cases are almost always accompanied by pain, though not of the most severe kind; they, however, make but lit- tle impression upon fhe placenta, nor do they much diminish the size of the uterus; yet with each return there is more or less blood discharged, and the woman rendered faint by the frequency, ra- ther than the quantity evacuated at each contraction, except when there is a large portion separated; then, as in every other instance, she will be more quickly exhausted. 1171. In cases like these, it seems to be agreed, that nothing but putting the uterus in a condition to contract, b}' the removal of such portions of the placenta as can be readily detached, will put a slop to the flooding, or even moderate it; and it seems also well understood, that even this does not place the woman beyond danger — the efforts of nature arc not always availing, and the 54 426 HEMORRHAGE, BEFORE woman dies from the mischief created by a retained portion of the placenta. 1 172. Should the discharge continue after a part of the placenta is removed; the acetate of lead, ergot and frictions, should be con- tinued; and astringent and detergent liquors should be thrown from time to time into the uterus itself, by means of a proper sy- ringe.* 1173. Let this case be treated with what address it may, it is replete with danger to the woman; she may sink from the perti- nacity of the discharge, or succumb under fever, or other evils excited by a putrif3'ing placenta. It is no part of my plan to speak of the subsequent treatment of such cases; I can with much con- fidence refer, for more information' upon this head, to the very able treatise of Mr. Ramsbotham, just mentioned: and I may here take occasion to say, it is not only for this subject, but several others of high interest, I would recommend every practitioner of midwifery to the perusal of his vv^ork. d. IV. — Where everything is as at III. excejjt that the Uterus enjoys its full power. 1174. This variety is not only less frequent, but is much less dangerous, than the one just spoken of; for the uterus, when en- joying its full powers, will contract, with sufficient force to pre- vent any serious mischief from haemorrhage, though there may be considerable waste before the uterus is emptied of the placenta — this requires the same manual treatment in the beginning, and the same medical routine for the subsequent symptoms.! * A considerable variety of substances have been proposed for this purpose: as alum and water, wine and water, wine alone, vinegar, &c. — but what has an- swered best in my hands, in the very few instances of this kind which have fallen under my notice, has been a strong infusion of chamomile flowers, in which a piece of quicklime has been slacked, and permitted to settle perfectly cleai-. This may be used, moderately warm, three or four times a day, or oftener if re- quired. The common pewter syringe for enemata, with a flexible tube attached to it, answers perfectly well — the gum elastic tubes, for the tliroat or bladder, may be very reacUly fixed to the extremity of tliis instrument. In one instance, I saw port wine and water, with a little alum, used with great advantage. f Tlicre is a variety in this division, which cannot be considered as strictly l)elonging to the subject under consideration; yet its own importance will, I hope, be a suflicient apology for introducing it here — it is, where the placenta is completely adherent, and tlic uterus powerfully contracts upon this mass, and prevents the introduction of ihe hand, or of even a couple offingers, for the re THE PLACENTA IS EXPELLED. -127 e. V. — Where there is an entire, or partial separation, but the Uterus in a state of exhaustion or syncope. 1175. This variety is most truly alarming, and requires the most prompt and judicious interference, that the woman may not almost instantly die. The case occurs: 1st. Where a long-pro- tracted labour has much exhausted the patient, previously to de- livery, but where delivery has eventually been unexpectedly sudden. The uterus, from previous fatigue and exertion, becomes enfeebled, though capable for the moment of a powerful effort, which suddenly terminates the labour, but by which its power is expended — the placenta, from the long-continued and frequently repeated pains, was ready to separate, and waited but for the con- traction which expelled the child, to destroy its connection with the uterus, to fall loose or nearly so into its cavity, and thus give opportunity to the exposed vessels to pour out a torrent of blood. 2d. It takes place, and this more frequently than from the cause just mentioned, when the labour has been very rapid; and where the child seemed to be floated from the uterus by a sudden gush of the waters — under such circumstances, the uterus is some- times instantly deprived of its tonic power, and thrown into a state of absolute syncope, as it has been happily termed by Leroux. Or, 3dly. It may arise, (and it but too often does,) from the too hasty delivery of the child, after the head has esoaped through the OS externum — here I would wish to caution the young prac- titioner against one of the most formidable errors that can be com- mitted against sound practice, or just principles. For at this moment, the uterus has expended much of its power, in pushing the child thus far; and if some little time be not allowed it to re- cover its nearly expended strength before the body is hurried through the pelvis, it will be sure to increase, and perpetuate the inertia, into which it has just fallen from severe exertion: hence, moval of it, were this even practicable. It is fortunately, of I'are occurrence — I have seen but two cases of it; in neither of which was there flooding; indeed, scarcely a drop of blood was discharged in tlie one instance, and in the other only a few small coagada were expelled, the whole not amounting to four ounces. Tins case must be trusted to nature; for after repeated examinations the uterus was not found to relax sufficiently, even to attempt the removal of the placenta. This mass was expelled entire, on the third day, in the one case, without any unpleasant consequences; but in the other, it employed many days before it was thrown from the uterus, and then in small detached masseg accompanied with great foctor, thirst, and fever. The patient eventually did. well, though she remained weak a considerable time. 428 HEMORRHAGE, BEFORE we have always to apprehend a flooding, where the shoulders are expelled by the same effort that delivers the head; more especi- ally, if the child be large, and the waters but very recently ex- pended; or where the child is small, and the quantity of w^ater great, and that but a short time discharged. Should this condi- tion be accompanied with a partial separation of the placenta, an alarming haemorrhage will necessarily ensue; and if with an entire one, death may be the almost immediate consequence. 1176. When haemorrhage proceeds from either of the causes just stated, it will be evident that nothing but the most prompt interference, and the employment of the most active agents, can prevail against so formidable an issue of blood, as now pours from the vagina. No time must be lost by temporizing; the woman will sink if not instantly succoured. Frictions upon the abdomen should be quickly commenced, and be actively pursued; doses of ergot — cold water poured from a height upon the abdomen, if the frictions do not very soon recall the contractile power of the uterus; and if much faintness from the loss of blood attend, a small quantity of moderately strong brandy and water should be given every few minutes, until this disposition is relieved ; this will pretty soon follow its exhibition, if the means for re-exciting the uterus should be successful. Fresh air should be freely ad- mitted, but the feet and legs should be kept warm by bottles of warm water or heated flannels; the ergot should be instantly given in small but frequently repeated doses; that is, five grains every ten minutes, for two or three doses. But should this not excite contraction promptly, twenty grains should next be given, and repeated again and again if necessary. It is presumed that during this time frictions upon the abdomen and other means would be employed. 1177. Since the last edition of this work, I have had several instances of flooding in which I have had recourse to the ergot with entire success ; I can therefore now, and do with much pleasure, add my testimony to that of others in its favour. 1178. But I must here repeat, that my great dependence is upon the abdominal frictions ; having so far never known them to fail. Some practitioners have introduced ice* into the cavity of the uterus, under these circumstances, and it is said with suc- cess. I can say nothing upon the influence of this remedy from * Levret, I believe, was tlie first who had recourse to this remedy in the man- ner above stated, and it lias since been recommended by otliers — it has lately been advised by Mr. Barlow. THE PLACENTA IS EXPELLED. 429 my own experience, and were I tempted to employ this substance, 1 should not judge it necessary to conduct it within the cavity of the uterus ; from a belief, (not, however, I confess, confirmed by trial,) that it would be everyway as effectual, if it were held in the vagina. I shall illustrate this condition by a case taken at random from a number of similar ones — for all these cases are so much alike, as to require but one general mode of treatment. Mrs. was delivered by a midwife, after a very easy but rapid labour, of a healthy fine child — the placenta was very quickly expelled, as it was found, as the midwife said, loose in the vagina; a very profuse flooding immediately ensued, for the relief of which she attempted nothing, assuring the friends of the lady it was a common occurrence, and from which nothing was to be apprehended — but the patient becoming pale and faint, her friends were alarmed, and I was sent for in great haste. After my arrival, I was informed that the patient had been delivered about twenty minutes, and the placenta had been extracted about fifteen of that time. When I came to the bed-side, I was per- suaded the patient was dead — no pulse could be felt, and for some time there was no respiration ; syncope had just taken place. I instantly commenced a brisk friction upon the abdomen — order- ed brandy and water by the tea-spoonful to be given with fre- quency ; warm applications to be made to the feet and legs — the curtains to be opened, and fresh air admitted from the door and win- dows, and immediately sent for pills of the acetate of lead and opium. In the course, perhaps, of two minutes after the abdo- minal frictions were commenced, I had the satisfaction to feel the uterus beginning to harden under the hand, and every instant after, to acquire more and more firmness; in about ten minutes it was found much diminished in size, and much more solid — in the act of puckering itself up, a large quantity of coagula and fluid blood were expelled from the vagina, which so alarmed the igno- rant midwife, to whom was consigned the task of watching the discharge, that she declared the woman must die if I did not de- sist from '< rubbing the womb so violently;" but the cause of this poor creature's alarm was to me a great comfort, and only induc- ed me the more steadily to persevere in the plan of irritating the uterus. The disposition to syncope was now much lessened, and the pulse could, by a nice examination, be felt returning to the wrist — increasing in volume and force as the faintness diminished; and in about half an hour more the patient was considered out of im- 430 ITiEMORRnACE, BErOHE mediate risk. To guard against a return of the flooding as effec- tually as might be, I directed two grains of the acetate of lead, and a half grain of opium, to be given every half hour; the fric- tions upon the abdomen to be renewed, should the uterus be found to relax ever so little; and for this end, a very intelligent lady present, was instructed to perceive any change of this kind that might take place — the brandy and water to be given only pro re nata; and the most perfect rest was enjoined, though the position of the patient's body was a very constrained one. I again saw my patient in about two hours, (having given orders to be in- stantly sent for, in case of any unfa%'Ourable change before I re- turned,) and found her situation in every respect improved; she had had no return of haemorrhage, but was occasionally troubled with after-pains— her faintness had gone off entirely, and her system was re-acting with considerable force — her position was now altered very much to her satisfaction; the brandy and water was stopped, and she was permitted, instead of it, to take a few spoonsful of tapioca, seasoned with lemon juice and sugar, from time to time — the pills of the acetate of lead were directed once in two hours. From this time her recovery was as rapid as such a prodigious waste of blood would permit; milk was formed in sufficient quantity after rather a longer period than usual, and the only subsequent inconvenience she experienced was a head- ache; which almost invariably follows excessive uterine haemor- rhage; this was relieved by keeping the bowels freely open. f. VI. — Where there is either a jiartial or co7nj)lete sejjaration of the Placenta, and where the body and fundus are in a state of inertia, while the neck enjoys its tonic powers. 1179. This is the most insidious situation in which the uterus can well be placed; and it is one in which inexperienced practi- tioners lose patients more frequently than any other, after the birth of the child. The neck of the uterus enjoying its powers, at a time that both fundus and body are in a state of inertia, gives rise to such an accumulation of blood within the uterine cavity, as will destroy the patient, without its being suspected that such a discharge is going on — in this case, the haemorrhage will be concealed; for a coagulum blocking up the os uteri, will prevent either fluid blood, or coagula, from issuing; and as there is no apparent flooding, the inexperienced accoucheur rests satisfied (hat all is going on well: nor is he roused always from this state THE PLACENTA IS EXPELLED. 431 of security, until the patient is in articuio mortis; or when, per- haps, all human aid would be unavailing. 1180. This case should warn the practitioner of limited expe- rience, against a false estimate of liis patient's security; and should teach him never to failj ascertaining the state of the ute- rus, by a careful examination, through the abdominal parietes, as already advised. If, upon placing his hand upon the abdomen, he find the uterus voluminous, but far from being hard; if, upon inquiry, he learn, that there is little or no discharge from the vagina; if he observe his patient become pale and faint, with a hurried breathing; if, upon touching the wrist, he find the pulse weak, frequent, or extinct; the skin cold and clammy, lie may be pretty certain there is a concealed haemorrhage;* he has now not a moment to lose, to rescue the woman from an impending fate — he must be firm, prompt, and self-collected; and instantly put in practice every remedy that may promise relief. 1181. He should commence by abdominal frictions; and, if he find the uterus becoming harder in consequence, he should per- severe, until he thinks it has acquired a disposition to contract — should the hardening of the uterus not be attended with a dis- charge of coagula, &c. from the vagina, he must conclude, either that the neck of the uterus is too resisting to be overcome by the contraction of the body and fundus, without farther aid, or that these are too feeble to overcome the resistance of the os uteri, though the latter may be comparatively weak — in either case, he must attempt to give to the uterus an increase of power, by re- moving its contents. 1182. This must be conducted with much cautious coolness, that the remedy must not increase the evil — the frictions upon the abdomen must be intrusted to some proper assistant, and they should be kept up with persevering constancy, while the practi- tioner carefully inserts his hand into the vagina — should he find clots there, he should remove them, if they ai'e not immediately forced oft' by the effort which will most probably be excited, by the introduction of the hand. 1183. This being done, he is to insinuate finger after finger into the OS uteri, and gradually attempt its dilation; should it be very resi'iting, the resistance must be cautiously overcome; and if this * I say, '* pretty certain thei-e is a concealed hxmorrliag'e;" foi- 1 cannot say he may be altogether certain; since a rupture of the uterus may be attended w iUi all these symptoms. 432 HEMORRHAGE, &C. be properly conducted, it will perhaps, never offer such opposi- tion, as to render any considerable force necessary — perseve- rance in a well-directed manner; I am persuaded, will be all that is necessary. 1184. When the hand has gained possession of the cavity of the uterus, the wrist should be so pressed against the side of the neck of the uterus, as to make room for the escape of any coagula or fluid blood, that may be disposed to issue — by managing in this way, he may empty the uterus so gradually, as almost to insure its subsequent contraction, and this will be much aided by the ex- ternal friction. He is now to search for the placenta;* if it be but partially detached, he must cautiously separate the remaining adhesions — when this is done with care, and under the precau- tions above suggested, he is to remove it by rotating the hand now in possession of the placenta, against the internal surface of the uterus, until it manifest a disposition to contract; and then, and not till then, should the hand be withdrawn. 1185. Should the placenta be found entirely detached, it must be delivered with the same regard to uterine contraction. After the delivery of the placenta, pressure and friction should be con- tinued upon the abdomen; nor must these be abandoned, until the contracted uterus give assurance of recovered energy. 1186. In addition to what has now been directed, the other re medies which have been suggested should be had recourse to — the sugar of lead, ergot, and cold applications, under the restric- tions already proposed, should be tried — this case, and the one next to be considered, offer, perhaps, the best chances for the er- got; the brandy and water should not be omitted, if the woman be very faint, and much exhausted. The after-treatment will sug- gest itself; and after-symptoms must be treated pro re nata. * It may be well to observe that, in every attempt to separate the placenta, we sliould, before we commence tlie operation, fix the uterus as firmly as it can wellbe done, by tl\e external application of the unemployed hand upon the fun- Jus — in fact, it should never be attempted without this precaution; as the ope- ration is not only very difficult, if this be neglected, but is also very uncertain — the woman if possible, should be placed upon her back, as I have directed for other purposes. It may also be proper to suggest another caution connected with this operation, which is, that we be certain that we have removed the whole of the placenta; except in those cases, where it is expedient to leave a portion to the natural efforts of the uterus, as in the too adherent placenta. It is, however, sometimes almost impossible to determine this, where the placenta islobulated, as now and then happens. See Leroux, Buudelocque, 8ic. HiEMORRUAGE, &.C. 433 Sect. VIIL — 8. Of Flooding after the expuhioa of the Placenta. 11S7. When the placenta has been expelled, and is followed by flooding, the mode of proceeding is so similar to the last re- commended, that it will require but a few words to make its ma- nagement perfectly clear. In this kind of hsemorrhage, like the one we have just been considering, it is necessary that the uterus should contract before it can possibly be arrested ; therefore it will require the employment of all the means already pointed out for this purpose ; and here, as in the other cases, I rest my great dependence upon abdominal frictions, the acetate of lead, ergot, cold applications, &c. 1188. Should the concealed haemorrhage take place, it must be treated much after the same manner as before the placenta is expelled;* (1179, &c.) that is, the hand must be introduced into the uterus, and the coagula suffered gradually to escape, while the uterus is gently stimulated by the hand passing cautiously over its surface ; and when it is found to contract upon it, it may be slowly withdrawn ; the after-treatment must necessarily be the same. This case, generally speaking, is of much less diificuU treatment than where we have the placenta to contend with ; and will always, so far as I have yet experienced, yield to the treatment proposed, provided a proper chance be given to their employment — it cannot be supposed they will be availing when the patient is in articulo mortis. 1189. It sometimes, however, happens, that a portion of the placenta is left, either entirely, or partially attached to the ute- rus, which will give rise sooner or later to haemorrhage — this may sometimes be immediately detected by the inspection of the pla- centa itself — at other times this will be found impossible; espe- cially in those cases where we are under the necessity of bring- * This case is sometimes very suddenly fatal. I was once called by a mid- wife, to visit one of her patients; but upon my arrival, I found the woman dead. The midwife was much surprised, and could not account for her death; as " the labour was natural and easy, and the placenta had come quickly away." I told her my suspicions of the case; and these were afterwards confirmed, by opening' the body — the whole cavity of the uterus was filled with blood, and distended to nearly the size of one at the full period of gestation— the mouth of the uterus was found sufficiently closed to retain the blood dischai-ged from the sui-face to which the placenta lad been attached. 55 434 HEMORRHAGE, &C. ing away this mass piecemeal — if this accident he discovered at once, it is best, I believe, to remove it; unless it should be a por- tion that is too adherent. Should this not, however, be discover- ed before the uterus has contracted firmly upon it, it will be much better to suffer it to remain, and trust to nature for its expulsion, than to run the risk of provoking a flooding; exciting a great deal of pain, or of producing inflammation. But should flooding at- tend, we must deliver the retained portion, and this can almost always be done, as the mouth of the uterus is generally found open or yielding when haemorrhage attends; but should it be found otherwise, it must be trusted to nature; the excess of dis- charge must be moderated by the tampon — if this be employed, it will be well to renew it every twelve hours; taking care to wash out the vagina before it is replaced, with the infusion of chamomile tea, wine and water, &c. 1190. The retained portion of the placenta sometimes may not, however, be suspected for several days after deliver}^; but we have a right to conclude that it is retained, when there is frequent return of pains, and a discharge of coagulum after coagulum from the vagina, followed by fluid blood upon each relaxation of the uterus. When the discharge of fluid blood happens in quick suc- cession and in weakening quantities, we should immediately at- tend to the condition of the uterus; if it be found sufiiciently yielding to admit the hand, it must be carefully introduced, and the portion detached, and withdrawn. '' We may sometimes suc- ceed in detaching it by insinuating a couple of fingers into the uterus, and moving them in a circular manner between it and the placenta, so as to loosen it, and then remove it either by hooking it with the finger; by the natural efibrts of the uterus; or by the small crotchet recommended for the removal of the secundines in cases of early abortion. If neither the finger nor the crotchet succeed, we must trust to nature; taking care to keep the dis- charge in subjection by the tampon. 1191. The young practitioner is cautioned against treating this ♦ Baudelocque tells us, he has known this kind of haemorrhage show itself on the tenth day, and has been obliged to pass the hand into the uterus, to ex- tract it. (System, Vol. II. p. 27.) I am, however, disposed to think, that in cases of this kind, the ergot would be the better remedy; it should be tried at least. It is true, that this opinion is founded upon its success in a single case. But analogy is so mucli in its favour independently of this, we must repeat it, it should be triedj it may save botli time and pain. MEANS FOR PREVENTINft HiEMORRHAGE. 435 case with indifference; it is one not unfrequently attended with danger, and sometimes death has ensued very quickly, as La Blotte and others assure us. Should he be doubtful of his own judgment in this case, let him, b}'- all means, (as well as in every other case of danger,) request the advice of an older practitioner. Sect. IX. — 9. On the means for jircvcnting Flooding. 1192. Having considered at some length the haemorrhages which may take place during pregnancy, and such as may follow delivery, let me say a few words upon the mode of preventing those which may succeed to labour, as I am of opinion that much may be done to this purpose. From what has been said, it will be evident, that whatever interrupts the tonic contraction of the uterus, or produces its relaxation after it has contracted, will occasion a flooding; provided there be a separation of a part, or of the whole of the placenta; it is equally evident, that whatever will insure this contraction, or contribute to it, will either pre- vent or diminish haemorrhage from this part. Much, then, will depend upon the manner in which the last stage of labour is con- ducted, to insure the future contraction of the uterus. 1193. This subject has been treated by Dr. Denman, with much apparent interest; but his advice upon this point is not con- formable to my own experience. I shall quote his directions in his own words. The doctor says, " when I had been attending women who were prone to violent haemorrhages after the birth of the child in former labours, I have made it a rule to keep them in an erect position till the waters were discharged by the spon- taneous breaking of the membranes, and the child was on the point of being born. By this method it appeared clearly to me, that the uterus acted more favourably, the placenta came away more naturally, and the quantity of blood lost was often much more diminished."* 1194. Now, I ask any one at all conversant with the economy of the uterus, during, and after labour, how an erect position, the sudden evacuation of the waters at the moment " the child was about to be born," can contribute to the only circumstance at all available in the case under consideration, namely; the perma- nent contraction of the uterus? In the first place, an erect posi- tion will always be attended with a quicker circulation than a ' Introduction to Midwifery, Francis's ed. p. 494. 436 MEANS FOK PREVENTING II^MORRHACxE. recumbent one; and will permit the waters to escape with more suddenness and rapidity; consequently, the risk of atony must be increased. It is admitted upon all hands, and among these, by Dr. D. himself, in other parts of his works, that if the uterus be too suddenly emptied, there will be a risk of inertia, or, at least, of great irregularity of action; if this be so, how can the interest of the woman be improved by this practice? 1195. All writers upon midwifery declare, that the sudden evacuation of the waters, and the delivery of the child almost at the same instant, are the most common causes of the atonic state of this organ. Yet we are advised by Dr. D. to encourage these events, with a view to prevent it! So far all theory is against it; and I will now appeal to experience to prove it to be, at least a doubtful practice. 1196. There was a period of my life at which I looked upon Dr. Denman to be the highest authority in midwifery; and, at that time almost implicitly followed his instructions upon every point of practice; and consequently upon the subject in question. But in doing so, I was persuaded from sufficient trials of the plan, that it not only did not answer the end for which it was pro- posed, but that it was decidedly mischievous; I of course aban- doned it so soon as I was convinced of this truth; and substituted one almost diametrically opposite; and with which I have every reason to be satisfied. As it was impossible to determine, a. priori, which patient might be attacked with a flooding after deliv- ery, it became necessary to follow some general rule with all, (where practicable,) by which the risk of this accident should be diminished. 1197. It therefore suggested itself that whatever would insure, with most certainty, the tonic contraction of the uterus, would best guard the patient against the contingency of a flooding; and what appeared to me the most rational to insure this, was to take off" the distention of this viscus as gradually as possible, by the early evacuation of the waters; to diminish the force of the circu- lation as much as was practicable, by making the woman pre- serve a horizontal posture when the pains became urgent; and to interdict stimuli of every kind, as wine, or any other liquor, heat, and all unnecessary exertion. 1198. But let me make myself understood, when I say '^ the early evacuation of the waters." It is a fact notorious to every practitioner, that the membranes, if left to be ruptured entirely MEANS FOR PREVENTING HEMORRHAGE. 437 by the force of the uterus, would remain entire in many, and, per- haps, in most instances until the child was about to be pushed through the os externum. Now were this plan to be pursued, the uterus would be suddenly, instead of gradually emptied; and consequently the risk of flooding would almost necessarily be in- curred. But if, instead of this, we rupture the membranes so soon as the labour is active, and the os uteri sufficiently dilated, or easily dilatable, we should give opportunity and time for the uterus to contract, before the child would be expelled, and thus guard against the evil we are apprehending. The uterus would, by this plan, diminish in size in the exact proportion to the water displaced; it would apply itself to the whole surfaceof the child, the inequality of which would serve as an important and healthy stimulus, (all things being equal,) and excite it to more certain contraction. 1199. Daily experience proves the justness of this reasoning and practice; for how rarely do we see a flooding follow those deliveries where the liquor amnii has been discharged even a few hours previously ! and what can produce the exemption from this accident, but the uterus having had sufficient time and opportu- nity to contract? It is true, that this alone may not always be sufficient to protect the woman against a haemorrhage, but I am convinced, from many years of experience, it is the principal' one.* The directions given for the delivery of the body of the • I have, within the last few years, given the sccale cornutiim a short time prc- v'iously to the delivery of the child, with tlie happiest effect. It was given, as declared in the following case: — Mi-s. , aged thirty -three years, in labour with her seventh child. One of her friends informed me, that she had always been liable to flood exces- sively very soon after the expulsion of the placenta; and that with the child before the present one, she had been nearly exhausted by the profuseness of the discharge. To prevent a recurrence of this, I prescribed the following mix- ture: — R Pulv. Secale Cornut. ^ss. Sacch. Alb. giss. Aq. Cinnam. simp. §j. M. Of this, one-tliird was given every twenty minutes, about an hour before the child was expected to be born. The child was delivered in three quarters of an hour after the first dose. The placenta was soon detached, b}^ the efforts of the uterus alone; and was found to be firmly contracted, immediately after. No flooding supervened — indeed, nothing but a moderate lochia followed. Mrs. , aged twenty-six, of rather a leucophlegmatic habit, and excessive- ly afflicted with fluor iilbus, had with her first child a painful, but active labour of about three hours continuance. Very soon after the delivery of the placenta, 438 MEANS FOR TREVENTING HJEMORRHAGE. child, after the head has escaped, and the abdominal frictions, must also be considered as matters of great moment, and should never be neglected, especially with women who are " prone to flood" after delivery. excessively severe after-pains began, accompanied by a pretty profuse discharge of blood and coagida. These were repeated in very quick succession, until she became very faint, and much exhausted. I gave her five grains of the acetate of lead, and sixty drops of laudanum; frictions were made upon the abdomen. In half an hour the sugar of lead was repeated, with much advantage; the pains and dischai'ge were now much abated^ and the uterus remained pretty per- manently contracted. I however ordered, in case pain continued, to repeat the laudanum, witliout the sugai- of lead. She remained very weak for a number of days, as she had lost a great deal of blood. Her second, tliird, and fourth labours, were followed by the same disagreea. ble consequences^ for in each of which the uterus relaxed itself, after the expul- sion of the placenta, after having been firmly contracted for half an hour. AVitli her fifth laboui-. May 24th, 1827, I resolved upon putting in practice, the early ruptm-ing of the membranes, and the exhibition of the ergot. After her pains became active, I ruptui'ed the membranes, tliough the uterus was not fully di- lated. In about an hour the os uteri was entu-ely expanded, and the labour advanced with considerable rapidity; about twenty minutes before I expected delivery would take place, I gave her five grains of the secale cornutum, and repeated it in ten miiHites, and in ten minutes after I gave ten grains more, making twenty grains altogether. Delivery now ensued; the placenta was spontaneously thrown off" in twenty minutes, unattended by flooding, and fol- lowed by very little pain. I waited an hour and a half but no hemorrhage took place. Thirty drops of the black drop had been given immediately after tlie first after-pain, and this was followed by twenty more. The after-pains ceased, and the lochial discharge was very moderate; in a word, she was better on the tliird daj^ than she had been previously at the end of a fortnight. I have delivered tliis lady four times since May, 1827 — in each labour the same precautions were used, with similai- hajjpy results. I am of opinion, that were this lady neglected after delivery, she would most probably die from hsmorrhage; for with even attentions sedulously pursued, a strong tendency to relaxation is constantly perceived in tJie uterus, for the first hour after de- livery. ( 439 ) CHAPTER XXXII. OP THE ASSISTED DELIVERY OP THE PLACENTA, 1200. The tonic contraction almost exclusively detaches the placenta from the uterine surface, in order that it may be expel- led. This takes place at various periods after the delivery of the child, as the tonic power of the uterus may be in a greater or less perfection, or as the connecting medium of the placenta and ute- rus may be more or less dense — it will, therefore, be found, that the placenta may be cast off immediately after the expulsion of the child, or it may require some time to effect this end, without our considering it to be a morbid adhesion of this mass.* 1201. It is desirable at all times, that the placenta be expelled pretty quickly after the child. And if this do not take place spontaneously in due time, it is proper that we should give such assistance as will facilitate its exit, without the introduction of the hand. There has been much diversity of opinion, what pe- riod or interval, constituted "the proper time," for the extrusion of the placenta — some fixing a longer, and others a shorter term, much to the embarrassment of the young practitioner — but this point, I conceive is easily settled, by taking the indications from the condition of the uterus itself, and not from the number of mi- nutes or hours which may have elapsed. 1202. I have always objected to making " time" the criterion for action in midwifery; and my aversion is by no means abated, when an attempt is made to make it a rule for the delivery of the placenta; for the same objections must obtain here, as in the cases I have already declared it should not govern in. I have stated (1200) by what power the separation of the placenta is effected; and that it would necessarily require a longer or shorter interval, as the agent may be more or less active. It will follow, then, that the expulsion of this mass may be either very prompt, (1200) • We may remark in general, that the time the uterus requires to throw off" the placenta, is in some measure indicated by the state of the foetal circulation —if this be quickly interrupted after the birth of the child, the placenta will be detached soon; if the circulation continue, it will require more time. This may be easily understood; as cither of these'circumslanccs betrays tlic want of great force in the tonic contraction. 440 ASSISTED DELIVERY OF THE PLACENTA. or be rather tardy; I have already pointed out the duty of the accoucheur in the first instance, and the mode by which he is to execute this duty; (556) I shall therefore, in this place, only con- sider what is to be done in the latter case. 1203. I have stated in effect, (1200) two principal causes for the tardy separation of the placenta: namely, 1st. A diminution of the tonic power; and, 2d. Too great a firmness in the connect- ing medium of this mass with the uterus; each of which requires a little difference in management. The first of these may be known: 1st. By the uterus being rather larger and softer than it sliould be, a short time after delivery; 2d. By no portion of this mass being within reach of the finger when introduced into the vagina; 3d. By there being no return of the alternate contrac- tions of the uterus; and 4th. When a force is applied to the cord, it gives the idea that the placenta is descending; but this being fallacious, for so soon as we cease to draw upon the cord, it in- stantly mounts again into the pelvis. Sect. I. — 1. Mode of acting iii Retention from want of Tonic Power. 