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PRINCIPLES OF MIDWIFERY.

THE

PRINCIPLES

MIDWIFERY;

IKCLUDING TBC

DISEASES OF WOMEN AND CHILDREN.

By JOHN BURNS, M.D., F.R.S.,

ftiaiua PKOPBMOE OP SURGKKT ZIT TRK UNIVBMITr OP GLASGOW, WTC»t MTC, TTC,

NINTH EDITION, GREATLY ENLARGED.

LONDON:
LONGMAN, ORME, BROWN, GREEN, & LONGMANS.

MDCCCXZXVII.

OLASOOWt
Edward Kboll, Pilntar to Um Uiiivtnlty, DvBlop

TO HIS OHACK

JAMES, DUKE OF MONTROSE,

CHANCBLLOB OF THB UNIVKB8ITT OF GLASGOW,

THE FOLLOWINO PAGES,

ARE RB8PBCTFULLY DEDICATED.
BY THE AUTHOR.

PREFACE.

In preparing this work, 1 hare endeavoured to proceed as
miic^i as possible upon the method of induction. I have coU
lected with care, the different cases which have been made
public, as well as my own private observations. To these, I
have added the opinions and advices given by others, in so far
as they seemed to be founded on facts, and supported by
experience. From the whole, I have deduced, in the different
parts of my subject, both the symptoms and the practice.

The anatomical descriptions, I have given from dissections
and preparations before me whilst writing.

Should this work fall, only, into the hands of those compe-
tent to judge in their profession, it would, if faulty or deficient,
do little harm ; but, as it has been circulated extensively, it
must, like other systems and elements, have an influence on the

VIU

opinions, and future practice of the student of midwifery ;
and will prove useful or injurious to society, according to the
correctness of the principles it contains. When I consider
how important the diseases of women and children are, and
how much depends on the prudent management of parturi-
tion, I feel the high responsibility which falls on those, who
presume to ^ve lessons in midwifery. I do, however, sin-
cerely trust, that the precepts I have inculcated shall be found
agreeable to experience ; — and, on a review of the whole, I
cannot say that I have either wasted the reader's time in idle
theory, or misled his opinion by mere speculation.

The emendations in this edition are numerous, and the
additions extend to nearly fifty pages.

ADDENDA, CORRIGENDA, &c.

The reader is requested to mark the following corrections
and ad^tions : —

Page 8, line 2\jjbr and read And. Point, after forward.

Page 8, line 22^ for vertebra read vertebrae.

Page 29, last line, add. The side of the sacrum may be
originally wanting, and the ilium united by ossific matter, to
that bone^ near the median line. Thus, the brim is turned
awry, or to one side, and contraction is produced. This has
been described by Nsegle. His account is given by Dr.
Rigby, in the Lond. Med. and Surg. Joum., Vol. vii., p. 365.

rage 52, delete line 5.

Page 55, line S,Jbr fully five, sometimes, read nearly four,
sometimes.

Page 58, line 1, after ^^ virgin," add. But Dr. Montgomery
has shown that these are spurious or imperfect.*

* ** Thejr diiVov** be mjM, ** in bavinc no prominence or enlargement of the
•miam onr them; the external coating ie generaUf abeent; there are no
iwdi on their lorlhee ; their shape ia triangular or aqnare ; their texture more
like the remalne of eoocnlam, and without a central caTitT or radiated white lines ;
and, Tery often, eerend are to he found in the same ovarium."

Page 58, line 2, after ^^ formed,*' add. It is not necessary to
state the objections to this theory. The corpus is gradually
absorbed, and some months after delivery, is completely re-
moved, or very indistinct.

Page 76, line 17, after " away," refer to note.*

* Dr. Kennedy showed me in the Dublin Hospital, a preparation, where the
whole mucous eoat was thrown off, like a wide tube.

Page 78, line 4, from bottom, after ** contract," add, It is
only aDowable in extreme cases, and the same may be said of
the actual cautery.

Page 79, aft;er line 17, should be Section Seventeenth.

Pa^ 93, after- the word ^* good," last line, add. In the
Dublin hospital. Dr. Kennedy has tried applying a piece of
sponge, witn one end on the orifice of the vagina, and the
other turned up to the groin, to carry the urine up, on the
principle of capillary attraction.

Page 125, delete lines 4, 5, 6, 7, from the top.

Page 1 43, add after line 24, following paragrapli : —

Dieffenbach, who objects to pessaries, advises a portion of
each side of the vagina to be cut out, and the edges brought
together by stitches. The orifice of the vagina may also be
contracted by the actual cautery, but neither of these can act
on the seat of the complaint They only prevent protrusion.
In women past the menstrual period, this has been attempted
by altogether obliterating the orifice of the vagina. It has
been done at an earlier period ; and the labour of this, called
Episieraphy, required to be undone to give birth to a child.

Page 153, line 30, a reference to note.

* Dr. Burtowr in VoL It. of Tnms. of FroT. Med. and Surf. AModatlon,
expresses confidence in Ibe early use ot Tenesection, topical bleedlnff, and caastic
issoes. One patient not only reooTered by these means, bat \toTt thrse chUdreo
at a birth, named Faith, Hope, and Charity.

Page 155, add to the last line : —

Mr. JeaAreson made an incision of about an inch long on the linea alba, between
the pubis and umbilicus. He then punctured, with a trocar, the sac, and when
em^ed, drew it out, and after appiyinc a ligature round its n«ek, out it off. The
patient reooTsred. Trans, of FroTindid Med. and Sur. AssodaUoo, VoL t. p.

Page 157, line 9, from bottom, add : —

Dupuytren descrilMS the disorfanized remains of a foetus, in a cyst connected
with the mesentery of a boy aged li.

Page 191, line 18, from bottom, y&r ^^ at first rather," read
in women at the full time.

Page 191, last line, after ^^ escapes," add. Dr. Montgomery
with Dr. Graaf, thinks, that it is formed between the outer
and inner layers of the vesicle. This is doubtful.

Page 193, Add to the note, —

The proportion of stillborn children Taries in different places ; but In aU, there
are more males Uian females, and more illegitimate tlian legitimate children.
At Paris, one male, in rather more than 16 births, is dead, and^one female, in
rather more than 19. In Genera, one-seventeenth of the whole'births is dead,
whilst in Boliemia, there is only one-sixtv- third. In the Dublin Hospital, if we
exclude premature births, and take only tnose at the full time, it appears from Dr.
Collins' tables, that one-twentieth is stillborn, in Glasgow, if we lake the register
for baptisms sind burials, it, in one year, was one-fifteenth, in another, one-twenty-
third. Last year, (1886,) there were 702 stiUbom children buried, but this
includes aU premature foBtuses Intored. There were 9825 births engrossed, but It
Is to be obserrad, that many are not registered, and therefore the calcutotUm must
be imperfect.

Page 195, Add to the note, —

Dr. Montgomery gives an instance, from his own knowledge, of a lady going
291 days from the date of conception ; and another, where the ladj menstruated
in the first week of January, and was delivered on the 14Ch day of NoTrmber.

Page 208, Note to line 6.

For the ^nrpemm of nMdlml juri^rttdencc, I refer, on this lubjeci, to au
account of the leofth, weight, Bee,, of the foetus, and ita dii!ierent organs at
^rariMis periods of intra-uterine life, to Med. Leg. par Derergie, Tome I. p. 495,
et at^

Page 211, After ^^ putamenisy*' add, which itself is ulti-
mately absorbed.

Page 221, line 5, after '^ chorion," add, which consists of
two layers.

Page 225, Ikie 22, after '< blood," add, There are two
layers of the chorion, both of which are prolonged on or in
the tHU. The yessels from the fostus pierce the inner layer,
and get between the two.

Page 237, Add to last note.

In the Mnseoni of the Lying-in Hospital at Dublin, there is a preparation
the nterma, elongated to above a foot, seems to form the front of the cyst.

Page 241, line 6 from bottom, instead of " ducts. One"
readj *^ ducts ; one" and line 8, instead of ^' epidermis. A"
read *' epidermis ; a."

Page 242, line 6, for ^' mucushcoat," read mucous coat.

Page 294, To last line of note, add.

Dr. Macartney relates the case of a woman, who near the full time, had the
mpCnred hy a Uek by a cow. The child was retained in the alMlomen,
any serers symptoms. Dub. Jonrn. tIL 412.

Page 416, Note to line 19.

In the Maiseii d'Aeeonchemcnt at Paris, the right shoulder presented at least
ive tfaaes oftcncr than the left.

Page 444, line 22, add, it has been proposed to inject,
within the os uteri, a little olive oil.

Page 450, line 11, M. Montain says, that infusion of ergot
injected within the os uteri, has an euect on the pains. This
reooires confirmation.

Page 531, line 7, after ^< speedily," add, owing chiefly to
the detachment of the placenta, or loss of its assistance. This
may happen sooner in one case than in another.

rage 559, Note to line 4.

Mr. Radford rdates a ease where it was reduced in a quarter of an hour, after
ssvcnl days had elapsed. Dub. Joum. No. zxxiy.

Page 559, line 1 0 from bottom.

Mr. Badford met with a case where, at a certain period, he found the uterus
diminished to the sixe of a pear, and the os uteri tightly girt about its neck.
There was purulent discharge, which continued long, but on a subsequent exami-
nation, the tnmoor had disappeared, the upper part of the vagina forming a
esmplete cul-de-sac.

Xll

Pagis 651, line 6 from the bottom, after ^* paUiative," add,
that is to say, it does not remove the imperfection, but it may
preserve life. Sir Astley Cooper expects much from thb,
when there is no ulceration on the surface of the sac.

Page 650, line 23, add. In a case of umbilical hernia,
where -urine was discharged by the unobliterated urachus,
compression was successfmly employed by Schmidt.

CONTENTS.

BOOK I.

OF THE aTRUCTURE; FUNCTIONS, AND DISEASES OF THE PELVIS AND
UTBRINE SYTTElf. IN THE UNIMPREONATED STATE; AND

DUEINO GESTATION.

CHAP. I.
C^ike Bonei cfike Pelvis.

Page

SsonoN 1. General view .... 1

2. Osia inDominata .... 2

3. Sacnmi and coccyx ... 5

CHAP. il.

Of the ArtJeukUkm of the Banes cf the Pelvis, and their occasional

separaiiou*

SsonoH 1. Of the sympbysis pubis ... 6

2. Sacro-iliac junction ... 7

8. Vertebral junction, and obliquity of the pelris 8

4. Separation of the bones • ib«

CHAP. III.
Of the Soft Parts whkh Hne the Pelvis.

Sectiom 1. Muscles ..... 14

2. Arteries ..... 17

3. Nenres • • . ib.

4. Lymphatics .19

CHAP. IV.
Ciflhe Dimensions of the Pelvis.

Section 1. Brim and outlet • .20

5. Cavity ..... 21

XIV

Sbgtion 3. Pelvis above the brim . . .23

4. Axis of the brim and outlet . 24

CHAP. V.

Of the Head of the Child^ and He progreu through the Pelvis

in Labour,

Section 1. Bones of the head . . .24

2. Size of the head • .25

5. Passage of the head .26

CHAP. VI.
Of Diminished Ctqtaeifyt and D^oirmJty qf^ Pelvis.

Sbotion 1. Deformity from rickets .29

2. Deformity from malacosteon .31

3. Deformity from exostosis and tomoors 33

4. Means of ascertaining the dimensions and sice

of the head when broken down 37

CHAP. VII.
Cf Augmented Capaeily of the Pelvis 39

CHAP. VIII.
Of the External Organs of Generation.

Section 1. General view . • . .39

2. Labia and nymphie • .40

3. CUtoris 41

4. Urethra • . ib.

5. Orifice of vagina and hymen 44

6. PeriniBttm .46

CHAP. IX.

of the Internal Organs of Generation and Rectum.

Section 1. Vagina ..... 47

2. Uteras and its appendages . .49

3. Rectum • .58

CHAP. X.
Of the Diseases qfthe Organs ^ Generation.

Section 1. Abscess in the labium .60

2. Ulceration of the labia . .61

Page

Sbctiom 3. Excrescences on the labia .

4. Scirrhous tumours

5. Polypous tnmonrs

ib.

6. CEdenaa . . . . .

7. Hernia, laceration, &c.

ib.

8. Diseases of the nymphe

9. Diseases of the clitoris

10. Diseases of the hymen

1 1. Laceration of the perinffium

12. Imperfection oi the yagina

Id. Inflammation and gangrene of the vagina

14. Induration, ulceration, and polypi

15. Inversion . . . . .

16. Watery tumour • . . .

17. Hernia • • • • .

ib.

18. Encysted tumour and varices

19. Spongoid tumour . . . .

ib.

20. Erysipelatous inflammation

2L Fluor albus . . . .

22. Affections of the bladder

23. Excrescences in the urethra

24. Deficiency and mal-formation of uterus

25. Hysteritis, acute and chronic

100

26. Preternatural sensibility of the uterus

105

27. Ulceration of the uterus, cauliflower excres-

cence, &c. . . • .

106

28. Scirrho-cancer . . . .

110

29. Tubercles ....

117

30. Spongoid tumour . . . .

121

31. Calculi ....

122

82. Polypi ....

123

33. Malignant polypi

129

34. Moles ....

ISO

35. Hydatids ....

131

36. Aijueous Discharges and Dropsy .

134

37. Worms ....

135

38. Tympanites

ib.

39. Prolapsus uteri

136

40. Hernia ....

146

41. Dropsy of the ovarium

ib.

XTI

P*fe

Section 42. Other diseases of the orarium

157

43. Deficiency

159

44. Diseases of the tubes and ligaments

ib.

CHAP. XI.

OfMenstruoHan

160

CHAP. XII.

Of Hysteria

163

CHAP. XIII.

Of Diseased States {fthe Menstrual Action,

Sbction 1. Amenorrhoea ....

167

2. Formation of an organised sabstance

177

d. D^rsmenorrhcea • .

178

4. Copious menstruation

179

5. Menorrhagia ....

180

CHAP. XIV.

Of the Cessation qftke Menses

189

CHAP. XV.

Of Coneeptum and the term of Gestation

191

CHAP. XVI.

Offhe Gravid Uterus.

Sbotion 1. Siie and Position ....

194

2. Development of the uterus, and state of its

cervix ....

196

3. Muscular fibres

197

4. Ligaments ....

198

5. Vessels • . . •

ib.

6. OfthefcBtus ....

199

7. Its peculiarities • . • ,

204

8. Orologie or development of the embryo

208

9. Decidua .....

220

10. Chorion .....

221

11. Amnion . • • . .

ib.

12. Placenta .....

222

13. Umbilical cord ....

226

CHAP. XVII.

OfSterUitjf .

229

«•

xvu

CHAP. XVIII.
Of Exhro'Vierme Prtgnaney.

SscTiON 1. SymptoniBy progretSy and species
2. TreatmeDt .

CHAP. XIX.
Of ike Signs rfPreffnaney

Faft

230
288

240

CHAP. XX.

OftkeDuetmsofjPrefftuttU IVomm.

Section 1. General KBPecto

246

2. Febrile state . . . .

350

8. Vomiting . . . . .

252

4. Heartbom . . . . •

255

5. Fastidions taste .

ib.

6. Spasm of stomach and dnodenam

256

7. Coatiyeness . . . . •

ib.

8. Dianrhcsa . . . • .

558

9. Piles . . . . .

259

10. Affections of the bladder

260

11. Jaundice . . . . .

261

12. Coloured spots . . . .

262

13. Palpitation . . . . .

ib.

14. Syncope . . . . .

263

15. Dyspncsa and congh

264

16b Hemoptysis and hsmatemesis

ib.

17. Headach and conyulsions

265

18. Tootbach . . • . .

267

19. Saliration . . . . .

ib.

20. Mastodynia . . . .

ib.

21. CESdema . . « . .

268

22. Ascites . . . . .

269

23. Redundance of Liquor amnii

270

24. Watery discharge .

272

25. Varicose ydns

274

26. Muscular pain

ib.

27. Spasm of ureter

275

28. Cramp ....

ib.

29. Sensibility, spasm, and inflammation of the i

Items ib.

xviii

Page

Section 30. Dislressing motion of the child . . 2^76

S ] . Distention of the abdomen • ib.

S2. Hernia ..... 277

33. Despondency .... 278

S4. Retroversion of uteras . . . 279

35. Antiversion .... 296

36. Rnptnre of oterus . . . • ib.

37. Abortion, and treatment of pregnant women 294

38. Uterine hsmorrhage • • 329

39. False pains .... 368

BOOK II.

OF PARTURITION.

CHAP. I.

Of the Clasiificaiion of Laboun

CHAP. II.

' Of Natural Labour.
Sbction 1. Stages of Labour

2. Duration of process

3. Of examination

4. Causes of Labour * .

5. Management of Labour

CHAP. IIL
OfPremaiure Labour

CHAP. IV.

of Preternatural Labour
Order 1. Presentation of the breech

2. Of the inferior extremities • .

3. Of the superior extremities .

4. Of the trunk . . . '

5. Of malposition of the head, presentatioa of

face, &c. • • • .

6. Of the umbilical cord

7. nnrality of cfaildroD and monsters

372

the

375
379
382
392
395

406

409
410
415
416
426

427
433
434

CHAP. V.
Of Tedious Labour.

Page

Ordbr 1* From imperfection.or irregularity of muscular action 438
2. From some mechanical impediment . . 458

CHAP. VI.

()f Instrumental Labours,

Order 1. Cases admitting the application of the forceps or

lever • . • . • 463

2. Cases reqairing the crotdhet 496

CHAP. VII. ^
€f ImpmOiaMe Labour . 508

CHAP. VIII.

Of CompHoaied Labour,

Order 1. Laboar complicated with uterine hsBmorrhage 515
2. With hsmorrhage from other organs ^ 516

S. WitE syncope . . . . ib.

4. With convulsions . • .517

5. With rupture of the uterus • . 527

6. With suppression of urine • 536

BOOK III.

OF THE PUERPERAL STATE.

CHAP. I.
Of As Treaimeni afkar Delivery 538

CHAP. 11.
€f Uterine Hcemorrhage . 541

CHAP. III.
Of Imoarnon amd Reiroflexion of the Uterus . 555

CHAP. IV.

OfAfterpaifis ... 562

CHAP. V.

Pace

Of Hytteraigia . . 564

CHAP. VI.
O/Rdention (fPari o/Oe Placenia 565

CHAP. VII.

Of Strangury . . . 568

CHAP. VIII.

CfPneumama. • • ib.

CHAP. IX.

(y S^patnufdic and Nervaut Disorders ^ ib.

CHAP. X.
Of Ephemeral Fever or Weid, and BemiUeni Fever 572

CHAP. XL

Of ike Milk Fever . . 577

CHAP. XII.
Of MiHary Fever . 578

CHAP. XIII.
Of Intestinal Fever 579

CHAP. XIV.
General Remarks an Abdominal Inflammation^ in the Puer-
peral SiaU •....• 581

^ CHAP. XV.
Cf Infkmmatian <f the Uterus . 584

CHAP. XVI.
Of Periionaal InfiammaOon . 592

CHAP. XVII.
OfMaUgnani Puerperal Fever 598

CHAP. XVllI.
OfSweUedLeg 667

XXI

CHAP. XIX.

Page

OfParafyns • • .618

CHAP. XX.
Of Puerperal Mama and PhremiU ib.

CHAP. XXI.
Of Branchocele . 620

CHAP. XXII.
Of Diarrhoea . .621

CHAP. XXIIL
OflnfitmwuiiiomqftheMamnuijandExtoriaiianoftkeNtpp ib.

CHAP. XXIV.
Cf Tympaniies 630

CHAP. XXV.
Of Ae Signs cActf a Woman has been reeenify Delivered 681

BOOK IV.

OF THE MANAOElfENT AND DISEASES OF CHILDREN.

CHAP. I.

<y iAtf Management of Children*
SscTiosf I. Of the separation of the child, the treatment

of ttiU-bom children, and the marks which
show that they have not breathed 684

8. Of cleanliness, dress, and temperatore 642

a Of diet . • .643

CHAP II.

(>f Congenile and Surgical Diseases.

SacTiON 1. Harelip ..... 647

2. Imperforated anns, urethra, &c. 648

3. Umbilical hernia . . * . 650

4. Spina bifida • • . . ib.

XXII

Skction 5. Marks

6. Swelling of the scalp

7. Distortion of the feet

8. Tongne-tied

9. Malformed heart
10. Swelling of the breast, hydrocele, prolapsus

ani, umbilical hamorrhage,and excoriation,
incontinence of urine, scalds and boms,

652
ib.

65t)
ib.
ib.

earach, &c

■ a

. 4

654

11. Foetid secretion from the nose

• 1

658

12. Ophthalmy .

• «

659

13. Spongoid disease of the eye, and Melanosis ,

ib.

14. Scrofnla

•

660

15. Rickets

• «

651

CHAP. IIL

OfDemHium .

652

CHAP. IV.

Of Cutaneous Disea$es.

Section 1. Strophulus intertrinctus

•

667

2. Strophulus albidus .

. 4

668

3. Strophulus convertus

ib.

4. Strophulus candidtts

• I

670

5. Lichen . •

. t

ib.

6. Intertrigo •

•

671

7. Anomalous eruptions, pustules,

and biles

ib.

8. Pompholyx and pemphigus .

• )

673

9. Miliary eruption

• «

674

10. Prurigo

•

ib.

11. Scabies,

• <

676

12. Herpes

• i

677

13. Impetigo

m *

680

14. Ichthyosis ,

• «

681

15. Lepra

•

ib.

16. Psoriasis .

. •

682

17. Pityriasis .

685

18. Porrigo

• f

686

19. Scabs from i

'crmin .

• «

691

ZXlll

P*ie

SKcmoM SO. Alopecia and ophiatii

692

21. Purpura or petechisB

ib.

22. Erysipelas and erythema •

693

23. Excoriation behind the ears

696

24. Ulceration of the gums

697

25. Erosion of the cheek, sloughing ulceration of

the pudendum ; . •

698

26. AphthflB • • • * •

701

27. AphthfB on the tonsils

705

28. Malignant, aphthous, or putrid sore

throat,

often attended with croup .

ib.

29. Excoriation of the tongue, gums, and

lips .

707

30. Syphilis ....

708

31. 8kin-bound

712

32. SmaU-pox.

714

S3. Cow-pox •

720

34. Chicken-pox •

724

35. Urticaria •

726

oo. Dcariauna • •

728

37. Measles •

785

as. Roseola .

789

CHAP. V.

Of Cerebral and Spinal IrrUaiion and Congestionf and
RenUiteni Fever • • . • . 741

CHAP. VI.

Of Bydroeephahu • 766

CHAP. VII.

Of CaiiivultswnM and Edanqma . 779

CHAP. VIII.

Of Chorea andParalyns • 786

CHAP. IX.
OfOwv . .790

CHAP. X.

Cf Hooping' Cough . . 802

xxiv

Pjige

CHAP. XL

Of Catarrh^ BronchitUf Infiammalion ofi/ie Pleura^ and
of the Stomach and Intestines .... 807

CHAP. XII.

Of VomiHng . . .812

CHAP. XIII.
Of Diarrhcea , 813

CHAP. XIV.
CfCosHveness . 823

CHAP. XV.

OfCMc . . .824

CHAP. XVI.
Of Marasmus . • 825

CHAP. XVIL
Of Tabes Mesenierica 826

CHAP. XVIII.

Of Worms . , .830

CHAP. XIX.
Of Jaundice . 882

CHAP. XX.

Of Diseased Lwer . 833

CHAP XXI.

Of Fever ... 836

THE

PRINCIPLES

MIDWIFERY

BOOK I.

OF THS OTRUCTURE» FUNCTIONS, AND DISEASES OF THE PELVIS AND

UTERIHE SYSTEIf, IN THE UNIMPREONATED STATE,

AND DURING GESTATION.

CHAP. I.

Of the Bones of the Pelvis,

SECTION FIRST.

The practical precepts and rules in Midwifery, are easily
understood, and readily acquired. They are drawn, from
the structure and actions, of the parts concerned in parturi-
tion ; and whoever is well acquainted with this structure, and
these actions, may — from such knowledge, deduce all the
valuable and important directions, which constitute the Prac-
tice of Midwifery.

One of the first, and not the least important, of the parts
concerned in parturition, is the pelvis, which must be exsu-
nuned, not only on account of its connexion with the uterus
and vagina, but also of its own immediate relation to the
delivery of the child, and the obstacles which, in many
instances, it opposes to its passage.

The pelvis consists, in the full grown female, of three large
bones, two of which are very irregular, having no near resem-

blance to any other object ; on which account they have been
called the ossa innominata. These form the sides and front
of the basin or pelvis. The back part consists of a triangular
bone, called the os sacrum, to the inferior extremity, or apex
of which, is attached, by a moveable articulation, a small
bone, which, from its supposed resemblance to the beak of a
cuckoo, has been named the os coccygis.

The OS innominatimi, in infancy, consists of three separate

Cieces: the upper portion is cialled the ilium, or haunch
one; the under, the ischium, or seat bone; and the anterior,
which is the smaJlest of the three, is called the os pubis, or
share bone. These all join together in the acetabulum, or
socket, formed for receiving the os femoris, and are connected
by a very firm gristle or cartilage. This, before the age of
puberty, is converted into bone, so that the three different
pieces are consolidated into one, though the names given to
the bones, originally, are still applied to the different parts of
the united os innominatum. It has been observed, that women
who have bom children, have, after their fortieth year, the
centre of the expanding portion of the ilium considerably
thinner than those who have not.

The sacrum also, which seems to consist only of one curved
triangular bone, is really made up of several pieces, which,
in the child, are nearly as distinct as the vertebrse, to which,
indeed, they bear such a resemblance, that they have been
considered as a continuation of them ; but from their imper-
fect structure, and subsequent union, they have been ciJled
the false vertebrae.

The bones of the pelvis are firmly joined together, by means
of ligaments and intermediate cartilages, and form a very
irregular canal, the different parts of which must be briefly
mentioned.

SECTION SECOND.

When we look at the pelvis, we observe, that the ossa
innominata naturally divide themselves into two parts, the
uppermost of which is thin and expanded, irregularly convex
on its dorsum or outer surface, hollow on the inside, which is
called the costa, and bounded by a broad margin, extending
in a semicircular direction from before backwards, which is
caUed the crest of the ilium. The under part of the os inno-
minatum is very irregular, and forms, with the sacrum, the
cavity of the pelvis. The upper expanded part has little
influence on labour, and serves, principally, for affording

attachment to muscles, and supporting the yiscera. In the
under part, we have several points to attend to.

Ist. The upper and under parts form an angle with each
other, marked by a smooth line, which is a continuation of
the margin of the pubis, or anterior part of the bone. It
extends from the symphysis pubis, all the way to the junction
of the OS innominatum with the sacrum, and is called the
finea iliopectinea. It is quite smooth and obtuse at the sides,
where the two portions form an angle ; but at the anterior
part, where the upper portion is wanting, it is sharp, and
sometimes is elevated into a thin spine like the blade of a
knife.

2d. The upper portion is discontinued exactly about the
middle of this Une, or just over the acetabulum ; and at the
termination, there is, from this portion, an obtuse projection
overhanging the acetabulum, which is called the inferior
spinous process of the ilium, to distinguish it from a similar
projection about half an inch higher, called the superior spine.

3d. The under part of the bone is of the greatest impor-
tance, and in it we recognise the following circumstances.
Its middle is large, and forms, on the outside, a deep cup or
acetabulum, for the reception of the head of the thigh bone.
On the inside, and just behind this cup, it forms a smooth
polished plate of bone within the cavity of the pelvis, which
IS placed obliquely with regard to the pubis, and has a gentle
slope forward. The cone of the child's head, in labour, moves
downwards, and somewhat forwards, on this, as on an inclined
plane ; it may be called the plane of the ischium, although a
part of it be formed by the ilium.

4th. Standing off from the back part of this, about two
inches beneath the linea ilio-pectinea, is a short projection,
called the spine of the ischium, which seems to encroach a
little on the cavity of the pelvis, and is placed, with regard to
the pubis, still more obliquely than the plane of the ischium.
It must, consequently, tend to direct the vertex, as it descends,
still more towards the pubis.

5th. Beneath this, the ischium becomes narrower, but not
thinner ; on the contrary, it is rather thicker, and terminates
in a rough bump, called the tuberosity of the ischium.

6th. Next, we look at the anterior part of the bone, and
find, that just before the plane of the ischium, there is a large
hole in the os innominatum. This is somewhat oval in its
shape; and at the upper part within the pelvis, there is a
depression in the bone, which, if followed by the finger or a

probe, leads to the face of the pelvis. The hole is called the
foramen thyroideum.

7th. Before this hole the two ossa innominata join, but form
with each other, on the inside, a very obtuse angle, or a kind
of smooth rounded surface on which the bladder partly rests.
The junction is called the symphysis of the pubis.

8th. The two bones, where they form the symphysis, are
joined with each other for about an inch and a half; then they
divaricate, forming an angle, the limbs of which extend aU
the way to the tuberosity of the ischium. This separation or
divarication is called the arch of the pubis, which is princi*
pally constructed of the anterior boundary of the foramen
thyroideum, consisting of a column or piece of bone about
hsuf an inch broad, and one fourth of an inch thick, formed by
the union of the ramus of the pubis, and that of the ischium.
9th. At the upper part of the symphysis, or a very little
from it, the os innominatum has a short obtuse projection,
called the tubercle of the pubis, into which Poupart's ligament
is inserted ; and from this, there runs down obliquely, a ridge
on the outside of the bone, which reaches all the way to the
acetabulum, and overhangs the foramen thyroideum.

10th. When we return to the back part of the os innomi-
natum, we find, that just after it has formed the plane of the
ischium, it extends backwards to join the sacrum ; but in
doing so, it forms a very considerable notch or curve, the con-
cavity of which looks downwards. When the sacrum is joined
to the bone, this notch is made much more distinct. It is
caUed the sacro-sciatic notch or arch, for one side is formed
by the ischium, and is about two inches long, the other is
formed chiefly by the sacrum, and is about half an inch
longer. In the recent subject, strong ligaments are extended
at the under part, from the one bone to the other, so that this
notch is converted into a regular oval hole.

1 1th. Lastly, this notch being formed, the bone expands
backwards, forming a very irregular surface for articulation
with the sacrum ; and the bones being joined, we find that
the 08 innominatum forms a strong, thick, projecting ridge,
extending farther back than the spinous processes of the
sacrum. This ridge is about two inches and three quarters
long, and is a continuation of the crest of the ilium, but is
turned downwards ; whereas were the crest continued in its
former course, it would meet with the one from the opposite
side, behind the top of the sacrum, forming thus a neat semi-
circle ; but this ridge, if prolonged on both sides, would form

an acute angle, the point of junction being opposite the bottom
of the sacrum. From this, strong ligaments pass to the
sacrum, to join the two bones.

SECTION THIRD.

The sacrum forms the back part of the pelvis. It is a
triangular bone, and gently curred; so, that, whilst a line
drawn firom the one extremity to the other, measures, if it
subtend the arch, about four inches, it will, if carried along
the surface of the bone, measure full half an inch more. The
distance between the first or straight line, and the middle of
the sacrum, is about one inch. The breadth of the base of
the sacrum, considered as an angular body, is full four inches :
the centre of this base is shaped like the surface of the body
of one of the lumbar yertebrae, with the last of which it joins,
forming, however, an angle with it, called the great angle or
promontory of the sacrum. From this the bone is gently
curved outward on each side, toward the sacro-iliac junction,
contributing to the formation of the brim of the pelvis.

The upper half of the side of the bone is broad and irregu*
lar, for articulation with the os innominatum. The anterior
8ur£Bbce of the bone is smooth and concave; but often we
observe transverse ridges, marking the original separation of
the bones of the sacrum. Four pair of holes are found dis-
posed in two longitudinal rows on the face of the sacrum,
communicating with the canal which receives the continuation
of the spinal marrow ; through these the sacral nerves, issue.
These holes slope a little outward, and betwixt the two rows,
IS a smooth surface, for the attachment of the rectum. The
posterior surface of the bone is very irregular ; and, we observe,
Ist. The canal extending down the bone, for receiving the
continuation of the spinal marrow. 2d. At the upper part of
this are two strong oblique processes, which join with those of
the last lumbar vertebra. 3d. On a central line down the
back of the canal, there is an irregular ridge analogous to the
spines of the vertebrae. 4th. The rest of the surmce is very
irr^ular and rough; and we observe, corresponding to the
holes for transmitting the sacral nerves on the exterior surface,
the same number of foramina on thjs posterior surface, but, in
the recent subject, they are covered with membrane, leaving
only a small opening for the exit of nervous twigs.

The cooc^ IS an appendage to the sacrum, and as it is
incbned ibrwards from that bone, the point of junction has
been called the little angle of the sacrum. It is, at first,

probe, leads to the face of the pelvis. The hole is called the
foramen thyroideum.

7th. Before this hole the two ossa innominata join, but fomi
with each other, on the inside, a very obtuse angle, or a kind
of smooth rounded surface on which the bladder partly rests.
The junction is called the sjrmphysis of the pubis.

8th. The two bones, where tney form the symphysis, are
joined with each other for about an inch and a half; then they
divaricate, forming an angle, the limbs of which extend all
the way to the tuberosity of the ischium. This separation or
divarication is called the arch of the pubis, which is princi-
pally constructed of the anterior boundary of the foramen
thyroideum, consisting of a column or piece of bone about
hw an inch broad, and one fourth of an inch thick, formed by
the imion of the ramus of the pubis, and that of the ischium.
9th. At the upper part of the symphysis, or a very little
from it, the os innominatum has a short obtuse projection,
called the tubercle of the pubis, into which Poupart's ligament
is inserted ; and from this, there runs down obliquely, a ridge
on the outside of the bone, which reaches all the way to tiie
acetabulum, and overhangs the foramen thyroideum.

10th. When we return to the back part of the os innomi-
natum, we find, that just after it has formed the plane of the
ischium, it extends backwards to join the sacrum ; but in
doing so, it forms a very considerable notch or curve, the con-
cavity of which looks downwards, When the sacrum is joined
to the bone, this notch is made much more distinct. It is
called the sacro-sciatic notch or arch, for one side is formed
by the ischium, and is about two inches long, the other is
formed chiefly by the sacrum, and is about half an inch
longer. In the recent subject, strong ligaments are extended
at the under part, from the one bone to the other, so that this
notch is converted into a regular oval hole.

1 Ith. Lastly, this notch being formed, the bone expands
backwards, forming a very irregular surface for articulation
with the sacrum ; and the bones being joined, we find that
the OS innominatum forms a strong, thick, projecting ridge,
extending farther back than the spinous processes of the
sacrum. This ridge is about two inches and three quarters
long, and is a continuation of the crest of the ilium, but is
turned downwards ; whereas were the crest continued in its
former course, it would meet with the one from the opposite
side, behind the top of the sacrum, forming thus a neat semi-
circle ; but this ridge, if prolonged on both sides, would form

an acute angle, the point of jixnction being opposite the bottom
of the sacrmn. From tlixs, strong ligaments pass to the
sacrum, to join ibe t^vro \>oTie3«.

SECTION THmO.

The aacrmn forms th.e 1>ack part of the pelvis. It is a

triangular ^ne, aad geTitly curved; so, that, whilst a line

drawn from t)ie one eiLtremity to the other, measures, if it

subtend tbe axc^L, aboxLt four inches, it will, if carried along

&e Boiface of Vhe \>oiie, measure full half an inch more. The

££Stance ^>elween t\ie first or straight line, and the middle of

the sacrum, \a about one inch. The breadth of the base of

the sacrum, considered as an angular body, is full four inches :

the centre of tlna base is shaped like the surface of the body

of one of the lumbar vertebrae, with the last of which it joins,

fomung, hcyweyer, an angle with it, called the great angle or

promontory of tbe sacrum. From this the bone is gently

coryed outward on each side, toward the sacro-iliac junction,

contnbuting to the formation of the brim of the pelvis.

The upper half of the side of the bone is broad and irregu-
lar, for ax^nlatiou with the os innominatum. The anterior
surface of the bone is smooth and concave; hut often we
observe transverse ridges, marking the original separation of
the bones of the sacrum. Four pair of holes are found dis-
posed in two longitudinal rows on the face of the sacrum,
communicating with the canal which receives the continuation
of the spinal marrow ; through these the sacral nerves, issue.
These holes slope a little outward, and betwixt the two rows,
is a smooth surface, for the attachment of the rectum. The
posterior surface of the bone is very irreguLir ; and, we observe,
I St. The canal extending down the bone, for receiving the
continuation of the spinal marrow. 2d. At the upper part of
this are two strong oblique processes, which join with those of
the last lumbar vertebra. 3d. On a central line down the
back of the canal, there is an irregular ridge analogous to the
spines of the vertebne. 4th. The rest of the surface is very
irregular and rough ; and we observe, corresponding to the
holes for transmitting the sacral nerves on the exterior surface,
the same number of foramina on th^s posterior surface, but, in
the recent subject, they are covered with membrane, leaving
only a small opening for the exit of nervous twigs.

The coccyx is an appoidage to the sacrum, and as it is
iDcImed forwards from that bone, the point of junction has
been called the little angle of the sacrum. It is, at first,

probe, leads to the face of the pelvis. The hole is called the
foramen thyroideum.

8th. The two bones, where they form the symphysis, are
joined with each other for about an inch and a half; then they
divaricate, forming an angle, the limbs of which extend all
the way to the tuberosity of the ischium. This separation or
divarication is called the arch of the pubis, which is princi-
pally constructed of the anterior boundary of the foramen
thyroideum, consisting of a column or piece of bone about
half an inch broad, and one fourth of an inch thick, formed by
the union of the ramus of the pubis, and that of the ischium.
9th. At the upper part of the symphysis, or a very little
from it, the os innominatum has a short obtuse projection,
called the tubercle of the pubis, into which Poupart's ligament
is inserted ; and from this, there runs down obliquely, a ridge
on the outside of the bone, which reaches all the way to the
acetabulum, and overhangs the foramen thyroideum.

10th. Wlien we return to the back part of the os innomi-
natum, we find, that just after it has formed the plane of the
ischium, it extends backwards to join the sacrum ; but in
doing so, it forms a very considerable notch or curve, the con-
cavity of which looks downwards, When the sacrum is joined
to the bone, this notch is made much more distinct. It is
called the sacro-sciatic notch or arch, for one side is formed
by the ischium, and is about two inches long, the other is
formed chiefly by the sacrum, and is about half an inch
longer. In the recent subject, strong ligaments are extended
at the under part, from the one bone to the other, so that this
notch is converted into a regular oval hole.

11th. Lastly, this notch being formed, the bone expands
backwards, forming a very irregular surface for articulation
with the sacrum ; and the bones being joined, we find that
the OS innominatum forms a strong, thick, projecting ridge,
extending farther back than the spinous processes of the
sacrum. This ridge is about two inches and three quarters
long, and is a continuation of the crest of the ilium, but is
turned downwards ; whereas were the crest continued in its
former course, it would meet with the one from the opposite
side, behind the top of the sacrum, forming thus a neat semi-
circle ; but this ridge, if prolonged on both sides, would form

an acute angle, the point of junction being opposite, the bottom
of the sacrum. From this, strong ligaments pass to the
sacrum, to join the two bones.

SECTION THIRD.

The sacrum forms the back part of the pelvis. It is a
triangular bone, and gently curved; so, that, whilst a line
drawn from the one extremity to the other, measures, if it
subtend the arch, about four inches, it will, if carried along
the surface of the bone, measure full half an inch more. The
distance between the first or straight line, and the middle of
the sacrum, is about one inch. The breadth of the base of
the sacrum, considered as an angular body, is full four inches :
the centre of this base is shaped like the surface of the body
of one of the lumbar vertebraB, with the last of which it joins,
forming, however, an angle with it, called the great angle or
promontory of die sacrum. From this the bone is gently
curved outward on each side, toward the sacro-iliac junction,
contributing to the formation of the brim of the pelvis.

The upper half of the side of the bone is broad and irregu-
lar, for articolation with the os innominatum. The anterior
surfEice of the bone is smooth and concave; but often we
observe transverse ridges, marking the original separation of
the bones of the sacrum. Four pair of holes are found dis-
posed in two longitudinal rows on the face of the sacrum,
communicating with the canal which receives the continuation
of the spinal marrow ; through these the sacral nerves, issue.
These holes slope a little outward, and betwixt the two rows,
is a smooth sur&ce, for the attachment of the rectum. The
posterior sur&ce of the bone is very irregukr ; and, we observe,
1st. The canal extending down the bone, for receiving the
continuation of the spmal marrow. 2d. At the upper part of
this are two strong oblique processes, which join with those of
the last lumbar vertebra. 3d. On a central line down the
back of the canal, there is an irregular ridge analogous to the
spines of the vertebne. 4th. The rest of the sur&ce is very
irregular and rough ; and we observe, corresponding to the
holes for transmitting the sacral nerves on the exterior surface,
tiie same number of foramina on th^s posterior surface, but, in
the recent subject, they are covered with membrane, leaving
only a small opening for the exit of nervous twigs.

The coccyx is an appendage to the sacrum, and as it is
inclined forwards from that bone, the point of junction has
been called the little angle of the sacrum. It is, at first,

Strobe, leads to the face of the pelvis. The hole is colled the
bramen thyroideum.

8th. The two bones, where they form the symphysis, are
joined with each other for about an inch and a half; then they
divaricate, forming an angle, the limbs of which extend all
the way to the tuberosity of the ischium. This separation or
divarication is called the arch of the pubis, which is princi-
pally constructed of the anterior boundary of the foramen
thyroideum, consisting of a column or piece of bone about
half an inch broad, and one fourth of an inch thick, formed by
the union of the ramus of the pubis, and that of the ischium.
9th. At the upper part of the symphysis, or a very little
from it, the os mnominatum has a short obtuse projection,
called the tubercle of the pubis, into which Poupart's ligament
is inserted ; and from this, there runs down obliquely, a ridge
on the outside of the bone, which reaches all the way to the
acetabulum, and overhangs the foramen thyroideum.

1 0th. When we return to the back part of the os innomi-
natum, we find, that just after it has formed the plane of the
ischium, it extends backwards to join the sacrum ; but in
doing so, it forms a very considerable notch or curve, the con-
cavity of which looks downwards, When the sacrum is joined
to the bone, this notch is made much more distinct. It is
called the sacro-sciatic notch or arch, for one side is formed
by the ischium, and is about two inches long, the other is
formed chiefly by the sacrum, and is about half an inch
longer. In the recent subject, strong ligaments are extended
at the under part, from the one bone to the other, so that this
notch is converted into a regular oval hole.

11th. Lastly, this notch being formed, the bone expands
backwards, forming a very irregular surface for articulation
with the sacrum ; and the bones being joined, we find that
the OS innominatum forms a strong, thick, projecting ridge,
extending farther back than the spinous processes of the
sacrum. This ridge is about two inches and three quarters
long, and is a continuation of the crest of the ilium, but is
turned downwards ; whereas were the crest continued in its
former coiu^e, it would meet with the one from the opposite
side, behind the top of the sacrum, forming thus a neat semi-
circle ; but this ridge, if prolonged on both sides, would form

an acute angle, the point of junction being opposite, the bottom
of the sacrum. From this, strong ligaments pass to the
sacrum, to join the two bones.

SECTION THIRD.

The sacrum forms the back part of the pelvis. It is a
triangular bone, and gently curved; so, that, whilst a line
drawn from the one extremity to the other, measures, if it
subtend Uie arch, about four mches, it will, if carried along
the surface of the bone, measure full half an inch more. The
distance between the first or straight line, and the middle of
the sacrum, is about one inch. The breadth of the base of
the sacrum, considered as an angular body, is full four inches :
the centre of this base is shaped like the surface of the body
of one of the lumbar yertebrae, with the last of which it joins,
forming, however, an angle with it, called the great angle or
promontory of the sacrum. From this the bone is gently
curved outward on each side, toward the sacro-iliac junction,
contributing to the formation of the brim of the pelvis.

The upper half of the side of the bone is broad and irregu-
lar, for articulation with the os innominatum. The anterior
sur&ce of the bone is smooth and concave; but often we
observe transverse ridges, marking the original separation of
the bones of the sacrum. Four pair of holes are found dis-
posed in two longitudinal rows on the face of the sacrum,
conununicating with the canal which receives the continuation
of the spinal marrow ; through these the sacral nerves, issue.
These holes slope a little outward, and betwixt the two rows,
is a smooth surmce, for the attachment of the rectum. The
posterior surface of the bone is very irregular ; and, we observe,
Ist. The canal extending down the bone, for receiving the
continuation of the spinal marrow. 2d. At the upper part of
this are two strong oblique processes, which join with those of
the last lumbar vertebra. 3d. On a central line down the
back of the canal, there is an irregular ridge analogous to the
spines of the vertebre. 4th. The rest of the sur&ce is very
irregular and rough; and we observe, corresponding to the
holes for transmitting the sacral nerves on the exterior surface,
Uie same number of foramina cm th^s posterior surface, but, in
the recent subject, they are covered with membrane, leaving
only a small opening for the exit of nervous twigs.

The coccyx is an appendage to the sacrum, and as it is
inclined foTwards from that bone, the point of junction has
been called the little angle of the sacrum. It is, at first,

probe, leads to the face of the pelvis. The hole is called the
foramen thyroideum.

8th. The two bones, where they form the symphysis, are
joined with each other for about an inch and a half; then they
divaricate, forming an angle, the limbs of which extend aU
the way to the tuberosity of the ischium. This separation or
divarication is called the arch of the pubis, which is princi-
pally constructed of the anterior boundary of the foramen
thyroideum, consisting of a column or piece of bone about
half an inch broad, and one fourth of an inch thick, formed by
the union of the ramus of the pubis, and that of the ischium.
9th. At the upper part of the symphysis, or a very little
from it, the os mnominatum has a short obtuse projection,
called the tubercle of the pubis, into which Poupart's ligament
is inserted ; and from this, there runs down obliquely, a ridge
on the outside of the bone, which reaches all the way to the
acetabulum, and overhangs the foramen thyroideum.

10th. When we return to the back part of the os innomi-
natum, we find, that just after it has formed the plane of the
ischium, it extends backwards to join the sacrum ; but in
doing so, it forms a very considerable notch or curve, the con-
cavity of which looks downwards, When the sacrum is joined
to the bone, this notch is made much more distinct. It is
called the sacro-sciatic notch or arch, for one side is formed
by the ischium, and is about two inches long, the other is
formed chiefly by the sacrum, and is about half an inch
longer. In the recent subject, strong ligaments are extended
at the under part, from the one bone to the other, so that this
notch is converted into a regular oval hole.

11th. Lastly, this notch being formed, the bone expands
backwards, forming a very irregular surface for articulation
with the sacrum ; and the bones being joined, we find that
the OS innominatum forms a strong, thick, projecting ridge,
extending farther back than the spinous processes of the
sacrum. This ridge is about two inches and three quarters
long, and is a continuation of the crest of the ilium, but is
turned downwards ; whereas were the crest continued in its
former course, it would meet with the one from the opposite
side, behind the top of the sacrum, forming thus a neat semi-
circle ; but this ridge, if prolonged on both sides, would form

an acute angle, thepoint of junction being opposite, the bottom
of the sacmm. Krom tills, strong ligaments pass to the
sacnim, to join t^e tipro l>oxie8.

SSCXION THIRD.

The sacrum forms tlie back part of the pelvis. It is a

triangukr \)one, and geiitly ciured; so, that, whilst a line

drawn from the one extiremity to the other, measures, if it

sahtend the arcli, about four inches, it will, if carried along

tbe surface ot the bone, measure full half an inch more. The

^stance between tbe first or straight line, and the middle of

the sacrum, is about one inch. The breadth of the base of

the sacrum, considered as an angular body, is fuU four inches :

the centre of this base is shaped like the surface of the body

of one of the lumbar yertebrse, with the last of which it joins,

fomung, boweyer, an angle with it, called the great angle or

promontory of tbe sacrum. From this the bone is gently

curbed outward on each side, toward the sacro-iliac junction,

contributing to tbe formation of the brim of the pelvis.

Tbe upper balf of tbe side of the bone is broad and irregu-
lar, for articulation with the os innominatum. The anterior
surfiace of the bone is smooth and concave; but often we
observe transverse ridges, marking the original separation of
the bones of the sacrum. Four pair of holes are found dis-
posed in two longitudinal rows on the face of the sacrum,
communicating with the canal which receives the continuation
of the spinal marrow ; through these the sacral nerves, issue.
These holes slope a little outward, and betwixt the two rows,
is a smooth surrace, for the attachment of the rectum. The
posterior surface of the bone is very irregular ; and, we observe,
1st. The canal extending down the bone, for receiving the
continuation of the spinal marrow. 2d. At the upper part of
this are two strong oblique processes, which join with tnose of
the last lumbar vertebra. 3d. On a central line down the
back of the canal, there is an irregular ridge analogous to the
spines of the vertebras. 4th. The rest of the surface is very
irregular and rough ; and we observe, corresponding to the
holes for transmitting the sacral nerves on the exterior surface,
the same number of foramina on th^s posterior surface, but, in
the recent subject, they are covered with membrane, leaving
only a small opening for the exit of nervous twigs.

The coccyx is an appendage to the sacmm, and as it is
inclined forwards from that bone, the point of junction has
been called the little angle of the sacrum. It is, at first,

probe, leads to the face of the pelvis. The hole is called the
loramen thyroideum.

7th. Before this hole the two ossa innominata join, but form
with each other, on the inside, a very obtuse angle, or a kind
of smooth rounded surface on which the bladder partly rests*
The junction is called the symphysis of the pubis.

9th. At the upper part of the symphysis, or a very little
from it, the os mnommatum has a short obtuse projection,
called the tubercle of the pubis, into which Poupart's ligament
is inserted ; and from this, there runs down obliquely, a ridge
on the outside of the bone, which reaches all the way to the
acetabulum, and overhangs the foramen thyroideum.

10th. When we return to the back part of the os innomi-
natum, we find, that just after it has formed the plane of the
ischium, it extends backwards to join the sacnun ; but in
doing so, it forms a very considerable notch or curve, the con-
cavity of which looks downwards, When the sacrum is joined
to the bone, this notch is made much more distinct. It is
called the sacro-sciatic notch or arch, for one side is formed
by the ischium, and is about two inches long, the other is
formed chiefly by the sacrum, and is about half an inch
longer. In tne recent subject, strong ligaments are extended
at the under part, from the one bone to the other, so that this
notch is converted into a regular oval hole.

11th. Lastly, this notch being formed, the bone expands
backwards, forming a very irregular surface for articulation
with the sacrum ; and the bones being joined, we find that
the OS innominatum forms a strong, thick, projecting ridge,
extending farther back than the spinous processes of the
sacrum. This ridge is about two inches and three quarters
long, and is a continuation of the crest of the ilium, but is
turned downwards ; whereas were the crest continued in its
former course, it would meet with the one from the opposite
side, behind the top of the sacrum, forming thus a neat semi-
circle ; but this ridge, if prolonged on both sides, would form

an acute angle, the point of junction being opposite, the bottom
of the sacrom. From this, strong ligaments pass to the
sacrum, to join the two bones.

SECTION THIRD.

The sacrum forms the back part of the pelvis. It is a

triangular bone, and gently curved; so, that, whilst a line

drawn firom the one extremity to the other, measures, if it

sobtend the arch, about four mches, it will, if carried along

the surface of the bone, measure fiill half an inch more. The

distance between the first or straight line, and the middle of

the sacrum, is about one inch. The breadth of the base of

the sacrum, considered as an angular body, is full four inches :

the centre of this base is shaped like the surface of the body

of one of the lumbar vertebras, with the last of which it joins,

forming, however, an angle with it, called the great angle or

promontory of the sacrum. From this the bone is gently

curved outward on each side, toward the sacro-iliac junction,

contributing to the formation of the brim of the pelvis.

The upper half of the side of the bone is broad and irregu-
lar, for articulation with the os innominatum. The anterior
surface of the bone is smooth and concave; but often we
observe transverse ridges, marking the original separation of
the bones of the sacrum. Four pair of holes are found dis-
posed in two longitudinal rows on the face of the sacrum,
communicating with the canal which receives the continuation
of the spinal marrow ; through these the sacral nerves, issue.
These holes slope a little outward, and betwixt the two rows,
is a smooth surface, for the attachment of the rectum. The
posterior surface of the bone is very irregular ; and, we observe,
Ist. The canal extending down the bone, for receiving the
continuation of the spinal marrow. 2d. At the upper part of
this are two strong oblique processes, which join with those of
the last lumbar vertebra. 3d. On a central line down the
back of the canal, there is an irregular ridge analogous to the
spines of the vertebrae. 4th. The rest of the surface is very
irregular and rough; and we observe, corresponding to the
holes for transmitting the sacral nerves on the exterior surface,
the same number of foramina on this posterior surface, but, in
the recent subject, they are covered with membrane, leaving
onlva small opening for the exit of nervous twigs.

The coccyx is an appendage to the sacrum, and as it is
inclined forwards from that bone, the point of junction has
been called the little angle of the sacrum. It is, at first,

altogether cartUaginoiis, and cylindrical in its shape, but it
gradually ossifies and becomes flatter, especially at the upper
part, which has been called its shoulder. In men it is gene^
rally anchylosed with the sacrum, or at least moves with
difficulty, but it almost always separates by maceration. In
women it remains mobile, and, during labour, is pressed back
so as to enlarge the outlet of the pelvis. By falls or blows it
may be luxated ; and if this be not discovered, and the bone
replaced, suppuration takes place about the rectum, and the
bone is discharged.

CHAP. II.

Of the Articulation of the Bones of the Pelvis^ and their

occasional separation.

SECTION FIRST.

The bones of the pelvis are connected to each other, by
intermediate cartilages, and powerful ligaments. The ossa
innominata are united to each other at the pubis, in a very
strong and peculiar manner. It was supposed that they were
joined together by one intermediate cartilage; but Dr. Hunter*
was, from his observations, led to conclude, that each bone
was first of all covered at its extremity with cartilage, and then
betwixt the two was interposed a medium, like the interverte-
bral substance which united them. This substance consists
of fibres disposed in a transverse direction.

M. Tcnonf is of opinion, that sometimes the one mode and
sometimes the other obtains. I am inclined to think, that
Dr. Hunter's description is applicable to the most natural
state of the parts, which are joined by fibro-cartilaginous sub>
stance ; but we often find, that this intermedium is not thicker
than writing paper, or, a more fluid substance is interposed ;
or, on the contrary, anchylosis may sometimes take place, a
circumstance which Dr. Hunter says he never saw, but which
I have met with. Besides this mode of connexion, there is
also in addition a very strong capsule to the articulation, the
symphysis being covered on every side with ligamentous fibres,
which contribute greatly to the strength of the parts. The

* Vi<l« Med. Ob*, and Inq. Vol. 11. p. SS3.

t Vide Mem. de FJueliUit. d« Scleooet, Tome vi. p. 172.

»'

fibro-«artiIagiiiou8 intermedium sometimes enlaiq^es posteriorly,
and, together with the capsule, encroaches a little on the
diameter of the pelvis.

The puhic, or subpubic ligament, is a strong, short band,
stretched across, immediately below the symphysis, and which
adds to the security. It is not strictly ligamentous, but more
fibro-cartilaginous, like the interosseus substance. It is, at
least, a quarter of an inch broad, and extends down the rami,
becoming thioner as it proceeds. It is covered by, or included
m the fibrous capsule of the symphysis.

SECTION SECOND.

The ossa innominata are joined to the sacrum by means of
a thin layer of fibro-cartilaginous substance, which covers
each bone ; that belonging to the sacrum is the thickest : both
are rough, and betwixt them is found a soft yellowish substance
in small quantity. The connexion of the two bones, therefore,
so far as it depends on this medium, cannot be very strong ;
but it is exceedingly strengthened by ligamentous fibres,
forming the sacro-iliac ligament, which serve as a capsule ;
and behind, several strong bands pass firom the ridge of the
ilium to the back of the sacrum ; sometimes the bones are
united by anchyloms. At the lower part, additional strength
is obtained hj two large and strong ligaments, which pass
from the ischium to the sacrum, and therefore are called the
sacro-sciatic ligaments. The innermost of these, arises from the
spine of the ischimn and is very strong, but at first not above
a quarter of an inch broad ; it gradually expands, however,
beo^ming at its insertion about an inch and a quarter in
breadth. It passes on to the sacrum, and is implanted into
the lower part of the side qf that bone and the upper part of
the coccyx. It converts the sacro-sciatic notch into a regular
oval hole, the inferior end of which, owing to the neat expan-
sion of the ligament, is as round and exact as the up^er. As
it makes a similar expansion downwards, its margin, as it
goes to the coccyx, is lunated. The outer ligament may be
said to arise from the side of the sacrum, and, like the other,
is broad at that part. It runs, for some time, in contact with
the inner ligament, and parallel to it ; but afterwards it separ-
ates, passing down to be inserted in the tuber ischii ; and,
when the %aments separate, iheir surfaces are no longer
parallel to each other. There is, in consequence of this
.separation, a small triangular opening formed betwixt the
ligaments; or rather there is an apertm-e like a bow, the

string being formed by the under ligament, and the arch
partly by the spine of the ischium, and partly by the upper
ligament.

SECTION THIRD.

The pelvb is joined to the trunk above, by means of the
last lumbar vertebra ; to the extremities below, oy the insertion
of the thigh bones into the acetabula ; and it is so placed that
when the body is erect, the upper part of the sacrum and the
acetabula are nearly in the same descending line. The brim
of the pelvis, then, is neither horizontal nor perpendicular to
the horizon, but oblique. This obliquity has been variously
estimated, at from 35° to 60**, that of the outlet from 5J-** to
18**. Naegele makes the first from 50** to 60°, the second
from 10° to 11°; the point of the coccyx seven or eight lines
above the summit of the arch of the pubis ; the sacro-vertebral
angle three inches and nine Unes higher than the pubb. He
mentions two extreme cases : in one the brim was almost per-
pendicular, and the organs of generation directed so backward
as to reverse the mode of sexual intercourse ; in another, the
brim was more horizontal, the organs directed forward, and
jthe anus forward;* and a very slight attention to the greater or
less curve of the lumbar vertebra in different individuals, may
satisfy any one that the obliquity of the pelvis must vary.
Were the ligaments of the pelvis loosened, there would, from
the obliquity, be a tendency in the sacrum to fall directly
towards the pubis, the ossa innominata receding on each side.
But the structure of the part adds greatly to the power of the
ligaments ; for it is to be observed, that in standing, and in
various exertions of the body, the limbs re-act on the pelvis ;
and the heads of the thigh bones pressing on the two aceta-
bula, force the ossa innominata more closely on each other at
the symphysis, and more firmly on the sacrum behind. It is
not possible, indeed, to separate the bones of the pelvis, unless
the connecting ligaments be diseased, or extemiu violence be
applied, so as to act partially or unequally on the pelvis.

SECTION FOURTH.

By external violence, the symphysis has been wrenched
open, as was the case with Dr. Greene ;t or the sacro-iliac
junction may be separated, as in the case of the young peasant,
related by M. Louis.$

• ArchivM, xiv. 250. * f Phil. Tran*. No. 484.

\ Vide Menu dc T Aoad. de Chir. Tome ir. p. 63.

phys
wall

By some morbid affection of the sjrmphysis, it may yield
and become loosened during pregnancy, or may be separated
during labour. Some have been inclined to consider this as
a uniform operation of nature, intended to facilitate the birth
of the child. Others, who cannot go this length, have never-
theless conjectured, that the ligaments do become somewhat
slacker ; and have grounded this opinion on the supposed fact
of the pelvis of quadrupeds undergoing this relaxation. But
the truth is, that this separation is not an advantage, but a
serious evil ; and in cases of deformed pelvis, where we would
naturally look for its operation, did it really exist, we do not
observe it to take place.* Still there is no doubt that often
the articulations do soften, and that the symphysis is more
easily divided than formerly ; but no separation takes place,
mien a person stands, pressure is made upon the sym-
rsis, and therefore, if it be tender, pain will then be felt. In
walking, pressure is made on the two acetabula alternately,
and the ossa innominata are acted on by the strong muscles
which pass from them to the thighs, so that there is a tendency
to make the one os pubis rise above the other ; but this, in a
aound state of the parts, is sufficiently resisted by the
ligaments. In a diseased state, however, or in a case of
separation of the bones, there is not the same obstacle to this
motion : and hence, walking must give great pain, or be alto-
gether impossible: even attempts to raise the one thigh above
the other in bed, must give more or less pain, according to
the sensibility or laxity of the symphysis. Standing has also
an effect on the sjrmphysis, as I have mentioned ; but some-
times the persoii can, by iSxing one os innominatum, with all
the muscles connect^ with it, and throwing the chief weight
of the body to that side, stand for a short time, easier on one

* Dcnnlt and Bedard nuunUio that the ariieiilatjoiit loosen, and Boyer says
that in one eaae, he found the sacro-iliac connexion separated to the extent of
half an inch ; Chaossier, that he fonnd the sf mphysis or the puhis separated to a
greater degree, in an easy lahoor. Gardien ohsonres that it onjy happens where
thcrs is a predisposition, for the head is too soft to force asunder the hones of
the pelTis. Par6 and Lonis, and more lately Piet, suppose that the separation
proceeds from swelling of the cartilages and simple extension of the ligaments ;
an opinion which Chaussier says he nas confirmed hy dissection. BaudelocqaCy
on the other hand, asserts that it proceeds from extension of the ligament alone,
the eartilagea remaining the same in thickness. Finault thought that the pro-
cess of relaxation itaight Im promoted hy the use of haths and blood-letting ; but
this is correctly denied by Uardien, alUiough both imagine that the relaxation is
beneficial. Yet the continental calculators admit, that, in order to gain two
lines in the antero-posterior diameter, there must be a separation of the pubis to
the extent of one inch. Perhaps to obviate an objection which might be brought
against the benefit of tliis natural separation, Plessman says, that all the three
articttlations relax simultaneously, and thereby a greater advantage is gained,
with lesB injury to the individual joinings. Maygrier la of the same opinion.

leg than on both. This is the case when one os innominatum
has been more acted on than the other, at the sacro-iliac
junction. The person can stand easiest on the soundest side.
The patient also, especially if the relaxation be accompanied
with any degree of relaxation of uterine attachments, in-
stinctively crosses her legs when standing, thereby obtaining
relief.

From these observations, we may learn the mischievous
consequences of a separation of the bones, and also the cir-
cumstances which will lead us to suspect that it has happened.
If the bones be fuUy disjoined, then, by placing the finger on
the inside of the symphysis, and the thumb on the outside, we
can readily perceive a jarring, or motion, on raising the thigh.

The rectus muscle is implanted, into the upper margin of
the pubis, by a thin but strong tendon, whilst an aponeurosis,
proper to the muscle, rises from the bone, and extends for an
inch and a half up its inner surface. This is further lined by
a sheet of fascia, continuous with the deep pelvic fascia, and
fascia transversalis. Farther, there is sent off from each rectus,
a band of tendinous substance, which goes to the tubercle of
the opposite side, and is continuous with Poupart's ligament.
These decussate each other, and at the point of decussation,
they not only are united to each other, but to the termination
of the linea alba, or union of the recti, so as to form a kind
of arch, which binds down the muscle here, and also, when
distended, will tend to tighten Poupart's ligament. Exterior
to the implantation of the recti, the tendon of the internal
oblique, is inserted into the margin of the pubis, whilst a de-
cussation of the pillars of the external oblique, of the
opposite sides, is spread over the face of the symphysis,
Owing partly to distention of the fibrous texture, and partly,
perhaps, to increased action consequent to pregnancy, the
parts about the pubis, and especially the bladder and urethra,
and even the whole vulva, may become very sensible. This
tender state may be communicated to the symphysis; or
some excitation, less in degree than that I have mentioned,
may exist, which, in particular cases, seems to extend to the
articulation, producing either an increased efiiision of inter-
stitial fluid in the intermediate cartilage, and thus loosening
the firm adhesion of the bones, or a tenderness and sensi-
bility of the part, rendering motion painful. In either case
exertion may produce a separation ; and certainly, in some
instances, has done so. The separation is always attended
with inconvenience, and oflen with danger, especially when

it occurs during parturition ; for abscess may take place, and
the palient sink under hectic fever; or inflammation may
be commmiicated to the peritoneum, and the patient die in
great pain.

^lien the accident happens duribg gestation, it sometimes
takes place gradually, in consequence of an increasing relax-
ation of the articulation, from slow but continued excitation.
In other instances it happens suddenly after some exertion.
It may occur so early as the second, or so late as the ninth
month, and is discovered by the symptoms mentioned above ;
such as pain at the pubis, strangury, and the effects of motion.
In some instances, considerable fever may take place, but in
g-eneral the symptoms are not dangerous, and I do not know
any case which has terminated &tally before delivery. A
state of strict rest, the application of a broad firm bandage
round Uie pelvis, to keep the bones steady, and the use of the
lancet and antiphlogistic regimen, if there be fever or much
pain, are the chief points of practice. Nor must it be
lorgotten for a moment, that although by these means, the
symptoms be removed, the patient is liable, during the
remaimng term of gestation, or at the time of delivery, to a
renewal of the relaxation or separation, from causes which, in
other circumstances, would have had no effect. So far as I
have been able to learn, a woman who has had this separation
in one pregnancy, is not, in general, peculiarly liable {o a
return of it in a subsequent pregnancy, though there may be
particular exceptions to this observation.*

When it happens during parturition, it sometimes takes
place in a pelvis apparently previously sound ; but in most
mstances, we have, during some period of gestation, symptoms
of disease about the symphysis ; and so far from making labour
easier, the woman oiten suffers more, when the symphysis is
previously relaxed. The primary and immediate effects are
the same as when the accident happens during pregnancy ;
but the subsequent symptoms are frequently much more
severe and dangerous, the tendency to inflammation being
strong. The pain may be either trifling or excruciating at
the moment, according to the sensibility of the parts. But
even in the mildest case, great circumspection is required,
violent inflammation having come on so late as a fortnight
after the accident. The means used in the former case are

* Dr. DeDman mentions an instance, where the patient, in three succeeding
pregnancies, was profreMively worse, and did not, until the lapse of eight years,
recover from the lamcDflis produced by the third delivery. Introd. VoL i. p. 16.

f^robe, leads to the face of the pelvis. The hole is called the
bramen thvroideum.

8th. The two bones, where they form the symphysis, are
joined with each other for about an inch and a half; then thev
diyaricate, forming an angle, the limbs of which extend au
the way to the tuberosity of the ischium. This separation or
divarication is called the arch of the pubis, which is princi-
pally constructed of the anterior boundary of the foramen
thvroideum, consisting of a column or piece of bone about
half an inch broad, and one fourth of an inch thick, formed by
the union of the ramus of the pubis, and that of the ischium.

9th. At the upper part of the symphysis, or a very little
from it, the os mnominatum has a short obtuse projection,
called the tubercle of the pubis, into which Poupart's ligament
is inserted ; and from this, there runs down obliquely, a ridge
on the outside of the bone, which reaches all the way to the
acetabulum, and overhangs the foramen thyroideum.

10th. When we return to the back part of the os innomi-
natum, we find, that just after it has formed the plane of the
ischium, it extends backwards to join the sacrum ; but in
doing so, it forms a very considerable notch or curve, the con-
cavity of which looks downwards. When the sacrum is joined
to the bone, this notch is made much more distinct. It is
called the sacroH9ciatic notch or arch, for one side is formed
by the ischium, and is about two inches long, the other is
formed chiefly by the sacrum, and is about half an inch
longer. In the recent subject, strong ligaments are extended
at tne under part, from the one bone to the other, so that this
notch is converted into a regular oval hole.

1 1th. Lastly, this notch being formed, the bone expands
backwards, forming a very irregular surface for articulation
with the sacrum ; and the bones being joined, we find that
the OS innominatum forms a strong, thick, projecting ridge,
extending farther back than the spinous processes of the
sacrum. This ridge is about two inches and three quarters
long, and is a contmuation of the crest of the ilium, but is
turned downwards ; whereas were the crest continued in its
former course, it would meet with the one from the opposite
side, behind the top of the sacrum, forming thus a neat semi-
circle ; but this ridge, if prolonged on both sides, would form

SECTION THIRD.

The sacrum forms the back part of the pelvis. It is a
triangular bone, and gently curved; so, that, whilst a line
drawn from the one extremity to the other, measures, if it
subtend the arch, about four inches, it will, if carried along
the surface of the bone, measure fiill half an inch more. The
distance between the first or straight line, and the middle of
the sacrum, is about one inch* The breadth of the base of
the sacrum, con^dered as an angular body, is full four inches :
the centre of this base is shaped like the surface of the body
of one of the lumbar vertebrae, with the last of which it joins,
forming, however, an angle with it, called the great angle or
promontory of the sacrum. From this the bone is gently
curved outward on each side, toward the sacro-iliac junction,
contributing to the formation of the brim of the pelvis.

The upper half of the side of the bone is broad and irregu-
lar, for articulation with the os innominatum. The anterior
surface of the bone is smooth and concave; but often we
obserre transrerse ridges, marking the original separation of
the bones of the sacrum. Four pair of holes are found dis-
posed in two longitudinal rows on the face of the sacrum,
communicating with the canal which receives the continuation
of the spinal marrow ; through these the sacral nerves, issue.
These holes slope a littie outward, and betwixt the two rows,
is a smooth surface, for the attachment of the rectum. The
posterior surface of the bone is very irregular ; and, we observe,
1st. The canal extending down the bone, for receiving the
continuation of the spinal marrow. 2d. At the upper part of
this are two strong oblique processes, which join with those of
the last lumbar vertebra. 3d. On a central line down the
back of the canal, there is an irregular ridge analogous to the
spines of the vertebr«. 4th. The rest of the surface is very
irregular and rough ; and we observe, corresponding to tiie
holes for transmitting the sacral nerves on the exterior surface,
the same number of foramina on th^ posterior surface, but, in
the recent subject, they are covered with membrane, leaving
onlva small opening for the exit of nervous twigs.

The coccyx, is an appendage to the sacrum, and as it is
inclined forwards from that bone, the point of junction has
been called the little angle of the sacrum. It is, at first,

to be rigidly employed, and the patient should keep her thighs
together, and lie chiefly on her back. If the separation have
been slight, re-union may take place in a few weeks, some-
times in a month ;* but. if great injury have been sustained,
it may be many months, perhaps years, before recovery be
completed : and, in such cases, it is probable, that at last, an
anchylosis is sometimes formed. The cold or shower bath,
which is more conyenient in this case than the plunge, is of
service in promoting the recovery ; and the bandage should
be kept carefully applied.

Eitner owing to the violence of the accident, or the peculiar
state of the parts, it sometimes happens, that inflammation
takes place to a very considerable degree in the symphysis ;
but it is to be remarked, that the symptoms are by no means
uniformly proportioned in their severity to the degree of the
separation. Inflammation is known by the accession of fever,
with acute pain about the lower part of the belly, greatly
increased by motion, succeeding to the primary effects ; or
sometimes from the first, the pain is very great, and not
unfrequently it is accompanied by sympathetic derangement of
the stomacn and bowels, such as vomiting, nausea, looseness,
&c. Presently matter forms, and a well marked hectic state
takes place. The patient is to be treated, at first, by the
usual remedies for abating inflammation, such as general and
loci(^ evacuation of blood, fomentations and laxatives. When
matter is formed, we must carefully examine where it is most
exposed, and let it out by a small puncture.t

* In one case, where the tympfaydfl wu divided, the patient wai able to walic
on the 15th dny.— In Dr. SmoUet*s case, although in the 8th month of geetation,
the bonee were found to rise abore each other, yet the woman reoorered in two
months after delivery. Smellie, Vol. ii. Col. i. n. i. c 2.

f As an illustration of this disease, I shall relate the outlines of a case men*
tioned by Louis, in the Memoirs of the Royal Academv of Surgery. A woman
in the 2d month of her pr^nancy, after pressing in » arawer with her foot, felt
a considerable pain at the lower part or her belty, greatly increased bv every
change of posture ; .and along with this she oomplained of strangury. She waa
bled, and purred, and kept at rest, by which means, especially the last, she grew
better. But in the two latter months of pregnancy, the symptoms were tenewcd*
so that presently she could neither walk, nor even turn in bed, without great
pain ; but her greatest suffering was caused by raising the len to pull on her
•tockings, as then the bones were more powerfully actM on. A slight degree of
hectic fever now appeared. Her delivery waa accomplished easily ; but on tha

evening of the 9d day, when straining at stool, after having received a clyster, the
pain, which had troubled her little since her labour, returned with as much seve-
rity as ever. On the 5th day the pulse was very weak and frequent, she sweated
profusely, and had a wlldness in her countenance, with symptoms of approaching
delirium. In the afternoon the pulae became full and tense, with vertigo and
throbbing of the arteries of the head.' llie pain at the symphysis was excruciatingt
and although she was fomented and bled seven timea, she obtained no relief. On
the 8th day the pain ibated, but diffused itaelf over the test of the pelvis, paHteu-
larly affectiog the left hip and the aaorum. On the II th day she died. On
opening the body, 4lMre was found a separation of the bones of the poMa, but the

The inflammatioii may be communicated to the peritoneum,

{producing violent pain in the lower belly, tumemction and
ever, and ahnost imiformly proves fatal ; though frequently^
the patient lives until abscess takes place in the cellular
substance within the pelvis. If any thing can save her, it
must be the prompt use of blood-letting and blisters.

In almost every case of separation of the pubis considerable
pain is felt in the loins, even although the junction at the
sacrum be entire, and the ossa pubis be very little asunder.
But when the separation is complete, and in any way exten-
sive, then the articulation of the sacrum with the ossa inno-
nunata,* especially with one of them, is more injured,! and
the person is lame in one or both sides, and has acute pain
about the posterior ridge of the ilium,t and in the course of
ihe psoas and glutei muscles. The mischief may also com-
mence in the sacro-iliac articulation, and the symphysis may
be little affected. The general principles of treatment are
the same as in the former case. When suppuration takes
place about the sacro-iliac articulation, the danger is greatly
increased.

A slight straining of the sacro-sciatic ligament is sometimes
combined with a similar condition, only to a greater degree,
of the muscles, the levator ani, for instance, or the pyriformis,
or both. This is productive of pain in walking, shooting as
it were directly back along the side of the pelvis at the outlet,
or near the perineum and inside of the thigh, or, in the case
of the pyriformis, it goes more round the trochanter. Rest
and the use of a roller are the best remedies.

captole WM entire, and mnch distended. It eonttf ined alioat an oanee and a half
•f matter. VThether the timely evucuation of this matter might hare eaved the
patient, i« a question worth oar consideration. I am dispoeed to answer it in the
afirmatiTe, from obserring, that wherever the patient has reeoTered in s'lch
cirenmstanccs, it has uniformly happened, that a discharge of matter has taken

• Dr. Lawrenee showed Dr. Smellie a peWis, where all the Inmes were sepa*
rated to the extent of an inch.

t In a case related by De la Malle, the pain did not appear till the 14th day
after ddirerr, and was felt first in the groin. The patient was unable to move
the ley. and had acute feyer, which proved fatal. The sacrum was found separated
tkree lines from the ilium.

In the operation of dlTiding the pubis In a parturient woman, it was found that
one sldeviclded more than the other, and consequently that side would suffer
moot at tbe saemm. Baudelocque L*Art, he. 206S.

I Dr. Smellie relates an insUnce, where, during labour, the woman fdt
▼iolent pain at the richt sacro-iliac symphysis. On the 5th day this pain was
eactremdy severe, and attended with acute fever ; but the symptoms Vrere abated
hf blood-letting, and a clyster, and fomentotions, which produced a copious
perspiration. She was not able to walk for five or six months without crutches,
oat was ivstorcd to ihe nse of the limb» hy the means of the cold bath. Coll. 1.
D. i. e. 1. *

In all cases of separation, when the patient has recovered
so far as to be able to move, the use of the cold bath acceler-
ates the cure ; the general health is to be carefully attended
to, and any urgent symptom interyening, is to be obviated by
suitable remedies.

CHAP. III.
Of the soft Parts which line the Pelvis.

SECTION FIRST.

Various strong and large muscles, pass from the spine and
pelvis to the thigh bones, and act as powerful bands, strength-
ening, in a yery great degree, the articulations of the pelvis.
These it is not requisite to describe, but it will be useful,
briefly to notice the soft parts which line the pelvis, and which
may be acted on by the child's head during labour.

Ist. When we remove the peritoneum and fascia from the
cavity of the pelvis, we first of all are led to observe, that all
the under portion of the os innominatum, and part of the
sacrum, are covered with a layer of muscular fibres, which
arises a little below the brim of the pelvis, and can be traced
all the way down to the extremity of the rectum. This is the
levator am ; it is a strong muscle, with many glossy tendinous
fibres, especially at the fore part, where it lines the ossa pubis.
It does not arise, in general, from the very front of the pubis,
but only from the outer part, of the smooth portion of the
bones, lying between the symphysis, and the margin of the
thyroid aperture. It contmues its origin from a tendinous
line which traverses the obturator intemus, all the way back
to the spine of the ischium. Its fibres tend toward the peri-
neum and anus, so that the muscle closes up partially the
outlet of the pelvis, not however like a funnel, to which it has
been compared, for it is incomplete both before and behind,
and is rather like two hands coming down from within, one
on each side, to hold up the contents of the pelvis. The
anterior portion of the outlet, it is evident, cannot be quite
occupied by the muscle, nor shut up by it. For it sweeps
down from the pubis, and its margin forms either a semicircle,
or an angular aperture, more or less acute, which embraces
the sides of the vagina, or, if the origin be very near the

symphysis, the margin of the muscle, descends closely by the
side of the urethra and vagina. The fibres pass on to termi-
nate in the extremity of the rectum, the sphincter ani, peri-
nemn, and on the vagina, to about three quarters of an
inch from its orifice. The vagina does not pierce the muscle,
but the muscle winds along its sides, which may be said to rest
on it at its passage. Ind^d, in many cases, the levator seems
to belong as much to the vagina as to the rectum, though
always stronger at the latter. But besides the support afforded
by the levator ani, which is deficient in some parts, much
assistance is given by the pelvic fascia. This, some way below
the brim, separates into two layers. The innermost is re-
flected like the peritoneum, but under it, to the bladder, upper
part of the vagina, cervix uteri and rectum, as I shall aiter-
wards notice. The outermost, or that which passes down on
the obturator intemus, is very strong. It descends on the
outside of the levator ani to the outlet of the pelvis, adhering
firmly to the rami of the pubis and ischium, or all the bony
margin, and, partly, prolonged to the soft parts. But a very
important part of this, is found at the arch of the pubis, for
there, it forms a sheet of strong fascia, extending across the
upper or anterior part of the outlet, and is similar to the
I^^mentum triangulare, as it has been called, of the male.
The urethra passes, as in the other sex, either through the
ligament at its border, or it may in both cases pass by the
very margin, firmly and intimately connected to it by a
production or detachment of the facial substance. In dif-
ferent individuals dissection would lead to the opinion, that
sometimes the one and sometimes the other mode prevailed.
Usually, the urethra in the female passes loosely tlurough it,
that is to say, is not firmly fixed, whilst the levator passes
down by the sides of the urethra, on the inside of this trian-
gular ligament. This ligament, or rather fascia, is extended
over the sides of the vagina, and prolonged forward on its
extremity towards its orifice, and is thus insensibly lost. A
similar prolongation, but of consequence very small, accom-
panies the urethra. It is thus evident that the pelvic viscera
must be supported, and the outlet of the pelvis secured, not
merely by the firmness of the perineum, and the tough sub-
stance of which it is composed, and by its transverse muscles,
but also, and essentially, by the levator ani, triangular liga^
ment, and prolongations of the deep pelvic fascia. But
besides these, which may be called internal supports, we find,
as will be again noticed, that a strong external fascia can be

traced from the gluteus muscle, forward over the perineum
and lahia, and that a deeper layer of this, is stretched broadly
between the ischium and coccyx, covering and supporting
there, the levator and sides of the rectum, and connected with
the sacro-sciatic ligaments. Thus, the outlet of the pelvis is
everywhere shut up, and the parts within, supported by mus-
cular fibres and fascia, and the strong and broad sacro-sciatic
ligaments, excepting at the new orifices of the canals. The
rectum is, indeed, shut up by its sphincter, whilst the oblique
direction of the vagina, and its connexions render a sphincter
less necessary, although it be not altogether wanting. The
importance of this inquiry will be understood, when we attend
to the production of prolapsus uteri. In pregnancy, some of
these parts must be more or less stretched and relaxed; and in
labour both the muscles and fascia may be greatly stretched.
But as the anus is brought forward during the passage of the
child's head, the fibres of the levator passmg along the vagina
are not so much distended as they would otherwise be ; still
there is a risk of a feeling of want of support, or of bearing
down, being experienced after parturition. When the head
has entered the pelvis in labour, we sometimes feel the fascia
behind stretched like a ligament across the front of the rec-
tum, and extending to the sides of the pelvis, and sometimes
faeces collecting in the rectum above this vagino-rectal reflec-
tion, may produce a kind of sac. If carried a little more for-
ward by being stretched, it may be pressed down as well as
backward, which should be its only direction, and then it not
only afibrds some resistance to the forehead, and we know
how any slight resistance sometimes retards labour, or causes
an unfavourable position, but also is greatly extended, and
contributes afterwards to the production of prolapsus.

2. External to the levator, on each side, we nave, arising
from the membrane that fills up the thyroid hole, and also
from the margins of the hole and the mner surface of the
ischium, the obturator intemus, which forms at that part a
soft cushion of flesh, the fibres running backwards and down-
wards, and terminating in a tendon, which passes over the
sacro-sciatic notch, running on it as on a pulley, in order to
reach the root of the trochanter.

3. We find the pyriformis, arising from the under part of
the hollow of the sacrum, and also passing out at the notch,
to be inserted with the obturator ; and in laborious parturi-
tion, the injury or pressure which these muscles sustain, is
one cause of the uneasiness felt in moving the thighs.

4th. From the spine of the ischium, originates the coccygeus^
which runs hackward to be inserted into tJbe side of the coccyx,
in order to move and support it. This gradually becomes
broader, as it recedes from its origin, and is spread on the
inside of the sacro-sciatic ligament. Thus the cavity of the
pelvis is lined with muscular substance, whose fibres are dis-
posed in a very r^ular order, and which are exhibited when
die peritoneum and its celluho* substance are removed.

5Ui. When we look at the upper part of the os innomzna-
torn, we find all die hollow of the ilium occupied with the
ihacua intemns, the tendon of which passes over the fore part
of the pelvis, to reach the trochanter of the thigh. Part of
this muscle is covered by the psoas, which arises from the
hmibar vertebrae, and passes down by the side of the brim of
the pelvis to go out wiUi the former muscle : though just upon
the brim, it does not encroach on it, so as perceptibly to
lessen the cavity. These muscles afford a soft support to the
intestines and gravid uterus.

SECTION SECOND.

Running parallel with the inner margin of the psoas muscle,
and upon the brim of the pelvis, along die posterior half of the
Knea iliopectinea, we have the iliac artery and vein ; the artery
lying, for the upper half of its course, above the vein, and for
die under half on the outside of it ; when filled, they, espe-
cially the vein, encroach a little on the brim. About three
inches from the symphysis, they quit the brim^ running rather
more outward, over the part which forms die roof of the
acetabulum, and pass out with the psoas muscle. The great
lash of arteries and veins connected with the pelvis, and in-
ferior extremities, is placed on the sacro-iliac junction. The
iliac vessels are so situated, that they escape pressure during
labour, when the head enters the cavity of the pelvis ; but the
hypogastric vessels must be more or less compressed, accord-
ing to the si2e or position of the head, yet the circidation is
nerer interrupted.

SECTION THIRD.

The nerves are of much importance. First, we attend to the
last dorsal nerve which, on tearing off the peritonemn, is seen
running along the lower margin of the last rib. It dirides into
two or often wree branches, which go to the abdominal muscles,
and one turns out on the crest of the ilium to the fascia
and skin, covering the gluteus, tensor, &c. The lower inter-

costal nerve also sends branches to the upper part of the
abdominal parietes. Second. The first lumW subdivides into
two, one, called the ilio-lumbar, gets between the internal ob-
lique and tranversalis pretty far back, runs forward about
hfidf an inch above the crest, and is lost in the abdominal
muscles; another, the ilio-pubal, also goes forward to the
back of the crest, but runs not above it, but along its inside.
It is hid by the iliac-fascia till it reach the middle of the crest,
when it presently gets between the internal oblique and trans-
versalis muscles which it supplies ; and then its continuation
passes the former, runs on between it and the tendon of the
external oblique, reaches the upper margin of the round liga-
ment, and issues with it at the mferior aperture of the inguinal
canal, to be distributed to the pubis and labium. Third. The
second lumbar gives o£P the external cutaneus nerve which runs
down on the iUacus muscle, and is seen through the fascia
tending to the space between the superior and inferior spinous
processes of the ilium, where it issues to supply the side of the
thigh all the way to the knee. Fourth. The same lumbar
nerve also gives off the genito-crural, which runs more inward
than the external cutaneous. It divides soon into two branches,
one of which enters the superior aperture of the canal with
the round ligament, and goes with it to the labium. The
other passes out under Poupart's ligament to the groin*
Fifth. The continuation of the second joins the third and
fourth lumbar nerve to form the anterior crural which nms
between the psoas and iliacus muscles, issues from under
Poupart's ligament to be distributed to the skin and muscles
of the thigh, and even the leg. Sixth. From the third and
fourth lumbar comes off the obturator nerve which runs along
the side of the cavity of the pelvis, about three quarters of an
inch below the brim to the foramen thyroideum, wnere it passes
out deeply covered by the muscles of the thigh. Seventh.
The three uppermost sacral nerves, with the fifth and part of
the fourth lumbar, join to form the sacral plexus, wnich is
nearly an inch broad, and about an inch and a quarter long»
resting chiefly on the pyriform muscle. The sacral nerves
do not, however, arise from the region of the sacrum, but
come off from the lumbar portion of the spinal marrow, a fact
to be remembered in the treatment of some diseases. Now
this plexus, besides giving off the gluteal nerves, forms the

Seat sacro-sciatic nerve, and also gives off the pudic which
[lows the course of the artery, and on re-entering the pelvis,
gives off branches to the rectum, &c. &c., then proceeds, as

win be afterwards described. Eighth. The third sacral nenre
not only joins the plexus, but sends a branch to unite with the
fourth, and form the haemorrhoidal nerves, which, with a
luemorrhoidal branch firom the pudic, goes to the anus, and
cellular substance round it. Ninth. The fifth sacral nerve
goes to the coccygeus, &c. Lastly. The lumbar ganglia of the
snrmpathetic nerve lie on the vertebrae at the inner margin of
the psoas muscle and communicate with the spinal nerves, each
by the reception of a pretty large branch. The sympathetic
nerve passes down into the pelvis deep in the hollow between
the psoas muscle and the promontory of the sacrum, so that
it is not injured in labour. The sacral ganglia lie on, or a
little to the outside of, the foramen by the side of the rectum.
The connexion of die sympathetic with the spinal nerve is
of consequence in explaining many diseases. Affections of
the lower sacral nerves have much mfluence in producing dis*
tressing sensations, such as that of bearing down, even although
there be little relaxation ; and, doubtless, such affections may,
by debilitating the muscles, prove an actual cause of prolapsus
uteri, or relaxation of the vagina. Neuralgia of the pudic
nerve, or excitation and sensibility of the parts supplied by it,
will afterwards be noticed. The last dorsal nerve and its
branches, as well as those from the upper lumbar, are often
the seat of pain in the course of pregnancy ; and I doubt not
in several puerperal diseases, different nerves are acted on in
different stages of labour. In the commencement, the anterior
crural nerve, or the nerves forming it, may be irritated or
excited, producing pain in the fore part of the thigh ; next,
the obturator, producing pain in the inside; thta the great
plexus, caudng pain in the back of the thigh or cramps of the
1^;8. In severe labour the nerves, especially the sciatic, may
si^er so much as to cause afterwards much pain or lameness,
or even palsy. Friction, the warm bath, or if the tenderness be
great externally, cupping are proper at first. Afterwards, re-
peated small bhsters, a well applied roller, and ultimately cold
sea water may be useftil in perfecting the cure.

SECTION FOURTH.

The lymphatics in the upper part of the pelvis follow the
course of tne iliac vessels, forming a large and very beautiful
plexus, from Poupart's ligament to the lumbar vertebrae.
These are out of the way of pressure during labour. Numer-
ous glands accompany them, which are sometimes enlarged
by disease, but they do not interfere with parturition. The

lymphatics of the cavity of the pelvis have glands in the course
of the vagina and rectum ; and these, if enlarged, may impede
delivery.

CHAP. IV.
Of the Dimensions of the Pehis.

SECTION FIRST.

Ths pelvis has been divided into the great and the little, the
first being formed by the expansion of the ilia, and the second,
comprehending all that part which is called the cavity of the
pelvis, and which lies below the linea ilio-pectinea. The
cavity of the pelvis is the part of the chief importance in
MidwifeiTy and consists of the brim, or entrance, the cavity
itself, ana the outlet. The brim of the pelvis, owing to the
projection of the top of the sacrum behind, and of the ossa
pubis before, has no regular shape, but approaches nearer the
oval than any other. The short diameter of this, extends
from the symphysis of the pubis to the top of the sacrum.
This has been called the conjugate, sacro-pubic, or antero-

Sosterior diameter, and measures four inches. The lateral
iameter measures from five inches and a quarter, to five and
a half, or sometimes to six ; and the diagonal diameter, or a
line drawn from the sacro-iliac symphysis to the opposite
acetabulum, measures from five inches and an eighth, to five
and a half ; but as the psos muscles, and iliac vessels, over-
hang the brim a very little at the side, the diagonal diameter,
in the recent subject, often appears to be the longest. From
the sacro-iliac symphysis to the crest of the pubis, on the
same side, is four mches and a half. From the top of the
sacrum, to that part of the brim which is directly above the
foramen thyroideum, is three inches and a half. The line, if
drawn to the acetabulum, in place of the foramen, is a quarter
of an inch shorter ; a line drawn across the fore part of the
brim, from one acetabulum to another, is nearly four inches
and a quarter.

The outlet of the pelvis is not so regular as the brim, in its
shape, even when the soft parts remain ; but it is then some-
what oval. The long diameter extends from the 8>inphysis
pubis to the coccyx, and measures, when the bone is pusned

back, as in labour, five inches, but an inch less when it is not.
The transYerse ^ameter, from the end of one tuberosity of
the ischium to the other, measures four inches. But a httle
bigfaer or £uiher back, where the inferior sacro-sciatic ligament
is inserted, it measures above half an inch more. Farther
forward where the rami begin, the distance is only two inches
and three quarters.* The outlet of the pelvis differs materially
from the brim, in this respect, that its margins are not all on
the same level ; an oval wire wiQ represent the brim, but, if
applied to the outlet, it must be curved. The outlet, from the
symphysis pubis to the tuberosity of the ischium, is semi-oval ;
but behind, it becomes more irregular, and bends upwards and
backwards. The arch of the pelvis, or the fore part of the
outlet, is four inches broad at its base ; and a perpendicular
line, dropped from its centre to the base is fuliy two inches
long. The top of the arch will permit a circular body to
come in contact with it, whose diameter is an inch and a
quarter. The length of each limb of the arch is three inches
and a quarter. The outlet is arched to a height of about
three inches, and the pillars of this arch recede gradually
toward the tuberosities. The latero-posterior boundaries
formed by the sacro-sciatic ligament, represent on each side,
an oblique line running inward and backward, whilst between
these, the coccyx forms a peak directed forward. This irre-
gular aperture is longer than it is broad, but is by no means
oval. When the soft parts are added, and we connect it with
the cavity of the pelvis, we then say, that in labour it forms
an ovoid opening of an ovoid tube, but the shape of the aper-
ture will vary according to the stage of propulsion.

SECTION SECOND.

The cavity of the pelvis is the next part to be attended to ;
and the most important observation to be made, is, that it is
of unequal depth. At the back part, it measures from five to
six inches, according as the coccyx is more or less extended ;
at the side, a line drawn from the brim, to the tuberosity of
the ischium, measures three inches and three-fourths. At the
fore part) the depth of the symphysis pubis, from its upper
margin to the under margin of the pubic ligament, is two
inches. When the surface of the child's head, then, is parallel
to the lower edge of the symphysis, the head is still far from

• The peWk oi tb« NcfTMi is tmaUer in aU its dimcDBloDi. Tbat of an Efjp-
tiao mummy, dimactcd bv Dr. GranviUe, measurwl £▼« and a half inches, in the
lateral, and bar and a buf In the aniero-poeterior diameter.

having entered fiilly into the cavity of the pelvis ; it cannot be
considered in the cavity, until it be lodged fairly in the hollow
of the sacrum.

It may be proper to notice the dimensions of different parts
of the cavity itself. An oblique line, drawn from the sacro*
iliac junction, on one side, down to the opposite tuberosity,
measures six inches ; and the long axis of the child's head,
before it takes the turn forwards, corresponds to this line.
From the ramus of the ischium, to the opposite sacro-iliac
junction, is five inches. From the posterior margin of the
inclined plane of the ischium, or anterior margin of the sacro-
Bciatic notch, to the opposite side, is six inches, or six and a
quarter. The diameter of the anterior margin, or edge of the
thyroid hole, at the same level, is four and three-quarters.
Tne plane, therefore, at the lower part, is two inches nearer
the opposite side before than it is behind, or at its posterior
margin. From the top of the arch of the pubis, or orifice of
the urethra, to the second bone of the sacrum, is from four
inches and five-eighths, to five inches and three-eighths,
according to the curvature of that bone. A line drawn from
the top of the arch to the top of the sacrum, is about a Quar-
ter of an inch more than the antero-posterior diameter of the
brim. From the top of the arch to the spine of the ischium,
is three inches and a half. From the tuberosity of the ischium
to the centre of the sacrum, is four inches. From the back
part of the tuberosity to the sacro-iliac junction on the same
side, is three inches and a half. From the extremity of the
tuberosity to the spine of the ischium, is two inches. From
the spine to the sacrum is two inches, and from the top of the
arch of the pubis to the plane of the ischium, is two inches.
The breadth of the plane itself is two inches, so that a line
traversing these different parts, from the symphysis to the
sacrum, would measure, including its slight irr^puarititp, six
inches. From the tuberosity to the inferior part of the thyroid
hole, is an inch and a half. The long diameter of the sacrc^
sciatic notch, is two inches and three-eighths ; the short, pne
inch and three-quarters. The cavitv froifi the brim to the
root of the spinous process of the ischium, although not quite
circular, is much more nearly so than at first would appear.
But when we come down to the point of the spine, the lateral
diameter is contracted, and still more in relation to the passage
of the head, which can project from under the arch.

In the living subject, we can readilv recognise these different
parts of the pelvis ; and by the relation which one bears to the

rest, we can aacertain, by careful examination with the finger^
not only the relative position of the head with regard to any
one spot, and consequently its precise situation and progress
in the pelvis, but also the shape and dimensions of the pelyia
itself.

SECTION THIRD.

The shape, extent, and dimensions of the great pelvis, or
tfiat part which is above the brim, must be mentioned like-
wise, especially as these are of importance in estimating the
deformity of a pelvis. From the symphysis pubis to the
commencement of the iliac wing, at the inferior spinous
process, is nearly four inches. From the inferior spinous
process to the posterior ridge of the ilium, a line subtending
the hollow of the costa, measures five inches. The distance
from the superior spine is the same. From the top of the
crest of the ilium to the brim of the pelvis, a direct line^
measures three inches and a half. The distance betwixt the
two superior anterior spinous processes of the ilium, is fiilly
ten inches. A line drawn from the top of the crest of the
ilium to the oppo»te side, measures rather more than eleven
inches, and touches, in its course, the intervertebral substance
betwixt the fourth and fifth lumbar vertebrae. A line drawn
from the centre of the third lumbar vertebra, counting from
the sacrum to the upper spine of the ilium, measures six
inches and three-quarters. A line drawn from the same
vertebra to the top of the symphysis, measures seven inches
and three-quarters, and when the subject is erect, this line is
exactly perpendicular.

To conclude my observations on the dimensions of the
pelvis, I remark, that the shape is different in the child and
the adult. The dimensions of the brim are reversed in these
two states ; the long diameter of the foetal pelvis, extending
fix)m the pubis to the sacrum. By slow degrees, thie shape
changes. These changes, however, must be effected by the
general growth of the body, and the term of puberty. At
nine years, the conjugate ^meter is two inches and seven-
eightns, the lateral an eighth less ; at ten years of age, the
antero-posterior <Uameter is three inches and a quarter, the
lateral is an eighth more ; at thirteen, the former is still the
same, but the latter has increased to three inches and three
quarters ; at fourteen, the former is three and three quarters,
the latter four inches. Just before puberty, pefhaps so late
as eighteen, the antero-posterior diameter is three inches

and seven-eighths, the lateral four and a half. These mear
surements I give, however, from individual pelvises. If a girl
should very early become a mother, the shape of the pelvis-
may occasion a painful and tedious labour.

SECTION FOURTH.

Finally, we are to remember, that the brim, and the outlet
of the pelvis, are not parallel to each other, but placed at a
considerable angle. The axis of the brim will be represented
by a line drawn from near the umbilicus, downwards and
backwards to the coccyx ; that of the outlet, by a line drawn
from the orifice of the vagina to the first bone of the sacrum.
The precise points, however, which these lines will touch,
must vary a little, according to the conformation and obliquily
of the pelvis, and the prominence of the abdomen* Eacti
different part of the cavity of the pelvis has its own proper
axis, and the line of motion of the child's head must always
correspond to the axis of that part of the pelvis in which it is
placed! A pretty good idea of this subject, with regard to
labour, may be obtained, by placing a xnale catheter, of the
usual curvatiu*e, in the axis of the brim, and making its ex-
tremity pass out at the axis of the outlet.

CHAP V.

Of the Head of the Childf and its progress through the Pelvis

in Labour.

SECTION FIRST.

The head of the child is made up of many different bones,
and those of the cranium are very loosely connected together
by membrane. The frontal, temporal, parietal, and occipital
bones, compose the bulging part of the cranium, and their
particular soape regulates the direction of the sutures. The
occipital bone is connected to the jMirietal bones, bv the
lambdoidal suture, which is readily discovered through the
integuments, by its angular direction. The parietal bones
are joined to the frontal bone, by the coronal suture, which
is distinguished bv its running directiy across the head ; and
they are connected to each other bv the sagittal suture, which
runs in a direct line from the occipital to the frontal bone :

as the o6 firontiB, in the foBtus, consistB of two pieces, it can
sQfmetimes be easily traced with the finger, eren to the nose.
Let the sagittal suture be diyided into three equal parts.
From the middle one, which I call the central portion, a line
or hand may be drawn to the lateral part of the lower jaw,
and which will traverse the parietal protuberance and the
external ear. As this, in labour, is parallel to the axis of the
brim of the pelvis, until the head makes its turn, I call it the
hne ofaads. The upper and anterior angles of the parietal
bones, and the corresponding comers of the two pieces of the
firontud bone, are rounded off, so as to leave a quadrangular
vacancy, wfaidi is fiUed up with tough membrane* This is
called the great, or anterior fontanel, to distinguish it from
another smaller vacancy at the posterior extremity of the
sa^ttal suture, which is called the small fontanel. The first
is known by its four comers, and by its extending forward a
little betwixt the frontal bones ; and whenever it is felt, in an
examination, we may expect a tedious labour ; for the head
does not lie in the most lavourable position. The little fon-
tanel cannot, during labour, be perfectly traced, as it is lost
in the angular lines of the lambdoidal suture, which, however,
ought to be readily discovered. The head is of an oblong
shape, and its anterior extremity at the temples is narrower
than the posterior, which bulges out at the sides, by a rising
of the parietal bones, called the parietal protuberances : from
these the bones slope backwards like an obtuse angle, to the
upper part of the occiput, which is a little flattened, and is
called the vertex. The general shape of the back part is
hemispherical. From these protuberances, the head also
slopes downwards and forwards to the zygomatic process of
the temporal bone, becoming, at the same time, gradually
narrower.

SECTION SECOND.

The longest diameter of the head is from the vertex to the
chin, and this is near five inches. From the root of the nose
to the vertex, and from the chin to the central portion of the
sagittal suture, measures four inches. From the one parietal
protuberance to the other, a transverse line measures from
three inches and a quarter, to three inches and a half. From
the nape of the neck to the crown of the head, is three inches
and a naif. From the one temple to the other, is two inches
and a half. From the occiput to the chin, along the base of
cranium, is four inches and a half. From one mastoid process

to the other, along the base, is about two inches ; from cheek
to cheek is three inches, or from that to three and a half, or
in large children even four inches. The most unyielding, if
not also the longest part, is the base of the cranium, takenm>m
the root of one zygomatic process, to that of the other. This
is often nearly four inches. Although these may be the
average dimensions of the head, yet owing to the nature of
the sutures, they may be diminished, and the shape of the
head altered. The one bone may be pushed a little way
under the other, and, by pressure, the length of the head may
be considerably increased, while its breadth is diminished;
but these two alterations by no means correspond, in a regu-
lar degree to each other.

The size of the male head is generally greater than that of
the female. Dr. Joseph Clarke,* an excellent practitioner,
upon whose accuracy I am disposed fully to rely, says that it
is a twenty-eighth or thirtieth part larger. It is a well
established fact, that owing to the greater size of male chil-
dren, women who have the pelvis in any measure contracted,
have often a more tedious labour, when they bear sons than
daughters ;t and many who have the pelvis well formed, sufiPer
from the effects on the soft parts. Dr. Clarke supposes,
that one half more males than females are bom dead, owing
to tedious labour, or increased pressure on the brain; and
owing to these causes, a greater number of males than females
die, soon after birth. In twin cases, again, as the children
are smaller, he calculates, that only one-fifth more males than
females are stillborn. Dr. Bland X says, that out of eighty-
four stillborn children, forty-nine were males, and thirty-five,
females.

SECTION THIRD.

By comparing the size of the head with the capacity of
the pelvis, it is evident that the one can easily pass through
the other. But I apprehend that the comparison is not
always correctly made, for the child does not pass with the
long diameter of its cranium parallel to a line mrawn in the
direction of the long diameter of the brim of the pelvis ; but
it descends obliquely, so that less room is requured. The
central portion of the sagittal suture passes first, the chin

• Fhil. Traiw. Vol. IzzyI.

t The ennium of the famale if more roanded or prolwtiiif ftt the dda^ and
behind, than that of the male, which ia flatter there.
t Phil. Traoi. Vol. Ixsi.

being pLaeed on the breast of the child. Now, the length of
a Une drawn firom the nape of the neck, to the crown of the
head, is three inches and a half; a Ihie intersecting this,
drawn from the one parietal protuberance to the other, mea-
sures no more. We hare, therefore, when the mere cranial
part of the head descends, in natural labour, a circular body
going through the brim, whose diameter is not above three
inches and a half; ^d thus, no obstacle or difficulty can, at
this stage, arise from the size of the pelvis. There is so much
qMce superabounding betwixt the pubis and sacrum, as to
prevent all risk of injury from pressure on the bladder,
urethra, or rectum ; and as the long diameter of the head is
descending obliquely, the sides of the brim of the pelvis are
not pressed on. Tnis is so certainly the case, that the head
may, and actually often does, enter so far, without any great
additional pain or difficulty, although ike capacity of the
pelvisbealS^contracted. 'xheLJlestand xnL ^yielding
part of the head, we have seen to be near the base, across
from the zygomatic processes, and here it stops, if there be
any resistance from a contracted pelvis. The upper part of
the ear, is below the level of the brim, but the resisting bones
are above. In natural labour, when the shoulders, which
measure five inches across, come to pass, then the brim is
completely occupied. If, however, any contraction should
take place in the lateral diameter, the child would still pass,
the one shoulder descending obliquely before the other.

It is of great consequence to understand the passage of the
child's head in natural labour; for upon this depends our
knowledge of the treatment of difficult labour. The head
naturally is placed with the vertex directed to one side, or a
little towards the acetabulum, and the forehead, owing chiefly
to the action of the promontory of the sacrum, is turned in
the same degree, towards the opposite sacro-iliac junction.
When labour begins, and the head comes to descend, the
chin is laid on the throat or upper part of the sternum, and
the central portion of the sagittal suture, or sometimes th^
parietal protuberance is directed downwards, nearly in the
axis of the brim of the pelvis. When, by the contraction of
the uterus, the head is forced a little lower, its apex comes to
touch the plane of the ischium. Upon this the posterior
sloping part of the parietal bone slides downwards and
forwards, as on an inclined plane, the head being turned
gradually, so that, in a little time, the face is thrown into the
hollow of the sacrum, and either the vertex or parietal bone near

it present at the orifice of the vagina. The natural direction
of such a body as the head of the child, in going down the
inclined plane, would be forward upon the foramen thyroids
eum, and then forward and downward by the inside of the
ramus of the ischium. At the same time the other end of
the ellipsis formed by the head would be acted on by that
substance, which fills the sacro-sciatic space. The direction
of this is obliquely backward toward the side, and then toward
the hollow of the sacrum. The side of the forehead would
thus be directed as on a plane, downward and backward
toward the third bone of the sacrum. It then meets the
ligament at the back part and slopes down, and more com*
pletely back on it, so that the front of the forehead is thrown
quite back and rests on the coccyx. The vertex at the same
time is guided quite forward by the oblique position of the
ramus of the ischium, but it does not always present exactly
at the arch of the pubis, for the parietal protuberance may
take the lead. In the end, the surface of the distended
coccyx and soft parts connected with it and the perineum,
have the head resting on them as an inclined plane, and
direct it forward as in the birth.

The complete turn of the head is not accomplished till it
have got entirelv into the cavity of the pelvis. The shape of
the head and its difference in obliouity, in different pre-
sentations, will explain why, in this the natural position, the
head both turns more readily, and descends faster than in
malposition.

As the basin is shallow at the pubis, and the head enters
obliquely, it is felt near the orifice of the vagina, and even
touching the labia and perineum, before the turn be completed,
and when the ear is still at the pubis. The whole of the
cavity of the pelvis is so constructed, as to contribute to this
turn, which is further assisted by the curve of the vagina, and
the action of the lower part of the uterus, on the head of the
child. The head, whilst its long diameter lies transversely,
continues to descend in the axis of the brim of the pelvis ;
but when it is turned, it passes in the axis of the outlet.
When the turn is making, the direction of the motion is in
some intermediate point ; and this fact should, in operating
with instruments, be studied and remembered. When the

Eelvis is narrow above, and the sacmm projects forward, the
emispherical part of the head is lonff of reaching the incUned
plane of the ischium ; and when the head is lengthened out,
so as to come in contact with it, wc find, that although the

projection of the Bacnun directs the vertex sometimes prema-
turely a litde forward, yet, the tendency to turn fully, is re-
sisted by the situation of the bones above ; a great part of the
craninm, and all the face, being above the brim, and perhaps
in part loeked in the pelvis. By a continuation of the force,
the shape of the head may be altered : even the vertex may
he tamed a little to one side, its apex not corresponding
exactly to the extremity of the long diameter of the head ;
the integuments may be tumefied, and a bloody serum be
effused between them, so as greatly to disfigure the presenta-
tion. As, therefore, in tedious labour, occasioned by a de-
formed pelvis, the skull may be much lengthened and misshapen,
we are not to judge of the situation of the head, by the posi-
tion of the apex of the tumour which it forms ; but we must
fed for the ear, which bears a steady relation to that part of
the head which presents the obstacle.— The back and upper
part of the head are compressible, but the base of the skull
and the &ce are firm. A line drawn from the neck to the
forehead, passing over the ear is to be considered as the
boundary betwixt these parts of opposite character; and
therefore we attend to the relative situation of the ear, as it
ascertains both the position of the head, and its advancement
throogh the brim.

CHAP. VI.
OfDiminuhed Capacity , and DeformUy of the Pelvis.

SECTION FIRST.

Thy pelvis may have its capacity reduced below the natural
standard, in d^erent ways. It may be altogether upon a
small scale, owing to the expansion stoppmg prematurely, the
different bones, however, being well rorm^ and correct in
their relative proportions and distances. This may occasion
punful labour, but rarely causes such difficulty as to require
the use of instruments. Sometimes the bones are all of their
proper size, but the sacrum is perfectly strsdght, by which,
although both the brim and oudet are sufficiently large, vet
the cavity of the pelvis is lessened; or when all the other
parts are natural, tne spines of the ischium may be exuberant,
encroaching on the lower part of the pelvis.

Another cause of diminished capacity, is the disease called
rickets, in which the hones in infancy are defective in their
strength, the proportion of earthy matter entering into their
composition being too small. In this disease, the long bones
bend, and their extremities swell out; the pelvis becomes
deformed, the back part approaching nearer to the front, and
the relative distance of the parts bemg lost. The distortion
may exist in various degrees. Sometimes the promontory of
the sacrum only projects forward a very little more than
usual, or is directed more to one side than the other ;* and
the curvature of the bone may be either increased or dimin-
ished. K the sacrum project only a little, without any other
change, the capacity ol the brim alone is diminished ; but if
the curvature be at the same time smaller than usual, the
cavity of the pelvis is lessened; but unless the ischia approach
nearer together, or the lower part of the sacrum be bent for-
ward, the outlet is unaffected ; and in most cases of moderate
deformity, the outlet is not materially changed. In greater
degrees of the disease, the anterior part of the brim becomes
more flattened, the linea ilio-pectinea forming a small segment
of a pretty large circle. The sacrum forms part of a concen-
tric circle behmd ; and thus the brim of the pelvis, instead of
being somewhat oval, is rendered semicircular or crescentic,
and its short diameter is sometimes reduced under two inches.
The promontory of the sacrum may either correspond to the
symp&yris pubU, or may be directol tot one sid^ rendering

* It la not necenary to giro examples of eTery degree of deformity ; but It may
be useful to lelect some specimens of the different kinds. The slighter degi

do not rM^uIra to be particularized. * I shall first of all give the dimensions of a
dried pelvis, so contracted, as to prevent a child at the full time from passing
without assisUnce. From the pubis to the sacrum, it measures three inches ;
from the acetabulum to the sacrum on the right side, two and a half inches ; on
the left, two inches and seven-eights; from the brim above the foramen thyrol*
deum, to the opposite sacro-iliac Junction, five inches; from the same part of the
brim on one side, to the same on the opposite, three inches and a half; transverse
diameter, fuur Inches and seven-eighths ; from the arch of the pubis to the hollow
of the sacrum, five inches ; from one tuberosity of the ischium to the other, four
inches and a half; from one spine to another, four inches and a half; the arch of
the pubis is natural. The distance from the face of the third lumbar Tertebn to
the spine of the ilium on both sides, is six inches. These dimensions may bo
compared with those of the well-formed pelvis. The symphvsis pubis has the
eartilnge in the inside, prcijecting like a spine, which added to the smallness of the
pelvis when recent. The linea ilio>pectinea also, on the left side, Is for the length
of two inches as sharp as a knife ; and from these two causes, the cervix uteri and
bladder were torn In labour.

f In a pelvis of this kind, which I shall describe, the rertebne and sacrum lean
much to the left side. The line from the promontory of the sacrum to the part
of the pubis opposite, is barely an Inch and a half; but an oblique line drawn to
the symphysis, which is to the right of the promontory, is near two inches. From
the promontory to the side of the brim at the Ilium, on the left side, Is two inches
and three-tenths; on the right sids» throe Inches and foar-tenths. On the left

the shape of Uie brim more irregular, and the dimensions
smaller on one side than the other. In some instances, the
shape of the brim is like an equilateral triangle; and although
the diameter firom the pubis to the sacrum be not diminished,
jet the acetabula being nearer the sacrum, the passage of the
head is obstructed.

SECTION SECOND.

The pelvis is likewise, especially in manufacturing towns,
sometimes distorted by malacosteon, or softening of the bones
of the adult. This is a disease which sometimes begins soon
after delivery, and very frequently during pregnancy. It is,
indeed, comparatively rare in those who do not bear children,
and it is always increased in its progress by gestation. It
must be carefully attended to, for, to a negligent practitioner,
it has at first very much the appearance of chronic rheuma-
tism. It generally begins with pains about the back, and
region of the pelvis. These ptdns are almost constant, or
have little remission. They a^e attended with increasing
lameness, loss of flesh, weakness, and fever ; but the distin-
guishing mark is diminution of stature, the person gradually
becoming decrepit. In the well known case of Mad. Supio^
where the disease began after a fall, the patient at last was
only twenty-three inches high. Her skeleton is still preserved
in the museum of L'^cole de Medicine. In malacosteon, the
pelvis suffers, but the distortion is generally different from that
produced by rickets ; for whilst the top of the sacrum some-
times sinks lower in the pelvis, and always is pressed forward,*
the acetabula are pushed backwards and inwards, towards the
sacrum and towards each other ;t so that, were it compatible

dde, from the Uteral part of the eacram to the acetabulom, ia nine-tentha of an
inch ; on the right aide, fully two incbea. Now, in thia pelvis, when the soft
porta are added, we ahall find an ovaJ body may paaa on the right side, whoae
Jonci~

long diameter ia three inchea and a half, and whose short diameter la barely two
inchea.

In a pelvia with a aemicircniar brim, whoae short diameter, as the middle and
each side, ia one inch and a half, an oTal could naaa, when the soft parts aro
added, whose long diameter is about two inchea ana a quarter ; and the short one
about an inch and a quarter.

* In a weU-formed peWis, a line drawn transversely along the brim, and in
contact with the sacrum, either touches at its two extremities, the sacro-iliae
jonciioos, or the linea ilio^pectinea, about half an inch before them ; but in a very
deformed pelvia, such a line will touch the brim, at. or even before the acetabula.
In a well. formed pelvis, a line drawn from the middle of the linea ilio-pectinea
on one side, to the same spot on the opposite side, is about an inch, or an inch
and a half distant from the sacrum. But in a deformed pelvia, thia line would
either pass through the sacrum, or altogether behind it.

f The following are the dimensions of a pelvis of this kind, which I select as a
Bpedmeo. From the spinous process of the ilium on one side to the other, is
eight inches and three- fourths. From the lumbar vertebne to the spinous pro-

with life, for the disease to last so long, these parts would
meet in a common point, and close up the pelvis, or at least
convert its cavity mto three slits. The ossa pubis form a
very acute angle ; so that the brim of the pelvis, instead of
being a little irregular as in slight cases of rickets, or semi-
circular as in the greatest degree of that disease, consists,
when malacosteon has continued long, of two oblong spaces
on each side of the sacrum, terminating before, in a narrow
slit, formed betwixt the ossa pubis.* in this narrow space,
«when the woman is advanced in her pregnancy, the urethra
lies with its orifice sometimes drawn up and directed back-
ward, and the bladder resting upon the pendulous beUy : so
that, if it be necessary to pass the catheter, we must sometimes
use one made of elastic materials, or a male catheter, directing
the concavity of the instrument towards the pubis. If the
instrument be large, and the ossa pubis very near each other,
it may be jammed betwixt them, if it be mcautiously intro-
duced. In this disease, as well as in rickets, it is to be
remembered, that the promontory of the sacrum may over-

of tbe iliam on the right side, six inches ; on the left side, one inch and
seven-eighths. From tbe spinous process of the ilium back to its ridge, two inches
and a half. From tbe symphysis pubis to tbe sacrum, one incn and three-
fourths. From tbe right acetabulum to tbe sacrum, six-tenths of an inch ; from
tbe left, seven-eighths of an inch. From tbe brim alwve tbe foramen tbyroideum
to tbe same point on tbe opposite side, seven-eighths of an loch. From tbe same
part of the brim to tbe opposite sacro-iliac junction, three incfaea and a half on
both sides. From tbe tuberosity of one isdiium to that of the other, two Inches
and a half. From tbe tuberosity to tbe coccyx, three inches. From tbe spine
of one ischium to that of tbe other, three incheo and a h^f. From tbe lower
part of the symphysis pubis to tbe boUow of tbe sacrum, four indies ; distance of
tbe rami of tbe pubis, five-eighths of an inch.

This pelvis has a triangular brim ; for it wlU be observed, that tbe brim abova
tbe foramen tbyroideum measures nearly an inch across, and therefore there is a
considerable space betwixt tbe two ossa pubis, gradually, however, becoming
narrower toward tbe junction of tbe bones ; but little advantage in delivery can
be gained from this. IVhen we examine It with a view to determine what
bulk mav be brought through tbe brim, we find that It is by its shape vlrtoally
divided Into two cavities, one on tbe right, and tbe other on tbe left side, and
tbe short diameter of tbe one is six-tenths of an Inch, and that of the other
•even-eighths of an inch ; therefore no art can bring a chUd at the fuU time
tbrouffb it.

In Uiis pelvis, tbe sacrum has fallen so forward at tbe top, that in a standing
posture tbe face of that bone is almost horizontal, and Its under part with tbe
cocevx is bent forward like a book. Tbe vrrtebrs are much distorted. In a
pelvis preserved In one of the museums in Paris, tbe sacrum almost resta on the
acetabular portion.

* This is the case In a pelvis where tbe distance from tbe part of tbe brim
above tbe foramen tbyroideum on one side, across to tbe same part on tbe opposite
aide. Is only five-eighths of an inch. From tbe right acetabulum to the sacrum is
an inch and tbree-elghths. From tbe left is one inch. This pelvis at the brim Is
externally triangular, but it is, from tbe near approximation of the bones,
virtually semicircular, tbe space betwixt tbe two ossa pubis being so trifling as
not to merit consideration ; and the diameter of tbe brim here is one inch, exclu-
sive of the small slit betwixt tbe bones, Tbe sacrum in this pelvb is very much
curved, and tbe outlet smaU.

bang the contracted brim, so as more effectually to prevent
the head from entering it.

Rickets being a disease, which is at its greatest height in
infancy, we have not at present to consider the treatment.
Malacosteon is, on the contrary, a disease of the adult ; and
generally affecting women about middle age. It is a consti-
tutional disease allied to the nature of osteo-sarcoma, and,
like it, attended with considerable pain in all the affected
parts. Like it also, it is incurable in the present state of
medical science. As there is a very great deficiency of earth
in the bones, it has been proposed to give the patient phos-
phate of lime, but little advantage has been derived from it ;
and, indeed, unless we can change the action of the vessels, it
can do no good to prescribe any of the component parts of
bone. We have, in the present state of our knowledge, no
means of rendering the action more perfect, otherwise than
by endeavouring to improve the general health and vigour of
the system, by the use of tonics, the cold bath, and attending
to the state of the bowels. Anodyne frictions, and small
blisters, sometimes relieve the pain.* As gestation uniformly
increases the disease, a separation from the husband should
take place.

SECTION THIRD.

The pelvis mav be well formed externally, and yet its
capacity may be duninished within, by exostosis from some of
the bones ;t or it may be affected in consequence of a fracture
of the acetabulum, from which I have seen extensive and
pointed ossifications stretch for nearly two inches into the
pelvis ; or steatomatous or scirrhous tumours may form in the
pelvis, being attached to the bones or ligaments, of which I
have known examples.} An enlarged ovarium, § or vaginal

• Up«n the ralgeet of deformity of the pelria, and for tables of many particular
instaoera of disUntioo* I have great pleasure in referring the reader to the worka
of Dr. HoU, a practationcr of sound Judgment, and extensive knowledge.

f A case of this, by Dr. Leydig, requiring the Cesarean operatioUf and refereneea
to other eaan of exostoais from the aacrum, lumbar Tertebrwi or pubis, may be
Immd In the Edinburgh Journal, VoL zzzy. p. 449.

t Dr. Denman mentioDa a fatal case of this Icind, to which Dr. Hunter wai
caUed. The child wm delivered by the crotchet, but the patient died on the
fourth day. A firm fatty excrescence, springing from one side of the sacrumi
waa found to have occasioned the difficulty, vide Introd. VoL ii. p. 72.—
Bandelocque in the 5th Vol. of Recueil Feriodique, relates a case, where, in con*
fsquence of a scirrlioua tumour Adhering to the pelvis, the crotchet was necessary.
In a subsequent labour, the Caesarean operation was performed, and proved fatal
to tho mother. Dr. Drew records an instance where the tumour adhered to the
aaero-aoiatic ligament, and was successfully extirnated during labour. It waa 14
inches In cirenmfereDce. Vide £din. Journal, VoL L p. 2a

S A Ihtal cMo of this kind oceomd to Dr. Ford, and is noticed by Dr. Denman,

hernia,* may also obstruct delivery, even so much as to
require the crotchet ; and therefore, although they be not
indeed instances of deformed pelvis, yet as they diminish the
capacity of the cavity, as certainly as any of the former causes
which 1 have mentioned, it is proper to notice them at this
time. Vesical hernia, or prolapsus of the bladder, may impede
labour. Enlarged glands in the course of the vagina, polypous
excrescences about the os uteri or vagina, scirrhous of the
rectum, and firm encysted tumours in the pelvis, may likewise
afford an obstacle to the passage of the child. Some tumours,
however, graduallv become diffused by pressure, but re-appear
after the child is bom ; others burst, and have their contents
efiused into the cellular substance. A large stone in the
bladder may also be so situated during labour, as to diminish
very much the cavity of the pelvis ; and it may be even neces-
sary to extract the stone before the child be delivered, if it
have not been pushed above the brim in proper time.

Tumours in the pelvis are produced either by enlargement
of some of its contents, as for mstance the ovarium or glands ;
or, by new formed substances. The ovarian kind are often
moveable ; the others generally fixed, and they may consist of
fatty or fibrous substance, or fluid contained in a cyst.f Some
of these have only cellular attachments, and are removed
easily by making an incision through the vagina, and turning
out the tumour, or evacuating its contents.t Other tumours
are cartilaginous, and instead of being connected only by

Vol. ii. p. 75.— Another fftCal iDtUnce !■ recorded by M. fiaudeloeqae, L*ArCf
■ection 1964. See also a case by Dr. Merriinaii« Med. and Cbir. Trans, ill. 47.
This ovarium contained a flaid, and probably might hare been opened during
labour with advantage. Of the propoeal to extirpate the ovarium, I shall here*
after speak.

* Several cases of this kind have been met with, and In one related by M.
Brand, and noticed by Dr. Sandifort in his Obs. Anat. Path., the woman died
undelivered.

f A rtij important case of this kind is related by Mr. Jackson, in the Med.
Rep. for Marcn 16S6. The tumour, which was very large, was situated behind
the rectum, and filled the sacrum so completely, as only to permit of bringing
down the chUd by the feet with great difficulty. The finger Inserted into the
rectum, after delivery, ascertained the existence of fluctuation between the rectum
and coccyx : a puncture was made, and six pints of straw« coloured fluid evacuated,
and the patient recovered completely, but not without great suffering from pain of
the head, tenderness of die vertebne, numbness of the lower extremities, quick
pulse, &C. From these symptoms the collection seems to have been connected
with the sacral portion of the spinal cord, or at least with the nerves given oiF by
It, and those situated behind the rectum.

I M. Peletan details several cases of tumours within the pelvis, seme of than
fatty or fibrous, and easily turned out, merely by making an Incldon over them,
through the vagina ; one encysted containing purlform matter : and one about an
inch long, of a cartilaginous nature, adhering to the descendinjr branch of the
pubis, the vagina being divided, it was cut on with scissors. C^lnl4|ue Chfarur.
glcale, Tom. I. 803, S06, 384, S8S, 260. Mr. Park likewise relates several

cellular matter, are attached to the pelvis firmly, or grow from
it. They adhere either by a pedicle, or by an extensive base.
In the first case the tumour is more moveable than in the
second, where the fixture is firmer. These can only be extir-
pated by cutting deeply into the cavity of the pelvis, and the
incision requires to be made through tne perineum and levator
ani, like the incision in the operation of lithotomy in the male
subject. We are much indebted to Dr. Drew for the first
case of an operation of this kind ; and as the tumour adhered
by a neck, it was easily cut ofi^, and the success was complete.
In a dreadful case which I met with some years ago, the
attachments were extensive, and the tumour so large as to fill
the pelvis, and permit only one finger to be passed between
it at the right side of the basin. It adhered from the
symphysis pubis round to the sacrum, being attached to the
urethra, obturator muscle, and rectum ; intimately adhering to
the brim of the pelvis, and even overlapping it a little towards
the left acetabulum. It was hard, somewhat irregular, and
scarcely moveable. The patient, Mrs. Broadfoot, was in the
ninth month of pregnancy. There was no choice, except
between the Caesarean operation, and the extirpation of the
tumour. The latter was agreed on ; and with the assistance
of Messrs. Cowper and Russel, I performed it on the 1 6th of
March, a few hours after slight labour pains had come on.
An incision was made on the left side of the orifice of the
vagina, perineum, and anus, through the skin, cellular
substance, and transversalis perinei. The levator ani being
freely exposed, the tumour was then touched easily with the
finger. A catheter was introduced into the urethra, and the
tumour separated from its attachments to that part. It was
next separated from the uterus, vagina, and rectum, partly
by the scalpel, partly by the finger. I could then grasp it as
a child's head, but it was quite fixed to the pelvis. An
incision was made into it with a knife, as near the pelvis as
possible; but from the difficulty of acting safely with that
instrument, the scissors, guided with the finger, were employed
when I came near the back part ; and instead of going qiute
through, I stopped when near the posterior surface, lest I
should wound the rectum, or a large vessel, and completed
the operation with a spatula. The tumour was then removed,

chieflj of tarnonn, containiDg liquid or soi^ eontents, and which were pierced
inm the rrngtim daring labour. Med. Chir. lYaoa. iL 293. See also a yaluable
paper on the sasM Mibjeet by Dr. Merriman, in the 10th VoL of that work, p. fi7,
and in his Sjmopaia, p. 57, and remarka by Dr. Datis in his Elements, p. 106.
Abo a am if Boyer, Traits, Tom. x. p. SM.

and its base, or attachment to the bones, dissected off as
closely as possible. Little blood was lost. The pains imme-
diately became strong, and before she was laid down in bed
they were very pressing. In four hours she was delivered of
a still-bom child, above the average size. Peritoneal inflam-
mation, with considerable constitutional irritation, succeeded ;
but by the prompt and active use of the lancet and purgatives,
the danger was soon over, and the recovery went on well.
In the month of May the wound was healed. On examining
per vaginam, the vagina was felt adhering as it ought to do,
to the pelvis, rectum, &c. The side of the pelvis was smooth ;
and a person ignorant of the previous history of the case, or
who did not see the external cicatrix, could not have discovered
that any operation had been performed. After a lapse of
more than fifteen years, she stiU continues weU, but has never
been again pregnant.

The practical remarks which I would offer on this subject,
are,

1st. That whenever the tumour is moveable, it ought to
be pushed above the brim of the pelvis in the commencement
of labour, and prevented from again descending before the
child's head.

2d. That on a principle to be hereafter more fully incul-
cated, we ought never to permit the labour to be long pro-
tracted, but should early resort to means for relief. By a
contrary conduct the child indeed may be ultimately expelled
by nature, or be brought away by art, but the mother is in
great danger of perishing, either firom subsequent inflamma^
tion, or exhaustion, or hemorrhage.

3d. As it is impossible to decide with certainty on the
nature or contents of many of these tumours, we ought, in aU
cases where we cannot push them up, to try the effect of

Suncturing from the vagina with a trocar. If the contents be
uid, we evacuate them more or less completely ; if solid, we
find that the canula, on being withdrawn, is 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.

4th. When the size of the tumour cannot be sufficiently,
or considerably diminished by tapping, I am inclined, firom
the unfavourable result of cases where the perforator has been
used, and from the severe and lon^ continued efforts which
have been required to accomplish delivery, to recommend,
when practicable, the extirpation of the tumour, rather than
the use of the crotchet ; and this may be accomplished best

and moat safelv by the mode adopted in the case of Mrs.
Broadfoot. There mavy however, be situations where the
incision ought to be mode in the vagina : but these are rare.
But extirpation cannot in any mode be proposed, if firm cohe-
sions have been contracted between the tumour and vagina or
rectum.

5th. K the extensive connexions, extent, or nature of the
tumour, or danger from hemorrhage, prohibit extirpation, or
the patient will not submit to it, and if it have been early
ascertained 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.

6th. Much and justly as the Csesarean operation is dreaded,
it may with great propriety be made a question, whether in
extreme cases, that, would not be less painfiil, and less
hazardous to the motiier, than those truly appalling sufferings
which are sometimes ii^cted 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 time, against the bones of
a contracted pelvis, and that in point of fact, recovery has
taken place, although the strength of two able practitioners
was exerted during several hours so as to be exhausted ; but
such an instance cannot establish the general safety of the
practice.

7th. It is scarcely necessary for me to add, that there may
be inferior degrees of encroachment, which admit of the sa^
and successful application of the forceps ; and of this matter
we judge by the size of the tumour, and capacity of the pelvis.
It will hereafter be explained that a very small degree of ob-
struction may retard delivery, rather by influencing the action
of the uterus, than by the mechanical resistance opposed.

SECTION FOURTH.

In order to ascertain the degree of deformity, and the
capacity of the pelvis, different instruments have been invented.
Some of these are intended to be introduced within the pelvis,
and others to be applied on the outside, deducting in the
latter case, three inches for the thickness of the pubis, sacrum,
and soft parts. If an instrument, or line, be carried from the
arch of the pubis, to the top of the sacrum, about half an

inch is to be deducted from the measured distance on account
of the obliquity of the line. But this method is so uncertain,
that I do not know any person who makes use of it in prac-
tice. The hand is the best pelvimeter, and must in all cases,
where an accurate knowledge is necessary, be completely
introduced within the vagina. By moving it about, and
observing the number of fingers which can be passed into
different parts of the brim, or the distance to which two fingers
require to be separated in order to touch the opposite points
of the brim, or the space over which one finger must move in
order to pass from one part to another, we may obtain a suflB-
cient knowledge, not only of the shape of the brim, cavity,
and outlet of the pelvis, but also of the demree to which the
soft parts within are swelled, as well as oi the position and
extent of any tumour which may be formed in the pelvis.
We may be further assisted by observing, that in great degrees
of deformity or contraction, the head does not enter the brim
at all ; in smaller degrees it engages slowly, and the bones of
the cranium, form an angle more or less acute, according to
the dimensions of the brim, into which it is squeezed. An
examination, by the introduction of the finger into the vagina,
even in labour, is quite useless, for we can, in this way, obtain
no information. So far from touching the promontory of the
sacrum, we can reach only a little way along that bone, or
above the coccyx. Even if the finger be laid from the point
of the coccyx, in the dried pelvis, it will only touch the third
bone of the sacrum. In front, if we push the finger high, we
can, if the bladder be empty, and the parts lax, feel the upper
margin of the pubis.

As in many cases of deformed and contracted pelvis, it is
necessary to break down the head in order to get it through
the cavity, it will be proper to subjoin the dimensions of the
foetal head when it is reduced to its smallest size. When the
frontal, parietal, and squamous bones are removed, which is
all that we can expect to be done in a case requiring the
crotchet, we find that the width of the base of the cranium,
over the sphenoid bone, is two inches and a half. The dis-
tance from cheek to cheek is three inches. From the chin to
the root of the nose is an inch and a half; and by separating
the symphysis of the jaw, the two sides of the maxilla may
recede, so as to make the distance even less. From the chin
to the nape of the neck, when the chin is placed on the breast,
IS two inches and three-quarters. When, on the contrary,
the chin is raised up, and the triangular part of the occiput

" - 39

kid back ob the neck, the diataiiee from the throat to the
occiput is two inches. The smallest part of the head, then,
which can be made to present, is the face ; and when this is
brought through the brim, the back part of the head and neck
maj, although they measure two inches, be reduced by pres-
sure so as to follow the face. The short diameter ot the
chest when pressed, is an inch and a half; that of the pelvis
is the same. The diameter of the shoulder is one inch.

CHAP. VII.
OfAu^menied Capacity of the Pelvis,

A TBBY large pelvis,* so far from being an advantage, is
attended with many inconveniences, both during gestation
and parturition. The uterus, in pregnancy, does not ascend
at the usual time out of the pelvis, whicn produces several
uneasy sensations; it is even apt, owing to its increased weight
to be prolapsed; or, if the bladder be distended, it may readdly
be retroverted. At the very end of gestation, the uterus
may descend to the orifice of the vagina ; and, during labour,
forcing pains are apt to come on before the os uteri be pro-
perly dilated, by winch both the child and the uterus may be
propelled, even out of the vagina; and, in many instances,
although this may not happen, yet the pains are severe and
tedious, especially if the practitioner oe not aware of the
nature of the case.

CHAP. vni.

Of the Exiemal Organs of Generation,

SECTION FIRST.

Part of the sjrmphysis pubis, and insertion of the recti
muscles, are covered with a very considerable quantity of

* ThfB UXkmiag an the dimensloM of a Ycry large peWis which I possess. The
eoojttcate di>metqr is four inehcs and three-fourths ; the lateral five inches and
tf Te-cifhths ; the diagonalt five inches and a half. From the symphysis puhls
fta th« sacTO-JUac joDctioo, five Inches. From the top of the arch of the pubis to
the sBcroai, is five inches and tliree*cighths. From one tuberosity of the ischium

cellular substance, which is called the mons veneris. From
this the two external labia pudendi descend, and meet together
about an inch before the anus; the intervening space receiving
the name of perineum. On separating the great labia, we
observe a small projecting body about a finger's breadth above
the pubic ligament. This is the clitoris, and it is surrounded
by a duplicature of skin called its prepuce. From this dupli-
cature, or rather from the point of the clitoris, we find arising
on each side, a small flap, which is continued obliquely down
on the inside of the labia, for about an inch and a quarter.
These receive the name of nymphse, or labia minores or
interna. On separating them, we observe, about nearly an
inch below the clitoris, the extremity of the urethra; and,
just under it, the orifice of the vagina, which is partly closed
up, in the infant state, by a semilunar membrane called the
hymen. These parts are all comprehended under the general
name of vulva, or external organs of generation.