1204. When this state of things presents itself, all attempts to deliver the placenta must be forborne, until we have by properly instituted frictions over the region of the uterus, obliged it to contract and harden itself under the hand; and at the same time retire lower into the pelvis — when these alterations show them- selves, we almost always find they will be accompanied by pain; and, if we now co-operate in a proper manner, we shall find the placenta to arrive within reach of the finger, and announce its se- paration by a small discharge of fluid blood, or coagula, or both, and fall into the vagina, from whence it may be extracted, as has been directed. (556.) Sect. II. — 2. Retention from too firm adherence. 1205. In the second case, (1203) we shall find the uterus re- duced in size; firm and pretty well sunk in the pelvic cavity; and may be even attended with pain, without bringing the pla- centa within reach of the finger, and if we draw upon the cord as in the other case, there is little or no retraction after we inter- mit the force. 1200. Tliis case requires, for the separation of the after- birth, ASSISTED DEHVEKY OE THE PLACENTA. 441 not only a firmer contraction of the uterus, but a longer continu- ance of it; as well as a particular application of force to the placenta itself, by means of the cord. Force, to be successfully applied for the separation of the placenta, must be directed in such a manner, as to act perpendicularly to its surface; or its in- fluence will be destroyed — to effect this, we must first ascertain the part of the uteiois to which this mass adheres. This is to be known by observing the part of the pelvis to which the funis seems inclined ; as this will point out the portion of the uterus to which the placenta is adherent — thus, if the cord descend behind the symphysis pubis, the placenta vvill be attached to tlie anterior part of the uterus; if before the projection of the sacrum, it will be found at the posterior part of the uterus ; if to either side, the placenta will be at the side on which the cord is found. u. Mode of acting in this case. 1207. Having ascertained the location of the placenta, we must so arrange a couple of fingers within the vagina, that draw- ing the cord horizontally will act in the desired direction upon it ; that is, if the placenta be attached to the anterior portion of the uterus, we place the cord behind the fingers, and press it back towards the projection of the sacrum, while we draw the cord with the other hand ; if to the posterior portion, we place the cord before the fingers, and carry it as high as we can well reach, towards the superior strait, and then draw with the other hand; if placed at the lateral portions, we must introduce the fingers of either the right or left hand, as it may be the right or left side of the uterus to which the placenta is attached, and then place them in such a manner that the horizontal drawing will act in a proper direction — if the placenta be at the left side, we must introduce the fingers of the right hand, and vice versa. By act- ing thus, we may succeed in bringing down a placenta, which, without it, might require the introduction of the hand. 120S. In this situation of the placenta, (1203) we are almost certain to have the co-operation of the alternate contractions of the uterus; and it is proper that we take advantage of them, hy making gentle exertions by the cord at the same time; if no pain come on, we should solicit the farther contractions of llie ilterus, by frictions and moderate pressure upon it, whiie we gently and steadily pull at the cord. We should now and then ascertain if 442 ASSISTED DELIVERY OF THE PLACENTA. the placenta is descending : this is best done by slacking the trac- tive force; and then observe whether the cord remounts, or whe- ther it remains stationary. If it ascend, we may be certain that the placenta is either not detached, or that the uterus is not aiding in its expulsion — in such case, we should be very careful that the degreeof force applied to the cord, be not sufficient to destroy its union with the placenta; and that we do not urge its deliverance too importunately. 1209. If we find the cord not to remount, or if it remount but very little after we have ceased to draw, we may be assured the placenta is descending, and will occupy more or less of the vagi- na; from whence it may be easily extracted, as it is now within reach of the finger. 1210. It very rarely happens that the introduction of the hand is necessary to deliver the placenta, in the situations I have just described; method and address, are all that are required to over- come the existing difficulties: and, perhaps, there is no other condition of this mass, in which it has been so often, and so wan- tonly, dragged from the uterus, because a little resistance was of- fered by the causes just stated. It would seem to be a sufficient reason with very many inexperienced practitioners, to introduce the hand for the delivery of the placenta, because it does not im- mediately precipitate itself into the vagina after the birth of the child; or does not instantly obey the force that is applied to itj however ill-directed, or inopportune, that attempt may be. 1211. Or if the practitioner be timid, and obey a direction but too common in books upon this subject, that a certain period of time must elapse before any attempt be made to deliver the pla- centa, he may let the proper moment elapse for the successful ap- plication of a well directed force, and thus convert a case of great simplicity, into one which will require the aid of art. 1212. I say, that the time for interference of the accoucheur for the delivery of the placenta, should always be regulated by the condition of the uterus itself; and that condition is, when- ever it is firmly contracted — this rule I believe will never de- ceive; or, at least, I have uniformly acted upon this principle; and so far I think I am safe in saying, I have not had cause to believQ it wrong. I acknowledge that some address is required for the successful delivery of this mass ; but as this is easily ac- quired by a proper attention to the laws, by which it is ex- pelled, I should hold that man in some measure accounta- ASSISTED DELIVERV OF THE PLACENTxV. 443 ble, if he produced mischief, by an improper, or ill-directed ma- noeuvre. Time, simply considered, can never form a safe rule for the delivery of the placenta; the degree of contraction of f/ie uterus, alone, can point out the proper moment to operate, or teach us, when it would be iinproper to attempt it. 1213. I am decidedly of opinion, that the necessity for artifi- cial delivery of the placenta is often created by obeying a rule taken from time, let that period be longer or shorter; for time in itself, can neither produce the conditions required, nor command them, if they be absent. For the uterus may be disposed to throw off the placenta, and it would do so if properly aided, long be- fore the fixed period may arrive; or it may be in a state of such feebleness at that moment, as to render it highly dangerous to attempt it — hence, on the one hand, an injury may be done to the uterus by the manual delivery of the placenta by the resist- ance which it now offers to the attempt; or the woman be ex- posed to a severe and perhaps a fatal haemorrhage, by our acting at the limited moment; it is therefore, improper, to permit the uterus to contract by improperly delaying the moment to act, so as to enclose this mass, and require force to open it; or by inat- tention to its state of imperfect contraction, to induce a flooding, by acting, because a specified time has elapsed. 1214. Should a portion of the placenta be separated, and a flooding accompany these conditions of the placenta, it must be treated as directed for this case. (1147, &c.) Sect. III. — 3. Of the Delivery of the Encysted Placenta. 1215. In consequence of the contraction of a portion of the body of the uterus, before the placenta is delivered, it is some- times confined in a distinct apartment, as it were, of this organ; and this, agreeably to my own experience, is always at the fun- dus. The mechanism of this accident is easily understood, if we recollect the strong disposition the body, and especially its lower part, has to contract, or narrow itself, w^hen the distending cause is removed; and especially, while the placenta remains undeli- vered. 1216. Some have thought this contraction could take place only when the placenta was attached to the side of the uterus; and others, only when it adhered to the fundus; of this last opi- nion was Baudelocque; and it entirely comports with my own experience of this condition of the uterus— indeed I might say 444 ASSISTED DELIVERY OF THE PLACENTA. limited cxjierience; for such it truly is; as I have very rarely met with it; and never, so far as my recollection may be depended upon, when I have had the entire management of the case. Dr. Douglass, of Dublin, has considered this condition of the uterus altogether artificial; or arising from some irritation near the mouth of this organ ; either by acting upon the cord, or by the introduction of the hand. 1217. He says, "the exciting cause of the uterus assuming the hour-glass form is irritation, produced either in the vagina by in- judicious pulling at the umbilical cord, or in the cervex uteri, by the accoucheur's hand, searching there in vain for the placenta." 1218. "That the proximate cause is a spasmodic constriction of the muscular fibres of the uterus at the lower verge (not the* centre), of that section termed its body, and just where it ceases to be thickly m.uscular." 1219. " Thence I conclude," says the doctor, " that this hour- glass contraction is not produced by any principle of action inhe- rent in the uterus itself, and that whenever it does occur, it is caused by mismanagement." 1220. " Therefoi'e, in order to avoid such occurrences, the prac- titioner should always refrain from exciting unnecessary irrita- tion." 1221. " And in those cases of unavoidable retention of the pla- centa, wherein it may be necessary for the accoucheur materially to interfere, he should, having cautiously inserted it within the vagina, push his hand briskly up to the very fundus of the uterus. And in this operation, he should direct the hand forward towards the umbilicus." This case is seldom or never attended b}' hsemorrhage.* 1222. This case may be known by the fundus of the uterus reaching higher than common; by its being smaller in its trans- verse direction, as can be detected through the abdominal parie- ties ; by an elastic feel of the cord ; by no pain attending ; by the placenta not being within the reach of the finger; and if upon the introduction of the hand, the cord is found to pass through an aperture of greater or less size, and the placenta felt to lie within the cavity formed by this contraction. * I was called not long since to a case of this kind, in which as I was inform- ed by the gentleman who had charge of the case, that the patient had suffered a considerable loss of blood — this appeared to have been the case, as I found the patient was very much exhausted on my ai-nival — she however did well. ASSISTED DELIVERY OF THE PLACENTA. 445 a. Mode of Ojocrating in iJiis Case. 1223. In the hour-glass contraction of the uterus, it hecomes always a matter of necessity to operate, and this should be under- taken so soon as this situation is ascertained; as I believe no ad- vantage has ever been derived from waiting. It is in vain the action of the uterus is solicited; or that force, however well direct- ed, be applied to the cord; nothing but the introduction of the hand, and that made to pass the stricture, can relieve the placenta from its confinement. 1224. The woman should be placed upon her back, as directed for turning, (732) or the application of the forceps; (755) the hand must be cautiously introduced into the vagina, and forwarded agreeably to the direction of the cord, which should be taken al- ways for a guide. This will bo found passing through an aperture of uncertain size; sometimes larger, sometimes smaller; into which the fingers, one after the other, must be introduced, and its dilata- tion gradually effected, until the whole hand is enabled to pass the stricture.* When the hand has possession of the chamber which contains the placenta, this mass must be separated carefully if it be adherent,t or if loose, it must be seized with sufficient firmness to secure its following with the hand when this is withdrawn. 1225. Some little management is required in withdrawing the placenta, or rather in the mode of seizing of it — it must not be grasped by the whole hand, and kept in it by contracting the fin- gers; for its bulk, with that of the hand, will exceed the opening through which it has to pass. This is not an unusual predicament, and has sometimes been attempted to be overcome by force, to the discomfiture of the operator, and to the serious injury of the patient. 1226. During the introduction of the hand into the uterus, and • Wcdonotrecommeiidthedirectionjustgivcnby Dr. Douglass, (1221) "to push the hand briskly up to the very fundus of the uterus." On the contrary, tills operation should be deliberately and cautiously performed, or much mis- chief may ensue; for such is the resistance sometimes offered by the constric- tion, that it would rec[uire much force to overcome it, especially if it be sud- denly applied. And if suddenly applied might injure the connection of the ute- rus with the vagina. — See pal's. 1226, 1227. f Dr. Douglass says, it is always found adherent, or rather that it is never found detached. (Observations on the hour-Glass contraction of the ifterus, p. 10.) Dr. .Ramsbotham says, that it is generally found detached, {Practical Observa- tions, Am. ed. p. 144.) and this comports with my own observations. 446 ASSISTED DELIVERY OF THE PLACENTA. especially while contending with the stricture, the uterus must he firmly fixed by the other hand being pressed upon its fundus, un- til possession is taken of the placenta, and the hand is about to be \\ ilhdrawn. After the after-birth is delivered, I have thought it best to re-enter the uterus to the very fundus, so as to be certain that neither a portion of the placenta, nor coagula are left be- hind. 1227. This operation is always to be slowly and cautiously per- formed, as the woman may be much endangered by a contrary practice — she may, by rudeness and want of tact, be liable to sub- sequent inflammation of the uterus, or its immediate rupture. It is to the patient always an operation of severe suffering, however well-conducted, unless the stricture resists but very moderately; therefore to add to it by rudeness or mal-adroitness, is both cruel Sect. IV. — 4. On the enclosed and jjartiaUy lorotruded Pla- centa. 1228. It sometimes happens that the placenta is confined in the uterine cavity, though detached from its surface, in consequence of the sudden contraction of the mouth of the uterus. It would perhaps be difficult to assign the reason of this disposition in the mouth of the uterus to close, before the placenta is expelled — it may arise from some peculiar stimulus, or from some preternatu- ral irritability of this part of this organ, over which we have no control. 1229. This situation of the uterus and placenta may be known, by the latter being unusually long detained, when, from the hard- ness and well contracted condition of the former, we should not have anticipated such delay; by the force applied to the cord, not making the placenta descend; by an absence of hsemorrhage; nay, almost of discharge; by the contracted condition of the os uteri, by the placenta being felt when the finger is passed through it: and by the absence of pains. 1230. It would be in vain to attemptthedelivery of the placen- ta by any exertion made upon the cord, though this is almost al- ways resorted to; and as the whole of the uterus will sink lower into the pelvis by this effort, the inexperienced practitioner ima- gines that the placenta is descending — he continues his traction under this illusion, and thinking a little more force will overcome the difficulty, he multiplies it; the cord is ruptured, and his diffi- ASSISTED DELIVERY OF THE PLACENTA. 447 culties are increased — he now becomes alarmed ; and the panic spreads to the patient and her friends ; everything is thi-own into confusion ; a consuUation is demanded, and a rival practitioner robs him of the little reputation he may have acquired, and thus interrupts his progress in business. Or, fearing the consequences a discovery of this accident might produce, he disengenuously conceals it; and attempts, without method, the delivery of the imprisoned placenta, to the immediate torture and the subsequent injury, of his patient — not knowing exactly what causes the delay, or the nature of the difficulties which oppose him, after ex- cruciating his patient, by unavailing efforts, he in a paroxysm of mental anguish, abandons her and declares, the case must be left to nature. 1231. The modes of proceeding in such cases, are: 1st, to re- call the contractions of the body and fundus by the exhibition of the ergot in common doses ; and 2d, should this not succeed within an hour, the uterus must be gently entered by slowly dilating the OS uteri, and the placenta removed — this, if carefully and method- ically attempted, is not so difficult as might at first be imagined. The woman should be placed as directed for turning, (732) and during the passage of the hand through the os uteri, the uterus should be firmly supported as suggested. (1226) 1232. I have ventured to suggest the exhibition of the ergot in this case rather from analogy, than experience — as in a case of retained placenta, after a premature labour of the seventh month, and another under similar circumstances at the sixth month, I happily procured the expulsion of these masses by this remedy.* 1233. As a general rule, I am of opinion, that the sooner we operate, all things being equal, the better, as the obstinacy of contraction is in proportion to the lapse of time, unless the alter- nate contraction of the uterus come in to our aid. 1234. There are three other situations of the placenta, which may be regarded as varieties of this case ; the first, is where a small portion of this mass is pushed through the os uteri; the se- * I must however observe, that I have no doubt of the sufficiency of the « Ergot" to procure the discharge of the phicenta after the birth of a child at full time, though I cannot give a proof of it. The analogy between the two cases under consideration, is too strong to admit a doubt upon the subject, though the occasions for the employment of this article, will, from the veiy nature of the economy of the uterus, be much more rare in cases which arrive at fuU time than those in which dehvery takes place prematurely. 448 ASSISTED DELIVERY OF THE PLACENTA. cond, is where about one-half has escaped ; the third, is where the greater part of this mass is without the mouth of the uterus. In all these instances, the farther progress of the placenta is pre- vented, by the os uteri firmly embracing it; at least so firmly, as to render the attempt to relieve it by the cord, not only fruitless, but perhaps mischievous, by causing its rupture. Mode of acting in each case. 1235. If the placenta be found in the first situation enumerated, (1234) we may procure its descent, by employing the crotchet recommended for the delivery of this mass, in cases of flooding from abortion, (see figure in Treatise on Diseases of Females, chapter on uterine haemorrhage, by the author,) or by dilating the OS uteri as recommended, (1224) first pushing up the protrud- ing portions. 1236. For the second condition, the hand must be introduced into the vagina, and a finger passed under the edge of the os uteri, by which successive portions of the placenta must be hooked and brought downward, until the whole is relieved. 1237. In the third instance, all that is required is, the intro- duction of the hand into the vagina, and the firm seizure and compression of the placenta, as near the os uteri as possible; com- pression near the stricture, diminishes the bulk of the placenta so much, as to permit it to escape, by drawing the whole mass to- ward the OS externum. 123S. The cases T have just described, are far from being un- common; and few, offer greater embarrassment to the inexperi- enced practitioner. The cause of the detention of the placenta in many cases is not sufficiently well understood, or sufficiently early ascertained, to render them free from risk — I therefore, recommend to the young practitioner, to search for this mass whenever any unusual delay in its delivery takes place, though the case be not attended by flooding, or other accident, provided, he has previously put in practice all the means which are usually essential to its expulsion, and they have failed; or, having waited until the condition of the uterus, as ascertained by the hand through the abdominal parietes, gives evidence that it has con- tracted sufficiently, if not successfully.* * For the mode of actinjj in " placental presentations;" under all their vari- ous forms, see Chapter on "Unavoidable Iliemorrhag-e;" for the plan of proceed- ASSISTED DELIVERY OF THE PLACENTA. 449 Sect. V.— 5. Of the Delivery of the Placenta, ivhen the Cord is broken or is very feeble. 1239. An undue force applied to the cord with a view to de- liver the placenta, may rupture the funis; hence, the important caution, of not applying too much. It sometimes happens, how- ever, that a very moderate force will destroy its connection with the placenta — this may arise from a weak state of this production, though it may be sound; it may arise from a morbid condition of it; or from its being in a state of putrefaction. 1240. Those who are in the habit of seeing many cases of midwifery, can pretty well judge of the firmness or strength of the cord, so soon as they see it; and will regulate their endea- vours to extract the placenta by it. When the funis is frail, or ve- ry tender, it should never be used as a means to deliver the after- birth; it should always be preserved as a guide for the hand, should it become necessary to enter the uterus. The rupture of the cord in itself, does not necessarily create difficulty; since, if this part be very delicate, we do not employ it in our attempts, to free the uterus of the placenta— therefore, in such cases, the placenta derives no advantage from its preservation, as regards its unaided delivery; but it may be of important service, should it be necessary to relieve it by the hand. 1241. It \\\\\ follow from what has been said, (1240) that it is not always necessary to make an artificial case of a rup- tured cord; for the expulsion of this mass is nowise promo- ted by its preservation, if the cord be too feeble to act with it; delivery, therefore, in such case, must depend upon the .spontaneous efforts the uterus makes to clear itself of this burthen, and not upon any force that may be applied to the funis. 1242. But, though the preservation of the cord may not aid us in our attempt to deliver the placenta when it is too tender to be an agent, yet it is highly important, notwithstanding, that it should be carefully preserved; especially as we cannot determine a priori, the cases in which it may be necessary to deliver this ing in hsmorrhagy from a partial separation of the placenta; for the rule of conduct where it is too adherent, and attended by flooding; for rules to be ob- served, in hemorrhage from atony of the uterus after separation of the placen- ta; &c. see Section oil "Hemorrhage before the placenta is expelled," &c. 57 450 ASSISTED DELIVERY OF THE PLACENTA. mass, artificially; for, during its continuance within the uterus, some accident may attack the patient, and render it indispensa- bly necessary to interfere and hasten its delivery. 1243. It may, however, be remarked, as a general rule, that the placenta is longer in descending when we cannot aid it by the the cord, or when the cord is separated from it, than when it is strong and preserved — the reason is obvious. We should, there- fore, in such cases, promote the contraction of the uterus by fric- tions; and, from what I have experienced of the action of the er- got, (1221) 1 should be induced to give it a trial before I would pass the hand into the uterus; for the hand should not be intro- duced until it has been satisfactorily proved that the ergot had failed. 1244. Should we not succeed by these means in relieving the uterus of its burthen; and, especially, should any accident com- plicate this period of labour, we must introduce the hand, and de- liver the placenta. The difficulty in this case is no greater than in common cases, provided the cord, (however feeble it may be,) is preserved, since this will, with proper management, conduct us to the placenta, as certainly as a stronger one — but if it be sepa- rated, a great deal of embarrassment may be sometimes created, by not being able to distinguish the placenta from the uterus, if this mass be not detached; if it preserve its connection with the uterus, the unskilled hand will find much difficulty in distinguish- ing it from the surface of this organ. a. The Si'gjis hy which the Placenta may he detected. 1245. The following marks will, however, lead to the detec- tion of the placenta; 1st. If the fingers pass over the internal sur- face of this body, its vessels, distended by blood, will generally be distinctly felt; 2d. If the placenta be pressed by the fingers, the woman will scarcely perceive their presence; whereas, if the uterus be touched, she will complain; 3d. If the hand be placed over the uterus, externally, opposite the one within the uterus, the thickness of the parts will declare, whether it be the placenta which interposes between them, when this mass is on the ante- rior part. h. The mode of acting in this case. 1246. When it is ascp"tained that the hand is in contact with ASSISTED DELIVERY OF THE PLACENTA. 45). the placenta, the latter must be cautiously separated from the uterus, by insinuating the fingers between them. There is some- times a difficulty in getting behind the placenta, in consequence of the membranes interposing between the hand and the surface of the uterus. To overcome this hinderance, the hand should be placed behind the membranes, and then permitted to travel up to the placenta itself, and effect the separation. 1247. Should the placenta be found loose in the uterus, it must be taken hold of and withdrawn. 1248. I have a few times met with difficulty in the delivery of the placenta from its excessive size. These instances have uniformly occurred in cases of permature delivery, or rather where the delivery was not premature, but where the child had died some time before its birth. In the particular cases alluded to, the children were not found putrid; but, on the contrary, were hard and rigid, though a little swoln; the funes were always much enlarged, very tender, and engorged with a brown blood; the placentas were found in these cases to distend the uterus so much, as to give the suspicion, to those unacquainted with the nature of such cases, that there was a child remaining in the uterus. 1249. In looking over my records of these cases, I do not find one that did not require the introduction of the hand for its de- liverance; and, in two of these, the placentae were so enormously large, as to nearly fill a common-sized chamber pot. This pro- digious increase appeared to be owing to the infiltration of water into the meshes of the placenta. In all the cases of the kind now under consideration, no aid was derived in the delivery of the placentae from the funes, as they were uniformly found so frail as to not permit any force to be applied to them. ( 452 ) CHAPTER XXXIIL OF PUERPERAL CONVULSIONS. 1250. This truly frightful disease may attack a woman, per- haps, at any period of utero-gestation; but more frequently after the sixth month. Dr. Lyman says, " it seems to be a question with some writers, whether the disease we are considering, ever attacks antecedently to labour. I believe, we may very safely answer this in the affirmative. I do not recollect having seen it earlier than the latter part of the seventh month."* 1251. I do not recollect at this moment having met with any writer who has questioned the liability of the pregnant woman to convulsions. I am certain this opinion must be wrong, as I have witnessed a number of cases of convulsions where labour was not present, and where there was no reason to believe this process had any agency in their production. That women are much more liable to this disease when this process is about to commence; or after it has advanced, is agreeable to all observation; and that labour frequently follows a few days after, as Dr. Lyman ob- serves, is equally true: for we believe with him, that the partu- rient effort has very often, either a direct or indirect agency in their production; or in other words, is the exciting cause. The causes assigned for convulsions have been various; some have supposed they arise from some peculiar irritation of the uterine fibre from pregnancy; others considered them truly epileptic; while others regard them as nervous, or hysterical. 1252. This difference in views, necessarily leads to a difference in treatment — the first, makes safety consist alone in immediate delivery; the second, forbids the practice; while the third, relies upon the use of opium. From what I have seen of this formida- ble complaint, I am persuaded, that there is no one cause con- stantly operating to produce puerperal convulsions; nor is there any one mode of cure applicable to all cases. To be successful in the management of this complaint, it is necessary that at- tention be paid to the species of this disease, with which the woman may be attacked; I have, therefore, from a conviction * New England Journal, No. IV. >'ol. III. third Series, p. 344. PUERPERAL CONVULSIONS. 453 that they do not all depend upon one and the same cause, divided them into; first, epileptic;' second, apoplectic; and third, into the hysterical; each of which may attack under two distinct con- ditions of the uterus, and requiring from that circumstance a dif- ference of management. 1253. Convulsions are almost always preceded by symptoms which denote their approach; in the epileptic species, the premo- nitory symptoms may exist a number of days before convulsions show themselves; it is uniformly attended by a strong determina- tion to the head, producing an engorgement of the vessels; hence, head-ache of greater or less intensity, ringing of the ears, a tem- porary loss of vision, giddiness, &c. are alwayspresent before the convulsive stage shows itself. From these symptoms being fol- lowed by convulsions, I have always, when consulted upon such occasions, advised the immediate loss of blood, pretty smart purg- ing, and an abstemious diet. By thus anticipating the attack, I feel assured I have in a number of instances prevented this terri- ble disease. 1254. Some are attacked by a severe pain in the stomach, which Dr. Denman considers as more fatal than when the head is the seat of pain; of this I can say nothing from my own experience. I may remark, that the longer the premonition, the milder the attack appears to be. In the most suddenly fatal case I ever saw, the patient suddenly cried out, " my head, my head!" convulsions instantly ensued, of which she died in a few hours — See Case IV. 1255. Pregnant women may be attacked with convulsions from causes not connected with gestation, or at least with labour — as the attack is not accompanied with any signs of it. These, if my observations be correct, are more unmanageable and fatal, than when pregnancy may be the remote cause. When pregnancy is instrumental in the production of convulsions, it is almost always at that period, when the uterine fibres are at their greatest stretch; where the os uteri is disposed to dilate; or where they suffer from some peculiar irritation, over which we have no control; or some inconvenience from the contents of the uterus, which has the same effect; and such convulsions are almost always of the epileptic species. 1256. These convulsions, so far as my observations have ex- tended, are never preceded by an aura, as in epilepsy, properly • We do not pretend by this term to insist on its character being the same as in true epilepsy— the term is only adopted, from the want of one more strictly perhaps appropriate. 454 PUERPERAL CONVULSIONS. SO called. But after the patient has suffered for a longer or short- er period the symptoms just named, (1253) she is seized with quickl}^ repeated spasms — the face and eyes are twitched in all possihle directions, with incredible quickness — the arms, legs, nay, the whole body, is violently agitated — one side is sometimes more affected than the other; the face becomes flushed, livid, black; the tongue is strongly thrust forward between the teeth, by which it is almost always severely wounded. Respiration at first is much hurried, and eventually becomes almost suspended; the ca- rotids beat violently; the jugulars are much distended; a pecu- liar sibilating noise is made by the mouth, not unlike what Is termed " a cat spitting;" froth issues from the mouth, tinged with blood from the wounded tongue. The pulse in the beginning is full, frequent, and tense; but quickly becomes rapid, small, and eventually almost imperceptible;* the urine and fasces are some- times discharged involuntarily; a cold clammy sweat bedews the whole body, and the fit begins now to decline. 1257. The convulsive motions gradually subside — they never cease suddenly and at once — their force and frequency abate; the pulse becomes more distinct and less frequent; the breathing is less hurried, and less oppressive; the face loses part of its lividi- ty; the muscles are agitated but at intervals, and their action re- sembles the commotion excited by passing a brisk electric shock through them, and eventually they sink into repose. The patient, however, remains for the most part insensible or comatose, with stertorous breathing or loud snoring; she cannot be roused by any exertion for some time, and if she recover for a moment her scattered senses, she is without the slightest recollection of what has passed. This truce is almost always of short duration; con- vulsion follows convulsion, without our being able to determine the period or cause of their return. 1258. When convulsions attack a woman absolutelyjn labour? or when this is about to take place, we may observe a pretty re- * I do not remember to have witnessed .the condition of the system mention- ed by Dr. Lyman; namely, "oedema, and a remarkable slowness of pulse as the precursors of convulsions," p. 347. I have often remarked the bloatedface after the attack, but never an cedematous condition of the system previously to it. Not that this condition of the system, especially of the lower extremities is uncom- mon, but that I have never found those who were subject to it, more liable to the attack of convulsions than those in whose system this condition did not ob- tain. Indeed, it would seem that tliey should be less obnoxious to it, as this class of females arc rarely so plethoric as others, as effusion in the cellular tissue seems to relieve this over-fulness. PUERPERAL CONVULSIONS. 455 gular occurrence of the fits with the probable return of the pains — for though the patient be insensible to external occurrences, she appears to manifest by her moans, and the suspension of re- spiration, her sensibility to uterine contraction. This appears to me to be so manifest and decided, that I think I could tell what is going on at the mouth of the uterus, without an examination per vaginum. 1259. The face becomes very much swoln, especially the lips and eyelids; indeed the whole body seems to partake in a greater or less degree of this intumescence, but in no part so conspicu- ously as the face. So completely is the countenance changed, or rather disfigured, that oftentimes it could not be recognized by the dearest or most intimate friend; nor does this swelling im- mediately subside with the convulsions which caused it; it fre- quently remains many days after they have ceased. Dimness of sight, nay, blindness for weeks, are not unusual consequences of this disease. 1260. In the apoplectic species we have nearly all the premo- nitory symptoms enumerated above, (1253) but of much shorter duration.* It may, like the epileptic, attack at any period of * In a case of this species, which fell under my notice some time since, I thought it was not accompanied by either as much frothing at the mouth, or with as much sibilation, as in the epileptic. Mrs. , aged seventeen, preg- nant with her first cluld, complained, on the 20th of July, 1824, of slight pains resembhng labour; and also a general diffused pain, but severest in her limbs; so much so, in these parts, as to render her almost incapable of moving them; some fever, though slight. Dr. Shaw, under whose care she was, ordered her to be bled and purged. 29th, 3 o'clock A. M. was attacked witii labour pains; .at first they were slight; but had much increased by the time tlie doctor was called. Upon examination, the os uteri was found a little opened; and at 8 o'clock A. M. was attacked with strong convulsions, which were repeated about every twenty minutes. She was bled about twenty ounces; convulsions continued to recur. At 10 o'clock the same morning, the os uteri was pretty well dilated; and from a belief that convulsions were at least maintained by uterine distention and irritation. Dr. Shaw ruptured the membranes, with a hope of tranquillizing them. At tliis time, I was called in. I found the patient totally insensible to any external impressions; nor had she discovered any sensibility after the second fit; breathing with considerable difficulty, and snoring pretty loud. The pulse was full, frequent, and hard, and the skin hot. Upon examining per vaginam, tlie liead of the child was found at the lower strait, presenting with the poste- rior fontanelle behind the left foramen ovale, and entirely witliin the uterus— up to this time, about thirty -five ounces of blood were drawn. She was attack- ed with a fit soon after examination. There was something remarkable in the character of her convulsions — her eyes were but little agitated : tlie pupils much 456 PUERPERAL CONVULSIONS. gestation, but does not always necessarily produce, or be accom- panied by labour. From this, it would appear it may be brought on by causes independent of pregnancy, though this process may with propriety be regarded as an exciting cause; for it sometimes takes place when this process is at its height, and labour is no otherwise accessary to this end, than increasing by its efibrts, the determination of blood to the head. This species may perhaps ■with much propriety, be considered only an exalted degree of the epileptic — in this, the epileptic, there is perhaps only engorge- ment; in the other, there is almost constantly efiusion. 