The labia and perineum are covered with a firm subcuta-
neous fascia, proceeding, as formerly noticed, from that of the
gluteus muscle and inside of the thigh. It covers the erector
clitoridis, and, going quite round by the arch of the pubis,
helps to fix the external parts firmer to the bones, and this
fixture, is greatly aided by the internal layer, which proceeds
from within the pelvis. The perineal fascia, is stronger than
that, which covers the labia.

SECTION SECOND.

The labia have nothing peculiar in their structure, for they
are made up of cellular and fattv substance, covered by a
fascia. Their outer surface has the appearance of the com-
mon integuments ; and at the age of puberty, is, together with
the mons veneris, generally covered with hairs. Their inner
surface is covered by the mucous membrane of the vidva.
They are placed closer together below than above ; and at
their junction behind, a small bridle called the fourchette,
extends across, which may be considered also as the anterior
margin of the perineum. It is generally torn when the first
child is bom. There may be only a semilunar margin formed
by the fold of mucous coat.

The nymphffi at first look like duplicatures of the inner

to the other, U fire inches and ft half; ftnd the arch la rtrj wide. 0epth of the
pelvis at the sacrum without the coccyx, fire indies. Brndth of the sacruaa at
the top, four inches and seven eighths. Depth of the pdvis at the sidsa, Ibar
inches. There is a pelvis in the moseiun of &L Bartholomew's, the msasyfftnts
of which are as hu-ge, although the spine is rtrj much distorted.

surfiftce of the labia, but they are, in fact, very different in
their structure. They are distinct yascular substances,
enclosed in a duplicature of the skin, which descends from
the extremity of the clitoris. When injected by filling the
pudic artery, each nympha is found to be made up of innu-
merable serpentine yessels, forming an oblong mass. This
at the upper part joins the clitoris, to which, perhaps, it
serres as an appendage, whilst the loose duplicature of skin
in which it is lodged, by being unfolded, permits the labia to
be more safely and easily distaaded, during the passage of the
child. They generally become narrower as they descend
toward the yagina, and terminate opposite its orifice or that
of the urethra.

SECTION THIRD.

The clitoris is a small body resembling the male penis,
surrounded by a prepuce, but haying no urethra. It consists
of two corpora cayemosa, which arise from the rami of the
ischia and pubes, and unite on the symphysis of the pubes.
These are furnished with two muscles analogous to the erec-
tores penis of the nude. When the crura and nymphse are
filled with wax, we find on each side, two yascular injected
bodies, one of them in close contact with the bones, the other
more internal with regard to the symphysis of the pubes.
Wlien the one is injected, the other is injected also, and both
are connected together at the upper part. The clitoris,
formed by the junction of its crura, projects, apparently, about
the eighth part of an inch, a part of it not being seen, and it
is supported by a pret^ strong suspensory band which arises
from the symphysis, u we pull out the point of the clitoris,
we raise the membrane, so as to form a kind of cylindrical
prolongation to the upper commissure. The cellulo-fibrous
band is contained within it. When distended with blood, it
becomes rounder, and a little more prominent. It is endowed
with great sensibility, and its surface coyered by a multitude
of neryous papills. It is placed on the face of the symphysis
pubis, about three quarters of an inch, aboye the upper margin,
of the orifice of the urethra.

SECTION FOURTH.

On separating the nymphs, we find a smooth channel, or
yestibulum, extending down from the clitoris, for about three
quarters of an inch ; at the termination of this, and just aboye
the yagina, is the orifice of the urethra, which, although not

one of the organs of generation, deserves particnlar attention.
The bladder is lodged in the fore part of the pelvis, imme-
diately behind the symnhysis pubis ; but when distended, it
vises up, and its fundus has been known to extend even to the
umbilicus. It is connectecl to the fore and upper part of the
vagina, for an inch, or an inch and a half, by dense cellular
substance, and a fascia which passes off from the one to the
other. Then, from the implantation of the vagina, just above
the anterior lip of the os uteri, it adheres to the front of the
cervix, sometmies merely to its termination in the lip, but
oftener for about an inch up from the os uteri. There, the
vesical fascia, passes off to the front of the cervix, or body of
the uterus, and at the point of this reflexion the peritoneum
also is reflected. Inflating the bladder, scarcely raises the
peritoneum, higher, from the face of the uterus. In the
collapsed state of the bladder, the peritoneum lines the sym-
physis to its bottom, and is connected to its inner surface, by
lax cellular substance. But when distended, the peritoneum
rises with it, and is carried above the pubis.*

The urethra is from an inch, to an inch and a half long,
and passes along the upper part of the vagina, which is thicker
and more corrugated in its tract, so that we have the decep-
tive feeling, of the urethra being felt through the vagina, like
a thick fleshv cord. It adheres to the fore or upper part of
the vagina till it terminate in the neck of the bladder, which
consists of an elastic fabric, acting, though not apparently
muscular, like a sphincter. The acUierence of the two canals,
is so intimate, that, although we can separate them by dissec-
tion, yet, at first, they seem as if connected by a common
septum. Beyond this, the vagina adheres to the bladder. A
kind of fascia passes off from the vagina, to the urethra and
bladder, connecting them firmly at the sides. The levator
ani embraces the urethra and side of the vagina, and a layer
of fascia also covers this muscular sheet here. The structure
of the urethra is extremely simple, for it consists of a contin-
uation of the internal coat of the bladder, covered with a dense
but dilatable substance, of about the thickness of parchment.
On slitting up the canal, numerous mucous lacunae mav be
discovered in its course, and two of these, considerably above
the orifice, are peculiarly large. The urethra is very vascular,
and, when injected and dried, its orifice is perfectly red. In
the unimpregnated state, it runs very much in the direction

* See retroTeralo uteri Mid proli^eut TerioM.

of the outlet of the pelvis ; so that a probe, introduced mto the
bladder, and pushed on in the course of the urethra, would,
alter passing for about three inches and a half, strike upon
the fimdus uteri, and, if carried on for an inch and a half
£urther, would touch the top of the second bone of the sacrum.
But, a little deviation of the urethra upward, directs the
probe to the promontory of the sacrum.

When we trace the upper or anterior face of the vagina
curving upward towards the svmphysis, we discover an irre-
gular slit or the orifice of the urethra, where the rugous
va^na ends and the smooth vestibidum begins. The canal
of the urethra runs first a little downward within the pro-
longation, and then,' when it comes to the orifice of the
▼agina itself, it runs in its course. It is, therefore, not quite
straight, but slightly curved, at its extremity, unless the
vagina be much drawn up. The uterus being much connected
with the bladder at its lower part, it foUows, that when it
rises in pregnancy, the bladder wiU also be somewhat raised,
and pressed rather more forwards, and the vagina being
elongated, the urethra, which is attached to it, is also directed
a Utile more upward, and perhaps brought nearer the inside
of the symphy ms pubis. In those women who, from deformity
of the pelvis, or other causes, have a very pendulous belly,
the bladder, during pregnancy, is sometimes turned over the
pubis, the urethra curved a httle, and its opening somewhat
retracted within the orifice of the vagina.

When it is necessary to pass the catheter, it is of conse-
quence to be able to, do it readily, which is by no means
difficult. The woman ought to be placed on her back, with
her thighs separated, and the knees drawn a little up : a basin
is dien to be placed betwixt the thighs, or a bladder may be
tied firmlv to the extremity of the catheter to receive the
urine, 'the instrument is then to be conveyed under the
thigh, and the labia and nymphs, being separated with the
finger, it is to be run gently down tiie fossa, under the clitoris,
that leads to the orifice of the urethra, which is easily dis^
tinguished, like an irregular depression situated just above the
entrance to the vagina, higher or lower from the orifice,
according as the vagina is in its natural state or retracted.
The point of the instrument is to be moved lightly down the
fossa after the finger, and it wiU readily slip into the iu*ethra.
It is then to be carried on in the direction of the axis of the
outlet of the pelvis, and the urine drawn off. The catheter
may also be readily introduced by placing the point of the

finger just on the orifice of the vagina, and the instrument
being then glided along the finger, it either at once, or by the
slightest motion upward and downward, slips into the urethra.
This operation ought always to be performed in bed, and the
patient is never to be exposed. In cases of fractures, bruises,
&c., where the woman cannot turn from her side to her back,
the catheter may be introduced from behind, without moving
her« When the bladder is turned over the pubis, as happens
in cases of great deformity of the pelvis, it is sometimes re-
quisite to use either a flexible catheter, or a male catheter,
with its concavity directed forward. When the uterus is
retroverted, if we cannot use a silver catheter, we may employ
a gum catheter. When the head of the child in labour has
entered the pelvis, the urethra is pushed close to the symphv*
sis of the pubis ; then the flexible or flat catheter must be
introduced parallel to the symphysis, and the head of the
child may be raised up a little with the finger. This, indeed,
of itself, frequently permits the urine to flow, and when the
urine is retained after delivery, it is often sufficient to raise
up the uterus a little with the finger.

SECTION FIFTH.

The orifice ^strictly) of the vagina is nearly opposite to the
anterior part of the tuberosity of the ischium, about an inch
and a half below the sjrmpnysis of the pubis, and in the
direction of the axis of the outlet of the pelvis. It is, in all
ages, but more especially in infancy, considerably narrower
than the canal itseu, and is surrounded by a sphincter muscle,
which b about three quarters of an inch broad, and divided
ftt>m the levator ani by a slight sulcus. It may be said
to arise behind from the sphincter ani and transversales
perinei, and to be connected before with the clitoris. It is
accompanied with a vascular plexus, called plexus retiformis.
The sphincter is sometimes spasmodically contracted, and the
nerves so sensible that pain is felt in coitu, and at last some
degree of permanent circular stricture is produced. The cure,
in all stages, is division in a lateral direction of the constricted
part. When this is neglected coition sometimes produces
phlegmon or abscess. In children, the orifice is always shut
up by a membrane called the hymen, at the upper part of
which there is a semilunar vacancy, intended for the trans-
mission of the menses. Sometimes it is imperforated, at
other times it is cribriform, or partially or totally absorbed.
In adult rirgins the hymen is situated tliree-eighths of an inch

back from the fourchette, at the bottom it Is fully a quarter
of an inch broad^ and its sides or horns ascend by the aide of
the vagina to the side of the urethra, like small nymphse, end-
ing there as the nymphae do, in the prepuce of the clitoris.
It is formed by the duplicature of that £ftscia which covers the
labia. The mucous membrane of the fossa navicularis is traced
ap over this, whilst that of the vagina goes up on its inner
surface, the two becoming continuous at the margin* The
hymen has been supposed to be originally formed of four
angular portions, but often in the adult no trace of such
boundaries is to be found, though sometimes we see on each
side a paler and thinner line, as if it would rupture more
easily there.

Immediately behind the orifice of the vagina, between it
and the fourchette, there is a short transverse hollow or sinus
within the labia, which extends farther back than the vagina.
This has been called the fossa navicularis. It is quite smooth,
whereas the vagina is rugous. The boundary is often marked *
by a smooth transverse fold or band.

The pudic nerve, after re-entering the pelvis, gives off
several small branches, which go to the obturator intemus,
sphincter am, and extremity of the rectum. It then divides
into two. The trunk, as it may be called, runs forward with
the artery to the clitoris, covered, as it proceeds along the
rami of the pubis, by the erector. The other division is
distributed to the perineum and vagina. It approaches the
vagina, nearly in aline with its junction with die perineum,
and subdivides and ramifies, on die end of that passage, but
chiefly on its orifice. This nerve is ofi;en pretematurally
sensible, so as to cause great pain in coitu, as well as at other
times. It may be exposed, by cutting through the skin and
fascia, at the side of the labium and perineum, beginning on
a line with the front of the vaginal orifice, and carrying the
incision back for two inches. The nerve being blended with
cellular substance, is not easily seen in such an operation ;
but it may be divided, by turning the blade of the knife, and
cutting through the vagina to its inner coat, but not injuring
that. Merely slitting the orifice of the vagina, will not do,
unless we carry the incision fully half an inch up from the
orifice, and also divide the mucous membrane freely in a
lateral direction. It is not necessary to particularize^ the
distribution of the pudic artery. It is found running within
the ischium^ between that and the vagina, if the finger be
introduced to about the second joint. It runs nearly an inch

and a quarter above the bare point of the tuberosity, and may
be felt pulsating. It is higher than the nerve.

SECTION SIXTH.

The perinseum is that space which intervenes between the
anus and orifice of the vagina, or rather the margin called
fourchette. It is from an inch, to an inch and a quarter
broad, and consists, first, of thick skin, beneath which is dense
cellular substance ; then, there is a strong fascia covering a
muscular substance more or less distinct, within which there
is again cellular substance but not very dense, and last of all,
there is the under surface of the extremity of the vagina.
The angle formed, by the passing forward of the vagina, from
the termination of the rectum, is filled with cellular substance,
but, tracing behind, we find that as soon as the two canals
meet, they become united, as will be afterwards explained.
This. union forms the recto-vaginal septum. The muscles
consist of levator ani, within, as already described, and which,
winding by the back or under surface of the vagina, unites
with the portion from its opposite side, and also with the
sphincter ani and end of the rectum. The transversalis peri*
naei is not always distinct, but is sometimes strong. The
external sphincter ani passes from the coccyx, round the
extremity of the rectum, and terminates in the perinseum in
such a way, that the portion from the opposite sides, whilst
they pass forward, also cross each other, and are lost in the
transversalis. Another muscle arises from all this intermix-
ture in the perinseum, and encircles the orifice of the vagina.
It is found within the labia, like a band, on each side of the
vagina, extending forward towards the clitoris. It is the
constrictor vagin®. The perineal arteries from the pudic
ramify amongst these muscles. The firmness of the perimeum
and the support it a£fords, as well as its resistance to the
passage of the child, depend not only on the muscles and
rigidity of the skin, but still more on the strength of the fascia.

CHAP. IX,
Of (he Internal Organs of Generaiumj and Sectum.

SECTION FIRST.

Thb intemal organs of generation consist of the vagina, with
the uterus and its appendages.

The vagina is a canal, which extends from the vulva to the
womb. It consists, principally, of a peculiar dense cellule-
fibrous substance, of a greyish colour, endowed with elasticity.
This substance becomes laxer as we proceed upward, and
every where it is vascular, but the veins are particularly nu-
merous, especially behind. Near the orifice, a plexus reteformis
is formed. This is covered by a thin sheet of muscle, the
sphincter, and that by the levator ani and fascia. . This
dense coat, is identified with the upper part of the lips of
the OS uteri, and connected, by ceuular substance, to the
parts the vagina passes along. It is lined by a continu-
ation of the mucous coat from the inner surface of the labia ;
and this intemal coat, which is as thick as parchment, and
strong as weU as elastic, forms numerous transverse rugae, on
the anterior and posterior sides of the vagina ; but near the
orifice they do not extend across, but are short oblong eleva-
tions. Often, in virgins, we see a slight longitudinal ridge of
the mucous coat, and also one at the back part, all endi^ in
or near the inner surface of the hymen. Sometimes the pos-
terior ridge bifurcates over the hymen, and is implanted by
two limbs into it. About a quarter of an inch bade from the
urethra on each side is a little projection or caruncule of the
mucous coat. There is also sometunes one in front just under
the urethra, and more frequently one behind. These are
called carunculae myrtiformes. The inferior one may partly,
perhaps, be formed by the inner member of the hymen when
rmtured. But these eminences or folds are not very regular.
They are called carunculs myrtiformes, and are most distinct
after the hymen is torn, the base or origin of which may,
perhaps, increase their size. Near the uterus the vagina is
smoother. They are peculiar to the human female, and are
most distinctly seen in the virgin state ; but after the vagma
has been distended, they are more unfolded, and sometimes
the surface is almost smooth. In the whole course of this
coat, may be observed the openings, sometimes pretty large.

of numerous glandular follicles, which secrete a mucous fluid.
In the foetus this is white and milky ; in the adult it is nearly
colourless. The mucous coat is reddish near the orifice,
higher it is grayish, and at the top it is often mottled, as if
there were patches of echymosis. The vagina is very vascular;
and when tne parts are well injected, dried, and put in oil of
turpentine, the vessels are seen to be both large and numerous.
Just below the symphysis pubis, we observe a great congeries
of vessels siurrounding the urethra and upper part of the
vagina. Exterior to the proper tissue of the vagina, is a coat
of cellular substance, connecting it to the neighbouring parts.

The vagina forms a curved canal, which runs very much
in the course of the axis of the outlet and cavity of the pelvis.
It is not round, but considerably flattened ; it is wider above
than below, being in young subjects much contracted about
the orifice. Near puberty the orifice may be less than half an
inch in diameter, whilst within that the canal is nearly three
quarters. Hence the marks of stuprum violentum in the virgin,
and more especially if puberty hiive barely arrived, must be
souffht for in the condition of the orifice of the vamna, and
some sweUing or redness of the nymphe and in^e/f the
labia. The hymen is torn, its fragments bloody, and if com-
plete penetration have been effected at such an age, and under
such circumstances, even the orifice of the vagina will probably
be partly torn, the fourchette also perhaps injured. After a
short time the inflammation produces muco-purulent discharge.
I notice here only the local svmptoms, and sav nothing of the
others, such as detection oi semen, &c. The fore part is
continued obliquely up, toward the symphysis of the pubis, or
vestibule, and the junction is perforated by the urethra, whilst
the back part terminates more abruptly* At its upper end, it
does not join the lips of the os uteri directly, but is attached
a little above them, higher behind than before, so that the
posterior lip of the uterus b better felt than the anterior. In
the infant, the vagina is attached still farther up, and the lips
of the uterus project in it something like a penis. The length
of the fore part of the vagina is, when not extended, about
three inches.

The inner coat of the vagina is reflected over the lips of
the uterus, and passes into its cavity, forming the lining of
the uterus. The junction of the uterus and vagina, is so
intimate, that we cannot make an accurate distinction betwixt
them, but may say, that the one is lost in the other. The
vagina adheres, before, very intimately, to the urethra ; and

wben ihat terminates, it is adherent to the bladder, for about
an inch and a half, by thin cellular substance. These are
also bound together by a common fascia. Behind, it meets
the rectum, and their connexion forms the recto-vaginal
septum. There is, if stretched, nearly an inch of the vagina
between the os uteri, and where it is connected to the rectum.
If not stretched, the extent is sometimes only half an inch.
This portion is covered by a reflection of the peritoneum, and
within that, by a thin fascia, reflected from the face of the
rectum, to the vagina and cervix uteri. At the side, the
peritoneum descends a little lower. From the junction, nearly
to the extremity of the vagina, the two canals are connected
by thin cellular substance, in which is a vascular plexus parti-
^ilarly of veins, and when separated from eacn other the
surface of both is seen to be smooth. The extremity is con-
nected to the rectum, at the front of the perinaeum, by firm
fibrous substance, which shuts up all connexion with the peri-
naeum itself. We can easily separate the canals from one
another from this point, upward, to the reflection of fascia at
the top of the vagina, when again we should have a barrier.
We can, therefore, see how a cyst of fluid could easily be
formed, in the tract of the recto-vaginal septum, and how this
fluid should be shut out from the perimeum, and also from
the abdominal cavity, not merely by peritoneum but by fascia.
Matter forming under the perineal fascia, might also, for a
time, be prevented from extending up, along, or within the
septum.

When the finger is introduced into the vagina in sUu, the *
urethra is felt on its fore part, resembling, from the thickness
of the vagina, a firm fleshy cylinder. Behind, the rectum can
be traced down to the point of the coccyx. At the side, the
ramus of the ischium and of the pubis, together with the
obturator intemus muscle, are to be distinguished. In a
well formed pelvis, the finger cannot easily reach beyond the
top of the coccyx, or lower part of the sacrum ; during labour,
however, the parts being more relaxed, the bone may be felt ^ ^
a little higher. ^ ^\

SECTION SECOND.

The uterus is a flat body, somewhat triangular in its shape, ' ^
being con^derably broader at its upper than at its under
part. It is divided by anatomists into the fundus, or upper
part, which is slightly convex, and lies above the insertion of
the Fallopian tubes : the cervix, or narrow part below ; the

women from eighty to a hundred, the uterus is divided into
two, by a septum between the body and fundus.

The substance of the uterus is made up of numerous fibres,
disposed very irregularly, and having a considerable quantity
of interstitial fluid interposed, with many vessels ratifying
the peritoneum, and are distributed on the ovaria, tubes, and
amongst them. A dense succulent texture is thus formed,
which constitutes the substance of the uterus. On opening
the womb, several irregular apertures may be perceived on
the cut surface : these are the venous sinuses. The fibres
which we discover are muscular ; but we cannot, in the unim*
pregnated state, observe them to follow any regular course.

The arteries of the uterus are four in number, with cor-
responding veins. The two uppermost arteries arise either
high from the aorta, or from the emulgent arteries. They
descend, one on each side, in a serpentine direction, behind
the peritoneum, and are distributed on the ovaria, tubes, and
upper part of the uterus. These are called spermatic arteries.
The two lowermost, which are called uterine, arise from the
hypogastric arteries. They run, one on each side, to the
uterus, fully half an inch above the lips. They supply the
cervix and upper part of the vagina. Thus, the fundus uteri
is supplied by the spermatic arteries, and the cervix, by the
uterine arteries ; and these, from opposite sides, send across
branches which communicate one with the other. But besides
this distribution, the uterine artery is continued up the side
of the uterus, and meets with the spermatic, so that, at the
two sides, we have arterial trunks, from which the body of
the uterus is liberally supplied with blood. The veins cor-»
respond to the arteries, but are uppermost. The nerves of
the uterus are derived from two sources, the sympathetic and
the sacral nerves, particularly the third, with filaments from
the fourth, and sometimes the second. The sacral nerves
intermix with the sympathetic, forming plexuses for the
uterus, vagina, &c. Do these two sets of nerves perform
separate functions ? Are the sympathetic branches functional,
and the sacral sensitive ? In certain cases of uterine diseases,
the sacrum about the second bone is tender when pressed.
The spermatic plexus is formed on the face of the aorta at
the origin of the spermatic artery, and descends along with it
to the ovarium and tube. The most important plexus is
called, by Tiedeman, the great superior lumbar plexus, and
is situated before the fifth lumbar vertebra, and the common
iliac artery* Accompanying the uterine artery, it supplies

the body of the utems, and sends down a branch to communi*
cate with the sacral portion. The superior and inferior
lateral plexuses go to the cervix uteri, vagina, bladder, and
rectum.* There is a particular sjrmpathy between the nerves
of the cervix and os uteri, and the stomach. I have known
•even touching the os uteri in the early stage of labour, or in
the end of pregnancy, with the finger, uniformly produce
sickness and violent retching.

The lymphatics, in the unimpregnated state of the uterus,

are small and not easily discovered. Those from the upper

part of the womb, and from the ovaria, run along with the

spermatic vessels, terminating in glands placed by the side of

the lumbar vertebrae. Hence, in diseases of the ovaria, there

may be both pain and swelling of the glands. But the greatest

number of lymphatics run along with the uterine artery,

several of them passing to the iliac and sacral glands, and

«ome accompanying the round ligament. This may explain

why, in certcun conditions of the uterus, the inguinal glands

swell. Others run down through the glands of the vagina ;

and hence, in cancer of the womb, we often feel those glands

hard and swelled, sometimes to such a degree, as almost to

dose up the vagina.

The ureter passes by the side of the cervix, to enter the
bladder nearly on a line with the os uteri.

The uterus is covered with the peritoneum, which passes
off from its sides, to reach the lateral part of the pelvis a little
before the sacro-iliac symphysis; and these duplicatures,
which, when the uterus is pulled up, and the bladder empty,
seem to divide the cavity of the pelvis into two chambers, are
called very improperly the broad ligaments of the uterus. In
the male the peritoneum passes from the pubis and antero^
lateral part of the brim of the pelvis to tne bladder, dips
down along its back part, and thence is reflected off at the
sides towards the cavity of the pelvis, and behind on the rectum.
Hence, when the bladder is either distended or pulled up, the
hand can be slidden down between it and the rectum into a
deep recess, extending fit>m one side of the pelvis to the
other. This is visible when the empty bladder is pulled up,
but not when it is distended with air or water, for then the
back of the bladder is in contact with the face of the rectum,
and the recess can only he discerned by gliding the fingers
down between these two viscera. The same recess exists in

* Tiedeman, Tab. N«ry. Uteri, or Home's Lectures, VoL tL Plata 19 and
SI, and Mr. C Hawkiiia, Id PhU. Tram. 1625, p. 70.

•die female, with this difference, that the peritoneum is con-
tinued from the bladder to the uterus, covers it and passes
down along its back, and a little way along the vagina, and
thence is reflected to the rectum and sides of the pelvis. It
descends lower by the sides of the vagina and rectum^ and,
also, at the very back, where these join, than at the latere*
posterior part, therefore, we have a fold there, at each side,
forming a kind of pouch, between the rectmn and vagina, and
likewise, we have two slight lateral prolongations of the recess.
In the unimpregnated state, when the bladder is empty, and
the intestines pulled up out of the pelvis, we see it sloping
backward and downward till it meet the anterior part of the
cervix uteri. It covers the uterus, descends on the very top
of the vagina, from which it passes back, to come, as in the
male, in contact with the rectum. The uterus is not hori«-
zontal, but lies obliquely in the bottom of the cavity, forming
as it were the floor. Then we mount up from it to the rec-
tum, and, in the collapsed state of the bladder, if the uterus be
not raised, so as to show the posterior chamber*, we would sup*
pose that a hollow sheet of peritoneum might, without intemip*
tion, be traced from the pubis along the base or outlet, and
up in front of the sacrum. When the bladder is distended,
the peritoneum is scarcely raised, that is, reflected higher
from the face of the uterus. The uterus is somewhat, but
not much, raised along with the bladder. The uterus b
so placed, that in general nothing can enter between it
and the rectum ; but it may happen that some folds of the
intestine do get between the uterus and rectum, and the
slight pressure thus produced is sufficient to cause a dis-
turbance of the intestinal functions, and even some degree
of obstruction to the passage of the stools, either through
the fold or through the rectum ; and in this, as well as in
some other cases, clysters do not pass up, but the rectum is,
when they are thrown in, pressed anteriorly against the
tumour formed by the fold and by the uterus, and a kind of
invagination takes place within the gut. The os uteri is nearly
in its natural situation, but the presence of the intestine gives
a thickened feel to the cervix, which it does not really possess.
In obstinate constipation from this cause, the whole hmd should
be introduced into the vagina, and the uterus and intestine
pressed up, at the same time that a saline clyster is thrown
mto the rectum through a flexible tube, cautiously introduced
to near the top of the sacrum. The intestine may descend
still lower, and push forward, or even evert, a part of the

vagina, or may descend more by its side; thus we have
vaginal, perineal, or pudendal hernia produced, according to
tbe direction taken.

If the finger be fully introduced into the rectum, we can
feel through it, the posterior lip, and part of the back of the
cervix uteri. In the natural position, we cannot touch the
body, and a probang must be introduced, to the extent of
fully five, sometimes even six inches from the anus, in order
to get on a line with the top of the fundus. This lies nearly
at the height of the top of the second bone of the sacrum, or
a little higher, or lower, according to circumstances. The
OS uteri is directed forward in proportion as the fundus is
inclined backward.

At all times when the finger is introduced into the rectum,
the extremity of the uterus may be felt pressing on it. In
some cases of enlargement or prolapsus, the pressure seems
to be productive, not only of more or less obstruction to the
passage of the stools, but also of uncomfortable sensations,
tenesmus, &c. In greater displacement of the uterus, (ante-
version or retroversion, for instance,) the pressure is some-
times such as to produce almost complete obstruction, feculent
vomiting, and a hngering death; and in some of these cases,
the 03 uteri appears on an examination per vaginam, much
more in its proper situation than would be believed without
experience.

When the uterus is raised, and the lateral duplicatures of
the peritonenm, called the broad ligaments, are stretched out,
we observe, that at the upper part they form two transverse
folds or pinions, one before, and the other behind. In the
first of these, the Fallopian tubes are placed ; in the second,
the ovaria. These folds become broader toward their ex-<
tremity, so that they have an angular shape, the broadest

Eart being fully 1^ broad; that is, there is that distance
etween the end of the tube and the ovarium.
Besides these duplicatures, we likewise remark one on each
side, which extends from the fundus uteri, just before the
entrance of the tube, to the llnea ilio-pectinea at the side of
the pelvis, and then runs on to the groin. This contains, a
pretty thick cord, which arises flatiy from the fundus uteri,
and passes out at the inguinal canal, being then lost in the
labium pudendi. These cords, which are called the round
ligaments of the uterus, consist of numerous blood vessels,
some lymphatics, small nerves, and cellular matter. They
pass by the side of the bladder, crossing over the ureter.
The Fallopian tubes, in quadrupeds, are merely continua-

tions of the horns of the uterus : but in the human female,
they are very different in their structure from the womb.
They appear to consist in a great measure of spongy fibrous
substance, which, as Haller observes, may be innated like the
clitoris. They are hollow, forming can£us, lined with a con-
tinuation of the internal coat of the uterus ; and as they lie
in the anterior pinion of the broad ligaments of the uterus,
they are covered of necessity with a peritoneal coat. They
ori^nate from the upper oiniers of the uterine cayity by
very small orifices, but terminate at the other extremity in
an expanded opening with ragged margins, which are cwed
the fimbriae of the tube. The internal surface of the canals
is plaited, the plicae running longitudinally.* The extremity
of the tube, is curved by the pinion of the broad ligament, so
that it cannot be pulled straight. In its curved state, the
tube is about four inches long.

The ovariaf lie in the posterior pinion of the broad liga-
ment. They are two flattened bodies, from an inch and a

' * Pnrkinje, VidentlDe, and Sharpey, hare obterTed in rabbits, after improfna-
tlon, minute portions of tbe muoout membrane moTing briskly and whirling
round their axis. These motions, called elliary, are supposed to propel the oTum*

f In birds, we find that the ovaria contain a rreat number of yolks of different
sizes. Those which are nearest the wide canal called the ovidact, which leads
to the cloaca, are largest, while those remote from It are rery minnte. The fuU
grown Tolk, is detached from the ovarium, and in its passage down Is furnished
both with the albumen and the necessary membranes and shell. In TlTiparons
fishes, as tbe skate, ray, &c., the same structure obtains, lliese animals hava
two OTaria, containing egss of different sizes ; the smaller are white, the larger
yellowish, and they pass down to an oviduct, which contains a glandular bwlT
that furnishes the covering of the egg. Each ovary has a separate oviduct, wbiea
forms a vast sac, that terminates In the sides of the cloaca, by orifices that have
a duplicatui^ like a valve. The cloaca Itself forms an ample reservoir, that
seems more like a continuation of the oviduct than the terminallon of the
rectum. In oviparous fishes, the ovaria are known under the name of roes, and
all the visible ^gs are of the same size, and so numerous, that some contain
above 200,000. They are enveloped in a fine transparent membrane; and
septa from this envelope, divide the Internal parts, and furnish points of attach-
ment to the ova, which are expelled previous to fecundation. These are called
oviparous fishes; and have, prop^ly speaking, no oviduct. The ovaria of
frogs resemble those of fishes, and the ova are, previous to expulsion, enveloped
in a glairy fluid. In the slur we find both testicles and ovaria. The ovarium
is a grape-like tissue, containing numerous small grains, or ova, attached br

pedicles, which are canals that lead Into the oviduct. This Is a serpentine
that after having adhered to the testicle, opens In the common cavity of genera-
tion, in which also the penis or duct from the testicle opens, and during oopolft-
tlon, the two individuals mutually impregnate each otlier. The ovarii of tha
adder are like strings of besds.

The ovarium of the omithorhvncns, contains yolk bags like tbe fowl, but cov-
ered by a firm membrane. In tbe opossum, these are imbedded In tbe ovarium.
The hedgehog has an ovarium like a bunch of crapes ; and the ovarium of tbe
dvet has a knotted surface, and resembles a packet of little spheres ; the eommon
sow has also an ovarium somewhat resembling, externally, that of oviparous
animals. Most other quadrupeds have an ovarium more smooth and somewhat
oblong In shape, and In general the tube and ovarium are unconnected, as In the
human female ; but In the otter, my brother obesrvcd, that both were contained
in a kind of capsule formed by the peritoneum, so that vcDtral csCr»- uterine
pregnancy cannot take place in this animal.

quarter, to one and a half long, somewhat oval, but genei^y
broader at the remote, and narrower at the near end. The
broadest part is from half, to five-eighths of an inch : the
thickness a quarter. They have, when a section is made, a
glandulo-cellular appearance, in which small vessels may be
seen* Besides being covered by the peritoneum, they have a
proper coat called albuginea, which seems to send septa more
or less distinct into their substance. In this substance are
embedded at different depths, vesicles called Graafian. These
are not definite in number, for sometimes not more than a
dozen, at other times above twenty have been found. They
are in different degrees of development, some deep, not
larger than coriander seed, others more superficial, as large
as peas, and seen through the tunica albugmea slightly pro-
jecting. They have two coats, or membranes, adhering to one
another, and the outermost beautifully vascular. This is
adherent to the surrounding substance. They are filled with
albuminous fluid, containing numerous globules, visible by the
microscope. But, besides the fluid, we also find an ovulum,
not larger than a minute grain of sand, but observable by the
naked eye. The structure of this will be noticed hereafter.
After impregnation, one of the vesicles enlarges and becomes
more prominent. Its own membrane and the coats of the
ovarium, either burst or are absorbed, and the ovulum passes
into the fimbriated extremity of the tube, which at this time,
is adherent to the ovum. K we remove a vesicle, even
before impregnation, and subject it to the microscope, we
see within it a disc, more or less circular, surrounding the
ovulum, or on which it rests. It is formed of closely col-
lected globules, and is called the proligerous disc. When
the ovum is expelled, the ruptured vesicle is filled with a
reddish mass, connected with the inner coat, and for a time
having either a small central cavity, or the centre is occupied
by a little albumen. The exterior opening, through which the
ovum had escaped closes, the central cavity gradually dis-
appears, and there is only left a uniform globular structure,
called firom its colour, corpus luteum, though in some animals
the colour is not yellowish. It has been supposed, that even
when impregnation did not take place, tne vesicles went
through the same course, and burstmg, discharged a useless
ovulum, consequently, that the existence of corpora lutea was
no proof that me female was not a virgin. That the vesicles
must burst, or be ultimately absorbed or destroyed is clear.
The prevailing opinion at present is, that corpora lutea may

be found in the virgin. Sir £. Home considers the corpus
to be a nidus in which a vesicle is formed.

In the foetus, the ovaria and tubes are placed on the psose
muscles ; but in the adult, they lie loosely in the pelvis, and
the uterus sinks within the cavity. At fourteen, the ovarium
is fully an inch long, half an incti broad, and a quarter thick.
Just before puberty, it is above an inch long, and five-eighths
broad. Even in mfancy, the rudiments of vesicles may be
observed, but till after puberty, they are indistinct.

SECTION THIRD.

The rectum deserves attention here, as its diseases become
frequently the object of consultation. Its structure is similar
to that of the other intestines, but it is only covered by the
peritoneum in part. This membrane forms its outer coat so
far down as its connexion with the vagina, then it only pro-
ceeds some way down its lateral part. Beneath the perito-
neum, and all the way to the orifice, we have a muscular coat,
consisting chiefly of longitudinal fibres in the upper part, and
principally of circular fibres in the under third. These be-
come more distinct, as we approach the anus, so that the
intestine is surrounded as it were by a belt of muscle for two
inches, whilst higher, the fibres become less strong. This
has been called the internal sphincter, but it may be con-
sidered as a stronger part of the muscular coat. The exter-
nal sphincter surrounds the orifice, it is flat and broad, and
its extremities decussate one another in the perineum. It
arises from a ligamentous band, which extends from the ex-
tremity of the coccyx, to the back part of the rectum at the
anus, and which serves as a support, in so far, to the rectum.
This band, more distinct in some cases than others, may be
described as merely a thicker part, in the median line, of that
general fascia, already explained, which extends from the
sacrum and coccyx to the ischium and perineum. In all
cases at the top of the internal sphincter, or where the fibres
are becoming weaker, there is in both sexes a slight invagi-
nation or descent of the mucous coat, sometimes oi the whole
thickness of the rectum, felt distinctly when the finger is
introduced. This often becomes the earliest seat of disease
or induration, and then bears some resemblance to an os uteri.
In its natural state, I have known it mistaken for a stricture ;
and whilst this invagination is felt within, there is sometimes
a partial distention of the gut above, so as to form a diverti-
culum turning over the reflection of the pelvic fascia, in which

when a portion of fseces lodges, a serious obstmction may be
produced ; and, felt from the ya^na, it may resemble a part
of an enlarged uterus* If the finger about this point, or higher
or lower, according to the position of the uterus, be directed
forward, the os uteri is distinctly felt pressing on the intestine,
the posterior lip is felt as distinctly almost as the sound is in
the male urethra through the rectum, and when the uterus ii
tender, pain is produced by touching it from the rectum. In
some cases of slight prolapsus, the pressure of the uterus,
aided by the weight and impaction of the small intestines in
the pelyis, on the face of the rectum, affords some resistance
to the passage of the stools, but this is greater when the uterus
is retrorerted eyen in a slight degree, for then the obstruction
is sometimes complete. It is not supposable by an inexperi-»
enced person, how slight a pressure wul obstruct the rectum,
and giye rise to obstinate costiyeness, emaciation, yomiting of
feculent matter, and at last death. I therefore particularly
call the attention of the young practitioner to this subject,
and to the effect of very slight <]tisplacement, of any kind, of
the uterus. Another circumstance connected with the rectum,
particularly with the sphincter, demands notice. I mean a
species of spasm, or stricture, accompanied with great sensi-
bility of the luemorrfaoidal, and, perhaps, also of the puden-
dal neryes ; in the latter case, the sphincter of the yagina is
often spasmodicaUy contracted, and there is pain in coitu.
When the sphincter ani alone is affected, there is great pain
at the time of haying a stool, often of the burning kind,
shooting up the sacrum and back, and continuing for an hour
or two afi;er a motion. It is sometimes so bad as to produce,
in hysterical habits, fainting or hysteric fits ; any examination
with the finger causes great pain, which lasts a considerable
time. This state is generally connected with a local irrita*
tion, such as a fistula, or excrescence within the anus, or a
mere fissure of the orifice, nor seen till it be opened, by press-
ing its sides with the finger from one another. In this case,
blood is often discharged by stool, and the case passes for
one of internal piles. In some instances, no fissure exists, but
only the painful sensibility of the sphincter, and this may be
the case at a yery early period of life. Keeping the bowels
regular, and injecting a little olive-oil, often mitigates the"
complahit, and I haye eyen known these means cure it. But
the most certain remedy is that proposed by Boyer,* namely,
diyiding the sphincter with a bistoury ; and he remarks what

* fiof er, Tome x., p. 125.

I know to be true that it is not necessary to divide it in that exact
spot where the fissure exists. I need scarcely say that in the
case of complication with fistula, the operation for that disease
also divides the sphincter more or less. After the division, the
wound is to be filled with lint, as in the operation for fistula.
Within the muscular coat is a dense cellular layer, called
by some the mucous coat, and in this the glands are lodged.
The internal coat is a mucous membrane, and this by the
contraction of the circular muscular fibres, is often thrown
into longitudinal plies. The nerves of the lower part of the
rectum are numerous, and the vessels of this intestine are
both large and numerous, so that in laceration of the recto^
vaginal septum, and other lesions, the hemorrhage is often
considerable, and requires the plug to stop it. Excrescences
often form on the surface of the rectum, and prove serious,
both from pain and hssmorrhage. They produce very nearly
the same symptoms with the fissure already described, but
by straining, they are discovered. They ought to be pro-
truded and removed. But the most formidable disease met
with here is schirrus, generally of a cancerous nature. For
a description of this, I refer to works on surgery, and as to
the practice, it ought to be purely negative, that is, we should
avoid every thing which can excite either the system, or the

Eart. The bowels are to be kept regular, and the stools soft,
y a mild laxative, sometimes aided by a clyster of tepid water
cautiously administered, and in the latter stages, anodynes are
required to allay pain, and sometimes injections of water, to
remove acrid, and foetid matter. Medicated injections seldom
do much good, and the hip bath is only useful as a tempo-
rary soother, when it allays pain. A suppository consisting
of cicuta and opium, is often of more service. The operation
of extirpation has lately been performed, and we are told
with success, by M. Lisfranc*

CHAP. X.
0/the Diseases of the Organs of Generation.

SECTION FIRST.

The labia are subject to several diseases : of these, the first
which I shall mention, is phlegmonoid inflammation. This

• KcT. Med. Juln, 18S6.

may occur at any period of life, and under various circum-
stances, as, for example, along with the irritable state of the
Sihincter already described ; but frequently it takes place in
e pregnant state, especially about the sixth and seventh
mon^ of gestation, and it may suddenly occur, oftener than
once in the same pregnancy. Occasionally, it makes its
attack in childbed, in consequence of the violence which the
parts may have sustained in labour. It is marked by the
usual symptoms of inflammation, namely, heat, pain, throbbing,
and more or less swelling, not unfrequently attended with
fever. The swelling is sometimes hard and moveable, like a

fland, especially when the progress is slower than usual,
n general, the course of the disease is rapid, the pain and
inflammation are at first very acute, and the part swells
speedily. In a few hours, especially if a poultice have been
applied, the abscess begins to point at the inside of the labium,
and the nympha either disappears, or if it remain, it is pushed
out of its place. Sometimes it bursts within thirty-six hours
from its appearance. By means of cold saturnine applica-
tions, and gentle laxatives, the inflammation may perhaps be
resolved, but most frequently it ends in suppuration, which is
to be promoted by fomentations and warm cataplasms. If
necessary, an opiate may be given to abate the pain, and a
pillow must be placed between the knees, to keep the part
n'om pressure. If possible, the abscess ought not to be
punctured; but, if the pain and tension be unbearable, we
must indulge the patient by making a small opening ; a good
deal of blood will in this case come with the matter. After
the abscess bursts, the parts may be dressed with any mild
ointment. Should the opening of the abscess be higher than
its bottom, it will be necessary, if the discharge continue,* to
lay it open, after which it will speedily heal. Owing to the
subcutaneous fascia of the labia, these abscesses never break
outwardly.

Sometimes an elastic, small, but tedious tumour, ending in
abscess, forms near the nympha, and is exquisitely painful to
the touch. A poultice must be applied, and the patient re*
main on a sofei.

SECTION SECOND.

The internal surface of the labia is often the seat of ulcera^
tion and excoriation, which may generally be avoided by the

« VMe Mr. Hty'n Sargical Obcenrations, p. 188.

daily use of the bidet. The usual foim under which excoriation
appears, is that of a raw surface, as if the cuticle had been
peeled from a blistered part. Most frequently these sores
are the consequence of acrimony, produced by inattention to
cleanliness, especially in children ; and in their case the labia,
if care be not taken, may cohere. The treatment consists
in keeping the parts clean, bathing the sore with a weak
solution 01 sulphate of zinc, and preventing cohesion. Should
the parts not heal readily, they may be washed with brandy,
or a very weak solution of nitrate of silver, or touched with
caustic. When adhesion takes place, it may, if slight, be
destroyed, by gently pulling the one labium from the other ;
if firmer, the parts must be separated with the knife. In
either case, reunion must be prevented by washing the surface
frequently with solution of alum, and applying a small piece
of lint spread with simple ointment. Simple itching of the
parts may be removed by the tepid bath, a dose of castor oil,
and fomenting the parts with milk and water.

Sometimes we meet with deeper ulcerations, which it is of
great importance, to the domestic happiness of individuals, to
distinguish from chancre. Nothing seems easier in a book,
than to make the diagnosis, but in practice it is often very
difficult. A well marked chancre begins with circumscribed
inflammation of the part ; then a small vesicle forms, which
bursts, or is removed by slough, and displays a hollow ulcer,
as if the skin had been scooped out; its surface is not polished,
but rough, and covered with pus, which is generally of a buff
or dusky hue ; the margins are red, and the genend aspect of
the sore is angry. But the most distinguishing character of
the chancre, is considered to be a thickening or hardness of
the base and edges of the ulcer. The progress of the sore is
generally slow either towards recovery or augmentation.
When remedies are used, the first effect produced is removing
the thickening by degrees, and lessening the discharge, or
changing its nature, so that the surface of the sore can be
seen ; it has then, in general, a dark fiery look, which con-
tinues until all the diseased substance be absorbed, and the
action of the part be completely changed. Now, from this
description, we should, it may be supposed, be at no loss in
saying whether a sore were venereal ; but in practice, we find
many deviations from this description. The thickening may
be less in one case than in another, and may not be easily
discovered, yet the sore may be certainly venereal. Pecu-
liarity of constitution, or of the part affected, can modify

greatly iihe effects of the yinis* There may be extensive
inflammation, or phagedsnic ulceration ; and yet the action
may be venereal. It is, however, satisfactory to know in these
cases, that in a little time, unless extensive sloughing have
taken place, the appearance of the sore becomes more decided^
the proper character of chancre appears, and the usual remedy
cures the patient.

Phagedena is a very troublesome, and sometimes a formi-
dable disease, especially to infants. I shall here only notice
that form which appears in adults, and which, as it is infec-
tious, may be mistaken for syphilis. It commences with a
livid redness of the part, succeeded speedily by vesication
and ulceration, which extends laterally, and sometimes pene«
trates deep. The ulcer has an eating appearance, is painful,
discharges a great quantity of matter, and very often is
attended with fever. A variety of this disease is attended with
superficial sloughing, which may be frequently repeated, and
is generally preceded by a peculiar appearance of cleanness
in the sore. This is not to be confounded with sloughing,
produced by simple inflammation or irritation of the parts,
which is smular in its nature and treatment to common
gangrene. We must foment the sore with decoction of camo-
mile flowers, mixed with a little tincture of opium, and then
apply mild dressings. Rest is essential to the cure : and if a
febrile state exist, it is to be obviated by venesection or laxa-
tives, according to its type and severity, mild diaphoretics,
and decoction first of sarsaparilla, and then of bark. Extract
of cicuta internally, is often of service, and a poultice of
hemlock is a good application. If a bubo form, it is to be
treated in the same way. In cases where the pain is consider*
able with sloughing, and the mild treatment has not speedily
proved effectual, it is of service to destroy the surface by
wetting it with strong nitrous add. This gives great pain for
a little, but an opiate relieves it, and it does not return.
Solution of chloride of lime, afterwards, forms a good appli-
cation. If there be no fever, mercury, or the nitrous acid,
often effectually change the action of the parts, but must
always be given with caution.

Sometimes irritable sores appear on different parts of the
labia, or orifice of the vagina, in succession, healing slowly
one after another. These have an inflamed appearance, the
maigins are sometimes tumid, and the surface is at first irre-
gular and depressed, but afterwards it forms luxuriant granu-

lations. There is another sore met with on the inside of the
labium, and which generally spreads to the size of a sixpence.
The surface is quite flat, and sunk a little below the level of
the surrounding parts. The margins are thickened, and
sometimes callous, the discharge thin, and the ulcer not in
general painful, the surface soft and q>ungy without a hard
base. These sores generally agree best with stimulants,
especially caustic and escharotics. When they do not yield
to this treatment, it will be proper to have recourse to a
cautious course of mercury. Some of these, like the phage-
daena, are infectious.

Some of these sores are occasionally productive of secondary
symptoms, such as ulcers in the throat. When these succeed
a sore which has run its course differently from chancre, and
been healed without the use of mercury, it is allowable to
suppose, that they also may be cured, merely by attending to
the general health, and perhaps by local applications. But
if they continue without amendment, or threaten danger
to any important part, we must not delay making trial of
mercury.

SECTION THIRD.

Sometimes after a slight degree of inflammation, producing
heat and itching of the parts, numerous excrescences appear
within the labia. These are either soft and ftmgous, or bard
and warty. Both of these states may be induced by previous
venereal inflammation; but they may also occur independently
of that disease. Even where there is an offensive discharge
from the ftmgi or warts, we are not always to conclude that
they are s^hilitic, but be guided in our judgment by con-
comitant curcumstances. Warty excrescences are moat readily
removed, by the application of savin powder by itself, or mixed
with red precipitate ; and during its operation, the parts may
be washed with lime water. The powder must be applied to
the root of the warts, for their substance is almost insensible.
Fungous excrescences may sometimes be removed by ligature ;
but when the parts are sensible, they must be destroyed, by
applying a v^trong solution of caustic with a pencil, or
sprinkling them with escharotic substances. K these cannot
be borne, we must first abate the sensibility by tepid fomen-
tations with decoction of poppies, or water with a little
tincture of opium, or decoction of cicuta, or weak infusion of
belladonna. Should there be ground for suspecting a syphilitic

action, mercury must be given, at the same time that we make
suitable local applications ; but in doubtful cases, I have seen
this medicine given without any benefit. These excrescences,
firom their appearance, their great pain, and foetid discharge,
may surest an opinion of their being cancerous ; but they
be^n in a different way, and generally yield, though som&*
times slowly, to proper applications.

SECTION FOURTH.

Solid tumours may form in the labia, and are distinguished

by their hardness, and by their moving imder the skin, until

adhesion from inflammation takes place. These tumours are

sometimes scrofulous and have little pain, even when they

have gone on to suppuration. Often, however, they are

cancerous ; and these are distinguished from the former, by

their great hardness and inequality, and by their shooting

pain. If they are not removed, the cancerous abscess points

to the inner surface of the labium, its top becomes dark

coloured, sloughs off, a red fluid is discharged, and presentiy

fungus appears. Soon after this, the glands at the top of the

thigh, and sometimes those in the course of the vagina, swell.

If all the diseased parts can be removed, an operation must

be performed.* If they cannot, we must palliate symptoms

by proper dressing and opiates.

SECTION FIFTH.

Soft fleshy appendiculae, or firm polypous tumours, some-
times spring from the labia. Both of these, especially the
latter, may give trouble by their weight or size. They may
also, by being fretted, come to ulcerate, and the ulceration
is always of a disagreeable kind. They ought to be therefore
early removed by the knife or the ligature. If the base be
broad, the double ligature must be employed : but the knife
is always to be preferred, especially, if there be any hardness
about the part, where the ligature must be apjplied.

Encysted tumours may form in the labia. They are
elastic, and contain a glairy fluid. The cyst may be laid
open, or it is to be dissected out.

Mr. Clark t describes, under the name of the oozing tumour
of the labium, an enlargement which affects, particularly, fat

• An eoonnoas tamoar which cotered the two oppw thlrd« oj**** thigh, and
extended aUmg the TsgiiM^ <^d rectum, was extirpated by M. Goutayron.
Bojrer, Trait^ Tom. z. p. 397.

t Uo Di«chaiiea» Fart ii. p. 127.

women, and which, although it may extend eren to the mons
veneris, does not project above a hne or two above the sur-
face, and undergoes little change of colour. It discharges,
however, from its surface an abundant quantity of water or
serum, which may, by fretting the part, produce excoriation,
or cause an erysipelas. He advises the application of starch
powder alone, or mixed with astringents, but thinks spirits
still better. Temporary relief may be obtained by cold water.
If the health suffer, and bark do no good, the parts have been
extirpated. As the disease seems to consist in a serous
secretion from the follicles of the skin, a solution of nitrate of
silver, so strong as to act as a mild caustic, might be useful.

SECTION SIXTH.

CBdematous tumour of the Ikbium is either a consequence
of pregnancy, or a symptom of general dropsy. The tumour
is variable in its size. When it depends on pregnancy, it is
seldom necessary to do any thing : and even in time of labour,
although the tumour be great, we need be under little appre-
hension, for it will yield to the pressure of the child's head.
But if, at any time, during gestation the distention be so
great as to give much pain, then one or two punctures may
be made, in order to let out the fluid ; but this is very rarely
necessary. Gentle laxatives are generally useful. Blisters
applied to the vicinity of the part have been proposed ; but
they are painful, and even dangerous. When the swelling
depends on dropsy, diuretics are to be employed : but if the
woman be pregnant, they must be used cautiously •-

SECTION SEVENTH.

Pudendal hernia is formed in the middle of the labium. It
may be traced into the cavity of the pelvis, on the inside of
the ramus of the ischium, and can be felt as far as the vagina
extends. It differs farther from inguinal hernia, which also
lodges in the labium, in this, that there is no tumour discov-
erable in the course of the round ligament from the groin.
It sometimes goes up in a recumbent posture, or it may by
pressure be returned. A pessary has httle effect in keeping
it up, unless it be made inconveniently large. It is not easy
to adapt a truss to it, but some good ia done with a firm
T-bandage, or one sindlar to that used for prolapsus ani. If
it cannot be reduced, we must support it by a proper bandage,
which is not to be drawn too tight.

Sometimes the labia are naturally very small, at other

times uncomnumly large ; one aide may be larger than the
other.

Liaceration of the labia is to be treated like other wounds.
When the hemorrhage is great, the vagina, if the vessel
cannot be seen, must be plugged, and a firm compress applied
externally, with a proper bandage*

SECTION EIGHTH.

The most frequent disease to which the nympha is subject^

is elongation. When the part protrudes beyond the labia, it

becomes covered with a white and more insensible skin. But

sometimes it is firetted^ on which account, or from other

causes, women submit to have the nympha cut away. This

is done at once by a simple incision; but as the part is

exceedingly vascuJar, we must afterwards restram the

hemorrhage, either with a ligature or by pressure. By neglect,

the patient may lose blood, even ad deliguium* In some

countries, this elongation of the nympha is very common.*

In others, the nymphe, together with the preputium

cUtoridis are removed m infancy.! The nymphs are subject

to ulceration, tumour, and other diseases, in common with

the labia.

Sometimes by falls, but oftenert in labour, the vascular
structure of the nympha is injured, and a great quantity of
blood is poured out into the cellular substance of the labium,
producing a black and very painful tumour.§ This may take
l^ace even before the child is expelled ; and, in a case of this

* The feuudei amonf the Boij«niiaiis have the nyuphtf aometimn Sre inohes
loof. Th^ eolonr is a. livfd blue, like the excrescences of a turkey. Vide
Barrew^ Traveia in Africa. Vol. L {>. 879, Med. Chir. Thins. Vol. vii. p. 164.
See aiao an account of the Hottentot in the Lancet, No. 476b p. 147.

f On the shores of the Persian Gulf, among the Christians in Abyssinia, and
in Egypt anumg the Arabs and Copts, girls are circumcised. Niebuhr saysy
that at Kahita, the women wlio peiform this operation are as well known as
midwifes. Travels. Vol. ii. p. SSa— Dr. Winterbottom, in his account of Sierra
J^cooe, Vol. ii. p. 289, says It is practised among the Mandlngo, Foola, and 8oo«

I M. CansaaboD has inserted a memoir on this subject. In the 1st Vol. of
Rccueil Perfodique, which contains several useful eases. In one of these, the
tnasoor was prsdnced on the seventh month by a kick, and terminated fatally by
hwBorrhage.— In another given by Sedillot, the labia became prodigiously dis-
tended daring labonr, and the bead of the child could not be touched. The hibia
were torn by the attendant. AHerward the child was delivered with the lever.
—In cases related by Baudelocque, Bnisdor, ftc., the tumours were opened, and
the vagina Ragged, whilst the wound was stuffed with lint dipped in solution of
alum, to prevent hiemorrhage.

§ In a case related by Mr. Reeve, the tumour, which I suspect proceeded from
the rupture of the nympha, was perceived first in perineo, but soon occupied all
the left lahf nm, which was enormously distended. The osin at first was so great
as to eaose syncope. The parts sloughed, and discharged pus and clotted blood.
Bark was given, and she got well. Lond. Med. Jovr., Vol. iz. p. 1 19.

*»»i,'- •

kind, the midwife, mistaking the swelling for the protruded
membranes, actually perforated the labium, and caused a
.considerable discharge of blood.* More frequently, however,
the tumour appears immediately after deUvery^t and the
attention is directed to it both by its magnitude and its
sensibility, which is sometimes so great as to cause syncope.
It is tense, throbbing, and may also be accompanied by severe
pain in the legs, and violent bearing-down efforts,) as if
jmoiher child were to be bom, or, as if the womb were
inverted. It has, however, been known to advance so slowly,
as not to attract attention for two davs. There are also
instances where the inflammation runs high, and the recto-
vaginal septum sloughing, fseces are discharged by the
vagina.§ Sometimes either in this complaint, or by laceration
of a vessel in the pelvis, blood collects along the side of the
vagina, forming a land of false aneurism in the pelvis.

In the course of a short time the tumour bursts, and clotted
and fluid blood is discharged. || This process should be
hastened by fomentations and poultices, and the pain be
abated by opiates; but if it be very great, relief may be
obtained by making a free opening in the inside of the labium, ^
which may prevent the parts from sloughing. Whether the
tumour burst, or be punctured, the previous inflammation
may close the vessels so as to prevent hemorrhage ; but if it
do not, the vagina is to be gently filled with a soft cloth to
prevent the fluid from extending along the sides of the
pelvis. A compress is also to be firmly retained externally,
to check all haemorrhage from the aperture. If inflammation
run high, it is to be abated by the usual means. If the dis*
charge be foetid, it is to be washed out by syringing first with
tepid water, and then with a weak solution of chloride of lime.

• Vide caM by Dr. MaitUod, in Mad. Comment. Vol. vi. p. ttk-^-Dr. Per-
fect rplatee a ease, where it barat iCaelf before the child was born, and diseharfod
maeh blood. Vol. ii. p. 63.— In another, which ended fiitaUv, the tvmoor hmtt
after delivery, and diachaiYod five poands of blood. Vide Pknk KloBiitn,
pw 111 — Case by M. SediUot, in Kecaeil Period. Tom. i. p. S60.

f Vide cases by Or. Macbride In Med. Obs. and iuq. Vol. t. p. SS.

^ In Mr. Blacden*s case, related by Dr. BailUe, the woman soon after delivcrx
had Tiolent bearing-down pains, as if another child were to be bom. A mo^
strous swellini^ appeared in the right labium, extendinf to the perinaam. A
large incision was made, which did not heal tiU the Hist day. Med. and Phyaknl
Journal, Vol. ii. p. 42.

§ Vide Fichet do Flechy, Obserr. p. S75. The patient was cured by Intro-
dncing a compren Into the Tagina, and dreanng the sore with digestlro ointment.

I In Mr. Hompage*s case the tnmour bant daring labour. Med. and Phya.
Jour. T. AS.

5 Le Dran relates a case, where abore SO ounces of blood were ovacvatcd by
incision. Consulutions, p. 4IS. See also Mr. fiaillie*o case, Mod. and Phyo.
Jour. xl. 42.

Wounds of this part are peculiarly dangerous, from tli^
^reat quantity of Uood which may be lost* I have been
iayoured, by Dr. Corkindale, with an account of four cases of
murder, effected by stabbing, apparently with scissors, at the
side of the nympha. In one case, the wound entered the
cavity of the abdomen, in the rest, it did not go deep. In
none, was there any distinct yessel wounded, but in all, the
loss of blood proved speedily fatal. All the women were
under the influence of ardent spirits at the time, and one of
them was pregnant*

SECTION NINTH.

The clitoris may become schirrous, and even be affected
with cancerous ulceration. In this disease, it is generally
thickened, enlarged,* and indurated, and the patient com-
plains of considerable pain. Presently, ulceration takes
place, and the margins are everted. This is sometimes com-
bined with schirrous uterus. A large warty looking tumour
has followed a venereal affection.f tJnless the whole of the
diseased part can be removed, we must be satisfied with
palliating symptoms, but if an operation can reach the whole
of the disease, it should be performed. As the upper part of
the nympha almost always participates in the disease, and
must be cut, considerable haemorrhage may be expected.
Erysipelatous inflammation is apt to follow, or the bladder
or uterus may become inflamed.

The clitoris sometimes becomes pretematurally enlarged.!

' * Mr. ISmmooa cut off a olitorli, wbSch formed a tamour nine inches in length,
Mnd fourteen in dreamference, at the largest end. The eireamferenoe of the
stem was fire inches. Med. and Phys. Journal, Vol. ▼•?•!• In * case related
bj Kramer, where the clitoris was enlarged, with cauliflower-like excrescences,
and the right nvmpha indurated, the parts were successfolly removed by the
knife, after fallhig with the ligature, which produced unsupportable pain.—*
Schmucker's Misod. Surg. £ssays. Art. xxiii. In Dr. Auchincloss's case, part
of the urethra was removed with the ditoris. Glasgow Journal, Vol. il. p. 165.
See also Dr. Macfarlan's Report.

{Mr. Lewis' ease, Med. and Phys. Joum. xxy. 286.
Upon this subject, see Amaud on Hermaphrodites,
n a child aged three yean, I found the mons yeneris prominent, and, as wdl
as the labia, covered with a considerable quantity of red hair, llie labia were
large and thick, like thoee of a grown woman, but shorter. Their inner surface
waa white and rugous, until near the orifice of the vagina, where the skin was
red. At the top the labia divaricated, and showed a larve clitoris, which hung
down like the penia; it was upwards of an inch long, and about half an inch in
diameter, and furnished with a thick wrinkled prepuce. It had a distinct glans,
at the end of which was observed something like a perforation ; but on raisins
It n|H this was seen to be only the esrtremity of a deep sulcus, which extended all
the way to the urethra, or orifice of the vagina. It resembled the male urethra
ilit op. The sides of this were formed by the nympha. A little before the
erillce of the urethra, there was a longitudinal eminence, like the vem montanum,

This is said to be most frequent in warm climates ; and in
these, extirpation is sometimes performed. Haller assigns a
cause for the enlargement* More firequently the enlargement
is congenital, and especially if accompanied with other con*
fusion of parts, the person may pass for an hermaphrodite.
The clitoris may be affected with disease rather of a schirrous
than cancerous nature. I have seen it several inches long,
thickened and expanding towards the extremity, into pdypus
looking enlargements covered with smooth mucous membrane
in some places ulcerated. It is doubtful in some cases
whether tne disease be really in the clitoris, or only in its
prepuce.

SECTION TENTH.

The most frequent disease of the hymen is imperforation ;
but this is not so common as is supposed, for, in many cases
the orifice of the vagina is closed by a strong membrane,*
and by careful examination, the hjrmen with its natural per-
foration may be seen closely applied to the face of this. In
consequence of this occlusion, whether by the hymen or not,
the menses are retained. The uterus is seldom distended^
at least to a great degree, but it is raised up, and the vagina

Jrodigiously distended, so that a tumour is formed in the
vpogastrium, like the uterus in the sixth or seventh month
of pregnancy. When an opening is made, the vagina is then
found to be the chief seat of the collection, and die os uteri
is felt enlarged in a lateral direction, the lips are extended
laterally, and the opening is much larger, but the finger
cannot be carried into the cavity of the uterus. In this dis-
ease, the orifice of the vagina is always prominent, and some-
times so much so, as to resemble polypus, or a prolapsus
uteri ;f or it becomes fretted and covered with scabs. £ven
the perinseum may be stretched, as if the head of a child

The TiffiiM WM that ap hj the h jmen. The ntenia wu large, like Unit of •
firl of foorteeD yean of age, and waa ehaped like bera. The owla were of oar«
rcepoDdiflur else ; one of them lay on the pMoa maaele, the other wae loeee in the

CiTia. liie tubee were Smhrlated at their emremUy, bat in their coarae were
lotted and aerpentlne, like the eenBaenoeflBent of the rtm defercne. The nterua
Waa Tery Taacnbr, and had an InSamed appeannoe. Ita month waa apparently
InperTioua*

In a aaale child that f lately ww, the external parta rewmble thoee of the
female. The lerotom la deft like the fuUm, the pcnle conaitta only of eorpeim
caTCTnoia, and the orethra opene between the labia formed hj the ecratam«

* The aame effeet may be prodnoed, by a eontlnnatlon of the akin being
tended oTcr the porta. It must be eat np. See a oMe by M. Laney, In Uapport
General de la Soeietd Phllomatlque, Tom. ii. p. 88.

f Vide caae of a patient of 0r. Chamberlain*!, In Cowpcr^ Analemy.— Caae
bjr Mr. Fryer, in Med. Facto and Oba. Vol. vUl. p. laS.

rested an it* Menfltruation is generally painful, and p&ins
like those of labour come on, especially about the menstrual
period;! such a case may, therefore, by inattention, be
miataken for parturition4 The sufferings of the patient are,
in some instances increased by the addition of painful reten«
tion of urine,§ or pain in passing the feces, || or conrul--
sioiuuY When the catheter is required, it is easy to see that
it often must be directed upwards, owing to the distention of
the vagina. Imperforated hymen, as it is called, is by no
means uncommon, and the treatment is very simple, for the
part is eauly divided.** The retained fluid is thus evacuated,
sometinies in Tery great quantity. It has yery rarely the
appearance of blood, bemg generally dark coloured, and
pretty thick, or even like pitch. Febrile and inflammatory
8]fmptonis may follow the operation, ft particularly if there be
a thicker substance to divide than the mere hjrmen.

The hymen, although perforated as usual, is sometimes so
strong as to impede the sexual intercourse; yet in these
cases impregnation has taken place, and the hymen has been
tom,tt or cut in the act of parturition. Conception may take
place, although the hymen be imperforated.§§

* Cue by Mr. Sherwln, in Mad. Raeorda, ftik p. 879.

t CfeM bj Mr. Kjrymcrf io Med. Annals, VoL vl. p. 947. By Mr. Eaton, in
Med. Comment. VoL U. p. 187. and a variety of other caaes. This, in every
instanee I have known, ins been the greatest complaint.

f Dr. Snellle candidly acknowledges, that in one instance he took the pn>-
trusion 1^ the hymen for the membranes of the ovum forced down by labour pains.
These pains were accompanied with suppression of urine. He let out about two
quarts vf blood. ColL i. n. i. c 6.

5 In a case related by Benevoll, the belly was very much swelled, and the urine
suppreaaed. He attempted to pass the catheter, but without success. Next day
be repeated bis eodeavour» and pushing with more force than prudence, consider*
Ing hb object, he ruptured the hymen, and immediately a great quantity of dark
matter was evacuated, even to the extent of at pints.— See also Mr. Fryer's case.
— ^Mr. Warner relates the case of a little jrirl, where the hymen was continued
half way over the orifice of the urethra. The effects were at first attributed to
■tone In the bladder ; but the nature of the case being mftdo oat, sho was cured
by dividing the hymen. Casest p. 7&

I In a case by ddr. Bardy, the patient, who was fifteen years of age, had every
month, for some days, niu in the uterine region. The external parts were gbeatly
Mfemdod and stretehea as in labour, and the nymphv formed merely two lines.
Itie anus was thrust backward and distended, and she passed the urine and
isfiees with great pain ; tlie hymen from irritation waa covered with scab; the
health had auAred. Six pounds of thick gelatinous matter were evacuated by
indsion. Med. and Chir. Review for September, 1807.

J Vide Case by Mr. Fynney, Ui Med. Comment. VoL iU. p. IIM. ^ . ,^
• Io Mr. Fynney's case, the part to be divided, was very thick ; and in Dr.
M<Cormick*s ease, the vagina seemed to be in part impervious. Med. Comttienf.
VoL iL p. 168.— In general the membrane Is tnin.

ft Vide Mr. Niven's case, in Med. Comment. VoL ix. p. SSa— The symptome
gradnaliy abated. In a case related in the Medical Gaaette, No. 142, lata! pcH'
leneal inflammation took place on the third day.