1261. In the hysterical species, we have not the same train or continuance of the premonitory symptoms. If head-ache attend, it is neither so severe nor so permanent; there is a ringing in the ears, globus hystericus, and palpitation of the heart. The face is much less convulsed — less vacillation of the eyes, while the larger muscles of the body are much more violently agitated; the pa- tient, at times, is very obstreperous: and the muscles on the pos- terior part of the body are almost always violently contracted ; so much so, that the body will sometimes describe an arch back- ward. I have considered this last circumstance, as strongly marking this species of convulsion. The face is much less flush- ed, than eiiher of the two other species ; but never pale, agree- ably to my observations, as some have remarked."* 1262. There is no frothing at' the mouth; and the peculiar sibilating noise which so strongly characterizes the first, and per- haps the second species, is entirely wanting in this — the patient, after the fit can, for the most part, be roused to attention, or will frequently become coherent, so soon as she recovers from the contracted; hei' face was but little suffused; there was less frotliing at the moutli, and less sibilation tlian is usual. I applied the forceps, and deUvered her in a few minutes without the slight- est difficulty. She remained after this for two hours without a fit; at the expi- ration of this time, they recurred about every half horn-, until nine o'clock, P. M. when they ceased, but without any amendment in the condition of the patient — she appeared completely apoplectic. She continued much in this situation until six o'clock in the evening of the 31st, at wh'ch time she died. Leave could not be obtained to inspect the body. She did not complain of head-ache until the 29th, and this but a short time before she became con\'ulsed. She lost, alto- gether, eighty -two ounces of blood; was freely purged, and once cupped. * Dr. Lyman says, "it is particulai-ly important that we should know how to distinguish puerperal convulsions from such as are purely hysterical." p. 351. In this 1 fuUy agi-ec; and I should have felt grateful, had he added to our know- ledge in diagnosis, by observations of his o\\ n. He has however, laid down no mai-ks by which we can distinguish one species from the other. PUERPERAL CONVULSIONS. 457 fatigue or exhaustion occasioned by the violence of her struggles; and, though she may lie apparently stupid, she will, nevertheless, sometimes talk, or indistinctly mutter. After the convulsion has passed over, she will often open her eyes, and vacantly look about; and then, as if suddenly seized by a sense of shame, will sink lower in the bed and attempt to hide her head under the clothes. The pulse is much less disturbed, nor does it ever ac- quire that extreme velocity and tenuity it does in the other two species, for respiration is never so much in danger of being sus- pended.* 1263. This species attacks women of delicate and nervous ha- bits; the recovery from it is always more rapid, and never, so far as I have observed, leaves any imperfection of vision. 1264. As nothing is so satisfactory, as regards the application of remedies for any disease, as the detail of cases, in which their routine is exhibited, I shall make no apology for inserting the following from my "Essay on Puerperal Convulsions." See "Essays upon various Subjects connected with Midwifery." Case First. Mrs. , a delicate small v/oman, twenty-three years of age, pregnant with her first child, was attacked, on the 16th of No- vember, 1809, at 8 o'clock, A. M. with epileptic convulsions. I saw her in an hour after the attack; previously to my seeing her, she had had three fits, and a fourth was coming on just as I en- tered the door. Three or four days previously to the attack, she complained of a violent jaw or tooth-ache, which was looked upon as rheumatic, and no attention was paid to it. On the 15thj that is, the day before her illness, she was seized with an extreme- ly acute head-ache; and, during the night, and just before the onset of the fits, she was violently sick at stomach, and vomited a large quantity of thick glairy mucus; immediately after this she said she could not see, and was in a few minutes more seized with convulsions. She laboured under these violent and * Doctor Lyman says, "every variety of the disease is to be regarded as dang-erous; for though a patient should appear but slightly injured by the first attack, a subsequent one may prove suddenly fatal." p. 350, loc. cit. I have never seen death follow the hysterical species; though the convulsions may have been very violent. Nay, females who are subject to this afteclion, are some- times occasionally affected with convidsions during the whole period of utero- gestation, and this without disturbing its economy — the same may be said of constitutional epilepsy. 58 458 PUERPERAL CONVULSIONS. terrific symptoms in an extreme degree. I instantly bled her from a large orifice in the arm 3xxxv. by measure; this, as I have just said, was at 9 o'clock A. M. Eleven o'clock, had two fits during my absence, and was now in the tliird — bled 5xii. Ordered a strong infusion of senna as an enema — os tincse a little opened, but rigid. One o'clock, P. M., had two fits since last visit — injection operated — pulse still active — face flushed — very restless and uneasy, arising, as I believe, from the pains in the uterus — OS tincse rather more dilated — to be bled by cups ^x. Four o'clock, P. M., one fit; cups drew well; senna operated again two or three times; very comatose — ordered cold applications to the head by means of a large bladder, partly filled with water and some ice — blisters to the legs. Seven o'clock, P. M., no fit since last visit — pulse very active — very restless, constantly mak- ing efforts to get out of bed* — os tineas not much more dilated; took 5X. blood; senna continued to operate. Ten o'clock, P. ^I., no fit since last visit; pulse still too active; took 5X. more of blood ; cold applications. Seventeenth, Mr. Purnell, now Dr. Purnell, one of my pupils, staid all night with the patient. He said she had one fit, after which he took fx. of blood; senna con- tinued to operate. At 10 o'clock, A. M. I saw her; stupor much less; recognized her friends, and asked some questions; she did not see well, a slight squinting was observable. Seven o'clock P. M. better, pulse less active; but had three stools since the morning visit. Eighteenth, Mr. de la Motha, now Dr. de la Motha, another of my pupils, staid with the patient last night. She passed a good night, was tranquil and rational; no return of fits during the night; two stools. Saw her at 10 o'clock, A. M., skin dry and hot, face a little swelled, but perfectly collected. Eight o'clock, P. M., face more swollen, and a little flushed; much head-ache, pulse very active; great thirst; took 3X. of blood, much relieved by it; pulse softened, and diminished in fre- quency; cold applications continued. Nineteenth, passed a good night, free from fever andpam; no return of convulsions; bowels rather tardy; ordered senna tea. Continued much in this condi- tion until 2Sth, twelve days from the first attack; this morning was seized with brisk labour-pains, and was soon delivered of a dead child. From the degree of putridity, it is presumable that the child died early in or before the attack. On this case it may be proper to remark: 1st. That the child * I have considered this as a pretty certain sign of labour going- on. PUERPERAL CONVULSIONS. 459 had not been felt to move for several da3-s before the patient was taken ill — but this is by no means a certain proof of its death. 2d. Signs of labour were manifested on the first day of the illness, but were evidently suspended, or at least not progressive, after the second. I occasionally examined for several days, but found the OS tincae so rigid, as to preclude the idea of manual assistance; it was therefore not attempted. 3d. Had manual aid been resort- ed to, I have no hesitation in believing it would have been ex- tremely injurious. 4th. That the convulsions were controlled ten days before delivery took place, although from the state of the uterus, it was evident it would sooner or later take place. 5th. That the attack commenced between the seventh and eighth month of pregnancy. The lady's next pregnancy was not at- tended by this untoward accident; strict attention was paid to her during the whole period of gestation. She was kept on a milk and vegetable diet — her bowels were kept open. She was occa- sionally blooded, especially when she complained of head-ache — she took, for several months, three or four doses daily of the tincture of foxglove, with, I think, evident advantage; and was at the proper time happily delivered of a fine child. In her third pregnancy she attended much less to herself, and was not under medical restraint, in consequence of which she was again attack- ed by convulsions, and was held very much as above related, with the exception that labour was much more rapid. Her fourth pregnancy was again fortunate, as she again submitted to medical direction. Her fifth pregnancy I have understood was again un- fortunate, and attended with convulsions like two of the former — I did not see her in this last pregnancy, having been absent in the country when it happened. Case Second. Mrs. , aged twenty-six years, pregnant of her first child — a large plethoric robust woman, was, on the 9th of September, 1811, at about five o'clock, A. M. taken with labour-pains, and sent for her midwife; before the midwife arrived she was seized with terrible convulsions, and 1 was immediately sent for — the fits were frequently repeated, and were from their extreme vio- lence very threatening — her face was immediately swelled — her eyes fairly protruded from their sockets — her tongue terribly wounded, &c. 1 instantly bled her from the jugu^r vein more 460 PTTERPERAL CONVULSIONS. than three pints — examined her, and found labour approaching — ordered a brisk injection — saw her two hours after — had had several severe fits — pulse extremely active — labour advancing — bled her twenty ounces — injection repeated — a stream of cold water was poured on her head during the interval of the fits — eleven o'clock, A. M. fits not so severe, but pretty frequent — pulse still very active — took a quart of blood — apparently much relieved — lay quieter — one o'clock, P. M. had had two or three fits — very restless — mourned every few minutes, desirous of get- ting from the bed — bled her ^xii — examined and found the head low in the pelvis, and delivered with the forceps — she had two or three fits after delivery; and remained insensible to everything for forty-eight hours. She now began to show some signs of re- turning sensibility — was bled twice in the interval — cold was applied to the head, and legs blistered — she was purged freely by senna tea. After this, she gradually recovered her senses. She was left completely blind for two weeks; she then began to see imperfectly, but was six weeks before she could distinctly discern objects. It may not be amiss to observe, the child was living. This case is remarkable, on account of the severity of the dis- ease, and the large quantity of blood that was drawn in the short period of a few hours. She lost in the first six or seven hours of her illness, one hundred and twenty ounces of blood, and about one hundred and forty altogether: a quantity that might at first sight startle the timid or inexperienced practitioner; but when he reflects that here was a patient labouring under one of the most ferocious complaints in the whole catalogue of human dis- eases; the brain threatened with immediate destruction; the pa- tient of prodigiously full habit; one who not only neglected the kindly warning of head-ache, giddiness, and occasionally loss of vision, by not having recourse to bleeding — but, contrary to the advice of her midwife, fed freely, and remained long costive — what then could avert the threatening consequences of this dis- ease, but the most prompt and the most subduing remedies? Had not the bleeding been carried to the extent it was, I really believe it would have been unavailing. Even as it was, it did not prevent temporary blindness. Her second pregnancy was not attended with any untoward circumstance. PUERPERAL CONVULSIONS. 461 Case Third. Mrs. , Nov. 10th, 1797 — pregnant with her second child, and in the eighth month, was seized while at the ironing-table with vertigo.* She fell, and was immediately attacked with con- vulsions. T was living near; and was instantly sent for — I found her labouring under the general symptoms of this disease — I bled her from both arms at once, and took from each arm nearly, if not quite, a quart of blood. She appeared for a short time much relieved; that is, the convulsions were abated — I examined her, but found no change in the os tincse. An injection was ordered, which operated well — about an hour after the bleeding, her pulse rose very much ; her breathing was more laborious and sterto- rous, and some convulsive twitchings played over the whole body. She was entirely insensible to all external impressions — the pu- pils of the eye were much dilated; fearing a violent repetition of the convulsions, I again tied up the arms, and took about twenty-five ounces more of blood — this seemed again to moderate the symptoms — no change in the os tincse. Four o'clock, P. M. three hours after the attack, the convulsions were renewed with considerable violence — she was let blood to the amount of twenty ounces — cold water was poured on the head — she was again more tranquil, but not less comatose, though the breathing was less loud; she had a copious black stool. Six o'clock, P. M. had had several fits, but not as violent as at first — pulse still too active; took eighteen or twenty ounces of blood from the arm — as the pulse was now considerably reduced, applied a pair of blisters to the legs, and sinapisms to the feet. Ten o'clock, no convulsions since last visit, breathing freer, but loud — swallowed a little water with some difficulty — passed no water since the attack; introduced the catheter, and drew off a large quantity — had two stools — made an effort to vomit. Eleventh, six o'clock, A. M. was called to her suddenly, as her breathing was becoming more laborious and loud, and face more flushed, with some convulsive agitations; pulse rather too active; had ten ounces of blood by cups, and a large blister placed between the shoulders. From this time there was no return of convulsions. She gradually re- covered her recollection, but remained until some time after her * She had comp>ained. all the morning of intense head-ache, and several times said she could not see — slie was advised to leave off work, but would not. 462 PUERPERAL CONVULSIONS. delivery, (which took place at the regular time, and with a living child,) with imperfect vision, especially in one eye. She was, for many years after this, subject to violent head-aches, whicli were relieved constantly by bleeding. She had several children after this attack, without convulsions. Case Fourth. Mrs. , October 1, 1803, had been in labour several hours; she had every appearance of being happily delivered of the fifth child, when, during a strong pain, she instantly cried out, " my head, my head!" and immediately fell into convulsions. She was under the care of another physician, to whose aid I was instantly called by his own desire — the convulsions were strong, and very frequently repeated — she was largely bled ; on examination, the child was found to be far advanced, and was speedily delivered by the aid of the forceps — the convulsions, however, continued in spite of every exertion to relieve them, and she died in about three or four hours from the attack. Leave was obtained to open the body; the longitudinal sinus of the dura mater contained, (by estimate,) between two and three ounces of blood; the pos- terior left ventricle was filled with a bloody serum — the other ventricles appeared sound, as did the other parts of the brain — no other part was examined. Case Fifth. Mrs. , aged 24, pregnant for the first time, was taken in labour on the 10th March, 1797 — her labour proceeded regularly, and the child's head was at the inferior strait, and every rational expectation was entertained of a speedy delivery, when she sud- denlj' cried out with pain in her head, and declared she could see no one in the room; these symptoms had continued but a few minutes, when she was seized with convulsions — she was under the care of the late Dr. Shippen, who requested that I might be sent for, and desired I would bring my forceps with me. I found the patient in a strong fit, with her face literally as black as a negro — it was agreed she should be bled extensively — this was done from the left jugular vein, to the amount of nearly two quarts; it had an immediate eflect in tranquillizing her. I now examined her, and found the head low in the pelvis; I applied the forceps, and delivered her of a dead child. Upon examina- tion, it was found there was another child ; the uterus soon dis- PUERPERAL CONVULSIONS. 463 covered a disposition to act; but fearing injury from delay, I immediately delivered by the feet; which were the presenting parts; the child was healthy and did well: the mother had no return of fits, and she rapidly recovered the use of her health, ex- cepting that of her eyesight, which did not return, so as to dis- cern objects, for several days; and her vision was very feeble for several weeks. Case Sixth. I was called on the 10th of July, 1811, to Mrs. , who was, at the moment of my arrival, and had been for a consider- able time before, in a strong convulsive paroxysm. I found se- veral men diligently employed in holding her, and opposing her motions; she was raised in the middle like an arch, while her feet and head nearly met. She was between seven and eight months pregnant and subject to hysterical affections. — She was thrown into this by some altercation with one of her neighbours — cold water was dashed in her face, and she was blooded to the amount of sixteen ounces. The spasms began to give way soon after, and in the course of about fifteen minutes ceased. She sighed very deeply, and struck her arms very forcibly against the bed, and in a few minutes more, inquired what all these men were doing with her. I gave her fifty drops of laudanum, and two tea-spoonfuls of the tincture of assafoetida in some sweet- ened water, and she had no return of the fit. — She went her full time without a repetition of them, and was safely delivered of a healthy child. I shall now subjoin two other cases, to show of how much con- sequence a proper distinction is, in the treatment of puerperal convulsions. Case Seventh. I was called on the 1 6th of April, 1810, to Mrs, — , said to be in strong convulsions. I was from home when the messenger arrived, but went so soon as it was in my power. When I went into the sick chamber, I found Dr. with the patient. He told me " Mrs. had been attacked about two hours before with convulsions, and was in the ninth month of pregnancy — that, pre- viously to the attack of the fits, she had complained of violent pain in the forehead, which she told her husband she could cover with her finger. She had this pain several days, but it was much more 464 PUERPERAL CONVULSIONS. iniense this morning, and was attended with a sensation, as if a piece of hlack gauze was before her face. She was stooping for some time over a trunk, in which ?he was arranging some articles, when she was seized and fell on the floor in strong convulsions," She was now lying senseless and v^^ithout motion on the bed; she breathed very lieavily, and snored loudly — her face much swoln and of a purple hue — the pulse frequent and small, and the extremities cold. I inquired what had been done, and was in- formed by Dr. he had given her, twice, sixty drops of laud- anum at a time, and that since the last dose she had had no fit, and was, in his opinion, very much better, requiring nothing but sleep to restore her. — I told him very plainly, that I thought he had mistaken the patient's case, and had, in my opinion, sealed her fate by the use of the laudanum, — He appeared alarmed, but not altogether convinced, — We did everything that we thought might be useful J but all exertion was unavailing, and the patient died in about three hours. — I could not procure leave to open the body. About three months after the above event had taken place, viz. on the 20th of July, 1810, the same gentleman was called to Mrs. , labouring under convulsions. I was sent for at his request. Before I arrived, he had bled the patient very freely, (40 ounces,) by which she was considerably relieved — she was near her full time of gestation. From her peculiar motions and breathing, I suspected labour had commenced — she was examined, and the os uteri was dilated to about the size of a dollar. It was, however, pretty rigid. The convulsions returned with considerable force; the patient was again bled about thirty ounces; a stimulating in- jection was thrown up the rectum, which operated freely; the mouth of the uterus was now well dilated ; I turned, and delivered a living child. Mrs. had one fit after delivery, but it was not severe. She recovered her senses and feelings on the second day after delivery, and no other inconvenience was experienced, except some dimness of sight, and slight head-ache. Several days before the attack of convulsions, she had complained of the head-ache, and that particular sensation of a nail being driven into the head, and also an occasional loss of sight. The two cases just related, form a happy contrast in the mode of treatment; the first case proving so unfortunate, made a strong INVERSION OF THE UTERUS. 465 impression on the mind of Dr. , who very properly profited by it in the second case. He candidly confessed they were as si- milar as any two cases of disease could be, and declared himself much shocked at the reflections which the unfortunate case gave rise to. In every case of convulsions, it is but too common for bystand- ers to oppose, by strength, the contractions of the agitated muscles. This practice cannot be too severely reprehended; for it is both injurious and unnecessary; it subjects the patient to severe mus- cular pains, which last for very many days after the fits subside. All that should be done in such cases is, to prevent the patient doing herself mischief, or to prevent her from throwing herself from the bed; and as a very moderate exertion is sufficient for this purpose, therefore, violence should never be employed. CHAPTER XXXIV. ON THE INVERSION OF THE UTERUS. 1265. This untoward, and too fatal accident, is, perhaps, more frequent than is commonly supposed. Instances of sudden death after delivery often remain unaccounted for;* and there is every reason to believe, that this displacement of the uterus is sometimes the cause. Examinations of women who have died during labour, or soon after delivery, are not so frequent as their importance seems to demand. This indifference to examinations after death, arises, first, from an adequate estimate of their value, even by • Levret in his chapter, " sur la cause la plus ordinaire, de la mort subite, &c. tres peu de temps a]n-es I'accouchement," attributes the greater part of such deaths to the want of contractile power in the uterus, thereby giving rise to fa- tal haemorrhages. He does not appear to have been aware, that the partial in- version may be a cause of death, or in some instances contribute to it, as he passes without notice this cu'cumstance in the case he quotes from Mauriceau; who says, on opening the body, " nous trouvames le fond de la rtiatrice un peu deprime enbedans, comme est le cul d'une fiolle de verre, au lieu d'avoir une figure rond, comme on le voit ordinairement." Obs. 230. Wliile Ant. Petit thought the "inversion of the uterus to be impossible;" and declared that those authors who mention tliis condition of tlie uterus, had mistaken a polypus at- tended by a i)rolapbus of tlie vagina for it. i9 466 INVERSION OF THE UTERUS. medical practitioners; second, from the aversion most people feel to have their friends' remains disturbed; third, to the disingenuous conduct of the attending physician himself^ who may not wish the cause of death to be ascertained, lest it should do injury to his character, either from his not having known or suspected the true one, or by exposing some lesion for which he fears the world would hold him accountable, though he had no agency, either di- rectly or indirectly, in producing the accident by which death has been produced. Hence, as I have just observed, this complaint is, most probably, every now and then concealed; and therefore, the frequency of the inversion of the uterus in producing death, cannot be exactly estimated. 1266. Inversions of the uterus may be either complete, or in- complete — by a complete inversion, I mean the passing of the fun- dus and body of the uterus through the os externum, or being turn- ed entirely inside out, to the very mouth of this organ; when this takes place the mouth of the uterus is looking upwards, and is within the cavity of the abdomen. But it is not necessary to the complete inversion, that the body and fundus escape through the OS externum; as this condition may happen, and yet the uterus be concealed within the vagina. 1267. Mr. Burns says, when the inversion is complete, the fun- dus is " protruded out of the vagina." This is not essential to the definition; since, I have known the uterine tumour to pass through the OS externum, without entirely inverting the neck to the mouth; and again, I have known the inversion to be complete, and the fundus not escape from the vagina. 1268. The incomplete, is where neither the body nor fundus have entirely escaped through the os uteri, and may be in differ- ent degrees; first, the simple depression, or where the fundus falls down to the mouth of the uterus; but is prevented from passing through it, by the latter being contracted; or the force may have been insufiicient for thisjpurpose; second, where it has passed perhaps half its length through the os uteri; third, where it is com- pletely inverted, with the exception of a portion of the body and neck. In the two latter conditions, the body and fundus may be compressed or strangulated, by the neck of the uterus contracting forcibly upon the protruded part; or it may be free from this re- straint; each of these presents different indications. 1269. Proximate cause. — For the uterus to become completely inverted, several circumstances must combine; first, the fundus INVERSION OP THE UTERUS. 467 must most probably contract, while the body and neck must be flaccid ; second, a force or weight must be applied to the fundus, which is capable of making it descend through the os internum: this force may be a power applied to the cord; and the weight may be the placenta itself, when it is engrafted immediately upon the fundus, or the pressure of some of the abdominal viscera, &c. But let it be remembered that, in the incomplete, the mouth of the uterus looks downwards, or into the vagina, and is always within the vaginal ■portion of the jjelvis, though completely filled hy the descending jioy^tion of the body of the uterus. See par. 1266. See Plates XIV., XV., XVI., XVII. 1270. Remote cause. — The remote cause of this accident, is the want of power or disposition, in the body and neck of the uterus, to contract. This may be occasioned by an over-disten- tion of this organ, from an excess of liquor amnii; from the unu- sual size of the foetus; from a compound pregnancy; from hsemor- rhagy; from passions or emotions of the mind ; from exhaustion, in consequence of previous disease; from long-continued uterine efforts to effect delivery, &c. 1271. Symptoms. — When this accident takes place, the woman almost instantly complains of a severe and distressing pain about the region of the uterus ; an effort to force or bear down; nausea, and sometimes vomiting; great faintness, with more or less hae- morrhage; cold clammy sweats; pulse small, frequent, or ex- tinct. A variety of nervous symptoms may also occur of a most distressing kind, arising most probably from the new situation tlie abdominal viscera are forced to take, when deprived of the sup- port of the uterus. 1272. If we examine per vaginam, it will be found that the vagina is occupied by a firm resisting tumour, covered by the placenta, or otherwise, as the period may be at which this acci- dent occurs; or the fundus and body may be pushed through the OS externum, either bare, or covered by the placenta. This ca- sualty may take place immediately after the birth of the child; or it may not occur for hours, or even days, after this event.* If * A very remarkable case of "complete inversion" taking place a long time subsequently to labour, is given with great clearness and accuracy, by Mr. Watkinson, in Med. and Phys. Jour. Vol. VII. p. 433. This case was of long duration, and eventually and suddenly fatal, after it had been amputated by cuttirig through the prolapsed and inverted vagina. Mr. AV. assigns, as the cause of death, the relaxed state of the os uterij and perhaps of the uterus it- 468 INVERSION OF THE UTERUP. the hand be now placed upon the abdomen, we shall fail to find the uterus, 1273. Incomplete. — The incomplete must have the same ge- neral causes as regards the effect upon the fundus and body — that is, the fundus cannot be supported by the body, from its loss of power, by the operation of either of the same remote causes, (1270) but is prevented from entirely passing through the neck, by the latter contracting, and arresting it within, or only permit- ing it to pass in part. The same general train of symptoms oc- cur, but this condition is almost always attended with a greater discharge of blood, than when the inversion is complete.* If an examination be carefully made per vaginam, the fundus of the uterus may be detected in one of the situations mentioned for this species or variety of inversion, (1268.) 1274. The incomplete inversion, we have observed, has va- rious degrees of derangement; namely, from the simple depres- sion, (1268) to the entire escape of the inverted body of the ute- rus; but they are not equally distressing or dangerous, though neither condition is free from risk. Thus the simple depression, is not necessarily as fatal as when the fundus alone has passed through the os uteri; and the latter not so full of danger, as when the inversion more nearly approaches to being complete. Per- haps mere depression, unaccompanied by haemorrhage, might not be absolutely fatal; but as there can be no possible security against this condition, longer than the placenta preserves its en- tire connection with the uterus, it must be regarded as a case of possible, nay of probable danger; and consequently, should never be trusted after it is detected, 1275. The symptoms, however, in each of these degrees of in- version, differ only in intensity; for all are marked by a peculiar- ity of suffering, the force of which, will very much depend, upon the extent of the displacement of the fundus and body of the ute- self, occasioned by the long-proti-acted hasmorrhage, and the formation of co- agula; in expelling the latter, the uterus was perhaps inverted. * It is a remarkable fact, that less blood is lost when the uterus is completely than when it is partially, inverted. This is not, perhaps, of difficult explana- tion; since, when the inversion is complete, the uterus contracts to a certain extent; and by this contraction, the now internal surface of this organ is made to impigne upon the vessels which carry blood to it, and thuslnterrupts or cuts off' fresh supplies of this fluid. It may also be proper to observe, that haemor- rhage is never so suddenly alarming, in cases of inversion, as it is when it arises from the uterus being in a state of atony, and the placenta detached from it. INVERSION OP THE UTERUS, 469 rus, and the constricting force of the os uteri through which they may have passed. For instance; the simple depression will be marked by less suffering, than when the fundus has passed the mouth of the uterus; and the alarming symptoms in the last case, will be in proportion to the contraction of the os uteri; if this be feeble, the risk, and sufferings, will be comparatively moderate; but when the stricture is very severe they are not only of the most distressing kind, but highly dangerous. Yet each of these con- ditions may accidentally be equally dangerous, though not equally alarming in the intensity of their symptoms. Thus, the simple depression, may be as fatal as a more extensive displacement, in consequence of the profuseness of the flooding which may attend it, though the sufferings of the patient may be much less severe than when the inversion is more extensive. (See Case I.) 1276. The mechanism of inversion is sufficiently simple; it seems to require but a state of atony of the uterus to produce it, with, (perhaps,) more or less pressure upon the fundus of this organ; or, possibly, the mere contraction of the fundus, and the implantation of the placenta on this part. When this derange- ment takes place before the delivery of the after-birth, we have much reason to suspect that its weight, as well as its location, materially contribute to its production — this location of the placenta, indeed, seems to be almost a sine-qua-non to inversion; for we either find the placenta discharged from the vagina, or else attached to the fundus of this organ; now, had the placenta been attached to any portion of the body of the uterus, that part must have contracted that it might be thrown off; and that con- traction of the body of the uterus, most probably would have given such support to the fundus as to have prevented its falling down. 1277. It is almost universally believed, that an undue force applied to the cord for the delivery of the placenta, is the princi- pal cause of this accident; but in this I differ from such as have adopted this opinion ; and for the following reasons: first, because the accident has occurred after the delivery of the placenta; se- cond, because it has taken place, when no such force has been applied.* But the caution, not to apply much force to the cord * In evidence of this, Mr. Welsh says in his account of a case of inversion, that, " on dividing- the funis to remove the child, I was extremely surprised to 470 INVERSION OF THE UTERUS. to deliver the placenta is founded upon just and important prin- ciples; since, did the disposition to inversion exist, and this mass be attached to the fundus, it would be almost certain to produce it; whereas, perhaps, without such force, the woman might escape from the danger. 1278. Mr. Burns, after enumerating several causes of inver- sion, such as pulling of the cord; the too sudden delivery of the child when the cord is too short, &c. says, " from the same cause, or sometimes perhaps from sudden pressure of part of the intes- tines on the fundus uteri, occasioned by strong contraction of the abdominal muscles, a part of the fundus becomes depressed like a cup, and encroaches on the uterine cavity. - This generally rectifies itself if let alone." I would inquire, for the sake of in- formation, how this dipping of the fundus is known to exist? and how it is ascertained, that it " generally rectifies itself if let alone?" 1279. I can readily comprehend, that an unusually short cord, with the sudden expulsion of the child, may produce inversion, even when there is no disposition to atony in the uterus; as the fundus may be dragged down at the instant relaxation is about to take place; but I confess myself entirely at a loss to comprehend what Dr. Merriman* may mean by a short cord, when its length permitted a child, by a sudden effort of the uterus, to be "thrown to the extremity of the bed," though this cord was " naturally short, besides being twice passed round the child's neck," and the placenta retained, " though low in the pelvis." Quere, if this be a short cord, what constitutes a long one? 1280. The indications in inversion are simply these; first, to restore the prolapsed fundus when practicable; second, to pre- vent a reinversion after restoration; and third, if the fundus can- not be restored, to prevent death by taking off" the constriction oc- casioned by the contraction of the mouth of the uterus. 1281. When the fundus is prolapsed to the mouth of the uterus but contained within it, should the mouth of the uterus be suffi- ciently yielding, the hand must be gradually passed through it, and the fundus carried upward until restored — if the placenta has been thrown off", we need but retain the hand within the ute- findthe uteru3 completely inverted, and lying without tlie labia, on tlie thigh. ' — Load. Med. andPhys. Journal. Vol. F! p. 451. * Dcuman's Midwifery, Francis's ed. p. 514. INVERSION OP THE UTERUS. 471 rine cavity, until we have sufficient evidence of its disposition to contract, and to maintain that contraction. If the placenta has not been thrown off, it will be found either loose or adherent — if loose, it must be withdrawn with the hand, after we are satisfied that we may trust the uterus to itself. If adherent, we must gently separate it after the uterus shows signs of returning power, and wdien separated, it must be taken from the uterus, when the hand is retracted. It is more than possible that the mouth of the ute- rus may contract so firmly in this species of inversion, as to pre- vent the introduction of the hand to restore it. In this case, shall we act upon the hope that this case "generally rectifies itself if let alone," or shall we attempt the restoration of the fundus by some safe mechanical contrivance? Might not a stiff piece of whalebone, or tough wood, armed by a piece of rag, be employed with a prospect of success? for we must ever deprecate violence to the mouth of the uterus. 1282. Should the fundus have escaped in part through the mouth of the uterus, it should be as quickly as possible returned, by pressing the most depending and central portion of the tumour, gently, steadily, and perseveringly in the direction of the axis of the OS uteri until it retire; then if it do not return to its proper situation by its own resiliency, we must pursue it with the \\^j^d. through the mouth of the uterus, nor should it be left unsupported until placed in situ. And the hand must be kept in the uterus, until, by the contraction of the uterus, there is assurance it may be withdrawn with safety. 1283, We now and then meet with cases, in which therelaters would seem to persuade us that some especial providence had in- terfered to save their patients, since they record departures in the animal economy that can be accounted for upon no other principle. Now, nothing is more to be dreaded than the atony of the uterus after delivery; we have already declared it to be, (1270) one of the remote causes of the "inversion of the uterus;" and every body acknowledges it to be the reason why haemorrhage takes place after delivery, when the placenta is separated, either par- tially or altogether. Yet we find mention of a case of inversion by Dr. Loftier, in which the fundus of the uterus could not be re- tained after reposition, owing to the loss of the tonic power of this organ, but again and again descended through the os uteri.— " The fundus uteri having receded through the orifice of the uterus, ■ I pursued it with my hand, which I kept in the uterus, waiting for 472 INVERSION OP THE UTERUS. the contraction of this organ. But after I had continued in this position about half an hour without perceiving any contraction, I was obHged to withdraw my hand, when the fundus immediately descended, but was prevented passing through the orifice." A variety of things were done for twelve hours to promote the con- traction of the uterus, as stimulating injections into its cavity, frictions, &c. but all to no purpose; for the uterus remained in the same flaccid state, and he was at last under the necessity of propping up the fundus by a tube made of horn. This was ef- fected without much difficulty; the lochia passed off properly, &c. and the woman recovered. Now this case is altogether a miracle! — a woman had an uncontracted uterus; a separated placenta; and yet there was no haemorrhage!!! — at least no mention is made of any, though the uterus remained days uncon- tracted. * 1284. If the placenta offer itself before the prolapsed fundus, we may, if detached, deliver it immediately; but if it be adherent, and the mouth of the uterus does not offer too much resistance, it must be carried up with the fundus, and separated, as before directed, (1281). Should we, however, find much opposition to reduction, and this evidently, in part, arising from the bulk of the mass to be restored, it will, (perhaps, )t be best to separate it care- fully, and then carry up the fundus. 1285. Should the inversion be complete, it will, for the most part be impossible to restore it, J especially if several hours should have elapsed after the accident. Dr. Denman says, " the impos- sibility of replacing it, if not done soon after the accident, has been proved in several instances, to which I have been called, so early as within four hours, and the difficulty will be increased at the expiration of a longer time. Whenever an opinion is ask- ed, or assistance required, in those cases which may not impro- perly be called chronic inversions, it is almost of course that the * Med. and Phys. Journ. Vol. n. p. 207, ■\ I say "perhaps," because I cannot speak more positively upon a subject on which my experience is so limited. The propriety of this practice I wish to leave to farther observation, for having met with but four cases of " inversion,"^ I think that number inadequate to establish the best mode of practice. t I would not dare to say, it would be impossible to restore tlie uterus after its complete inversion; though I beUeve it, at tliis moment. § Since ike above period J kuue been several more cciaei of inversion. Sec note lo par, 1301. INVERSION OP THE UTERUS. 473 reposition should be attempted ; but I have never succeeded in any one instance, though the trials were made with all the force I dare exert, and with whatever skill and ingenuity I possessed ; and I remembered the same complaint being made b)'^ the late doc- tors Hunter and Ford ; so that a reposition of a uterus which has been long inverted, may be concluded to be impossible. It seems as if the cervix of the uterus continued to act, or had soon acted in such a manner, as to gird the inverted uterus so firmly, that it could not be moved." This account of the impracticability of restoring the fundus when the inversion is complete, is in strict conformity with my own experience. 1286. It is true, it is said, that the uterus has been reinstated after "complete inversion ;" but of this we may justly entertain doubts ; for the one recorded by Mr. White, purporting to be of this kind, was certainly not one of ''complete inversion." In Mr. White's patient, we recognize nothing more than a partial one, as the symptoms declare. Mr. W. says he saw the patient about an hour after the accident, and "found the uterus of the size of a large new-born infant's head, totally inverted.''^ Yet he declares the woman " was in great pain, and had lost much blood ;" neither of which circumstances attends complete inversion ; for it seems to be agreed, that there is not much haemorrhage at this time, and I know that pain immediately ceases when it becomes com- plete, as I shall state presently. 1287. This patient "was very faint, and no pulse could be felt in either arm :" a condition which constantly attends the partial inversion ; especially, when the mouth of the uterus contracts firmly upon the body, producing a strangulation of the uterus : which was precisely the situation of Mr. W.'s patient ; for he de- clares " the neck was a little contracted." Now, it must be obvi- ous upon a moment's reflection, that, if the inversion were com- plete, the mouth of the uterus cannot be felt ; for this part now offers its opening to the cavity of the abdomen, and is not tangible by the finger. See case second, and Plate XVI. 1288. There is a condition of the partial inversion, where it is as certainly impossible to restore the fundus, as if the inversion were complete ; and this is, where the fundus and a part of the body have passed the os uteri, and the latter contracts, " so as," as Dr. Denman expresses it, "to gird the inverted uterus firmly, so that it cannot be moved. '^ When this happens, the stricture occasioned by the contracted mouth, is so firm and resisting, that 60 474 INVERSION OF THE UTERUS. a finger cannot be passed between its edge and the confined ute- rus — in this case, I believe it to be impossible to pass the fundus, as the constriction would not yield to any force we could use with safety. 1289. This variet}^ of partial inversion, produces the most ter- rible and alarming symptoms imaginable; pain, faintness, vomit- ing, delirium, cold sweats, extinct pulse, convulsions, and, if not speedily relieved, death. Under such sufferings, when all hope of restoration is at an end, I have advised, with a view to termi- nate them, and to preserve life, that the fundus and body should be drawn still farther down, so as to complete the inversion. Should the placenta be attached, it must be carefully separated before we draw down the fundus. 1290. The propriety and safety of this plan, are, it must be con- fessed, predicated upon the happy result of a solitary case; but, from its entire and speedy success in this instance, it is rendered inore than probable that it will be of equal advantage, if employ- ed in others. " All reasoning upon the subject," is certainly in its favour; and experience, so far as a single case may be entitled such, is equally so. See note to par. 1301. 1291. Should the practitioner, however, be so fortunate as to meet with a case where the mouth does not confine the protruded part, he should attempt restoration, however large a portion of the uterus may have passed through the os uteri, by gentl)?-, but firm- ly compressing it, so as to reduce its size; having first removed the placenta, if not previously done, and urging the prolapsed part upward in the axis of the os uteri. In such a case, perseverance may, I am willing to admit, do much, and it ought most certainly to be tried if there be the smallest chance of success. 1292. The chance, however, should be clearly ascertained, by carefull}^ examining the condition of the constricting part — if it be soft and yielding, a hope may be indulged that the resistance may, by proper proceeding, be overcome. If this friendly condi- tion obtain, there will be, beside this pliant disposition of the os uteri, an absence from all, or nearly all the terrible symptoms just enumerated (1289); but, if he cannot find the mouth of the uterus by a careful examination after the placenta is removed, and if there should be an absence of the train of appalling symptoms above named, he should desist at once from every attempt at re- duction, as his efforts will not be attended by success; and the con- INVERSION OP THE UTERUS. 475 tinuance of them will not only give his unhappy patient niuch unnecessary pain, but will hasten her death. 1293. The mode to be pursued, when it is necessary to com- plete the inversion, is simply to place the woman upon her back near the edge of the bed; and have her legs supported by proper assistants — the hand is to be introduced along the inferior part of the vagina, but sufficiently high to seize the uterus pretty firmly; it is then to be drawn gently and steadily downward and outward, until the inversion is completed; this will be known by a kind of jerk announcing the passing of the confined part through the stricture. Traction should now cease, and the part be carefully examined; if the inversion be complete, the mouth of the uterus will no longer be felt, and there will be an immediate cessation of pain, and other distressing sensations. 1294. The proposal just made, "to convert an incomplete in- version into a complete one," in cases in which it is deemed im- possible to place the fundus in situ, is either an important im- provement in the treatment of this complaint, or is a most mis- chievous direction: it therefore not only merits, but absolutely requires a dispassionate, and candid examination. In inquiring into the merits of this case, I shall lay aside every feeling of self- love that might reasonably be supposed I would cherish, as the author of an original, and perhaps a highly important suggestion; and I will, also, as far as either my experience, or my reading shall enable me, give the subject a temperate, and liberal con- sideration. 1295. In this investigation, I will first inquire into the nature of the case, which is supposed to require this operation; second, determine the situation, and condition of the parts, after the in- version is complete; and third, investigate the cases, which pur- port to be cases of complete inversion, and in which, the uterus is said to have been restored to its natural situation. 1296. I. It has been always found, when the greater bulk of the uterus has passed the os uteri, that the most alarming symp- toms inunediately ensue; and if the parts be not speedily relieved from this unnatural situation, the case will almost constantly ter- minate in death. (See case first.) The terrible symptoms just spoken of, arise from that portion of the uterus, which is below the circle of the os uteri, becoming strangulated by the firm and obstinate contraction of the neck, by which it is now surrounded, to say nothing of the new situation of this organ — namely, its inter- 476 INVERSION OF THE UTERUS. nal surface forced to become the external. Everybod)^ conver- sant with the anatomy of the uterus after parturition, will ac- knowledge, that the portion of the uterus which passes through the mouth in a case of inversion, is vastly greater than that por- tion which constitutes the neck; especially, when the latter has a disposition to contract by virtue of its tonic power. Now, this contraction must take place before the threatening symptoms can show themselves; consequently, the part which is protruded must very much exceed in size that through which it has escap- ed. For the body and fundus of tlie uterus, even in the natural relation of these parts to each other, are much larger than the neck of this organ; and when they are newly freed of their con- tents, and are fully engorged with blood, those proportions are increased; and such is the disposition of the neck of the uterus to contract, that in most instances it is found to be small and resist- ing, very soon after deliver}'; while the body and fundus, though in the healthy exercise of their powers, remain for a long time comparatively large. It must therefore follow, that unless the bulk of the body and fundus can be reduced to the size of the constricting circle of the os uteri, or the constricting circle be enlarged to a dimension equal to that of the body and fundus, one cannot be made to pass through the other. 1297. II. The situation and condition of the parts, after the m- version is complete, is very different from what they were before this had taken place. These changes consist, 1st. In the entire removal of the constriction, in consequence of the neck of the uterus itself becoming also inverted; and consequently, every portion of the body and fundus being removed below its grasp. 2d. By the capacity of the os uteri being still more diminished; as it is no longer distended by a portion of the body of this organ; consequentl}', the body and fundus are increased in size, if not positively, certainly relatively, while the capacity of the mouth is diminished; as the latter naturally becomes smaller than the former. The uterus will now resemble a pear suspended by its stem; (see Plate XVII.) and the relative proportion between its extremities is pretty much in the same degree, as that which ex- ists between the two extremities of a pear. 129S. The uterus in a state of complete inversion, is suspended by the upper portions of the vagina, and can be pushed a consi- derable distance upwards into the pelvis, if we press its fundus in tliat direction; or, by a contrary force, it may be dragged to INVERSION OF THE UTERUS. 477' some distance beyond the os externum; consequently, it is capa- ble of considerable motion. 1299. Now, in order that the body and fundus may be restored after inversion, they must return through the contracted mouth of the neck of the uterus; and with a view to explain the nature of the difficulty that must be encountered in the attempt to perform this operation, let us take an example from a suspended, pear- shaped, gum elastic bottle; and the material, by which it is sus- pended, capable of bearing but a limited degree of force. Let us imagine, however, in our example, that we wish either to produce its inversion, or to restore it, after it has been inverted. If we adopt the latter, (for it is more analogous,) we must take for granted, that the neck, from some cause or other, had lost its power of resistance, and had permitted the fundus and body to pass through it; and that now, it is our design to restore them; but at a time when the neck has recovered its powers, and is now in a state of contraction, or resistance. I will ask any man of can- dour, if under such circumstances he would think it possible to restore the fundus and body; (if we may so term the two portions of the gum elastic bottle ;) we are well persuaded that he will not, and for the following reasons: 1st. Because the neck of the uterus, or of the bottle, if we pursue the example, is now nearly, or quite at its minimum size, while the body and fundus preserve a greater size than natural; and consequently are much larger than the neck. 1300. 2d. Because there is too great a disproportion between the size of the body to be passed, and the opening which is to permit it to do so, if the natural relation of the parts exist, which in this instance must be admitted. 1301. 3d. Because, though it might be possible to. make the mouth of the uterus yield, by a sufficient force being directly ap- plied to it, yet we cannot in this case take advantage of this pro- bability ; since our force can only be applied in one way, and that way an imperfect one; namely, by urging the fundus towards the constriction, and attempting to make it pass the contracted mouth of the uterus. But in this consists one of the difficulties of the operation ; for, be the body and fundus of the uterus either firmly contracted, or comparatively flaccid, great difficulty would be experienced in pressing the centre of the fundus towards the axis of the mouth, if it be even practicable,* • In two cases of inversion, one complete and the other nearly so, I persever- ed in the attempt at reduction, nearly two hours. The plan I pursued, in both, 478 INVERSION OP THE UTERUS. 1302. 4th. Because, if the fundus be thus carried to the mouth of the uterus, it cannot be made to pass, from the excess of its bulk, and the resistance of the contracted mouth, unless a force be employed that shall overcome all opposition; and if this be ap- plied, the vagina at its union with the neck of the uterus will yield sooner than the mouth of the uterus. 1303. 5th. Because, Drs. Denman, Hunter, and Ford, have (1285) all confessed, they failed in every attempt they had made lo restore the fundus in a complete inversion; and I will most candidly add, that the same failure has attended my exertions, after the best directed, and the most persevering endeavours, I could devise. 1304. 6th. Because, no pressure, or force however well-direct- ed, hovvever long-continued, can diminish the fundus and body and I believe It is the only one which promises success, was, after grasping the bulk of the protruded part firmly, but gently, for half an liour, with the inten- tion of dispossessing it as much as possible of blood, and thereby reducing its bulk, I then placed the ball of my thumb to the centre of the fundus, and gently and steadily pressedit in the direction of the axis of the mouth. After contin- uing this pressure for a long time, I found my thumb buried in an indentation of about an inch in depth, which encouraged me to persevere a considerable time in the same kind of force. At one time I thought my efforts were about to be crowned by success, as I believed I was making the fundus encroach upon the circle through which it must pass, before it could be reduced. But I was too soon convinced my hopes were delusive; for upon an accurate examination of my proceedings, I foimd my supposed progress was altogether owing to the straining of the os uteri at its connection with the vagina; and I was obliged to abandon an enterprise that at one moment I had flattered myself was about to be successful, as my patient's strength was fast weai'ing away. The only re- maining chance, as I believed, was to complete the inversion; this I did with- out difficulty. It afforded relief; but the patient was too much exhausted to profit by it; she died thirty-six hours after. It maybe proper to mention that when I first saw this patient, she was nearly exhausted by hemorrhage and suf- fering and almost pulseless. After completing the inversion, she seemed to improve as a moderate reaction took place; but it was short lived; she sank after this time not to be again roused. The other case which happened within a short time, (April, 1827,) the patient was not much exhausted; as the mid- wife became early alarmed, and I was sent for soon after the accident. I have reason to believe, the midwife completed the inversion by dragging at the pla- centa which brought the fundus of the uterus throug-h the os externum. This was reduced after a few minutes, by gently and firmly pressing it upwards in the direction of the vagina. I persevered in this case, as industriously and as steadily as in the other, and with no better success. Tliis woman labours under a considerable bloody discliarge, but which is gradually diminishing; and is re- covering strength slowly .f f I have seen this patient within a few days, (Oct. 1827.) She has nearly recov- ered her usual strength, but is still pale and sickly in look. INVERSION OF THE UTERUS. 479 below the natural size of the mouth of the uterus, when this is in a state of contraction. 1305. III. I shall now examine such cases as purport to be in- stances of reduction, after " complete inversion." From what I have already said upon this subject, it will be seen, that a very indistinct notion has been entertained of the complete "inversion of the uterus;" and if our definition be referred to, (12G6) and admitted, as it certainly should be, I think it will be easily shown, that no one instance in which it is said re-inversion was eflfect- ed, was a case of " complete inversion."* 1306. We have already given our reasons for not allowing Mr. White's case to have been one of " complete inversion of the uterus," (1286) and the same argument will apply to all such as purport to be of this kind, as far as I have had it in my power to examine them. Thus we find a case stated in the '' New England Journal," Vol. I. third series, p. 264, which is called a case of complete inversion, and in which reduction was effected. The relator says, "the attending physician pulled gently at the cord; immediately the placenta pushed forward, protruded at the exter- nal orifice, and was followed by the uterus, completely inverted. The placenta still adhering, he separated it with the fingers, and returned the organ as he siqiposed into its proper placeA On Saturday, (the day after the delivery,) the patient was taken out of bed, when the uterus immediately protruded out of the body, followed by a copious discharge of blood. Dr. was in a few minutes called in, and pushed the protruded uterus within the vagina, supposing that this was all that was necessary to be done, or rather concluding he had returned the prolapsed part into its original situation. The loss of blood was considerable, so much so as to jjroduce syncope, from which she was gradually restored by cordials, friction, and volatiles. A moderate discharge still con- tinued to flow till about twelve o'clock at night, when the pulse began to sink, accompanied with faintness and great prostration of strength." "Upon examination," says the relator, "I found the uterus completely inverted, occupying the whole of the vagina, the neck reaching above the pubis."" He then declares, the fundus by proper manipulation, was restored. This case, however, proved eventually fatal. • Ml*. Nevvnham makes the absence of the neck surrounding the prolapsed part essential to a complete inversion. f We presume he intends to be understood, by the words "returned the or- gan into its pi-oper place," that he restored the protruded body and fundus to their natural situations. 480 INVERSION OF THE UTERUS. 1307. This case, we may safely declare, was not one of "com- plete inversion" of the uterus; and for the following reasons: — First, because the phenomena were not those which accompany a complete inversion; there was too much haemorrhage, and too many distressing symptoms.* Second, because, the author ex- pressly and conclusively determines this point, by saying, "Me neck of the uterus reached above the ptibis." I have already pointed out the situation of the mouth and neck of the uterus in the complete and incomplete inversion of the uterus, in par. 1285. 1308. In a review of my "Essays on various subjects connect- ed with Midwifery," by a writer in Vol. III. No. II. p. 157, of the third series of the New England Journal, &.c. I tind the following observations in reference to my proposal of converting a partial inversion into a complete inversion, when there is no chance of restoring it, and the symptoms are threatening. " The practice in this case," (case second,) " was successful in rescuing the pa- tient from imminent danger. It left her the subject ofiywerted uterus the remainder of life. This last fact makes the question of adopting Dr. D.'s method a very serious one, and in considering this question we are met by others. Is there no chance of reduc- ing the uterus after the stricture has been removed in the man- ner proposed above, and should not its reduction be attemjjted either immediately after, or as soon as the patient is enough re- cruited to endure the fatigue, and pain of a trial? A case has been related to us of at least two days standing, in which the phy- sician having grasped the uterine tumour in his hand, gradually compressed it, and after a long-continued effort, succeeded in re- ducing this organ. This was related by the physician who per- formed the operation. The inversion here was complete^ and this may make such a difference between the cases as to render it ques- tionable whether similar means would be applicable to both." 1309. This critique involves a number of separate propositions, which we shall notice in their order. First, " It left her," (the patient,) "the subject of inverted uterus for the remainder of life." The question which presents itself to meet this objection, is simply, whether an accoucheur is not bound to avert death • " But it is worthy of notice that, frequently, complete inversion is not ac- companied with haemorrhage." Burns, p. 516. This obtained in Dr. Hamil- ton's case, and tliis is ageeable to the observations of others. In Dr. Denman's case II. which was a case of complete inversion, he says, " tlic hemorrhage was not profuse.'- INVERSION OP THE UTERUS. 481 when it is in his power? or, at all events, is he not bound to do, at the moment he is obliged to decide, the best he can for his patient? This certainly will be answered in the affirmative: for he has no right to inquire whether death might not be pre- ferable to life, upon the terms he can give that life. For if he decide that it is, and he permit his patient to die, rather than sub- ject her to the penalty, that the preservation of her life will im- pose upon her, he is guilty of a species of murder. It is there- fore decidedly his duty, his imperious duty, to preserve life when it is in his power, be the terms of that preservation what they may. 1310. If this be granted, it will also be ceded I trust, that I was acting strictly in the line of my duty, in affording the only apparent chance for life, or even of comfort, to an almost expir- ing woman. 1311. That it was an experiment, is granted; and its success was yet to be proved; it turned out fortunately, and rescued the patient I honestly believe from death; and if the history of this case be carefully read, (case second,) it will be seen, that it was considered altogether hopeless, after the attempt at reduction, which was conducted with all the little ability I was master of, had proved fruitless ; and that the patient might be considered in "articulo mortis;" I therefore think there can be little doubt, that I did the best the situation would permit. 1312. I would ask, for information, what better, could have been done under the existing circumstances? for the patient was almost expiring; and would have very quickly died if relief had not been afforded. The attempt at restoration, the only one on which we could rely, it is seen had failed ; the " anceps reme- dium,''^ presented itself; and it proved successful. But let me now be clearly understood upon this subject, as declaring, that the proposition in question, is never to be acted upon, but as the dernier resource ; and that I have never proposed it but as such, will, I think distinctly appear, if what I have said be carefully read. 1313. It is asked, " is there no chance of reducing the uterus after the stricture is removedV^ I would ask in turn, can the stricture be removed? Has the writer ever known it removed? If he have not, I think the question answers itself, since we have no control over it; and we fear we cannot have, as a little reflec- tion on the situation, and functions of the parts, will show almost Gl 482 INVERSION OP THE UTERUS, its impossibility; for which reason I am decidedly of opinion that a " complete inversion" never has been reduced. It is true we may suppose a case, and then deduce the possibility of restora- tion in complete inversion — we may imagine the neck of the uterus to be in a state of relaxation ; and if it be so, no difficulty in the restoration of the fundus, presents itself. But let this con- dition be proved to exist, before we speculate upon the advan- tages that v.'ould result from such a state of things. See par. 1268 and 1339, &c. and fig. XVII. 1314. It will be seen at once, by reference to the structure of the parts concerned in this accident, that the structure in question is nothing more nor less, than a natural, or functional condition of the OS uteri ; for a state of contraction is thp natural state of this part, when its functional powers are in a healthy condition; conaequently, it ahvays closes after the contents of the uterus are discharged. It seems, that the writer of the article under consi- deration, looks upon this stricture, " as an accidental state of the OS uteri, and that this condition can be removed by remedial agents ;" than which in our opinion, there can be no greater error. If this <' stricture" was the effect of spasm, or of some accidental state of the os uteri, we might perhaps, find a remedy for this unfortunate condition of the part; or it might, after a given time, relax itself; but when it is well known to be the natural result of its structure, and that nothing but force can possibly overcome it, we may look in vain, I fear, for remedies to relax it. 1315. If the OS uteri were flaccid during an inversion, the chance of restoration would be greater, nay nearly certain ; but as this condition can only be the result of a diseased state of this part, it will only take place from an accidental combination of circumstances, which we can neither command, nor control. The only agent we have at command, is mechanical force ; now, we know, that this power can very rarely be suecessfuly, or even safely employed, for the reason above suggested, (par. 1300, 1301, 1302, 1303, &c.) I shall mention, however, presently, that this relaxed condition of the os uteri, sometimes exists. 1316. But, with a view to render this suggestion certain; or at least occasionally successful, it is stated in the gross, that re- storation had been performed after complete inversion, by a phy- sician who gave the account himself. He says, that he had re- stored the fundus after the lapse of forty-eight hours, and that the "inversion was complete." We are not favoured with any of INVERSION OF THE UTERUS. 483 the particulars of this case to prove it to have been complete; we are obliged to abide by a bare ipse dixit, which seems to be at once contradicted, by the very mode employed for the reduction, as we shall attempt to show. See fig. XVI. 1317. But before we proceed farther, let us observe, that the term " complete inversion" has almost always been vaguely em- ployed. When the fundus of the uterus escapes through the os externum, it is called by Drs. Denman, Merriman, Mr. Burns, M. Leroux, and others, a complete inversion of the uterus; there- by, making the situation of the fundus the distinctive sign of a complete inversion, instead of the condition of the neck of the uterus. Now if this definition be admitted, we may look for many instances of the reduction of a "complete inversion," without a single genuine instance occurring to authenticate the success of the operation. For I have seen more than one instance of partial inversion, in which the fundus was protruding the external parts; and could cite many more. 131S. The reviewer farther states, that "there was a period in the above case, (case second,) in which reduction might have been performed." This, however, is merely opinion; and cannot be either proved or disproved, yet with a view to this, he says, *. 442. f Revue Med. loc. cit. OF TWINS, &c. 497 1341. The uncertainty whether a woman be pregnant of one or more children, fortunately is of no consequence, until the la- bour has positively commenced; for, previously to this time, our conduct in every respect should be the same, as if there were but one child. But at this period it would in many instances be ex- tremely useful, when the children were offering untowardly ; as the cause of difficulty would then be ascertained, and the indica- tions fairly declared. In cases of twins, the situation of the chil- dren, either as regards themselves, or the pelvis, may be more or less favourable, and consequently, complicate the labour in proportion. 1342. The situation of twins or triplets may be such as regards each other, as to offer almost insuperal difficulties to delivery. Such was the case, in the history of a twin labour, given by Dr. Erwin; the head of one fajtus was placed so closely over the neck of the one which presented the breech and was delivered all but the head, that this part could not be made to descend by any force, or ingenuity, that this physician could employ. The crotchet was resolved on and used; after this, by great exertion, the head was extracted; but to the surprise of the gentleman, it was uninjured by the crotchet. This pointed out the situation of the heads of the children as stated above. 1343. Dr. Clough* also met with an instance, in which great difficulty was experienced, but not equal to the one related by Dr. Erwin; such cases bid defiance to rules: everything must be left to the good sense and discretion of the practitioner. 1344. Twins may, first, be enclosed in one common covering of membranes, and inhabit the same nidus, and float in the same waters; second, they may each have a separate amnion, while the^horion may be common to both; third, each may have its own membranes, waters, and placenta. 1345. The different siluation in which twin children may be placed while in utero, especially the two first, (1344) disturb every projected scheme, with respect to impregnation; they un- settle that which has been hitherto thought pretty well proved, as regards the ovaries, the fecundation of ova, and the absolute nature of the ovum itself; and throw into confusion that which has been thought clear; or, they oblige us to extend our notions * Lond. Med. Journ. vol. 25. 63 498 OF TWINS, &c. of the powers of the corpora lulea, very much beyond what they have hitherto been. 1346. They disturb (1344) all the schemes for impregnation, since they all suppose, that each ovum is a separate and distinct germ, and included in distinct coverings; yet two are found in- volved in the same common covering with two umbilical cords, and with one placenta. It unsettles that which has been thought pretty well confirmed as regards the ovaries, to wit: that they furnish ova for impregnation, upon different portions of its sur- face, yet two embryons are found to bathe in the same waters, and with one placenta for their support; providing, it would seem, that an ovum may contain more than one germ, which may be fecundated at one and the same time. They throw into confusion that, v/hich has, especially of late, been thought perfectly clear and well understood, as follows: that the corpora lutea furnish the ova for impregnation; that each corpus luteum yields its own oyum, and that each ovum brings with it, from its nidus, its own chorion and amnion; yet they are both found common to two children ; or the chorion alone common, and each has its amnion; yet with distinct cords and a placenta in common — now I would ask, how this can be, agreeably to our present notions of impreg- nation? Does it not oblige us to extend the powers of a corpus luteum, and make us admit, that one ovum may contain the ru- diments of two foetuses, or oblige us to call in question the ar- rangements just spoken of?* (1345) 1347. The third situation of foetuses in utero (1344) proves, that two ova may furnish embryos with their own coverings, since they exist separately and distinctly in some cases of twins: and their separate existence renders it more than probable that they were the product of different ova, and as probable that tach issued from a separate ovarium. For, if we do not admit this, we must allow that, which not only wants proof, or even pro- bability, and ver}'' much more difficult to reconcile; name- ly, that a fallopian tube can successfully transmit two ova * May we not reasonably doubt, that two children can float in the same wa- ters as an original disposition of them? May we not suppose that the muscular exertions of the children may have broken the separating membranes, and thus permitted the waters to unite? For it cannot be doubted, that they have been found together: as Dr. Denman (Francis's ed. p. 541,) tells us, his fi-iend. Dr. Sims, informed him of a case of twins, where the funes were so closely twined together, as to appear but one. OP TWINS. &c. 499 at one and the same time, or consecutively; which, agreeably to all the present known schemes of the ovum getting possession of the uterus, would be very difficult to reconcile, though not per- haps, impossible; but by admitting a simultaneous action in the tubes, and each ovarium furnishing an ovum, the explanation is easy; therefore to be preferred. But a truce with speculation. 1348. The labour of a woman pregnant with twins, begins in every respect like a labour in which there is but one; but its pro- gress in general is neither so regular nor so rapid. The latter circumstance is not difficult to explain; since it is impossible that either child can receive the undivided influence of the contract- ing uterus, and therefore, it cannot be so rapidly expelled; or they may be so situated as to impede, if not to oppose, each other's exit; hence, the labour is slower, at least with the deli- very of the first of the children; but with the second it may be quicker, nay, even rapid. This being the case, if we could even determine before hand, that the labour is a twin case, we should not alter our conduct, except there be something in the labour itself, which would require interference, independently of its be- ing a compound pregnancy. 1349. In general, nay almost always, we do not know we are encountering a twin case, until after the birth of the first child; we may then suspect this to be the case; 1st. When the child is small, compared with the size of the abdomen of the mother, and the quantity of water discharged; 2d. If the abdominal tumour have not subsided as much as if it were a single child ; 3d. Because the child may be felt through the abdominal and uterine parietes; 4th. Because there is, in general, a renewal of uterine contrac- tions, and the child can be felt per vaginum, if its membranes have given way, or the membranes themselves when distended with the waters if they are entire. 1350. After the birth of the first child, and we have ascertain- ed that there is a second, it then becomes a question, what is to be done with the second? Accoucheurs seem to have puzzled themselves in answering this plain and simple question, and have attempted to lay down rules, which are calculated to embarrass, rather than instruct, the inexperienced practitioner. The rule upon this subject is plain, and void of all ambiguity, since it is founded upon the disposition and situation of the uterus itself. Baudelocque alone is rational on this subject. 