H M. Bauddocque mentions an instance where the hymen resiftted» for lialf
an nonr, the strong actfen of the uterus. Note to Section 84l«

§5 Vide Ambrose Pari, Hildanus, cent. ilL ob. 60.— Ruysch. oh. 82.— MaurU

' When the hymen is torn in coitu, some blood is eyacuated,
irhich, in many countries, is considered as a mark of yir^nity.
But, as eyen the presence or absence of a hymen, cannot be
looked upon, as affording any certain proof relatiye to chastity,
this test must be considered as altogether doubtful. Wlien
the hymen is ruptured, and there is an inflammation about the
external parts, some haye, in cases of alleged rape, considered
the crime as proyen. But whoeyer attentiyely examines the
subject must admit, that these are yery fallacious marks ; that
they may exist without any yiolence haying been employed ;
and that a woman may haye, if preyiousiy stupified, been
yiolated, without exhibiting any mark of injury. Practitioners
therefore ought, in a legal question of this nature, to he
cautious how they giye any opinion, especially if they haye
not seen the person immeoiately after the cnme has been
committed.*

SECTION ELEVENTH.

The perinseum may be torn during the expulsion of the
head or arms of the child. In many cases, the laceration
does not extend farther back than to the anus, nor eyen so
far. This is a yery simple accident, and re(|uires no other
management than rest, and attention to cleanhness, by which
the parts unite, at least to such an extent as, in general, to
preyent inconyenience. But as the recto-yaginal septum is
carried forwards and downwards, when the perinsum is put
on the stretch prerious to the expulsion of the head, it some-
times happens, that the laceration extends along this septum,
and a communication is formed betwixt the rectum and
yagina. In some cases, the sphincter ani remains entire,
although the rectum be lacerated, that is to say, the rent
passes by the side, sometimes both sides of the ormce, and of
the sphincter, and yet may extend up the septum. But in
almost eyery instance wnere the septum is lacerated, the
sphincter also is torn. This accident is attended with con-
siderable pain and haemorrhage, and succeeded by an inability
to retain the ffleces, which pass rather by the ya^^na than the
rectum. Prolapsus uteri is also in some instances, a conse-

Suence of this laceration* This accident is sometimes pro^
uced by attempts to distend the parts prerious to deliyery,

eMQ, ob. 488. In a am lately published by Cbmrnplon, the nrelbni wu fTMtlj
dOated, and had Mrred as a ■abatitoto for the Taglna, noCwithatanding which the
female became nrecnant, and waa deliYerfd by dividing the hymen. Jour, de
Med. Tome IxtIII. p. 84. , «. „

* Vide Baudelocqae, TArt, Ac lec S4S, ct Foder< Med. Legale, Tome iU
p. S.

or by the use of instrumeiits ; but it may also take place, even
to a great d^ree, in a labour otherwise natural and easy,
and in which no attempts have been made to accelerate de-
livery. At the same time, I must say, that I have never
known the septum torn, in any woman, who was delivered
alone. The most effectual way to prevent laceration, is by
supporting the perineum when it is stretched, and keeping
the head from being suddenlv forced out. When the parts
have been actually torn, our nrst attention is to be directed
to the repressing of the haemorrhage, which is sometimes
considerable, and this is best effected by temporary compreeh
eion, which favours the formation of coagula. Next, we are
to consider how the divided parts may be united. Rest, and
retaining the thighs as much togemer as possible, cdong
with frequent ablution, in order to remove the urine, which
sometimes for a few days flows involuntarily, or the lochia
and stools, are requisites in every mode of treatment. Indeed
when the luine can be retained, but seems to irritate the
parts, when voided, it should for some time be drawn off with
the catheter. As there is nothing in the structure of the
parts, to prevent their re-union, it has very feasibly been
proposed, to induce a state of costiveness, and prevent a stool
for many days. But with only one or two exceptions, this
method has failed, the subsequent expulsion, of the indurated
fasces, tearing open the parts, if adhesion had taken place.
An opposite practice, that of keeping the bowels open, and
the stools soft or thin, by gentie lioatives, has been much
more successful, the rent, in some instances, healing in a few
weeks; and this is the practice I would recommend to be
adopted, taking care, at the same time, to keep the parts in
contact, by confining the patient to bed, with the thigns kept
together. During this period, the stools are, at least for a
time, passed sometimes involuntarily ; but in other instances,
they can from the first be retained, if the patient keep in bed.
Sutures have been frequently employed, and, although they
are never in the first instance to be resorted to, nor till the
tender condition of the parts has gone off, yet, they ought
certainly, at last to be had recourse to, if re-union cannot
otherwise be effected. The edges of the divided parts must
previously be made raw. If the laceration in the septum be
extensive, it may be requisite to apply either one or two
stitches there, by using a speculum vaginas, and a needle,
fixed in a handle, with the eye at the sharp end. If the rent
be small, it may be sufficient to place two stitches in the
perinaeum. When the sphincter ani remains entire, but the

septum is torn, some have considered it necessary to divide
that muscle ; but others, with more reason, omit this practice*
During the cure, some introduce a canula into the vagina, to
support the parts, and others apply compresses dipped in
balsams ; but it is better to apply merely a pledget, spread
with simple ointment to the part. If the radical cure faU, the
patient must use a compress, with a spring-bandage, if the
stools cannot be retained. But it sometimes happens that the
torn extremity of the rectum, or the anterior part, containing
a fragment of the sphincter, or a portion of the internal
sphincter, as it has been called, forms a kind of flat valve,
which rests on the posterior surface at the coccyx, so that the
orifice now resembles a slit, and the faeces, unless very liquid,
remain in the hollow of the sacrum, and do not pass through
the valvular orifice, till an effort be made to expel.* Some-
times the perinseum unites, but the septum does not, and the
inner surface of the rectum protrudes into the vagina.t In
this case the edges of the septum must be made raw, and
stitches used. When an opening takes place between the
two passages, not by kceration but ulceration, from chancre
or other causes, the same treatment must be adopted,
though, in one case, under tiie care of Dr. Gibb, the
aperture became considerably contracted, by the use of the
actual cautery*

When the laceration does not extend into the rectum, but
takes a more lateral direction, distress is often produced,
rather by the feeling of falling down, or weight in the rectum,
or by its actual protrusion, than by uterine bearing down.
The front of the gut and back part of the vagina are turned
forward and downward, and excoriation of the skin adds to
the evil, whilst pain and heat are felt extending down the
inner side of the thigh. We can only, as a radical cure,
have recourse to sutures, after paring the edges. Should
these fail, we must use a compress and spring-support.

• Upon this taMeeC» Tld« La Motto's IMt^ ; and Qwso md Olimtlons kf
Noel, Sauosrotc, XniDel, and Sedillot, in the fourth and seTcoth VoL of tho
Reeuell Periodique. Merriman*s Synopsis, p. 104. Edin. Journal, Nov. ISSS.
Dr. Oenman mentions an instance where the pcrineam was not torn ap» hot
perforated hj the head. Both Petit and Gardien notiee the fact, that the stools
aaj ultimatsljr oome to be retained, Imt do not eeem aware that this depends
on the formation of a valve. They think it owing to the enhinetar regainlnf Ito
power. See also a paper in Archires, zrii. p. f84; and a discussion on pertora*
tion of the perineum, the eommlsiura and anus remaining entire, by Moreau and
Capnson, in Tome zxiii. pp. 882—294.

t Dr. Nieol's esse, Edin. Journal, zzxll. 24. The operation was perfermod
three times, and ultimately with success. There was pr»f oss hvmorrhi«e In tha
second attempt. Bi. Roox has repeatedly used the stntehsr with success On
rcmovinf the ligature, a small ftstuha> opening remained for some time between
the rectum and vagina, but in a asvcnth case the union was oonpleto at ftrst.

SECTION TWELFTH.

The yagma may be unusually small. I have known it not
quite three inches long, and sometimes it is very narrow*
The size, if necessary, may be enlarged with a tent of pre-
pared ^nge.* Should pregnancy take place before it be
niUy dilated, we need be under no apprehension with regard
to delivery : for, during labour, or even long before it, relax-
ationt takes place. Sometimes the vagina is wanting,t or
impervious, or all the middle portion of the canal is filled up
with solid matter. More frequently, however, there is only
a firm septum stretched across, behind the situation of the
hymen, or higher up in the vagina; and this, which has
usually a small perforation,§ it may be necessary to divide.
The finger is to be introduced to the septum, and along it a
probe or director is to be carried, and the septum explored
to discover an aperture. Then, by means of a probe-pointed
bistoury, or curved scissors, the part is to be divided. If
there be no perforation we dare not operate unless there be
very distinct fluctuation fi*om retention of the menses. In
this case the obliteration is generally near the orifice, or there
IB no orifice, but a fibrous septum, and sometimes the whole
canal is very hard. Fatal inflammation may follow the opera^
tion. When there is a contracted vagina, with stricture at
one part, there is usually pain in coitu, and sometimes during
menstruation. The stricture may be carefully divided, but
nothing can alter the unusual contraction from mdurated tex-
ture. In some cases, there is a great confusion of parts, and
mdeed it is impossible to describe the varieties of conforma-
tion ; for the vagina may follow a wrong course, or commimi-
eate with the urethra, or the rectum | may terminate in the

* Vide Van Swieten Comment, in aph. ISSOu

t In a caM where the Taglna would not admit the point of the litUe finger» the
ebUd was ddivend after eighteen houn* labour. Flenk Elementa, p. lia See
alao Van Swieten.

t Where it le deficient altogether, then a aound introduced into the urethra ia
hit hj the fingo* from the reetnm with merely a thin aeptum interpoeed. In one
cue ranted by Boycr even the e^rnal parts were almost entirely wanting, and
the breasts were very small.

S This may produce bad effects, from retention of the menses. M. Magnan
nlaites the case of a girl, sged twenty-two years, who had been subject to monthly
colics and suppression of urine. An incision vas made through the membrane,
and two poonds of blood let out. Hist, de la Society de Med. pour 1776, art. ii—
I sometime ago saw a lady who before marriage had the hymen diTlded on
aeoonnt of imperforatlon. But she was erer afterward sulject to great pain
daring the menstrual period. The discharge came away verr slowly, and was
dark and ill smelled. A septum was found nesr the oe uteri, and toward one
aide a small opening was dlsoorercd, through which a director was pushed, and
then the part divided by a bistoury, the greatest portion of the blade of which
was wranped up in lint. The operation was succenful.

I In tnia case the fsoes do not always pass continually. The patient has been

vagina, &c. Malformation does not always prevent preg-
nancy,* but it usually occasions much pain about the menstrual
period, and where there is a deficiency of the canal, and the
menses are still secreted, they are retained, and the hypogas-
trium becomes swelled and painful.f

SECTION THIRTEENTH.

In consequence of very severe labour, inflammation fol-
lowed by gangrene of the vagina, may be produced. If the
sloughs be small, then partial contraction of the diameter of
the canal may take place, and cause much inconvenience from
retention of the menses,} or during a subsequent labour ; but
in this last case, the parts gradually yield, and it is seldom
necessary to perform any operation : the pain, however, is
sometimes excruciating tiU the part yield.§

In some instances, the sloughs are so extensive, that the
whole vulva is destroyed, or part of the urethra and vaffina
come away, or general adhesion takes place, leaving only a
small opening, through which the urine and the menses flow.
Should this by any means be obstructed, the discharges can-
not take place ; and sharp pains, or even convulsions, may be
the consequence. Sometimes calculous concretions form be-

known not to hvn a ttool onoe in a fortnight, which probahly depended on the
fatem being indurated, and the commonicauon email.

* In the SSd Vol. of the Phil. Thine, p. 142, there le a caee related, where
there wae a kind of doable Taglna, eepamtea by a tranereree eeptum or membrane.
The oriAoee were very email. During labour the pain was eo great ae to produce
convttUione. She wae delivered, by laying the two paeeagee into one. Coapmaa
relatee a caee of malformation, where the woman was impregnated, and In labour
all the forcing was felt at the anus. From this an opening was made through into
the vagina, and the child was bom per anum. Portal mentions a girl, who had
only a very small aperture at the vulva, for the evacuation of the urine ; tha
menses came from tae rectum ; nevertheless she became pregnant. Before do*
liverv, the orifice of the vagina appeared, and she bore the child the usual way.
Precis de Chirurgie, Tom. 11. p. 745.

f De Haen relates a cai« of this kind, where an operation wae unfortunately
performed. The patient died, and it was found that the bladder had been
opened by the incision, and the dlschaige, mistaken for retained menses, had been
urine and blood. The uterus was unopened and distended with menees. Boyer
■lentioos two casee, where attempts were made |o puncture. In the one Irom the
rectum, In the other from the neck of the vagina. Both proved fatal irom In-
tammation.

I Kiehter In Comment. Gottlng. Tom. ii. art. 2, relates a case of a girl, aged
twenty years, who for three yeare. had been suliject to violent pains about the
sacrum, with tremours and syncope every month. The vagina was found to be
doeed at the upper part. In consequence, it wae imagined, of a variolous uloer in
infancy. Fluctuation was felt In the vagina, when prcesnre was made with
the other hand on the abdomen. The contraction was opened, and a qnantltv of
blood let out. Dr. Merriman, in his Synopsis, p. 67, mentions a case wlicro
there was a gristly contraction in the vagina, produced by a former eevere labour.
The patient, again pngnant, was delivered after a labour of thirty-six hours, but
died on the second day. The vagina was found ruptured in a alight dcgrecb

$ Harvey, excrdt. Ixxiil. p. 48S.

ybnd the adhermg part,* or even without any apparent pre-
vious disease.

Whenever we have reason to expect a tender state of the
parts after delivery, we must be exceedingly attentive ; and
if the vagina, or any other organ, be inflamed or tender, we
must bathe the parts frequently, and inject some tepid water
eently, to promote cleanliness. Saturnine fomentations and
mjections are often of service, but they must not be throwji
high. The urine must be regularly evacuated, and, should
a slough take place, we must, by proper dressings, or the use
of a thick bougie, prevent coalescence of the vaginal canal.t

Abscesses and smuses connected with the vagina, must be
treated on the general principles of surgery ; but it is proper
to mention that sometimes the orifice of the sinus is exces-
sively tender to the touch, insomuch as almost to produce
syncope. In all cases of extreme sensibility of this canal, it
ought to be carefully examined, and the painful spot may
point out the seat of the disease. The sinus should be laid
open, and haemorrhage prevented by the injection of cold
water, or insertion of lint, wet with a styptic.

The sphincter, or orifice of the vagina, may become so
painfully sensible, as to occasion exquisite suffering on intro-
ducing the finger, or during coitus, or even on having a stool.
This state may be produced by exposure to cold, excessive
venery, &c. It is sometimes dependent on little tubercles,
or inflamed patches at the orifice, in which case we may trv
the free application of nitrate of silver, with or without scari-
fication. But if there be no tubercles, and especially if there
be tightness at or within the orifice, we must in one or more
places divide the mucous coat, as high as there is any thing
Uke a band : afterwards we apply a tepid poultice. See p. 45.

SECTION FOURTEENTH.

The vagina may be contracted by scirrhous glands in its
course, or induration of its parietes, which become thick and
ulcerated, and communicate with the bladder or rectum.
This disease is generally preceded by, or accompanied with,
scirrhous uterus, and requires the same treatment.

Foreign bodies in the vagina produce ulceration, and fun-

* vide PoxM Thdt^ p. 140 Case by Mr. Furton, in Med. and Phyi. Jour.

Vol. tL p. 2.

t In some oerto of Africa, the yiffina ie made impervionet in order to prerent
coition. Thti operation \m generally performed betwixt the age of eleren and
twtlre years. Brown's Trayelsy p. 949.

goufl excrescences. . The source of irritadon being remoTed,
the parts heal ; but we must, by dressing and injections, pre-
vent coalescence. Earthy incrustations may also form.

Polypous tumours may spring from the vagina, and are to
be distinguished from polypus of the uterus by examination.
The diagnosis betwixt polypus and prolapsus, or inversio
uteri, will be afterwards pointed out. The cure is effected
by the application of the ligature more solito.

SECTION FIFTEENTH.

Inversion or prolapsus of the vagina, is easily known by the
fulness within tne orifice in slight, or the actual protrusion,
especially at the back part, in great degrees. At first, the
tumour is soft, but if it be allowed to remain long protruded,
the surface may become firm, and more like skin, or it mav
inflame or be fretted. The whole circiunference of the canal,
may be relaxed and descend, but it is usually the posterior
part, at the recto-vaginal septum, which is most affected.
The whole length of the canal may be relaxed, and in that
case the uterus descends more or less ; but in what is gene-
rally called inversion of the vagina, it is chiefly the part near
the orifice, which is relaxed, or rather, to speak more cor-
rectly, which is deprived of its due support, by extension of
the mscia at the outlet of the pelvis, and defective action of
the levator ani. The bladder and urethra are seldom much
affected, but in those cases where the anterior part of the
fascia, at the pubis, and the levator there, are relaxed, the
bladder does descend a little, and the urethra is corrugated,
and perhaps somewhat altered in its direction. The rectum,
in every degree, is more or less drawn down, and brought
forward, sometimes so much so, as to form a kind of pouch in
the protruded vagina. This being a disease of the connexions
of the vagina, rather than of the vagina itself, applications to
that passage cannot be depended on. Still, astringent injec-
tions, or lotions, may be tried. But we must trust more to
the cold hip bath, and strict attention to the bowels, in order
to prevent accumulation in the rectum, and a spring-support
similar to that used for prolapsus ani. It is seldom expe-
dient to remove a portion, or section of the side, of the pro-
truded part, with a view to make it contract. Excision of
the whole is neither safe nor necessary. Pregnancy at first
rather increases it, but in the latter stage it is relieved. Ais
it is apt to return after delivery we must keep the patient

fbr some time in a recmnb^it posture, and'must aUo, during
delivery, by due support, prevent the parts from being too
much pressed down.*

SECTION SIXTEENTH.

Water sometimes passes down from the abdominal cavity,
betwixt the vagina atid rectum, protruding the posterior sur^
face of the vagina in the form of a bag ; and the accumula-
tion of water in the cavity of the pelvis is sometimes so great
as to obstruct the flow of the urine, or produce strangury.
When the person lies down the swellmg disappears. If
large, a canole held on the opposite side, sometimes shows it
to be transparent; and in every case, fluctuation may be
felt. As this symptom is connected with ascites, the usual
treatment of that disease must be pursued, and, if necessary,
the water may be drawn off by tapping the abdomen, or
rather by piercing t the tumour, wmch is to be rendered
tense, by pressing it with the finger.

Sometimes the intestine passes down betwixt the vagina
and rectum, forming perineal hernia, or protrudes either at
the lateral or posterior part of the orifice of the vagina, like
the watery tumour ; but it is distinguished from it by its
firmer and more doughy feel, and by the manner in which it
can be retomed, which also shows that it is not an encysted
tumour. By handling it, a gurgling noise may be heard,
and sometimes indurated freces may be felt. Sometimes the

* Barton niatea a ease, wfa«re the prolapsed Taslna was nlitaken for part of
the placenta, and rudelj paUedy by which it and the Madder were torn. System^
p. 170.

StoHen velatea a ease, where this was complicated with calculi. These being
removedy the parts were redaced, and a cure obtained. Casss, Obs. 2>

f Mr. Henry Wstson, in the Med. Couimuoloations, Vol. i. p. 162, called the
attention of practitioners to this disease. In a case he relates, he drew off in the

month of June, four gallons of fluid, by tapping the vagina; and immediately
after this, she psssed the urine freely, whicn she could not do before. She re»
quired again to be tapped in two months, and died in Norembcr. The left ova*
rinm was found to lie converted into a cyst about the else of a sow*s bladder, but
it had not l>een touched by the trocar, in one case, he punctured with a lancet
instead of a trocar, but tnis was succeeded by troublesome h«morrhiu;e. The
good effects of tapping are also seen in a case related by Mr. Coley, in Med. and
Phys. Journal, Vol. vii. p. 412. In this, two gallons of water were drawn off,
and she continued well for iive months, after which dropeical symptoms returned,
and although diuretice gave her some relief, yet she was at last cut off. In the
case of Mrs. Jarritt, related by Sir W. Bishop, in Med. Commun. Vol. ii. p.
960, pain wm felt in the right side of the belly, after parturition, accompanied
with tnmedMtion. In twoyears the ragina became prolapsed, the tumour being
four inches in diameter. The tumour was punctured twice ; the first time 46
pints, the second 51, were drawn off. Diuretics had no effect. In a esse related
DT Or. Denman, the woman was pregnant, and no operation was performed.
C5n the fourth day after her delivery, after a few loose stools» she expired.
Introd. VoL i. p. 150.

protruded or everted l^urface of the vagina is ulcerated. As
the 08 uteri is pushed forward, and the posterior part of the
vagina occupied by the herniary tumour, this complaint may
put on some appearance of retroverted uterus. A case of
this kind is mentioned by Dr. John Sims, in Sir A. Cooper's
work on Hernia. In other cases it is impossible to feel the
OS uteri and the feeling is much like what one should expect
were the uterus itself turned upside down into the hernia.
Indeed, I have reason to believe that I have seen this happen.
This complaint is frequently attended with a bearing-down
pain ; and on this account, as well as from its appearance, it
nas also been mistaken for prolapsus' uteri. Sometimes the
tumour does not protrude externally ; but symptoms of
strangulated hernia may appear, the cause of which cannot
be known, unless the practitioner examine the vagina. In a
case occurring to Dr. Maclaurin, and noticed by Dr. Den*
man, the patient died on the third day, and the disease was
not discovered till the body was opened. Should a woman
have vaginal hernia during pregnancy, we must be careful to
return it before labour begin, for the intestine may become
inflamed, and the faeces obstructed, by the head entering the
pelvis ; or the labour itself, if the head cannot be ndsed and
mtestine returned, may be impeded so much as to require the
use of instruments. Vaginal hernia requires the use of a
pessary, or a spring-support. But I must add, that I have
Known so much distress loUow the induction, that the patient
was happy to get the hernia reproduced.

The rectum sometimes protrudes into the vagina, and
always does so, more or less, in an inversio vaginae. It forms
a kind of sac or dilatation on the front of the gut, and comes
forward on or over the perinseum, and permits of a lodgment
of faeces. This is remedied by the gloDepessary after all the
indurated faeces have been removed. The farther accumu-
lation is prevented by laxatives. It is possible for partial
distention of the rectum in front, or at the sides, to take place
higher up, and cause obstruction to the faeces, or tumour in
the vagina, but this I mention not on my own authority.
The upper part of the rectum is really not a strdght gut,
but curves to the left side, and if the attachment be lax, a
portion may, if distended with indurated faeces, form a greater
curve, or land of pouch, productive of pressure on the fundus
uteri, and obstruction to the stools.

SECTION EIGHTEENTH.

Indolent abscess, or encysted tumours, may form betwixt
the vagina and neighbouring parts. These, are distinguished
from hernia and watery tumours, by being incompressible,
and not disappeuing by change of posture. The history of
the disease assists the diagnosis, and examination discovers
the precise seat and connexions of the tumour, though it
cannot with certainty point out the nature of the contents.
I have formerly explained, how a fluid could be confined,
between the rectum and vagina, in the septum. These
tumours seldom afford obstinate resistance to delivery; by
degrees they yield to the pressure of the head, but sometimes
they return after delivery. The treatment is similar to that
required in other cases of tedious labour, and the tumour
must be opened, if we cannot deliver the woman otherwise
with safety to the child. Even in the unimpregnated state, if
it cause irritation, or if the bulk of the tumour be so great as
to impede the evacuation of urine or fseces, an opening must
be made. After delivery, in those cases where no operation
is performed, the tumour sometimes inflames and indurates
even so low as the perinseum. Friction on the perinfleum,
has in these circumstances done good.

Varicose tumours of a knotted form, disappearing or be-
coming slack by pressure, and aneurismal tumours distin-
guishable by their pulsation, may form about the vagina, and
ought not to be interfered with, except by supporting them
wiUi a globe in the vagina.

SECTION NINETEENTH.

A very dreadful disease, which I have called spongoid
tumour, may form either within the pelvis, or about tne hip-
joint, or tuberosity of the ischium, and spread inwards, press-
ing on the bladder and rectum, sometimes so much as to
require the use of the catheter. We recognize the disease,
by its assuming very early the appearance of a firm elastic
tumour, as if a sponge were tied up tightly in a piece of
bladder. Presently, it becomes irregular, and the most pro-
minent parts burst, discharging a red fluid, which is succeeded
by fungous. protrusion. But I have never known it proceed
to this last stage within the pelvis. I know of no remedy,
and would dissuade from puncturing, except in the very
last extremity. I have never met with a case where it was
necessary.

SECTION TWENTIETH.

The orifice of the yagina, together with the labia, and
indeed the whole vulya may be affected by eryaipelatoua in*
flanunation. This appears under two conmtions : 1^ it may
originate in the Yulva, and spread inwards, eren to the uterus;
or, 2c%, it may begin in me womb, and extend outwards.
The parts are tumid, painful, and of a dark red colour. The
second affection is most frequent after parturition; but the
first may occur at any age, and under a variety of circum-
stances* It may be confined to the external parts alone, or
it may quickly spread within the pelvis, and destroy the
patient, for this disease generally terminates in gangrene.
Vigarous* says, this state may be distinguished from abscess
of the labium, by both labia being equally affected. The
general history of the case, and proper examination, will
point out the difference. When the disease is confined to
the external parts, we may hope for a cure, and even for the
preservation of the parts, by giving early, quinine and opium
mtemally, and applying to the surface, pledgets dipped in
weak solution of sulphate of zinc, with the addition of a tenth
part of camphorated spirit of wine. When this application
gives continued pain, fomentations with milk and water, or
with decoction of chamomile flowers may be substituted.

A highly sensible or inflamed state of the parts f may occur
in nymphomania, or libidinous madness, either as a primary
or secondary affection ; and shoidd the patient die undo* the
disease, the parts are generally found black. The tepid bath
and fomentations ffive relief, and sometimes satiunine applica-
tions are beneficial. The acetate of lead has also been given
internally. Some advise rubbing the parts over with nitrate
of silver. If the patient be feverish she ought to be blooded^
and have cathartics administered, and be put on spare diet.
Nauseating doses of tartar emetic, or foil doses of the medi-
cine, given so as to operate briskly, are of service, especially
if followed by sle^. Strict and prudent attention must be
paid to the mind.

* Maladiet dM Tnbmm, Tom. II. p. 169.

f In the diMtM deteribed by wamm m cuUnh of th« utorai, <h« mnoom eatl
it inftun«d, aod th< ditesM bcffni by itdiiiif of tbo rvlwm, viifiBav and nt«ni%
lncr«Mlng to a great dq^ree, and attended with frequent detire to make water»
and eometimee nyaiplionania. Pain of tlie tiypofaetrium eenet on, with levw.
In aome daye a diicliarge of mneo-pnnalent matter takco plaoe^ hat the cure k
not completed for many weeks, and It may end In obstinate flnor albos. Vene-
seetioD» tepid baths, laxatiTCi, and dlapboretioei are the proper remedies.

A constant heat and tenderness of the parts, if not occa-
sioned by uterine disease, may be relieved by bathing with
solution of sulphate of zinc, and using laxatives.

Prurigo is often symptomatic of disease in the uterus, or
irritation in the neighbouring parts ; and in these cases can
only be removed by acting on the cause. When it is not
dependent on any evident local disorder, it is allayed or cured
by keeping the bowels open, avoiding stimulants, and applying
to the affected parts ung. hyd. nit. or bathing frequency with
tincture of myrrh diluted with rose water, or very weak solu-
tion of muriate of mercury in emulsion of almonds, or the
same salt mixed with lime water, or lime water alone, or
solution of sulphate of zinc alone, or with laudanum, or of
nitrate of silver; or acetate of lead dissolved in emulsion of
almond, or decoction of chamomile flowers, &c« This affeo*
tion may attend the early period of pregnancy, or the cessa-
tion of the menses. Sometimes, especiidly during pregnancy,
the itching and heat are attended with some inflammatory
swelling of the labia, with or without a turbid serous oozing,
and perhaps with redness and tenderness of the orifice of the
vagina. Besides the use of laxatives, rest, and mild diet, we
may bathe the parts with weak solution of sulphate of zinc,
or of copper, or one of the lotions just mentioned, or dust the
parts with calamine alone or mixed with white lead.

Prurigo affecting the anus alone, or along with the puden-
dum, mav arise from ascarides or other removable irritations;
but, in elderly females, this symptom should always lead to an
examination of the rectum, for it often attends stricture or
alteration of the intestine, which should be early attacked by
suitable means. So &r as itching and local uneasiness re-
quire prescription, nothing often succeeds better than a sup-
pository consisting of three grains of extract of hemlock and
one of opium.

SECTION TWENTY-FIRST.

The vagina is always moistened with a fluid, secreted by
the lacunae on its sumce. To this is added the secretion
from the glands of the cervix uteri, and the serous exhalation
from the membrane of the uterine cavity. Naturally, the
balance between secretion and absorption is such, that except
on particular occasions, no fluid is discharged from the vagina.
But in a diseased state, the quantity of the secretion is greatly
increased^ and the discharge, whetner proceeding solely from
the vagina, or partly also from the womb, receives the name

ef fluor albus, or leucorrhoea. Some confine the term, strictly,
to a discharge from the inner surface of the womb, and in
order to determine whether the secretion proceeds from the
uterus or not, it has been proposed to stuff the vagina com-
pletely for some time, and then inspect the plug, to ascertain
whether that part corresponding to the os uteri be moistened.
But this test is not satisfactory, and will seldom be sub-
mitted to. The speculum has been used for the same purpose.

When the discharge proceeds frpm the womb, it some-
times injures the function of that organ so much, or is de-
pendent on a cause influencing the uterus so strongly, as
to interfere with menstruation, either stopping it altogether,
or rendering it too abundant or irregular in its appearance ;
and in such cases, the woman seldom conceives. Very fre-
quently, however, the menses do continue pretty regularly ;
and in those cases, the other discharge disappears during
the flow of the menses, but is increased for a little before
and after menstruation. When the menses are obstructed,
it is not uncommon for the fluor albus to become more abun-
dant, and to be attended with more pain in the back, about
the monthly period. In such cases it has been thought that
the leucorrhoea served as a substitute for menstruation, and
that it was dangerous to check it. If a woman who has ute-
rine leucorrhoea conceive, the discharge stops, but a vaginal
secretion is, on the contrary, not unfrequently increased.
This it has been thought dangerous to check suddenly, but it
ought not to be allowed to continue profuse, as it causes
abortion.

On this subject it may be well to attend to the following
circumstances: Isij Simple excitation, can increase the natural
secretion without changmg it. 2d, A continued increase of
action, more particularly if accompanied with any degree of
irritation, changes the appearance. 3<f, As affections of the
uterus and vagina, can act on the nerves, and produce not
only pain in the back, and more remote and extensive effects,
80, affections of the nerves, produced directly or sympatheti-
cally, can cause discharge. On this principle, many females
have leucorrhoBa, for some time, before menstruating at
puberty, and others have it, always, for a day or two before
the monthly period.'

Ruor albus may occur in two very different states of the
constitution, a state of plethora, or disposition to vascular
activity, and a state of debility. The one is marked by a full
habit, a good complexion, and a clear healthy skin. The

other by a pale countenance, a sallow surface, a feeble pulse,
and generally a spare habit. The one may be attended with
vertigo, or disease produced by fulness. The other by
dyspepsia, palpitation, and those complamts which are con-
nected with debility-
Scrofula gives a strong predisposition to this disease, as
well as to £^ections of mucous membranes elsewhere, and
often seems to operate without the aid of any evident exciting
cause.

The discharge is produced either by the lacunae of the
vagina, or the glandular and exhalent apparatus of the uterus.
The most ample and the most frequent source is from the
vagina. The discharge itself may consist simply of the
natural mucus of the part increased in quantity, in which case
it is glairy and transparent ; or it may be so far changed as
to become opaque, and white like milk, which is particularly
the case when ihe organs of secretion of the upper part of
the vagina and cervix uteri are affected ; or it may be puru*
lent. We also occasionally meet with a discharge like jelly,
sometimes turbid, sometimes clear and amber coloured. It
proceeds from the cavity of the uterus, particularly its cervix,
and seems to depend on a state produced by present, or pre-
viously existing, inflammalion. After deatn, by pressing the
uterus, we squeeze out from it a gelatinous looking substance,
probably fibrin. This may happen in acute fever, but also as
a chrome affection, in which case the female is sterile as long
as it lasts. The thin glairy transparent discharge is justly
considered as the mildest degree, and it is favourable when
the discharge, having been previously white, or green, or
Yellow, returns to this state. In all cases when the discharge
IS white, and particularly when there is pain in the region of
the uterus or back, the state of the cervix uteri should be
ascertained. These, may all occasionally be mixed ^th a
little blood from the uterme vessels, if there be a tendency to
menorrhagia, but not otherwise, unless there be organic
disease. In those cases where the discharge is yielded by
diseased structure,, it is modified by the nature of that
structure, and by the existence of ulceration and erosion.
When it proceeds from the morbid part itself, and not
from the uritating. effects of that part on the vagina, by
sympathy, it is generally fcetid, and purulent, often of a
dark colour, mixed with blood, and alternated by uterine
hemorrhage. There is often heat about the parts, and other
symptoms of disease. In all ambiguous, and m every chronic

case, it ia necessary to examine carefully the state of the
uterus and vagina.

Fluor albus is usually accompanied with pain, and sense of
weakness in the back. The functions of the digestive organs,
are always ultimately injured, and in those women who are
of a weak habit, they are impaired from the first. In them,
the discharge adds greatly to the debility, and all the diseases
arising from that state increase, such as indigestion, derange-
ment of the hepatic secretion, torpor of the bowels, palpi-
tation, swelling of the feet, &c. In the more plethoric
patients, the debilitating effects are longer of appearing, but
they are not exempted from affection of the stomach.

va^nal discharges may be divided into three classes,
dependent on three different sets of causes, acting on the
secreting apparatus. First, the symptomatic, produced bv
an irritation existing in the vagina or its neighbourhood.
Of this kind is the discharge produced by prolapsus, and
other displacements of the uterus, polypus, the early sta^e
of scirrhus, ascarides, &c. Second, that produced by the
action of causes directly on the apparatus, and this is more
idiopathic. Amongst these causes, especially in scrofulous
constitutions, we may notice such as excite increased vascular
action, or a state bordering on inflammation, if not actually
inflammatory ; as, for example, pessaries, stimulating applica*
tions to the passage, excessive venery, especially if accom-
panied with intemperance in eating or drinking, exposure to
cold, perhfips in the same way as catarrh is produced. Such
causes as induce a combination of debility and excitation mav
also occasion it, as, for instance, abortion when not well
recovered from, and hence also it often exists in that state,
which gives rise to monorrhagia. Frequent parturition can
only act, in this way, when it leads to some disordered action
of the parts, for oftener it acts by causing some degree of
prolapsus. The third division includes those cases, where the
origins of the nerves influencing the secretion are affected.
When the functional nerves of the uterus are impaired or dis-
ordered in their action, as, for instance, in the state of
amenorrhoBa, the nerves which influence the vaginal secretion
are often affected, and an increased discharge produced.
The original state, in this case, may have been produced by a
direct affection of the uterus itselt, or indirectly by sympa-
thetic influence. We may in consequence of remote sympatny,
as, for instance, alteration in the action of the nerves of the
stomach, bowels, or other viscera, have, by the connexion

of their origins with those of the uterus and ragina, alteratioD
produced in the latter, and the effect thereby induced can
only be remored by discoyering and removing the remote
cause. In describing the nerves of the uterus, I hare noticed
the strong smpathy which exists between the stomach and the
OS uteri. The state of the spinal cord in the sacral region,
is also a frequent cause of discharge, and it will hereafter be
mentioned that it is capable of producing pain in the uterine
organs and pelvic cavity, as certainly as if a cause of inflam'*
mation or excitement had been directly applied to the parts*
This state seldom exists without pain m the lower part of the
back, and tenderness on pressing the sacrum ; at the same
lime I admit that dischaj^es, arising from causes operating
directly on the secreting si;^aces, are sometimes attended with
pain in the back, but seldom unless there be either some
degree of prolapsus, or very considerable local irritation.
Debility has been enumerated as a cause of leucorrhcea, but
we find many degrees of weaJkness without this concomitant^
and it is very difficult to conceive how it should act in any
other way than as a predisposing cause. In this way, particu*-
larly in scrofulous constitutions, it renders very slight exciting
causes efficient.

In the treatment of the first class, we must confflder the
primary cause of the disease, for it would be vain to expect
a cure till that be removed. Our object must be, to remove
the local cause, to improve the general health, and aid, by
topical applications, particularly, mild astringent injections,
when piles or ascarides in the rectum are detected, tne usual
remedies must be resorted to.

In the second class, we must endeavour to discover and
check the operation of the immediate exciting cause, and use
such general remedies as the state of the constitution seems
to require. Should the patient be plethoric, or robust, it is
necessary, in the first instance, to diminish the fulness and
activity of the vessels, by mild, and perhaps, spare diet, by
moderate doses of laxative medicine, but rarely, by the
lancet. Regular exercise is, in this view, of benefit, but,
in all cases, fatigue increases the discharge. TheUy we
give bitters with alkali, to improve the state of the stomach
and bowels, and employ an injection of solution of acetate of
lead, which is to be thrown three or four times a^-day into the
vagina, and this may afterwards be exchanged for one of a
more astringent quality. I agree with those who think, that,
in cases connected witn plethora, astringent injections, espe-

cially if used early, are hurtful, and may ffive a diapositioii
to uterine diseases. Tepid water is in tnis state tne best
injection.

If the disease occur in a weak habit, or if the plethoric
state, though it existed at one time, haye now been removed,
the internal remedies must be more directly tonic, and injeo*
tions of various astringents must be employed ; of these the
two best are solution of sulphate of alumin, and decoction of
oak bark. We may also use solution of sulphate of copper,
nitrate of silver, or sulphate of zinc. Port wine alone, or
with a little brandy, may be tried, or water slightly acidulated
with nitrous acid, or iniusion of chamomile flowers, with the
addition of a little tincture of opium. But a general rule to
be attended to, is not to use any injection so strong as to
irritate. It has been proposed to rub the sur&ce of the vagina
with nitrate of silver, but I cannot speak of this with so much
confidence as the French do. The action of cold and damp is
to be avoided, as these are hurtful in every affection of mucous
membranes, whether chronic or acute. Of the internal reme*
dies, some are intended to act on organs sympathizing with the
secreting parts, as emetics, others as general tonics. Emetics,
on account of their operation on the stomach and alimentary
canal where these organs are in fault, are accordingly advis-
ed by most writers ;* but they are not to be employed during
the existence of plethora ; and, indeed, are onl^ to be admin-
istered, in such cases, as would otherwise requure them, from
the state of the stomach. Purges have also been used,t in
order to carry off noxious matter ; but they are only to be
given, so as to keep the bowels regular,! for brisk and
repeated purging^ is hurtfuL§ Tonic medicines, and those
which improve the action of the chylopoietic viscera, such as
lime water, myrrh, bark, steel, rhuoarb, sarsa, uva ursi,
iodine, &c., are also of utility, and along with them we may,
with great advantage, employ the cold bath; particularly
sea-bathing, which is also aided by the change of air, which
attends its use. The same might be said with regard to
. Tunbridge and some other watering places. Kino has been'
advised by Vigarous and Gardien, and when astringents are

• SmeUiat VoL i. p. ST.^Vigaroiu, Tome I. p. S61.— Mend, Aled. FnonUt
cba|». xiz. Mct. 8d.~DeniDan, Vol. IL p. ] 04.— See aleo EtmulWr, RlTcniUb

t Cbombon jtfalad. dea FlUce, p. 107.— Mead, Med. Preeepto^ chap* sis*
ct« 3d*

I Stoll PnelectJonca, Tomna IL p. SSa

S Vifaraw, Malad. dea Fenunea, Tenia i. p. 261.

proper, it ma^ be employed in tlie form of tincture. The
diet is to be hght and nourishingy^and the patient ought not
te indulge in too much sleep.

Various medicines have been proposed with a yiew of acting
specifically on the secreting parts, such as cicuta, balm of
Gilead, diuretic salts, calomel, guaiac, copaiba, cantharides to
the extent of producing stranguary, electricity, arnica, &c. ;
but they haye very little good effect, and sometimes do harm.
Of all these, the tincture of cantharides, essential oils, and
cubebs, by exciting the yessels in chronic secretions, seem
to be the oest, but no internal medicine can be much depended
on, in this yiew. By suckling a child, the discharge has in
some instances been remoyed. Plasters and liniments haye
been applied to the back, and sometimes relieye the aching
pains. Opiates are occasionally required, on account of
uneasy sensations. When it has succeeded to some eruptiye
disease, sulphureous preparations haye been adyised.

In the third class, much attention is required to discoyer
the cause of the disease, and when discoyered it is not always
easy to remoye it. In doubtful cases we cannot go wrong,
at least in employing all the ordinary means for the general
improyement of the health. When the sacral neryes are
affected, the ceryix uteri is often tender, and whether this
tenderness be a consequence of the affection of the neryes or
an original disease, really does not materially alter the prac-
ticfe, and in either case, if not remoyed, it is likely to lead
ultimately to serious organic disease. It is to be managed in
the first stage, by the warm sea-water hip-bath, laxatiyes, rest,
ayoiding all irritation, and by bleeding promptly, either gene-
rally, or topically from the sacrum, according to circumstances.
Leeches applied to the os uteri, when that is red or tender,
haye been lauded by late continental writers. Issues on
the side of the last lumbar yertebra are sometimes of use.
After the tender state is nearly subdued, and the dis-
charge has become more chronic, the cold bath, tonics,
and mild yegetable astringent injections, are proper. H it
'still continue we may use the copper pill, or bismuth with
sarsaparilla, internally. When the digestiye organs are in
any way affected, it is of the greatest importance to remoye
that aroction by the sedulous and early use of tonics, antacids,
purgatiyes, and other proper remedies. Disease, organic or
functional, of the liyer, has been known to produce this dis-
charge.

Purulent discharge implies preyious inflammation, and the

present existence either of sinus, ulceration, or a morbid
change of a secreting surfiice. Ulceration may be ascertained
by examination. Sinus, is more difficult to discover, for
the aperture may be small, but, in general the discharge is
very offensive, and in greater quantity at one time than
another. The part is aliBO tender to the touch. The last is
attended by smarting in making water, and other symptoms
excited by the action of a yirus. To this species belongs
the gonorrhoea, which is to be cured by mild laxatives, and
injections, first of acetate of lead, and then of sulphate of
zinc, dissolved in water. The two first states are to be man-
aged according to the causes which gives rise to them.

Some, with whom I do not agree, consider uterine discharge
as the most frequent, and divide it into the acute and chronic,
dependent on inflammation of the mucous coat. The acute
marked by fever, pain in the uterine region, tenderness of
the OS uteri, and glairy discharge. The chronic, by the
absence of uterine pain, and by a milky discharge, seen by
the speculum to proceed from the uterus. The first is treated
by leeches, the mp-bath, light diet, and douches per vaginam.
The second they treat by tonics and astringents. Others
consider the clear discharge to proceed from tne cavity of the
uterus, and use astringent injections into that cavity ; when
the discharge is more opaque, they place its source in the
follicles of the cervix and os uteri, which last they make to be
red, swollen, and tender, and sometimes ulcerated ; and M*
Melier says the ovaria often become affected. Astringent injec-
tions, and the application of nitrate of silver to the os uteri,
are the remedies used. It is admitted by them, that in
such cases, the woman is barren so long as the complaint
continues; but it is notorious, that innumerable instances
occur, of conception taking place during the existence of
leucorrhcea, a clear proof, on their own principles, that it
must have been vaginal, and therefore that the uterus is not
so invariably the seat of the disease as they maintain.

SECTION TWENTY-SECOND,

The bladder is subject to several diseases. The first I shall
mention is stone. This excites very considerable pain in the
region of the bladder, remarkably increased after making
water. There is also irritation about the urethra, with a fre-
quent desire to void the urine ; but it does not always flow
freely, sometimes stopping very unexpectedly. The urine
deposites a sandy sediment, asd is often mixed with mucus.

These symptoms lead to a suspicion that there is a stone in
the hladder, but we can be certain only by passing a sound.
By means of the warm bath, opiates, and the medicines im-
properly called lithontriptics, much relief may be obtained,
and very often the stone may be passed, for the urethra is
short and lax, so that calculi of great size hare been yoided.
But when these means faU, the stone must either be removed
by dilating the urethra, or by lithotrity. Lithotomy has been
performed during pregnancy.* Sometimes the stone makes
its way, by ulceration, into the yagina.t It has even been
known to ulcerate through the abdominal integument8.t

In many cases the symptoms of stone are met with, although
none can be found in the bladder. This is frequently the
case with young girls, previous to the establishment of the
catamenia, or with women of an irritable habit; and when
they are elderly, it leads to a dread of the existence of cancer
of die womb. There is no organic disease, nor have I ever
known it, in such people, end in a diseased structure of the
bladder or kidneys ; mdeed, they rarely complain of uneasi-
ness about the kidneys. In many cases there is only a fre-
quent desire to void water, attended with pain or smarting.
In others the vesical or urethral affection is combined with
much sensibility, but no inflammation of the orifice of the
vagina. The pain may be about the neck of the bladder, but
often it is referred, cmefly to the course of the urethra. I
have tried many remedies, such as soda, uva ursi, narcotics,
anti-spasmodics, tonics, and the warm and cold bath, but
cannot promise certain relief from any one of these.§ In
process of time, the disease often subsides and disappears.
If there be much tenderness about the urethra on touching it,
or if its orifice appear red, it will be proper to commence with
the application of leeches to the vulva, and then apply a poultice
of lintseed meal, with the addition of laudanum. If this do
no good, a bougie should be intruded daily, and retained for
a quarter of an hour. When that fails, the application of
nitrate of silver to the internal surface of the urethra is useful.
l£ the vagina be tender, and pain be felt on introducing the
finger, division of the side of the mucous coat at the orifice
of the vagina is the best practice, as advised at page 45.

• DMdiampt TnlU de TOper. de la Tama» Tome iv. p. 9.

J HildaDos, eeot. L obc 68 sod 69.

f Vide Cue by M. Caamoiid» in Recueil Period.

$ in a CMe of this luDd, deieribed by Mr. f attoD ai a Bpatmodie affection of
the neck of the bladder, calomel appeared to cure the oomplaiot. Lond. Med.
Journal, VoL z. p. 560.

Contraction of the orifice of the bladder, with an irritable
state of the urethra, may succeed labour, or attend female
diseases, and occasions great pain in voiding the urine. It
requires anodynes, tepid fomentations, laxatives, and some-
times the gentle introduction of the catheter.

Induration, or scirrhus of the bladder, produces symptoms
somewhat similar to calculus, but there is a greater quantity
of morbid mucus mixed with the urine; and blood with
piunilent matter is discharged, when ulceration has taken

Elace. No stone can be found, but the bladder is felt to be
ard and thick. Sometimes it is much enlarged, with such
appearances, as give rise to an opinion, that the uterus is the
part principally ajSected.* ,The scirrhus and ulceration may
extend to the uterus and va^na. In this disease we must
shun all stimulants, and put the patient on mild diet ; avoid
every thing which can increase the quantity of salts in the
urine; keep the bowels open, with an emulsion containing
oleum ricini ; and allay irritation by means of the tepid bath
and opiates. Mercury, cicuta, uva ursi, &c., with applications
to the bladder itself, nave seldom any good effect, and some-
times do harm.

Chronic inflammation of the mucous membrane of the
bladder, produces frequent desire to void urine, and the dis-
charge of viscid mucus, which sometimes has a puriform ap-
pearance. Cicuta and balsam of copaiba seem to be the best
remedies.

Polypous tumoursf may form within the bladder, produc-
ing the usual symptoms of irritation of that organ. Most
dreadful sufferings have been caused by worms in the
bladder.

In consequence of severe labour, or the pressure of instru-
ments, part of the bladder may become gangrenous, and a
perforation take place by sloughing.} The woman complains
of soreness about the parts, and does not void the urine freely*
In five or six days the slough comes off, and then the urine
dribbles away by the vagina. The aperture, which most

* Morgagnl relates an important case, where there waa a hard palnfal tamoar
In the hypofaatric n^on. accompanied with flaor alboa, uterine h»morrliage, and
•tillicidium of urine. After death, the bladder wae found rery large and idr-
rhous, with two large bodies in the cervix, preventing the urine from being
retained. The uterus was disoMed only in consequence of its vicinity to the
bladder. Epist. xxxix. art. 31.

f Of this disease I have never seen an instance; but Dr. Baillie mentions a
case, in which the greater part of the bladder was filled with a polypus. Morbid
Anat. p. 898. Fungous tumours are much more frequent.

i Puaos maintains, that it is always the bladder, and not the ursthra, that
suffers.

{reqnently is transyerse, may be in the upper part of the ure-
thra, or in the portion of bladder which is connected with the
yagina, or in that which adheres to the lower part of the
uterus, but the first and last are more rare. In all cases of
seyere labour, and indeed in eyery case when the urine does
not pass freely and at proper interyals, and especially if there
be tenderness of the parts, we must draw off the water, in order
to preyent distention and farther irritation of the bladder ; and
ihe parts must, if there be a tendency to slough or to ulcerate,
be kept yery clean, and be regularly dressed, in order to pre-
yent improper adhesions. If the bladder should give way, or
haye been actually torn, we are, if the opening be not extensiye,
warranted to expect a cure by keeping a catheter, haying a
receiyer attached to it, const^mtly in the bladder, to prevent
the water from flowing by the aperture. If this haye been
done early, and the parts be kept clean, and inflammation
subdued, when it existed, by suitable means, the bladder heals
in a period, varying from one to three months, according to
circumstances.* If neglected, the urine constantly oozes from
the orifice of the vagina, though sometimes the fistula is so
small that it can with difficulty be detected with the finger,
or the nail, or a probe, after a director or staff has been intro-
duced by the urethra. The patient in a recumbent posture
can retain some water, and void it partly by the natural
orifice. In such cases, where the state nas been of long
duration, we may still hope for a cure by the catheter ; but
if we fail, then we may take the aid oi the application of
nitrate of silver to the edges, which is both intended to make
ihem raw, and also to promote contraction.! The exact situa-
tion of the fistula may be discovered by using a speculum.
Instead of caustic the actual cautery has been employed by
Dupuytren. The catheter is not to be discontinued. Some
purpose to introduce a sponge into the vagina, to press on
the fistula, or to fill the vagina with a caoutchouc bottle,
having a piece of sponge t fixed to that part of its surface
which corresponds to the fistula, but it is more likely to irri-
tate than to do good.§ In extensive openings it has been

• Thlt raceeeded In a very had case related by Sedilliot, Reeaeil Period. Tome
i. p. 187. Many have heen recorded since. See also Dr. Cumin in £din. Jour,
xxi. 02.

4 Lallcmand cored a patient by applying nitrate of silver, and, when the eschar
fell and the edges were raw, using la sonde-airigne. Archivesi 18S6. p. 48S.

i Medieo-Chir. Trans. Vol. vi. p. 683.

$ Dr. fialmanno, showed me a patient who derived much comfort, from having
a boUow tin globe, like a pessary, inserted into the vagina. It was perforated at
the upper part like a pepper box, and from. the under, a catheter descended, which

propoedd to make the sides raw, and then retain them by
means of needles, whilst a catheter was also employed.* In
a case I met with, there was an attempt by nature, to plug
up the opening.f

Sometimes, after a severe labour, the woman is troubled
with incontinence of urine, although the bladder be entire*
This state is often produced directly by pressure on the neck
of the bladder; sometimes it is preceded by symptoms of
inflammation about the pelvis, and, in such cases, the os uteri
is often found afterwards to be turned a little out of its proper
direction, and the patient complains much of irregular pains,
about the hypogastrium and back. When she is in bed,
some of the urine collects in the vagina, and comes from it
when she rises ; after she is up, it comes from the urethra
alone, which distinguishes this from the complaint last de-
scribed. Time sometimes cures this disease. The cold bath
is useful, unless it increase the pain ; and m that case, the
warm bath should be employed* It may be proper to use
the bougie daily, and idso tincture of canthaiides, and
pressure.

Delicate females may have involuntary discharge of pale
urine, containing ammoniaco-magnesian pnosphate, connected
with, or dependant on, disorder of the digestive and nervous
Bvstem. Attention to the state of the bowels, regulation of
tne diet, due exercise, the cold bath, and the nse of tincture
of cantharides, generally effect a cure.

The bladder may descend, in labour, before the uterus,
producing much pain; or it may prolapse for some time
previous to labour, attended with pains resembling those of
parturition, and sometimes with convulsive or spasmodic affec-
tions,t especially when the catheter is neglected. When the
prolapsus vesicae takes place as a temporary occurrence dnr-

entand Into » flat flaak, siupeDded betwten the thighs. Little or no urino otetpod
by the Tagina. Thia plan mif ht be combined with tho oae of a eathoter in tbo
urethra.

» Lallemand la ArehiTca Gte^ralee, AvrO, 1826. Tiila operation vroTod fiital
on the tenth daj, owing to inflammation, in a caee under M. Rooz. Jour. Hehd.
1880.

t The patient to whom I allude had, I understood, four yean before her death,
bean deliTired with the foreepe, and eoon afkerwarde had ineootlnenoe of urine.
I found a lam perforation in the bladder, exactly resembling the fauces without
an uTula. The uterus was a little enlarged and indurated ; and Its mouth, which
was ulcerated and fungous, lay in this opening, pnijecting into tlio bladder, and
Closing up the eommunication betwixt the bladder and vagina.

t In a case related by Sandifort, the suppression of urine was always attended
with oonTulsive coo|:h. Lib. i. cap. 6. And in a case ralated by Dr. J. HamUton
itt£yr*i2SL^^^*** before parturition, th« mnadas of tlie body

ing labour, or antecedent to parturition^ we must be earefiil
not to mistake the bladder for the membranes, for thus irre«
parable mischief has been done to the woman. It has also
been mistaken for a hydrocephalic head. The bladder, when
protruded, is felt to be connected with the pubis. It retires
more or less when the pain goes off. If the patient be not in
labour, the uneasiness is to be mitigated by keeping the blad-
der empty, and allaying irritation with opiates, and taking a
little blood, if feverish or restless. If labour be going on, the
bladder must Ukewise be kept empty, and may, during a pain,
be gently suppcnrted, by pressing on it with two fingers in the
yagina, oy which the bladder is preserved from injury. This
prolapsus vesicae, may also take place, in the unimpregnated
state, for a portion of the bladder rests on, and is connected
with the upper and anterior part of the vagina. If this part
be relaxed, so as to permit oi inversion of it, then, the bladder
must descend with it, and form a tumour, of a size varying
with the fulness of the bladder.

From a relaxation or laceration of the continuation of the
pelvic fascia, the bladder may descend betwixt the vagina
and pelvis, so as to form a tumour within the vagina, or
at the anterior or lateral part of its orifice. This is called
a hernia of the bladder. There is some degree of bearing-
down pain in walking, particularly when the bladder is
full. Some patients complain of pain in the groin, others
at the navel, and some suffer little or no inconvenience,
except pain about the bladder when it is distended. K the
disease have continued long, or if the procidentia of the
anterior part of the vagina be considerable, the os uteri is
directed backward : and when the finger is introduced into
the vagina, the anterior part of that canal can be pushed up
farther than usual over the fore part of the cervix uteri, which
tben appears to be elongated, and perhaps in some cases the
anterior lip is actually lengthened. Inis hernia* is often
att^ided with suppression of urine. If inattentively exam-
ined, it may be taken for prolapsus uteri ; but it wiQ be found
to diminish, or even disappear, when the urine is voided,
and by pressure, the urine may be forced through the urethra.
In a case dissected by my brother, the bladder was found to
form a hernia on both sides of the pelvis, hanging like a fork
over the urethra.

• vide the Memoin and £eMTi of Verdier and Sabbatier, and Hoin. Sandlfort»
Di«. Anat FlMh. Ub. L cap. iil. ; and Cooper on Hernia, part U. p. 66.

Both in prolapsus and hernia of the bladder, we have
recourse to the use of a globe pessary , or one of an egg-
shape ; and if there be much relaxation of the vagina or parts
of tne outlet of the pelvis, astringent injections and an ehstic
support acting on the perinaeum will be useful. Straining
and all muscular exertion should be avoided. Sometimes
it is combined with calculus in the bladder. In this case, it
has been proposed to open the bladder, extract the stone, and
keep up a free discharge of urine through the urethra, in
order to allow the communication with the vagina to heal.
Deschamps advises, that the opening should be made near
the pubis, and not at the posterior part of the tumour, lest
that part of the bladder be cut, which, when the tumour is
reduced, would communicate with the abdominal cavity. I
can see no necessity for making anv change in the mode of
extracting the stone on account of the procidentia. The
urethra mav be dilated as proposed by Sir A. Cooper, or the
stone may be broken.

SECTION TWENTY-THIRD.

Excrescences may, notwithstanding the opinion of Morga-
gni, form in the course, or about the orifice of the urethra,*
and generallv produce great pun, e^ecially in making
water; on which account the disease has sometimes been
mistaken for a calculous affection. The pain is of the burn-
ing kind, and not only affects the part itself, but, in irri-
table females, produces a sensation up the spine compared to
a shivering, and sometimes causes a cold fit. The agony is
at times so great, as to excite convulsions, and it is not
uncommon for the patient to have an increase of her suffering
about the menstrual period. Sexual intercourse does not
increase the pain, but sometimes relieves it. The tumour is
vascular, florid, moveable, and exceedingly tender. When
excrescences grow about the orifice of the urethra, they are
readily discovered ; but when they are high up it is much
more difficult to ascertain their existence. Dr. Baillief says,
they cannot be known, but by the sensation, given by the
catheter passing over a soft body, but this I never have been
able to corroborate. They however, in one case, were dis-

* Mr. Sharp mentlont « case where they grew in email qoantltv upon the
orilloe, produciDg excruciating torment till they were extirpated. Critical Inq.
p. 168.

f M«rbid Anatomy, p. 991.

covered, by turning the instrument to one side, so as to open
the urethra a little.* A pair of small forceps introduced into
the urethra and then opened, will readily show the canal.
When their situation will permit, it is best to extirpate them
with the knife or scissors; or if near the orifice, as they
generally are, a ligature may be applied. Sometimes they
haye yielded to the bougie, though they had returned after exci*
sion.f But when small and numerous, I haye found it better
to introduce a bit of lint, first moistened, and then lightly
coyered with powdered nitrate of silver. It is to be with£awn
in half a minute. The removal of large excrescences has
occasionally been attended with very severe symptoms.^
The daily use of the bougie, for some time after extirpation,
is of service.§

Sometimes the urethra is partially, or totally inverted, ||
forming a tumour of the vulva, attended with difficulty and
pain in voiding urine. A slight inversion may be relieved by
a bougie; when there is a considerable prolapsus, resisting
the use of the bougie, the part may be cut off. The bladder
sometimes is everted, and protrudes at the orifice of the urethral
It is distinguished from eversion of the urethra, by being

* Tn the instance related by Mr. Warner, tbe arine was voided in drops with
great pun, especially about tbe menstrual period, and there were sometimes eVen
conTulsions. He dilated the urethra, by inclining the catheter to one side, and
thos saw two ezcrescenoes near the upper end. He divided or laid open the
urethra, and cut off the excrescences sucecmfully with scissors. Cases, p. SOO.

f Brsomfield's Snigery, Vol. ii. p. 896.

I In the patient of Mr. Hughes, the disease was taken at first for prolapsus
uteri, for there was a substance filling the os externum, and appearing without
4he Tuljra. It was a spongy excrescence, from Uie whole circumference of thf
meatus. It was drawn out with a tEread passed through it, and then cut off.
Strangury, with pain about the pubis, and fever, took place, on which account
the catheter was introduced. Suppression of urine repeatedly occurred; and
as it was often difficult to introduce the catheter, the semicupium was employed,
«iid always with advantage ; but once after it, she became faint, and the limbs
were convulsed. A stricture being suspected at the upper part of the urethra,
a bougie was introduced, and kept in the canal, which removed the symptoms.
Med/Facts and Obe. Vol. iii. p. 26.

$ In Mr. Jenner*s case, the irritation of the bladder was great, and the menses
were irregolar. A fungus was found, filling the orifice of the urethra ; this was
cat off, and the bougie used for an hour ertiy day for a fortnight ; a little before
the extirpation, a haemorrhage took place from the excrescences. Vide Lond.
Med. Journal, VoL vii. p. 160.

I M. Semin relates a case of a girl, eleven years of age, who from her fifth year
had been subject to frequent attacks of difficulty in voiding the urine. He had an
opportunity of examining her after a violent attack, and found a cylindrical body,
four inches long, projecting from the vulva ; and whenever she attempted to make
water, this pr^ection swelled up. It was amputated with success. Recueil
Period. Tool. xvlL p. 804. Seguin relates a case which was reported to be
strangulated hernia. A black and red tumour of considerable size was found
hetweso the labia ; tbe catheter being first introduced into this, a ligature was
hound over it, and the tumour came off on the fourth day. Nout. Journal,
Tome vi. p. 288.

surrounded by Its orifice* It can be returned, and then a
large bougie should be used. The urethra is sometimes con-
tracted by a varicose state of its vessels, or by a stricture ;
but these are not common occurrences. In continued irrita-
tion of the urethra, with difficulty of voiding water, the bougie
is often of great service, even although there should be no
contraction of the canal itself. K this do not give relief,
there is reason to suppose that the disease depends on the
state of the nerves, coming off from the lower part of the
spine, and a savin issue should be applied there. Sometimes
the urethra is pretematurally dilated,* but this does not
necessarily cause incontinence of urine.

The mucous coat of the urethra is sometimes thickened,
and its vessels become varicose. This produces general
swelling of the urethra, felt by the finger in the course of it,
pain on pressure, and in coitUj with a discharge of mucus, and
tormenting desire to make water. When the patient bears
down, the urethra is partially everted, and appears swelled
and vascular. These vessels should be scarified, the part
bathed with an astringent lotion, and gentle pressure made
with a thick bougie.

In a case, where, after a fall, the urethra became very wide,
and the bladder lost its power of retention, a cure was effected,
by cutting out part of the canal, and reuniting the sides of
the wound by stitches.!

SECTION TWENTY-FOURTH.

The uterus may be larger than usual, or uncommonly sinall,^
or it may be altogether wanting.§ Unless these circum-

* In Dr. Cluuiib«rlAin*f MUenk who had the h/moo imporfontad, the urethra
was ao dilated aa to admit the Soger ; and Portal found it, in an aoalocoua caa%
dilated lo aa to form a cttl«de-Mo, adoftittinf the point of the thumb. -Ceure
d'Anat. Medlcale, Tom. ill. n. 476.

f Mr. Uobart. Med. and Fh ja. Jour., Izir. 883. .

\ Momgni mentions a porter's wife, in whom the uterus waa found not aboTo
an Ineh lonf , and without any ovarii The pudendum was extremely small, and
there was scareely any appcaranoe of a clitoris. In the PhiL Trans, for 1806^
there is a ease where the uterus of a woman, twenty-nine yean of age, was not
larger than in the infant stats^ and searesly any appearance of oraria. She oeaeed
to grow at ten years of age, had no hair on the puhts, nerer menstruated, and had
an aTerslon to men. I luve eeen the uterus of the adult not larger than that of
a child I the woman never menstruated, and had ywj flat breaata.

'^ Columbus dissected a woman who always cemplained of great pain in eeitu.
The Tacina was very abort, and had no utcrua at ita termination. Sea also
Rome Med. 72. p. 179.

Fromondos relates an Instance, where the plaoe of the oe extcmam was oe-
eu^ed with a cartilaginous substance.

Menacnl was oonsultcd by a barrsn woman, whose Tagina waa only a third
part of the usual length, and Ita termiaatioo felt firm and fleshy. He adTised a
dissolution of tiM mamage.

Stances be oombined with some deficiency, or unusual con-
fonnatioii of the external parts or vagina, the peculiar or*
ganixation is not known till after death. It is, however, not
uncommon for the external parts to be very small, when the
uterus is of a diminutive size; and when it is altogether want*
ing, the vagina is either very short, or no traces of it can be
found. In either of these cases, no attempt shoidd be made
to discover an uterus by incisions, unless, from symptoms of
accumulation of the menses, we be certain Uiat an uterus really
exist.* In some instances, the skin at the point, corre^
sponding to the situation of the orifice of the vagma, has been
pressed in, so as to form a short sac, which in the erect pos--
ture, prolapsed like a bag. This has been cut in search of
the uterus, and nothing found but cellular substance. It haa
been supposed that peculiar feelings about the monthly period,
or the existence of sexual desire, indicated the presence of
ovaria. These have sometimes been found attached to a mass
of cellular substance, or even to the bladder.

The uterus may be double :t in this case there is some-
times a double vagina, but generally only one ovarium and
tube to each uterus. This conformation does not prevent
impregnation.

The uterus is sometnnes divided into two, by a septum
stretching across at the upper part of the cervix ;t or the os
uteri is almost, or altogettier shut up,§ by a continuation of

M. M«yer in Scbmader's Emmju, mentions a etie where tfaeTSgina «>^ ntcrue
were wanting, bat the oraria existed. The labia and clitoris were small, and
there were no nymphs. Mr. Ford dissected a child who had no m ina, nterus,
or ovaria. The urethra and rectam terminated dose to each other. Med. Facts,
Vol. T. p. 98.

* Nahodina mentions a rash operator, who nndertook, by Incision, to find the
ntcras ; hut after ontcinf^ a littU he came to some tsssoIs which oblif ed him to
stop. .

t Vide Hist, del' Acad, de Sciences, 1705, p. 47.--HaIler Oposo. Path. 00.
AordPs cases ■Pnroell in PhiL Trans. Ixir, p. 474i— Cancstrioi in Msd.
Facts, VoL iiL p. 171.— Valisneri met with a doable nterus and double valTa.
C^era Tom. iii. p. 888.^Dr. Pole deecrlbes a double oteros, in the 4th VoL of
Mom. of Medical Society, p. 92. See abore 40 references in Ploneqaet*s Digesta.
In Dr. Lee*s case, in the Medico-Chlr. Trans, the uterus of a woman who died
In childbed was di^ded into two lateral portions, opening into a cenrix common
to both, and havinf an orifice of the usual form. Each horn or division had its
own OTum and tube.— Breschet*s case, in the Mus^e. Dopuytren, has a double
traglna. Geias mentions a case where there was a child In each nteraa, lioth oC
whom Uired.

I Baillie*s Morbid Anatomy, chap. xix. . . .

§ LIttre found it almost dosed, by a continuation of the Inner surfiMe of the
TijriDa, Mem. de T Acad, des Scienos% 1704, p. 27 ; and in the ssTenth month of
prmancy, doeed by a glandular substance, 1705. p. 2 — Morgagni found it shut
with a membrane. Epist. xItI. art. 17.-»Boehmer quite shut up. Obs. Anat.
fasc 3. p. 02.— Ruysch saw it so smaU as scarcely ta admit a pin ; and Sandifort
so weU dosed, that nothing bat air could be forced throogh It. Obs. Anat. Path,
lib. U. o. U. p. 07.

100

the lining of the womb or yagina, or "hj adhesion, conse*
quent to ulceration, or by original conformation ; and in this
last case, the substance of the os uteri is sometimes almost
cartilaginous. The menses either come away more or less
-slowly, according to the size of the aperture, or are entirely
retained when there is no perforation, As long as the menses
are discharged, nothing ou^ht to be done ; but if they are
completely retained, and violent and unavailing efforts made
for their expulsion, an opening must, as a matter of necessity,
be made from the vagina. In such cases, the uterus has
been tapped with success;* but it has also happened, that
fatal inflammation has succeeded the operation.

The vessels are sometimes enlargea ; and I have seen the
spermatic veins extremely varicose, in an old woman who
tuid been subject to piles ; but I do not know that any parti-
cular inconvenience results from the venous enlargement.

SECTION TWENTY-FIFTH.

The uterus is very subject to inflammation after parturi-
tion, and this is to be considered in another part of this
work* But here, it is to be remarked, that inflammation,
simply, or combined, in different degrees, with irritatiuon, may
attack the uterus in the unimpregnated state, and if I can
call the attention of the young practitioner early to this for-
midable disease, I shall have performed what will amply
reward me for writing this worK. The disease may attack
the young, and especially the married, or those who are more
advanced in life, particularly about the time when the menses
become irregular. One of the most frequent causes is expo-
sure to cold, by light dress, for instance, during the menstrual
|>eriod, but the use of strong injections or any other irrita^
tion of the uterus may excite it. It is very apt to be brought
on by a lon^ walk, or other exertions, in delicate or irritable
females during menstruation, and then the attack is very
sudden. There is a constant pain in the lower part of the
belly, or near the pubis, and sometimes extending to the back
and groin. This pain is permanent, but not unbearable,
although most uncomfortable. It is aggravated by pressure
above the pubis, and also in attempts to make water, and
sometimes also in gobg to stool, for which there may be
frequent abortive calls. The cervix is sensible, and, some-
times, in one spot, acutely so, when touched, and, generally,

* Tbc meoMi beinf nUiowl, mnd gnat mIo excited, ibey were let oat with «
trocar by Sebatser. Vide Sondifort, p. G9.

lOI

ilie position is lower than it ought to be. The pulse is gene-
rally accelerated, and the skin is hot, but sometimes the
pulse is feeble, and the skin cool, or the feet and hands
cold, the bowels rather constipated, and the stomach irri-«
table, and there is great thirst, with a dry hard tongue;
any attempt to sit up, often produces syncope. Violent and
eyen bearmg-down pains, come on in paroxysms, not indeed
of yery long duration, but often repeated at short intenrals,
and these with the other symptoms render it impossible to
mistake the case. If the disease make its attack during
menstruation, the discharge is immediately checked ; if in the
intenral, it does not come on at the usual time unless the
disease be remoyed. Retroyersion or anteyersion of the womb
may also take place, in which case suppression of urine is
added to the other symptoms. Headach, globus, and other
Sympathetic, but not essential, symptoms may add to the dis-
tress. It is of the utmost consequence to remoye this early,
and at once, not that it proyes rapidly fatal, unless the in«
flammation extend to the intestines or peritoneum,* but because
it lays the foundation of organic disease in the uterus, which
no art can afterwards cure. It is indeed impossible to say
how many cases of chronic inflammation, as it is called, or of
troublesome enlargement, or of scirro-cancer of the uterus
may be dated from an attack, perhaps an ambiguous one, of
inflammation, and which might, with aU its train of eyils and
disasters, haye been preyented by attention to that primary
cause. When there is feyer, the lancet ought not to be
omitted, but it must not be pushed far, as it seldom completes
the cure. Leeches, to the number of eighteen or two dozen,
applied to the pubis or the lower part of the back, are of
decided efficacy, and may require to be renpeated, either there,
or to the top of the sacrum and groin. Some of the French
surgeons prefer their application, directly, to the uterus per
yaginam. They think that their external application is hurtful.
The hip-bath is useful, and then the apphcation of a poultice
' to the hypogastrium. It has been objected to the bath, both
in this and other uterine diseases, that it tends to draw more
blood to the part. I look on this more as a theoretical opinion
than as one rounded on experience : whateyer soothes, gene-
rally, does good. The bowels are to be freely opened, and

* Eren in this cMe, the patient may live for many weeki, and after death, I
have foand the ateme enlarged and suppurated, the round ligament evrollcn in
the inguinal canals, and the iniestinee not only matted, but adhering to the
pcritoiiettm» lining the abdominal parietee.

102

when the symptoms have abated^ opiates alone or combined
with diaphoretics are proper. The continuation of the par-
oxysms of pain, is best prevented by anodyne clysters. Con-
stant but slight, pain, remaining after the use of these remedies,
will require the application of a blister above the pubis.

When the mucous membrane is the chief seat of the inflam-
mation, a purulent secretion takes place, and may be confined,
for a considerable time, within the cavity, and the uterus
becomes enlarged. This is to be distinguished by the history,
and if a spontaneous discharge do not take place, relief may
be obtained by introducing a small bougie into the os uten,
and on to the cervix. This is at least safe if done gently.
The use of the hip-bath, and the application of warm poiu-
ticea to the hypogastrium, accelerate the progress and give
relief.

Sometimes, as a consequence of inflammation, more or less
distinctly marked, but occasionally without any very distinct
indication of uterine disease, we mid part, or the whole of the
womb softened, and its substance very easily torn. This is
met with in both the gravid and unimpregnated state, and
in the latter, we often &id pus, either infiltrated into the sub-
stance, or contained in numerous, but small, abscesses. More
rarely, it is contained in a kind of deciduous membrane, lining
the cavity of the uterus. It also is found in the veins. The
causes of this disease, and its nature, are not yet well under-
stood, and its existence is not certainly known till after death.
A modification of the ramoUissement affects the mouth rather
than the body of the uterus, converting it into a black and
fcBtid putrilage. I think it is rare as a primary disease, for
nsually there is an affection of some of the neighbouring parts.
In such cases as I have seen, the substance of the uterus has
been more vascular than natural. The mucous coat thickened
but not injected, and near the os uteri dark in colour. Either
one or both lips have been gangrenous, and sometimes in the
cervix, one or more small cavities are seen filled with black
fluid.

An insidious inflammation of the whole uterus, or of the
cervix, is not uncommon. It may be called a chronic in-
flammation, and sometimes follows the acute form, but oftener
comes on more slowly. There is more or less ^ain in the
uterine region, varying from a mere feeling of weight, heat,
or uneasiness, to actuid pain. When the uterus is consider-
ably enlarged, there is always more or less prolapsus, or
anteversion or retroversion, or lateral obliquity, in different

103

degrees, and attended with the usual symptoms* There is a
discharge of white mucus, which sometimes becomes puriform,
and this often is mixed with blood; or there may be consider-
able lusmorrhage. The countenance becomes sallow or un»
healthy, the appetite is impaired, and the digestion suffers ;
and rery often the most prominent symptom is pain in some
part of the abdomen, distant from the uterus, most frequently
m the vicinity of the liver. The strength declines slowly,
but there is little fever, but often a compucadon of hysterical
and anomalous affections. Examination discovers the uterus
to be enlarged, but not indurated. The cervix is more or
less increased in circumference. The os uteri is soft, open,
and tender to the touch, particularly at one spot, and its lips
sometimes feel rough, as if the skin were abraded. If examined
by the speculum, tibe colour is generally redder than natural,
or the vessels are seen more numerous, which is not usually
the case in sdrrhus. The disease for a time seems to be of
a simple nature, for on cutting the uterus its substance does
not seem materially altered in texture, though increased in
quantity, but in process of time, change of organisation takes
place, too often that of scirro*cancer. Bearing in mind then,
the formidable consequences of continuance, we must, in all
donbtftd cases, make an early and careful examination per
vaginam, and if we find any symptom or indication of the
existence of this disease, use early means for its removal.. So
long as there is any thing like increased activity of the vessels,
and increased sensibility, we may hope to obtain benefit by
the application of leeches to the groins, or uterus itself,
and by the regular use of mild saline laxatives, the tepid salt
water hip-bath, and light diet, with abstinence from all stimu-
lants of every kind, and a state of as much rest as is com*
patible with health. The injection of a continued stream of
warm water into tiie vagina has been advised by Gardien,
but it has not been used by others. All concomitant symp-
toms must be attended to, and relieved by the appropriate
means, and pain is to be allayed by an opiate or by cicuta.*
We view this affection as a slow but simple inflammation, and
we employ the usual plan for its removal, resting confident,
that if we succeed in this, we remove also the swelling.

In this stage, which may continue longer than is generally
supposed, no medicines have the power of producing direct

* Tbe Introdaction of Ave grains of extiHGt of cicuta at night into the vaeina
may rire rallof. Pain about the groin is relieved by leeches, or a blister kept
•poB by ssTln ointmont.

104

absorption, and thereby lessening the size. If we subdue and
remove the inflammation, or the existing action, we remove
that which has caused and kept up the swelling, and the
absorbents, by the power of nature alone, will do meir part of
the duty. It is thus that in many other local inflamnuitions
topical bleeding, or venesection when required, speedily re-
moves swelling ; and it is thus that in certain dropsical affec-
tions, the lancet, in a few days, produces a perfect absorp-
tion, whilst the vessels had till then remained uninfluenced by
the most powerful medicines. But we must not push this
doctrine too far, or carry the leeching, &c., beyond the bounds
both of utility and safety*

When the disease has become still more chronic, the chance
of removal is less, for the texture is more altered, but still we
may succeed. If the cervix be felt thickened, but not in-
durated, and the pain be not of the stinging kind, or the
constitution much broken down, we may still attempt the
removal. If asked, how? the natural reply would oe, by
Dromotin| absorption, and then we would look into the Materia
Medica, for the list of alteratives, and the medicines which
are there authorized to excite absorption. But there are no
medicines of any decided virtue in this way, in so far as
tumours are concerned, or which excite the absorption of a
tumour, without also, at least, acting in an eaual degree on
every other part of the body. Those which seem to act
directly on a tumour, often do so by destroying or removing
that condition which kept up the local disease, and thus per-
mitting nature to go on with absorption. Mercury does this
in a venereal bubo, and in certain affections of the testical it
promotes absorption, either by destroying the remaining
inflammatory action, or by acting injuriously on the new
formed substance, and rendering it unable to live, or thrive.
It may excite the new substance more than it can bear with
impunity, and then we get rid of it. Iodine, if it have any
effect on bronchocele, acts in the same way. We must, there-
fore, in the case under consideration, trust to general, not to
specific remedies. The great rule of practice is to lessen the
determination of blood to the uterus, and to diminish inordi-
nate action. We may still, if we gain any ground, employ
leeches, so long as these do not debilitate or injure the
system, and they have of late been applied to the os uteri.
We avoid aU stimulants, and therefore enjoin a strict diet.
We allay sensation and soothe, by the use of the tepid hip-
bath, and perhaps anodynes. We use means for improving

105

the health without exciting the system; and particularly we
direct our attention to the state of the bowels. By keeping
up their action, and increasing that of the kidneys, we some-
times promote general absorption ; and if we have previously
so far removed the inflammatory condition of the tumour, but
left it in a kind of ambiguous state, this plan may prove
beneficial. On this principle, the use of saline minerid waters
may be resorted to ; muriate of lime has been extolled as an
alterative, but it is only in this way that it acts, when it
does any good at all. Mercury, on the principle already
noticed, may also do good, but its effects should be carefully
watched ; for if it do no good, it does harm, and may exas-*
perate a tumour which might have otherwise remained quiet.
Iodine has been recommended by Dr. Ashwell when the cervix
and OS uteri, being glandular, are affected. He gives it
internally, and also rubs the part from the vagina with an
ointment composed of 3ij of hydriodate of potash, and giss of
simple cerate. The size of a nutmeg is to be used at a time.
If tne body of the uterus be the seat of disease, he expects no
benefit from it.

Some women who have borne several children, and more
especially if of a strumous constitution, have the uterus rather
bulky, and its lips swoUen, and perhaps fissured, but they are
not pretematurally hard nor tender. Such a state is often
attended with feeling of bearing-down, and with leucorrhoea.
Irritating applications should be avoided, and the general
health improved by mild tonics, cold bathing, &c.

Wounds of the uterus are dangerous in proportion to the
inflammation they excite.*

SECTION TWENTY-SIXTH.

There is a state of preternatural sensibility productive of
uneasiness in the uterine region, accompanied with the sen-,
sation of bearing-down, arising rather from an affection of
the origin of the pelvic nerves, than from any inflammation
or displacement of the womb itself. The attention of the
patient is called to it, by pain in the hypogastric region, and
in one or both groins, a sense of bearing-down, accompanied

* In one InitanM the woman was murdered by tbroiiting a niece of glam np
the Tacina ; and HaUer noticea a fatal case, in which a piece of lead was tbmat
into the utema. Crouzit relates an extraordinary instance of a silTer needle
beings introdnced Into the uterus during pregnancy, with a view, it would appear,
of abstracting blood locally. It could not be got out again : abortion took place;
and the needle was afterwards discharged by an external abscess. Archives
Generales, Tom. UL p. 80.

106

with a discharge of white mucus. The painful sensation, is
not always confined to the region of the uterus, but may affect
both the rectum and bladder. The top of the sacrum is
tender to the touch, and generally aches at all times. There
is usually numbness or pain, with great feebleness, in the
lower extremities, and sometimes tenderness on pressing the
skin of the thigh and leg* The patient cannot walk easily,
nor stand without suffering. There is either a feeling of pain-
fulness, or of weight in the head, with pain in the neck and
superior extremities. The countenance is not altered, and if
originally florid, continues so. The pulse is yariable, the
bowels constipated, the tongue foul. In some cases the uterine
symptoms, are complicated, with spurious appearance of affec-
tions of the liver or stomach. Tne general strength is less
than the appearance would indicate ; but it is in a marked
degree less m the inferior than the superior extremities. By
examination the uterus is found not to be enlarged, but the
cervix and mouth are generally more tender than usual, and
one spot often is particularly so ; when this is pressed, the
pain thrills up through the abdomen, or to the back. All the
symptoms, particulany the pain in the hypogastrium, are in-
creased during the menstrual period. — The disease is brought
on by too great exertion, especially during menstruation; but
it may also be produced by cold, or other less evident causes.
This doubtless may depend on tibe existence of some degree
of inflammation, but much more frequently it is neuralgic.
In the early stage leeches should be applied to the back, rest
in a recumbent posture enjoined, the bowels kept open, and
the diet regulated. The French say they cure tids by apply-
ing leeches to the uterus itself. In more advanced stages,
a caustic issue should be formed on each side of the last lum-
bar vertebra, but these are not infallible. Pain is often more
relieved by compound powder of ipecacuanha than by any
other opiate. Tonic medicines, such as iron in full doses,
quinine, &c., are useful, and in a state of convalescence the
searbath is proper, if the sensations permit.

SECTION TWENTY-SEVENTH.

The OS uteri may, from irritation, become ulcerated like
any other part ; purulent matter is discharged, but as there
is vaginal discharge this is not easily detected ; the patient
feels pain in coitu, or when the uterus is pressed. There is
sometimes a sense of heat in the hypogastrium, and often
pain in the back or even the groins. As the ulcer is shallow

107

it is not easily discoTered b^ the finger, but the speculum
eslubits on one or both of the hps, a spot very red and abraded,
Tarjing in size in different cases. The repeated application
of strong solution of nitrate of silver, along with the internal
use of sarsaparilla is the usual treatment. Ulceration, fol-
lowing change of texture, is more frequent. Of this kind is
the phagedena, or the corroding ulcer of Dr. Clarke, a most
obstinate and dreadful disease of the womb, which begins in
the membrane covering its mouth, and goes on gradually
destroying its substance, until almost the whole uterus be
removed ; and sometimes it spreads to the neighbouring parts.
It is marked early by haemorrhage, soon followed by a feeling
of heat in the region of the uterus, but as the disorder
advances, the pain is often excruciating, and is compared to
the effect of a burning coal, fixed, constant, and not shooting;
copious, fcBtid, purulent, or sanious discharge, alternating
with haemorrhage ; small but freouent pulse, wasting of the
flesh, and occasional swelling ot the inguinal glands : no
tumour is felt externally, but the beUy is flat. Examination,
per vaginam, discovers the destruction which has taken place,
and how far it has proceeded. It also ascertains, that the
part which remains is not enlarged to any considerable degree,
but is tender to the touch. This disease is rarely met with
till after the cessation of the menses.

On inspecting the body after death, the pelvis is often
found filled wiUi intestines, matted, and adhering to the
pelvis, and to one another.* In the midst of the mass, there
are sometimes one or two simple abscesses, containing healthy

us. On tearing out the mass, the uterus is discovered to
destroyed all to the fundus, or a small part of the body.
If the disease have not spread very far up, then the intestines
are generally unaffected. The uterus is very little enlarged,
but the cervix has, when cut, the appearance of firm fibrine,
or of the common schirrus, with here and there small cysts,
not larger than pin heads. The fundus is more healthy, and
the cavity is perhaps a little distended with fluid. The
mucous coat seems to be diseased a little higher than the
hardened part of the substance of the uterus, and the progress
is regularly from below upward. The ulcerated surface is
dark, flocculent, and has a dissolved appearance, whilst the
substance in its immediate vicinity is vascular and livid.

The rapidity of the destruction is various in different cases.

* Dr. Churchill nys, that unlike cancer the uterus In this disease is moyeahle,
but this is gooeraUy only in the early sUge. Dublin Jonro. iz. 44SL

108

It is very difficult to cure this ulcer, or even to check its
progress. Sometimes mercury has effected a cure, either by
itself, or combined with cicuta ; but in such cases I believe the
disease to have been syphilitic, for, in general, mercury does
more harm than good ; hyocyamus, or other narcotics, have
been given alone. Nitrous acid occasionally gives relief,
and when greatly diluted, so as to be weaker than vinegar,
forms a very proper injection. A very weak solution of
nitrate of silver, is also a good injection, or the uterus itself
may be touched with a stronger solution. Should the pain
be great, tepid decoction of poppies, or water with the addi-
tion of tincture of opium, will be of service as an injection.
Fomentations to the lower belly, and friction with campho-
rated spirits on the back, also give relief : but soon, opium,
taken internally, affords the only mitigation of suffering, and
the quantity required is often great.

There is another kind of ulcer, which attacks the cervix
and OS uteri. It is hollow, glossy, and smooth, with hard
margins, and the cervix, a little beyond it, is indurated, and
somewhat enlarged, but the rest of the uterus is healthy*
The discharge is serous, or sometimes purulent. The pain
is pretty constant, but not acute ; and the progress is gene-
rally slow, though it ultimately proves fatal, by hectic. In
this, and all other diseases of the uterus, the morbid irrita^
tion generally excites leucorrhoea, in a greater or less degree;
but examination ascertains the morbid condition of the part.
Topical bleeding, the hip-bath, saline purgatives, and spare
diet, have been proposed, but are of no avail fiirther than
as they may, during a period of increaaed action, allay that
temporary condition. Some benefit may be derived from the
warm salt-water bath, the regular use of a solution of a saline
purgative, or a laxative mineral water. The ulcer is some-
times benefited by the repeated application of nitrate of
silver. This is especially the case when the ulcer is small.
When the part is only indurated, ulceration not having yet
taken place, the occasional application of leeches to groins,

Jmbis, or os uteri, will be proper. In this stage, the cervix is
elt hard and sensible to the touch, and there is leucorrhoea,
and pain in the uterine region. A gentle mercurial course
with sarsaparilla is occasionally of service, but it must have
its effects watched, as it may hasten ulceration. Iodine is
sometimes useful. Some consider this disease as a species
of cancer, but the ulcer is never cauliflower-like.

Hard or soft granulations varying from the size of a millet

109

deed to that of a pea, have been described under the name of
the granular mflammation. Topical bleeding and emollients
have been advised in the subacute form, tonics and caustic
in the chronic. But if there be induration of the cervix it
must be dangerous to exasperate the excrescences.

Excrescences, pretty firm when touched, and broader at
the extremity than at the attachment, may spring from the
OS uteri, and generally, I apprehend, originate from a lobu-
lated or fissured state of the parts. The surface is granu-
lated, and the little projections may be torn off, and in coming
away seem brittle. They bleed readily and profusely ; but,
when not irritated, the discharge is serous, and so great, that
thick folds of cloth are soon wet, as if the liquor amnii had
been coming away. In the incipient stage, the discharge may
be Uke fluor albus. Very little pain attends the complaint,
but the patient sinks, partly, from the debilitating effects of
the discbarge, partly, from the influence produced by the
disease, on the organs of digestion and the system at large.
Afier death, the excrescence is found to be fliaccid, and
hanging into the vagina like shreds. The cervix uteri is a
Utile thickened, and the substance in place of being dense is
cellular, or contains small cysts. Hence it is evident, that
astringents cannot effect a cure, and, at the most, are but
uncertain palliations. The ligature is the best remedy, and
is useful in so far as it removes the excrescence ; but if that
be connected, as it generally is, with disease of the cervix,
the relief can be only temporary. Caustic should be applied
if the ligature fail or cannot be used. The general health,
and the improvement of the digestion, must be attended to.

A peculiar growth is described by the late Dr. Clarke,*
under the name of cauliflower excrescence, which is probablv
of the nature of that I speak of. It springs from the os uteri,
the base is broad, the surface granulated, the substance is
like the placenta, and the fragments torn off are white.
Pressure does not give pain, and the patient seldom, indeed,
suffers from pain. The discharge is at first watery, but
stiffens the cloths, of which, twenty or thirty at least may be
wet daily. In the progress of the disease, more or less blood
is lost, the weakness is great, vomiting and nausea come on,
and the patient smks. No age, after twenty, is exempted
^om the disease. The excrescence is coverea, by a very fine

* Vide IVuu. of a Society, &o. VoL Hi. p. 921. See aleo Sir C. M. Ciarke on
diaebui^ Part 8d» p. 67.

110

membraiiey from which the discharge is poured. A small part
of the OS uteri may give rise to it, or it may occupy the whole
circumference, but it is never in the cavity. The progress
is variable, and sometimes so rapid that the pelvis is filled
with it in nine months ; and it may even protrude from the
vagina. When seen, it is of a bright flesh colour. It does
not always prevent pregnancy. (Clarke, p. 67.) After deaih
it resembles a ^^ soft, flaccid, slimy, whitish substance," like
the foetal portion, of the placenta, of a calf macerated. The
only treatment likely to give relief, is the application of the
ligature, or of destructive caustic. When the vessels are con-
stricted by the former during life, or collapse after death,
the solidity of the tumour is lost, and it resembles merely a
glairy substance. When these are not resorted to, astringent
mjections are to be employed. No reliance can be placed
on internal medicine of any description, and scarcely more on
topical bleeding.

Venereal ulceration may, although the external parts be
sound, attack the uterus, producing a sense of heat with pain.
There is at first very httle discharge, and this consists of
glairy mucus ; but if the disease be allowed to continue, foetid
purulent matter comes away. The chancre is at first small,
and there is no hardness about the os literi, nor is it per-
ceived to be dilated; but it is painful to the touch, and
sometimes bleeds after coition. By the speculum, we discover
a superficial ulcer, greyish on its surface, and red at the
margins with sometimes a fissure crossing it. The purulent
discharge appears earlier than in cancer, but the health for a
time is not affected. Then the ulcer spreads, and may
destroy a greatpart of the womb and bladder, and occasion
fatal hectic. Tne history of the patient may assist the diag-
nosis. The treatment consists in a course of mercury, with
sarsapariUa, which I have always found produce a good effect
soon afler the commencement.* The mcer may with advan-
tage be touched with nitrate of silver.

SECTION TWENTY-EIOHTH.

Carcinoma or scirro-cancer, may begin in any part of the
uterus, or sometimes even in the appendages. But as oppor-
tunities are not frequent, of ezamimng the womb in the early
stage of the disease, and as, in course of time it involves

• Vld« Pewton on C«oe<r, p. 101.

Ill

parts not at first affected, we haye it not yet decided, what
the comparatiye liability, of different parts of this viscus, is
to the disease.* In some cases of dissection, we find it con**
fined to the lips, neck, and low part of the body. In others,
the fundus and upper part of the body, are alone diseased,
whilst in a great many, the whole uterus is indurated ; but
most pathologists consider the cerrix as the part in which it
begins oftener than elsewhere.

Hus disease may occur in a female under twenty, but it is
much more rare in the young and the yery old, than in the
intermediate period. The greatest number of cases occur
between thirty and forty-fiye years, next to that, in the fiye
foUowing years, next to that, between twenty-fiye and thirty.
It is yery difiicult to assign a cause, for it attacks the married
and unmarried under eyery circumstance.

Leucorrhoea alone, or combined with monorrhagia, is often
one of the earliest symptoms. Presently, if not at first, there
are an aching in the back, a feeling of heayiness in the
hypogastrium, with dull pain about the top of the thighs, and
sense of bearing-down ; these symptoms are too often unat-
tended to. Then, there is daiifcing pain, betwixt the pubis
and sacrum, or in the course of the yagina, with a sensation
of glowing heat, more or less frequently experienced, and
often attended with dysuria and mucous deposition from the
orine. Itchiness of the yulya, which is affected with a kind
of flabby swelling, or with erysipelatous inflammation, is not
uncommon. The patient is often troubled with flatulence,
heartburn, and sometimes with yomiting, and cutaneous
eruptions from sympathy with the stomach. The general
health soon suffers, the countenance becomes sallow, the
pulse quickens, the strength declines, and the body wastes.
A foBUd, purulent, or bloody matter is sooner or later dis*
charged, which indicates that the disease has proceeded to
ulceration. Repeated haemorrhages are now apt to take
place, and hectic is established. The pain is constant, but
subject to fi^uent aggrayations, and the weakness increases.
In the progress of the disease, repeated attacks of retention
of urine may come on, requiring the use of the catheter for
more than a week at a time. These go off, when the pressure
of the tumour, is directed to another course. Incontinence of
urine may next arise, either from ulceration of the bladder,

* Dr. Montgonifry in a Valuable Ftiper, Memt to think, that it begins leldomer
in the cenriz, than perhape it really does. Dublin Heepitel Reporti, Vel. t.
p. 4lt.

112

or loss of contractibility in the orifice, from a participation of
disease. In some cases the bowel siiflfers, and a communica-
tion may take place with the rectum, whereby much bloody,
or brown, foetid matter is discharged by stool, mixed with
clots of blood. The thigh and leg may swell, and become
hard or tense. Pain, fever, want of rest, discharge and loss
of blood, ultimately exhaust the patient; and death termi*
nates at once both her hopes and suflTerings.

At first, by examination per vaginam, the uterus is felt as
if it were etdarged ; the ceryix is apparently expanded, and
the OS uteri hard, open, irregular, and generally more sensi-
ble to the touch, a circumstance which causes pain in coitu.
A little blood is often observed on the finger after an examin-
ation. In some time after this, the os uteri is turgid, with
irregular projections, as if it contained small cysts, and,
presently it b felt to be ulcerated, excavations being formed,
the sides of which are retorted, so as to make the surface
broader.

The cervix uteri is sometimes totally indurated, and con-
siderably enlarged, before ulceration take place, but in other
cases, the augmentation is much greater after ulceration, than
before it.* We also sometimes meet with a circumscribed
induration embedded in the substance of the cervix, which is
apparentiy healthy, though it seldom continues long so.
Such a tumour may become as large as the fist, adhering to
the pelvis, so that it cannot be moved, and pressing so much
on the rectum or bladder, according to its situation, as to
give rise to much obstruction to the evacuations from either
of these parts. The uterus itself, is seldom so much enlarged,
in genuine cancer as in tubercle, and very often, even when
altogether affected, it is not above double its natural size ;
but, occasionally, we do find the tumour so large, as to be
felt, during life, like a child's head in the abdomen. The
tubes and ovaria may participate in the dbease, or it may
begin in the ovarium.f

In some patients, the disease proves fatal very early, if

• VI4« StaliMrt Vander Wid. obt. 87.— Scgcnu in Mli. Car. 1671, lAm. 181.
NoCwUbttandinjr tbew caooerooa ezeraeencM about tbe ot uteri, a woman may
ooneeiTe. Dr* Deoman relates a case wbere there wae a large ezcreeoenee In tbe
ffniTid eUte, with jprofnie bleedinc. Tbe bead of tbe child was leewncd, but tbe
woman died undellTered. VoL iT. p. d5. When tbe oa uteri hae been affected
with seirrhna, and tbe woman has conoeiTed, tbe utems baa eometimce bee6
^ptured, or tbe woman died undellTered. Hlldanui, cent, t obe. 67. Hontine
Ooera, Tom. il. lib. 2. obe. 6. Blancard Anat. p. 998. Hiet, de I'Aead. dee
Seleoeet, 170ft, p. AS.

t Vide Frocbaaka Annot. Acad. fate. Sd.

113

there be profuse hiemorrhage; in others, great deyastation
takes place, and the bladder* or rectumf are opened. In many
cases, the vagina becomes hard and thickened, or irregu-
larly contracted, with swelled glands, in its course. The
position of the uterus is often natural, but sometimes it i»
inclined to one or other side, or approaches to a state of
retroversion, or anteversion.

On examining the diseased part after death, it is found to
be thickened and indurated, and sometimes its cavity is en-
larged. The substance is of a whitish or brownish colour,
intersected with firm membranous divisions; and betwixt
these, there are, firequently, numerous small cysts, the coats
of which are thick and wmte. They contain a vascular sub?
stance, which, when wiped clean, assumes a light olive colour.
In proportion as the disease advances, some of the cysts
enlarge and thicken still more ; and, when opened, are found
to contain a bloody lymph, and to have tne inner surfEice
covered with a spongy vascular substance, similar to that
which fills the small cysts, but rather more resembling fungus.
Presently, some of these cysts, augment so much, as to
resemble abscesses, though they are not, properly speaking,
abscesses, and soon afterwards they burst. It is rare for a
cyst to burst, on the exterior surface of the uterus, which is
covered with the peritoneum.

As this disease is apt to be mistaken for fluor albus,
menorrhagia, nephritis, or dyspepsia, it is of great impor*
tance that the practitioner should be on his guard, and exar
mine early and carefully per vaginam. The speculum, which
appears to be used, in France, very unnecessarily in some
uterine affections, has been employed in this case, but the
finger is quite suflBcient to ascertain the existence of the dis-
ease. Much harm is done by the use of astringent injections,
meant to cure the supposed fluor albus.

This is a very hopeless disease, but still much may be
done to check its progress, or mitigate its symptoms. When
uneasy sensations, about the cessation of the menses^ in*
dicate a tendency to uterine disease, we find advantage from

* Le Drm attended a patient who had aU the irniptoms of ecirrhoiia uterae,
and, hy examination, fung one excreaoencee were K»and ehootinf down into the
Tacina. The pain waa contlnaa^ and could only be mitigated by the oonaUnt
nae of opium. Urine waa diaeliamd by the Tagina, and after death the bladder
waa foiud to be perforated. The fondoa and body of the ntcma were not much
diaeaaed.

f M. Tenon found, in a caae of canceroua nterua, all the |NMterior part of the
womb uJoerattd, the reetuu dliwaaed, and a communication formed betwixt
them.

114

die use of laxative waters,* and spare, or at least mild, diet,t
and flannel dress*! If by examination, we discoyer any altera-
tion in the shape, size, or sensibility of the womb, we must
have recoiirse, to the daily use of from two to three drachms
of sulphas potassae cum sulphure ; and if this lose its effect,
some other laxative must be ordered. The tepid bath every
night is likewise useful, so long as it allays uneasy sensations.
I have never known it derive more blood to the part, or accele-
rate the progress. When there is much sense of throbbing,
heat, or pain about the pelvis, taking blood from the loins by
cupping, or from the puois and groins by leeches, is of service,,
and the patient should keep in a norizontal posture as
much as possible. Leeches have been applied to the part itself,
and the bites are said to heal kindly. 1 have no experience
of their utility in this case. I can conceive their mitigating
the condition in an early stage, but not their curing a
genuine cancer. Every excitation, both of the part and of
the ^stem, should be avoided*

When the disease has evidently taken place, we must pro*
ceed on the principle of avoiding such causes as excite action
in general ; for the longer we can keep a scirrhus from going
into a state of activity and inflammation, the longer do we
keep the disease at bay. It is therefore scarcely necessary to
add, that if the patient be married, she must not sleep with
her husband. The most rational, almost only useful, practice
is, to adopt such a mild system as shall keep down action^
and prevent the parts from passing on to ulceration. I wish
to impress on the reader, that we, m many cases, have this in
our power, although we cannot, by any specific remedy, check,
tar less destroy, the disease. It is, however, not sufficiently
active in the opinion of some, nor splendid enough in that
of others, and, therefore, useless, or even hurtful, drugs, such
as mercury, conium, aconitum, arsenic, &c., are prescribed*
Whilst every stimulus is shunned, we may, in the more
vigorous constitutions, find it useful to enjoin abstinence in
diet, forbidding also such articles of food, or beverage, as

* Rodcnr relates a ease where ecirrhons ewelliDg was cared hj keeping the
bowels apen, and glTliif ererjr third ereDlng « Ireni ten t« twenty gralna of caliv
mel— Hallcr Dlsp. Med. Tomos It. p. 676. The ntUlty of calomel is donbtfaL

f Absolute abstinenee has been rseommeDded by Ponteao, (EaTTSo Post. Teas.
L p. 106. He relates a eaee, whieh waa eared by eonflninf the patient to eoa
tfe ploet— Mr. Pearson, p. US, gives two soeesssfol ossss. In the first, the
otems was sniarged and retroTerted, but by Tsry spare diet, was reetored to lla
natnral state.

t An Issne In the arm or Itg has bsen adWeed, and In plcthoriehablt%or when
there are wandering eymptoms, It maj be usefol, bat not otherwise.

115

ferment in the fitomach, as this state of the aliment aggravates the
symptoms. On the other hand, if we find that the abstemious
plan, in anj case, by weakening too much, permits the morbid
action to make progress, we must at once change the regiment
Our object is to avoid excitement, whilst we shun debihty.

When ulceration has taken place, the matter should be
washed away, morning and evemng; or, if the syringe do not
give pain, tepid water, or weak solution of chloride of lime,
may be injected. It has been said that phosphoric acid, so
diluted, as not to be stronger than very weak vinegar, allays
pain, but I fear that, as yet, we know nothing more to be
depended on, in this view, than the different preparations of
opium given internally. The addition of firom half a dram,
to a drcun of powdered valerian, to the opiate, makes it often
more beneficial. We guard against the constipating effects.

An operation has been proposed, under two different
circumstances; first, when the disease is supposed to be con-
fined to the lower part of the cervix uteri, and consequently
when the excision is partial ; second, when the whole or the
greater part of the uterus is affected, and it is entirely re-
moved. Dr. Osiander, of Gottiugen, was among the first,
who proposed to pull down the cancerous neck, by transfixing
it with a ligature, and then to cut off the diseased part. He
performed the operation nearly thirty times, but it b said
abandoned the practice before his death. Altogether, the
operation has been performed .above a hundred times, with
varying results.* There are two material objections to the
operation, independent of the immediate danger. The one
is, that the patient seldom applies to an operator till the dis-
ease have gone too far, even granting it to have been origi-
nally confined to the os, or cervix, uteri, to permit of hope that
it is quite removeable, or that we can safely extirpate all the
unsound structure. The second is, that it is notorious that
there may be a tendency to, nay a certainty of, disease
spreading, although, the immediate vicinity of the morbid
texture seem sound. In the case of a cancerous breast, it is
most dangerous to trust to apparent soundness, and make it
a general rule to be satisfied with partial extirpation. In the
case of the uterus, we cannot be siu*e that we have got
beyond the indurated part, till the operation be performed,

* LSatnne pabliihoa a eoie where the woman afterwards became twice pregnant*
and was delfrered at the fall time. ArchiTes, T. xiz. 42* In a memoir he save,
that out of 99 caaee he cured d4» bat this statement has been contradicted by
Pkialy, who Kftn that to his knowledge 19 died speedily out of S8.

116

and if we have not, then, unless we go to a most dangerous
extent, we have done worse than nothing. Operation-
mongers will ridicule these objections, but the more sober-
minded part of the profession, will come to the conclusion,
that either cancer of the uterus, is verj different from cancer
of other parts, or, that when the os and ceryix uteri, have
been extirpated, with apparent success, the disease has been
quite of a different nature from that of cancer* The same
remark applies to reputed cures effected by caustic,* a
treatment even worse m genuine cancer, than excision. It
is pled, that although the disease may not have been cancer,
yet it would have ended in that. Perhaps it might not.

The second circumstance, under which we have to operate,
is that in which it is necessarv to remove the whole uterus*
I need not enter into a detail oi the steps, as these belong to
another department, but I remind the reader that we must
always do here, what we must sometimes do in the first case,
in order to removethe disease ; viz., open the peritoneal cavi-
ty. We have not only the risk arising from hsemorrhage,
which may indeed be got over by a ligature, applied on the
course of the vessels going to tne uterus, but we have the
greater danjzer, arising from the shock to the system, or the
induction of peritoneal inflammation. Should the patient
escape these immediate dangers, we have not only the great
hazard, still to look to, of a return of the complaint, from the
contamination of the glands, or other parts within the pelvis,
but we have also serious, and even fatal consequences, arising
from changes in the position of the bowels, and the effects of a
moderate degree of mflammation on the bowels, so altered, in
producing obstruction or mortal constipation. This, we were
not prepared to look for, from the effect of extirpating the uterus
when it was inverted, but, in that case, the cavity of the belly is
not opened, nor is the intestine so much altered m its position.f

* Llsfinuio met ooe part of nitrmte of mcreurj, dinolred In dffat of nitroiu oeMy
for the deotraetion or Urg* bloody cuicerout ezcretceooat. In more limplo
nloeratSon, he dilutei thU with tirelTe paru of water. The part is wet with it
by meant of lint fixed to italk.— 1 fear tbe French make too Iree with oaoetio in
uterine dieeaee.

t Vide Diet, dee Sciences Medlcales, art. Matrioe et Hyitcrotomie and caeea
hy Saater, Reeamler, Graefe, Holscher, VelMao, Lislraiie, Lafenbeek, Dn«
pnytren, kc Palette seised an ulcerated womb with pincers and drew it dowUf
then cot the raf Ina roand the tumour, and detached it with little loos of blood-
Inflammation took place, and the patient died on the third nif ht. R«t. Med.
Tom. z. p. 89. Dr. Binndel extirpated the uterus, by openlnf the peritoneal
eaTlty from the Tag Ina, in four casea, all of which proved fatal, thoof h one of the
women lived a year. Lond. Mrd. Gazette, 11. SM, 793, 780, and III. 797. See
also a case by Mr. Banner, VoL ii. p. 683. Recamler Archives GenenJes, xxi.
76. Ronx. BoUctlns, Oct. 1839^ and a good paper in £dln. Journal, xzxiU. S77.

117

In two instances^ the uterus was extirpated by making an
incision above the pubis. It is scarcely necessary to add,
that both proved rapidly fatal.

SECTION TWENTY-NINTH,

Tubercles are conunon in the uterus, after middle age,
insomuch that M. Bayle says, that in seven months he met
with fourteen cases, and is of opinion that no unmarried
woman after the age of forty is witnout them. Thev consist
at first of dense fibrous substance, but in process of time they
become more like cartilage, or even bony, especially on their
surface.* On examining the tumour, it is sometimes found
to be intersected with membranous divisions ; and a section
always exhibits a compact granulated, or laminated, whitish
surface without vessels, and occasionally with ossific portions.
A tubercle may take place in one spot, and all the rest of the
uterus may be healthy, and nearly of the natural size. The
magnitude of the tubercle is very rariable, and it may either
project on the outer surface,! or within the cavity of the
womb ; and in this last case, the adhesion to the surface of
the cavity ma]^ be slight t after the tubercle has fully pro-
jected. In tms it differs, even in its most detached state,
from polypus, which is attached not by cellular substance,
but by a pedicle. One or more of these may be thrown off,
with pains like those of labour. In other instances, the
tubercle, if it do not originate from the mucous membrane,
at least interests it so, that it seems to extend from it, into the
cavity of the uterus on the one hand, and the substance or
parietes, on the other, so that when a section is made, the
membrane seems to divide the tubercle into two portions.
Sometimes there are a great many tubercles, which are found
in various stages of projection, and the uterus may become
greatly enlarged, and very irregular externally .§

* Sandifort Ota. Aoat. Path. lib. i. cap. tIU.— Bayle in Joar. de Med. Tome
T. p. 62.— Mnrray de Oiteostcamate^ p. 14. et eeq. Oardien, Tome I. p. 421.
From Dr. Boetoek'a analjtla, the oasific part eeemo to be formed chiefly of
phosphate of lime, with a little animal matter and carbonate of lime. Med.
Chir. IVana. Vol. zJz. p. 91. In the same Vol. is a paper by Dr. Lee on fibro-
calcarcone tomoor of the uterus.

f A tteatome U described by Kummer, which sprang from the fundus uteri,
by a pedicle only an inch thick. It weighed 40 pounds, was 46 inches in cireunv
ferenee, and 13 in diameter. Quarterly Journal for Oct. 1822.

f fialllle's Morbid Anatomy, chap. ziz.

$ 1 have found the uterus much larger than a child's head of a year old, with
many prujeetions and tubercles.— Peyer has a similar case, Parerg. Anat. p. 131.
We also find it extending towards the umbilicus, like the gravid uterus in tne 6th
and 7th month. One uterus weighed nearly 401b.

118

In one case, the size of the womb was large, and two thick
hard ridges could be felt in the abdomen, extending obliquely
up by the sides of the umbilicus. The lower and anterior

Eart of the womb was large, and filled the brim of the pelvis
ke a child's head, whilst, near the promontory of the sacrum,
the OS uteri was felt healthy, though compressed. This woman
had no complaint except what proceeded from bulk ; the blad-
der, contrary to expectation, was not in any degree affected ;
the stools easy, and menstruation regular. In some cases,
we find the os uteri pressed toward the pubis.

I have neyer seen the tubercle end m ulceration, nor the
substance of the uterus, though thickened, have abscess
formed in it. This obserration I find confirmed by other
practical writers, who state that it tends not to suppuration
but ossification. The effects of this disease are chiefly
mechemical, and often altogether trifling, for I have known it
exist many years, without injuring either the health or the
complexion ; at other times, we have pain in the back, and
sometimes in the hjrpogastrium, which, if there be much
enlargement of the womb, is swelled, hard, and irregular,
dyspeptic symptoms, leucorrhoea, and at length feverishness,
and gradual loss of strength. There may also be ante or
retroversion with their attendant symptoms. The progress is
generally slow, unless the cervix uten, which is almost always
sound with regard to this disease, be affected with phagedena
or cancer, or, unless simple inflammation be excited, by pres-
sure on some neighbouring part* That is to say, this disease^
occurring by itself, is seldom directly hurtnil, except by
mechanical or sympathetic irritation or haemorrhage. During
the active stage, pain is perhaps felt, but it goes off when the
tumour ceases to grow, which it often does. Tubercle rarely
if ever begins in the cervix, but it may commence in the lower
part of the body of the uterus, and extend downwards as well
as outwards, so as to appear to have begun in the cervix.
Menstruation may be rendered irregular, but often continues
unaffected. Menorrhagia is sometimes a very early attendant,
and when it takes place repeatedly, and severely, m the pro-
gress of the disease, it comes to constitute the chief source of
danger. Such tumours, especially when on the outer surface
of the uterus, do not always prevent pregnancy.

This disease can only be confounded with diseased ovarium,
but it is harder when felt through the belly, not so moveable
at first, and a difference may generally be felt per vaginam.
It may be combined with tumour of the ovarium. On intro-

119

ducing the finger into the vagina, in the early stage, tlie uterus
is felt enlarged, and bulging either before or behind. The
lump is a little painful when pressed ; it is felt to make a part
of me womb, and very often is situated on the anterior sur-
face, in contact with the bladder. The cervix may be a little
developed, but is healthy.

No remedy has any power in removing the diseased sub-
stance, and therefore our treatment consists in palliating
symptoms, especially in attending to the bladder and bowels.
We also, upon general principles, keep down activity, and
guard against inflammatory action. The antiphlogistic regi-
men should be pursued in moderation. The bowels, espe-
cially, should be kept open, and every source of irritation
removed. If a violent attack of pain take place, we apply
leeches, and then a warm poultice, and give an opuite.
Women may live a long time, even although these tumours
acquire considerable magnitude, more especially if no great
sanguineous discharge take place, or, if we be careful always
to moderate or check that, by the plug and other means.

Sometimes the whole uterus is a Uttle enlarged, and changed
into a white cartilaginous substance, with a hard irregular
surface ; or it may be enlarged and ossified,* and these ossi-
fications may take place even during pregnancy .f Steato*
matous or atheromatous tumours of various size8,t or sarco-
matous § or scirrhus-like || bodies, may be attached to the uterus.
All these diseases sometimes at first give little trouble. Even
their advanced stage has no pathognomonic mark, by which
they can be discovered, as they produce the usual effects of
uterine irritation. I must also add, that they are very little
under the power of medicine. The most we can do, is to
palliate symptoms, by which, however, we greatly meliorate
the condition of the patient.

Strumous affections of the uterus, are not uncommon, and
are sometimes considered as scirrhous, but there is no sting-
ing pain, and often indeed little sensation, except that of

Vide Mem. de T Aoed. de Chirurf . Licataad relmtee » caee of a woman who

the ntema and bladder. It prodaced conitant lectaurla, reUercd ody by lying on
the bock. M cd. and Pbya. Jonnial, VoL Ui. ]». fl67.

f Vide ObaeiT. on Abortion, 2d edition, p. 97.

I Vide Rbodiue, cent. ilL ob. 46 Bcehmer Obe. Aoat fasc Sd.— Stoll Ratio

Mad. part U. p, 379.

S Vide yriedna. In Sandllort*t Obeerv. Ub. i. c viii. and a cue by Sandifcvt
himaelf, where the tnmonr adhered by a cord, Ub. ir. p. I !&

I Baader Obo. Med. ob. 29k p. 170L

120

bearing-down. There is also fluor albus, and sometunes
menomiagia. The cervix is found enlarged, but not punful
nor ulcerated. Attention to the bowels, the use of a spring-
support, such as is employed in prolapsus uteri, and sea baw^
ing, are the most beneficial remedies. Iodine may be given,
alternated with chalybeates.

Tuberculous matter may be deposited in the substance of
the uterus, or on the inner surface. In some instances the
uterus enlarges so much as to be felt above the pubis, and is
not only tender to the touch, but the seat of much pain, espe-
cially during the night. This is, in such cases, not easily
distinguished from scirrhus, but often, after continued leucor-
rhcea, alternated with moderate sanguineous discharge, there
is voided, per vaginam, a thick or caseous looking substance.
Such cases have always proved fatal, quite independent of
tubercles in the lungs, wnich ofl;en accompany tiie uterine
deposition.

Xiastlv. I may here notice a tumour, in its structure, much
resembhng some cases of diseased ovarium. It is of a con*
sistence like very soft liver, of a light reddish colour, and
containing cysts of various sizes, filled with bloody serum. It
adheres to the inner surface of the uterus, to a greater or a
less extent, according to its duration, and sometimes, when
the uterus is as large as an adult head, there may be a non-
adherent tract, from the os uteri to the fundus, not more than
an inch or two broad. If the uterus be slit open in the tract,
the tumour, at first, looks like a large polypus, and is, per-
haps, smeared with a layer of clotted blood. It is covered
here, by a thick smooth coat, which is reflected off to the
uterus, at the line of adhesion. It can also be traced between
the tumour and the uterus, and, when the soft proper texture
of the tumour, is torn off from it, we should almost think,
that it was an inner layer of the uterus, or a thickening of
the mucous membrane. It indeed would seem, as if it had
grown in the substance of that membrane, and to be, every
where, covered by it, in a very thickened state. The sub-
stance of the uterus, is not thicker than usual, and is of a
pale colour. The peritonseal coat is healthy, but the ovarian
vessels large. In some places the uterus feels soft and elastic,
as if a fluid were contained. The uterine vessels are enlarged,
particularly the sinuses, several of which are covered by the
tumour, just as they are by the decidua, in the gravid state.
The arteries can, by injection, or by being filled with fibrine,
be more readily, than the veins, traced into the tumour. This

121

is not productive of pain; but, like the polypus, the chief
danger is from repeated attacks of hsemorrhage, which may
at last sink the patient. The treatment is to be directec^
principally, to the prevention, or immediate moderation of
these, and the improvement of the general health. It is most
important to remember, in this, and many other diseases, both
of adults and children, incurable in their nature, that life may
long, and with tolerable comfort, be prolonged, by supporting
the strength, avoiding all exciting causes of aggravation, and
resorting to the means for removing every bad symptom, or
checking any debilitating discharge, as promptly and as j[ili-
gently as if we were confident of, thereby, effecting a perfect
cure.

SECTION THIRTIETH.

The uterus is more frequently affected with spongoid
tumour than is supposed, manv cases of that disease passing
for cancer. This is a tight, but soft and elastic tumour, the
substance of which, bears some resemblance to brain, and
contains cysts of different sizes, filled with red serum or blood,
or bloody fimgus, according to circumstances. There is no
certain way of distinguishing or discovering this disease, in its
early stage, for it often gives very little trouble, and any
symptoms which do occur, are common to other diseases of
the womb. The tumour, however, enlarges, and can at length
be felt through the abdominal parietes. It is soft and elastic,
and on the first application of the hand, feels very like a tense
ventral hernia. There may be two or more tumours of
unequal sizes in different parts of the belly, which can be felt
to have a connexion with each other, and may frequently be
traced to the pubis. Per vctginam, the state varies in different
cases ; but by pressing on tibe external tumour at the same
time, we discover its connexion with the womb below. We
may find ulceration, or the os uteri soft, and tumified, and
opened, or the posterior lip may be lost in a soft elastic
tumour, and quite obliterated, wlulst the anterior one, after a
pretty careful examination, is felt hiffh up, and apparently
sound. Pressure seldom gives pain, till ulceration be about
to take place, and no blood is usually observed on the finger
after examination, unless a fungus have protruded. So far as
I have seen, fluor albus is a rare attendant on this disease in
the early stage, and little inconvenience is at that period
produced, except what may sometimes result from pressure on
the bladder, causing strangury or suppression of urine,

dli

122

attended with fits of considerable pain, like those excited by
a stone. Slight discharges of blood generally attend the
formation of the disease; and at this early stage, the os uteri,
and sometimes the cenrix, may be felt tumid, smooth, and
elastic. The complexion is sallow, but the health b tolerably
good, till ulceration or inflammation take place. Ulceration
may occur in different parts; it may be directed to the
vagina, and then we have foetid blooay discharge, or some-
times considerable haemorrhage, and mtimately the bladder
or rectum is involved in the destruction ; or, bloody fungus
may protrude from the exterior surface of the uterus into the
general cavity of the abdomen, and at length the bowels become
inflamed and glued together : or, the tumour may adhere to
the parietes of the abdomen, and the skin after becoming livid
ives way, and a fungus shoots out from the belly. As the
isease advances towards ulceration, the health is more im-
paired, hectic fever takes place, and the patient is ultimatdy
cut off.

The whole treatment, I am sorry to say, consists in palli*
ating such sympathetic or local symptoms as may arise in the
course of the disease.

SECTION THIRTY-PIRST.

Earthy concretions are sometimes formed in the cavity of
the uterus, and produce the usual symptoms of uterine irri-
tation; and Vigarous considers them as very apt to excite
hysterical affections. Dr. Bostock found these, sometimes, to
consist chiefly of carbonate of lime, oftener, the phosphate
predominated. As in the bladder of urine, the constant pre*
sence of a calculus tends to thicken its coats, so the irritation
of a stone in the uterus can excite a disease of the substance
of the womb, and produce ulceration, which may extend to
the rectum. The disease in question is very rare, and can
only be discovered by feeling the concretion with the fingw,
or a probe introduced within the os uteri, which is sufficiently
open to permit of this examination. Nature, it would appear,
tends to expel the substance ;* and we ought to co-operate»
if necessary, with this tendency. We must also relieve sup-

'OttaUvsrdatMiaeAM wbcreltwasoompllcirtad wHbprdkpaoitttcrL All«
a length of time, irrcn palDi eame on» and in m boar a iMve Mone was expaUed;
next day a laiger etooe presented, bat oanld not be broof ht away vntU .the m
uteri wae dilated. Frwa time to time after thie, email eUmee were expelled ;
but at last ebe got completely well. See alto a caee by BouTet, in Rons. Jour,
de Med. T. xlL

123

preasion of urine,* or any other urgent symptom which may
be present*

SECTION THIRTY-SECOND.

Polypous tumours are not uncommon, and may take place
at any age, even in infancy ; but they are not oflken met with
in very young women. They are most frequent in married
women whilst the menstrual function still exists. The greatest
number of cases seem to occur between thur^ and forty, and
next to that, in the succeeding ten years. They always affect
the health, producing to a greater or less degree, want of
appetite, dyspeptic symptoms, uneasiness in the uterine
region, a yariame swelling of the abdomen, aching pain in
the back, bearing-down pains, perhaps retention or incoiK
tinence of urine, tenesmus or obstinate and continued costive-
ness, and a dragging sensation at the groins. At first, there
is generally a mucous discharge ; but at length blood is dis-
charged, either from the rupture of some of the veins of the
tumour, or in part from the uterine vessels themselves, in which
case it is often in greatest quantity at the menstrual period ;
the permanent discharge not unfrequently becomes foetid*
Sir C. Clarke, in his work, very properly notices, that the
blood often coagulates over the polypus, and comes off like a
ring. The discharge of blood and mucus, and the constitu-
tional disorder often produced, cause great debUity, emada^
tion, frequency of pulse, and ultimately death.

By degrees, the polypus descends, without pain, from the
uterus, or painful efforts are made, more quickly, to expel the
tumour, the body of which passes into the vagina,t and some-
times occasions retention oi urine,t or it may, when at stool,
or otherwise, be forced out of the vagina, and project from
its orifice. In those cases, where the polypus arises from the
cervix uteri, it generally comes into the vagina with little pain^

* Tliis iNfored fatal in a ehOd of five yean old.

t In a caae which occorred to the late Mr. Hamilton of this place, the polvpus
was expelled hy laboor paint, hut the woman died exhausted.— In a caee related
Vt Vater It waa ezpdied when the woman was at stool. UaUer, Diap. Chir.
Tom. iii. p. 621. See also a case in the same work, p. 611, hy Schanckiixs.—
In the patient of Vaconssain, the polypus was expelled after serere pain ; Its
pcdide was felt to pulsate rery strongly, but a ligature being applied, the tumour
was cut off. Instantly the ligature disappeared, being drawn up within the

Selyis, but on the third day It dropped off. Mem. de TAcad. de Cbir. 1'om.
1. p. 688.

t Vide case by Vater, in Haller, Dispnt. Chir. Tom. iiL p. 0S1.— In the ease
famished by M. Espagnet, an attempt was made to introdnce the eatbdler ; hot
a straight one being employed instead of a curred one, or an elastic catheter, it
was found neoeasary prerionslT to make an Incision In the fore part of the poly-
pus, which had protruded. Mem. de TAcad. de Chir. Tom. ill. p. 681.

124

or irritation, beyond, merely, what causes mucous discharge.
But when it is attached to the cavity of the uterus, expulsive
pains are more likely to occur, and, both before and aner the
descent into the vagina, bloody dUscharge like menorrhagia
takes place. The pedicle remains in utero, and the bad
consequei^ces formerly produced still continue, except in a
few cases, where the ttunour has dropped off,* and the patient
got well. In such cases it has been supposed that the os uteri
acted as a ligature ; and to the same cause is attributed the
bursting of the veins, which produces, in many instances,
copious haemorrhage. But although haemorrhage be most
frequent, after the polypus has descended, yet it may take
place whilst it remams entirely in utero, which it may do for
a very long time.

It sometimes happens that the uterus becomes partially
inverted,t before or after the polypus is expelled mto the
vagina; and this circumstance does not seem to depend
altogether on the size of the poljrpus, or its weight. Polypus
may also be accompanied with prolapsus uteri.t In many
cases, after the descent of the polypus, the uterus is rather
shortened, its sides are not thickened, and the size and shape
of the cavity, will, in some degree, be modified, by the size
imd situation of the attachment.

Polypi may be attached to any part of the womb, to its
fundus, cervix, or mouth ; and it has already been observed
that there is less tendency to haemorrhage, when they are
attached to the cervix, than either higher, or to the os uteri
itself. There are then three situations where polypi may
be formed. In the second, they must project into the vagina
sooner than in the first. In the third, tney are, from the com-
mencement, in that canal. The polypus, in this case, may be
connected either by a narrow pedicle, or, one of the lips of
the OS uteri, seems thickened and elongated to form the stalk,
or, it mav grow from all the circumference of the os uteri.§
Haemorrhage, though less frequent in the last than in the first
species, may occur in all, and also before the polypus issue from
the uterus. If there be an union betwixt the os uteri and the
tumour,! or if they be in intimate contact, polypus may pass

^ * Mam. de T Acad, de Chir. Tom. iii. p. 653.

t Vid« CAM by Goulard, in Hist, de TAcad. dea Scieneci, 1792, p. 43.*Dr.
Donman, in bis cngraTings, glTSs two platM of InTcnioiiy ono from Dr. Hun-
ter's Museum, tbe otber from Dr. Hamfltoo.

i Med. Comment. Vol. It. p. 22a

$ See a case of tbis kind wbers the ligature proTfd faUl, In Goocbt p* 27a

I Mem. of Med. Society in London, YoL t. p. 12.

125

for inTersio uteri ; but the histoiy of the case, and attentive
examinalion, will point out the difference, which will be noticed
when I come to consider inversion and prolapsus of the uterus.
Here I may only remark, that the womb is sensible, but the
polypus is insensible, to the touch, or to irritation; but it
should be recollected, that if the polypus be moved, sensation
can be produced by the effect on the womb.

Polypi, are of cufferent kinds. The most frequent kind is
of a firm fibro-cartilaginous structure, covered with a pro-
duction of the inner membrane of the womb ; and indeed it
often proceeds chiefly from a morbid change of that mem*
brane, and a slow subsequent enlargement of the diseased
portion. It may, however, originate from the substance of
the uterus itself like a tubercle, and some imagine that the
polypus is merely an exuberant growth of part of the uterine
tissue. The enlargement is generally greatest at the farthest
extremity of the tumour, and least near the womb, so that
it is pyriform, and has a kind of pedicle formed, which
contains distinct blood vessels. A slender prolongation,
like a worm, occasionally depends from the os uteri to
the extent of an inch or two, and of equal thickness
throughout. But if the membrane of the uterus be affected
to a considerable extent, and especially if the substance of
the uterus be diseased, then, the neck, or the attachment of
the polypus, is broad, and there have been instances of the
polypus having more attachments than one, which has been
attriDuted to adhesion consequent to inflammation, for a
polypus may not only inflame, but suppurate even in its centre,
when the poljrpus is very Wge, and does not protrude from
the vagina, it may either distend, or push up, the uterus, so
as greatly to enlarge the abdomen.

The vessels are chiefly confined to the surface, but they,
especially the veins, are sometimes considerable. These
give a mottled appearance to the surface, and are a source of
haemorrhage, wmch is greatest after the polypus is partially
or totally expelled. At the same tune, it is to be remembered,
that blood often comes from the surface of the uterus itself.
If the patient live long, the tumour is disposed to ulcerate.
The ulcer is either superficial and watery, or it is hollowed
out, glossy, with hard margins, or it is ningous. The two
last varieties are most frequent.

Some polypi are soft and Ijrmphatic, but these are rare in
the cavity of the uterus. Vesicular, or soft cellular polypi,
sometimes spring from the inside of the cervix. They are

126

generally small and pediculated, and bleed on being touched,
indeed a characteristic is hsemorrhage. Herbiniaux says,
the pedicle is comparatiyely large, and some later writers are
disposed to yiew these soft poljrpi as malignant, but this
certainly is not invariably the case. Those little glandular
bodies, often seen between the rugae of the neck of the
uterus, and supposed by Nabothus to be ova, may enlarge
and form thick vascular cysts filled with lymph, or curdy
matter, and are supposed to produce the vesicular polypus just
noticed; but it is not established that they are the only
source. Dr. Lee gives a good drawing of this tumour in the
Med. Chir. Trans. Vol. xix. Some polypi are firm without,
but contain gelatinous fluid, or substance like axunge within.
Some are solid, others cellular, with considerable cavities,
containing glairy or fatty matter alone, or mixed with hair, or
blood alone, has been found in them.

Polypi are hurtful at first, by the irritation they give the
uterus, and by sympathetic derangement of the abdominal
viscera. In a more advanced stage, they are attended with
debilitating and fatal haemorrhage, and often with febrile
symptoms, especially if the discharge be ofiensive, or the
surface ulcerated. Uterine inflammation may also prove
£atal. Nothwithstanding the existence of polypus, however,
it is possible for a woman to conceive,* and we are even told
that the placenta may be attached to the polypus.

Polypi were long ago described under tne name of sarcosis,
fungus, moles, &c., and by Smellie were considered to be
^nlATged glands. Some denominated them cerosis or queue
de la vulve, others, mal St. Fiacre, &c. Various means
were proposed for their removal, such as excision, tearing
them away, or burning them. Levret, first of aU, gave
a methodical account of the disease, and proposed, inva^
riably, to employ the ligature. Since his time, the practice,
of most surgeons, has been, to pass a ligature round the base,
or footstalk, of the polypus, and tighten it so firmly as to kill
the part. The ligature consists of a firm silk corcC or a well
twisted hemp string, properly rubbed with wax, or covered
with a varmsh of elastic gum. This is better Uian a silver
wire, which is apt to twist or form little spiral turns, which
impede the operation, and may cut the tumour. It is difficult
to pass the ligature properly, if the polypus be altogether in
utero ; and it ought not even to be attempted, if the 00 uteri

* In M. Gulot*s MM, thejpolypot was expelkd.— M. htmi add* other cMei,
M«n. de r Acad. d« Chir. Tom. ill. p. 54&

127

be not {uUy dilated. On this account, if the symptoikiB be
not extremdy ui^ent, it is proper to delay until the polypus
bave wholly, or in part, descended into the yagina; and
when this has taken place, no good, but much evil, may
result from procrastination. It has eyen been proposed to
accelerate the descent of the polypus, and produce an inyer-
sion of the uterus,* a most improper practice. Ergot has
been giyen to promote expulsion,t and both Dupuytren and
Heryez, haye diyided the os uteri.

A double canula has been long employed for the purpose
of passing the ligature, one end of which, was brought through
each tuhns, and the middle portion, forming a loop, was car*
ried oyer tiie tumour, either with the fingers, or the assistance
of a silyer probe liaying a small fork at its extremity. By
practice ana dexterity, this instrument may doubtless be
adequate to the object in yiew ; but without these requisites,
the operator shall be foiled, the ligature twisting or going
past tiie tumour, eyery attempt ^ying much uneasiness to the
patient, and, not unn-equently, after many trials and much
irritation, the patient is left exhausted with fatigue, yexation,
and loss of blood. This is yery apt to happen, if the polypus
be BO large as to fill the yagina. The process may be facili'-
tated by employing a double canula, but the tubes made to
separate and unite at pleasure,^ by means of a connecting
base, or third piece which can be adapted to them like a
sheath. The ligature is passed through the tubes, which are
to be placed close together, and no loop is to be left at the
middle. They are then to be carried up along the tumour,
generally betwixt it and the pubis. Being slid up along the
finger to the neck of the polypus, one of them is to be steadily
retained in its situation, whilst the other is carried completely
round the tumour, and brought again to meet its fellow. The
two tubes are then to be united by means of the common
base. The ligature is thus made to encircle the polypus,
and if necessary, it may afterwards be raised higher, witn the
fing^ alone, or with the assistance of a forked probe.

nhen the ligature is placed in its proper situation, it is to
be gradually and cautiously tightened, lest any part of the
uterus, which may be inyerted, be included. If so, the patient

• M. BmddocqiM obtcrret, « Nous regsrdioDt ee raiyenement necflnaire pour
oHair la focriton de la malade." IUcimU Period. Tomo iv. p. 1S7.

t Soe a paper by Dr. M*Farlano in Glawow Med. Joomal, VoL i. p. 411.

t An Inetmment of Uiie kind io propooed by M. CuUerier, and ia dcoeribed by
M. Lefanehenz In bis Dinert. rar Ice Tmneon CireonicritCB ct Indolentcs du
tiaea eenolaire do la raatrloe et du Tagin.

128

complains of pain, and sometimes vomits; and if these
symptoms were neglected, and the ligature kept tight, pain
and tension of the hypogastrium, fever, and convulsions would
take place, and in all probability the woman would die.*
In some instances, however, the womb has been included
without a fatal effect.f Dr. Gooch advises that in every
Case the ligature should, for safety, be applied as near the
body of the polypus as possible, believing that the remains of
the pedicle will die like the umbilical cord. This opinion,
however, wants confirmation. Dr. Hunter had a uterus, in
which there was a short stalk, and he mentions that he was
uncertain whether it were an incipient polypus, or the remains
of one which had been extirpated.

Even when the uterus is not included, fever may succeed
the operation, and be accompanied with slight pam in the
belly ; but the symptoms are usually mild, and no pain is felt
when the ligature is first applied. At the same time it must
be admitted, that abdominal inflammation may unexpectedly
supervene. Three cases of this kind are related by Dr.
Hamilton.

If the first tightening of the ligature, by way of trial, give
no pain, it is to be drawn firmly so as to compress the neck
of the tumour, sufficiently, to stop the circulation. It is then
to be secured at the extremity oi the canula ; and as the part
will become less in some time, or may not have been very
tightly acted on at first, the l^ature is to be daily drawn
tighter, and in a few days will make its way through. After
the polypus is tied, it is felt to be more tiu*gid, and harder ;
and, if visible, it is found of a livid colour, and, presently,
exhales a foetid smell. These are favourable signs. The
diet is to be light, and all irritation avoided during the cure.

* Dr. OeDham, Vol. L p. 94, mentions a yoonr lady who bad luflierad long
from uterine bvmorrhafe. A poljpus wai foano Juet to have cleared the oe
vteri ; a Ilgatare was applied, bat as she felt serere pain, and Tomited, It was
slackened. Ewwj attempt to renew the ligature had the same effect. In six
weeks she died, and it was found that the uterus was inverted.

f M. Herbiniaux, Tom. ii. obs. 17, relates a case. The ligature seemed to
•et on an inverted portion of the womb, producing pain, fever and convulsions ;
it was slackened, but afterwards, notwithstanding a renewal of dreadful suffering.
It was, with a perseverance hardly to be commended, employed so as at last to
remove the polypus.— Dessault found, after having appliM a ligature round a
polypus, ana cut the tumour off next day, that part of the fundus uteri was
attached to the amputated substance ; the patient did welL Baudclocque sup*
poses that some eases related as examples of amputation of inverted uteri.

were merely polypi, accompanied with inversion. Recueil Period. Tom. in

r). 116. A case is mentioned by M. Deguise, where a very large polypus,
7 inches in circumference, and weighing three pounds and a half, was removed

116. A case is mentioned by M. Deguise, where a very large polypus,
inches in circumference, and weighing three pounds and a half, was rem
ligature^ but not without pain, spasms, nausea, cold extremities, hiccup
difflcult respiration, with frequent pulse. Nout. Journal, Tome il. p- 199.