1351. I have said the rules of practice in cases of twins, after 500 OF TWINS, &C. the birth of the first child, were free from all difficulty or ambi- guity; for after one child is expelled, one of two things must hap- pen, either that pains will pretty quickly ensue, and deliver the second if its position be natural, or that there will be a suspension of pain. 1352. If the first case obtain, we must conduct the labour, as if it were an original labour, and not to be interfered with so long as there is a rational expectation that nature is competent to relieve herself; and if this promise be not made, or seasonably fulfilled, we must interfere as upon any other occasion, where interference might be necessary. When pains follow the expul- sion of the first child, there is every expectation they will accom- plish the delivery of the second; first, because it will receive the whole influence of the uterus, which was divided before; second, because the subsequent pains will be more powerful than the antecedent ones; since the uterus is now smaller, and its tonic contraction more perfect, which, (cseteris paribus,) always in- creases the alternate contractions of this organ; third, because the parts have been dilated, and are of course made to yield by the passage of the first child ; therefore thepe is less resistance to be overcome. 1353. If the second situation, namely, where there is a suspen- sion of pain, our duty is equally clear — for it will depend altoge- ther upon the situation of the uterus itself. This condition will consist in its being uncontracted or contracted. 1354. If in the first condition, it will be attended with hsemor- rhage,* or be free from it — if with flooding, we are to deliver as we would in any other case of haemorrhage, and be regulated by the same rules which govern upon such occasions; if no haimor- rhage be present, we must solicit the contraction of the uterugby frictions upon the abdomen, until it contract. If it be contracted, and pains do not pretty soon follow, I have long thought it best to make the labour an artificial one, and for the foUov/ing rea- sons.! 1355. First, because if pains do not come on in the course of a half hour after the tonic contraction of the uterus is well esta- blished, it is altogether uncertain when they will take place; and • The same may be said of eitlier of the other accidents that may complicate a labour. (651) f I believe it would be a good general rule of practice, when the contractions are feeble, or very far apart, to administer the ergot. OF TWINS, &0. 501 the patient is then left in great anxiety for the event; second after the expulsion of the first child, a haemorrhage or other acci- dent may ensue which will oblige us to deliver under all the em- barrassments it gives rise to; third, there is nothing to apprehend in terminating the labour, as the tonic contraction is secured; and no difficulty can be created, since the uterus will readily permit turning, if the head present; or to deliver, as directed when either the breech, feet, or knees present, when there is a necessity of making an artificial labour of the case; fourth, we remove at once the anxiety of the woman; which, if long continued, may have a very unfriendly influence upon the powers of the uterus. 1356. All rules of conduct, taken from the lapse of time, are liable to very serious objections; for mere waiting does not insure the proper condition of the uterus to render our acting safe; and we are never to proceed to delivery if that proper condition, (1201, 1202) does not follow^ however long we may have waited, for, at the end of four hours, (Dr. Denman's* rule,) it may be just as im- proper to deliver, as it may have been at fifteen minutes after the birth of the other child; and if contraction justifies us to deliver at the end of four hours, it justifies us at any intermediate period at which it may take place. And if we are to act at the end of four hours be the condition of the uterus what it may (for nothing is said of the state of this organ), we shall as certainly do mischief by our interference if the uterus be not contracted, as if we had acted at any other antecedent period. If then we do not insure the contraction of the uterus by waiting, we gain nothing; and it will be proper, therefore, to act whenever we are assured, that the powers of the uterus are in full and healthy play, be this when it may. 1357. Should any of the enumerated accidents (651) compli- cate a labour of twins, we must act as in any other case; taking care at the time, to distinguish tlie proper feet, when we are about to bring them down, and when both sets of membranes are rup- tured: but if they are not, and we discover it to be a twin case in proper time after we have commenced the operation, to be care- ful not to rupture the membranes of the remaining child. If the breech, feet, or knees ofier, we must bring down the feet, or act upon them, as has been directed — or if the head present, and the labour be far advanced, we must use the foiecps, though * Introduction, Francis's ed. p. 540. 502 OF TWINS, &c. we are certain it be a twin case. Or should any thing untoward take place during the transit of the second child, we must act as the nature of the case requires, without reference to its being a twin. 1358. In my estimation, Mr. Burns* lays down two very doubt- ful rules for the management of twin cases — the first is, that " if effective pains do not come on in a quarter of an hour, the child ought to be delivered by turning." The second is, " if the posi- tion of the second child be such as to require turning, we are to lose no time, but introduce the hand for that purpose before the liquor amnii be evacuated, or the uterus begin to act strongly 071 the childy 1359. If we were to act agreeably to these directions, we should almost constantly have cause to repent the enterprize; for we certainly should do mischief by exposing the uterus to a state of atony; and thus provoke, perhaps, a fatal hsemorrhage. I must repeat, in such cases, we should pay no regard to the time which may elapse after the birth of the first child; it Ts to the condition of the uterus alone we should direct our attention, and that alone should regulate our conduct. For, if the uterus be well contracted, we may act at any period it may be necessary, with perfect safety; but if it be not, nothing can justify the interfer- ence, save, that the patient may be attacked by one of the acci- dents enumerated above. (651) a. On the management of the Placenta. 1360. From what has been said above, (1344, &c.) it will not always be found that each child in twin cases will have its pla- centa; yet it is generally the case ; and though only connected by interposing membrane, we are obliged to deliver them together. Before, however, we make the attempt to deliver the placenta, when have reason to suspect there is another child: or when this has been ascertained, we should apply two ligatures upon the funis of the delivered child, and cut between them; as the cut extremity in such cases yields a good deal of blood sometimes; and occasionally it is said, even to the exhaustion of the second child. We should never attempt to deliver the placenta in twin cases, until both children are born. 1361. This bleeding may happen where both funes belong to * Principles, James's ed. p. 406. OF TWINS, &c. 503 one placenta, or where the two children are supplied by one ori- ginal cord, branching some distance from the placenta to furnish a funis to each — and, as we cannot beforehand ascertain such devi- ations, it is best to guard against the chance of mischief by the ap- plication of a ligature; this may bo removed after the birth of the second child, that it may discharge some of the blood contained in the placenta, for the reasons before stated. (554) 1362. The delivery of the placentse of twins must be conduct- ed upon the same general principles as if there were but one — but rather more time should be given, and caution exercised in twin cases; because, the uterus has been more distended during gestation, and more severely exercised sometimes during parturi- tion with a single birth: consequently, the tonic contraction will be more slowly and reluctantly performed, and the. woman more exposed to flooding. Brisk frictions should be immediately instituted, and sufficiently persevered in, to insure the object for which they were employed. 1363. When the tonic contraction of the uterus is confirmed, we may then, and never until then, proceed to the delivery of the placentae — they will be found either occupying the vagina, or be beyond the reach of the finger. If in the first situation, they may be extracted by a small force exerted upon the cords, and the aid of a finger introduced into the vagina. If in the second we must co-operate with the uterine contractions when they exist, by pulling gently, but pretty firmly, by the cords, but not with equal force on each — if we do, we tend to bring both placentae at the same time to the os uteri; and their united bulks, will not readily pass it— we should therefore act more firmly upon the cord first out, as it is more than probable its placenta is nearest the uterine orifice, and will more easily descend, and at the same time, brino- the. other with it. 1364. Should there be no pain to aid in the expulsion of the placentse, we must continue the abdominal frictions, and act occa- sionally upon the cords, by applying rather more force upon the first, than upon the second, for reason just stated. (1363) A slight dischai-ge of fluid blood, or small coagula, almost always an- nounces the descent of the placenta; this is equally observed when there are two; and when we find this taking place, we must con- tinue a gentle tractive effort, until they are lodged in the vagina from this they must be withdrawn as already intimated. (1363) 504 OP TWINS, &c. 1365. Dr. Denman says,* "when the placentae are separate, that of the child should not be extracted before the birth of the second child, as a discharge of blood must necessarily follow, and perhaps a haemorrhage." This certainly would be rational advice, and highly useful, were we informed, how we are to know beforehand, when the placentae exist separately. I have al- ready directed, (1363) that the first placenta is not to be meddled with, in twin cases, until the second is ready for delivery, and with this direction I believe we must rest satisfied; and without ascertaining whether it be separate or connected. 1366. Dr. Denman farther says, " if there have been a necessi- ty of extracting the children by art, it is comTnonly, but not uni- versally, necessary to extract the placentas also by art; but if the placentae are detained beyond a proper time, we will say two hours^ after the birth of the second child, it is desirable, though there may be no very urgent symptoms, that we should inform ourselves of the cause of this distention, and act accordingly. 1367. The first of these remarks, namely, that the interference of art is necessary to the delivery of the placentae, if it has been necessary for that of the children, is by no means agreeable to my experience; nor do I see the slightest relation between these events; and if acted upon by inexperienced practitioners, as it certainly will be, when advised by such high authority much mischief will ensue. And to the second, I must again object, as the rule is taken from time; which can never in itself constitute -a reason, nor develope a principle; for, as I have upon another oc- casion remarked, it may be just as improper at the end of two hours to deliver the placentae as it was immediately after the de- livery of the last child. 1368. If artificial means be resorted to, care should be taken that both placentae are detached from the uterus,whether they exist separately, or if they be merely joined by membrane; if there be but a placenta, it must be removed, as upon common occasions. 1369. In cases of twins, a much larger surface is occupied by the placentae than if there were but one; we should on this ac- count be very careful to renew the frictions upon the abdomen, after their expulsion, that the uterus may contract as much as possible; and thus tend to diminish the subsequent discharges, which are but too apt to be in excess. * Francis's edition, p. 541, 505 CHAPTER XXXVI. OF PRETERNATURAL LABOURS. 1370. Agreeably to the classification I have adopted for la- bours, it will be at once understood, that the class termed pre- ternatural, will consist of all such, as shall not present either the head, the breech, the feet, or the knees. Authors have made a very numerous collection of preternatural labours: some of which occur so rarely, as to be seldom, or perhaps never met with, even by an old and experienced practitioner. 1371. Baudelocque has been too lavish in his divisions, and subdivisions of this class of labours; for they serve rather to con- fuse, than to elucidate. To the inexperienced practitioner, his distinctions are appalling; for, they cannot Avell be retained in the memory; consequently, his rules cannot always be acted upon. But little injury can arise from this want of memory; provided, the general principles which are to govern in such cases be re- collected; for they are all to be treated by " turning."* If, then, the principles laid down for this operation be well recollected, little or no embarrassment can present itself. 1372. It may, however, not be amiss to remind the inexpe- rienced practitioner, of several of the most important rules upon the operation of" turning." 1373. 1st. This operation must never be attempted so long as the OS uteri is not dilated or easily dilatable. 1374. 2d. That the woman must be placed upon her back, that the utmost freedom may be given to the operator's hands. 1375. 3d. That the time for the introduction of the hand into the vagina, is during a pain, after having been well lubricated. 1376. 4th. But after the hand is in the uterus, every attempt to turn must be made in the absence of pain. 1377. 5th. That it is rarely a matter of indifference, which hand is to be employed for the pui-pose of turning; therefore, the rule upon this subject must never be violated. • Except such cases .is leave no doubt of tlie death of the child, and which inay be terminated, by the crotchet. 64 506 PRESENTATION OF THE ARM AND SHOULDER. 1378. 6th. That whatever be the situation of the child within the uterus, the feet must be brought into the pelvis, so as to bend the body forwards. See Chapter on "Turning." 1379. I shall however, treat of one case of '< preternatural la- bour," from the general class; because, it is by far the most fre^ quent, as well as the most difficult — this case is the "presenta- tion of the arm and shoulder. " CHAPTER XXXVII. OF THE PRESENTATION OF THE ARM AND SHOULDER. 1380. Should the hand descend into the pelvis, either by not keeping it up as directed, (716) when it accompanies the head, or any other part; or when it seems to fall into that cavity at the time the membranes give way, it will almost always become a source of trouble; especially, if under the care of a practitioner, who supposes, he cannot do better than to act upon it, to effect delivery. When the hand is not supported, so as to allow the head to descend without it, the arm is almost sure to come into the passage: this frequently, but not necessarily, declares the shoulder at the orifice of the uterus. 1381. Or the shoulder itself may present originally, without the hand being down, as a necessary consequence. This presen- tation is more frequent than any other, in which the head, knees, feet, or breech, do not present. The roundness of the shoulder favours its taking this position, 1382. I have chosen to consider under one head the presenta- tions of the shoulder, and the arm; because, the indications are precisely the same, as well as the mode of acting, for the arm itself produces no essential difference in treatment. 1383. Before the mouth of the uterus is well opened, and the membranes are rent, it is difficult to distinguish the shoulder; but when these changes have taken place, the clavicle, scapula, and ribs serve to distinguish this part. 1384. The shoulder may present in four different ways at the PRESENTATION OP THE ARM AND SHOULDER. 507 superior strait; but these positions become very difficult to dis- tinguish, unless the arm be down at the same time.* When the arm is down, the hand will serve to discover the position of the shoulder. The hand will offer itself at one of the sides of the pelvis; and its back or palm, will present either anteriorly or posteriorly: the position of the shoulder must therefore, in such cases, be learnt from the particular situation of the hand. 13S5. In the first position of the shoulder, the head and side of the neck of the child is to the left side of the pelvis, and the 7nght arm down; the back of the hand will be anterior, the palm pos-terior. 1386. In the second, the head and side of the neck will be toward the left iliac junction; the palm of the left hand w'lW then face outwards: the back will look to the posterior part of the pelvis. 1387. In the third, the head and side of the neck will be to the right side of the pelvis ; the left arm down, with its back looking outwards, and the palm inwards. 1388. In the fourth, the right arm will be down, with its palm looking outwards, and its back inwards. 1389. If turning be resorted to, it will avail much to employ the proper hand. In the first and fourth, the right hand must be used; in the second and third, the left. 1390. In performing this operation, the rules laid down for turning in general, must not be neglected; that is, the feet must be brought down in such a manner as to bend the spine ante- riorly, &c. &:c. 1391. The presentations now treated of, are certainly very far from favourable; yet they are by no means so menacing as is commonly represented. If these labours were treated according to correct principles, they would offer no difficulty beyond what is usually encountered in turning, unless complicated by accident. • Velpeau tliinks by his arrangement of these presentations of the shoulder, much arfiblguity is avoided — he designates them by the titles of " dorso-pubic, dorso-sacral, and i-ight and left dorso-iliac." We see no advantage in this — for in proportion as distinctions (which are necessarily arbitraiy,) are multiphed, the greater will be the confusion to the student. Indeed Velpeau admits this liimself, just before, and instances in proof, the arrangements of Baudelocque, Meygrier, and Gardien — we shall therefore continue to adopt the order of Baudelocque, especially as none have improved upon his plan. Velpeau, we think extremely obscure in his directions for the management of "Shoulder presentations." 508 PRESENTATION OP THE ARM AND SHOULDER. (651) But if the favourable moment for acting be not taken advantage of, or should not have presented itself, much difficulty may be experienced ; and the case becomes subject to interference, by cutting instruments, &c. 1392. It should be constantly borne in mind, that the arm it- self offers no indication, save that of pointing out the position of the shoulder; therefore, no manoeuvre performed upon it, can advance the interests of either mother or child, or facilitate the object of the operator. Consequently, all the cruel, as well as absurd treatment to which the arm is sometimes subjected, such as scarification, amputation, &.c. should always be avoided; since it can never improve the process of turning, if the child be dead; and it will almost unnecessarily destroy it, if living. 1393. In a well-formed pelvis, the presence of the arm offers no embarrassment to the operation of turning; therefore, every attempt to remove it from the inferior portion of the pelvis, either by trying to replace it within the uterus, or by amputa- tion, is only losing time, or improperly irritating the parts, or subjecting the protruded part to an unnecessary, and sometimes to a cruel operation. 1394. There is no presentation that gives rise to so much bad practice, as the presentation of the arm; for its mechanism is ge- nerally but very ill understood. The arm itself, is almost con- stantly supposed to offer great difficulties, by its presence in the vagina; hence it has been scarified, twisted off, or amputated, to the disgrace of the profession. It is true, that in most instances these severe operations have been performed after the supposed death of the child ; but in many other cases we fear, that the life of the child has not been taken into consideration.- (1396.) 1395. The death of the child should never be admitted with too much facility ; but especially, in the cases under considera- tion, as no operation upon the arm itself can ever increase the chance of gaining the feet. Therefore, in arm presentations, the amputation, or other operations upon it, should always be forbid- den; especially, as the signs of death ai*e in many instances as equivocal, as the evidences of life are obscure. 1396. Chapman relates a most instructive lesson upon this sub- ject; a lesson which should always be present to the mind of him, who may feel disposed to act in defiance of the best experi- ence, by amputating the arm, under the pretext that the child is dead. In the case alluded to, the accoucheur amputated the PRESENTATION OP THE ARM AND SHOULDER. 509 arm, on the prcsuinption that it was dead; it was, however, alive, and lived to manhood. And more recently, a surgeon was sued for amputating the protruded arms of a child from an expiring mother, and where it was not possible to render assistance as he believed in any other way. The child, though supposed long dead, proved to be alive. 1397. It is therefore best not to meddle with the descended arm; for if turning be attempted, it offers no difficulty to the pas- sago of the hand ; and if the crotchet, or any cutting instrument be resorted to, it cannot interfere with its operation. 1398. The indication in these presentations is to bringdown the feet, and deliver. It has, however, been suggested, that we may attempt the restoration of the head to the cavity of the superior strait, by removing the shoulder from it; I believe this to be al- together theory. I do not even advise the attempt; for indepen- dently of its difficulty, I am persuaded that it would be attended with more pain and risk to the patient, and injury to the child, than a well-conducted turning. 1399. Mr. Barlow isof ojjinion that this is practicable; he says, " I come now to treat of that species of preternatural presenta- tion where one or both arms present, and the head either resting on some part above the brim, or advanced along with either of the superior extremities into the pelvis. The mode of delivery sanc- tioned by authors in this division of presentation, appears involved in some degree of ambiguity; for little variation of practice has been adopted, whether the presentation of the hand or hands at the brim of the pelvis, or that of one or both arms descended low in the vagina, the same plan of delivery in every state, however dissimilar the case may be, seems to be invariably pursued. I conceive there requires much discrimination as well as variety of practice necessary to be adopted, according to different situa- tions and stages in which the foetus is found to present under this distinction of preternatural presentation." 1400. " If the accoucheur has the management of a case of this kind from the time of the discharge of the liquor amnii, and the hand of the child is ascertained to present, and the head can be brouglit into the axis of the pelvis, it should be effected as early as the state of the os uteri will admit, and the i-eductiou of the hand in this state of the case may frequently be accomplished by pushing it up and supporting it at the brim of the pelvis till the 510 PRESENTATION OP THE ARM AND SHOULDER. head becomes engaged in the superior strait: if the other hand should protrude, it may be encountered by a similar expedient. If these attempts prove ineffectual, I would recommend the ac- coucheur to introduce a piece of sponge or other soft substance along the cavity of the pelvis during the absence of pain, and wedge or restrain the presenting hand or hands above the supe- rior strait, till the head has cleared the brim of the pelvis." 1401, On these directions it may be proper to remark, that when the arm or arms present, it can never be proper to attempt to bring the head of the child to " the axis of the pelvis,'" and for the following reasons; first, the arms cannot present before the membranes are ruptured; and after this the parts will have de- parted to some distance from the head: and in proportion as they advance in the pelvis, will the head depart from "the axis of the pelvis." Secondly, it most frequently happens, that at the mo- ment the arm has escaped from the orifice of the uterus, this part is no more dilated than is sufficient to permit the arm to pass; or if it has been more largely dilated it will be found to have con- tracted itself so as to embrace the arm pretty strictly; conse- quently, much force would be required to pass the hand into the uterus. Thirdly, that if the hand be made to pass the contracting OS uteri, it will be found, that its operations within the cavity of this organ, will be extremely limited, and by no means adequate to the reduction of the head. For every attempt to change its position will be opposed by the contracted uterus, which now, by virtue of its tonic power, accoiDmodates itself to the various ine- qualities of the surface the child presents to it. Fourthly, if it were even possible to restore the head to " the axis of the supe- rior strait," the arm or arms would accompany the head, and thus create great embarrassment to the progress of tlie labour, (718) Fifthly, I believe it will be found the best practice, when we are under the necessity of introducing the hand into the ute- rus in such cases, to finish the delivery by turning. 1402, Mr. Barlow's directions respecting the attempt to return the arm or arms, I believe would be altogether unavailing, though as we have said elsewhere (716) that the hand very often may be prevented from prolapsing into the vagina, by supporting it un- til the head shall pass under it; but this can never be the case with the arms. It will be seen that Mr, B. has not made the ne- cessary distinctions between the hands accompanying the head. PRESENTATION OP THE All M AND SHOULDER. 511 and the arm presentation;* for the latter always implies the exit of the arm from the os uteri; while in the former, the hands are enclosed in the uterus, or but very little advanced beyond the edge of its orifice. Now, there is an essential difference between these two conditions, and they require very different modes of treatment; the directions of Mr. B. may answer very well when only the hands offer, but they would be totally inadequate for the restoration of the head. 1403. When the arm accompanies the head, it is found that it almost always advances, pari passu ; and it is true, that this circumstance is not always subversive of the natural order of the labour. But this can only happen, vv^here the diameter of the head and arm, do not exceed the diameter of the pelvis. See section, on the presentation of the hand with the head, p. 256, par. 716, &c. 1404. The circumstances which would render the restoration of the head to the axis of the pelvis practicable, (if it be practi- cable,) will also give facility to bringing down the feet; namely, a sufficient relaxation of the uterus, and the absence of pain. Moreover, if these conditions obtain in the first instance, it will of course be very uncertain whether the powers of the uterus will be sufficiently restored to expel the child after the adjust- ment of the head; consequently much time might be lost, and much anxiety be created, and this for a success, that is altogether contingent. 1405. There are three modes of proceeding in presentations of the arm; the first, as I have just stated, is to turn; the second, to trust to the powers of nature to produce what has been termed the ''spontaneous evolution of the child," and the third, is the employment of cutting instruments to the child itself. 1406. When the arm presents in a labour at the full period of utero-gestation, we should entertain no hope or expectation that nature will relieve herself while the child continues in this position ;t consequently this case must be always regarded as " preternatural," and the bringing the child by the feet, is the * Mr. Barlow speaks of the presentation of both arms — a presentation, we have never seen, though we do not pretend on this account, to deny such an occurrence. t Unless the rare occui-rence of «« spontaneous evolution" by u forced con- struction be considered an exception. 513 OF THE CONDITION OF THE UTERUS. only operation that can be performed with a view to tlic safety of both mother and child. 1407. Notwithstanding the indication in this case, is so obvious, yet it is not always practicable to fulfil it. This arises from — 1st. the condition of the uterus; and 2d, from the situation of the arm and shoulder within the pelvis. Sect. I. — Of the Condition of the Uterus. 1408. I have already noticed above, (1392) that the protruded arm or hand offers of itself no difficulty to turning; the difficulty exclusively depends upon the condition of the uterus, and espe- cially of that of its mouth. If both be in such a state of relaxa- tion as will admit the passage of the hand without much force, (as often happens soon after the escape of the waters, where the la- bour has progressed regularly,) no more, or perhaps sometimes even less difficulty will be experienced, than in turning when the head presents, and the uterus equally favourably disposed. 1409. Our attention should therefore be constantly directed to the state of the uterus, and especially to that of its neck; and our conduct should be regulated alone by their condition: for what- ever may be our desire to aid the suffering woman, or relieve the threatened child, we must never incur the risk of being disap- pointed in both, by forcibly entering the resisting OS uteri. When violence has been committed on this part by mechanically mak- ing it yield to the hand, inflammation, laceration, and gangrene have sometimes followed; nor is this all: the operator has been foiled in his attempt to bring down the feet by the os uteri con- tracting itself round his wrist, and thus obstructing the descent of the child. I once witnessed death to follow immediately, or rather during, a rude attempt to turn. The operator had with great diffi- culty passed her hand, (the patient was under the care of a mid- wife,) through the os uteri; and after a long and uncertain search, became possessed of the feet: in attempting to bring them down, she exerted so much force, as to rupture, (I believe,)* the uterus. The poor woman expired in about five minutes after I entered the * Tills belief is founded on what occurred during this attempt to turn; name- ly, a slight hemorrhage from the vagina; sickness, and vomiting; cold clam- my sweat, &c. — of the pulse, I can say nothing; it was extinct when I saw tlie patient — the attendants of course could give no account of it, and the midwife was too much occupied by her operation to examine it. OP THE CONDITION OF THE TTTEUUS. 513 room, and while the midwife was still exerting all her force upon tiie legs of the child. The persons present informed me, that the midwife after she had learnt I had been sent for, declared it was unnecessary, as she " could deliver the woman as well as any- body" — she therefore redoubled her exertions, to make good her assertion: the consequences I have just related. She most indus- triously laboured in this attempt, for more than an hour, 1410. The midwife told me, that "the arm had been down many hours, and the pains were very strong" — but added "not- withstanding this, the child did not come nearer the world ; I therefore determined to wait no longer, and proceeded to turn, as I had several times done in like cases. The mouth of the womb was close round the arm of the child ; but I did not mind this ; for I got first one finger in it, then another, and at last mj^ whole hand. But indeed, doctor, this was hard work. When I got through, I never was so long finding the feet; but all my strength could not make them come down; and the poor woman died, be- cause I did not begin sooner." I took this poor ignorant creature aside, and frankly told her, she had destroyed her patient; and exacted, on pain of exposing her, a solemn promise, that she would never attempt the like operation again. 1411. Therefore, when the mouth of the uterus strongly op- poses the introduction of the hand, it should not be attempted; in such a case, it will almost ahvays be found if the waters have been long drained off, that the tonic contraction of the body and fundus, will also offer much difficulty to turning. This being the situation of the patient, nothing can justify the attempt to turn; for one of the following consequences will almost certainly follow: 1st. If the hand be made to pass the stricture, it will be at the expense of so much injury to the neck of the uterus, that the one or other of the evils stated above will follow. 2d. If the hand be made to pass the constricting os uteri, the body and fundus will offer so much resistance, as to defeat the safe turning of the child; or 3d. If the child be safely delivered, it may be at the expense of the life of the mother. 1412. It seems then to follow, that this condition of the os uteri, as well as of the body and fundus of this organ, must be changed before any attempt is made to bring down the feet of the child. With this in view, we must induce such a state of relaxation, as shall enable the hand to pass, and the turning to be performed, without the risks stated. This can be almost cer- 05 514 SITUATION OF THE ARM AND SHOULDER tainly effected, by a sufficient loss of blood. To exemplify the practice in such cases, I shall relate one, from my "Essay on the Means of lessening Pain," &c. in which this remedy was success- fully employed. 1413. " 1802, January 29th, Phoebe Hall, a black woman, in labour with her seventh child; arm presented, and down for se- veral hours; arm considerably swollen, as the midwife had ex- erted considerable force upon it; the mouth of the uterus con- tracting closely round it. I got Dr. Carter, (a gentleman who accompanied me,) to introduce his hand into the vagina, and place a finger within the os uteri — this he did with some diffi- culty, as the uterus was very rigidly closed upon the arm. I tied up the patient's arm, to let her bleed until he should tell me the mouth of the uterus was sufficiently dilated. When 1 had drawn from forty to fifty ounces of blood, she became sick and faint; at this instant Dr. Carter cried out with rapture that the uterus was sufficiently dilated — upon my examining, I found it to be the case ; the turning and delivery were soon accom- plished." 1414. It must be observed, that such labours as are attended with fever, always require the loss of considerably more blood, than when none attends; and it has been found best, in such cases, to draw the blood at two or three operations; but carry- ing the last to faintness, or at least to sickness of stomach. Now, the labours in question are almost always accompanied by fever, if they have been long protracted; consequently, will frequently require the adoption of the plan just proposed. Sect. II. — Of the Situation of the Jirm and Shoulder within the Pelvis. 1415. The situation of the arm and shoulder within the pelvis, may be such as to render turning, if not impracticable, at least unsafe. 1416. The arm, to the very shoulder, may be protruded through the os externum; and the shoulder itself so impacted, and the contraction of the uterus so firm, as to render it impossi- ble to turn, with any prospect of success to the child, or safety to the mother. Our conduct in this situation of things, must be regulated altogether by the condition of the child ; and this will be either living, or dead. It must therefore be ascertained in WITHIN THE PELVIS. 515 which of these states it may be, before we decide on the mode of acting. 1417. With a view to determine this, the hand should be pass- ed into the uterus until it reach the umbilical cord — if this pul- sate, the child is of course living ; if it do not pulsate, the child is cert inly dead. a. The Manner oJ\Bcting, if the Child be living. 1418. Having ascertained the child to be living, our conduct should be such, as to give it the best possible chance to be deli- vered alive. The choice of means will lie between turning, and waiting for the spontaneous evolution of the child. As regards turning, it must not be disguised, that it is an operation of hazard to the child even under the most favourable circumstances of the uterus, or position of the child; and of course, the risk will be in proportion to the departure from these best conditions; yet it of- fers in this case, almost the only alternative. 1419. In the situations of the parts in the presentation now un- der consideration, two diiBculties will necessarily present them- selves; 1st. The uterus will be found firmly contracted on the body of the child; so much so, sometimes, as to render it almost impracticable to turn; or at least, it would be hazardous, unless the operation be very carefully conducted. In such a case, it should not be attempted but with the utmost caution, and not without previously endeavouring to diminish the resistance of the fundus and body of the uterus by free blood-letting, as just pro- posed, for the rigidity of the os uteri, when it creates a difficulty. After the patient has been liberally bled, the opposition to turn- ing is sometimes so much diminished, as to render the opera- tion not only practicable, but safe even to the child. Should the blood-letting procure no relaxation, the case becomes a folorn one ; especially, for the child. 1420. We should not, however, for this reason, abandon the poor woman to her fate; for even under a severe contraction of the uterus, a well-directed gentle force will sometimes overcome difficulties, that at first appeared insurmountable ; especially, after a liberal dose of opium.* If the practitioner be inexperienced, he should, if possible, call to his aid a more skilled operator. He should never attempt to overcome by force, the difficulties which * It will be borne in mind, that a free bleeding must be performed, before the opium is given. 