129

The bowels and bladder must be attended to, and if there be
sympathetic irritation of the stomach, soda water is useful,
with small doses of laudanum. The foetor may be dimin-
ished, by injecting weak solution of chloride of lime. When
the tumour is very large, it may be necessary, after it is
detached, to remove it with a hook. If the polypus have
protruded from the yagina, then, after a ligature has been
applied round its pedicle, it may at once be cut off.

Excision has been latety reviyed by Osiander, Siebold,
Dupuytren, and others. The tumour is seized with forceps,
drawn down, and its neck divided ; out of two hundred cases,
Dupuytren says, he had occasion only in two to use the plug
on. account of haemorrhage. The operation has also been
successful here. The small soft polypi, or those of any size
which haye a narrow neck, haye been twisted off successfully,
and this mode is preferred by Lisfranc.

Vaginal polypi require no special consideration.

SECTION THIRTY-THIRD.

There are other tumours still more dangerous,* as they
end in incurable ulceration, and are so connected with the
womb, that the whole of the diseased substance cannot be*
removed. These always adhere by a very broad base,t and
cannot be moved freely, or turned round like the mild poly-
pus. They are sometimes pretty firm, but generally they are
soft and fungous, or may resemble cords of clotted blood.
When dissected they are found to be very spongy, with cells
or cavities of various sizes; sometimes they are laminated.
These, which have been called vivaces by M. Levret, are
always the consequence of a diseased state of the womb; but
they are not always, as that author supposes, vegetations from
an ulcerated surface. They do, however, very frequently
spring from that source, being generally of the spongoid
nature. Occasionally they have been mistaken for a piece of
a retained placenta, and portions of foetid fimgi have been

* Vide Hem. de F Ae«L de Chlr. Tom. Hi. p. 6a8.^Herbinaaz Obserrations,
Tome L ob. 89.— Baillie's Morbid Anatomy, cbap. kI&— Vlgarous, Malad. dee
Femmei, Tome i. p. 485.

f Dr. Demnan, VoL i. p. 95, relatee a ceee of polypoe with broad stem, which
wae enppoeed to be a canoer of the uterus. The ligature was applied, and
In eight or ten days it eame away ; but when the polypus was remoTed, another
eabstaDoe, nearW of the same size, was found to have grown into the vagina.
The woman died in a month. I have seen the common polypus combined with
an indorated thiefconiag of ^e vterus, and fungous or flooeulent state of the carity.
In one eiee of this kind, the uterus and rectum freelr communicated by ulcera«
tion. See aleo some caaee in Trans, of a Society, &o. Vol. iii.

130

torn away, in attempts to extract the supposed placenta, or
OYum, or the hand has been thrust far into the mass.

The hypogastric region is tumid, and painful to the touch,
even more so than the tumour itself, which, felt per vaginam,
is less sensible than the womb. Sometimes little pain is felt
in this disease, except when the womb is pressed. The tu-
mour often bleeds, discharges a sanious matter, and may
shoot into the yagina: but in this it differs from polypus,
that it comes into the vagina generally by growth, and not
by expulsion from the womb, which does not decrease or
become empty as the vagina fills. The treatment must be
palliative, for extirpation does not succeed, the growth being
rapidly renewed. Opiates and cleanliness are most useful.

SECTION THIRTY-FOURTH.

Moles* are fleshy or bloody substances contained within
the cavity of the uterus. They acquire different degrees of
magnitude, and are found of various density and structure.f
They may form in women who have not bom children,^ or
they may succeed a natural deliv^,§ or follow an abortion,
or take place in a diseased state of the uterus.! It is the
opinion of many, that these substances are never formed in
the virgin state, but always are produced from a blighted con*
ception, and no case that I have yet met with, contradicts the
supposition, for we are not to confound, with them, simple
coagula discharged in disordered menstruation. The symp*
toms produced by moles are, at first, very much the same
with those of pregnancy, such as nausea, fastidious appetite,
enlargement of the breasts, &c. ; but the belly enlarges much
faster, is softer, and more variable in size thim in pregnancy,
being sometimes as lar^e in the second month of the supposed,
as it is in the fifth of the true pregnancy. Pressure occa-
sionally gives pain. Petit observes, that the tiunour seems
to fall down when the woman stands erect, but this is not
always the case. Per vaginam there is no ballottement at

* Suidifort OIm. Pifttli. Anat. lib. 11. p. 7&— Selimld de Coneremflnt. Uteri, la
H«U«r*t Diip. Mad. Tomut W. p. 740.

f Sometimes the mm meure to be patrld, and ii ezpdM'witb grett Imuboiw
rbage. Vide ctee by Dr. Blaokboum, Lond. Med. JootimI, VoL IL p. Itt.—
Sometimes it has a kind of oeeeoos coTerinf , as In the ease by Hankopht in
Haller. Disp. Med. It. p. 716, or It is hollow within, or eontalne Teddes.

I La Motte, ehw. tII. This chapter eontalne ssYeral nseful easw, one of which
prored Attal from hcmoffbsise.
Jf Hoifman. Opera, Tomus ill. p. 168.— StahL CoOef. Caaoale, cap. fasrl. p.

I With seirrhos of the ntems, Halter's DIsp. Med. W. pp. 751, et 758.

131

the period when that should be perceived in preffnaiicj.
It must be confessed, that the symptoms are, at first, m most
cases, ambiguous, nor can we for some time arrive at
certainty, ui general, the mass is expelled within three
months, or before the usual time of quickening in pregnancy,
Uiough there are mstances of its being retained above a year*
More or leas pain and luemorrhage accompany the process,
which is very smiilar to that of abortion, and requires the same
management.* Sometimes the expulsion may be advantage-
ously hastened, by pressing the substance gently with the
finger, but we must be careful not to lacerate it, and leave
part behind. If the mole be retained beyond the usual time
of quickening, we find that the bellv does not increase in the
same proportion as formerly, and tne womb does not acquire
the magm^tude it possesses in a pregnancy of so many months'
standing. There is also no motion perceived. Mmy of the
symptoms may proceed from polypus ; but in that case the
breasts are flaccid, and the usual marks of pregnancy are
absent. The os uteri is not, necessarily, small, in a case of
polypus, whereas in that of a mole, if there have been no
expulsive pains, it is generally so.

When a woman is subject to the repeated formation of
moles, I know of no other preventive, than such means as
improve and invigorate the constitution in general, and the
uterus in consequence thereof. This is of no small import-
ance, as a weak state of the uterine system predisposes to
more formidable diseases, and may be followed by scirrhus of
the womb or of the breast.

SECTION THIRTY-FIPTH.

Hvdatids may also enlarge the womb, and these frequently
are formed, in consequence of the destruction of the ovum
at an early period,t or of the retention of some part of the

* Fai4M adTittt blood-lettlDf, Thdt^ ik 211 Vifurooi raeommflodt aa«ti€s

and piiifmtlYta» to faroar the expulsion, Tome L p. 116. Othon rabbing the m
nieri with ntt. of belledonna.

t In the HiaC of Acad, of Sclenoee for 1714* Is the eaee of a woman who hap-
pciied to fall in the third month of prefnaney. The belly, however, inereoeed
in eize till the fifth, when it began to leieen. In the sixth she was dellTered of a
bag, as large aa the fist, with a placenta and fiatus of the slxe of a kidney bean.
In this esse, hydatids were not formed ; but in the History of 1716, is a ease,
when the woman faUiog in the second month, had the OTum oonyerted into hy-
datids, which were expelled in the tenth month. As hydatids often sooeeed to
geDoino pregnancy, the symptoms mmj at first be exaoUy the same with thoee of
precnancT, nay, even motion may be felt, bat afterwards the child may die^ and
nytetids form. Mr. Watson, In the Phil. Trans. VoL xli. p. 771, gives acase, where
there was, for a long time before the expnlsion of hydatids, a quantity of blood
dischaigad arcry night ; pains at last oame on, and expeUed many hydatids. In

132

placenta, after deliyery or abortion. We possess no certain
diagnostic : when they are formed in consequence of coagula,
or part of the placenta remaining in utero, the symptoms
must be such as proceed from the bulk of the womb, or from
its irritation, as if by a polypus. The remarks in a pre-
ceding section are therefore applicable here ; but in a great
majority of cases, hydatids are formed in consequence of
the destruction of an oYum; and, accordingly, the symp-
toms at first are exactiy the same with those of pregnancy.
These cease when the ovum is blighted, and the time when
this happens, is marked by the breasts becoming flaccid, and
sickness and the sympathetic effects of pregnancy going off.
The conception remains, and the beUy either continues
nearly of the same size, or, if it increase, it is very slowly.
It is generaUy softer, and the uterus lighter than in preg-
nancy; of course there is no ballottement. Menstruation
does not take place ; but there may occasionally be discharges
of blood in different degrees, and there often is at one period

this tmt, ihm cyaptomt of ungoanef were cTideiit from N«t. to Feb. WImb
tbe OTum is blif hted, tlie belly cesses to eslarfe la tbe doe proportloo, snd the

bnssts become flsecid.

Dr. Denman fives an eDgrmyiiif of s decmsed orom ; and Sir £. Home relates
where the patient, after beiof attacked with ftoodinf , and Tomitinf , and

spasm in the abdomen, died. On opening her, the womb was fonnd fillea with
hydatids, and its month a little dilated. Trans, of a Society, he. VoL ii. p. SOa
— Soch cans as I have seen were attended with condderaUe discharfe ; bat as a
grtat part of it was watery, it made a grmter appearance than the real quantity
of Used would hoTe canaed.

In a case related by Valleriola, n. 91, the woman had at ftrrt her usoal symp-
toms of pregnancy, but in the eif nth month expelled hydatids.— >Piehart in Zod.

Med. GalL an S, p. 7S, relafem a similar case, but the hprdatids were capelled in
the fourth month without hamorrhsfo. GKbcr casw ofhydatids are to lie found
in Tulpius, lib. ilL c SB. Schenkius, p. 68S, Mereatns, de Holier, affect. Ub. lU.
e. a Christ, a Veiga, Art. Med. Ub. iii. 4 la c. IS, reUtes an instancs of sixty
hydatids, as large as chestnuts, being expelled.

Stalpairt Vender Wid, Tom. i. p. 301, mentione a woman who, in the ninth
meoth, after enduring pains for three days, expdlcd many hydatids, and the
prscsss was followed by lochia. Lsssius, Obs. Med. lib. Jr. ob. IS, mentions a
widow who for sereral years had a tumid bdly : alWr death, hydatids were found
In utcro. See also Manricean*s Observations, obs. 967. Uusrch, Obs. Anat.
Chir. 1^ 95. Albinus Annot. Acad. lib. L p. 60, and tab. ili. flg. 1. dsscrJbiis in
an abortion of the commencement of this change. The Tesiclee are not larger
than the heads of pins. Wrisberg dcaeribcs a mere advanced state in Not.
Comment. Getting. Tom. ir. p. 73; and Sandifort, in his Obs. Anat. Path,
lib. 11. e. a tab. tI. Sg. 6, has a cass extremely dletinct. See alao Hallcr Opuae.
Fhth.ob.48.

Vigarous Malad., 1^ Tom. L f. 985, prsposm mercury to hiU the hTdatids.
Hs knew an instance where the woman diecharged hydatida always when eho
went m ta aardt-rcU, Mr. Mills rslatos a ease, where the woman betwixt the
eecond and third month, had symptooss of abertion, and afterwards. In the Aflh
or sixth, expelled above three pints of hydatids. Vide Med. and Pbys. Journal,
VoL IL p. 447. r- #

When the msm is etpdled,it is found either to consist sntirely of emaU vesldee,
or partly of vesidee, and partly of more solid remains of the ovum, or ceagnlum
of blood. A nmm weighing eeveral pounds onay be expelled at one Ume.

133

or other, a very troublesome discharge of water, so that cloths
are requured, and even with these, the patient is uncomforta-
ble. No motion is perceived by the woman, and the size of
the belly and state of the womb do not correspond to the sup-
posed period of pregnancy. In some instances, the health
does not suffer; in others, feverishness and irritation are

{>roduced. After an uncertdn lapse of time, but usually
onger than in the case of moles, pams come on, and the mass
is discharged, generally in portions, at longer or shorter
intervals, often with considerable, sometimes with profuse
haemorrhage, for they are connected to the uterus, by the
remains of decidua or placenta, which receive vessels. This
expelling process, may sometimes be advantageously assisted,
by introducing the hand to remove the hydatids, or to excite
the contraction of the womb ; but this must be done cautiously,
and only when haemorrhage or some other urgent symptoms
occur. These must be treated on general principles.

In some cases, milk is secreted alter the hydatids are ex-
pelled. In others, a smart fever, with pain in the hypogas-
trium, follows. It requires laxatives and fomentations.—
When hydatids form in a blighted ovum, their number varies
greatly m different cases. In some, I have seen only a little
bit containing vesicles, often only the under part which had
been for some time detached in a threatened abortion. In
others, almost the whole is changed, and the mass much en-
larged. This I presume, is connected with the womb, by
the unchanged portions alone ; and therefore, in examining
the inner surface of such an uterus after the mass was expel-
led, we should expect to find it more or less similar to the
gravid state, according to the greater or less change in the
ovum. The relative magnitude of the vessels in the two
states has not been ascertained, few opportunities being
afforded of dissection in this disease.

Sometimes there is only one large hydatid, or, at most, a
very few in the womb, and the preceding remarks will also
be appUcable, in a great measure, to thb case. In the ad-
vanced stage, we find the belly swelled, as in pregnancy;
but the breasts, although sometimes tense, are oftener flaccid,
and no child can be discovered in utero, nor does the woman
perceive any motion. There may be pam in the abdomen,
and obscure fluctuation is discernible externally, whilst per
vaginam it is more distinct. The neck of the womb is smaU,
and the case much resembles ovarian dropsy, except that the
tumour occupies the region of the uterus. The duration of

134

this complaint is uncertain ; but the water is at last discharged
suddenly, and after making some exertion. The bag after-
wards comes away, and the process is not attended with
much pain.* It is most prudent to be patient ; but if the
symptoms be troublesome, the fluid can be drawn off by the
OS uteri. This disease, a solitary hydatid, is oftener com-
bined with pregnancy, or with a mole, than met with alone.
The first combination f is not uncommon, and I have seen
the hydatid expelled some weeks before labour. Hildanus
giyes an instance of the second, where the ovum was con^
verted into a mole intimately connected to the uterus, and
complicated with a collection of fluid to the extent of six
pounds* In this case, so much irritation was given, as to
exhaust the strength, and produce local inflammation. It
may also happen that many small hydatids may be discharged,
and yet pregnancy go on to the full time. A case of this
kind is mentioned by M. Thuillier, where discharges took
place from the middle of pregnancy tifl the end, and at one
time there were some bearmg-down pains, but no dilatation
of the 08 uteri.

SECTION THIRTY-SIXTIL

A difierent disease from that described in the last section,
is an increased secretion from the uterus itself, or rather the
glands of the cervix, accompanied generally with symptoms
of uterine irritation, and if the woman menstruate, the
menses are pale and watery. There may be a constant
stillicidium of water,t or, from some obstructing cause, the
fluid may be for a time§ retained, and repeatedly discharged

• HildaDiu, I think, relates the hletoiy of a woman who wai lapposecl to
he preniaiit» hut, dmrn uoetu emm marUo nm kabtret^ a aadden Iniuidatioa swept
away her hopes.

t llildanus relates a case of this kind in his own wife, AJeitiima «t ckarunma
amiMM aeo. Bydatlds mav also be oomhined with pr^fnaaey. The same author
tells us of a woman, who» In the fifth month, was dEellTarcd of a mola aqoosa, or
▼eslde oontalninr ten peonds of water : she did not miscarry, hut went to the
foiltimab a I-- » /»

t Hoffman mentions a woman who had a constant stillicidium, a pint being
discharged dally. It at kst prored fatal. Opera, Tom. ill. p. 16a

$ Kirkringius, p. 28, considers dropsy of the ntoms as impossible, and says,
that ererr cass of collection of water aepends on a larce hydatid. Dr. Dcnman
oeems to be much of the eame opinion. Bnt we find Instances where water is
accnmnlated and repeatedly dtacnarged, apparently from the rsmoral of a tem-
porary obotmction. Femcliuo relates a case, where the woman always before
™""*fniatIon discharged much water. Path. lib. <vi. c. 15. And M. GeofiW>y
^■^^A case of repeated discharge. Vide Fonreroy, U Med. Edare^, Tom.
U. p. 287. A case Is reUted by Turner, where the external membrane of the
uterus was said to be dkundcd with water. The menses were suppressed, and a
secrttloo of whitish fluid took place from the breasts. Phil. T>ans. No. 207.

135

in gushes. When retained in considerable quantity, it con-
stitutes what has been called dropsy of the uterus. Al-
though this may be connected with an organic affection
of the womb, or some substance within its cavity,* yet I
have met witii it where no hydatids were discharged, where
the womb felt sound, and a cure was at last accom*
plished. We must always examine carefuDy, for it may
proceed from hydatids, or from disease, or excrescences
about the os uteri. If nothing can be discorered, we
must in the case of stilliddium, proceed upon the general
principle of improving the health, and injecting mild astrin-
gents. I need scarcely caution the practitioner, not to con-
found a discharge of urine, from an injury of the bladder,
with this complaint. In delicate females, tnere is sometimes
a stiUicidium, of pale inodorous urhie, to a great degree
daity, excepting at, or near the menstrual period. It is
difficult for the patient to say, whether it come from the womb
or the bladder, but the question is decided, by keeping her
for some time in bed, with a catheter in the bladder. Im-
proving the general health removes this. Tonics, sea bathing,
if it agree, and the use of copaiba, or tincture of cantharides
are of benefit. In retention of the fluid, or dropsy of the womb,
it may be evacuated, by introducing a tube by the os uteri.

SECTION THIRTY-SEVENTa

Wormst have been found in the uterus, producing consid-
erable irritation ; and gmerally, in this case, there is a foetid
discharge. We can know tms disease only by seeing the
worms come away. It is cured by injecting strong bitter
infusions, or solution of chloride of hme.

SECTION THIKTY-EIGHTH- '

Sometimes^ air is excreted by. the uterine vessels, and
eomes away involuntarily, but not always quietly. By intro-
dndng a small elastic-gum tube into the uterus, and retaining
it there for some time, the air is discharged as fast as it is

Dr. Thmntoo dcKribet a case wbere the uterus oootained eight quarts of dark
coloarsd iuid. Mad. Chir. Traoa. ziii. p. 17(K

« Vaiidius, Tom. L p. 48S^ Mjra, that ha fausd an uterus eontaftning 180 plots
•f Sold, and Hi sides ia many plaeeascirrhouBu 1 wtsb he may nut have aiii^tlren
the e'varinai fer the womh.

f Viganns^ Mabid. Ton; L p. 4l2.*Mr. Ceeluoo meotiooa a ease, where
Bsaggu<a fpeie dIselMtfged hefors the menstroal fluid, lln woooaii was cured, by
Injsetiof oil, and lofnsioa of eamomile iowen. Med. Commeot. Vol. iii. a. 6S.

I Vide Vinnias' Maladies, Tom. i. p. 401. Rcroe Medieale^ Tom. Sr. p.
4eM— 486. £ond. Med. and Phys. Jour. Vol. Ixvi. p. 8S1.

136

extricated, and the state gtfing rise to the production is ulti-
mately removed. Air may also be retained in the uterus so
as to distend it, and swell the hvpogastrium. This tympa^
nitis may begin without any evident cause, but more fre-
quently it succeeds to symptoms of hysteritis, produced partly
by exposure to cold. The primary affection is to be relieved
by bleeding and the application of tepid poultices or blisters,
eher which, the tube, if necessary, may be used for some time.
It may also depend on the putretaction of some retained sub-
stance, in which case the practice evidently ought to be, to
wash that out with the syringe.

SECTION THIRTY-NINTH.

The prolapsus, or descent of the uterus, takes place in
various degrees.* The slightest degree, or first stage, has
been called a relaxation ; a greater degree, a prolapsus ; and
the protrusion from the external parts, a procidentia. It is
necessary, early, to attend to this disease, so as to ascertain
its existence, as it may, if neglected, occasion bad health, as
well as many uneasy sensations. The symptoms at first, if it
do not succeed parturition, are ambiguous, for some of them
may proceed from other causes, particularly, as has already
been noticed, from an affection of the nerves which supply
the uterus, and in this case,, one part of the back is generally
pained on pressing it.f They are, principally pain in the
back, groins, and about the puois, increased by walking, and
accompanied with the sensation of bearing-down. There is
a leucorrhoeal discharge, and sometimes the menses are
increased in quantity. In a more advanced state, there is
strangury, or the urine is obstructed, till the woman lay
down, or press up the tumour, and she feels a tumour or
fulness towards the orifice of the vagina, with a sensation
as if her bowels were falling out, which obliges her instantly
to sit down, or to cross her legs, as if to prevent the protru-
sion. This is accompanied with a feeling of weakness.

* Vid« memoir bj SAl»tIer» la 3d toI. of the M cmoln of tho Academy of
Sarnrr.

f Tbe tendoniMi b tometimcs at the Toy eooeyz. On examination per
Taginam, no part of tlie ntema it painful, Imt in pnadng orcr the eoocyz, and
on ita tidea, tne finger being introduced to the aeoond Joint, tbe patient eomplalnay
and tbe pain extenda forwvd to tbe pubis, where there ia often a fixed tender*
neas, or pain, on making water, although none be leit on going to atooL The
bowela are inflated, and the Umbo are weak. A auppoaitory of ii^9 graina of
extract of eicuta, with one of opium, should be introduced into the rectum ererj
night for some time; and If this give no relief, the akin over the bottom of the
eacmm must be bllatered.

187

There may also, during the course of the complaint, but
especially after it has continued for some time, be added
many symptoms, proceeding from deranged action of the
stomach, and bowels, together with a variety of those called
nerrous. On this account, an inattentive practitioner may
obstinately consider the case as altogether hysterical, until
emaciation and great debility be induced.

But if the patient have been recently delivered, there is
less likelihood of the practitioner being misled. She feels a
weight and uneasiness at the pubis and hypogastric region,
with an irritation about the urethra and bladder, and some-
times a tenderness in the course of the urethra, or near the
vulva. A dull, dragging, pain is felt at the groins, and when
she stands or walks, she says she feels exactly as she did
before the child was bom, or, as if there were something fiill
and pressing. Pains are felt in the thighs, and the back is
generally either hot, or aches. These symptoms go off, in a
great measure, when she lies down,' though in some cases,
Qiey are at first so troublesome, as to prevent rest. In some
instances, no pain is felt in the back; but whenever the
patient stands, she complains of a painful bearing-down
sensation, or sometimes of pressure about the urethra, or
orifice of the vagina.

By examination, the uterus is felt to be lower than usual,*
and the vagina, in one part or other, is always relaxed, and
sometimes it is inverted. Unlike, however, the simple in*
version, the vagina, in this case, is often most relaxed in front,
coming down on, or before, the uterus. Next to this, it is
most relaxed at the sides; frequently, but not invariably,
least behind. From the connexion of the rectum with the pelvic
fascia, that intestine, to a certain extent, is drawn down with
the uterus. Sometimes, when the finger is pressed against the
fore part of the vagina, near the uterus, we feel as if there were
almost a rent of the fascia, or connexion above. Next, the
OS uteri descends so low as to project out of the vagina. In
the greatest degree, or procidentia, the uterus is forced alto-
gether out, inverting completelv the vagina, and forming a
large tumour betwixt the thighs. The intestines descendf

* In the adult, the usnal diitanoe of the os uteri, from the posterior margin of
the orifice of the wina, is about two Inches and a half, bat sometimet it ie three.
From, the orifice of the urethra, to the os uteri in front, is about two inches.

t Sometimes the situation of the abdominal yisoera is Tsry much altered. In
Mr. White's ease, the liver was found to descend to the lower part of the belly»
and the diaphragm was lencthened so as to allow the stomach to reach the
umbilical region. Vide Med. Obs. and Inq. Vol. ilj. p. 1. In a complicated

138

lower in the pelvis, and even may form part of the tumour,
being lodged in the inverted vagina, giving it an elastic feel.
In some instances, this unnatural situation of the bowels, gives
rise to inflammation, by which the intestines become connected
together with cords of false membrane, and adhesions also mav
be formed with the bladder. The uterus is partially retroverted,
for the fundus projects hnmediately under the periniBmn, and
the OS uteri is directed to the anterior part of the tumour.
The orifice of the urethra is sometimes hid by the tumour,
and the direction of the canal is perhaps changed ; and the
bladder, if it be not scirrhous, or distended with a calculus of
large size, may be carried down into the protruded parts ;* so
that a catheter passed into it, must be directed downwards and
backwards. It is, however, quite possible, for the uterus even
to protrude, with little change in the situation of the bladder,
or direction of the urethra. Of this, any one may satisfy
himself, by experiments on the dead subject.

In some instances, instead of partial retroversion, there is
a slight degree of anteversion. This is particularly the case
when there is any fulness on the anterior part of the fundus,
or it may be caused by certain conditions of the ovarium or
neighbouring oi^ans. This state is attended with more pain
in the back, and more bearing-down, in proportion to the
degree of descent, than any other kind of simple prolapsus.
The finger introduced into the rectum feels the os uteri resting
on the extremity of that gut.

The procidentia, is attended with the usual symptoms of
prolapsus uteri, and also with difficulty in voiding the urine,
tenesmus, and pain in the tumour. If it have been long or
frequently down, the skin of the vagina becomes hard, like
the common integuments, and it very rapidly ceases to secrete.
The mouth and neck of the womb also, in such cases, elongate.
Sometimes the tumour inflames, indurates, and then ulcera-
tion or sloughing takes place. This procidentia may occur
in consequence of neglecting the first stag^ and the utems is
propelled with bearii^-down pains ; or it may take place all

I, rdatod hy Schlinekcrr Um pylonu bung down to the pubis. HaUcr, Ditp.
Med. ir. p. 419.

* Tbie point ii rery well conaidcred by Verdier> In bit paper on hernia of the
Urlnerr Bladder, iu the Ant VoL of Mem. de r Acad, de Chir. See ako a paper
by M. Tennon, In Mem. de rinslitut, Tom. ri. pw 614.— Mr. Phget rclalei a
rery lotereeting caee of prolapeua uteri, in wbkh the bladder became retroverted»
Iving above the utcrua. It could not deeeend before It, or alonjr with it, being
nUed with a calcnlue^ weighing 27 oonoee, and othcre of a emaller eiae. Some

SrU of the bladder were an inch thick; a catheter ooald not ke introduced,
ed. and I'hyo. Jounial, Vol. ri. p. 991*

139

at once, in consequence of exertion, or of getting np too aooil
after deliyery ; it may also occur during pregnancy, as I shall
pres^itly notice, and even during parturition. Sometimes it
18 complicated with stone in the bladder,* or with polypus in

the uterus.t

By experiments made on the dead subject, it is evident that
the descent of the womb, is chiefly prevented, by the fascia
which passes off from the cavity of the pelvis, to the upper
part of the va^na. Greater degrees, are also checked by the
&sda triangukris, which reaches to the orifice of the vagina ;
likewise by that of theperineum, aadby the levator ani, anddeep
transversalis perinaei, for all these tend to support the canaL
( See pp. 1 4 — 16.^ If we pull down the uterus with a hook, we
see the effect of different d^rees ; aad, first, we find the fascia
which is reflected to the vagina, stretched like a band on each
side, in a direction downward, and forward, from the notch
where the sciatic nerve issues. The round ligaments are some-
times but not always affected. The ureters are a little stretched.
No effect is produced on the bladder, but the peritoneum,
there, is a litue wrinkled. The rectum is drawn down more
or less, and if kept tightW up, resistance is afforded to the
descent. The lateral reflections of fascia and peritoneum,
from the top of the vagina to the rectum, are stretched, even
if the rectum be not kept up. This will make the face of the
gut come forward in prolapsus. If we dissect the perineum,
we find that the fascia triangularis is a Uttle protruded, and
so is the levator ani, which we know is intimately connected
with the vagina. That canal is, at its top, inverted to a
^eater or less degree, according to that of the prolapsus.
Those parts, then, which are thus stretched in the dead, must
in the nving subject, be relaxed and elongated, to which I
attribute the production of prolapsus. Scarcely any percep-
tible increase can be made to the quantity of intestines in the
pelvis, but, from the relaxation of the fascia, their pressure is
more felt ; and, although the rectum descend little, yet eveo.
that little, is sufficient from the direct influence on its extremity,
and also from its sympathetic effect on the sensation of the other

* Royteht fnUng soom hard bodies in tiM tmnoiir formed by the protruded
ports, eat owt 48 eiUeiili from the Madder. M. Tolet extracted fifty, and afterw
wmrds eared the woaian with a pesiarj. DuYemey met with a large calcalas in
the bladder, with procidentia uteri ; and Mr. Whyte relates a similar fact. Mtd»
Obs. utd Inq. VoL iiL p. 1. See also Deochamp's Traits de la Tallies, Tom.
It. p. 148.

-f Vide the ease of a girl aged tweotj-one vears, related by Mr. Fynney. The
polypous ezcrescenee was extirpated from the os uteri, aikl then a pcesary was
employed. Med. Comment. VoL ir. p. tiS,

140

intestines, to occasion a feeling of bearing-down. It is also
easy to see how the sacro-sciatic nerres may, in certain cases,
be affected, as the fascia connected with them is stretched.
In greater degrees, approaching to procidentia, the round
ligaments are stretched, but dividing these does not add much
to the facility of drawing down the womb. Even the perito-
neum, which we should, a priori, think too lax to afford much
support, does contribute to the resistance, for, both the pelvic
portion, and that which spreads over the top of the sacrum
and lumbar vertebra, are tightened when the uterus is pulled
down. The levator ani, and fascia at the outlet, are much
more affected than in the slighter and more common degrees ;
but, stiU, the parts affording the greatest obstacle to the
pulling down of the womb, are the fascia at the top of the
vagina, and the other vaginal attachments.

Some have, from theory, denied the existence of prolap-
sus,* and others have disputed whether the ligaments were
torn or relaxed. There can be little doubt, that when it
occurs speedily after delivery, it is owin^ to the weight of the
womb, and the relaxed state of the ligaments, fascia, and
vaginal connexions. From these causes, getting up too soon
into an erect posture, or walking, may occasion prolapsus,
particularly in those who are weak or phthisical. Laceration
of the perineum does not always cause it, for the connexions of
the uterus, above, may remain firm or unelongated. In the
unimpregnated state, it may be produced by dancing much
during menstruation, by straining, or any long continued
exertion, when there is a predisposition to it, from relaxation
of the parts, caused by frequent parturition, debility, or
stretching of the fascia and levator ani. Laceration of the
fascia may also permit it. Fluor albus is considered to be a
cause, but it is more frequently an effect. Sometimes a fall
brings it on. No age is exempt from it.f

mien symptoms indicating prolapsus uteri are present, we
ought to examine the state of the womb, the patient having
lately been, or rather being, in an erect posture. The
symptoms sometimes, at first, turn the attention rather to the

^ * Kirkringio* mys. Nemo vidiit nemo teneitf decepH ommea ima^uefahOf aUp§ deef •
piunl ; kueitaa mutaam eolU qma extra pudemdum promimet keee neibu ftdi huHbrio*
Opera, p. 48. Vide alao Job a Meckren, Obterr. ChSr. c. 61. Barbette Chinirf .
c 8. KooDbayeen, Obe. Chlr. part I. ob. 2.

f Dr. Monro mentions a proetdentia uteri, in a Tvry young girl. It was |ire-
ceded by bloody discbarge. Works, p. 585. Another case Is related br Sariard,
Obe. 15, In which the prolapsed uterus was mistaken for the male penis ; and aa
Goldsmith's soldier beliered they would allow him to be bom in no pariah, ao
this girl was in danger of being determined to hare no sex.

141

bladder or pubis, than the womb ; but a practitioner of ex«
perience, will think it incumbent on him, to ascertain the real
situation of that viscus. If we find that there is a slight
degree of uterine descent, we must immediately use means to
remoye the relaxation of the yagina : for nothing can directly
act on the fascia. These consist in the frequent injection of
solution of sulphate of alumin, either in water, or in decoc-
tion of oak barK,* repeated ablution with cold water, and the
daily use of the cold bath. By corrugating the yagina, and
unless they do so they do no good, they render it less lax,
and more able to maintain its position, and if this can be done,
the fascia and leyator may recoyer their tone. Tonics are
useful, chiefly in so far as they improye the general health,
but laxatiyes are eyidently indicated to keep the bowels regu-
lar, and preyent accumulation of faeces. All exertion is to
be ayoided, and a recumbent posture much obseryed. Dr.
Hamilton objects to this, as injurious to the health, but the
adyice is not incompatible with such exercise as may be
useful. This position it is eyident, must, in the early stage,
be the most effectual mean, as it allows time and opportunity
for the parts to recoyer dieir tone or tightness. If these
fail, or if the ^ease exist to a considerable degree, then,
besides persisting in them, we must haye recourse to the
assistance of mecnanical means. One of the most useful of
these, is what I haye long recommended, namely, a spring-
truss, similar to that used for prolapsus ani, but with a larger
Cd, pressing on the perineum, and also perhaps a yery little
yond it, on the orifice of the yagina.t This, in general, is
more useful and more comfortable than a pessary, but in bad
cases the latter may require to be conjoined. This, or
a firm T-bandage, must also be employed with a large globe
pessary, where the perineum is greatly lacerated. But, in
that case, it may be adyisable to try first the plan of making the
edges of the rent raw, and then using stitcnes ; or by apply-
ing caustic, to try and procure some more contraction by
granulations. If we fail, we are not worse than before the trial.
^ Pessaries haye been introduced into the yagina, with the
view of allowing the uterus to rest on them, and thereby

* Oiian^kr Mdrlttm the insertion, into the Tigina, of a bw of fine Unen, filled
with powdered o«k bwrk, at the eame time that the patient ie confined for three
woeke to bed. The liberal nae of tinetore of kino, internally, haa been advieedy
bat it haa no effect on the yagina or ite oonnexione.

t It ia iiaefal to have this connected to a pretty broad, bat thin, plate well lined
or atoffed, and adapted, accurately, to the shape of the lower part of the back, and
upper part of the pelvis. This la attached to a firm band, which buckles round
the pelvia and body.

142

keeping it up. This can only be in any degree accomplished,
if they be so broad as to stick in the canal, and like a plaU
form, bear up the uterus; or so long, as to rest on the
perineum at one end, and support the womb at the other.
The first kind are rarely, if ever, now employed. The second
can evidently only do good, when the perineum is firm, and
does not yield to their pressure, and where the relaxation is
principally, or solely, at the upper part of the vagina. The
spring-support, on the other hand, acts chiefly on the perineum
and orifice of the vagina, preventing them from yielding, and
thereby not only relieving much the sensation of bearing-
down, but also contributing to the restoration of the relaxed,
or elongated parts, to their natural state. Dr. Hamilton in
his late work, argues strongly against the use of pessaries,
but I think carries his objection too far, and trusts too much
to the T-bandage, which is with great cUfficulty kept firm and
eflicient. There are doubtless many cases where the spring-
support alone is sufficient, but wnen it is not, the globe
pessary may with advantage be conjoined, as we thereby act
both on the perineum and uterus, and, also, by pressing on
the posterior wall of the vagina, assist in preventing the lower
part of the rectum from being drawn forward, by its con-
nexion with that canal. Pessaries generally excite a mucous
discharge from the vagina, on which account, as well as from
the dislike many patients have to them, they are seldom
employed in the commencement of the complaint, or till other
means have failed.

Pessaries are made of wood, gilt ulver, steel or hair,
covered with elastic gum, &c., and are of different shapes,
some oval, some flat and circular, some like spindles, or the
figure of eight, others globular. Of all these, the globular
pessary is the best, and whilst it is not so large as to make
injurious pressure on the rectum or urethra, it ought to be of
such a size as to require a little force to in^duce it into the
vagina; that is to say, it must be so large as not to fall
through the orifice, wnen the woman moves or walks.^ It is
retained by the orifice of the vagina, rests on the perineum,
and when it fits, often gives immediate relief. Both for the
purpose of withdrawing it easily, and also for attaching it to
a prdle, that it may not drop out at an inconvenient time,
it has a tape attached to it. whichever be employed, it ou^ht
to be taken out frequently and cleaned.* By diminishing

* Morand rvlatas the eiM of a wrnnan who bad fostld diaeharfe fWiiii the vagina,
aecompaoicd with pain. On examination, fungoiu ezereaoeneea ware diaeorerad

143

gradually the size of the pessary, and umis astringents, we
may peniaps be able at last to dispense wi£ it. In all the
stages, a firm broad bandage applied round the abdomen,
frequently relieyes the uneasy sensations about the bowels,
back, and pubis, which may be understood from what I haye
said ' respecting the cause of some of those feelings. It is
farther necessary to mention, that the symptoms and treat-
ment of prolapsus, may be modified, by circumstances which
precede it, but with which it is not essentially connected. For
instance, a tender or inflamed state of the uterus, and its
appendages, may take place after deliyery, and when con-
yalescent, the patient may rise too soon, or sit up, striving to
make the child suck, and thus bring on a degree of prolapsus.
In this case, it is evident that tibe symptoms may be more
acute or painful^ and they cannot be removed by mechanical
contrivances, until by rest, laxatives, and occasional fomenta-
tions, the morbid sensibility of the parts within the pelvis be
got rid of. The uterus may also, independently of pregnancy,
become veir sensitive, along with prolapsus, so that when-
ever the patient sits quickly down, pain is felt darting through
the pelvis to the back, and coition has the same effect. A
recumbent posture, and small blisters applied to the lower
part of the back, and, perhaps, leeches applied to the os uteri
are useful.

If a procidentia be large, and have been of long duration,
the reduction of the uterus may disorder the contents of the
abdomen, producing both pain and sickness. In this case,
we must enjoin strict rest in a horizontal posture. The belly
should be fomented, and an anodyne a^biinistered. Some-
times it is necessary to take away a little blood ; and we must
always attend to the state of the bladder, preventing an accu-
mulation of urine. When the symptoms have abated, a
pessary must be introduced,* and the woman may rise for a
little to ascertain how it fits ; but, as in other cases, she ought
for some time to keep much in a horizontal posture, and avoid

in tb€ f^nti, and amongrgt tbese a bard rabstance, wbicb being extracted, was
found to be ]»art of a aUver penary. The yagina contracted at tbia spot, and tbns
though In a diiagrecable way, preyentcd a return of the prolapsus. Pessaries
havo also uleerated through Into the rectum ; and Mr. Blair mentions a woman,
in the Lock Hospital, who hnd introduced a quadrangular piece of wood into the
vagina as a pessary, and which ulcerated through into the rectum, jiroducing
great irritation, Med. and Phys. Journal, Vol. x. p. 401. It is likewise neces-
sary, if the pessary bays an opening in it, to obserre that the cerrix uteri do not
gat into the opening, and become strangulated.

* Dr. Denman Tcry properly advises, that a pessary should not be introduced
Imaiediaioly after the uterus b reduced. Lond. Med. Journal, Vol, yii. p. 66.

144

for a still longer period every exertion. If there have existed
inflammation of the displaced bowels, during the continuance
of the procidentia, serious consequences may result from the
reduction, owing to the adhesions which have formed. Should
there be much difficulty and pain attending the attempt to
reduce, it ought not to be persisted in.

If the tumour, from having been much irritated, or long
protruded, be large, hard, inflamed, and perhaps ulcerated,
it will be impossible to reduce it until the swelling and inflam*
mation be abated, by a recumbent posture, fomentations,
saturnine applications, laxatives, and perhaps even blood-
letting.* Aner some days we may attempt the reduction,
and will find it useful previously to empty the bladder. The
reduction, in general, causes, for a time, abdominal uneasi-
ness which sometimes increases to a great degree, accom-
panied with constipation, rendering it necessary to allow the
tumour again to come down. If the uterus cannot be reduced,
and be much diseased, it has been proposed to extirpate the
tumour. This has been done, it is true, with success,! but it
is extremely dangerous ; for the bladder is apt to be tiedt by
the ligature, which is put round the part; and as the intestines
fall down above the uterus into the sac, formed by the inverted
vagina, they also are apt to be cut§ or constricted. As a
palliative, Richter advises the use of a suspensory bandage.

A prolapsus uteri does not prevent the woman from becom-
ing pregnant;! ^^^ ^t is even of advantage that she should

* M. Hoin, meoeedcd in rsdaeing a Tery laWt bard, and cren nloerated pro-
cidentia, bj fomentation!, reat, and low diet. Mem. de TAcad. de Chlr. Tom.
lii. p. 866.

t See Rowuet, Plater and Platner, Inet. CUr. section 1447. WedeUoa de
Procid. Uteri, c 4. Vollcamer, in Miecel. Cor. an. % ob. Sr96. Another case
may be ieen in Journal de Med. Tom. Ixvili. n. 195. Pari (EuTres, p. 970.—
Carpus extirpated it with succcm. Vide Langii Epist. Med. lib. li. eplst. 99.—
$leTogtius relates a distinct case, where the womb was found in the Ti^na, as if
in a purse. Dissert. 12.— Benevenius says he saw a woman whose uterus
slouf hed off. De Mirand. Morb. Causis, cap. 12.— Dr. Elmer snpposss he has
met with a similar case. Med. Pbys. Journal, VoL xriii. p. d44.«- A distinct
case is related by Laumonler. The patient was long subject to prolapsus uteri,
but at last the womb, with the vagina, was forced out so Tioiently, that she
thought all her bowels had come out. At the upper part of the tumour there
was a strong pulsation. It was extirpated chiefly by ligature. 'Hm woman
died some years afier this, and the womb was found wanting. La Med. EclarC,
par Fourcroy, Tom. It. p. 33. M. Bandelooque, howerer, says, that the utcms
was only nartiallv extirpated. Vide lieeueil Period. Tom. t. p. 392. See also
cases by Marschall, Feeder^ Langenbedc, and Recamler.

I This happened In Ruysch's case. Obe. Anat. rii. Delpech in a cass of
successful extirpation, separated the bladder from the vagina. In this case both
the uterus and mina were indurated and ulcerated.

S This occurred in a case related by Henry, ab Heers, Obe. Med. p. 192.

I Herfey reUtes a case, where the tumour was as large as a man*s bead, ulce-
rated, and discharged sanies. It was proposed to extirpate the prolapsed uterus.

145

become so, as we thus, at least for a time, generally cure the
prolapsus. But we must take care, lest premature labour*
be excited; for the uterus may not rise properly, or may
again prolapse, if exertion be used.

Sometimes, especially after a fall,f when there is a wide
pelvis, the uterus may prolapse during pregnancy, although
the wonum have not formerly had this disease. Our first
care ought to be directed to the bladder,^ lest fatal sup-
pression of urine take ]^lace.§ Our next object is to re-
place the uterus, and enjoin a state of rest in a recumbent
posture. When there is no protrusion, but a mere descent,
rest alone is all that is necessary, and in neither case would I
advise a pessary. If it cannot be reduced, || a very rare state
indeed, the uterus must be supported by a bandage,^^ until,
by delivery, it be emptied of its contents. It is then to be
reduced. I have never known any instance of protrusion;
but I have found the uterus so far prolapsed as to have its
orifice at, or a little beyond, that of the vagina. The neck,
even in the beginning of the ninth month, in such cases,
was conical, and less developed than usual, whilst the lips
were ihick and protuberant. The finger could be passed up
beyond the lips, along the cervix, and excepting a feeling of
bearing-dovni, no inconvenience was experienced, nor was
there any difficulty in voiding the urine. The management
of prolapsus during labour will be afterwards considered.

if prolapsus be threatened, or have taken place after
delivery, in consequence, for instance, of getting up too soon,
we must confine the woman to a horizontal posture, till it

•

but the foUowiog nigbt a foetui wm espelledf spiikama hnaihtdin*, Openi p.
55S. See ako a caae by Mr. Antrobus, in Med. Museum, Vol. L p. 88.

* Vide Mr. HiU*B case, in Med. Comment. Vol. it. p. 88.

f Dr. Barton had a patient, who in the fourth month of pregnancy fell, and
was thereafter seized with suppression of urine. The os uteri was found ahnost
at the orifice of the Tagina. lie drew off about three quarters of urine, raised up
the wombk and introduced a pessarr. System, p. 166.

I Mr. Drmj mentions a case, where, in the fourth month of pregnancy, the
woman was seized with pains, like those indicating abortion, accompanied with
sappTesiion of arine. The os uteri was rery near the orifice of the vagina.
Thia disease proring fatal, the bladder was found to be thickened, enlarged, and
in part mortified. Vide Med. and Phys. Journal, Vol. ill. p. 456.

$ Reink mentions a woman who was pregnant of twins. In the fourth
month the womb prolapsed, and caused a fatal suppression of urine. The Tagina
at the upper part, was corrugated and inverted. Haller, Disp. Chir. Tom. iii.
p. 56&.

I See a remarkable caae of prolapsus in the gravid state, where the whole
uterus protruded, and reduction was not accomplished till after delivery, by
F. C. Fabrlcins, in Haller, Disp. Chir. Tom. ill. p. 484.

5 Vide Memoirs by M. Sabatier, in Mem. de rAcad. de Chir. Tom. iii. p.
370. A case was lately (1826) published by Sleboldj in his Joumali of a large
prolapfos in the pregnant state.

146

bave regained its proper size and weight; and this diminution
is to be assisted by gentle laxatives, particularly the daily use
of the sulphas potassse cum sulphure, in doses of from two to
three dracnms. The bandage, formerly noticed, is also useful
and comfortable.

In some cases, the cervix uteri lengthens and descends
lower in the vagina, though the body of the womb remains
in situ. This is not to be confounded with prolapsus, for it
is really a preternatural growth of part of tne uterus ; and
this portion, or elongation, has been removed by ligature.
The anterior lip has descended to a great degree in kbour,
insomuch, that it has been mistaken for presentation of the
placenta.

SECTION FORTIETH.

Inguinal hemiffi of the uterus have been long ago described
by Sennert, Hildanus, and Ruysch, and very lately by Lalle-
ment. This species of displacement may occur in the unim-
pregnated state, and the woman afterwards conceive; or it
may take place when pregnancy is somewhat advanced. If it
be possible to reduce the uterus, this must be done ; and in
one stage an artificial enlargement of the foramen, through
which the uterus has protruded, may assist the reduction. If,
however, gestation be far advanced, then an incision may
require to be made into the uterus when pains come on, that
the child may be extracted. But it has happened, that even
in this untoward situation, the natural efibrts have expelled
the child by the vagina, although the uterine hernia, protrud-
ing by a separation of part of the abdominal muscles, hung
down at first so low as the knee.

SECTION FORTY-FIRST.

The ovarium is subject to several diseases, of which the
most frequent is that called dropsy. The appellation, however,
is not proper, for the affection is not dependent on an
increased effusion of a natural serous secretion or exhalation.
A very frequent species of this, originates in the Graafian
vesicles. These enlarge, are filled with serous fluid, and their
coats become less vascular, though still furnished with vessels.
They change their nature so as to become simple cysts, scat-
tered through the ovarium, and gradually enlarging in size,
whilst the mtermediate substance either remains with little
alteration, or becomes increased in quantity and thickened.
In the first case, it is not unusual for one, or at the most two

147

cysts, to acquire a considerable size, whilst the rest make
comparatively slow progress. But it is not always so* In
the second, there is not any certain proportion between the
size of the cysts, and that of the new-formed solid substance,
nor does it appear necessary that the solid change should be

I receded by cysts. They may be simultaneous in their origin,
believe that this form, which has been called, perhaps not
very properly, cystic sarcoma, may originate in the substance
of the ovarium, and have cysts formed independent of the
vesicles. A disease, analogous to this form, is met with in
the male testicle. And I have, in the male, found, in conse-
sequence of a blow, the same kind of tumour increasing in the
abdomen to a very great size. This second kind of cystic
affection o{ the ovarium, consists in a peculiar change of
structure,* and the formation of many cysts, containing some-
times watery, but generally viscid fluid, and having cellular,
fibrous,t or indurated substance interposed between them,
firequently in considerable masses. They vary in number and
in magnitude. There is rarely only one large cyst contain-
ing serous fluid ; most frequently we have a great many in a
state of progressive enlargement ; the small ones are perhaps
not larger than peas, others are as large as a child's head,
whilst the one which has made most progress may surpass in
size the gravid uterus at the full time. The inner surface of
the cysts may either be smooth, or covered with eminences
like the papillse of a cow's uterus.} Their thickness is various,
for sometimes they are as thin as bladders, sometimes fleshy,
and an inch thick. The fluid they contain is generally thick
and coloured, occasionally foetid, and in some mstances, mixed
with flakes of solid matter, or tufts of hair. Sometimes, it is
altogether gelatinous, and cannot be brought through a small
opening ; or it contains masses of white substance, like boiled
wnite of egg ; or the thick fluid may vary at different stages
of its flowing, being sometimes like oil, and sometimes yellow
like bile, or brown. Occasionally, the whole quantity is nearly
serous, as in ascites. The analysis of this has not led to any
result of practical utility. It has been supposed, that in some
cases, the fluid was contained in the distended covering of the

* JjB Dnn mrUf this dropsy always Wins with a ■clrrhiis, and ii only a
•ymptom of it.'—Ur. Hunter says he nerer found any part of a dropsical OTarium
in a truly scirrhoiis state, and be is right.

f Dr. Johnston*s patient bad a right OTarium converted into a fleshy mass
weighing nine pounds, and full of cvsts. Med. Comment. Vol. tU. p. 265.

I I hare seen the inner surface of tlie ovarium studded OTer with nearly two
dozen of large tamonrs. M. Morand notices two cases, in which a similar struc-
ture obtained.

146

bare regained its proper size and w^ht; and this diminution
is to be assisted by gentle laxatives, particularly the daily use
of the sulphas potassse cum sulphure, in doses of from two to
three drachms. The bandage, formerly noticed, is abo useful
and comfortable.

In some cases, the cerrix uteri lengthens and descends
lower in the vagina, though the body of the womb remains
in sitn. This is not to be confounded with prolapsus, for it
is really a preternatural growth of part of tne uterus ; and
this portion, or elongation, has been removed by ligature.
The anteriw lip has descended to a great degree in labour,
insomuch, that it has been mistaken for presentation of the
placenta.

SECTION FORTIETH.

Inguinal hemiae of the uterus have been long ago described
by Sennert, Hildanus, and Ruysch, and very lately by Lalle*
ment. This species of displacement may occur in the unim-
pregnated state, and the woman afterwards conceive; or it
may take place when pr^nancy is somewhat advanced. If it
be possible to reduce the uterus, this must be done ; and in
one stage an artificial enlargement of the foramen, through
which tibe uterus has protruded, may assist the reduction. If,
however, gestation be far advanced, then an incision may
require to be made into the uterus when pains come on, thiU
the child may be extracted. But it has happened, that even
in this untoward situation, the natural efforts have expelled
the child by the vagina, although the uterine hernia, protrud-
ing by a separation of part of the abdominal muscles, hung
down at first so low as the knee.

SECTION FORTY-FIRST.

The ovarium is subject to several diseases, of which the
most frequent is that called dropsy. The appellation, however,
is not proper, for the affection is not dependent on an
increased efiusion of a natural serous secretion or exhalation.
A very frequent species of this, originates in the Graafian
vesicles. These enlarge, are filled with serous fluid, and their
coats become less vascular, though still furnished with vessels.
Th^ change their nature so as to become simple cysts, scat*
^Tf^ ^hrou^h the ovarium, and gradually enlarging in size,
whilst the intermediate substance either remains with littie
In tlT^^fi*^' ^^ becomes increased in quantity and thickened.

^® ^^®* *^e, it is not unusual for one, or at the most two

- 1

148

ovarium, the substance of which, after bemg infiltrated, had
been absorbed. I have never seen a case which confirmed
this.

The tumour has been made up entirely, or in part, of
hydatids,* forming a separate disease, or conjoined with the
former. In the case of hydatids, the fluctuation must be ob-
scure, but, even in cystic disease, until the size become large,
and especially in more solid tumours, fluctuation cannot be
discovered. There is no certain diagnosb, nor is this of
great importance, as both are aUke intractable, excepting in
so far as the cysts may be, for a time, emptied by puncture.

Ovarian disease is more apt to affect those who have borne
children, than the unmarried ; and the latter verv rarely till
they are past the age of twenty-five, oftener not till consider-
ably older. Scrofulous habits are most liable to it.

The effects or symptoms of this disease of the ovarium,
may all be referred to three sources, pressure, sympathetic
irritation, and action carried on in the ovarium itself. It
sometimes, though not often, begins with pretty acute pain
about the groins, thighs, and side of the lower belly, with
disturbance of the stomach and intestines, and occasionally
S3mcope. A few patients, feel psdn very early in the mammse,
and M. Robert affirms, that it is felt most frequently in the
same side with the affected ovarium. In some cases milk is
secreted.f But generally the symptoms are at first slight, or
chiefly dependent on the pressure or irritation of the parts
within the pelvis. The patient is costive, and subject to
piles, or strangury, which, in a few instances, may end in a
complete retention of urine ; the bowels are inflated, and in
almost every instance, from this cause, the belly is very early
enlarged, and the circumscribed tumour is lost in the general
fulness. Sometimes one of the feet very soon swells. We
can rarely, either from the vagina or rectum, feel the ovarium,
as it seldom falls lower than the top of the cervix uteri. But
sometimes, especially, if there be any degree of prolapsus, a

* Sampson, in the Phil. Tnns. No. 140, describes an OTarium filled ^ith
hydatids, conUlninff 112 pounds of fluid.— .WilU meQiions a taiIor*B wife whose
orarlnni wetf^hed ahore 100 pounds, and contained parUy hydatida, partly gelati*
nous fluid. Haller, Disp. Med. Tom. iv. p. 447.

f In a case detailed by Vater, the patient had symptoms of pregnancy, secreted
milk, and eT«>n thought she felt motion. The belly continued swelled, and sho
had bad health for three vears and a half, when she died. I'he abdomen con-
tained much water, and the right ovarium was found to be as large as a man's
head, conUlning capsules, filled with purtdent-looking matter. 1 lie nterua was
healthy but prolapsod, and the ureter waa distended from pressure. Hallrr*s
Disp. Med. Tom. iv. p. 40. This was not a case of extra-uterine gestation, for
the orarium was divided into cells, and had no appearance of f«tns.

149

tumour may be felt betwixt the vagina and rectum, and the
OS uteri is thrown forward near the pubis ; so that, without
some attention, the disease may be taken for retroversion of
the womb.* In some time after this, the tumour, in general,
rises out of the pelvis,t and these symptoms go off. A move-
able mass can be felt in the hvpogastric, or one of the iliac
r^ons.t This gradually enlarges, and can be ascertained
to have an obscure fluctuation. The tumoiu* is moveable,
until it acquire a size so great, as to fill, and render tense,
the abdominal cavity. It then resembles ascites, with which
it in general comes to be ultimately combined.§ Little incon-
venience is produced, except from the weight of the tumour,
and the patient mav enjoy tolerable health for years. But it
is not always so, for the tumour sometimes presses on the
fundus vesicae, producing incontinence of urine, or on the
kidney, making part of it to be absorbed ; and it often irri-
tates the bowels, causing uneasy sensations, or an acute pain,
with vomiting or purging, and sometimes hysterical affections,
all of which are most likely to occur, or be worst, at the men-
strual period.| It augments in size and sometimes carries up
the uterus wiih it ;% so that the vagina is elongated, and this
is especially the case, if both ovaria be enlarged.** In many

• Mr. HonNi't caw, related by Dr. DenmaD, Vol. i. p. ISO, had rery much the
appearance of retroTernoo.

-f In some cues it does not ascend out of the pelvis, or if it do, the inferior part
of the tumour sinks again into it. Morgagni relates an instance where the
orarium weighed 24 pounds; and the lower part of it filled the pelvis so well,
that when it was drawn out, it made a noise like a cupping-glass when pulled
away from the skin. Epist. 89. art. 89.

\ Swelling and Induration of the iliac glands may somewhat resemble this
diaeasa ; but they are more fixed, more irregular to the feel, and more painful on
pressure.

^ It may be combined with effusion of water in the abdominal cavity. Dr.
Bosch*s patient had 16 pints of water in the abdomen, and both ovaria were en-
larpd so as to weigh 102 pounds. This patient complained of great pain and
weight in the lower belly, and over the right hip. She was much emaciated, but
the menses were regular. When she was tapped, not above two tca-cupfuls of
Huid were discharged. Med. and Phys. Journal, Vol. viii. p. 444. — Mr. French
met with a ease of ascites and dropsy of the ovarium. Toe ovarium extended
from the pubis to the diaphragm. This patient had voracious appetite. Mem.
of Medical Soriety, Vol. 1. p. 234.

g Case b^ Sir Hans Sloane, in Phil. Trans. No. 252 — Dr. PulUney*s patient,
whose ovarium weighed 56 pounds, had excruciating pain in the left side, spasms,
and hysterical fits. Mem. of Medical Society, Vol. li. p. 265.

4 This point is well considered by M. Voison, in the Recueil Period. Tom.
xvii. p. 871. et seq The bladder may also be displaced, as in the case of Made-
moiselle Argant, related by Portal, Cours d'Anat. Tom. ▼. p. 549.

•a If only one of the ovaria be enlarged, or if both be affected, but only one
much increased, the uterus is often not raised, because the ovarium turns on its
axis, and the uterus lies below it. In a case with which 1 was favoured by the
late Dr, Cleghom, both ovaria were greatly tumefied, and could be felt on each
side of the navel, whilst immediately beneath that, they seemed to be united by
a flat hard substance; and wh«i the urine was long retained, a fluctuation could

150

instances, howerer, the uterus, in place of rising, prolapses^
and occasions repeated attacks of retention of urine, by pres*
sure on the orifice of the bladder, or it is pressed forward
nearer the pubis, or turned somewhat oblique. In other cases
it is little altered. The urine is not in the conunencement
much diminished in quantity, unless this disease be conjoined
with ascites, and the thirst, at first, is not greatly increased*
But when the tumour has acquired a large size, the urine is
generally much dimimshed or obstructed. If, howeyer, the
bulk be lessened artificially, it is often, for a time, increased
in quantity, and the health improyed. This is well illustrated
by the case of Madame de Rosney,* who, in the space of four
years, was tapped twenty-eight tunes; for seyen days after
each puncture she made water freely, and in sufficient quan-
tity ; the appetite was good, and all the functions well per*
formed ; but in proportion as the tumour increased, the unne,
in spite of diuretics, diminished, and at last came only in
drops. The woman generally continues to be regular for a
considerable time, and may eyen become pregnant.

In the course of the disease, the patient may haye attacks
of pain in the belly, with fey^, indicating inflammation of
part of the tumour, which may terminate in suppuration,!
and produce hectic feyer ; or the attack may be more acute,
causing yomiting, tenderness of the belly, and high feyer,
proying fatal in a short time, or there may be seyere pain,
lasting for a shorter period, with or without temporary
exhaustion, and these paroxysms may be frequentiy repeated ;
but in many cases, these acute symptoms are absent, and
littie distress is felt, until the tumour acquire a size, so great,
as to obstruct respiration, and cause a painful sense of disten*
tion. By this time, the constitution becomes broken, and
dropsical efiusions are produced. Then, the abdominal coy-
erings are sometimes so tender, that they cannot bear pres-
sure; and the emaciated patient, worn out with restiess nights,
feyerishness, want of appetite, pain, and dyspnoBa, expires.

The efiects of this disease must yary according to the

be pcroeiT«d before tbat part. Upon di«ectl«n, a firm thick eobetance wm foond
eztending from the pnble to the nmrtif betwixt the OTarla. This wm the ntenie
and TBf ina. The utcrue iteelf wae lengthened, the oerrix wns three inehee long,
and all appearanee of oe tinoe wae deetn^yed. Her complalnte began after being
enddenW terrified : firet the felt eerere pain in the right groin, with weakneee of
the thigh, and eoon afterwardi, pcrcelTM a tumour in the bellyy preeentlj another
appeared in the left eide. She wae tapped eizteen timca.

• Portal, Coure d' Anat. Tom. t. p. 640.

f An obecure eaee ie related by Dr. Taylor, where a Tery large abeoeei is tup-
poeed to havt formed In the ovarium.— Quarterly Joumali July, 1686.

151

nature of the parts most acted on, and the peculiar sympa-
thies which exist in the indiyidual. When we consider that,
in many instances, the whole constitution, as well as different
organs, may hear without injury, a great, but very gradual
irritation, it is not surprising that this disease should often
exist for years without affecting the health materially, whilst
in more irritable habits, or under a different modification of
pressure, much distress, too often referred to hysteria, may
be produced*

This tumour has sometimes appeared to be occasioned by
injury done to the uterus in parturition, as for instance, by
hast? extraction of the placenta; or by blows, falls, violent
passions, firights, or the application of cold ; but very often,
no evident exciting cause can be assigned. In all cases after
delivery, when the patient complains of any degree of fixed
pain above or behind one groin, and particularly when this is
mcreased by pressure, and attended with an irregular and pro-
tracted febrile condition, we should, besides the usual atten-
tion to the bowels, detract blood fi'om the arm, or topically
by cupping or leeches, and then apply a blister. Although
some may be subjected to this active practice, who might
have done well without it, yet many others should be saved
from an incurable disease, the foundation of which is now
laid. In the unmarried, as well as the married, pain in the
ovarian or uterine region at the menstrual period, when dif-
ferent from that to which the female has been accustomed to,
demands attention, and at any time it is not to be overlooked,
especially if combined with constipation, or following ex-
posure to cold.

This disease is at first sometimes misunderstood, from the
most nrominent symptom, often, being tympanites. Even
careful examination, cannot always eariy discover a tumour,
amidst the inflated intestines. Afterwards, fluctuation is
discernible, and the disease may be taken for ascites, but in
general, the fluctuation is more obscure and circumscribed,
being seldom felt in the lumbar region.

In the first stage of this complaint, we must attend to the
effects produced by pressure. The bladder is to be emptied
by the catheter, when this is necessary, which is not often,
and stools are to be procured. It may be considered, how
far, at this period, it is proper to tap the tumour from the
vagina, and by injections or other means, endeavour to pro-
mote a radical cure. When the patient is pregnant, and the
tumour opposes delivery, there can be no doubt of the pro-

152

priety of making a puncture.* before haying recourse to the
crotchet. But this has only been resorted to, in order to
obviate particular inconveniences, and affords no rule of
conduct in other cases, where no such urgent reason exists.
I am inclined to dissuade strongly from any operation at this
period, because in a short time the tumour rises out of the
pelvis, and then the patient may remain tolerably easy for
many years. Besides, the ovarium in this disease, contains,
in general, numerous cysts, and as these, in the first stage,
are small, we can only hope to empty the largest. Perhaps
we may not open even that, and although it could be opened
and healed, still, there are others coming forward, which
will soon require the same treatment. Puncturing, then,
can only retard the growth of the tumour, and keep it longer
in the pelvis, where its presence is dangerous.

When the tumour has risen out of the pelvis, we must, in
our treatment, be much regulated by the symptoms. The
bowels should be kept open, but not loose, by rhubarb and
magnesia, aloetic piUs, cream of tartar, or Cheltenham salt.
Dyspeptic symptoms, may sometimes be relieved by prepara^-
tions of steel, combined with supercarbonate of soda, or
other appropriate medicines, thougn their complete removal
cannot be expected so long as tibe exciting cause remains.
General uneasiness or restlessness, occasionally produced by
abdominal irritation, may be lessened by the warm bath,
saline julap, and laxatives, whilst spasmodic affections are
to be relieved by fcBtids, and if these CeuI, by opiates. If, at
any time, much pain be felt, we may open the bowels, if
necessary, by a clyster, and then give an opiate. If these
means fail, we may, if the tenderness be ffreat, apply leeches,
and afterwards a Hnseed-meal poultice, followed, it the pain
continue, though not so severe, by a blister. Venesection
may be useful, when the inflammatory symptoms are acute
and the pulse sharp, but it is rarely required, never to be
pushed far, and not to be used merely on account of pain. I
wish most distinctly to state my conviction, that beyond the
object of palliating symptoms, the medical art can, at present,
not extend ; and it argues, in so far as our skill, at least, as
yet goes, a most unsupported confidence in the power of

• In A CMC notiMd by Dr. DeDO^n, the labour was obttr acted until the otm-
rium WW emptied, by piercing it from the Tag loa. 'llie woman died six montha
afterwarda. Introd. Vol. ii. p. 74. In Dr. Ford's raie. related by Dr. De».
man, the eratchet waa employed. See alio a case by M. Baudelocque^ TArt dcs
Acooacfa. § 1964.

153

phyac to propose more. Upon the supposition of this
disease being a dropsy, diuretics have been prescribed, but
without success,* and often with detriment. Some have
supposed, that diuretics do no good whUe the disease is on
the increase, but that, when it arrives at its acme, they are
of service. But this disease is never at a stand ; it goes on
increasing till the patient be destroyed. When they produce
any effect, it is cmeflv that of removing dropsical affections
combined with this disease; and in this respect, they are
most powerful immediately £^r paracentesis. With regard
to their power, or the power of any other medicine, of dimin-
ishing tbe size of the ovarium, my opinion is, that they have
no more influence on it, than they nave over a melicerous
tumour on the shoulder, or over the disease, when it occurs
in the testicle, or over the configuration of the patient's nose.
In one case, fomentations and poultices, were supposed to
have discussed a tumefied ovarium ;t and Dr. Hanulton has
lately stated, that he has cured seven cases by percussion, or
patting for a length of time daily on the tumour, using a
bandage so as to make constant compression, giving solution
of muriate of lime, and employing the warm bath.t As
some tumours seem to diminish, or be absorbed, under the
influence of nauseating medicines, it might be supposed that
in this formidable disease they might be tried with propriety;
but continued sickness,, for such a length of time, as must be
required to produce any sensible effect on the tumour, would
be as hurtful, at last, as the disease it was meant to remove,
whilst certainly, during its operation, it is much more dis-
tressing. The strongest objection, however, is, that the
proposal is just as useless as any other which has been made.
Having palliated symptoms until the distention become
troublesome, we must then tap the tumour, which gives very
great relief; and, by being repeated according to circum-
stances, may contribute to prolong life for a length of time.§

• Dr. Denman JuaUy obserrM, that dioretica hare no effect. Vol. i. p. 193.
And Dr. Hunter remarks, that " the dropsy of tbe OTarium la an incurable dis-
ease, and that the patient will hare tbe best chance of llring longest under it, who
does the least to get rid of it. Tbe trocar is almost the only iMUUatiTe.** Med.
Obs. and Inq. Vol. il. p. 41.

IVaU, however, relates a case of 14 years' standing, which was cured by diu-
retics; and it waa odculated that the tumour contained 100 pounds of fluid.
Hallcr, Disp. Med. Tom. Iv. p. 641. Are such tales correct?

t Vide Dr. Monro's fourth case, in Med. EMavs, Vol. t.

^ Hamilton on Mercurial Medicine, p. 202. ^e also Practical Observations,
Part i. p. 102. In this work, the otielirated author announces bis continued
confideaoe in the plan.

$ Dr. Denmau advises tbe operation to be deferred at long as possible, and I

154

As the uterus may be carried up by the tumour, it is proper
to ascertain, whether it be the rignt ovarium or the left, which
is enlarged ; and we should always tap the right ovarium on
the right side, and vice versa : by a contrary practice the
uterus has been wounded^* When the disease is combined
with ascites, it is sometimes necessary to introduce the trocar
twice, and the difference between the two fluids drawn off is
often very great. We must neither delay tapping so long as
to injure by great irritation and distention, nor have recourse
to it too early, or too frequently, for the vessels of the cavity
excrete much faster and more copiously after each operation;
and it is to be remembered, that this is a cause of increasing
weakness, not only from the expenditure of albumenous fluid,
but also from the increased action performed by the vessds,
which must exhaust as much as any other species of exertion.
It has been attempted, to produce a raoical cure, by lay-
ing open the tumour, evacuating the matter, and preventing
the wound from healing, by which a fistulous sore is produced ;
or by introducing a tent, or throwing in a stimulating injec-
tion.f Some of these methods have, it is true, been successful,
but occasionally they have been fatal ;t and in no case which

beUera he is right ; for ercry opermtioo is followed bT re-aocomnlatioii, which is
a debilitating process ; yet it is astonhhiog how mach may in the course of time
be secreted, without destroying the patient. Mr. Ford tapped his patient 49
times, and drew off 2786 pints. The . secretion was at last so rapid, that three
pints and three ounces were accumulated daily. Med. Commun. Vol. ii. p. 123.
—Mr. Martlneaa tapped his patient 80 times, and drew off 6831 P^nts, or 13
hogsheads ; at one time he drew off no less than 108 pints. PhlL Trans. VoL
Izxiv. p. 471.

• In a case of this kind related by M. Voison, the uterus was wounded,
and the patient felt great pain, and fainted. She died on the third day after the
operation. Recueil Period. Tom. vW. p. 362, &e.

f Le Dran relates two cases in the Mem. de TAcad. de Chir. Tom. iii. In
the first, the cvst was opened, and the woman cured of the dropsy, but a fistulous
opening remained, p. 4S1. In the second he made a pretty large incision, and
Introduced a canula into the sac The operation was followed by fever, delirium^
and Tomiting ; the woman retained nothing but a little Spanish wine for three
weeks. She discharged daily, 8 or 10 ounces of red fluid. At length, all of a
sudden, 15 ounces of wbito pus were eracnated, and then the symptoms abated ;
but a fistula remained for two years ; then it healed ; p. 442.

Dr. Houston relates the case of a woman in this neighlMurhood, in whom he
made an incision 2 inches long into the orarium, and then with a fir splint turn-
ed out a quantity of gelatinous matter and hydatids. He kept the wound opco
with a tent, and succeeded in curing the patient The diseass was attributed to
rash extraction of the placenta, and had existed for thirteen years. It was
attended with Tiolent pains. Phil. Trans, zxxiii. p. 6.

M. Voison relatas a ease which was palliated by tapping, and keeping a fistula
open. Recueil Periodique, Tom. xyil. p. 981. Ana l^rtal gires an Instance^
where, by keeping the canula in the wound for a short time, a nuUeal cure was
obtained, and the person afterwards had children. Cours d'Anat. Ton. ▼•
p. 664.

I De la Porte topped a woman who had a large tumour in the belly* but
nothing came through the canula. He made an incision of conaldenble tength,
and In the course of two hours and a half, extracted 35 lbs. of jelly. The lips of

155

I have seen, have they been attended with benefit. There
are two powerful objections to all these practices, besides the
risk of excithig fatal inflammation ; the first is, that the cyst
is often irregular on its interior surface, and therefore cannot
be expected to adhere, even if its organization otherwise per-
mitted ; the second is, that as the orarium, when dropsical,
seldom consists of one single cavity, so, although one cyst be
destroyed, others will enlarge, and renew the swelling : and
indeed, the swelling is seldom or neyer completely removed,
nor the tumour emptied, by one operation. Hence, even as a
palliative, the trocar must sometimes be introduced into two or
more places. We sometimes, in dissections, meet with a
solitary bag of serum connected with the ovarium, and can
suppose, that if this, after acquiring a certain size, were felt
distmctly fluctuating, per vaginam, it might first be punctured,
and then have means used for producing obliteration.

It has been proposed to extirpate the ovarium, after
puncturing it,* in order to reduce its size ; or the operation
may, on tiie same principle, be performed early, wnen the
tumour is still small and moveable, and this I should conceive
to be a much more favourable time, than after the ovarium
had been allowed to acquire a great size. The operation is
fiill of danger, but simple in its performance. We have only
to make an incision into the abdomen, proportioned to the
size of the tumour, and after tying a ligature around the
pedicle, cut away the mass, replace the intestines, and stitch
the wound. But how few patients could be expected to
recover from this operation. It may be said they must die
at any rate, whilst this gives 9, chance of complete recovery.

Um woand were then brought together. Next day 16 lbs. of jell j were eyacu-
•tcd, but prmmtly Tomitiog aod ferer took place ; and she died on the thirtieth
day, baTing diechargcd altogether 67 lbs. of fluid. This disease was of sixteen
months* standing, and was attributed to hsmorrhage. Alem. de 1* Acad, de
Chlr. T4nn. HL p. 153.

Dr. Denman notices the case of a patient, Tiho died the sixth day after inject-
ing the ovnrinm. V<^ 1. p. 422.

• This, has socoessfnlly been done by Lanmonler, as related in-'Mem. de la
Soe. Roy. de Medicin, 1782, and by Dr. Nathan Smith of America. Vide
£din. Journal for October, 1632. Mr. Lixars has lately published two cases,
where this operation was performed, and seems to hsTe been encouraged by a
wonderful history of a woman in America, who thought so little of the operation,
that in five days thereafter she was found making her bed. In one case both
oraria were diseased, and onlT one was taken away. The woman survived. In
the other case, the operation was fatal. Other two cases of abdominal operation
aro contained in the work ; in the one, no tumour of the oyarium existed ; in
the other, the extirpation, for good reasons, was not persisted in. There is an
necount of several gmcs of extirpation in Archives T. xz. p. 92. One successful
aft fieriin, by Dieifenbadi, and another by Hopfer : two fatal by him, and one
by MartinL See also a paper by Hevin, in Revue Med. 1866, p. 161.

156

True, but if performed early, we have a great probability of
the patient dying in a few hours, whereas, by palliatiyes, she
might have lived for many years. If delayed till a late period,
the constitution is broken down, and the chance of recovery
is still less. The operation after being commenced, has been
obliged to be abandoned, owing to extensive adhesions.

It has happened that a cyst has adhered to the intestine,*
and burst into it, the patient discharging glairy or foetid
matter by stooLf Such cases as I have known, have been
palliated, but only palliated, not cured, by this event. Some-
times the fluid has been evacuated per vaginam,^ or the
ovarium has opened into the general cavity of the abdomen,
and the fluid been efFiised there, or the same has happened in
consequence of a fall rupturing the ovarium.§

There is another disease, or a variety of the former disease,
in which bones, hair, and teeth, are lound in the ovarium.!
The sac, in which these are contained, is sometimes large,
and generally is filled with watery or gelatinous fluid. The
bony substance and teeth, usually adhere to the inner surface

* Or. Monro, in Med. Essays, Vol. v. p. 773, details the history of a patient
tfho had a diseased ovarium, and in whom the tumour pointed about four inches
below the navel. It was opened, but nothin|^ but air came out, followed next
day by feces : on the fifth day some pus was discharged. She gradually improved
in health, and the tumour of the bell^ subsided ; but in two yean afterwards the
suppuration was renewed, and she died. In this case, the colon had probably
adnered to the ovarium.

f Dr. Denman relates the case of a patient, who, having for some time>affer-
ed from pain and tenderness about tbe sacrum and uterus, and uterine bamor-
rhage, was suddenly seized with vomiting, syncope, pains In the belly, and costive-
ness; presently a tumour was felt in the right side, and this soon occupied the
whole abdomen. This patient was cured, alter purging a gelatinous fluid. Med.
and Phys. Jour. Vol. ii. p. 90.

I Dr. Monro relates a case of supposed prtcnancy, in the tenth month of which
the tumour was removed by an aqueous discharge from the vagina, in a future
attack, however, violent bearing*down pains were excited, and tbe woman died
exhausted. The left ovarium was found greatly enlarged with veaides. Med.
Essays, Vol. v. p. 770.

§ A case of this kind Is related by Dr. Addison. Peritoneal Inflammation
took place, but was overcome, and the fluid was absorbed. Guy's Heport, Nob
I. p. 41.

jl See Dr. BalUie'a Morbid Anatomy, chap. SO. Dr. J. Clegbam mentions a
woman who died ten days after being tapped. The right ovarium was found
greatly enlarged, and had many cells, some containing oalr, crctadous matter»
fragments of bone and teeth, others gelatinous fluid. Trans, of Royal Irish
Acad. Vol. i. p. 80. In Essays Phys. and Literary, VoL ii. p. 800, a cass is
mentioned, in which the one ovarium contained many vesicles ; the other con-
tained a mass, like brain, with bones and teeth. In the museum attadied to the
hospital at Vienna, there is a large ovarium, the inner surface of which is covwed
witn hair. Uorstius met with an ovarium, contalnhig hair, purulent>lookiog
and oily matter. Opera, p. 249. Schenklus met with fat and hair, p. 666, and
Schacher relates a simllsr case in HaUers's Dlsp. Med. Tom. iv. p. 477. Ituvsch,
ill his Adversaria, says he met with bones and hair, and Le Rich, iu tlie Hist,
de r Acad, dcs Sciences, 1743, met with hair and oil. In ecUs, together with bones
and teeth. See also RccusU Period. Tom. xvii. p. 462.

167

of the cyst. This disease produces no inconvenience, except
from pressure. It has been deemed by some to be merely
an ovarian conception; but it may undoubtedly take place
without impregnation ; nay, similar tumours have been found
in the male sex,* or a foetus, more or less perfect, has been
found in the abdomen. It is evident that our treatment must
be purely palliative.

SECTION FORTY-SECOND.

The ovaria are sometimes affected with scrofula, and the
tumour has proved fatal by producing retention of urine.
When it rises out of the pelvis, it is often productive of
hypochondriasis, and very much resembles the ovarian disease,
formerly mentioned, but is firmer, seldom ffives a sensation
of fluctuation, and sometimes is very painnd when pressed.
It rarely terminates in suppuration ; but when it does, the
fluid, as Portal observes, is blanchatre^JUamenteuXf grumeleux^
nud digere. The substance of the ovarium is soft, and similar
to that of other scrofulous glands. Occasionally, it contains
a cheesy substance, which is found, at the same time, in the
mesenteric and other glands. If it go on more acutely, there
is often great pain, emaciation, and sinking. Iodine, cicuta,
mercury, electricity, laxatives, &c., have been employed, but
seldom with benefit. The most we can do, is to palliate
symptoms, such as retention of urine, costiveness, dyspepsia,
or pain..

The ovarium may also be enlarged, and become hard like
seirrhus, or boBy,t or converted into a fatty substance,} or

* Davcmey nw a tumour extirpated from tlie scrotum, containing flesby
matter and bonca. GBuvrcs, Tom. ii. p. 562. And M. Dupuytren presented a
report to the Medical School at Paris relating the history of a tumour found in
the abdomen of a boy, containing a mass of hair, and a foetus nearly ossified. It
was supposed, tluit at conception, one germ bad got within another. See £din.
Med. Jour. VcJ. i. p. 876. From the respectable evidence of Baudelocque, Le
Hoy, &C., this cannot be placed on a footing with H alley's case of a greyhound
dog, who Toided by the anus a living wbelp ! PhlL '1 rans. Vol. xiz. p. 316.
I believe that bones, hair, &c, have been found in a gelding. Mr. Hichmore
publisl^es ao account of a foBtus found in the abdomen of a young man. See also
Med. and Phya. Jour. Vol. xxxiv. 317. Mr. Young's case in Med. Chir.
Trana. Vol. i. p. 234, and Mr. Philips in a girl. Vol. vi. 124. See also a paper
with cases of monstrosity by inclusion, several of which were under the skin of
the perineum, or in the scrotum, by Dr. Olivier, Archives T. xv. p. 36A, and 689.

t Schleocker mentions a woman, who, soon after delivery, felt obtuse pain in
the left side, and presently a swelling appeared in the belly. She had bad appe-
tite, sweUed feet, prohipsed uterus, and suppreAion of urine and fnoes. The left
orarium was hara and stony, and weighed three ounces. Haller, Disp. Med.
Tom. ir. p. 419. In this case the tumefaction of the beUy could not be caused
by the presence of the ovarium, but rather by the pressure on the intestines.

\ Vide case by FonUine, in Haller, Disp. Med. Tom. iv. p. 485. The patient
had tumour of the abdomen, with darting pains in the left side, extending to

158

undergo other chaoffes which it would be difficult to specify.
Sometimes it is anected with the spongoid disease, or what
has been called cerebriform cancer, and is changed into a
substance like brain, with cysts containing bloody serum.
The tumour in this disease feels tense and ebistic. It inay
burst through the abdominal parietes, and throw out large
fungous excrescences. Frequently we find, on cutting an
enlarged ovarium, that part of it resembles the spongoid
structure, having bloody fungous cysts, part is like firm jelly,
and part like cartilage, or dense fat. Often, the uterus
participates in the disease, or is embedded in it quite healthy.
1 have seen a mass of this kind weigh thirteen pounds.
Scirro-cancer may also affect the ovarium, but it is not so
common as other changes.

These more solid tumours, are not to be confounded with
those considered in the last section. They are distinguished
by their hardness or elasticity, and too frequently by the
greater distress they give, and their proceeding more speedily
to a &tal termination. Perhaps of all these, the modifications
of struma are the most frequent, and of these, the worst is
that which approaches nearest to the spongoid tumour.

Of the numerous internal remedies proposed, such as iodine,
cicuta, mercury, iron, &c., I feel compelled to say, that I
have not known any of them do good, farther than as they
acted on the general health. To attend to this is the most
important rule, and if no urgent symptoms be present, it is
almost the only treatment required. The bowels are to be
kept regular, the diet digestible, stimulants avoided, and the
surface defended from cold. Medicines, to promote diges-
tion, may occasionally be required. It is chiefly when the
tumour becomes partially inflamed, marked by sensibility to
pressure, and pain, sometimes excruciating, internally, or when
the neighbouring parts, such as the stomach or bowels, be-
come affected, that we are called on for active interference.
Pain without fever, and depending more on flatulence than
inflammation of the tumour, is to be relieved by opium ; inflam-
matory attacks by leeches, and the subsequent application of

the tbigh. The left OTurinm weighed 10 poande, the right was as Uige as the
fist, and both consisted of fatty matter. Portal lilcewise relates a case of this
diteaae, where the right orarium was as large as a man's head, very hard, and
filled with steatomatoos matter, weighing altogether 85 ponnds. The uterus
and bbdder were turned to the left side. No water was effused, but the person
was cut off by hectic and diarrhcea. Some steatomatous concretions were found
in the lungs. Conrs d' Anatomic, Tom. t. p. 640. For Tarious diseases of the
orarium. eee Dr. Seymour's Illustrations and I'latca, ISSO; and Crnveiihcir,
Anat. Path.

159

a poultice^ for venesection is seldom admissible; diarrhoea, by
clysters containing laudanum ; strangury, by fomentation, &c.
Acute inflammation is, perhaps, never confined to the
ovaria alone, but one may, doubtless, be the part in which it
originated, and from which it proceeded. For, we find that it
is sometimes enlarged, and contains pus, whilst the uterus
and other pelvic viscera are affected in a minor degree. In-
flammation is marked by increased vascularity of the ovarium,
its substance is redder, not merely from vessels, but bloody
infiltration. The vesicles are larger and more vascular ; and
hence, although the patient recover, cysts may form. In a
greater degree of inflammation the ovarium is larger, softer,
and more easily torn. It is infiltrated partly with serum, some-
times yellow, sometimes bloody. Afterwards, pus may be
infiltrated, or collected in an abscess, which in some instances
has opened into the uterus, the bladder, the intestines, or
even externally. We also meet with cases where the acute
fi^ptoms subside, or perhaps never have run very high, and
the patient lives for months or longer, during which time she
suffers more or less from pain in tiie lower beUy, vesical
symptoms, &c., and on death we find one or more small ab-
scesses in tiie ovaria, and the pelvic viscera often matted to
the intestines which cover them. Simple white induration
has been considered as a result of chronic inflammation, but it
may occur without any previous symptom. If the treatment
have not been active at first, so as to subdue inflammation, it
only remains in the subsequent stage to palliate symptoms, but,
even thus, much comfort mav be derived, and Ufe prolonged.
Prostitut^, sometimes have the ovaria enlarged, and converted
into a reddish spongy mass, with littie appearance of vesicles.

SECTION FORTY-THIRD.

The ovaria mav be wanting on one or both sides, or may
be unusually small. In such ca^es, it sometimes happens,
that the growth of the external parts stops early, and the
marks of puberty are not exhibited. The ovarium may form
part of a herniary tumour.

SECTION FORTY-FOURTH.

The tubes may be wanting, or impervious, or may be the
seat of dropsy sometimes to a great extent, by the two extre-
mities being shut up. Adhesion sometimes takes place between
the fimbriated extremity, and the ovarium. Muco-purulent
secretion, also, may take place, and if discharged by the uterus,

160

is supposed to constitute one form of leucorrhosa* They are
idso mvolyed in many of the diseases of the ovaria.

The round ligaments may partake of the disease of the ute-
rus, or may have similar diseases, originally appearing in them*
When they are affected, pain is felt at the ring of the oblique
muscle, and sometimes a swelling can be perceived there.

CHAP. XL

Of Menstruatioiu

Thb periodical discharge of sanguineous fluid, which takes
place every month firom the uterus, is termed the menses; and
whilst the discharge continues, the woman is said to be out of
order, or unwell.

In some instances, the discharge takes place at puberty,
without any previous or attendant indisposition ; but in most
cases, it is preceded by uneasy feelings, very often by affections
of the stomach and bowels, pain about the back and pelvis,
and various hysterical symptoms. These affections, which
are more or less urgent in different individuals, gradually
abate, but at the end of a month, return with more severity,
attended with colic pains, quick pulse, sometimes hot skin,
and a desire to vomit. There now takes place, from the
vagina, a discharge of a serous fluid slightly red, but it does
not in general become perfectly sanguineous for several
periods. When the discharge flows, the symptoms abate;
out frequently a considerable degree of weakness remains, and
a dark circle surrounds the eye. In a short time the girl
menstruates, often without any other inconvenience than a
slight pain in the back, though sometimes, during the whole
of her life, she suffers from many of the former symptoms
every time she is unwell ; and all women, at the menstrual
period, are more subject, than at other times, to spasmodic
and hysterical complaints. Attention to the origin, and
connexion, of the uterine nerves, will enable us to explain the
pain which attends menstruation, and the sickness which
sometimes accompanies it, as well as the general irritability of
the system, and particular sympatiiies which may be exhibited.
We niay, also, understand the bad effects consequent to an ineffi-
cient effort to menstruate, and the production of formidable
diseases, such as epilepsy itself, or of vicarious or coexistent
haemorrhage from the stomach. It ought to be remembered.

I6t

that the uterus has two sets of nerves, the one, derived from the
Bjnaapathetic, the other, from the spinal nerves. From an affec-
tion of these last, not only pain in the back may be produced,
but, in certain cases, tenderness in one or more spots, with fever,
pain in the sides or legs, or, from the cord being more exten-
sively affected, the oesophagus or stomach may be very sensi-
tive, so that food causes pain till it get out of the stomach.

When the function of menstruation is about to be established,
certain changes take place, denoting the age of puberty.
The uterus becomes more expanded, and receives its adult
form ; the vagina enlarges ; the mons veneris swells up, and
is covered with hair ; the pelvis is enlarged, and its shape
changed ; the glandular substance of the breasts is unfolded,
and the cellular part increased ; at the same time the mental
powers become stronger, and new passions begin to operate
on the female heart.

The age at which menstruation begins, varies in individuals,
and somewhat, also, in different climates. It has been con-
sidered as a general law, that the warmer the climate, the
earlier does the discharge take place, and the sooner does it
cease, but this seems to be only correct, to an extent more
limited, than was at one time supposed. In the temperate
parts of Europe, the most common age at which the menses
appear, is fourteen or fifteen vears.* In this country, men-
struation ceases about the rorty-fourth year, lasting for a
period of about thirty years, but in some instances it has
continued even till near sixty.

The quantity of the discharge varies, also, according to the
climate and constitution of the woman. In this country, from
four to eight ounces are lost at each menstrual period, but
this does not flow suddenly ; it comes away slowly for the
space of three or four days. Some women discharge less,
and are unwell for a shorter space of time ; others menstruate
more copiously, and continue to do so for a week. Generally
the discharge is less the first and last days. Most, menstru-
ate regularly every four weeks, but gome every three, or
nearly every five weeks.

' The menses are obstructed during pregnancy, and the
giving of suck ; but if lactation be very long continued, the
menses return, and the milk disappears or becomes bad.

* Mr, Robertwii has pubUsbed a paper on thli tubjeet, !ii the North of Eng-
land Med. and Surf. Joiur.f in which is a table, from which it appean, that toe
Rcatcst Dumber begin to menstruate in the fifteenth year, next to that, in the
th, then the IGth, 17th, and 13th.

162

' The discharge appears to be yielded by the uterine arteries,
opening on the surface of the cavity of the body, and fundus
of the womb ; but it is not an extravasation or hemorrhage,
for when collected, it does not separate into the same parts
with blood, neither does it coagulate. In many instances, a
great quantity has been retained for some months in the
uterus and vagina, but it never has been found clotted when
it was evacuated. It contains very little fibrin, and is said
by Mr. Brande to be a solution of the colouring matter of
the blood in a diluted serum. During menstruation the uterus
becomes rather larger.

Menstruation has been attributed to the influence of the
moon, to the operation of a ferment in the blood, or in the
uterus, to the agency of a general or local plethora, or to the
existence of a secretory action in the uterus. The last of
these is the most probable opinion ; but as this work is meant
to be practical, I decline the discussion of theories and specu-
lations. The use of menstruation seems to be to preserve the
womb in a fit state for impregnation ; at least we know, that
the presence of menstruation is generaUy necessary to, and
indicates a capability of, conception.

Although all the difierent parts of the body, be combined
into one system, and dependent on the operation of a general
principle, yet, individud organs do form separate systems,
acting according to their own laws, and in consequence of
possessing a peculiar vital energy. Nor does it affect the fact,
whether we refer the peculiarity to the nature of the organ
itself, or to the property of that portion of the medulla which
gives off its nerves. It is so connected with, and dependent
on, the general system, as, on the one hand, to be under its
control, and needful of its support, and on the other, to be
capable of exercising on it an mfluence, more or less power-
ful, according to the nature of the organ. The uterus forms
not only a system, acting by its own vitality, and according
to its own laws or constitution, but also is most intimately
connected with the ffeneral system, and with other organs.
The peculiarity of the female system consists in this, that
not only in general is it more susceptible than that of the
male, but it has within it, two very delicate individual systems,
the breasts and the uterus, capable, particularly the latter, of
many changes, which may influence the general health, as
well as other organs or systems. Whilst, then, I admit that
the uterus often is affected by the state of the constitution,
and has symptomatic affections of its functions, I, at the same

163

time, must maintain, that in manj other instances, the uterus
is primarily affected, and such affection is the cause, not the
consequence, of bad health. I remark further, that it is
quite a mistake to suppose, that when menstruation is not
property performed, the uterus is in a state of mere debility.
Great debility may preyent an organ from performing its
function, but we meet with yery few examples of pure debility,
either in the constitution, or in organs. There is, almost imme-
diately, superadded a state of excitement, or at least of disorder.
Hence, under circumstances apparently little different, we
♦may have in one case amenorrhoea, in another menorrhagia.

The action of menstruation, has an effect on the yascular
and neryous system, and on the stomach and bowels. All
tender or diseased parts are worse, and if yisible, their yessels
are more turgid, preyious to, if not also during menstruation.
The neryous system is more irritable, and conyulsiye affec^
tions of the body, or aberrations of mind, are more frequent
at this period tlum at other times. The stomach may be
affected with seyere sickness and yiolent retching, or, by sym-
pathy with the skin, may produce urticaria, whilst the bowels for
a day or two before menstruation, sometimes are much inflated
and costiye, or, at the period itself, are affected with spasm.

As the female system is more irritable during menstruation,
than at other times, and as changes effected in the system, or
in particular organs, at that time, may come to inteitelre with
the due performance of the uterine action, it is a general and
proper custom with physicians, and a practice consonant to
the prejudice of women themselyes, not to administer actiye
medicines, during the flow of the menses. It is also proper,
that indigestible food, dancing in warm rooms, sudden ex-
posure to cold, and mental agitation, especially in hysterical
habits, be ayoided as much as possible. By neglecting these
precautions, the action may either be suddenly stopped, or
spasmodic and troublesome affections may be excited. For
farther remarks I refer to the next chapter.

CHAP. xn.

0/Hytteria.

Although hysteria be not a diseased state of menstruation,
yet, as it is a yery general attendant, upon deyiations of that

164

action, and a very frequent and distressing complunt, to
which women are sulgect, it will be proper to notice it briefly
at this time.

In the well marked hysteric paroxysm, a sense of pain or
fulness is felt in some part of me abdomen, most frequently
about the umbilical r^on, or in the left side, betwixt that
and the stomach. This gradually spreads, and the sensation
is felt of a ball passing along. It mounts upwsrds, and by
degrees reaches the throat, and impedes respiration, so as to
^ve the feeling of a globe in the oesophagus, obstructing the
passage of the tar, and, as Van Swieten observes, the throat
appears sometimes really to be distended. The patient now
sinks down conrulsed, and apparently much distressed in
breathing, uttering occasional shrieks, something like the
crowing of a cock, or sobbing violently, or otherwise indicat-
ing a spasm of the muscles of respiration. She is generally
pale, and frequently insensible, at least during part of the
fit; but when she recovers, she is conscious not only of
having been ill, but of many things which passed in a state
of apparent insensibility. After remaining for some time in a
state of considerable agitation of the muscular organs, the
afiection abates, and the patient remains languid and feeble,
but gradually recovers, and presently is restored to her usual
health. This restoration is accompanied with eructation,
which indeed often takes place during the paroxysm; and
also, often, by the discharge of limpid urine, which, by
Sydenham, is considered as a pathognomic symptom of
hysteria. Headach is also apt to follow a fit.

Besides producing these regular paroxysms, hysteria still
more frequently occasions many distressing sensations, which
are bo various, as not to admit of description. Of this kind,
are violent headach, affecting only a small part of the head,
audden spasms of the bowda, dyspnoea, with or withont an
appearance of croup, and sometimes attended with a barking
cough, irregular chills, and sudden flushings of heat, spaa-
mo(^c pains, palpitation, syncope, &c. These, if severe, or
frequently repeated, are generally attended with a timid or

steria is the consequence, of the
leir origins. This may be pro-
e cause operating directly on
, by sympathy from irritation of
irticmarly the case with regard
and the i^mpathetic, but it also

165

holds true with regard to the whole spinal cord* When the
origins of the nerves are directly affected, or when high
arterial action, or even venous congestion exist there, the
disease induced, indeed, too frequently passes for a common
case of the simplest kind of hysteria, and is treated, accord-
ingly, by antispasmodics.* But the preternatural rapidity,
or marked slowness of the pulse, with suffusion of the eyes,
flushing of the tacej heat of the skin, pain, or distressing
sensation of fulness in the head, with weight or giddiness,
mark a more formidable and intractable disease. The imme-
diate abstraction of blood, rather generally than topically, can
alone arrest effectually the progress of this disease ; at the
same time, if the attacks be frequent, the lancet ought not to
be resorted to, if possible, to avoid it. Cupping the back of
the neck, or between the shoulders is better. If neglected in
the very commencement, a train of symptoms is induced,
bearing a greater resemblance to epilepsy than hysteria. In
acute attacks of vertigo, the use of the lancet, or of cupping,
but not of leeches, gives speedy relief, and the patient ex-
presses herself as relieved from a weight on her head, although
she had previously denied having had any such feeling. A
blister should be applied to the back of the head if the .symp-
toms continue, and part of this, it may be necessary to keep
open. A sensation of faintness, is best relieved, by ammo-
mated tincture of valerian. K the disorder prove still more
obstinate, we must examine the spine from time to time, as
when any spot becomes tender, the application of leeches or an

* I eoDuder both the common hjrsterical paroxvim, and the more severe and
danferons form, to be greatly dependent on the condition of the yetaele at
the boMof the akuU, and in the spinal cauaL The cord is freely supplied
with blood by the Tcrtebral, intercostal, lumbar, and sacral arteries, besides the
long spinal, which descends from the Tertebral, within the cranium. But con-

J^estion is more frequent in the complex venoua circulation. 'J'here are four
ottgitudinal spinal veins, two before, and two behind, llie anterior, one at each
side, are formed by sinuses, as long as the spaces between the inter-vertebral
ibnmen, each sinus communicating with the one above and below, so as to form
a continuous but not uniform canu. I'he posterior are smaller, and do not so
distinctly form individual sinuses. Both sets communicate freely on the surface
of the dura mater, so aa to form an anterior and posterior plexus, more complex
In the cervical and lumbar, than in the dorsal region. Farther, there is a plexus
«Q the fiioe of the posterior arch of the atlas, commnnicatinc with the vertebral
plexus, the transverse sinuses, and posterior occipital, as well as with the Jugular
vein and the spinal plexus described. The extent and intimacy of this communica-
tion deserves attention. The longitudinal veins along the spine, also receive, behind,
the dorsi-spinales from the outside of the back, and, before, the basi-vertibrales
from the bones themselves. They also in front, at each inter-vertebral space,
communicate with, or in other words, terminate in the vertebral, intercostal,
(ending In the axygoa) lumbar, and sacral veins. The influence of the aterioe
system and abdominal viscera on the venous circulation connected with the spine.
Is both obvious and important.

166

issue there, is of much use. The lower part of the lumbar
vertebrae, and upper portion of the sacrum, should especially
be examined, as certain sacral nerves pass to the uterus, and
are apt to be irritated in its affections ; as they likewise join
the hypogastric plexus, more extensive sympathies may take
place. It should never be forgotten, that pain of the head,
with giddiness and debility, may arise from an affection of
any part, even the lowest, of the spinal cord. Purgatives
are to be assiduously employed, and recoveiy is often pre-
•ceded by the discharge, at length, of dark and very offensive
stools. '

During a pure hysteric fit, the patient is to be laid in an
easy posture, a free admission of cool air is to be procured,
the face is to be sprinkled with cold water, volatile salts are
to be held to the nostrils, and if she can swaUow, 30 drops of
tincture of opium are to be administered, with the same or a
greater quantity of ether, or with a tear^poonfiil of ammoni-
ated tincture of valerian, in some carminative water; or,
should there be a tendency to syncope, a drachm of the
spiritus ammoniae aromaticus may be given in water. These
combinations, are also the most powerful remedies, in the
different hysterical affections above enmnerated, when there
is no vascular excitement with local fulness. Clysters, con-
taining assafoBtida, are sometimes of use.

In the commencement of a regular hysterical paroxysm, or
even of a paroxysm in which is blended somewhat of the
disease just described, sponging part of the head and body
with cold water is often effectual in checking its further pro-
gress. I may further remark, 1st, that local pain is frequently
removed by sinapisms, with or without the internal use ot
opium ; 2d, that severe affections of the organs of respira^-
tion, particularly if accompanied with full and frequent pulse,
are more readily relieved by the lancet than by antispasmodics;
and it is a great error to suppose that the mere name of
hysteria can render a remedy improper, which both expe-
rience and the general principles of pathology prove to be
worthy of confidence ; 3d, although the lancet be proper in
urgent cases, it ought not to be frequently resorted to, but
the paroxysms are to be kept off, by a strict attention to the
state of tne bowels^ and the employment of foetids, or mild
^raics ; 4th, in repeated attacks of spasmodic breathing, like
effectof Ml emetic may be tried before again taking
" jenesection have been recently eraploy-
of the emetic, a suitable dose of

167

tmcture of opium may be ^ven, and we delay the lancet tiff
the effect of these be seen ; in the meantime the patient is
in no danger of dying ; 5th, a state of coma demands either
general or local bleeding, or sinapisms to the scalp, according
to the state of the patient and the previous depletion ; 6thy
irr^ular action of the heart, or palpitation, requires, during
the attack, ether and opium; but if these fail, and the
patient be plethoric, some blood ought to be abstracted.

The prevention of regular hysteric fits, or of individual
^rmptoms, is to be att^npted by preserving a correct state of
the bowels, or even givmg, for a time, every day, pretty
powerful purges, which has a considerable effect on the state of
the nerves, both immediately, and by rendering more active the
venous circulation, so as to relieve congestion; afterwards we
have recourse to preparations of steel, quinine, or other tonics,
with moderate exercise, and the cold bath, if it do not pro-
duce languor, or coldness and headach. The mind ought
also to be called as much as possible from brooding over the
disease, for, in hysteria, the patient is frequentiy desponding,
and anticipating many evils. Fcstids are also sometimes, but
not invariably, of benefit, such as valerian, castor, assafoetida,
&c. The menstrual action, if irregular, must, if possible, be
rectified by appropriate remedies* The diet should be light,
and every attention paid to the improvement of the general
healtii.

Hysteria may occur during the course of other diseases,
or in the stage of convalescence from them. In the first case,
it may cause some deviation from the regular progress or
train of symptoms of the disease, and it is to be feared, some*
times calis the attention of the practitioner, from more serious
parts of the patient's malady.

CHAP. xni.

Of Diseased States of the Menstrual Action »

SECTION FIRST.

Amsnorbh(ea, or absence of the menses has been divided
into the retention, or emansio mensium^ and the suppression
of the menses. By the first term, we are to understand, that
the menses have not yet appeared, the action being longer

168

tlian usual of being established. By the second, is meant the
interruption of the action which has akeady been established,
and hitherto performed. This may be subdivided into checked
menstruation, and preyented menstruation, conmionly called
obstruction.

The retention of the menses, is very often attended with
chlorosis, or chloriasis, which, medically, signifies, merely a
greenish hue of the skin, without regard to the cause, and
tiierefore, it is applied by some to different affections of both
sexes; but, generally, it is confined to that modification of
amenorrhoea, which is attended by a dingy, pale, or greenish
colour of the skin; An affection of the nerves of a disorder-
ed organ, may produce both directly and circuitously, an
effect on the origins of other nerves, productive of phenomena
in parts distant from the seat of the disease. We see this,
amongst other instances, well illustrated by the influence
produced on the fifth apd eighth pair of nerves, by which we
have the expression, as well as the sensibility of the eye
affected, the face changed, and often a dark colour below the
eye. The tongue is affected in its sensibility, coating, and
even its size. Eveiy pathologist must have remarked the
change of colour in the skin in visceral disease, whether
organic, or merely functional, and this is always most evident
in a defective state of cutaneous circulation, which, were there
no morbid tinge, would produce simple paleness. It depends
on the alteration of the corpus mucosum, induced by the
cutaneous nerves, and is only observed where that substance
exists. When the colour depends on the state of the blood,
or its admixture with bile, the white of the eye is tinged,
which is not the case in chlorosis. This subject has been too
little attended to as yet, to lead to any accuracy in diagnosis ;
still, it is probable, that when the colour is much affected, the
uterus itself is more directly in fault, than where there is
more pallor, indicating general debility.

Chlorosis, is characterized, not merely by the colour of the
skin, for this is not essential to the disease, and the skin may
be deadly white, without a greenish tinge, but by a universal
and decided debility of the whole frame, and sometimes even a
degree of torpor of particular organs. There is not only
general weakness of the muscular system, but weariness and
languor of body, with listlessness of mind, perhaps, childish
caprice. The eye, in well marked cases, is dull. The lips
and tongue pale or blanched. The surface, particularly the
extremities, usually cold. The pulse is small and weak, oftra,

169

but not always, quick. It is easily fluttered, and palpitation
readily induced. The sleep is disturbed. The appetite is
impaired, and the patient loathes food, or is sick after eating,
or much troubled with flatulence and gastrodynia. Often,
there is a desire for indigestible substances, particularly chalk,
magnesia, or even cinders. The bowels are costive, often
obstiiiately so, or if not, the stools are dark and oflensive.
The belly generally is tumid, perhaps considerably swelled,
and Yariable in size. The hands and feet generally swell at
night, and the eyelids, if not the whole face, are full in the
morning. The urine is scanty, but generally clear. Whilst
the strength and the flesh decay,' other symptoms may be
added, such as acute pains, headach, breathlessness, and a
train of hysterical symptoms, and sometimes a cough ending
in consumption, or the patient may be affected with general
dropsy. It is satisfactory, howeyer, to know, that symptoms
both alarming and protracted, may be removed, and this has
given rise to an opinion, that consumption has been oftener
cured, than is really the case.

The menses may, from one person not arriving so early as
another at puberty, be longer of appearing in some women
than in others, and in such cases, no peculiar inconvenience
attends the retardation. If the female, though near twenty,
have still a child-like form, we may be sure that the uterus is
not yet developed, and that no medicines can excite the secre-
tion. But, when the retention proceeds from other causes, it
is to be considered as a disease, and often is to be attributed,
to a general want of vigour in the system, by which, not only
a new action is prevented from being formed, but also those
which were formerly performed, become impaired. But, in
other cases, the absence of the menses, depends upon a mal-
formation of the organs of generation, a deficiency of the
ovaria, and imperfect development of, or a special want of
energy in, the uterus. I have, in my remarks on menstrua-
tion, noticed the individuality of the uterine system, and that
it may, like other distinct organs, become directly impaired,
or otherwise disordered, in its function or action. It is sup-
plied, we have seen, by two sets of nerves, the sympathetic
and the sacral ; and if we admit the first to be chiefly func-
tional, we can the more readily conceive how an improper
state of the uterus may influence the whole system of the
sympathetic nerve, and especially the organs of digestion.
And, when we further consider, the other connexion with the
medulla spinalis, by means of the sacral nerves, we need be

170

at no loss to explain many remote effects^ produced through
that medium. Nor can we feel any hesitation in adndtting
the universaly as well as the variable, injury which may result
from the state of the uterus, considered as an original or
primary exciting cause, if we allow that affections of other
organs, such as the liver, can produce extensive disorder.
The state of the uterus, in amenorrhoea, is not always that
of mere inactivity, far less of simple debility, for, there may
be an inefficient effort made, to perform the action, which ia
productive of a state of a more complex nature. A state of
great debilitv, must influence the function of the uterus, and
may suspend its performance so entirely, as to prevent even
an effort to act. But in many other cases, an inefficient
effort does seem to be made, wmch induces a disordered, or
irritated, or excited state of the uterus, marked rather by its
sympathetic effects than by pain. Two species, then, of
amenorrhoea may be admitted, besides the endless variety
arising from peculiarity of constitution, and extent of sym-
pathy. In the one, toe uterus seems quiescent, and often
gives so little trouble, that the patient, in one respect, is
neither better nor worse, than before puberty. This is some-
times the case in chronic diseases, attended with great debiUty ,
such as consumption, or in cases where a great quantity of
blood has been lost. In the other, the uterus is not quiescent,
but some effort is made to act, and a state of irritation or
disorder is induced. The immediate cause of this inefficiency,
is not so easily known, but the state does often exist, for a
considerable time, about the age of puberty, and gives rise to
chlorosis or bad health. It may also be produced by depres»>
ing passions, as hopeless love, or by debilitating causes. If
we admit that this state of the uterus, often a combination of
debility and irritation, or at least obscure excitement, but
sometimes also of torpor, can influence the system, we may
also understand, how a general debility of the system, or a
particular affection of portions of the sympathetic nerve, aa
we meet with in a bad state of the digestion, may act on the
uterus, and induce the disease as a mere symptomatic ailment,
and in either of these cases, it ia evident, that the one must
react on the other, and increase, or keep up, both the general
and the uterine injury. The marked influence of the state of
the cervix and os uteri on the stomach, is often seen in labour,
by the production of sickness and vomiting in the first stage,
or by these effects being, in some cases, invariably produced,
even by inserting the &iger within the os uteri. We can

171

readily suppose, that the converse may happen, so that a cer-
tain state of the nerves of the stomach, may affect either a
part, or the whole of the uterus.

It follows from this view, that when the disease or defect,
is symptomatic, we cannot cure the patient till we improve
and strengthen the system, and more particularly the stomach
and bowels, which have so much influence on the whole
distribution of the sympathetic nerve. Even in the primary
affection, if we had medicines more certainly emmenagogue
than we possess, we must take the aid of this plan, and too
often must, when we succeed, attribute our success, chiefly,
to such general means as tend to improve the health and
strength, and counteract the hurtful effects produced in the
constitution. We would, then, recommend regular exercise,
proportioned to the ability of the patient ; the use of the hot
salt water bath every day, succeeded by friction with dry
flannel, or a soft brush ; sufficient clothing, and particularly
a flannel dress ; a nourishing and digestible diet, with a
proper portion of wine, avoiding every thing which disagrees
or ferments ; the administration of bitter and tonic medicines
in varied forms, particularly preparations of iron, such as
chalybeate waters, tincture of muriated iron, or the carbonas
ferri precipitatum, alone, or combined with myrrh, or sulphate
of iron with quinine. Tannin, to the extent of a hundred
griuns in the day, has also been proposed, but with littie
benefit. The use of Bath water, internally as well as exter-
nally, is of service in the chlorotic state, unless the patient
be of a fiiU habit, in which case purgatives must be premised,
and afterwards conjoined, so far as necessary. Or, from one
to two tumblers of warm water, with just as many drops of
diluted nitric acid, as flavours, without making it distinctly acid,
may be drunk in the morning. Strict attention must, in
evOTy case, be paid to the state of the bowels, which ought to
be excited to an active, and if possible a vigorous state, by
the regular, but not inordinate, use of stimukting laxatives,
fiuch as the aloetic pill, compound tincture of senna, or com-
pound tincture of gentian, combined with tincture of rhubarb
or aloes, or the pilidas aloes et myrrhae, with a grain of sulphate
of iron in each. Large doses ought not to be employed, and
after the bowels are unloaded, a small quantity of medicine
may be sufficient, if aided by a clyster of warm water in the
morning. The cold bath in chlorosis is seldom proper, as it
is apt to be followed by chilness, headach, and languor. It
is only useful, when succeeded by a sense of heat and comfort.

172

The warm salt water bath is of greater service, and is proper
even at an early stage. In proportion as the strength im-
proves, it may be made colder, tdl the patient can bear the
cold sea bath, to confirm the health. Besides this general
plan, it has also been proposed, to excite more directly the
uterine action, by marriage, one of the best emmenagogues,
and the use of medicines bearing that name : but with respect
to the latter part of the proposal, I must observe, that some
of these, if rashly employed, may, from their stimulating

Sualities, do harm, and they do not generaUy succeed without
be use of such means as tend to invigorate and improve the
system. Should the tonic plan, however, fail, then we ought
to employ some of those medicines which will be presently
mentioned.

In cases where the uterus is quiescent, from great general
debility, as in consumption, haemorrhage, &c., it is evident that
we need pay no direct attention to that organ, till we have
removed the general cause.

On this subject, I would farther remark, that although
debility be a powerful cause of amenorrhcea, yet it is neither
the only cause, nor the actual condition on which it depends.
For the uterus is not in a state of simple weakness, neither
can we, by merely exciting it, make it perform its proper
function. If so, cordials and local stimuli, should produce
more decided efiects than they do.

Chlorosis, whether produced in young girls, or succeeding
to abortion, laborious parturition, or fever, is often attended
with symptoms much resembling phthisis pulmonalis. In many
instances, the pulse continues long frequent; there is nocturnal
perspiration ; considerable emaciation, with cough and pains
about the chest, and yet the person is not phthisical; she suffers
chiefly from debility. But if great attention be not pud to
improve the health, the case may end in consumption, and
hence, many consumptive women, date the commencement of
their complaints, from an abortion, or from the birth of a
child, succeeded by an haemorrhage. In chlorosis, the symp-
toms are induced, not by previous pulmonic affections, but
by some other evident cause of weakness ; the pulse, although
firequent, is not liable to the same regular exacerbation, as in
hectic ; a full inspiration gives no pam, and little excitement
to cough ; the patient can lie with equal ease on either side ;
the cough is not increased by motion, nor by going to bed^
but it is often worst in the morning, and is accompanied with
a trifling expectoration of phlegm. It is not short, like that

173

excited by tubercles, but comes in fits, and is sometimes con-
TulfiiYe ; whilst palpitation, and many hysterical affections, with
a timid and desponding mind, accompany these symptoms. The
bowels are generally costive, and the patient does not digest
well. The stethoscope also ascertains tnat the lungs are sound.

In chlorosis, attended with symptoms resembling phthisis,
it is of considerable utility, to administer, occasionally, a gentle
emetic, and at the same time the bowels must be kept open.
Myrrh, combined with the oxide of zinc, is, I tnink, of
approved efficacy; and ammonia, given in the form of an
emulsion with oil, very often is effectual in relieving the cough.
A removal to the country, and the use of moderate exercise
on horseback, will contribute greatly to the recovery. The
diet ought to be light, but nourishing. In many cases, milk
agrees well with the patient ; but it is not necessary to restrict
her from animal food. Pain in the side, may be removed, by
the application of a warm plaster ; and, if the cough be trouble-
some, squill may be used as an expectorant, and an opiate
should be given at bedtime. K the skin be permanently hot,
or irregularly hot and cold, without weakemng perspiration,
the tepid bath is of service, or small doses of saline jsdap may
be given. Ten grains of Dover's powder, may be given at night
occasionally. Should the patient be of a phthisical habit, and
the symptoms increase, or continue obstinate, it will be proper
to remove her to a nuld climate, or the southern part of the
island. Emmenagogues are either useless or detrimental.

Retention of the menses, may take place, in combination
with a plethoric state. There is seldom in this case chlorosis.
The complexion is better than in the former state, and some-
times even florid, and the attending symptoms are of a
different description. There is often a duU heavy headach,
giddiness, palpitation, stitches, and generally a fuU pulse,
unless there be some degree of oedema. If the symptoms be
severe or acute, it will be proper to commence the treatment
by using the lancet ; but if not, we proceed at once to the use
of laxatives, at first active, though not severe. «Then, we
give the aloetic pill, and assist it in the morning, with a glass
or two of a mild solution of sulphate of magnesia, or a mineral
water, both aperient and diuretic. Bitters are also of use.
The diet should be light, and the exercise carried to the
extent of the strength ; after some time, if necessary, we con-
join an emmenagogue.

Suppression of the menses, may take place under two cir-
cumstances. The discharge may be suddenly checked diuring

174

its flow, or it may be prevented from taking place at the pros-
per period, by the operation of certain causes previous to its
expected return. The first, may be called checked menstru*
ation, and it is produced chiefly, by such causes as are capable
of operating, powerfully and speedily, on either the nervous
or vascular systems. The most frequent of these causes, are
violent passions of the mind, and the application of cold to
the surrace of the body, or standing long or walking far, if
the patient be delicate. The effect is to stop the discharge,
and produce great pain in the uterine re^on, with spasm of
the stomach or intestines, violent hvsterical affections, and
not unfrequently smart iever, and pernaps those inflammatory

rptoms described in chap. x. sect. 25th. After these subside,
womb may still be so much injured, or the general health
so impaired, that menstruation may not return for many
months. The most effectual means of relieving these acute
symptoms, are the semicupium, with full doses of laudanum,
combined with ipecacuamia, or with the saline jalap, and
warm diluents. A clyster is to be given to open the bowels,
and this, if necessary, is to be succeeded by a purgative. If
laudanum cannot be retained in the stomach, it must be given
as a clyster, with some assafcetida, and the belly fomented,
and rubbed with tincture of soap and opium, or have a poul-
tice, or turpentine applied to it. If there be febrile symptoms,
and particularly if uiere be any great degree of pain in the
region of the uterus, indicating a state of action, approaching
to inflammation,* some blood should be taken from the arm, or,
at least, leeches should be applied freely to the pubis or back,
previous to the use of these other means. Should the menses
not return at the next period, we must proceed, as shall pre-
sentlv be directed.

The menses may le prevented from returning, at the r^ular
time, by the inter^rence of causes during the interval. This,
which has been called obstruction, is naturally produced by
pregnancy, and, very generally, by such diseases as tend
greatly to weaken the patient. The first of these causes is
soon recognised, by its peculiar effects. In the second, the
effect is mistaken for the cause, the bad health being attributed
to the absence of the menses, and much harm frequently done
by the administration of stimulating niedidnes. But in such

wJA^\^'^f'tJu!:!J^l?i ^M!^'*^ V. **'• N«wiii.nB, wliere there wm
werj ftw trMSM of influnnatl«D. but « coaJdcnble cffMion of bloody wmm, and

SS^ ». ^ ' """ ^^^""'^ ""^^ ""^ di.c*ver»d, NouT?jJiSr^^.

175

cases it wfll be found, upon inquiry, that before the menses
were suppressed, the patient had begun to complain. In
them, the irregularity of the menses is symptomatic, and gene-
rally indicates considerable debility, or inability to perform
the function perfectly, induced, perhaps, by great &tigue, bad
diet, loss of blood, or long continued serous discharge, hectic
fever, or dyspepsia* At the same time, it is also certain, that
in many instances, the popular opinion, that bad health is
produced by obstruction of the menses is correct. Repeated
abortion, or excessive venery, ma^ in this way, render the
uterus incapable of performing its function, although the
general health may not, for a length of time, be injured.
The existence, likewise, of a different action in the womb,
may prevent menstruation ; hence the effect of one species of
fluor albus, that proceeding from the cavity of the womb, in
sometimes causing obstruction.

The immediate and remote effects of suppression are much
modified by the previous state of the system, particularly
with regard to irritability and plethora; and also by the con-
dition of individual organs,* which, if already disposed to
disease, may thus be excited more speedily into a morbid
action. In many cases, nausea, tumour of the belly, and
other indicatioiis of pregnancy are produced.

It also sometimes happens, that in consequence of suppres-
don of the menses, haemorrhage takes place from the nose,
lungs, or stomach ; and these discharges do, occasionally, oIh
serve a monthly period, but oftener they appear at irrq^ular
intervals. Recorded instances of vicarious dischai^es from
almost every part of the body are so numerous, that I might
fill a page with mere references.

When suppression of the menses takes place in conse-
quence of some chronic and obstinate disease, such as con-
sumption or dropsy, it would be both useless and hurtful to
attempt, by stimulating drugs, to restore menstruation. But
in those cases, where the menses are suppressed in conse-
quence of some removeable cause, which we conclude, if there
be no symptoms of other incurable disease, it is proper to
interfere, both as the suppression is a source of anxiety to the
patient, a cause of fartner injury, and also as the rational
means of restoration tend to amend the health.

* BaiUoa hat obwnred, that both In young girla, and dderly women, when
the menace are ohstracted or irreguUr, the aplccn Mimetimea awelli. and sabaidra
again when the menaea become Irregular. Ih Virgin, et Mulier. Morbia. Tom.
It. p. 76.

174

its flow, or it may be prevented from taking place at the pro-
per period, by the operation of certain causes previous to its
expected return. The first, may be called checked menstru-
ation, and it is produced chiefly, by such causes as are capable
of operating, powerfully and speedily, on either the nervous
or vascular systems. The most frequent of these causes, are
violent passions of the mind, and the application of cold to
the Burrace of the body, or standing long or walking far, if
the patient be delicate. The effect is to stop the discharge,
and produce great pain in the uterine region, with spasm of
the stomach or intestines, violent hysterical affections, and
not unfr^uently smart iever, and perhaps those inflammatory
symptoms described in chap. x. sect. 25th. After these subside,
the womb may still be so much injured, or the general health
so impaired, that menstruation may not return for many
months. The most effectual means of relieving these acute
symptoms, are the semicupium, with full doses of laudanum,
combined with ipecacuanha, or with the saline I'akp, and
warm diluents. A clyster is to be given to open the bowels,
and this, if necessary, is to be succeeded by a purgative. If
laudanum cannot be retained in the stomach, it must be given
as a clyster, with some assafoetida, and the belly fomented,
and rubbed with tincture of soap and opium, or have a poul-
tice, or turpentine applied to it. If there be febrile symjitoms,
and particularly if uiere be any great degree of pain in the
region of the uterus, indicating a state of action, approaching
to inflammation,* some blood should be taken from the arm, or,
at least, leeches should be applied freely to the pubis or back,
previous to the use of these other means. Should the menses
not return at the next period, we must proceed, as shall pre-
sentlv be directed.

The menses maybe prevented from returning, at the r^ular
time, by the inter&rence of causes during the interval. This,
which nas been called obstruction, is naturally produced by
pregnancy, and, very generally, by such diseases as tend
greatly to weaken the patient. The first of these causes is
soon recognbed, by its peculiar effects. In the second, the
effect is mistaken for the cause, the bad health being attributed
to the absence of the menses, and much harm frecniently done
by the administration of stimulating medicines. But in such

• A fiital case of tbte kind it nlated br Mr. Ncwnann, wbcre Ibcre Wire
vary few traect of inflamination, bat a eontiderable rffaiion of bloodj mtiub, mmII
coNfula in the peWU ; no ruptured Tettel was dUcovered. Nout. Journ. Tom.
zill. p. 90.

177

purgatiTe, disBolyed in a considerable quantity of water : and
sbould there be dyspnoea, with pain about the chest, increased
by inspiration, it will be proper to take away some blood.
Should the skin still remain hot, the common salme jalap
will be of service. The febrile symptoms being removed,
much advantage may be derived from a combination of
myrrh, oxide of iron, and the supercarbonate of potass ; and
if emmenagogues be thought advisable, the black hellebore
is the best. After sometime, the compound tincture of savin
may be combined with it. The aloetic pill is the best pur-
gative.

In the flabby relaxed habit, in which there is a disposition
to watery efiusion, laxatives, squiUs, and preparations of steel,
with regular exercise, and frequent friction of the whole body,
are the proper remedies of a general nature.

SECTION SECOND.

It sometimes happens, that the uterus, instead of discharg-^
in^ a fluid every month, forms a membranous or organized
substance, which is expelled with puns and haemorrhage, like
abortion. Morgagni* describes this disease very accurately.
The membrane, he says, is triangular, corresponding to the
ahape of the uterine cavity ; the inner surface is smooth, and
seems as if it contained a fluid ; and that it does so, I have no
doubt from my own observation ; the outer surface is rough
and irregular. According to Morgagni, the expulsion is
followed by lochial discharge.

Dr. Denman supposes, uiat no woman can conceive who is
affected with this disease; but some cases, and, amongst
others, that related by Morgagni, are against this opinion.
Mercury, bark, chalybeates, myrrh, and mjections, have all
been tried, but without much effect. A course of active but
not severe purgatives, the daily use, for some time, of the
warm sea water bath, with the decoction of sarsaparilla, will
form, perhaps the best general plan we can employ. When

Eiins begin to be felt, a dose of pulv. ipecac, comp. should
e given, and its effects assisted by some warm diluent. A
Jmowledge of this disease may be of great importance to the
character of individuals.

Chaussier mentions a case, where this membrane presented,
with pain, at the orifice of the uterus, and was pulled away
entire with the fingers. It was as large as a fig, and filled

• Vide EpUt. xlviii. Art. 2.
N

17B

Wlii:UDod^ fliiiid. CoUomb AcBcriboB r momlinBioiiB protriK
jriim Bimewhat.fiiiiiil8r, whioli he ooneeived to be a prokpsoB
4ar eveodoB of Hie internal membrane of the uleniB, and
(wfaieh mas removed by ligatuve -as a polypuB*'*

SECTIOJ^ THIRD.

MsDrtraation is aametkaeB attended with great pain, and

'die diadiarge generally takes pLice slowly, and is sparing.

it has move of the ohxDoeter of blood tiian of menaes, for at

Sate^ there.ase often shreds of fibrin, or little clots c^schorged.

If the discharge come freely after the first day, then the pain

oeaaes. In some, it is confined to the back, biH geBeralty it

also affects bodi the hvpogastrinm and thighs, or hips.

•With some, it preoedes tne discharge for more than a day,

but oftener for a shorter period. This diseoae is called

dysmenorrhoea. It seems to be dependant on an imperfect

menstrual action, and so long as this state continues, con-

•ception cannot lie ^pected to take phce. In the treotment^

ire most consider whether any general condition, or sympn^

thetic cause, or peculiar oiganisration of the uterine 6ystem,t

•can be discoyered to exist, and if so, we must act accordingly.

If no special indication, how^yer, can be obtained, we must

4endeayour to improye the state of the uterine neryes, by

regular and repeated friction with a stimulating embrocation,

such ae (m1 of rosemary, alone, or with camphor dissolyed in

it, on the himbar. and sacral regions. The bowels are to be

excited by means of laxatives, especially aloetics, combined

with the use of sareaparilla, or with a short course of iodine,

4nr such other stomachios as promote digestion. The die^

the clothing, and the exercise, are to be regulated, so as to

contribute, to the improvement of the general health, and if

the cold bath agree, it ought to be taken eyery morning, tf it

do not, we employ the tepid salt water bath. For a week

previous to the expected attack of pain, the semicupium

should be used every night, and some mild emmenagogue,

such as a tea^oonfm of ammoniated tincture o( guaiac, or

infusion of madder, with an aromatic, prescribed. Whenever

the pain begins, the patient should go into the warm hip>

bath, then go to bed, take an opiate, in a full dose, combined

with aromatic spirit of hartdiom, or with ipecacuanha, as in

* Diet, des Sctenees Medieftlci, mrt. Matrioa.

t It hM been rappoted, ttiat this discMe generally dnimded on amallneai oflha
M nteri, and that it was to be cured by dilating that vrith bongiea. Do we never
find it occur in women who have borne children, and have a laife aperture or
do we ever find the mentea retained in the wtcroa and'dlatendlof it ?

179

Daver^« pcmder, aild^ drU freely wme 'warm daueat, m u
to promote yergpiwiiarHi. The next mermng, a nuld pur«
jgative, oeqoiDed with aa aromatic, ie to he taken, and ^e
opiate, if neoesaary, repeated in the evemng. If the (qnate
caBOot be iietaiined on the «tomadi, it shouM be given in the
fixnn of clyster. Campher is leas effieacioiia, yet it some*
times succeeds where qfaum £axk* Ten grains, at laaat,
should be given for a dose, if the stomach wUl bear it.

This state of the womb sometimes produces, besides uterine
pain, apasnadic affection of the bowels, or yioleiit bearing-
down CTorta of the abdominail musdes, as if it were intend^
to expel the womb itaelL Such efforta are ako acmietimea
made periodically, when the menaea ape altogether or nearly
jobatmcted. Ui^er such circumataooes, we must examine
carefully inlD the state of the womb, and the appearance of
the discharge, or whether fibrous shreds be not expelled.

If no orgaxuc affection can be diaeovered, and the whole
-appear to rise from spaam, we have only to trust to opium in
ibe meantime, with auoh treatment in the intervals, as the
state of the system may point out. Some women, thoug}i
they menatoruate abundantly, suffer much pain, not only in the
uterine region, but also in die belly« like co£c, accompanied
with violent vomiting and headach. This is relieved by
bitters, tincture of hellebore, and eapecially tonic laxatives
during the interval, and by opiates during the attack of pain.

When there is tendemesa on touching the oa uteri, leedies
to the pubis, or sacrum, Hie tqpid hip-Jbath, and anodyne
dyaters, are indicated. If the pulse be frequent >or full, and
the skin hof^ v«;ieaection is useful.

SECTION FOUHTH.

Some women menstruate more copiously, or more fre-
.quently, than by the general laws of the female system, they
•ought to do* The dkoharge is menatruous, and does not
coagulate, which distinguish^ this state from uterine hcemor-
rhage. -Of the two varieties, we oftener meet with those who
menstruate ^sopioualy, and for a longer time than usual, than
with those who menstruate too often, far the generality of
theae, do not menstruate, but ha^e haomorrhage. Copious or
prolonged menstruation, is only to be considered as a disease,
when it is not natural, that is, when it has not been habitual,
Mxni when it produces weakness. It may occur in those who
jare robust and plethoric, or in those who are relaxed and
debilitated ; but women ^ tiie hitter description are ofbener

180

liable to hemorrhage, than to this state of menstruation. If it
be necessary to interfere, we must enforce that plan, which

i>reyents the vessels from being distended with blood, which
essens the determination to the uterus, and which rectifies
the state of the constitution that predisposes to this excessiTe
secretion. I need not be more particular, as I shall enter
^ore into detail, in the next section.

SECTION FIFTH.

Haemorrhage, has been ascribed either to an increased
impetus, or a relaxed and enfeebled state of the yessels, for I
speak not of haemorrhage from wounds or abrasions, and
hence has been divided into active and passive. In this dis-
tinction there is, I apprehend, more of formality than of
practical correctness. That a weakened and tender vessel,
shall give way to less force, than one which is strong, and may
be ruptured by very little effort, is true. We see it in the
case of diseased arteries, and in weak and delicate veins, where
the circulation is retarded by position or otherwise. A very
moderate ligature applied round a leg which is ulcerated
may make the veins give way, but these haemorrhages are of
that mechanical nature, allied to those produced by wounds.
Even in this case, of the effect of a ligature, it is not always
'the vein which is lacerated, but more frequently the artery,
which by the resistance is excited to greater eiPort. In all
* arterial naemorrhage there must be an excitement, and conse-
tjuently an increased action of the vessels of the part ; not a
mere excitement, for this may lead to inflammation or other
consequences, but one which leads to an action of a particular
kind, called the haemorrhagic, and which is more peculiarly
confined to the vascular part of the organ. It is probable
that the different constituent textures of an organ are sup-
plied by distinct nerves, and which, although apparently pro-
ceeding from the same trunk, might be traced as distinct
fasciculi to the origin of the nerve. But, be this as it may,
it is evident that excitation may be so modified, as, in some
eases, to manifest itself chiefly by vascular contraction, in
others, by sensation or inflammation, or haemorrhagic action
of the vessels ; and we as yet know too little of the nature of
the nervous system, and of the mutual relation of different
fibrillae, to be able to explain how certain remote (I speak as
to locality) and sympathetic causes shall, without any differ-
ence that we can detect, produce opposite effects. For
example, we often, in apparently the same state of the system.

181

and of its different organs, find sometimes menorrhagia, leu*
corrhcBa, or amenorrhoea, or an alternation of these produced.
No general state of the system is sufficient to produce haemor-
rhage. It is not essentially produced by either general
plethora or general debility, nor by local debility, for all these
states exist without haemorrhage. It is only produced by the
existence of a particular effort of the vessels of the part beyond
their power, whatever that power may happen to be. In
place, then, of dividing haemorrhage into active and passive,,
it is better to consider it as occurring in two different states of
the system, or of the vessels of the p^, but in both, as the»
result of action disproportionate to the power.

In either state, menorrhagia may be produced, by such
causes, aa act more or less directly on the uterine vessels,
especially about the menstrual period, such as dancing much-
during menstruation, or the use of stimulating and exciting
substances at that time, which exciting the whole system,,
produce a greater effect, on the uterine vessels from their
peculiar state. Any considerable effort, made during men*
struation, will be especially apt to have this effect, if there be
any degree of prolapsus, or if the irritation of a polypus, &c.,
be conjoined. The irritation of ascarides or piles can have
a similar effect. Another class of causes, acts by producing
an increased resistance to the arterial blood, by retarding the
circulation in the veins. '. Hence costiveness, or a sluggish
state of the bowels, by the effect on the whole system of the
vena portae, may produce both piles and menorrhagia. The-
state of the uterine nerves alone may cause it ; and this, as in
amenorrhoea, may be dependent on the origin of the nerves,,
being either directly affected, slowly, by some obscure cause,,
or, speedily, by some violent emotion of the mind, or sympa*
thetically by the condition of other organs, as the liver,
stomach, or intestines. All these act quite in a different way
from organic disease, whereby the vessels are opened by
destruction of their coats, or in some other mechanical way,
and hence we should always in menorrhagia examine the state
of the uterus. Even simple enlargement, may render any of
the causes already noticed more efficient, or this or other
organic alterations may be accompanied with such action as
produces haemorrhage. Hence the necessity of examination.