516 SITUATION OF THE ARM AND SHOULDER oppose him; a proper exercise of patient address sliould ever govern in such cases, if he mean to succeed. 1421. Secondly. In consequence of the firm contraction of the uterus, the shoulder, loe are told, is found so tightly wedged in the inferior strait, as sometimes not to permit the slightest motion upwards. I will riot sa)^, that this is never the case, but I must declare, it seldom happens, unless the proper time for acting has been lost, either reprehensibly or unavoidably. So far, I have never met with a case, in which I could not turn, if turning were the desirable mode of acting: but this has arisen, perhaps, from having been generally able to watch the proper moment for the operation.* 1422. In these cases, the proper moment to act, is, so soon as the OS uteri is sufficiently relaxed to permit the passage of the hand; and if this relaxation do not take place spontaneously, it should be procured as early as the nature of things will permit, by blood-letting and opium; and this as soon after the escape of the waters as practicable. If the case have been mismanaged, before a judicious practitioner has been consulted, he may not perhaps be able to terminate the labour by turning, with any prospect of success to the child; he is then to consult the interest of the mother alone; and this will perhaps be best advanced by waiting, so long as the child may continue to live. 1423. But should any accident complicate the labour, and ren- der immediate delivery proper, he should try to relieve the patient by turning, though it offer but a bad chance for the pre- servation of the child. If this be impracticable, (a circumstance, I am warranted in saying, of rare occurrence,) he must relieve the mother at the expense of the child, as will be directed pre- sently. 1424. The only other resource which presents itself for the preservation of the child, is waiting for what is termed the ^'spontaneous evolution of the child," h. Of Spontaneous Evolution. 1425. Dr. Denman, I believe, was the first to notice this re- * I have made several admissions abo^ e, tliat woidd appear to contradict, what I here urge — the cause of these ackiiowledgTuents, is my respect for the experience, and opinions of others, though not borne out by m)' own practice. I say also, tliat I would turn when tui-ning was the desirable mode of operating — mcanuig by this, that there arc exceptions to this rule: see pai". 1427.; also the article on turning in deformity of the pelvis. WITHIN THE PELVIS. 51 7 rnarkahle resource of nature, in shoulder or arm presentations. He enriched the profession by his history of it, and by instructing the practitioner, that in some instances, nature achieves with even safety to the child, that which art could not have per- formed. His explanation of this phenomenon is highly inge- nious, and was for a long time the received one; but it appears to have yielded to that of Dr. Douglass, even by the confession of Dr. Denman himself. See Dr. Douglass's Essay on Sponta- neous Evolution. There is a case lately recorded, where the child was delivered by the right foot, by the unaided efforts of the^uterus; it is thus related in the "Bulletin des Scien. Med." for July, 1830, page 95, from Siebold's Journal f iir Gebartzhiilfe, etc. T. viii. 3d cap. p. 712. Dr. Schneider was called to a woman on the 13th of Jul}^, 1822. He was informed, that the child had presented the arm, and that the delivery was efiected by the powers of the uterus alone. The people present could not inform him how the thing happened; but the patient declared, that the waters were discharged by the first pains, and that an arm of the child immediately fell into the va- gina. The wom.an instantly sent for help, but in a i'ew minutes after, violent and almost insupportable pains came on, during which time the woman felt as if the whole abdomen was turned upside down, (bouleverse. ) Very soon after the right foot of the child escaped, ar^d then the trunk and head. The right arm of the child was livid and swollen, proving, that this part first presented itself. The child was of middling size, but dead. The pelvis of the woman was very large. 1426. This chance for the preservation of the child, is however, of extremely rare occurrence; for in by far the greater number of instances of "spontaneous evolution," the child has been ex- pelled dead. Indeed, the delivery of the woman, by this change of position of the child, is in itself very rare. I have never seen a case. Yet the testimony on this point is conclusive, and will justify us in considering it a resource, after all the rational en- deavours have failed. 1427. I say, a chance for the child; for such only should it be considered; for if the child be dead we have no longer terms to keep with it; our attention must be solely directed to the safety of the mother. 1 should, therefore, recommend waiting for this *' spontaneous evolution," whenever turning forbad the hope of saving the child; provided the labour be not complicated by 518 SITUATION OP THE ARM, &C. either of the accidents enumerated; (651) but if the child be dead, and this ascertained as directed,* (1417) we should not wait for the uncertain event of " spontaneous evolution.'^ 1428. Dr. Merriman has very properly observed, "the occur- rence of the spontaneous evolution has been comparatively so rare, that no man would be justifiable in simply relying on it. The knowledge that it has sometimes happened, may, indeed, under some circumstances of extreme resistance to the passage of the hand into the uterus, reconcile us to the delay which I have re- commended; but we should never allow it to operate upon our minds, so as to induce us to neglect the proper means, and proper time of turning when we have it in our power. It is the duty of the accoucheur, on all occasions, to give nature every possible op- portunity of exerting herself for therelief of tlie patient; but it is equally his duty, when nature becomes embarrassed and oppres- sed, to interpose the timely assistance of art, lest nature, being compelled to relinquish the task, the patient shall fall a sacrifice to the delay."t c. Mode of Acting, if the Child be Dead. 1429. If it be ascertained, that the child is dead; and it should be impracticable to turn, we must attempt the delivery of the child, by the use of instruments. The instruments necessary for this purpose, may be, the scissors, and crotchet, or simply the blunt hook. Before, however, either is employed, the uterus should be either dilated, or dilatable; and this will almost always be found to be the case, where the shoulder is forced down to the OS externum. 1430. In this situation, we can always command the thorax or abdomen of the child; either of which may be penetrated by the scissors; and these aided by the crotchet, or blunt hook. It has been recommended by several, to bring down the head by pulling with a blunt hook fixed over the neck. It would seem, that this plan was first suggested by Celsus; it is however claimed for one Home by Heister, as an original invention. When the shoulder has really been thrust without the os externum, and the child certainly ^eac?, it may-be become a question, which of the two pro- positions will be most easy to fulfil. Dr. Sims has successfully * It miist be recollected, we can pass tlie hand to the umbilicus of the child, when it might be impracticable to turn, f Synopsis. WITHIN THE PELVaS. 519 used the blunt hook upon the neck of the child in at least two cases; in one, the head was delivered without separating it from the neck; the other was attended by this separation. In both in- stances, the child had been dead a long time. I can say nothing from experience, on either of these modes; therefore, will not decide positively on their comparative merits; it nevertheless strikes me, that the one, which will be attended with the least risk of violence to the soft parts of the mother, should be prefer- red; and that appears to be the one, which will diminish the child's bulk before it is forcibly dragged from the mother's pelvis; therefore, perhaps, the scissors and crotchet, may be the safer me- thod in this respect. 1431. It has been usual, it would seem, in cases where turning was impracticable, to wait for the " spontaneous evolution" to take place; but I would not recommend this plan, when it is certain the child is dead; and for these reasons: 1st. This '' evolution" is not certain to take place; 2d. If it do not, we certainly expose the woman to much suffering; and perhaps even to danger, for the hope of this favourable contingency. (1417) The British practitioners being much more familiar with these untoward cases of arm presentations, do not hesitate to operate with cutting instru- ments upon the child. We will therefore give a part of Dr. Leed's mode of proceeding in such cases. "On the 15th October, 1824, I was called to visit a patient of the Westminster General Dispensary, residing in Great St. Andrew Street. I found her in the following condition. The membranes had been ruptured fourteen hours, and \kiQ liquor am- nii had entirely escaped. The right arm, much swollen and livid, was protruding out of the external parts, and the shoulder and part of the thorax were firmly impacted in the pelvis, while the contractions of the uterus were violent and incessant. The pulse was quick, the face flushed, and the soft parts lining the pelvis were hot, dry and very tender. Thirty ounces of blood were drawn from the arm, and sixty drops of laudanum administered, before any attempt was made to alter the position of the child. After waiting for half an hour, when the pains had somewhat di- minished in violence, I attempted slowly to pass up my hand, but the pains were immediately renewed with redoubled force; and after persevering for upwards of an hour to turn, I was com- pelled to abandon the intention. Another practitioner then saw her, when other twenty ounces of blood were drawn from the arm, 520 SITUATION OP THE ARM, &C, and forty drops of laudanum were administered. He waited some time in tlie hope that the actions of the uterus would cease ; but this not taking place, he proceeded to endeavour to pass up his hand into the womb. This attempt again excited the most vio- lent bearing down pains ; and after long and fruitless exertions, he was also compelled to desist from the threatened danger of rup- ture of the uterus. Two hours having elapsed after this second attempt to turn, and the pains still continuing undiminished, I separated the arm from the body at the shoulder joint, laid open the thorax by the means of the crotchet, and, passing it through the opening thus made, fixed it on the lower part of the spine ; and on dragging down with a steady force, the child passed out of the external parts doubled. Though there was great distention of the parts at the outlet of the pelvis, no laceration of these took place. The superior aperture of the pelvis having been considerably under the ordinary dimensions, some resistance was offered to the passa«'e of the head ; but this was overcome without much diffi- culty. The patient speedily recovered, and has since been deli- vered by me of an eight months' child, where the breech present- ed, and where the life of the child was lost, from the time and force required to bring the head through the confined brim of the pelvis. On the 1st May, 1S27, I was requested to visit JMrs. Ka- gen, Charles's Street, Drury Lane, also a patient of the Westmin- ster General Dispensary. She had been two days and nights in labour, and was extremely exhausted with fatigue. The left arm much swollen was presenting, and around it a loop of the umbilical cord, which did not pulsate. There was great thirst and restlessness, and the abdomen was tense and very painful on pressure. The pulse was extremely quick. The uterus was con- tracting with great force, and I found it quite impracticable to pass up the hand, or to push back the presenting part, so firmly was it impacted on the pelvis. Sixteen ounces of blood were drawn from the arm, and an opiate administered at 4 A.M. At 7 o'clock the pains had almost ceased, but were instantly renewed on attempting to turn. The child being dead, I did not perse- vere long in my efforts to turn, but delivered without much diffi- culty in the manner already described. Here also there was contraction of the brim of the pelvis, of which a lamentable proof existed in a fistulous opening between the bladder and the vagina, WITHIN THE PELVIS. 521 reported to have been caused some years before by a protracted labour, which was ternunated by the use of the forceps. On the I4th May, 1827, I was called to a patient of the same Institution, in KingStreet, Drury Lane. The left arm presented, and the shoulder and thorax were forced deeply into the pelvis. The umbilical cord was hanging without the external parts and did not pulsate. The contractions of the uterus were strong, and were much increased on attempting to introduce the hand. The delivery was accomplished with the utmost ease, and in a very short time, as already described. The extraction of the child was effected very slowly, to allow of the dilatation of internal parts, and to prevent laceration of the perinceum. On the se- cond day after delivery, this patient experienced a slight attack of abdominal inflammation, which readily yielded to one copious bleeding and cathartics. In another case which has since occurred to me, and which in all essential circumstances, resembled the three now detailed, the same method of accomplishing delivery was adopted, and with similar success. I do not consider it necessary to define more clearly the cases to which the above practice ought to be applied, as it is hardly possible for any one, after the observations I have made, to mis- understand the object of this communication, or to suppose that the common operation of turning should be abandoned where there is a reasonable hope of saving the child's life, and that of the mother. The method of effecting delivery above mentioned, I was led to adopt, from reflecting what takes place in cases of sponta- neous evolution of the foetus; and it may be perceived, that in all the foregoing instances nature had begun, and was striving, though ineffectually, to complete this process. Since the occurrence of these cases, I have had an opportunity of perusing the essay of Dr. Douglass on this subject, and have been gratified to find he- has recommended the same mode of treatment, and has been also forcibly impressed with the impro- priety of turning in all cases of arm presentations. Dr. Sims, in the fortieth volume of the Medical and Physical Journal, stated similar views but did not lay down any specific rule of practice in such embarrassing cases. Dr. Da^s in his Elements of Operative Midwifery, p. 326, concludes some observations on this subject with the following 66 522 WITHIN THE PELVIS. words. ' If therefore, we suppose the child to be ah-eady dead, or the circumstances of the labour to be such as to make it im- practicable to bring it into the world alive by means of turning, or even to perform that important operation at all without ex- posing the mother to extreme danger, it would then, in my opi- nion, be the unquestionable duty of the practitioner to eifect the delivery by embryotomy.' Instead of extracting the child double, he recommends ' that it should be divided into two principal parts, head and body, by passing a properly adapted cutting instrument across, and through the entire structure of the neck;' and he has delineated in his invaluable work instruments for this purpose. Notwithstanding, however, his ingenious invention of cranio- tomy forceps, and of the power which they confer upon us of extracting the head, or any other part of the child from the ute- rus, still I should be disposed to avoid, if possible, the occurrence of the head remaining in the cavity of the uterus after the extrac- tion of the body, as it must be extremely difficult to find after- wards for perforation, and quite impossible to accommodate it to the diameters of the pelvis in passing. The difficulty of reaching the neck when the shoulder and thorax are thrust deep into the pelvis, and the head of the child is tilted up over its brim, appeared to me in the preceding cases so great as to be almost insuperable, setting aside the disagreeable process of passing uji cutting instruments so high within the ute- rus. " )23 CHAPTER XXXVIIT. ON PRESENTATIONS, WITH THE FALLING DOWN OP THE UMBILI- CAL CORD. 1432. We have already expressed our surprise, that the cord does not more frequently accompany the presenting part, and by its presence embarrass the labour, than it is found to do. Yet a prolapsus of the cord is comparitively, and fortunately, a case of rare occurence. 1433. It will readily occur, that a labour complicated with the descent of the cord, can only be threatening to the child; since the cord being down, cannot of itself, interfere with the me- chanism of a labour, or influence its duration ; consequently, can offer no threat to the mother. It is then the safety of the child alone, that claims our attention, or that presents us with any specific indication ; for on its welfare we must base all our rules of conduct. For, if the child be dead, and this can be determined by the want of pulsation in the cord, the funis being down, should not alone make us interfere with the labour. For Dr. Denman has very justly observed, '' it is only when the child is living, that any interposition can be required, or be of service ; yet it is remarkable, that writers on this subject have instituted their di- rections in general terms with regard to the state of the child, whether living or dead." 1434. We may sometimes determine, that the cord will pro- lapse, even before the membranes have given way ; for it may sometimes be felt, either single, or in folds, immediately before the presenting part. Its peculiar form, and its pulsations, can be perceived behind the membranes in the absence of pain, if the finger be placed against them, and the os uteri be sufficiently open ; and this at once decides the nature of the case. When this happens, it may be looked upon as an important warning, as it directs us to a peculiar observance in practice ; but if it only declare itself after the rupture of the membranes, by falling into the vagina, we necessarily loose the advantage, that a previous knowledge that this was about to take place, would give us. 1435. Some have attributed this accident to t!ic uterus being 524 OF PRESENTATIONS, WITH THE unusually loaded with the liquor amnii; but we believe witiiout sufficient reason ; for we have seen most abundant flows of this fluid unattended by this accident; and we have certainly wit- nessed it, where the quantity was not uncommonl}' great. Others have ascribed it to an unusual length of cord ; this is more pro- bable; since, it is presumable, that this circumstance would in- crease the liability to the accident, though perhaps it may not be essential to it : we may at all events most safely affirm, that we have seen cords of great length, where this protrusion did not take place. 143G. Perhaps it may be truly said, that this event is alto- gether accidental, or contingent; though Dr. Denman declares that some women appear more liable to it tlian others : it would certainly be difficult, were this even the fact, to determine in what the predisposition consists, as it does not seem to dejf&nd upon cither the quantity of liquor amnii or the length of the cord. 1437. I have said, that the circumstance of the cord, preceding the presenting part of the child, is altogether perhaps accidental, or contingent ; I believe this to be the case, from the difficulty of assigning the predisposing causes, as just observed, and the extreme rarity of the occurrence. I am of opinion, that when this happens, the following circumstances must take place; first, that the cord must be precipitated before the presenting part, and made to rest against the membranes ; in this case, the pro- lapsing of the cord would be inevitable; and the cause of this si- tuation of the cord, must be hidden perhaps in the same obscurity, as any other deviation in the presentation of the child itself. Se- cond, that if the cord should not originally offer with the present- ing part, then two circumstances must obtain, that the floating cord may be carried without the os uteri ; and these appear to be, first, a small, but powerful current instead of the diff'used and feeble discharge of the liquor amnii ; and second, that this current must meet in its course, a portion of the cord sufficiently long and disengaged, to be carried by it without the uterus. If it be ask- ed, how can this partial current be established, and endowed, with an adequate power to produce the accident in question ? I would answer, by the head or presenting part of the child occu- pying the superior strait so strictly, as to prevent the escape of the waters, but from a small portion of that opening ; and the force with which the liquor amnii shall escape, will necessarily be conimcjisuratc with the power, with which it is urged ; or in other i i FALLING DOWN OF THE UMBILICAL CORD. 525 words, it will be driven with an impetus, equal to the force, with which the uterus contracts. 1438. We need but insist in confirmation of this conjecture, that the presenting part every now and then does so completely occupy the superior strait, as to dam the waters above it, and thus create difficulty and delay in the labour; hence, the direc- tion to raise the head, that the waters may escape. 1439. But a truce with conjecture; it is enough for all practi- cal purposes, (since, did we know the cause, we could not pre- vent the effect,) that the cord does precede the presenting part; and that under two circumstances, as w^e have just stated. It is proper to observe, however, that each condition in v/hich the cord may prolapse, requires some difference of management. 1440. ^V"e will first notice the cases in which the presence of the cord is detected, before the waters have escaped. 1441. It almost supposes the os uteri to be opened to some ex- tent, when we are able to detect the presentation of the cord, since it requires some space to ascertain satisfactorily its presence; at least with sufficient certainty to make us determine on one mode of proceeding, in preference to another. 1442. We are directed in such cases, both by Dr. Denman and ]Mr. Burns, if the cord prolapse, and the os uteri be but little open- ed rather to wait the issue of the natural progress of the labour, than to forcibly enter the uterus; in this, we perfecly agree. But Mr. Burns, immediately after advises, " as soon as the os uteri will admit the introcUiclion of the hand, the child should be turned, if it can be easily done." And Dr. Denman seems inclined to the same mode of treatment, (hough a little more precise, and more guarded upon this subject than Mr. Burns; but both are advo- cates, under certain restrictions, for turning. 1443. Mr. Burns declares the sum of practice in this case to be, 1st, "that when the os uteri is not dilated, so as to permit turn- ing, we must not attempt it; but when turning is practicable, it is to be performed; 2d, when the head has descended into the pel- vis, the cord is to be replaced; 3d, or secured as much as possible from pressure; 4th, but if the circulation be impeded, the woman must be encouraged to accelerate the labour by bearing down, or instruments must be employed; 5th, when the presentation is preternatural, these directions are to be attended to, and the practice is also to be regulated by the general rules applicable to such labours." 526 ON PRESENTATIONS WITH THE 1444. Wc shall examine each of these directions in order, and, 1st, " that when the os uteri is not dilated, so as to permit of turn- ing, we must not attempt it; when turning is practicable, it is to be performed." Dr. Denman more cautiously advises, " if the child be living, and the presenting part high up in the pelvis, es- pecially, if the pains have been slow and feeble, it will generally be better to pass the hand into the uterus, to turn and deliver the child by the feet; using at the same time the precaution of car- rying up the descended funis, that it may be out of the way of compression." But, notwithstanding these positive directions, I am inclined to think that the question to be solved in such cases is, 1st, whether it be ever proper, to turn for the mere presence of the cord; and, 2d, if it be, what are the circumstances which render it so? 1445. Turning must always be looked upon as of doubtful safety to the child; (736) its adoption must therefore be constantly regarded as a choice of evils. In a case of prolapsed funis, it should be resorted to with great caution, especially, as there is no question, that children are frequently born alive after the cord has been prolapsed, and when the progress and termina- tion of the labour was confided to the natural powers. While on the contrary, the fact is equally well established, that they have perished during the extraction; and I believe we may safely say with Baudelocque, " and all this, in cases, where they might have been born alive, notwithstanding the exit of the cord, had the delivery beenjeft to nature." 1446. " For," adds he, " after the discharge of the waters which brought it (the cord) out, the expulsion of the child is often quicker than its extraction could be;" therefore, " we should in all such cases, add a long compression of the cord, to the danger sometimes inseparable from turning the child, and bringing it by the feet." 1447. Now, as it is admitted, that children have been born alive, when nature has not been interfered with, though the funis had presented, it follows, that this part, in such cases, does not necessarily suffer compression; consequently, turning, as a gene- ral practice, should not be inculcated, especially as we can often avert this dreaded pressure, by carrying the cord to that side of the pelvis to wliich it may most incline; or by restoring the funis within the uterus, beyond the risk of this accident. 144S. Turning can only be considered as the better means, FALLING DOWN OF THE UMBILICAL CORD. 527 when no farther reliance can be placed on the powers of nature to eflcct the delivery in proper time; or when the cord suffers either constant or occasional compression; either of which if con- tinued beyond a certain time, will inevitably de'stroy the child. It is not suflicient, because the pains are feeble and long in return- ing, to make us conclude, that the powers of nature arc incompe- tent to the end, and make us resort to tlie doubtful expedient of turning; for unless the cord be threatened with compression at the same time, the mere tardiness of labour, especially at the earlier part of it, oflisrs no immediate indication. 1449. For we may in many cases, urge the reluctant powers of the uterus to proper and efficient action, or restore them when they have flagged from exhaustion. The first, is sometimes suc- cessfully accomplished by bleeding, a stimulating injection, or by opium ; the latter, oftentimes most happily, by the secale cornutum. 1450. It may however, be necessary to turn, or otherwise treat this case, if it be complicated by other accident; but the propriety and nature of the choice, must be governed by the na- ture and force of the additional complaint. Or it may become absolutely necessary to turn, if the presentation be preternatural, agreeably to our acceptation of the term; (615) and often, highly expedient, at least to interfere with the regular course of the labour, when either the breech, feet, or knees, shall offer. Thus, if the breech, feet, or knees present, it may become necessary, for the preservation of the child, to bring down the feet^ and finish the labour by artificial aid. 1451. It should, however, constantly be borne in mind that even when we determine on this operation, it should be subject to all the regulations we have already imposed upon it. See Chapter "On Turning." 1452. When we have ascertained, that the funis is below the presenting part, I would depart from the rule I have laid dovvn, (544) of rupturing the membranes; I would, in this case, pre- serve them with the most scrupulous care, by not '' touching;" by strict rest on the part of the patient; and cautioning her against bearing down. By these means we may prevent the yielding of the membranes until the last period of labour ; and of course, prevent the compression of the cord, I do not know that this plan has hitherto been recommended ; though so obviously im- portant, when it can be complied with. I can, however, only 528 ON PRESENTATIONS, WITH THE speak of its utility, in a single case. I ascertained in the early- part of a certain labour, that the cord was presenting; and made up my mind not even to touch my patient until the pains should declare the last period to be at hand. Upon examination at the time I thought proper, I found the membranes ready to protrude the OS externum ; and in which, I could distinctly feel the pro- lapsed and pulsating funis. The head of the child was about to emerge from under the pubes; and the soft parts pliant, and every way disposed to yield. I now ruptured the membranes, and the head and body almost immediately followed the discharge of the waters. The child was healthy, and cried lustily. 1453. I do not wish more consequence to attach to this plan than it deserves; for I must confess, it is no direct evidence, that the safety of the child depended upon maintaining the integrity of the membranes to so late a period; as we know that the same happy results have followed delivery in cases of the falling of the cord without this precaution having been observed. Yet, one thing is nearly certain; that the funis cannot be either very long, or very severely compressed, so long as it is retained within the entire membranes. This plan would be particularly important with a first child; or where the uterus opens reluctantly; or where the labour progressed slowly, and the external parts offer much resistance. It must, however, be granted, that it cannot always be carried into execution, as there are several causes which may rupture the membranes, besides design ; yet, never- theless, when it can be done, we think it should be done. 1454. 2d. "When the head has descended into the pelvis," says Mr. Burns, " the cord is to be replaced, or secured as much as possible against pressure ; but if the circulat'.on be impeded, the woman must be encouraged to accelerate the labour by bear- ing down, or instruments must be employed." 1455. This rule necessarily divides itself into several very im- portant, ill-defined directions; it will, therefore be necessary to its investigation,- that we consider them separately. 1456. First. "When the head has descended into the pelvis, the cord is to be replaced." This direction has always been a oreat desideratum in the treatment of labours complicated by the presence of the cord, and various plans have been suggested by several ingenious and experienced members of the profession, nei- iher of which, however, has been very successful. The crutch FALLING DOWN OF THE UMBILICAL CORD. 529 of Burton; the leather purse of Mackensie; the attempt at its suspension of Croft, have been alike unrewarded by success. 1457. A more plausible method has lately been suggested by Dr. Dudan, which, he says, has been crowned with success in the instance in which it was tried. He proposes "to carry the pro- lapsed portion of the funis into the uterus by means of a gum elastic male catheter and ligature, in the manner following: — The catheter should be of the size of No. 8 or 9, with its stillet; a piece of narrow riband, or several thicknesses of strong thread of sufficient length, well waxed, must be introduced into the last eye of the catheter, and retained there by the extremity of the stillet. The cord must now be attached by the riband encircling it, w ithout drawing it too tight. If the loop of the cord be short, or not more than seven or eight inches, it may be tied in the mid- dle; but if longer, it should be doubled, and tied towards the cen- tre of the fold." 1458. " The cord must be returned within the uterus at one of the sides of the pelvis; if it be carried to the right side, the right hand should be used; if to the left, the left hand, making the op- posite hand serve as the guide to pass it between the head of the child and the neck of the uterus. As soon as the loop is found to penetrate between the head and uterus, it should be pushed with considerable force, and without our having fears, we may stop the circulation within the cord; or should it be interrupted for a short time, it is of no consequence. At the same time with the hand which serves as a guide, we may assist the passage of the cord within the uterus, and at the same time prevent its slip- ping in the loop of the riband." 1459. " When the cord is returned, we need be in no haste to withdraw the catheter; on the contrary, we should v/ait until the pains have made the head of the child engage in the superior strait, when it acts, if it may be so expressed, as a cork. Then the stillet must be withdrawn, and the catheter can easily be made to follow. The riband may remain, as it will be expelled with the child." 1460. This project I believe to be better than any other hitherto proposed, as it gives more entire command of the pro- lapsed cord, and by a means which cannot injure either mother or child. This plan so nearly resembles one I proposed some years ago, th-t they might well pass for the same. But that of Dr. Dudan is in one respect a considerable improvement on that 67 530 ON PRESENTATIONS, WITH THE of mine, by substituting the flexible male catheter for a piece of plain steel of proper size, with an eye to it, as I had proposed; while that of mine has perhaps an advantage in the mode of ap- plying the riband, or ligature. 1461. In Dr. Dudan's plan which by the by he describes very ill, the riband is tied over the cord with sufficient tightness, and the ends are passed through the eye of the catheter, and fastened within the canal by pushing up the stillet; while in my method the riband is passed round the cord without tying; the ends are then passed through the eyes by withdrawing the stillet suffi- cienily to leave them clear; the extremities of the riband are then drawn sufficiently tight to place the cord and catheter in contact. The advantage of this method is, that we can always regulate the degree of compression upon the cord; or we may take it off al- together if desirable; whereas in the other it must always remain the same. 1462. As these plans are rather difficult to comprehend from description, 1 have added drawings by way of illustration. It will be seen that I have availed myself of Dr. Dudan's suggestion of the flexible catheter. See plate XVII, and explanation. But to proceed. 1463. 3d. "Or secnrcd as much as possible from compres- sion;" to do this, we are directed by almost all the writers upon this subject, to carry the cord to one of the sides of the pelvis, and the side nearest to the prolapsed portion is always the best. We can sometimes succeed for a time in preventing the com- pression of the cord by this plan, but it will be readily understood that this cannot be permanent; as the head in changing its posi- tion to place itself under the arch of the pubes, will press upon it with more or less force and certainty. The child will now be in great jeopardy, and if not very speedily delivered will die. The woman should be solicited to aid herself as much as possi- ble, or the ergot should be given with a view to hasten the labour. 1464. 4th. "I3ut if the circulation be impeded, the woman must be encouraged to accelerate the labour, by bearing down, or instruments must be employed." 1465. This direction is more vague, perhaps, than any of the preceding; it runs counter in its tendency, if literally interpret- ed, to the advice of the most respectable authorities upon this subject; for if the circulation be arrested, the child will certainly TALLINCr DOWN OP THE UMBILICAL CORD. 531 die in the course of a very few minutes; and if the circula- tion have been stopped sufficiently long to cause the death of the child, it is agreed upon all hands, and even by Mr. B. him- self, the labour should not be meddled with, as it would be un- availing to do so ; consequently, the woman need not be urged to unusual exertion, nor should instruments, or any other artificial means be thought of. 1466. It is by no means uncommon, for the life of the child to be threatened in a case of the prolapsus of the cord, when the head is low in the pelvis; as there is a constant liability to its being placed between the head and the pelvis, and thus suffer more or less compression; we have already provided for this condition, (1449) when delivery can be performed in time to save the child, by the exertion of the woman, or by increasing the power of the uterus by the exhibition of the " Ergot;" or if the forceps can be commanded in time, they may sometimes be advantageously em- ployed. 1467. Now Mr. Burns vaguely prescribes the use of ^Hnstru- mentsf the choice of a proper one, might embarrass a youno- practitioner; though we are disposed to admit, that Mr. B. would select for his own use, either the forceps or the vectis, for he had just said so ; as the object unquestionably should be to save the child's life; but this should surely have been again designated, especially as he is x\ow posting up the points of practice. More- over, it appears to give contradiction to the cautions and distinc- tions he had just made before, and thus sets him against himself. For just above, he states: "if this be not practicable," (return- ing the cord,) "and the pulsation suffer, or the circulation be en- dangered, we must accelerate the labour by the forceps. If the pul- sation be stopped, and the child dead when we examine, then labour may be allowed to go on, without paying any attention to the cord." p. 404. Yet a few lines below, we find the ambiguous directions we have just quoted. Dr. Denman is much more pre- cise upon this subject; he observes that "when the head of the child presents, and has advanced far into the pelvis, if the pains be slow, and ineffectual, and the child living, it may be considered whether, without hazard to the mother, we may not employ the forceps or vectis; and by extracting the head sooner than there was reason to think it xoould he expelled by natural painsy preserve the child." I have italicised parts of Dr. D.'s direc- 532 ON PRESENTATIONS, WITH THE tions, with a view to point out tlie important omissions, in those of Mr. Burns. 1468. 1 would without hesitation have recourse to turning under the circumstances just stated, and the ergot had failed; (1449) or if the forceps were not at hand, or within timely reach, rather than supinely see the child perish ; unless, let it be observed, the waters had been so long drained off, and the uterus so firmly contracted, as to hold out no prospect of success, or unless the head of the child had escaped from the mouth of the uterus: I vvould disregard the head being at the inferior strait, provided it was still enclosed in the uterus; the waters not too long expend- ed; and the head easily movable in the pelvis. For I agree per- fectly with Dr. Denman it is sometimes best to go beyond the common rules of art, if we can save the child by doing so. 1469. 5th. "When the presentation is preternatural, (that is, agreeably to Mr. Burns, when any other part than the head presents,) these directions are to be attended to, and the practice is also to be regulated by the general rules applicable to such la- bours." 1470. I have stated that the woman may be delivered with- out assistance, when either the head, breech, feet or knees, pre- sent; but confessed, however, that the head is certainly the most favourable of these presentations. I have laid down rules for the management of each of these varieties of labour, when they are, and when they are not, complicated by accidents, which must constantly be kept in view in the management of the case in which the cord had prolapsed, of which we are now speaking. Mr. Burns' last direction contains just principles, and are worthy of attention: they would have been still more useful, had he fol- lowed the plan of Dr. Denman, by specifying the particular treatment of preternatural labours, accompanied by a falling of the cord. 1471. Dr. Denman says, "when there is a descent of the funis, with a preternatural presentation of the child, our conduct must have regard to both these circumstances." 1472. << Should the breech present, the case will very much resemble the presentation of the head; that is, the same methods for replacing the cord may be tried, and with rather a better chance of success. If these fail, instead of considering the labour as one of those which is to be resigned to the natural efforts, it FALLING DOWN OF THE UMBILICAL CORD. 533 may be expedient at a proper time to bring down one or both of the inferior extremities, taking care that the funis be not entangled between the legs of the infant." 1473. " Should the arm present, and such presentation be complicated with a descent of the funis, very little difference of conduct will be required; because, in the first place, we should determine to turn the child, and deliver by the feet, and the ad- ditional circumstance of the descended funis can require nothing more to be done. Yet, when the feet of the child are brought down, if the pulsation of the funis be lively or perceptible, it may sometimes admit of a debate whether it will be most proper to hasten the delivery, especially, if the os uteri be not sufficiently open; or to leave it to be expelled by the returning pains. In either case it will however be right, to attempt to return the funis within the uterus, and if it be in our power, out of the way of compression." 1474. Though the above directions are perfectly clear and well understood by the experienced practitioner, they are far from being sufficiently explicit to the student or the young practitioner. I would cite as an instance of the deficiency of precision, the ex- pression, '< it may be expedient at a proper time to bring down one or both of the inferior extremities." How would the unskill- ed know when the proper time for bringing down the feet had arrived? For the measure must be either useful or worthless: if useful, the uninformed should be instructed what constituted the proper time, that advantage might be taken of it; if worthless, it should not have been named, as it might create emban-assment. We will endeavour to supply the deficiency of Dr. Denman by stating, that the proper time for bringing down the feet when the breech presents, especially when complicated by the falling of the funis, is, 1st. When the uterus is well dilated, and the external parts well disposed to relax. 2d. When the breech does not descend with sufficient rapidity, to give promise that the coi'd should not be long compressed. 3d. When the breech is ill-situated as regards the pelvis ; (860) or when it does not readily engage in the superior strait. 4th. When the cord is likely to sufier, or is actually suffering compression, and the child's life threatened, if not speedily re- lieved. 534 ON PRESENTATIONS, &C. 5th. When there is a deficiency or the absence of adequate pains. 1475. As another instance, we may produce the caution, "tak- ing care, (in bringing dov/n the extremities,) that the funis be not entangled between the legs of the infant." In suggesting this caution, Dr. D. shows himself thoroughly well acquainted with the contingencies of the operation of bringing down the feet; a contin- genc}^ that has too often defeated the object of interfering with the labour, but he neglected to inform the inexperienced practi- tioner how this was to be avoided. He should have informed his readers, that the cord would most probably descend on one of the sides of the pelvis; and (almost) consequently, vvould be found either on the fore or hind part of the child. If on the fore part, the cord should be carefully carried up with the hand that is in search of the feet, and when these are found, the cord should if possible be made to pass over them, and made to lie above the legs, and upon the belly of the child, which will certainly pre- vent its getting between these extremities. 1476. If it descend on the back part of the child, it should be returned, above the brim of the pelvis, by the hand not to be employed for bringing down the feet; this will entirely remove it from the risk of its becoming entangled between the legs. (See rules for bringing down the feet in the breech presentations, S92, ct seq.) 1477. If it descend on the anterior, or posterior portion of the pelvis, the cord should be removed to one of the sides of the pel- vis; and when practicable to that side to which the back answers. 1478. If it should be found to descend between the legs of the child, the feet must not be brought down, until the cord has been slipped over one of the legs. 1479. If it be judged proper to use the forceps, their employ- ment must be subject to the rules which govern their application; always however being certain, that the cord is not interposed be- tween the blade of the instrument, and the head of the child. 535 CHAPTER XXXIX. OP THE EUJTUKE OF THE UTERUS. 1480. During labour, the uterus every now and then is rup- tured ; and, perhaps, even oftener than at present we dare assert — sometimes this accident is concealed from ignorance; and at others from design ; hence, many cases must occur of which the ])ublic remains uninformed. Nothing can justify the concealment of this event, though we can promise ourselves but little by the avowal ; but it is a duty we ovvc the connections of the unfortu- nate woman, as well as the profession itself. Concealment often arises from a previously adopted theory upon this subject ; and the supposed risk of professional reputation ; than which, nothing can be more disingenuous, or hypothetical. I would, in one word, recommend in all such cases, its most speedy avowal, to those immediately concerned in the event; and must declare, I should consider the conti-ary conduct, as highly derogatory to the honourable feelings which every medical practitioner should pos- sess ; as well as doing serious injur}^ to the advancement of ob- stetrical knowledge. 1481. In treating this subject, I shall, first, consider whether it be proper to attempt anything for the woman's relief, as there is much authority against it ; and because it is constantly made the plea, for the concealment of this accident ; second, I shall take into view the variously reputed causes of it, with their mode of action ; third, detail the symptoms and consequences of the rup- ture ; and fourth, indicate the mode of proceeding, under the various circumstances with which this accident may be compli- cated. 1482. Di'. Hunter considered any attempt to relieve a woman who had suffered a rupture of the uterus, as cruel — therefore it was not to be attempted. This ojnnion was afterwards more strongly enforced by the late Dr. Denman, who declared, that " when the uterus is ruptured at the time of labour, both reason and experience show, that the patient has a better chance of re- covering, by resigning the case to the natural efforts of the con- stitution, than by any operation, or interposition of art. " 536 RUPTURE OP THE UTERUS. 1483. I consider the assertion of Dr. Denman, to be in oppofsi- tion both to ''reason and experience;" to reason, because it would be a natural suggestion, that that woman's chance would be best, from whom many of the causes were removed, that would hinder recovery, by the delivery of the child, &c.; and to experience, because we have the most unequivocal proofs of recovery, upon record, where " the interposition of art" was resorted to. 1484. Thus Heister,* Douglass,! Hamilton,^ Ross,§ Kitc,l| Madame La Chaple,ir relate cases of entire recovery after the de- livery of the child, through the natural passages ; while Hamil- ton,** Thibault,tt Lambron,J| &c. give others of equal success, where gastrotomy had been performed. In all of these, however, -the success was confined to the mother ; the child was uniformly dead — but I have strong reason to believe, that this was very much owing to the delay which took place before the operation was performed. Indeed Burton§§ renders this almost certain, by the relation of a case which fell under his notice ; in this, the child was delivered alive, though the mother died ; while Mr. Haden relates an instance of the preservation of both mother and child.lill 1485. Thus, we can most successfully destroy Dr. Denman's celebrated aphorism on the subject of the rupture of the uterus, by producing cases, in which the " interposition of art" was followed by success. This, I think, should put the matter to rest ; espe- cially as there is no instance extant, at least with which I am acquainted, where the woman recovered at the full period of * Instlt. de Chir. torn. II. p. 137. f Essay on Rupture of the Uterus, p. 7. + Outlines, p. 344. MS. Lectures. § Annals of Med. Vol. III. p. 377. II Mem. Med. Soc. Vol.IV. p. 253. 1 Annuaire Med, Chir. torn. I. p. 542. ** MS. Lectures. ft Jour, de Med. for 1768. %\ Baudelocque, Vol. HI. p. 430. §§ Syst. of Mid. §43, p. 110. II II Dr. Davis relates a case of the rupture of the anterior portion of the uterus from which the patient recovered in about six weeks. In this case, the child was delivered by the craniotomy forceps, after having its head opened by Smel- lie's scissors. The neck of the bladder was so severely wounded, from its connection with the portion of the uterus injured, as to prevent her retaining her urine ever after. This case, tliough unfortunate as regards the last named injury, is nevei'theless a case in ])oint, to show that the woman may recover after the uterus has been lacerated. RUPTURE OF THE UTERUS. 537 utero-gestation, when the child was permitted to remain unde- livered. 1486. There are a number of instances upon record, which purport to be recoveries, after the rupture of the uterus, where the foetus was permitted to remain in the abdomen — but they are liable to a strong suspicion, and are far from standing the test of ri- gorous examination; they appear to be cases of extra-uterine con- ceptions chiefly, or of but the partial rupture of the uterus. By partial rupture, Imecm, where the muscular substance of this or- gan has suffered laceration^ but where the ivound does not pass through its peritoneal coat. Of this kind are the cases related by a writer in the Jour, de Med. for 1780, also those by Drs. Bell and Sims.* Dissection proved in several of these cases, that the peritoneum suffered only from distention. From all that I can learn from others, or my own experience, I cannot see any reason for withholding aid from the afflicted woman, who may have suf- fered this calamity — except, indeed, in that forlorn condition of the patient, where she would die before aid could be given. But what can we promise ourselves, by not attempting delivery? fori rnust again repeat, that, there is no instance of recovery at full time, from a rupture of the uterus, where the foetus was permit- ted to remain in the abdomen of the mother — nor should the opi- nions of Dr. Hunter, Dr. Denman, and Mr. Burns, be considered sufficient authority in such cases to screen from reprehension, any one who may have neglected an opportunity to discharge what I consider his bounden duty, by delivering his patient instantly, if practicable, when she has suffered a laceration of the uterus. 1487. Indeed, the objections of Dr. Denman, are not entitled to the smallest weight upon this point; since he is entirely at va- riance with himself. In his " Introduction to Midwifery, "t he ap- peafs to have entertained rational and liberal views upon this sub- ject; he there tells us, that, "beside some few others, (cases of rupture,) of which I have been informed, or which are recorded, a case has occurred to my very ivorthy, able, and exjierienced friend Dr. Andrew Douglass, in which the uterus was ruptured; he turned the child, the patient recovered, and had afterwards children." And Dr. Denman observes upon this case, " if no * See Essays on Subjects connected with Midwifery, where this subject is treated at large, (p. 201.) t Vol. n. p. 117. 68 538 RUPTURE OF THE UTERUS. other case had ever occurred, I apprehend this would be sufficient authority to render it in future, the indispensable duty of every practitioner to act in a similar manner; and bad as the chance is of the patient, to be strenuous in using all the means which art dictates to extricate her, if possible, from danger, or to preserve the child." 1488. Dr. Denman has by no means satisfied me, or perhaps any one, why his sentiments underwent a change upon this sub- ject; and the more especially, as it is a change to be considered as imfriendly to the cause of science, and to the interests of humanity — it seems he has drawn a conclusion upon this point, that satis- fied himself; though totally gratuitous, in the estimation of every body else; namely, " that there are more instances upon record of recoveries of women who have not been delivered, than those who have been delivered after rupture of the uterus." 1489. Were this position of Dr. Denman really founded in fact, it would deserve the most serious consideration; but as strong doubts must be entertained upon this point, it has not changed my opinion; first, because the subjects of comparison are not equal; as very many more women have been suffered to remain unde- livered after rupture, than have been delivered; consequently a conclusion cannot legitimately be drawn; as the proportions they bear to each other cannot be known; second, because I deny that there is a well-attested instance of the woman's recovery, when she was permitted to remain undelivered. 1490. From all I can collect from tiie histories of cases of rup- tured uteri, it would appear, that life is prolonged and suffering abated, by delivery;* it therefore involves a great moral question; and if the facts be as I have stated, and as I most seriously be- lieve them to be, it must resolve itself into inculcating it as an obligation, that we deliver whenever practicable, after the uterus has suffered laceration. 1491. Upon a comparison of an equal number of cases deliver- ed after rupture, with those not delivered, it was found, that the women who were delivered, lived much longer on the average, than those who were not delivered; now, if death caw be suspend- ed by our efforts, even for a short time, it will follow, it becomes a duty to make them; and, if we add to this, what we have very confidently asserted, that there is no instance of recovery where * See Essays on various subjects connected with Midwifery, by the author, p. 227. RUPTURE OF THE UTERUS. 539 delivery has not been performed, this first part of my inquiry must be terminated by declaring, it is almost always proper to interpose art, in cases of ruptured uteri. 1492. Very many causes are assigned for the rupture of the uterus; some of which appear totally incompetent to this end; while others of powerful agency, are but slightly glanced at. La Motte believed that the struggles of the child were capable of this accident; hence, by him, they are enumerated as a cause. In this he has been followed by Leveret and Crantz — indeed I may say some late writers. But the child is almost always pas- sive when the accident happens;* and 1 may add in proof of this, that the uterus has given way, after the death of the child. 1493. Dr. Dcnmant says, " the uterus may, independently of disease, be mechanically worn through in long and severe labours, by pressure and attrition between the head of the child, and the projecting bones of a distorted pelvis; especially, if they be drawn "into points or a sliarp edge." To this doctrine I cannot subscribe; first, because, before the membranes are ruptured, the head can- not rest with sufficient firmness against any given point to produce the necessary degree of "attrition;" second, that after the evacu- ation of the waters, the body of the child is so firmly embraced by the contracting uterus, that "attrition" cannot take place; third, there could not be sufficient friction generated between the smooth surfaces of the child's head and the uterus to produce It; fourth, in such cases the child's head should also exhibit marks of this "attrition," yet of this no mention is ever made. 1494. Salmathus, agreeably to Mr. Burns, considers a "thin- ness" of the uterus as a predisposing cause of rupture — but we have no evidence in any case whatever of this " thinness" exist- ing as an original conformation of the uterus before the rupture takes place — if it be found thin, (post mortem,) it may be occa- sioned from mere, exhaustion of blood, and not be an original condition of this organ. Mental agitation and frights are also said to occasion rupture of the uterus; but strong doubts should be entertained of such causes. 1495. I shall, therefore, pass without notice many causes repu- ted as capable of causing this accident; and consider only such, • Baudelocque. f Introduction, p. 105. 540 KUPTURE OF THE TTTKUUS. of whose agency no reasonable doubts can be entertained. I shall divide these; first, into those whicii act directly upon the uterus; and second, into those which have an indirect influence. 1496. The first may be considered mechanical violences; and may be both external and internal. The external may be blows, kicks, or violent pressure; the internal may be, ill-conducted at- tempts to turn the child; the attempt to return a prolapsed limb; the mal-adroit use of instruments ; or the unequal surface of the child itself. 1497. The second, or indirect, are such causes as may have a tendency to injure the continuity of the uterus by mechanically impeding the passage of the child; as a contracted pelvis; an un- usual sharpness in the linea ilio-pectinea; exostoses, tumours, scirrhi, and ulcers. 1498. The action of these two sets of causes are different; the first act directly, by exerting a force beyond the resisting power of the uterus; the second, by diminishing the strength o( apar- ticular jiortion of this viscus, so that its own contraction may be sufficient to overcome the resistance which this weakened part offers. 1499. The mode in which the first set of causes acts, is suffici- ently obvious without farther explanation. The second is not so clear, yet of most easy explanation. The head of the child, co- vered by the uterus on all sides, cannot, in a contracted pelvis, readily engage in the opening of the superior strait; it must, therefore, rest for a long time stationary, or nearly so, at its mar- gin — if this be sharp, or projecting, the uterus will suffer in pro- portion to the weight of the child, the force of the contractions of the uterus, and the period it may suffer this compression — in- flammation ensues ; and, if the cause be not soon removed, gan- grene will follow; when the uterus is thus weakened, it will be easil}?^ understood how a small force may ruptitre it. 1500. The second set of causes acts by preventing a regular de- velopement of the different portions of the uterus during preg- nancy ; consequently, one portion or other is put unduly upon the stretch, and of course weakened; and by its remaining pas- sive during labour, by being diseased, it cannot resist the efforts of the healthy portions. When the action of the uterus itself is the cause of the rupture, it always takes place at the moment of the greatest severity of pain. Boer and other German Pathologists have rendered it probable, that, that peculiar condition of the RUPTURE OF THK UTERUS. 541 uterus called " Softening," may be a cause of the rupture of this organ ; for though it is never perhaps absolutely until after death, yet it is rendered probable that it may exist during pregnancy, though perhaps in an inferior degree to what is observed in post mortem examinations, yet to a sufficient extent to cause rupture during labour; and this may also agreeably to the same authority be the cause of the death of the foetus in the last period of utero- gestation. 1501. Rupture ma}^ happen to any portion of the uterus; or in any direction; or at its connection with the vagina — it maybe more or less extensive; and the child with its appurtenances may pass entirely, or partially, into the abdominal cavity. 1502. When this accident happens, it almost always declares itself by such symptoms as cannot well be mistaken. I shall now consider those symptoms, under the third division of our subject. 1503. Crantz, Levret, and others, have supposed that the rup- ture of the uterus might be foretold by premonitory symptoms ; but I am very certain that few things can be more equivocal than the symptoms pointed out by Crantz; namely, that, "when a woman is threatened with a rupture of the uterus in a laborious labour, the belly is very prominent and tight; the vagina length- ened, and the orifice of the uterus very high; the pains are strong, leave little interval, and do not advance delivery." I have seen all these symptoms in their most exalted form, without the labour terminating by rupture; and in Mrs. M's case, which fell under my notice, and of which I have given a detail,* "strong pain with little interval" were not among its precursors; though a very extensive laceration of the uterus took place. M. Levret has added to these symptoms, but without increasing their cer- tainty, "that the pain the woman suffers, is always seated to- wards the middle of the epigastric region; that a last effort or vio- lent leap, succeeds to the repeated strugglings of the child, which announces its death and the rupture of the uterus." 1504. Did the signs just detailed, portend a rupture of the uterus, every laborious labour would be threatened with one — every symptom enumerated above, is almost the necessary eflect of the tonic action of the uterus, after the evacuation of the wa- ters ; yet fortunately for suffering woman, this accident is of com- paratively rare occurrence. * See Essays on various Subjects connected witli Midwifery, by the Author, p. 238. 542 RUPTURE or the uterus. 1505. The signs added by Levret are frequently witnessed, without a rupture supervening: and it has occurred, where these marks were absent — it is also well known, that the uterus has given way after the death of the child;* I therefore perfectly agree with Baudelocque, " that the rupture of the uterus has often taken place without iDeing preceded by any of them, and has not happened in other cases where their union declared it inevitable." The conclusion from this must be, that it would be extremely hazardous to act upon the presumption, that a rupture of the ute- rus was about to take place, because of the presence of several of the symptoms just mentioned — who could justify the employment of the forceps, or crotchet, or perform the difficult and oftentimes dangerous operation of turning, upon a mere surmise that this ac- cident might take place? 1506. I have said enough, I trust, upon the uncertainty of any sign or signs that would announce a rupture to be at hand; I shall therefore pass to the enumeration of the symptoms which declare it, after it has taken place: 1507. The woman feels for the most part, an acute pain at the place at which the rent happened — she generally cries out, and declares that something terrible has happened within her — the rupture is said sometimes to be accompanied by a noise which has been distinguished by the bystanders — a discharge of blood of greater or less extent takes place from the vagina — her face be- comes cold and pale — her respiration hurried — she is sick at sto- mach, and most frequently vomits — the matter discharged is sometimes the common contents of the stomach, at other times it consists of a very dark, even black-coloured substance, resembling coffee-grounds— the pulse is extremely frequent, small, flutter- ing, or extinct — she complains of a mist before her eyes, loss of sight, and extreme faintness — a cold clammy sweat bedews the surface of the whole body, and if not speedily relieved, convul- sions and death follow. 1508. These symptoms are, however, modified by several cir- cumstances; 1st, whether it be the uterus itself, or its connection with the vagina, that may be ruptured; 2d, whether the child has escaped in part or entirely into the cavity of the abdomen; 3d, whether the lesion has passed through the substance of the uterus alone, or has penetrated the peritoneum. * Annals of Med. Vol. III. p. 293. 303. RUPTUHE OF THE UTEKUS. 543 1509. 1. When the rupture has taken place either in the body or neck of the uterus, the ])ains either cease, or slacken so much as not to propel the child if it be still retained within the uterus. 1510. 2. When the child escapes entirely into the cavity of the abdomen, through the torn uterus, the most distressing and alarm- ing symptoms quickly follow — if but partially protruded, pain may effect the delivery of the child, or it may be extracted by art. 1511. 3. Should the wound stop at the peritoneal covering of the uterus, and not penetrate the abdomen, there is reason to be- lieve that the symptoms will not only be milder, but the chance of recovery increased. 1512. However strongly and decidedly marked the symptoms which accompany rupture may be, they are not exclusively to be relied on — but when they have excited suspicion, by their seve- rity and character, we should lose no time, before we ascertain it — this is to be done by a careful examination of the abdomen and the uterus; the first by the application of the hand externally; and the other by the finger or hand per vaginam. Should the accident occur before the rupture of the membranes, the tumour which they formed will shrink away; for, if the rent be through to the abdomen, it is more than probable that the membranes will give way, and the waters be discharged within it; but should the lesion stop at the peritoneum, they may remain entire for some time, though they may not again form a bag within the circle of the OS uteri. 1513. When the abdomen is examined externally by the hands, the foetus, if the rupture be complete, may readily be distinguished through its parietes; if the foetus cannot be thus detected, it is presumable that it has not escaped entirely from the uterus — but we are to ascertain this by a careful and more extensive examination. 1514. If the accident take place after the discharge of the wa- ters, the presenting part will either recede beyond the reach of the finger, or can be easily forced back by its pressure, (pro- vided the head or presenting part has not already engaged in the pelvis) — if the former obtain, the hand should be introduced, and the nature of the case clearly ascertained — should the os uteri be well dilated or easily dilatable, the hand should be passed into the cavity of the uterus, so that the extent of injury be well under- stood. But should the os uteri be firmly contracted, so as to refuse admission to the hand, without the application of much farce, the 544 RUPTURE OF THE UTERUS. point should be given up; for nothing can justify a violent entry into the cavity of the uterus. 1515. When the laceration takes place at the neck of the ute- rus, or at its union with the vagina, the child, with its appurte- nances, almost always pass into the cavity of the abdomen; in either of these cases, the presenting part will immediately remove itself from the superior strait; when this happens, we should, as quickly as possible, ascertain whether the accident has taken place, of which this circumstance would instantly give the suspi- cion. In cases like these, the examinations to this effect are more easily conducted, than when the body or fundus is the subject of the laceration; as the parts involved in the mischief, cannot con- tract like the uterus itself — the uterus, under such circumstances, will be found, for the most part, firmly contracted either on the posterior or anterior portion of the pelvis, as it may happen to be the posterior, or anterior portion of the vaginal circle, that may have sustained the injury — the intestines will frequently prolapse through the wound, which removes at once all doubt as to the na- ture of the accident — it is almost needless to suggest the propriety of a cautious and gentle examination, after the hand has entered the abdomen. 1516. When the nature of the accident is ascertained, it be- hoves us immediately to atttempt the relief of the unfortunate wo- man; and the means for this purpose are — first, to attempt deli- very per vias naturales; and second, to perform the operation of gastrotomy. 1517. We may perform the first, whenever the neck, or its union with the vagina is the seat of laceration, provided the pelvis is of a good conformation, and the child has escaped into the cavity of the abdomen — the feet of the child should be sought for, and the delivery accomplished as in a case of turning — but should the pelvis be so contracted as not to permit the child's head to pass, this mode of delivery must be changed for the second. Should but a portion only of the child have escaped through the rent, and the head be engaged in the pelvis, the forceps should be used, or if we are certain of the child's death, the crotchet may be employed. 1518. When either the body or fundus, or both, have suffered, and the child has escaped into the abdomen, the delivery per vias naturales may be either difficult or impossible, even in a well- formed pelvis; for the uterus will most probably contract itself so much as to render the re-passage of the child impracticable; the RUPTURE OF THE UTERUS. 545 only chance, in this case, is the immediate performance of gastro- tomy; should a contracted pelvis complicate tliis case, the latter operation is the only alternative. But should the uterus remain flaccid, and its mouth yielding, and the pelvis well-formed, we may succeed, though with difficulty, through the natural passages — but if this flaccid state of the uterus be attended by a deformed pelvis, the abdominal section is the resource. 1519. Should the vagina alone sufier, and the child pass into the abdomen, we should deliver by the natural passages, provided the condition of the pelvis will permit: if it should not, gastro- tomy must be had recourse to.* 1520. The operation of gastrotomy, I believe, is one which has never been performed in this country on the living subject, for rupture of the uterus; but there is no reason why it should not, when circumstances are sufficiently imperious — we have the experience of the European surgeons in its favour; and, however appalling it may appear, when viewed merely as an operation, it nevertheless would seem to add but very little additional suffer- ing to the unhappy woman.t 1521. But to derive advantage from this operation, " it should be performed as quickly after the accident as possible, while the patient still retains strength; and the incision should always be made on the side of the abdomen, which corresponds with the rupture of the uterus,"^ if practicable, or I may add, if that side can be detected. Should either the anterior, or posterior portion of the uterus have yielded, the child would most probably be in the middle of the abdomen, (provided the woman had not changed her position after the accident,) in which case the incision would perhaps be best made in the linea alba, as if the Cesarean sec- tion were about to be performed. 1522. As every case must necessarily be interesting, as well as instructive, in which bold and judicious operations have saved life, I will relate some instances of success, tbllowing the opera- tion of gastrotomy. Gastrotomy. 1523. Dr. L. Frank relates the following interesting, though » The reader, if he wish to see this subject more amply treated, may find it in « Essays on various Subjects connected with Midwifery," by the Author, p. '201. t Thibault des Bois, Joui*. de Med. for 1768. t Path. Chimr.tom. II. p. 239, par. M. Lussus. 69 546 RUPTURE OP THE UTERUS. rather too generally described case, in which g.istrotomy was successfully performed: 1524. "Angela Grossi, of Parma, aged forty-four, had borne five children, and had reached the ninth month of her sixth preg- nancy, without the occurrence of any accident. On the morning of the 9th of August, 1817, labour commenced; and whilst stand- ing up, she was seized with a faintness, accompanied by vomit- ing. She was therefore placed on her bed, by the assistance of her husband and midwife. At that moment, she stated that she experienced a feeling of laceration in the abdomen, and also a sensation of there being two children. A surgeon, who was called in, asserted that the effort of vomiting had carried the child upwards; adding, that another migiit propel it downwards; and advised the patient to remain quiet." 1525. "The midwife, however, remarking that the abdomen swelled, that the vomiting did not cease, and that the breathing became irregular, called in Dr. G. Rossi. On examination, he detected a rupture of the uterus; and on consultation with his father, and other medical men, it was unanimously resolved, to have recourse to gastrotomy." 1526. "Two hours after the occurrence of the accident, the operation was performed by Professor Cecconi, in the left hypo- gastric region, precisely at the point where the feet of the child were felt. When the incision was made, the child presented with the feet, and was extracted alive, together with the secun- dines. No bad symptoms are alluded to, and it is stated that the patient was perfectly recovered forty days after the opera- tion. Three years afterwards, she had a seven months' child, which lived a fortnight. After her recovery, a ventral hernia presented itself in the situation of the cicatrix, which, though ir- remediable, was not productive of much inconvenience."* 1527. In Germany the operation of gastrotomy has been per- formed with success, by Mr. Bulk, upon a woman of good con- stitution, and of thirty-six years of age. The patient during her pregnancy, suffered from a severe pain in the left and inferior side of the abdomen; her menses were not suppressed; and every six or eight days a clot of blood and mucus came away from the vagina. Her general health was good. 1528. About the middle of the eighth month, v/hile she was * Anderson's Uuurtcrly Journal, Vol. II. No. 1, for Oct. 1825. RUPTURE OF THE UTERUS. 547 washing some linen, she suddenly felt as if sonaething was tearing in her abdomen; at the same time, a swelling of the size of two fists, (poins,) formed in the right side below the umbilicfis. She fainted; and during six weeks she suffered dull pains in the abdo men. At this time she had true labour pains for forty-eight hours, and was attended by a midwife. The os uteri dilated so little as to admit but one finger. The tumour disappeared during these pains. The patient recovered, with the size of the abdomen un- diminished. 1529. In this condition she continued for two years and three months, menstruating regularly. She became again pregnant, and suffered but little inconvenience until the seventh month; when her abdomen became painfully distended, and of a bluish colour; fluctuation was induced on the least motion. At the full period, she was delivered of a large foetus, which she suckled for fifteen days; the infant then dying of an aphthous affection. . 1530. The milk ceasing to be secreted, she declined rapidly with hectic symptoms; the tumour re-appeared below the umbi- licus, of about the size of an egg; it soon opened, and discharged pus from small orifices. The patient's constitution was rapidly yielding, and gastrotomy was immediately performed. An incision was made with usual precaution through the linea alba into the cavity of the abdomen, from two and a half inches above the um- bilicus, to within nine lines of the pubis; care being taken to con- fine the intestines. A foetus of full size, in which putrefaction had commenced, was found on the right side of the uterus. '' I raised," says the operator, " the body with much care, and en- deavoured to trace the umbilical cord. This was turned over the uterus to the left side, and termanated in a vascular substance in state of suppuration, (probably the remains of the placenta,) which was situated below the great omentum. I pressed out and dried up, by means of a sponge, the pus which covered these parts. The uterus was an inch and a half in length, and an inch in breadth, of a pale rose-colour, and could easily be distended, (se laiss ait distendre aisement,) it was otherwise in a good condition. 1531. The wound in the abdomen was closed by sutures. The patient was in great danger from inflammatory symptoms for eight days; but eventually she recovered. She left her bed on the fifty-fifth day. PART IV. ON DELIVERIES PERFORMED BY CUTTING INSTRUMENTS, AP- PLIED EITHER TO THE CHILD OR MOTHER. 1532. Hitherto I have been treating of labours which could be terminated by the natural agents of delivery; those in which the hand alone could perform it; and those in which it was ne- cessary and proper to employ such instruments as were calculated to preserve both mother and child. I have now to consider those unfortunate instances, in which the labour is impracticable with- out either mutilating the child, or subjecting the woman to the Cae^rean section, or the section of the ossa pubis, commonly called the Sigaultean operation. 1533. There are a number of causes which may place an un- fortunate woman in the predicament of having .her child mutilat- ed, or force her to submit to the alternatives just mentioned. These causes are, 1st. A deformity of the pelvis; 2d. A defor- mity of the child, or its monstrosity? 3d. Accidental deformity, as hydrocephalus, dropsy of the abdomen, &c. CHAPTER XL. I. DEFORMITY OF TKE PELVIS. 1534. This subject has already been treated of; (45, &c.) but it was then mentioned as a mere deviation from the healthy mea- surement of the pelvis: I shall now consider the indications this unhealthy structure may produce. When the deviations are but small, a child may be delivered alive at full time; but the la- bour will be more tedious and painful, if the child be of the or- dinary size, than if the pelvis enjoyed its full and proper pro- portions. But the variations may be greater, or even at times OF TURNING IN A DEFORMED PELVIS. 549 excessive— the degree, therefore, will necessarily give rise to va- rious modes of terminating the labour by artificial means. 1535. The resources of art under deformities of pelvis, are, a. Turning. b. Forceps. c. Cephalotomy. d. Cesarean operation. e. Premature delivery. f. Section of the pubes. g. Regimen during pregnancy. Sect. I. — a. Of Turnings in a Deformed jjelvis, as a Means of saving the C/iikPs Life. 1536. When treating of this operation professedly, I took oc- casion to observe, (736) that it was always one of hazard to the child, even in a well-constructed pelvis; a fortiori, the risk must be greater in a contracted one. For this operation to be successful, even under the best management, it will require, 1st. That there shall exist a proper relation between the diameters of the child's head, and those of the pelvis; 2d. That the waters shall not have been too long drained off; 3d. That the breast of the child, and cord, shall not suffer compression ; 4th. That the head shall not be too long detained in the pelvis ; and 5th. That the neck of the child shall not suffer too much extension after the body is delivered. 1537. To obtain these advantages, requires no common com- bination of favourable circumstjinces; and as these for the most part must necessarily be contingent, it is no way surprising, that this operation should so often fail of success — and to all that may be required on the part of the mother and child to render it even probably safe, there must be added skill on the part of the opera- tor; for, without this, very often the child would perish, though the case may have been the most proper, or most easy of per- formance. 1538. Should the deformity then, leave less than three inches and a half in the antero-posterior diameter of the superior strait, we need scarcely look to this operation for success, as regards the child ; and when resorted to under such circumstances, it must only be considered as a remedy for the safety of the mo- 550 OF TURNING IN A DEFORMEn PELVIS. ther. In this country, indeed, even the diameter just specified, would rarely be suflTicient to give promise of success, under the best and most skilful management ; for the transverse diameter of the head of the greater part of the children born at full time, would exceed three inches and a half; now, should this diameter exceed this measurement but a quarter of an inch, or even less, it would create a difficulty that would menaces the life of the child. 1 well remember once to have sorely repented the trial, where I judged the small diameter of the superior strait, would certainly have been equal to three inches and a half. 1539. It will, therefore, follow, that turning in a confined pel- vis is, and must be, of doubtful safety, as regards the child. As one calculated to relieve the mother, or simply to terminate a labour, without taking into view its effects on the child, it might in ma- ny instances be successful; or, if the practitioner has been deba- ting within himself, the comparitive merits of the crotchet or turning, the latter will unquestionably merit the preference; since it gives a chance, though a forlorn one, to the child. But let it be observed, the consideration should have turned upon the em- ployment of the forceps, and not upon that of the crotchet, for this should always be considered as a dernier resource. 1540. We have stated, as one of the essentials to easy and safe turning, that a proper relation of diameters should exist between the pelvis of the mother and the head of the child. In laying down this axiom, we would wish to be clearly understood to mean, the absolute proportions, and not the relative. Or, in other words, the respective diameters of the pelvis, shall be of such ca- pacity as will permit the head to pass without any material ob- struction when its corresponding diameters shall be presented to them. If this be not the case, the force which must necessarily be employed to overcome the resistance created from the want of this proper relation of diameters will be such, as but too surely to destroy the child, and create at the same time, difficul- ties, which perhaps can only be overcome, by the use of cutting instruments. 1541. Again, we have said, that, besides the proper corres- pondence of diameters as just stated, it is almost a sine qua non, that the waters should not have been too long drained off", to ren- der even this favourable disposition available. For it is a truth, which almost every accoucheur must acknowledge who has at- OF THE FORCEPS IN A DEFORMED PELVIS. 551 tempted to turn in a strongly contracting uterus, that the want of success by this operation, even in a well-formed pelvis, is too often owing to its being undertaken when the uterus is very firmly embracing the child. If then, we have to contend against the two difficulties just enumerated, it is more, perhaps, than ten to one, that we do not succeed, in saving the child. 1542. We have also enumerated as another essential to the safety of the child, that its breast, as well as the umbilical cord, shall not suffer compression. But what skill or foresio-ht, can guard against such a contingency ; nay, almost against such a certainty ? And if this be beyond our control, as it too surely is, we need not wonder, at so many instances of failure, in this operation. 1543. We must again repeat, that the head must not be too long detained in the pelvis if success is to attend our exertions. But who can declare that this shall not take place ? since the ex- ercise of the most consummate skill cannot insure it; and who can guard against the ill-devised manipulations of ignorance ? 1544. Finally, we have declared, that the neck of the child must not suffer too much extension. But who can insure the life of the child against such a necessity, even in the hands of the skilful ? 1545. From what we have said, the conclusion will be easily- collected ; that even under the more favourable circumstances, turning is to the child a hazardous operation ; but that under per- verse ones, it is but too often fatal to it ; and, that it must ever be looked upon as a doubtful alternative, rather than as a probably safe resource. Sect. II. — b. Of the Forceps in a Deformed Pelvis. 1546. In my general view (761) of the forceps, I endeavoured to prove that their powers were pretty extensive, yet sufficiently limited. That their mode of action (784) was that of a double lever, with no mean compressing power — that this power, how- ever, could not be successfully employed (781) beyond a certain degree, with safety to the child. That, if more were exerted, it would be at the expense of the bones of the cranium, and the brain of the child ; therefore, there was a limit to their usefulness. In a pelvis where the opening of the superior strait in its small diameter will give three inches, these instruments have been 552 OP THE FORCEPS IN A DEFORMED PELVIS. successfully employed; of which Baudelocque* gives us an ex- ample which not only proves the useful powers of these instru- ments, but shows the little certainty with which the death of the child is marked, even by the combination of many of the most formidable signs. This case is full of instruction, and should be carefully read. 1547. But when the small diameter of the superior strait has less than three inches, these instruments cannot be employed at the full period of utero-gestation with any chance of success. To be useful even then, requires that the head of the child shall be of moderate size, and yielding; well situated, and that a skilful hand should apply them.t As, however, they offer a better chance, if properl}^ conducted upon the head than turning, they should be employed always in preference to this operation, when even a force not to be called great, would be required to make the head pass the superior strait; for the child will suffer less from a com- pression of the head, than from the severe extension of its neck; which it must necessarily undergo, when detained in a pelvis, in which the opening is less than four inches. 1548. It must, however, not be concealed, that these instru- ments are not safe, under the circumstances we are now consi- dering, but in the hands of a few; and are only rendered so to them, by their superior professional attainments, and the long habit of using them. To the inexperienced practitioner, they should be entirely forbidden; not only because they may destroy the child, but also because the mother may be severely, or irre- parably injured by their use. Should, however, the defect of size be in the lower strait, and that not excessive, the forceps will every now and then answer a valuable end, as the following case will prove: Mrs. had been in labour nearly six-and-thirty hours with a first child; the early part of her labour had been slow, but re- gular in its progress. The midwife to whose aid I was called, in- formed me, that the waters had been discharged after the uterus » System, par. 1898. ■}• " But, inasmuch as we have not discovered th^ means of applying sucli pressure to and for the benefit of the child, without, in the meantime, compro- mising' the more important interests of the mother, it should be held as the bounden duty of our art, in the treatment of such cases, (cases of narrow pelves) to refrain from all inordinately forcible attempts to deliver with the forceps." — Dr. Dauis's Elem. Opcr. Mid. p. 140. OP THE FORCEPS IN A DEFORMED PELVIS. 553 Was well dilated; the pains had all along been good; that the child was very loio, and seemed every moment ready to come, yet did not advance; for so soon as the pain ceased, it flew back to its old place, and had done so for many hours. The woman was in good health and spirits, notwithstanding the length and severity of her sufferings; she was free from fever; had had her bowels opened, and passed urine but a short time be- fore my seeing her — she was short of stature; waddled when she walked; and was very bow-legged. Upon examining her, I found that the lower strait was defective in its small diameter; the tu- bers of tlie ischia approached too much, and thus did injury to the arch of the pubes also. I waited for a pain to determine its influence — the head was well situated, but could not descend low enough to enable the vertex to pass under the arch of the pubes; it was, therefore, found rather mounted behind it. The head did not appear large, and its bones were supple. When a pain came on, the parietal bones rode over each other, and the scalp was pushed considerably in advance. I waited to try the influence of two or three more pains; but the head only advanced during their action; for so soon as this ceased, it raised upwards, as it had done for a long time, as stated by the midwife. The cause of the delay was obvious — the parietal protuberances could not be forced by the uterus, below the tubers of the ischia, that the head might pass througli the external parts. I was of opinion that nothing could relieve the head from its perilous si- tuation but the forceps; accordingly,! made it known to the friends of the patient, and subsequently to the patient herself— she cheer- fully acquiesced in the decision; the)^ were applied, and by mere- ly maintaining the ground gained by each uterine effort, without exerting much tractive force, I succeeded in half an hour to de- liver the poor woman of a living female child. The head was elongated to an unusual degree; but it recovered its natural shape in a few days.* 1549. It is not intended by what has been said, to discourage the obstetric practitioner in the use of the forceps, in cases in which their application might be difficult; on the contrary we would earnestly recommend to him the careful study of their mode of action, and the various manners in which they are to be * I was ever after obliged to deliver this patient with the forceps: tiiis hap- pened four times; and without the smallest accident to either mother or cliild. 70 554 OF THK FORCEPS IN A DEFORMED PELVIS. applied. The usefulness and agency of these instruments in pre- serving the life of the child, as well as that of the mother, is no longer problematical; for they have been confirmed by the united testimony of the European and American practitioners of midwifery, for the last fifty years. 1550. Important, however, as the forceps are known to be by medical men, neither they, nor the skill which directs them, are sufficiently appreciated by the public at large; indeed, the prac- tice of obstetrics is very far from being justly valued; and this must for a long time remain so we fear, as the public cannot easily be set right upon its utility. This involuntary injustice to this branch of medical science, arises mainly from the following causes. First, from the process of parturition being constantly viewed as an act, in which the practitioner has no other concern, than to silently watch the operations of nature. This we acknowledge is strictly true in a very great majority of cases; but in admitting this, we are not to pass over without observation, the exceptions, or those instances which require both prompt and judicious inter- ference. But these exceptions are entirely lost sight of; and they are lost sight of in many instances, because they cannot with pro- priety be made to meet the public eye, and this for reasons that will readily present themselves to a thinking mind, as well as the aver- sion every ingenuous mind has to the appearance of vain boasting. Yet the skilful practitioner has it often in his power to felicitate himself, that he has abridged severe suffering, or preserved hu- man life; but for which, he neither expects, nor can he receive, any evidence of public approbation. This does not, however, arise from any reluctance on the part of the world to do him justice, but because the nature of his exertions, and the indispen- sable application of his skill, must for the most part remain un- known, to every body but himself. 1551. Second. The difficulties with which the accoucheur has to contend, are almost unknown out of the profession; on this account, the most important operation which can possibly be per- formed, namely, the preservation of life by the use of the forceps, is put upon a par, nay, it is often placed below, some of the most trifling operations of surgery; for the public are not aware, that the most difficult operation on the living subject, is the scientific application of the forceps, when the head of the child has not de- scended so low as to occupy the vagina. 1552. How mucli greater eclat do most of the operations of sur- CEPHALOTOMV. 555 gery obtain, than a delivery by the forceps! yet we do not fear, nor do we hazard a contradiction when we say, there is no ope- ration in all surgery, that is not of more easy attainment, than the rational and just application of the forceps. 1553. Third. The comparative estimate of the mother's and the child's lives, contributes very much to lessen the value of ma- nual interference in cases of difficult labour. For when anything untoward arises, the life of the- mother alone is taken into the calculation; the child may oe immolated without a sigh, provided it be declared that either it, or the mother must be sacrificed. And if it be preserved, it is looked upon rather as a piece of good fortune, than as an evidence of any superior skill on the part of the practitioner. 1554. But let us not bs supposed to charge the public with vo- luntary injustice on this subject; this is far from our meaning; we only wish to insist, that the difficulties oftentimes to be over- come by the accoucheur, in order to save life, is altogether con- cealed from public view; and of the value of which of course they cannot accurately judge. Yet we feel it is proper that some delicate and proper effiart should be made to elevate the character of the well-instructed accoucheur above the ignorant and pre- tending practitioner; and to have a just value set upon the most difficult operation, in the range of medical science. Sect. III. — c. Cephalotomy. 1555. This operation destroys the child, with the intention, it is said, to save the life of the mother, by preventing her from dying undelivered, or subjecting her to the Caesarean operation. Dr. Osborn has treated this subject under two distinct heads; in conducting which he inquires, 1st. "Into the degree of de- formity, requiring the crotchet, the Caesarean operation, or the division of the symphysis pubis; their comparative merit ex- amined;" 2d. Pie then makes a "comparative estimate of the mother's life, and the life of the child in utero." 1556. His first inquiry results in his giving the preference to the crotchet; and from the following views. " He says, whenever the pelvis is so distorted in its form, and so contracted in its capacity, as not to permit the head of the child to pass unopened, it consti- tutes tiiat degree of laborious parturition," for which the conipa- 550 CEPHALOTOMY. rison of the merits of the crotchet, with that of the Csesarean ope- ration, &c. was instituted. Essays, p. 25.* 1557. That, "whenever a woman falls in labour, the small diameter of whose pelvis measures only two inches and three- quarters, one of the following circumstances must take place." 155S. «' First, the child's head must be opened, and the con- tents discharged, that the bones may be permitted to collapse, and the volume being thus diminished, it may afterwards be ex- tracted with the crotchet;" or, 1559. "Secondly, for the certain preservation of the child's life, the mother must be doomed to inevitable destruction, by the Csesarean operation:" or, 1560. "Thirdly, as a mean between the two extremes, the mother must submit to the section or division of the symphysis pubis; an operation of less danger to the parent than the Caesa- rean section, but at the same time certainly less safe for the child;" or, 1561. "Lastly, if none of these means will be permitted, the * It would seem that theorj', or conjecture, has had much to do in fixing' the nature and value of the child's hfe while in utero; and that the low estimate at- tached to them, has arisen more from terms, than a difference of qualities. Thus Alphonso Le Roy tells us, that "the birth of animals is a quick passag-e from one mode of existence to that of another." And, " that the child, while in ute- ro, hves after the same manner as a veg-etable." Velpeau has adopted these sentiments, with no additional value to the profession. Med. Matern. p. 4. For we would ask, does this comparison prove other, than that the child has life? Is it not a dispute about terms, to call the life of the foetus while in utero vegetable life; and tlvat which maintains its existence after birth, animal life? Has any one demonstrated that there is any difference in the quality of that principle, which we term hfe in these two conditions of the animal? Does not tlie difference consist simply in the manner in which this principle is maintain- ed ? or in other words, are not precisely the same principles essential to the child both before and after delivery ? Certainly they are. While it is in utero, does not the foetus require circulation, oxygenation, and nutrition, as much, quo ad hoc, as after it is born? That these essentials to its existence are apphed differently, and maintained differently, we agree; but the nature, and import- ance of the means, and agents are precisely the same. For the child would un- questionably die in utero, were either circulation, oxygenation, or nutrition withheld beyond a limited time; and death would follow, were either of these grand agents abstracted but for a short period after birth. In a moral point of view, the turpitude of destroying the life of the foetus by design, call it vegetable, or animal, as you please, will be the same; nor must we permit ourselves to undervalue it, or be seduced to destroy it wantonly, by employing terms which have no definite meaning; or if they have a definite meaning, the destruction of the principle called hfe, must in a moral light, be viewed as a crime. CEPHALOTOMV. 557 wretched mother, abandoned by art to the excruciating and un- availing anguish of labour, will probably expire undelivered." 1562. From this it would appear, that every woman who has less than three inches in the small diameter of the superior strait, must die, or be delivered by the crotchet, by the Csesarean ope- ration, or the section of the pubes, if at the full period of utero- gestation. In this all writers agree. But Dr. Osborn is of opinion that nothing but the crotchet should ever be employed under such circumstances, unless the opening at the superior strait has less than one inch and a half; for when there is this opening in the antero-posterior diameter of the superior strait, the child can be extracted by the crotchet, p. 64, and whenever a child can be ex- tracted by the crotchet, neither of the other operations should be thought of. 15G3. He is led to this conclusion, first, from his estimate of the value of the child's life while in utero, when compared with that of the mother. He declares the former to be " incomparably small," nay, '' diminished almost to nothing, and affords the most irrefragable argument in favour of the delivery by the crotchet in preference to either of the other methods," p. 24. And secondly, from his having delivered a woman safely by the crotchet, whose pelvis was said not to exceed one inch and three quarters, at the upper strait. 1564. Dr. Osborn commences his inquiry by stating, " a being in the uterine state of existence, sustains no immediate loss by the deprivation of the living principle, and can scarcely be said to incur any other positive injury. Before the operation, the child in utero cannot suffer mental anxiety, or apprehension from the threatened violence; nor does it feel, I am persuaded, the smallest bodily pain, in the actual commission even of such violence." The question is not fairly stated here — it is not whether the child suffer from this violence or not; the question is, whether it shall have a chance to live, or be destroyed ? the feelings of the child must not be taken into consideration, in weighing the question, which life, that of the mother, or that of the child, must be sacri- ficed. For if we deal honestly upon this subject, and conclude, that the life of either the mother or child must be forfeited, we are forced to the admission, that the child should be immolated, to preserve the mother. It then becomes fairly a matter of com- parison, which is tlie most valuable to society in all its relations. And I would yield the point without hesitation in favour of the 558 CEPHALOTOMY. mother's preservation; and I would do so* were the child a thou- sand times more sensible tlian it is. For did we withhold an ope- ration from a persuasion that the child in utero is endowed with great sensibility, and that like ''the poor beetle that we tread upon, in corporeal suffering; finds a pang as great as when a giant dies," I say, did we withhold an operation essential to the mother's welfare, from these considerations we should be exalting the mere sensibility of the child above the usefulness and importance of the mother, to the husband, parents, friends, and to society. I must therefore insist, that the sensibility of the child, be its degree what it may, must not be taken into the account, when this question is agitated. 1565. But let us believe the child to be as void of sensibility as a cabbage, or any other vegetable, while in utero; what does this prove as regards the proper question? certainly nothing — for necessity, and that necessity absolute, can alone justify the operation. For, were we to permit our sympathies to get the better of our duty; and suffer the mother to die from the exercise of feeling toward the child, we destroy her by such a proof of our sensibility; while on the other hand, if we wantonly or heedlessly kill the child, because we have persuaded ourselves it possesses nothing more than vegetable life, or life without sensation, we murder it, in conforming to an hypothesis. I therefore repeat, that the properties of the child, be they what they may, must never enter into the calculation, when it is inevitably fixed that either it or the mother must be the victim. 1566. The Doctor next declares, " as children before birth are incapable oi mental apprehension, so it is as undoubtedly true, that they are not yet arrived at, or in possession of, bodily sen- sation, and therefore cannot suffer pain or become objects of cruelty." I would inquire, how has the Doctor ascertained that " children before birth are incapable of mental apprehension?" for on this his remarkable conclusion is founded. Has he any proof whatever that this is really the case ? 1567. But before I proceed farther, let me show what Dr. Osborn means by " mental apprehension." — " Before the opera- tion, (of cephalotomy,) the child in utero cannot sufier mental anxiety, or apprehension from threatened violence; nor does it feel,' I am persuaded, the least bodily pain in the actual commis- sion even of such violence," p. 36. Again, "it is certainly from that apprehension, combined with other circumstances of misery. CEPHALOTOMY. 559 which usually precede and accompany the act of dying, that deatli can in itself be considered as the greatest of human evils — and from every one of those, the child in utero is exempt." p. 37. 1568. From this it is evident. Dr. Osborn supposes that bo- dily sensation is dependent upon "mental apprehension," or in other words, that there can be no "corporeal suffering," if there were no "mental apprehension." Is this agreeable to common, and daily observation? Has not the devoted ox, power to per- ceive the "smallest bodily pain," because it cannot, or does not anticipate its fate from the butcher's axe on the morrow ? Were we to adopt this hypothesis, it would make "mental apprehen- sion" tlie cause of corporeal sensation, which would most effec- tually confound all our philosophy. 1569. If I should be charged with having wrested Dr. O.'s meaning, though I have fairly quoted his words; if it should be insisted that, "mental apprehension," meant perception, still the doctor is chargeable with having employed a gratuitous datum — for he has not proved, that the brain of the foetus, especially at full time, (the period at which the operation he advocates is to be performed,) is incapable of perception; and until this be done, it is in vain to contend, that the child in utero cannot feel "the smallest bodily pain." On the contrary, does not the child ac- knowledge this in many instances? Is it not frequently provoked by external causes to move its little limbs? Nay, does it not do this very frequently without, to us, an obvious cause? May these stirrings not be considered as the exorcise of volition? Has it not a brain, and nerves emanating from it? Are these nerves mere cords without sensibility? Is the brain a mere glandular mass without function? I can readily believe their condition to be imperfect, but I cannot admit them to be without power or property. 1570. Does not the heart carry on the circulation as certainly, and as perfectly, quo ad hoc, in the foetus as in the born child? Could this organ perform its functions without a certain condition of the nervous system? If this be so, can the nerves be mere cords, without sensibility? If the nerves belonging to the heart be sensible, may not all others be so? 1571. In my opinion, then. Dr. 0. has not made good his po- sition; a position on which he appears to place much reliance for the supportof his thesis, though in mine it has nothing to do with the question, as 1 have just observed, (1564, 1565) fori must re- 560 CEPHALOTOMY. peat, that necessity, and strong necessity, alone can justify the operation under consideration — the preservation of the mother's life is the only motive to action, and the only ohject in view — if the child must be the sacrifice for the mother's safety, that sacri- fice is imperious, be the condition of the child what it may. 1572. Dr. Osborn next informs us, " that they (children in utero) cannot suffer from mental apprehension, is notorious to ge- neral observation. Even years elapse after birth, before the mind is susceptible of fear, or apprehensive of danger." Admitted : but what does this truism prove, as regards the subject in ques- tion? Nothing; for I still must insist, that necessity alone is to govern us; and if governed by that, the only question to be de- bated is, whether the child is to be absolutely sacrificed, for the jirohable safety of the mother? I say probable safety — for such only it is, as I shall attempt to prove presently. 1573. If we are under the necessity of opening the child's head our social feelings would derive some solace, could we be sure it did not suffer, or were we even uncertain of its suffering from the operation; but every thing opposes our drawing comfort from this source; for however our understanding may be con- founded by specious argument, or wily sophism, our feelings will constantly bear witness against the truth of the propositions, and the legitimacy of the conclusions. And I believe that God intend- ed it should be so. What evils would flow from this source, did we but convince ourselves, that foetal life was void of sensibility, sensation, or of value. 1574. The crotchet has been but too often wantonly employed, even where the practitioner had not adopted Dr. Osborn's opinion on the subject of foetal sensibility; how much more frequently then, will it be employed, when the wholesome restraint of the contrary opinion is removed? I am persuaded that the exercise of true feeling toward the unborn child, has more than once saved it from a severe and painful fate; but it must also be de- clared as my opinion, that it has too often fallen a victim to a false estimate of the mother's danger — for I have known it used where there was the most healthy construction of the pelvis, and where a little address in the use of the forceps, or even a little more patience, would have preserved the child from a premature death.* * I am happy to find my opinion on this subject strengtlicncd by a similar re- CKPHALOTOMV. 5GI 1575. Dr. Osborn further informs us, that "diseases which at any period attack the human body possessing sensation, with sufficient force to destroy life, are in general attended with such a degree of pain, as to excite extraordinary motion, and some strug- gle; at least in articulo mortis. It is highly improbable that this should take place in the uterus, and the mother be insensi- ble of their effect," p. 40. This statement at once brings Dr. Osborn's arguments to issue. He declares the struggle of an in- fant in utero would be an evidence of pain, and of course of its possessing ''sensation;" and, that if this struggle did take place even in articulo mortis, it is highly probable that the mother would be sensible of it — now, what is the fact upon this sub- ject? Why, that I have been repeatedly informed by mothers, that they were apprehensive their children were dead, because after a severe struggle or kind of fluttering, which has been de- scribed of longer or shorter duration, they felt them no more — and every accoucheur can bear witness to such statements from them. 1576. Dr. Osborn farther urges, that, ^' when we are compelled by dreadful necessity, to open the child's head while we know it is living in utero, that operation requires such extreme o^n^ jjainful violence, that, were the child endowed with the slightest sensa- tion, he must of necessity feel it; and his feelings must necessarily be accompanied with such struggles and exertions, as would be emphatically expressive of pain, and must be readily perceived b}^ the mother in a part so sensible and irritable as the uterus." p. 41. 1577. This is sheer sophistry — it is making a negative condition prove a positive position; or, in other words, it is making the absence of struggling prove the want of sensation; when the si- tuation of the child in utero is such, very often when it is neces- sary to perform this operation, as to render such evidence of its sufferings impossible. For this operation is recommended to be performed after the waters have been expended, and the uterus is firmly contracting round the body of the child. Now, it is well known to every accoucheur of any experience, that the uterus will in many instances so strictly gird the child, as to mark by Dr. James, wiiose opportunities afford Iiim ample room to witness the abuse of tliis instrimient in the hands of ig'norant practitiopers: in a note to Burns's Midwifeiy, p. c,5, note k, he says, he fears that "enibryulciais fi-equent- ly resorted to veiy unnecessarily at least, to make use of the mildest terms." 71 562 CEPHALOTOMY. preclude the possibility of " exertion," be its feelings what they may. 157S. Besides, in a case which T witnessed of the operation of cephalotomy, the woman declared to me without inquiry, that the most painful part of it was the struggles of the child. Now in this case the waters had been but recently discharged, and the uterus contracted but once in about twenty minutes. I mean not to lay undue stress upon this case; for it is not essential to my argument. I well know the imagination does much upon such occasions; and that a convulsive action of the uterus may have been mistaken for the motions of the child; though it was pre- cisely such a case as would lead to the belief, that the poor woman was correct; for the child was certainly alive when the operation commenced; the waters had been expended but a short time; and the woman's observation was spontaneous, and unprovoked. 1579. Dr, Osborn, however, tell us on the contrary, that" upon accurate and repeated inquiry in several such cases, he could not learn that the mother was sensible of any such alteration in the motion of the child, even at the commencement of the operation, when the violence offered to it first takes place, and must be most painful." This statement of Dr. O.'s amounts but to this negative; that in the cases in which he made <' repeated in- quiry," no struggles were perceived; but this is very far from proving, that none upon any occasion could take place. For this might well happen in " several cases," yet not be true in all; and if there have been one case in which the child was known to struggle in consequence of the operation, it is every way sufficient to destroy the arguments of Dr. 0.; since he makes struggling a proof of sensibility — and I most sincerely believe many such cases have occurred. There are two especial rea- sons why this maiy not commonly happen: 1st. As stated, (1577;) and 2d. The- child is sometimes dead before the operation is com- menced. 1580. " Having proved," continues Dr. 0. " that the loss which the child sustains, by the deprivation of the living principle, is so extremely small as almost to vanish to nothing, and that its bodily sufferings in the act of deprivation are absolutely none, it becomes proper, next, to inquire what is the value of an unborn child to its parents and to the community." p. 42. 1581. " Before the birth of the chWd, parental affection has not CEPHALOTOMY. 563 taken place^ which, for tlie wisest and best purposes, is one of the strongest, the most universal, and perhaps, the most uncon- trollable passions of the female breast; often changing, even in the subordinate parts of the creation, the very nature of a timid mother, into that of a ferocious animal. Disappointment of ex- pected pleasure only, not the loss of any object of this powerful passion, or the loss of any actual enjoyment, is the sacrifice the unhappy parent makes on this occasion." p. 43. 1582. We are of opinion, that Dr. 0. is far from having /;rove^, (except to himself,) that which he so complacently slates he has done, (1579.) And, if he had really "proved" that which we think he has merely taken for granted, it still would have no bearing upon the subject — the degree of sensibility of the child while in utero, or whether it possess any, is not the question, as I have before declared; for neither view of this question, should prove a motive of itself to the operation; nor should either deter from it; for this point must be settled upon other principles. 1583. But where Dr. 0. learned that parental affection did not exist before birth; is difficult to say; for I must declare, and I do this without fear of contradiction, that the affection of the parent is strong, nay, oftentimes very strong, for the child while in utero — and if any accident befall it, a sorrow, and sometimes of a deep kind, is for a long time indulged — I have known two instances of protracted, and deep-seated gloom, follow the birth of still- born children; and in one, it was not removed until a subsequent pregnancy gave promise of a more fortunate result; the other gradually yielded to time, and change of scene. 1584. It would be idle to say that these were not cases of dis- appointed or lacerated affection, but the mere privation of a pro- mised or anticipated pleasure. Besides, Dr. 0. tells us, that "pa- rental affection" converts, in the brute, "the timid mother into the ferocious animal;" from whence arises this recklessness of danger in the "timid mother," in defence of her offspring, when she exposes herself to death, and often meets it fearlessly in at- tempting to protect it. What anticipation of future or "expect- ed pleasure" exists in them? there are not, nor cannot be, any promised joys here; they look not forward for such reward; yet they unceasingly display affection and courage, that might put to shame some, who 5/iot