Uterine haemorrhage is accompanied with symptoms of
irritation, and, in almost whatever way induced, is attended
by pain of the back and loins, generally depending on the
state of the nerves, and often with a feeling of weight or even

189

cmhr stase^ il BBjr m cue state af the
be attended br & feicr of die natiore of amoeba ; bat
it bi£jii^ if ft ge to a great degree, or be long
pratncted, we hue great dd>ilitj prodnced, with or widiout
a particdbrkiDd of fewer; and at last the patient may become
drvpeicai, er soaie fintal nscerdi disease may derdop itsdf*

It is of great inportaaee to attend to die effect of haemor-
ibage. The loss of blood, is the loss both of a source of
energy and of & stJainltis, and mnst therefore directly weaken
or j^iminiah action, and this is certainly the immediate effect
of a sudden and grei^ loss of Uood* Syncope is the direct
consequence, which may be deadly* But if the haemorrhage
ndther prove immediately fatal,, on the one hand, nor be
perfectly recoyered firom, on the other, we hare some new
oirevaislanoes to attend to» The actual quanti^ of hlood is
diminished, and therefore less must circulate in the arterial
system, whidi must aoeordin^y contract in the same propor-
tion, it is Tery donbtfol if me yenous system contract in
the same degree, for there b always an ajccumulation of blood
found,^ eyen where haemorrhage is fatal, in the yena caya^
and veins of the brain, which is probably the cause of conyid-
sdon occurring, as mi early eflEect of rapid and profose haemor-
rhage. If this system diminish less, tnen, a still greater effect
will be produced on the arterial system, and it must contract
still more. So long as the circulation can go on, there is no
necessity, mraely from the diminished quantity of blood in the
system, that the heart should receiye and expel less at a time
than formerly, or that it should contract either quicker or
slower* These are not necessary consequences* But it does
follow, most distincdy, that tbe artn^ial, if not the whole yas-
eular system, mnst be in a new and unnatural state, and must
thereby be excited. A great er protracted haemorrhage, if
not speedily fatal, must be productiye of yascukr excitement,
marked by differcmt symptomsi according to the constitution
of the patient, and other oireumstances. It iis more or less
of a febrile na^ire, and it is usual to call it by the name of
re-action, merely, I presume, because the system baa not
sunk under syncope^ but tiie person has liyed long enough to
become diseased, it is a state arising, not from an effort of
nature, or a salutary action set agoing tx> counteract die
work of death, sb Mr. Hunter would haye said, but iti^
plainly the result of an existing excitement and irritation,
arising from ihe unnatural state of the vascular system. In
this state, whoever a locai cause exists, productive of action

hsyoiid iiliat Ike weakened cttDdition of Ike port can bear; tut
ere in great danger of a severe local disease, and hence none
are so fiable to inflammation of the utema and peritoneum».aa
those women^ who faaire suffered from nteriae hamorriiagy^
But besidiM these e£bcts on the yaacuiar system, there are
ether drcumstanees to be taken into account, particularly the
state of the circnhition in die brain, the general action oi
tile nenreus system, the exhaustmg effect of ex^tement of m
weakened system, the derangement of fimctunis, the intricate
conseifuence of yarious sympathies, and the opposite condition^
in which different parts may be in at Ike same time, as, foD
example, different portions of the brain. These, altoge&ery
sender ike consideration yery complex, and of high import-
ance in a pivctioal yiew* Increased susceptiUlity^ and
sometimes increased sensibility, may be Ike consequence of
haemorrhage, bnt not dmcdy or primarilg^ Functiona conw
nected with mnsonlarity are apt to be impaired,, hence the
peristaltic motion is slow, unless the mucous eoat of the intesh
tine be irritable^ £yen the heart would probably act dowly,
were no mmatoral excitement produced^ but^ bodi the unna^
tural and excited state of the arterial system, and the second-
ary efibct produced on the brain and medulla spinalis, muat^
in so fio* as these exist, or are not counteracted in particulac
eases, produce frequent and eyen irregular action of the
heart. The same causes, may also occasion painful conditions
ef the extremities of the nerves, whose origins are thus affect
ted, or eyen true inflammation may be excited,, or Tiolent
cerebral disorder produced, or from l3[xe state both of the
brain and of the yenous system, stupor or apoplexy may be
caused. The efiect of an erect posture in Ikis state- of the

Sstem, on the brain and heart, does not require explanationv
epeated disdiarges, after & certain, quantity has been at first
lost, must at each renewal, eyentually, add to Ike systematia
kritation, though perhaps,, at the moment, some relief be
experienced to some of the sensations. All the effects of
haemorrhage, may be modified by the preyious state of ike
system. Weak people generally suffer soonest, whilst a state
ef synocha is relieyed, and the system brought into an im«»
proyed state by the loss of a quantity of bloody which in^
health would haye perhaps proyed ultiniately fisital.

Married women, are more liable to monorrhagia than
yirgins, and it is rare for these, if otherwise healthy, to haye*
uterine haemorrhage.

The management during the attack, must depend on the

ISI

bearing-dowiu ia die eariy staoe^ it ins]r in one state of the
BjsteBi, be attended 1^ a fever of the nature of ^nocha ; hot
howeyer it hegin^ if it go to a great degree^ or be long
protracted, we have great debility produced, widi or wilhont
a particular kind of fever; and at laat the patient may become
dropsical, or some fetal yisceral disease may derelop itself.

It is of great importance to attend to the effect of haemor-
rhage. Ta9 loss of blood, is the loss both of a source of
enerffy and of a stimulos, and must therefore directly weaken
or diniiiiish action, and this is certainly the immediate effect
of a sudden and nei^ loss of blood. S^cope is the direct
consequence, which may be deadly. But if tne hsmorrhage
neither prove immediately fatal,^ on the one hand, nor be
perfectly recovered from, on the other, we have some new
eircumstances to attend to. The actual quantity of blood ia
diminished, and therefore less must circulate in the arterial
system, which must accordin^y contract in the same propor-
tion, ft is yery doubtful if ue venous system contract in
the same degree, for there is always an accumulation of blood
found, even where hasmorrha^ is fatal, in the vena caya,
and veins of the brain, which is probably the cause of convul-
sion occurring, as an early effect of rapid and profuse hannor-
rhage. If this system dunimsh less, then, a still greater effect
will be produced on the arterial system, and it must contract
still more. So long as the circulation can go on, there is no
necessity, merely from the diminished quantity of blood in the
system, that the heart should receive and expel less at a time
than formerly, or that it should contract either quicker or
slower. These are not necessary consequences. But it does
follow, most distincdy, that tiie arterial, if not the whole vas-
eular system, must be in a new and unnatural state, and must
thereby be excited. A great or protracted haemorrhage, if
not speedily fatal, must be productive of yascular excitement,
marked by different symptoms^ according to the constitution
of the patient, and other cireumstances. It is more or less
of a febrile nature, and it is usual to call it by tiie name of
re-action, merely, I presume, because the system has not
sunk under syncope, but the person has lived long enough to
become diseased. It is a state arising, not from an effort of
nature, or a salutaiy action set agoing to counteract the
work of death, as Mr. Hunter would have said, but it is
plainly the result of an existing excitement and irritation,
arising from the unnatural state of the vascular system. In
this state, wherever a bcal cause exists, productive of action

Inyoid; iiin± die iipeakened coDd^ of Ae part can biour, ii«
are in great danger of a sercare local disease, and hence none
are so Itable^to inflammation of the uterus and peritoneum».aa
those womenv who faaire suffered from uterine haanmrriiagei
But besides these eflbcts on the rascular i^stem, there are
•filer drcomstanoes to be taken into account, particularly the
state of tile dreulation in tiie brain, the general action af
the nervous system, the exhausting efiect of excitem^it of a
weakened system, the derangement of functiians, the intricato
eonseipience of Tsrious sympathies, and the opposite condition^
in which different parts may be in at die same time, as, foD
example, different portions of the brain. These, altogedier,
lender the consideration rery complex, and of high import-
ance in a piactioal: view. Increased susceptibility,, and
sometimes increased sensibility, may be the consequence of
haemorrhage, but not directly or primarily* Functiims conu
aected with muscularity are apt to be impaired^ hence the
peristaltic motion is slow, unless the mucous coat of the intesh
tine be irritable* Even the heart would probably act slowly,
were no unnatural excitement produced, out, boA the nnna>»
tural and excited state of the arterial system, and the aecond-
ary effect produced on the brain and medulla spinalis, musty
in so fiur as these exist, or are not counteracted in particular
eases, produce frequent and even irregular action of the
heart. The same causes, may also occasion painful conditions
•f the extremities of the nerves, whose origins are thus affect*
ted, or even true inflammation may be excited,, or violent
cerebral disorder produced, or from tiie state both of the
brain and of the yenous system, stupor or apoplexy may be
caused. The efect of an erect posture in this state of the
^stem, on the brain and heart, does not require explanation*.
Kepeated discharges, after a certain quantity has been at first
lost, must at each renewal, eventually, add to the systematia
kritation, though perhaps,, at the moment, some relief be
experienced to some of the sensations. All the effects of
hsnnorriiage, may be modified by the previous state of the
system. Weak people generally suffer soonest, whilst a state
ef synocha is relieved, and the system brought into an im«-
nroved state by the loss of a quantity of bloody which, in^
nealth would have perhaps proved ultinuctely fatal.

Married women, are more liable to menorrhagia than*
virgins, and it is rare for these, if otherwise healtiiy, to haTe>
uterine haemorrhage.

The management during the attack, must depend on the

184

state of the constitution, and the effect of the discharge. lo
full robust habits, when the pulse is firm, when a synocha
exists, and the haemorrhage has not produced much debility^
excellent effects may resmt, as in otner tonic hiemorrhagesy
from the early use of the lancet, by which the uterine dis-
charge is speedily checked, and that, before the organ be so
much injured, as to occasion a rapid return. But if the
pulse be small or weak, venesection is not to be proposed, nor
can I conceive, that it is in any case useful, if delayed long.
Whether the lancet be, or be not used, the succeeding part
of the treatment is much the some. The patient, on a gene-
ral principle, is to be kept from the very first in bed, that
she may be in a recumbent posture. This I consider as of
the utmost importance. Next, we are to moderate the action
of the vascular system by cold, that is, we are to have the
windows open, if m summer, and no fire if in winter, and no
more bedclothes than are necessary to prevent shivering.
The drink is to be sparing and cold. Sulphuric acid is to
be given freely, and along with this, digitalis may be pru-
dently administered, so as to moderate the circulation, but if
it have not ^eedily this effect it does no good, and is not to
be persevered in. It is never to be pudied far, nor to be
greatly trusted to. For the same purpose, nauseating doses
of emetic medicines have been employed, and, sometimes, but
chiefly in active haemorrhage, witn good effect, but we must
not continue them so long, as to produce much depression,
nor trust to them at all, if they do not speedily produce
benefit. I shall afterwards speak of lead. The diet is to be
almost dry, and of the least stimulating and repleting quality.
Wine and all excitants, are to be avoided. In order to
restrain the action of the uterine vessels, cloths wet with cold
water are to be applied to the vulva, or to the back and pubis.
If these do not check the discharge, the vagina must be stuffed
with a soft cloth, to retain the blood and promote coagulation.
Should the discharge have been so profuse as to produce
syncope, or at least great prostration of strength, the usual
means for restoration must be employed, but stimulants must
be carried no farther than is immediately necessary. In
cases so severe, that it is feared the patient could not other-
wise survive, the transfusion of blood, or rather the injection
of blood just taken from the vein of another person, has been
advised, but, as yet, we have too little experience of its
utility, to place implicit reliance on the effect.

In debilitated uahitaj or in plethoric patients, when the

185

discliarge has been profdse, and has produced much debility,
the treatment must be modified. Immediate confinement to
a horizontal posture, is, as in the former case, to be strictly
enforced. Cold must be applied sometimes generally, but
oftener locally. It cannot be carried so far as m the former
state, nay, in extreme cases, where the yital powers are much
depressed, and the extremities cold, it may be necessary to
apply warm flannel to the feet and legs, or even to the body
in general, to preserve the heat requisite for recovery. This
is a matter not of choice, but necessity, and, to the judgment
of the practitioner, it must be left, to avoid the evils arising
from the stimulating effects of heat, and the depressing effects
of cold. In this, much attention must be paid to the sensa-
tions of the patient. When the debility produced is not con-
siderable, we are satisfied with a horizontal posture, avoiding
the stimulating effects of heat ; stuffing the vagina, in severe
cases, to promote coagulation ; applying cloths wet with cold
water to the external parts, and administering a dose of opium
not less than two grains, and this is to be repeated if the
debility be greater. I consider this as one of the best reme*
dies we can employ, and when rejected from the stomach, it
must be given in the form of clyster or suppository. The
injection of solution of sulphate of alumin, or decoction of
odk bark into the vagina is useful, and also safer than the use
of vinous or spirituous injections, which have been proposed
by some eminent men. The diet is to be sparing, the drink
acidulated, and every exertion avoided.

If the debility be great, or the face pale, the lips blanched,
the extremities cold, the pulse small, and the patient attacked
with vomiting or syncope, the danger is not small ; it is great
in proportion to the extent of the weakness, and the obstinacy
of the discharge. In such cases the patient must be carefully
watched. The vagina is to be kept stuffed, or if the plug be
removed, it is only for the purpose of injecting a strong
solution of sulphate of alumm, or decoction of oak bark*
The strength is to be supported, by jellies and soups ; by the
moderate and well-timed use of wine, either cold or warmed
with spices ; by external heat, so far as it is necessary to pre-
vent the body becoming cold ; by opium, and by the use of
aromatic cordials, such as aromatic spirit of ammonia mixed
with cinnamon water. The use of astringents, if the stomach
can retain them, may be useful, such as the tincture of kino,
as advised below.

The immediate violence of the attack, in either of the

HBC

cases r hove been considermg^ being' orer^ tite- patient may
BBmain for some time free from & return of the discharge,
and liien may hare anoiher severe attack, or she may haye
every day more or less fatemorrfaage. I must, therefore, next
direct the attention^ to those means which are to be employed,
for tiie permanent cure of the patient, and which are dedu*
dble from principles, no less applicable' to the management
of the first attack. We have three objects to attend to. First,
to manage the gena'nd condition of the anrstem, which gives
predisposition and modifies the hasmorrhage. Second, to
remove or alleviate such afiections, as may sympathetically
influence the discharge, or to cure any morbid uterine condi«
tion which may exist. Third, to employ such remedies as
shall act on tne vessels of the uterus, either directly, or
through the medium of the nerves.

First, in the robust or* plethoric habit, we must lessen the
quantity of blood, and diminish the force of the circulation,
or the distention of uterine vessels, by diet of the least nour-
iriiing and stinndating Idnd ; a large proportion of vegetables
ought therefore to be taken at <Unner, and both wme and
malt liquor should be avoided. Indeed much" liquid of any
kind, wheih^ in the form of soup or of drink, may be hurtful,
by filling too fast the vessels. Regular exercise must be
resorted to, in such a degree as shall prevent fulness, and
improve the health, on &e one hand, without going the
length, on the other, of exciting the oirculation, so much as
to produce rupture. Some, dare make very little exertion^
Purgative medicines are of much service, especially those
which act also on the kidneys, such as sulphate of magnesia,
or Cheltenham salts. These not only lessen the quantity of
circulating fluids, but divert the current from the uterine
vessels* This may be ferther assisted by supertartrate of
potass, ethereal spirit of nitre, and other nuld muretics. As
an exception to the rule of employing laxatives, I must notice
those cases, where hsemorrhage alternates with, or seems
excited by, an irritable state of the bowels, and in such, the
use of opium is of signal benefit. The application of cold to
the surrace, especially, if unequal, and to the lower extrem-
ities, is hurtful, by determining to the internal parts. Heat,
in a stimulant view, is to be avoided, but on the other hand,
cold, by checking the perspiration, is hurtful. The sleep
should be abridged, and taken on a hard bed, with not
too much covering. After the plethoric or ^mochal con-
dition is removed, the cold bath is usually of great service,

at least if it do not give headbush or produce coIdoESB or
languor^

m accomplisfiiiiig liie second yieFw, we imiat examine oaro^
fiilly ioto t&- state of the Tarionff organs and fiinctions, and'
inquire into liie habits of die patient* Wherever any partU
cular alteration or symptom can be detected, it must be laid
hold o^ and attacked by suitable means. Ixt the first view, we,
by a eeneral plan, endeavour to improye the system at larger
and mns rectify the state of the uterus ; in the second, we^
improve the health by removing any little ailment, or everjr
deviation, however tnffing, and llius gain the same object;
If the uterus be enlarged or tender to the touch, we shouldi
have recourse to the meanB formeriy pointed out for remoying'
Aese conditions. By a recumbent posture, topical evacua-»
tions^ &c., we may not only cure the menorrhagia, but
prevent &tal organic disease from taking phce.

The diird, is^ not to be attempted, in general, till we have,-
as &r as possible, removed exciting causes and lessened pre-
disposition^ particularly, when that is connected with pletiioric
or synochal action of tiie vessels. The direct means, ccmsist
in uie injection of cold water frequently into the vagina, .or
of strong decoction of oak bark, or solution of sulphate ofi
alumin, or acetate of lead, provided these do not produce,,
as the^ sometimes do, hysteralgia. I have confidence in?
liiese mjections, and therefore place them in a prominent
place. IfatemaL astringents, such as rhatany root, or tincture
•f kino, in liberal doses, have been sometimes useful, and
when they are so, it must be tinrough the medium of tiia
nerves, ratiier than by absorption and circulation. But
some metallic salts act more decidedly on the nerves, and
affect the extremities of tiiose^ to which tiiey are not directiy-
applied. Lead is of this kind^ and its acetate has been long
ago adyised, a» an intramal remedy, botii by Dr. Reynolds
and Dr. Rtidu From two to four grains, witii half a grain*
ef opium, maj be gpiven, for a sbort time, every liiree or four
hours, as a pdL But it is better to give the same quantity
in solution, as this- acts more quickly, and we are more
certain of tiie quantity which is in operation in a given time.
As much distSfed vinegar should be added to the solution, as'
makes it acid, and water acidulated with vinegar may also be
taken occasionally as a drink. There is tiius no risk of the
acetate being converted into the carbonate, which is consid-
wed as tile only poisonous preparation of lead. Dr. Dewees
advises k as a clysta:, in the quantity of a scruple of the

188

acetate, and a dram of laudanum with a little water. Opium
alone, or cicuta or other narcotics, besides being useful in
other views, act also in this way, and are of decided service,
when the uterine nerves are in a state of irritation. Nitre
in doses of half a dram, three times a-daj, has sometimea
been useful.

In debilitated habits, whether the weakness have existed
from the first, or have succeeded to plethora, the practice, in
80 far as our first object, namely, attention to the general
condition of the system, goes, must be somewhat varied.
Moderate laxatives, especially mineral waters, are proper to
improve the tone of the bowels, and prevent languid circula-
tion in the veins. Tonic medicines are to be given, such as
different preparations of iron, chalybeate waters, as that of
Tunbridge, and bitters ; of the last, the uva ursi, in doses of
half a dram, three times a-day, is often of use. Sometimes,
advantage is derived from adding to any of these medicines,
such doses of Sp. Ether. Nitros. as shall direct moderately to
the kidneys. The cold bath is generally of service, and
should be succeeded by friction on the surface of the body,
to determine to the exterior vessels. Much liquid is to be
avoided, but the diet should be more nutritious than in the
former case, and so much wine may be given, as shall not
stimulate the circulation, or produce neat or flushing. Claret,
is the best, when it agrees with the stomach. Every thing
which can excite the uterine vessels must be avoided, such as
dancing, long walks, venery, &c. The other directions
ffiven, as to the second and third object, in treating the
iormer species, are nearly applicable here. I therefore need
not repeat what I have said, respecting the use of opiates,
astringents, or injections. A gentle emetic of ipecacuanha,
has sometimes a powerful effect in checking the discharge,
and never does harm, unless the patient be very greatlv
exhausted. If, in spite of these means, the hemorrhage still
continue or return, it may be kept up, by some organic affec-
tion of the uterus, not discoverable by the finger, perhaps as
yet in an incipient state ; by a diseased or varicose state of
the vessels ; or, if the patient be youn^, by a scrofulous con-
stitution, which does not readily yield to general remedies.
If anv organic disease be discovered, the treatment must be
varied according to its nature.

In constant stillicidium, unaccompanied with organic affec-
tion, the best remedies are tonics and astringent injections.
This, often stops, spontaneously, for two days, before and

189

^aSter menstmation. When it is uniform} there is iMscasionaUir
a bad aonell arising from the retention, in the cavity of the
uterus or yagina, of small clots, which putrefy. Injections
are the best remedies in this case.

In weak habits, there is sometimes a slight discharge of
blood for a day, at the end of a fortnight after menstruation*
This is to be cured by strengthening means.

The febrile and irritated state, produced by serere or
protracted haemorrhage, is best overcome, after checking the
discharge, by sedulous attention to the bowels, the use of
Bulphunc acid alone, or with quinine, and an opiate at night,
combined, if the skin be dry, with ipecacuanha. The nour-
ishment should be light, and regularly administered, in such
quantity, as the stomach, and the system will bear. The
patient, at the same time, should be cautiously accustomed
to sit up a little, first in bed, and afterwards out of it, taking
care that the feet do not swell from position. As soon as

Eossible, a little exercise in the open air should be taken^
ut no effort, likely to renew haemorrhage, should be per-
nutted. Headach, particularly of the throbbing kind, is a
frequent attendant, and is removed by the use of laxatives and
quinine, and cautiously persevering in attempting an erect
posture. Stitches ana pains, resembling pleurisy or other
mflammation, are usually muscular, and cured by sinapisms
or topical applications, or depend on a state of morbid excite-
ment of the nerves of the part, which will yield to an ornate
and laxative, which remove irritation from the bowels. But,
if local inflammation should actually take place, we must be
wary in the use of the lancet, and even if the urgency of the
case decidedly require it, we must take no more blooa than is
absolutely necessary for relief. Topical bleeding and small
blisters are safer.

CHAP. XIV.

0/the Cessation ofihjt Menses.

About the period when the menses should cease, they become
irregular, and sometimes are obstructed for two or three
months, and then for a time return. This obstruction, like
niany other cases of retention and suppression of the menses,
is accompanied with swelling of the belly, sickness, and loath-

190

ing^ «of f ood. These eflfeda are frequently lairtalpBii Ar ptegw
:imacj I for, as La Motte vemarlEB, many -wattnan haare such a
idi^ike to ace, that they would rsber peranade tiienisebeB
they are with child, than sunpoBe they are ioding any cf tim
leoiuecpienoes of growing cud ; and this pemiasiait they in-
«dulge, like Harrey's widow, dbncc, kmdem^ tpes omnU, in
fialum et pinguedniem JuoaaereL In this fiitoation, the bely
is soft and equally swelled, and eahurges more speedy after
the obstruction, inan it does in -pregnancy* No motion is felt,
<or if it be, it is from wind in the bowels, and ahifts its place.
Exercise, chalybeates, and kaEatiyes, are liie proper remedies
in this case.

The period at which the menses cease, or ^ the time of
life," is considered a cntioal, and, without doubt, it is an
important epodu If there be a tendency to any organic dis-
lease, it is greatly increased at this time, more eq>ecially, if it
.exist in the uterus or momrnffi ; and, indeed, the cessation of
<the menses does of itself seem, in some cases, toexcite cancer
*of the breast. Diseases of the liver, also, make greater pop-
gress at this period, or first appear soon affcer it. Dyspeptic
-affections are still more freguent. When there is no tendenqr
to local disease, it is very oonunon for women, after the menses
45ea8e, to become corpulent, and sometimes they enjoy better
health than formerly.

From an idea of the cessation of menstmation being uni-
formly dangerous, some, by the use of emmenagogues, tried
to prolong the discharge, otiiers, by issues, endeavoured to
ixrevent bad effects, llie first of these means, is foolish and
inirtful, the last is not necessary. When the heaUh is good,
no particular medicines are requisite ; but if there be a ten-
dency to any particular disease, then, the appropriate remedies
must be employed. The bowels must be kept open, in every
instance, and the general health should be attended to by
eeneral means. The delicate, must be treated very differently
from the robust and plethoric. No direct system of prescrip-
tion is requisite, but the earliest, and sligntest symptom, of
deviation irom health, should be attended to. Our directions
must be given, from careftd >con8ideration of predisposition,
or existing circumstances, and, if judicious, may be most
Tilnable.

isa

CHAP. XV.
Of ComequKom.

Conception fieems to depend upon die influenoe of the
aemen exerted on -the ovaria, through the medium of the rest
of the genital eystem; for women have cdnceiFed, ^ben
aemen baB been applied merely to the Tulva, the hymen being
entire*

The extremity of the Fallopian tuhe embraces the ovarium,
and adheres to it, till its peritoneal coat, and those of the
£rxBafan Tefficle are absorbed* Beer tMnks that the outer is
borst by the swelling of the inner coat, which abo qpesB and
eUowB the oYum to enter the tube, in order to treaoh die
ateruB« How longihe tube adheres, or how soon the ejei^
lian of the oynm is* accomplished, is not, in the human subject,
ascertained. In one instance, where the female drowned heiv
sdf the day after having connexion, Baer ibond the vesicle
turgid, the two coats separated from eadi other, but entire^
die innermost, thickened and yellower than 'before impregna-
tion. In another, eight days after impregnation, the ovum bad
escaped, and decidua was formed. In die rabbit, Mr. Jones
found, in for^-one hours, some of the vesicleB burst, with the
ovula at flieir orifice, but none in the tubes. On the third
day, he found them in the tubes. The 4»lyx left by the
disduirge of the ovum, is at first rather oval, about half an
inch long, but not so broad, with a cavity in the centre, or
tiiat may be -filled with bloody fibrin. The rim of the cavily
28 more than an eighth of an inch broad; and, if the vesselB
die finely injected, we see this to be made up chiefly of minute
arteries and veins, die former predommating at the surface.
If we break down the substance in which these ramify and the
central substance, and mix them with a little water, we find,
under the microscope, that they look like particles of sand.
Presendy, die vascularity decreases,. and, in tne human subject,
the yellow colour predominates. The aperture gradually
closes, and is marked by a cicatrix, whilst the cavity is
obliterated. From first to last this transformation of die
.calyx reodves the name of corpus luteum (p. 57). Baer aup-
j>oses, and I think jusdy, that the corpus is formed by tne
^^cSiange which the inner layer of the vesicle undecgoes, and
"which, as stated above, commences even before the ovulum
escapes. During the whole of prctgnancy, die ovarium is

199

more vascular than formerlji many of the vesicles are found
enlarged, and have more numerous vessels.

Sir E. Home imagines that the rupture of the coat of the
corpus takes place during coition, that the semen may be
directly applied to the ovum, but of this there is no proof;
whilst, on the other hand, there is incontrovertible evidence,
that many women have conceived, when the semen was
emitted only at the vulva. He thinks that the rupture of the
vesicle causes that slight discharge of blood from the vagina
which sometimes follows coition. But this is erroneous, for
x>bservations on rabbits show that the vesicle does not burst
for many hours after that.

It would appear, that although an ovum be impregnated,
yet, by various causes, the process afterwards mav be inter*
rupted ; the ovum shrivels and is absorbed. If there be
^an impervious state of the tubes, or any conformation or con*
dition, rendering it impossible for a child to be supported,
4he ovum decays, and the woman is barren. Or, if such a
fitate be induced after impregnation, and before the ovum
descends, the process stops.*

In the human subject, only one ovum is generally impreg-
nated by one seminal application, but sometimes two or more
may be carried down mto the uterus, and even after one
ovum has reached the uterus, and ffrown to a certain degree
within it, we find, that it is possible for a second to be ex-
cited into action, and brought down into the womb, where it
is nourished and supported ;t but it is not yet ascertained
what the greatest interval between the two conceptions may
foe. It appears to be established that a woman may not only
bear two living children of different ages, or of different
colours, but also that when a child dies in utero, it may be
retained and a new conception take place.}

Mr. Hunter§ supposed that eacn ovarium is capable of

* Dr. Half hlon foand, tluit hj dWidlnf the tnbw, aft«r a rabbit wai imprtf-
Yiated, the ova were destroyed. Or, if only one tube was cut, and the femile
afterwards beeame impre|^nated« corpora lutea wera foand In both ovaria, but no
4>Ta were found in the tube or horn of tiie atemsy on the injured lide. Phil.
Trent. Vol. Ixnvii. p. 175, kc

f Vide Med. and Phys. Joum. Vol. rvli. p. 460.

I Perey mentions the ease of a woman, whoee child In atero seems to hara
Tiecome blichted, after motion had been perceired. At the end of seven weeks*
from this time, she felt anew the incipient symptoms of preirnaney, and went on
to the full time from the sseond date, when she bore a child, smaU but lively.
After the placenta came away, a mass was expelled, in the midst of which was
found a female foBtus eorrsspondlng in sise to one of the fourth month ; the
neriod at which motion had eeased in the first ioslanoe to have been felt. Revue
Med. Tom. x. p. 129.

$ Vide l*hil. Trans. VoL UxvH.

193

producing only a certain number of ova; and that if one
ovarium be removed or rendered useless, the constitution
cannot give to the other the power of producing as many ova
as could have been done by both.

It has been attempted to ascertain what age, and what
season were most prolific. From an accurate register made
by Dr. Bland, it would appear, that more women, between
the age of twenty-six and thirty years, bear children, than at
any other period. Of 2,102 women, who bore children, 85
w^e from fifteen to twenty years of age ; 578 from twenty-
one to twenty-five ; 699 from twenty-six to thirty ; 407 from
<liirty-one to thirty-five ; 291 fit)m thirty-six to forty ; 36
from forty-one to forty-five ; and 6 from forty-six to forty-nine.

At Marseilles, M. Raymond says, women conceive most
readily in autumn, and chiefly in October ; next in summer,
and lastly in winter and spring; the month of March having
fewest conceptions. • M. Morand again says, that July, May,
June, and August, are the most frequent dates of conception;
and Novembw, March, April, and October, the least frequent
in the order in which they are enumerated. I have been
favoured with a register, for ten years, of an extensive parish
in this place, containing 72,000 inhabitants ; from which it
appears, that the greatest number, both of marriages and
inrths, take pla^ in May, and the fewest births in October.
From this, we would consider August and September to be
most favourable to conception ; but it is evident, that these
conclusions are liable to great uncertainty.* In Wurtemberg,
the greatest number of births, are in January, and the fewest
in June; abortions are to deliveries, as 1 to 41.t

Women are supposed to conceive most readily immediately
after the menstrual evacuation, but it is doubtful how far this
opinion is correct ; some even hold a contrary opinion, and
think they are more likely to conceive just before the period;

• It appean firom Dr. Cleland's tables, (published io 18Sl)that'tbepopalatioii
of this city and suburbs, is 202»426, the females, in the total, predominating to
the extent of 14,978, though tUl after fifteen years of ace, there is an excess of
maks. There are 49,504 females between the age of fifteen and forty years, and
e^es births within a year, of which 471 are stillborn. There are 8,281 living
male children, and 3,116 females. There are 89,082 married men, so that at au
•▼erage there is one child bom to four and a half married females ; of the
ehildren 877 die under one year of age, and 49 males more than females. There
an 1,919 marriages within the year, and in all 41,965 families, including the
married, widows, spinsters. &c. There ar« 55,964 children under ten years of
age, and of these lAout 1 in 28 die. By r«tarns iu France for seventeen years,
andiog in 2638, it appears, (hat in marriage, the number of oiales bom is to that
of Camalefl as 16 to 15 : diat of illegitimate children is diffenent, Tiz., 23 to 22— aH
an avem^B each marriage predueea nearly four ohildren.

f AsehlT. Gta. an. 76.

• o

194

and therefore, in calculating the time when labour should be
expected, it is usual to count from a fortnight afker the last
appearance of the menses, or to say that the woman should
be confined at the end of the forty-second week from the
termination of the last menstruation.

The process of gestation usually requires forty weeks, or
ten lunar months, or nine calendar months and a week, for its
completion; but many circumstances may render labour
somewhat premature, and it is even possible for the process
to be completed, and the child perfected to its usual size, a
week or two sooner than the end of the ninth calendar month.
On the other hand, it is equally certain that some causes,
which we cannot explain nor discover, haye the power of
retarding the process, the woman tarrying the child longer
than nine months;* and the child, when bom, beinf not
larger than the average size. How long it is possibfe for
labour to be delayed beyond the usual time, cannot easily be
ascertained; but it is very seldom more than a few days,
counting the commencement of pregnancy from the day pre*
cedinff that on which the menses ought to have appeared,
had the woman not conceived. The longest term I have met
with, is ten calendar months and ten days, dated from the
last menstruation. In the case of one lady who went this
length, her regular menstrual period was five weeks, and in
her other pregnancies she was confined exactly two days
before the expiration often calendar months after menstruation.

CHAP. XVI.
Of the Gravid Uterus.

SECTION FIRST.

When we compare the unimpregnated with the ffravid
uterus at the full time, we must be astonished at the change

* By the law ef this ooimtry, s child born ilx months after the marriage of
the mother, or ten months after the death of the father, is considered as le|ltU
mate. In the eridence giren on the cause of the Gardner Peerage, published b j
Dr. Lyal, there was a great difference of opinion. Some'acooucheurs limited the
period strictlj to forty weehs, or 280 days, others considered that it might be
extended to 31 1 days. Dr. Merriman says, that out of 114 pregnancies, calea-
lated from the last day of menstruation, and. in which the chudren appeared
mature, 3 took place at the end of the 87th week ; 18 in the asth week ; 14 Is
the 89th week; 88 in the 40th week; » in the 4l8t; 16 In the4ad; 10 In th«

195

which has taken place during gestation^ in its magnitude
alone.

In the ninth month, the size of the womb is so much
increased, that it extends almost to the ensiform cartilage of
the sternum; and this augmentation it receives gradually,
but not equally, in given times; for it is found to enlarge
much faster in the latter, than in the earlier months of
pr^nancy. This is true, however, only with regard to the
absolute mcrease, for in the first month, the uterus perhaps
doubles its original size, but it does not go on in the same
ratio. It is not twice as large in the ninth as in the eighth
month.

In the commencement of the second month, the uterus is
enlarged in every part without much change of shape.
Towards the end of the third month, it generally measures,
from the mouth to the fundus, about five inches, one of which
belongs to the cervix. In the fourth month, it reaches a little
higher, and measures five inches from the fundus to the
be^nning of the neck. In the fifth, it has become so much
larger, as to render the belly tense, and may be felt, like a
baS, extending to a middle point between the pubis and the
navel, and measures about six inches from the cervix to the
fundus. In other two months, it reaches to the navel, and
measures about eight inches. In the eighth month, it ascends
still higher, reaching to about half way between the navel
and the sternum. In the ninth month, it reaches almost to
the extremity of that bone, at least in a first pregnancy, when
the tightness of the parietes prevents it from hanging so
much forward as it afterwards does. At this time, it meas«
ures, from top to bottom, about twelve, or from the fundus to
the brim of the pelvis, eleven inches, and is more globular,
than elUptical, in its shape. The broadest part, is a little
above the middle, and is ten inches. For the first month,
the shape of the uterus is scarcely altered ; it is enlarged
in every direction. But after this, it swells before and
behind, and soon becomes somewhat globular, having the
cylindrical undistended cervix depending from it ; after the
fifth month it becomes more oblong, and by the seventh, it
resembles a balloon. These calculationB are not invariably
exact, suiting every case, but admit of modifications.

In pregnancy, the mouth of the uterus is directed back*

4Sd ; 4 in the 4ith ; a few eTen exceeded that. Hence, the greatest nnmber,
««npleta festatioo, In tke 40lh'week, and next to that, in the 41et.— Med. Chlr.
TVmu. VoL zUL

196

ward, whilst the fundus lies forward. This obliquity, how-
ever, does not. take place until the uterus begin to rise out
of the pelvis, and it always exists in a greater degree in those
who have bom many children.

From this position it appears, that the intestines can never
be before the uterus, but must lie behind it and round its
cddes. The uterus is usually directed to the ri^ht side, but
in the last months, if ihe pariites of the abdomen be not much
relaxed, it rises more perpendicularly.

Previous to the descent of the ovum, the uterus begins to
enlarge, especially at its upper part, or fundus ; and it is
worthy of notice, that the posterior face of the uterus always
distends more than the anterior one, as we ascertain by exa-
mining the situation of the orifices of the Fallopian tubes.

When the fundus begins to increase, it not only grows
heavier, but also presents a greater surface for pressure to
the intestines above : it, therefore, will naturally descend
lower in the pelvis, and thus project further into the vagina*
In this situation the uterus will remain, until it become so
large as to rise out of the pelvis. This ascent takes place,
generally, about the sixteenth week of pregnancy, if the
pelvis be well formed, and the uterus increase in the usual
ratio.

SECTION SECOND.

In the fifth month of pregnancy, the cervix begins to be
developed : so that by the end of the month, one quarter of
its length has become distended, and contributed to augment
the uterine cavity; the other three-fourths, which remain
projecting, become considerably softer, rather thicker, and
more spongy. In another month, one half of the cervix is
distended, and the rest is still more thickened, or the circum-
ference of the projecting part greater; the uterus has also
risen farther up, and the vagina is more elongated. In the
seventh, we may, with the finger, distinguish tne head of the
child pressing on the lower part of the uterus, which we can
seldom do before this. In the eighth month, the neck is
nearly effaced, and its orifice is as high as the brim of the
pelvis. In the ninth month, the cervix is completely de-
veloped, and the whole uterus more enlarged. The alterations
of the cervix are discovered, by introducing the finger into
the vagina, and estimating the distance betwixt the os uteri
and the body of the uterus, which we feel expanding like a
balloon.

197

The size of the lips, and extent of the mouth, or chink, of
the uterus, in the unimpregnated state, have already been
described. Soon after conception, the os uteri is said to close,
but this is only correct, in so far, as it is, at the end of the
cervix, shut up by albuminous substance. Its lips become a
little softer, rather thicker, and the orifice sometimes, but not
always, seems more circular* The changes, however, in the
early period, are not so marked, as to afford, of themselves,
positive indications of pregnancy. In proportion as gestation
advances, and the cervix stretches, tne lips become rather
thicker, and, although in a few instances, they may shorten,
yet, they always continue to project, until labour commence.
All the inner surface of the cervix uteri, in the whole
course of gestation, exhibits glandular follicles, which secrete
a thick viscid mucus. This extends from the one side to
the other, and fiUs up the top of the mouth of the uterus,
very perfectly, being thus interposed as a guard betwixt
the membranes and any foreign body. By maceration, it
may be extracted entire, when a mould of the lacunsB will be
obtained by floating it in spirits, saturated with fine sugar.

SECTION THIRD.

Vesalius describes three strata of muscular fibres, trans-
verse, perpendicular, and oblique. Malphigi describes them
as forming a kind of network; whilst Ruysch maintains,
that they appear at the fundus, in concentric planes, forming
an orbicular muscle. Dr. Hunter paints them as transverse
in the body of the uterus, but at the fundus describing con-
centric circles around each of the Fallopian tubes. These
contradictions of anatomists serve to show, what may readily
be seen by examining the uterus, that the fibres are not very
regular and distinct in their course, but the circular seem
to predominate. The lips of the os uteri have few, if any
muscular fibres.

The increased size of the uterus, is by no means, entirely,
owing to the addition of muscular fibres. These become
indeed larger, and better developed, but do not contribute
so much to the increase, as the enlargement of the blood
vessels, and perhaps the deposition of cellular substance.
This gives the uterus a very spongy texture, and makes it
BO ductile, that a small aperture may be greatly dilated,
without tearing. From examination, it appears, that although
the whole uterus do not grow thinner, in proportion to its
increase, yet it does, at the full time, become a little thinner

198

hear the mouth; whilst the fundus continues the same, or
perhaps grows rather thicker, at least where the placenta is
attached.

SECTION FOURTH.

No one, who understands the anatomy of the ligaments of
the unimpregnated uterus, will be surprised to find a great
change produced in their situation and direction, by preg-
nancy. The broad ligament, which is only an extension of
the peritoneum from the sides of the uterus, is, in the ninth
montb, by the increase of that viscus, spread completely over
its surface; and consequently, were we to search for this
ligament, we should be disappointed. Its duplicatures are
separated and laid smoothly over the uterus. It will there-
fore be evident, that we can no longer find the ovaria
and Fallopian tubes floating loose in the pelvis, nor the round
ligaments running out at an angle from the fundus uteri to the
groin. All these, are contained within duplicatures of the
peritoneum, or ligamentum latum ; and therefore, when this
IS spread over the uterus, it follows, that the ovaria, tubes,
and round ligaments, particularly the last, cannot now run
out so loosely from the uterus, but must be laid flatter on its
surface, by the extended peritoneum. This description,
applies only to the state of the uterus, at the full time.
Earlier, we may readily observe the broad ligament floating
out, so that the ovaria are more distant. The loose extre-
mity of the tube becomes more expanded, and very vascular,
4md forms a kind of cavity called the antrum.

The state of the ovarium has already been described.

SECTION FIFTH.

The origin and distribution of the blood vessels of the
uterus have been formerly noticed ; I have onlv to add, that,
in pregnancy, they become prodigiously enlarged. Even
before the ovum be very distinct, we find the uterine artery,
when injected, as large as the barrel of a goose quill, and
sending large branches round the cervix uteri, and up the
sides of the womb. The spermatic or ovarian artery, is
however, the chief source of blood, and at an advanced period
sends numerous tortuous branches up along the uterus. As

Eregnancy advances, the trunks, but especiaUy the branches,
ecome still larger, particularly, near the implantation of the
placenta. The veins are enkrged in the same proportion

199

with the arteries. They are destitute of valves, and receive
the name of sinuses.

The lymphatics are very large and very numerous. The
nerves have already been described. Both they, and their
ganglia, are increased in size during gestation.

SECTION SIXTH.

Although many opportunities have occurred to anatoniidts,
of examining not only abortions, but also the uterus itself,
at an early period of gestation ; yet, it has not l^en exactly
determined at what precise time the ovum enters the womb,
or, when the fcBtus becomes visible. This may depend,
pajrtly on want of information, respecting the exact number
of days, which have intervened betwixt impregnation, and our
exammation ; and partly, perhaps, upon irregularities of the
process in the human female, induced by various causes.

In a dissection performed by the late Mr. Hunter, and
related by Mr. Ogle,* no ovimi could be found either in the
uterus or the tubes, although it was conjectured that nearly a
monUi had elapsed from the time of impregnation. I have
examined very carefully three uteri, considerably within the first
month after menstruation, and have not been able to discover
either ovum or foetus ; but I cannot determine the exact
date of impregnation. Sir E. Home gives a representation
of a uterus, which was taken from a woman, who was supposed
to have been impregnated eight days before death. It corre-
sponds, exactly, in appearance to those I have alluded to. He
imagined that an oviun was seen, but from the description, there
is little doubt that he was deceived. We cannot calculate,
analogically, by examining quadrupeds, and even with regard
to them, investigators do not agree. In the rabbit, whose
period of utero-gestation is thirty days. Dr. Haighton says,
ne did not find ova in the uterus till the sixth day, whilst
Ck)8te says he found them in twenty-four hours. Mr. Jones
found them still in the tubes on the third day. Coste, on the
fifth day, found the ovulum, not increased in size, in the
horn of the sheep's uterus. From an observation of Baer's,
it appears that in women, decidua is formed by the eighth
day, and the ovum is out of the vesicle. Dr. Rainy showed
me an abortion which came away between the menstrual
periods, where the decidua vera was well formed, and the re-
flexa enveloped a cavity as large as a pea. In this, a small spot

* TntoNctiont of a Society, &c. Vo]. it. Art. tI.

200

supposed to haye been the OTum, had been seen. Weber,
in a female who poisoned herself eight days after coneeption,
found, between tne surface of the uterus and the decidua, a
yillous vesicle which he thought contained an embryo.
Velpeau, in an abortion, ascertained to 1)e at the thirteenth
day, found a distinct embryo with the vesicles and membranes.
Dr. Combe had a preparation containing a minute embryo,
but it was supposed that twenty-two days had elapsed.
MuUer, at thirty-four days, found the embryo two lines and a
half long, but, at the end of the third week, Velpeau says,
that if stretched out, it measures four or five lines. It curves
at this time so much, as to form nearly a circle. In the
sixth week it is curved, and resembles as it floats in water,
a split pea. In anotlier week it is as large as a small bee.
In the tenth, it is the size of a kidney bean. The size
however, appears to vary according to the natural bulk of the
foetus, and other circumstances which we are not acquainted
with. This cu^counts for the great difference in the repre-
sentations of different authors.

The embryo, at first, appears to the naked eye like two
oval bodies of unequal size, united together, and forming a
curve, or at first nearly a circle. The one of these is the
head, the other the trunk. The head is a membranous bag,
which is large in proportion to the body, but after the first
month of its growth, the relative size decreases : on opening
it, nothing but a soft pulp is found within. In a little time,
the face appears, the most prominent features of which are
the eyes ; these are proportionally larger in the embn^o, than
in the advanced foetus, and are placed low down. The face
itself, is small, compared to the cranium. The nose does not
appear until the end of the second month ; but somewhat
sooner, we may observe two apertures in the situation of the
nostrils. The mouth at first, is a round hole, but by degrees
lips appear, and after the third month they are closed, but do
not conere. The external ear is not formed at once, but in
parts, and is not completed before the fifth month ; even then,
it differs in its shape from the ear after birth. It is at first
like a gently depressed circle.

The extremities early appear, like the buds of a plant.
The arms are directed obliquely forward, toward the face,
and are larger than the inferior extremities. The genitals,
for a time, are scarcely to be observed, but in the third
month, they are large in proportion to the body.

The foetus docs not grow in an uniform ratio, but, as has

201

been observed by that careful anatomist, Dr. Soemmering,
the increment is quicker in the third than in the second
month. In the beginning of the fourth it becomes slower,
and continues so until the middle of that month, when it is
again accelerated. In the sixth month, it is once more'
retarded, and the progression remains slow during the rest of
gestation.

In the foetus, the inferior extremities do not grow in the
same proportion as the superior, and therefore, as Chaussier
has remarked, the centre of the body varies at different
periods. At the full time, it is situated a little above the
navel, whereas in the adult, it is at the upper edge of the
pubis. At the end of the eighth month, it is an inch above
the umbilicus. In the sixth at the end of the sternum, and
in the seventh between these two points. It has been pro*
posed, by attention to this measurement, to decide in cases,
otherwise doubtful, respecting the age of the foetus. Farther
assistance may be expected, from an examination of the
osseous system, as different bones begin to ossify at stated
periods. Some uncertainty, however, must be connected
with this rule, and, to a still greater degree, with the marks
taken from the development of the brain. In the early period,
there is no brain, but only the spinal cord, so that the foetus
resembles an animal of the lowest order. About the second
month, the brain is discovered, very small, and evidently
formed by a prolongation of the cord. The pons is not seen
tiU the fourth month, the pyramidalia are defined in the fifth,
the olivaria are not so distinct till the seventh, nor are the
convolutions of the brain seen till then. Before the sixth
month, the brain is semifluid. Hair does not grow on the
head, before the sixth month, and even then, it is very short,
sparse, and light coloured. The nails are indistinct, the
eyelids closed, and the membrana pupilaris closes up the
pupil. The heart is large in proportion to the lungs. In
the seventh month, the membrana pupilaris is removed, the
eyelids open, the nails are more distinct, the hair longer and
thicker, and on cutting the skin, we now, for the first time,
discover some deposition of fat. Formerly, the cells had
merely contained albumen. In the eighth month, the skin
becomes brighter in the colour, the hair is longer, a more
copious secretion of fat has taken place, the fluid in the gall-
bladder approaches more nearly, both in colour and taste, to
bile. The colon and rectum are nearlv filled with meconium.
At the full time the nails are quite rormed, the hair covers

202

the head, and is of its proper colour, the cells of the skin are
filled with fat, the lungs are large and red, the yalve of the
foramen ovale completely formed, the ductus arteriosus,
scarcely less than the aorta, and nearly an inch in length.

The proportion between the weight of the fcetus and its
involucra, is reversed at the beginning and the end of gesta-
tion. When the embryo does not weigh more than a scruple,
the membranes are nearlv as large as a small egg. Even when
the fcetus is not larger tnan a fly, the membranes resemble, in
shape and size, a chestnut. On the other hand, at the fiill
time, when the foetus weighs seven pounds, the placenta and
membranes, do not weigh a pound and a half, and the propor-
tion of liquor amnii is greatly lessened. In the twelfth week,
the foetus weighs nearlv two ounces, and measures when
stretched out, about three inches. The membranes are
larger than a goose's egg, and weigh, if we include the liquor
amnii, several ounces. In the fourth month, the foetus is five
or six inches long. In the fifth month, it measures from six
to seven inches. In the sixth month, the foetus is perfect and
well formed, measures nine or ten inches, and weighs about
one pound troy; whilst the placenta and membranes weigh
about half a pound, exclusive of the liquor amnii. The foetus
is now so vigorous in its action, that there have been instances,
though most rare, of its continuing to live, if bom at so pre-
mature a period. In the seventh month, it has gained about
three inches in length, and is now more able to live indepen-
dent of the uterus, though, even at this time, the chance of its
surviving six hours from birth is much against it. In the eighth
month, it measures from fifteen to seventeen inches, and
weighs four, or sometimes five pounds, whilst the involucra
weigh scarcely one. These calculations vary according to
the sex of the child, and also the conformation of the parents,
which accounts for the latitude I have given in the length,
which is less than that stated by some authors, but this I
cannot help. Male children generally weigh more than
females. Dr. Roederer concludes, from his examinations,
that the average length of a male, at the frdl time, is twenty
inches and a third, whilst that of a female is nineteen inches
and seventeen eighteenths.* Dr. Joseph Clarke has ^ven a
table of the comparative weight of male and female children
at the fiiU time, from which it appears, that although the

* A female U, generally, fully nineteea Inebce and a half, Munetimes nearly
twenty. The circamference of the head, at the largest part, little less than
thirteen inches.

203

greatedt proportion of both sexes weigh seven pounds, jet
Qiere are more females than males found below, and more
males than females above that standard. Thus, whilst out of
sixty males and sixty females, thirty-two of the former, and
twenty-five of the latter, weighed seven pounds ; there were
fourteen females, but only six males, who weighed six pounds.
On the other hwd, there were sixteen males, but only eight
females, who weighed eight pounds. Taking the average
weight of both sexes, it will be found that twelve males are
as heavy as thirteen females. At La Maternity, the average
weight was 6^ pounds ; out of thirty-five, there were ten
under six pounds. In the Wurtemberg report it is stated,
that some children weighed at birth from nine to fifteen
pounds, and were ^ from nineteen and a half, to twenty-eiffht
mches long. One married mother bore a child at tne lull
time, measuring seventeen inches, but weighing only three
pounds and a half. The placenta in some cases weighed
fully three pounds. The placenta of a male, weighs, at an
average, one pound two ounces and a half, whilst that of a
female weighs half an ounce less. Female children, who, at
the full time, weigh under five pounds, rarely live ; and few
males, who even weigh five pounds, thrive. TKey are gene-
rally feeble in their actions, and die in a short time.

When there are two children in utero, the weight of each
individual is generally less than that of the foetus who has no
companion, but their united weight is greater. When a
woman has twins, it either usually happens, that both chil-
dren are small, or one is of a moderate size, and the other is
diminutive ; though I have known instances, where both the
children were rather above, than under the usual standard.
The average weight of twelve twins, examined by Dr. Clarke,
was eleven pounds the pair, or five and a half each. Twins
require more pabulum n-om the mother, and a greater degree
of action in the uterus ; for two placentse must have their
functions supported. The uterus is also generally more dis-
tended, and produces greater excitation ; it has more blood
circulating in it ; and the weight of its contents, to that with
a nngle child, has been stated as twenty to fifteen. Twin
gestation, often produces a greater effect on the system, making
the women more disposed to disease, and less able to bear it :
hence the chance of recovery has been supposed to be four
times less in them, than in those who have single children.
The children, being generally feebler, than when only one is
contained in the uterus, are more disposed to disease; and, as

204

the mother is less able to suckle children after a twin labour,
many perish, who might have been preserved, by providing a
good and careful nurse, soon after birth, for the weakest child.

When the number of children increases above two, the
aggregate weight does not increase. Thus Dr. Hull of Man-
chester met with a delivery of five children, who did not
weigh two pounds and a quarter ; they measured from eight
to nine inches in length, and two of them were bom alive.

Calculations have been made of the proportion of single
births, to those where there were a pluraubr of children. In
the Dublin hospital, one woman in fifty-eight had twins. In
the British lymg-in hospital, one in ninety-one. In the
Westminster hospital, one in eighty. In my own practice,
about one in niaety-five. In the Dublin hospital, triplets
have not occurred above once in five thousand and fi^ times.
More than three are not met with, once in twenty tnousand
times. In la Maison d'Accouchment in Paris, there were, in
twenty years, 37,441 single births, 444 twins, and 5 triplets.
At Wurtemberg, there were twins, once, in about 86 cases,
triplets, once, in about 7,000.

The proportion of male children, bom in single births, is,
as has been already noticed, greater than of females ; but in
the Westminster nospital, it is worthy of remark, that the
number of male twins was only 16, whilst that of females
was 30. In the Dublin hospital. Dr. Collins makes the
proportion of males to females as 24 to 23.

SECTION SEVENTH.

The foetus has many peculiarities which distinguish it from
the adult, and which are lost after birth, or gradually removed
during gestation. In particular, the liver is of great sixe, by
which the abdomen is rendered more prominent than the
thorax. At birth it extends quite to the left side, and the
inferior margin of both lobes, though not of the cleft between
them, is nearly in a line with the naveL It appears venr
early, and increases rapidly till the fourth month, after whidb
its growth is slower. In the child, aft;er birth, the greatest
quantity of blood, in the liver, is venous, and from this the bile
seems to be secreted. But in the foetus, the blood is more
nearly approaching in its nature to arterial ; and no bile, but
a greenish fluid, different in its properties, is secreted. The
gaU-bladder merely fills the sulcus in which it lies. It
is about li inch long, and f broad. The umbilical vein,
which contains blood, changed in the placenta, enters the

205

Uver, and sends large branches to the left side; the vena
ports enters the lirer, and ramifies on the right side ; whilst
a branch, or canal of communication, is sent from the umbili-
cal yein to the vena port®. By this contrivance, the left side
is supplied, altogether, with pure blood from the placenta,
and the right side is supplied, with a mixture of pure and
impure blood, which does not form perfect bile. After birth,
as the circulation from the placenta is stopped, the branches
of the umbilical vein, which supplied the left side, should be
empty, did not the canal, which formerly served to carry a
portion of blo^d, from this vein to the vena ports, now, per-
mit this latter vessel, to fill the branches m the left side,
which henceforth form a part of the vena portae. The whole
liver is thus supplied with blood entirely venous. Bile is
formed, and sometimes in very considerable quantity. The
fissure between the two lobes of the liver, is situated in a line
running from the umbilicus to the sternum, and is to be found
midway between these points. The umbilical vein runs,
nearly, straight up from the umbilicus, and enters the fissure,
though a perpendicular line will go nearer its left, than its
right, margin. The distance from the umbilicus, to its
entrance, between the lobes of the liver, is from | to near an
inch. The arteries, if traced downwards, are for half an inch,
nearly parallel, and scarcely ^ distant; but as they descend by
the Bide of the bladder, they divaricate, and at the brim of
the pelvis, th^ external margins are | separate.

The blood of the foetus differs from that of the adult. It
forms a less solid coa^ulum, for in place of fibrous matter,
it yields a soft tissue, almost gelatinous. It is said not to be
rendered florid by exposure to air,* and that it contains no'
phosphoric salt. But soon after the foetus has respired, the
Colouring matter, exposed to oxygen, acquires the vemulion
tint, and salts are formed, particularly the phosphate of lime.
We know, that if we inflate the lung of a stillborn child, the
blood becomes bright.

The stomach is small, its two orifices being within 1^ inch
of each other, and its broadest part only 1 J. It contains a
little fluid. The intestmes, which at first, are seen like
threads arising from the stomach, are redder, and said to be
longer in proportion to the body in the foetus, than in the
child. They are at first uncovered, but, after some time, the
abdominal muscles and integuments, form a complete enclo-

* Biehat aiade ezperimenls to aMflrtain ikia upon GoIbmi pin and always
found iho foeul blood black. Anatomic Gencrale, Tom. ii. p. S48.

206

sure. The small intestines, contain a reddish albumen. The
large, are filled, though, sometimes, with the intervention of
a portion, almost empty, with a soft feculent substance, of a
d^urk green colour, called meconium.

The testicles, lie on the psose muscles; but, generally before
birth, they pass into the scrotum. The period at which they
do so, is variable. They are sometimes out of the abdomen
in the sixth month, and sometimes not till the eighth, or till
after birth. The ovaria, in the fifth or sixth month, lie across
the pso» and iliaci muscles, parallel to Poupart's ligament,
between it and the colon. At the full time they lie on the
psose muscles, and the tubes extend over the iliaci, nearly to
the crest of the ilium. The uterus is mostly out of the pelvis,
but hid, at first by the bladder which lies before it. It is
evidently triangular in its shape, as in the adult; from | to
I long, and ^ inch broad, at the ftindus. The kidneys are
1| inch long, and lobulated; the ureters thick. The reddish
glanduke renales are large. The bladder is more conical and
lengthened than in the adult. The spleen 1| by ^ in size.
The lungs are dense and firm, and part of a large gland,
called thymus, is contained in the thorax. Two highly vas-
cular bodies called the false kidneys, or, from their describer,
the corps de Wolff, extend, when largest, which is about the
middle of gestation, along the whole length of the spine, 'one
on each side. They disappear before birth, for, from them
are developed the true kidneys, testes, ovaria and tubes. The
round ligament in the female bears an analogy to the guber-
naculum in the male, both conducting, as it were, the ovaria
or testes down to their ultimate position. The tubes on each
side descend slowly, and unite at last so as to form a uterus,
the neck of which is afterwards formed, and the organ sinks
more into the pelvis, though, even after birth, the ovaria are
lonjg of leaving the brim.

The structure of the heart, is different from that which ob-
tains after birth ; for, though the auricles be divided into two
cavities, yet, these are seen, in the human fcstus, to communicate
freely by a vacancy in the septum ; and even after this is sup-
plied, it is only with a valve, which allows the blood to pass from
the right to the left side. This is the foramen ovale, which is
shut up after birth. Another peculiarity of the foetal heart is,
that the pulmonary artenr, although it divide into two branches
for the lungs, yet sends a third, and still larger branch,
directly into the aorta, just at its curvature, and this is the
ductus arteriosus. The blood is received in a purified state

207

from the placenta, by the umbilical vein, which, after giving
off branches in the liver, sends forward the continuation of
the trunk, to terminate in the vena cava, or largest of the
hepatic veins, and this continuation is named ductus venosus.
The mixed blood which is thus found in the vena cava, is
carried to the right auricle, and thence to the corresponding
ventricle. By the pulmonary artery it ought to be conveyed
to the lungs, but this would be useless in the fcetus, and
therefore Uie greatest part of it, passes on, by the ductus
arteriosus, to the aorta. It follows from this, that, as little
blood is carried to the lungs, so little can be brought from
them, by the pulmonary veins to the left auricle. Now, to
obviate this, and fill that auricle at the same time with the
right, the foramen ovale is formed; and thus, as the blood
can pass freely from the right to the left, the two auricles are
to be considered as one cavity, being filled and emptied at
the same time.

The aorta is distributed to the different parts of the body;
but this singularity prevails, that the hypogastric vessels run
up all the way to the navel, and pass out to form the umbilical
arteries. Alter birth, these arteries are obliterated in their
course to the navel, and the foramen ovale, and ductus arteri-
osus become impervious,

Cartilaginous plates are formed over the brain, which are
gradually converted into bones. These, at birth, are only
united by intermediate membranes.

The pupil of the eye, till the seventh month, is shut up
by a membrane; and the eyelids, for six months, adhere
together. It has been said, that there is neither pigmentum
nigrum, nor rete mucosum till after birth ; but tms I do not
thmk correct, more than the assertion, that a negro child, is
as fair as an European, till the ninth day.

The skin is covered with a white substance, which, though
unctuous to the feel, does not melt, but dries and crackles by
heat* It is miscible with spirits, or, with water through the
medium of soap or of oiL

The male fcetus differs from the female, in having the head
larger, but less rounded, and flatter at the back part. The
thorax is longer, and more prominent, and formed of stronger
ribs than in the female. In her, it is wider from the upper
part to the fourth rib, and narrower below ; the belly, ako, in
the female, is more prominent, and the symphysis pubis pro-
jects more. The upper extremities are snorter, than those
in the male ; the thighs are thicker at the top, and more

208

tapering to the knees. Dr. Soemmering says, that the
spinous processes of the lower dorsal, and upper lumbar
vertebrae, make in the male an eminence like a yoke, in the
female a sinuosity. I may remark, that as the clitoris is
large in the young foetus, females sometimes pass, in abortions,
for males.

When in utero, the foetus assumes that posture, which
occupies least room. The trunk is bent a little forward, the
chin is pushed down on the breast, the knees are drawn up
close to the belly, and the legs are laid along the back part
of the thighs, with the feet crossing each other. The arms
are thrown into the vacant space betwixt the head and knees.
This is the general position, and the child thus forms an oval
figure, of which the head makes one end, and the breech the
other. One side of it is formed by. the spine and back part
of the head and neck, and the other by the tace and contracted
extremities. The long axis of this ellipse measures, in the
ninth month fully ten inches, and the snort one, five or six.
In the eighth month, the lonff axis measures fully eight
Inches. In the sixth, betwixt four and five. In the fourA
month, it measures nearly three inches and a half; and in the
third, about an inch less. In the early months, however,
there b no regular oval formed, and these measurements are
taken from the head to the breech, which afterwards forms
the ends of the distinct ellipse. The extremities are at first
small and slender, and bend loosely toward the trunk.

SECTION EIGHTH.

On removing the shell of a hen's egg, we find that it has
been lined by the membrana putamenis, consisting of two
layers, separated at the large end, so as to form a small sac,
the folliculus aeris. Within this membrane is the albu-
men, which is thinner at the surface than deeper. If the egg
be 0{|ened under water, we find that these two portions, outer
and inner, are really separated from each other, by a very
delicate membrane, which appears to send irregular prolonga^
tions dirough the thick albumen, and, very distinctly, is traced
to the chalajEse, and thence over the whole yolk, so that it forms
a delicate covering to it. Besides this thin layer, called the
chalaziferous membrane by Dutrochet, the yolk is covered by
its own proper coat, called the vitelline membrane. On
removing this, we do not find the yolk run out; it still pre-
serves its shape by what looks more like a condensation of its
granules or substance, than a proper membrane. This,

209

however, is a distinct envelope of granular membrane, and it
is called the biastodermic vegicky or, afterwards, the umbilical
vesick. From the poles of the yolk there goes off, at each
end, a chalaza, so placed, that however the egg be rolled, one
surface is always uppermost ; and on that surface of the yolk,
we see, covered by the vitelline membrane, and partly sunk
in the yolk, or in the blastodermic vesicle, the cicatricula»
germinsd membrane, or bkutoderme. The centre or nucleus^
where ihe rudiments of the embryo first appear, is clear,
the rest, opaque and more granular. The cicatricida is not
seen for some time after the yolk is formed; then, a little
modification of the granules is perceptible, and lastly the part
is formed. On examining the cicatricula before the egg have
left the oviduct, a small vesicle is found in it, containing a
little speck, called the germinal spot, whilst the vesicle is
named after Purkinje, or, by some, called the germinal vesicle.
It is first contained in the middle of the yolk, but presently
rises into the centre of the cicatricula. Both it and the spot,
disappear before the egg enter the uterus. The small bias*
toderme, at first, consisting of a granular or mucous layer, has,
after incubation, formed on it, a smooth or serous layer, so
that now it is double. Presently, there forms between them
a third, containing blood, called the vascular layer. All the
three enter into the composition of the foetus. The first is
supposed to form the whole system of the digestive organs
and glands; the second, the nervous system, muscles, bones,
skin, and membranes ; the third, the vascular system. That
is to say, the " tissue generateur," is deposited and convert-
ed into these different parts. The cicatricula at first seems
identified with the granular coat, but at the tenth hour of
incubation, it can be separated from it.

These three layers not only form the embryo, but, as incu-
bation advances, extend over the granular envelope of the yolk,
but never enclose it completely. The vitelline membrane,
covering the cicatricula and whole yolk, must enclose every
thing already enumerated, and also every thing afterwards
formed, as for example, the allantois. But at a certain stage
this membrane is absorbed, and ceases to exist, its place being
supplied by what is called the false amnion, immediately to
be noticed.

Leaving the consideration of the development of the chick,
for a little, I may simplify the matter by first describing the
formation of the membranes. When the embryo begins to be
evolved, by the alteration of the coats of the blastoderme, it

210

lies with irbat is to be the belly on the yolk. This belly it
Bot yet shut up, and from its margins a doubling ol dit
fleroufl membrane of the blastoderme^ extends over the sidea
and extremities of the embryo to its batik, where it forms a
kind of purse mouth that soon closes, and leaves no trace of at
opening. There is thus produced, what may be called, $m
cmter tegument to the foetus, only, it does not adhere to Ha
surface. It howeyer embraces it closely, haying no water
interposed. There must also at this period be, at the belly, st
tiart where there is an opening in the amnion, leading direct^
into the belly. This gradually contracts and is called thla
lunbilicus. Now, let it be remembered, that owinff to tte
doubling of the membrane where it passes oJBT, and nrom {hit
being continued all the way along the back, there must be, itt
the whole of that course, two layers. If from the purse meath
behind, we trace the innermost rorward, we come to the mafgifl
of the umbilicus, and this which afterwards contains water ia
tile true amnion. But if in the same way we trace the ottter«
aiost forward, we find that when it reaches the yolk, it does
not, like the other, proceed to the umbilicus, but passes under
tiie vitelline membrane, and is lost on the granular membrane
supplying the place of the former, which is presently abaorbed*
This layer is called the false amnion. From this account it
is evident, that if any substance protruded from the abdomen^
it must pass between these two layers, and be covered l^
tiie one called false amnion. Now we find that a vesicle,
called allantois, or ovo-urinary vesicle, does protrude fron
the rectum. On attending to the history of this vesicle, we
find that in about thirty-six hours, it may with the glass be
seen projecting from the rectum and cloaca, but it is not distinct
to the naked eye till the fourth day. It passes out, exterior te
the amnion, by the side of its attachment to the abdominal pari-
etes, and appears as a vesicle filled with pellucid fluid, and
having vessels ramifying on its coat. These vessels arise from
the aorta, and return to the venous system. On the eighth day,
we find it to be flattened, but still containing fluid, spreading
over the true amnion and yolk, all the way to the junction of
the yolk and albumen. The vascular membrane of the yolk^
not yet described, extends no farther over the yolk than to
that junction. On separating the yolk-bag from its adhesion
to the albumen, we see on that part of the bag a broad circle,
almost as if there had been, there, a deficiency of membrane
closed by albumen. By the tenth day, the vascular produo>
tion is no longer a bag, the fluid is gone and the sides coming

211

in contact, we find dim a double Ifffer formed, whiclbi gradn-
»ny extends more «Dd more over ike albumen, and com^-
^etely endosea it and the yolk, about the fourteenth day*
.Still, from the description already giren of the course of
tills vesicle, between the true and false amnion, it is quite evi-
dent, that it must be covered by the latter, which snould be
interposed between it and die membrane of the shell. But
4hi8 is not the case, for Ae fidse anmion is absorbed or
lost, and on removing the raonbrana putamenis, we every-
where, find exposed, the vascular coat which receives the name
of chorion. At this period tben, the diick, if lifted out of the
^g, shoidd be found enclosed in its amnion, with the yolk
bangmg from, or attadied to, the outside of that bag opposite
to the diick, but sendhig a prdongation or vitello-intestinal
tube, through the aperture of the amnion at the umbilicus, in
order to enter the intestines. The diorion should be found
inverting the whole, as « higUy vascular membrane.

But there is another vascular membrane yet to be described,
which is found on the yolk. I have mentioned that the
blastoderme consists of a serous and mucous layer. Now,
between these, globules appear, at first colourless, then of a
greenish cokmr. These form little isles soon enclosed in
tubes or vessels. Red Uood is seen so early as the thirty-
dxth hour. The area, over which these ramify, has received
different names, figura venosa, vascular area, areolar or vas-
cular membrane. This area is surrounded at its margin by
a venous sinus called the vena terminalis, and which receives
blood from the veins of the area, or the vessels which are first
formed. This sinus is not a perfect oval, nor does the blood
circulate continuously round in it. But we may for under-
standing it better, divide the oval into two lateral halves,
having the embryo lying between them, so that we have
really two marginal sinuses, one on each side. These, at
both ends, bend to the under part of the head, where the heart
is formed, skirting as it were a fissure in the area. Two
therefore must go down by the ride of the head, and two
come up by the other extremity, all to enter the heart. They
are thus divided into the cephalic and caudal, terminal veins,
or entering vdns, as they are called by some. At the same
tune two branches in the chick shoot out from the new formed
aorta, and nunify on the area, returning the blood by its
veins to the sinus, and thence to the heart We have thus a
regular circulation established, and as the albumen recedes
frmn over the area, this comes in contact with the membrana

212

putamenis, and the blood in its vessels is subjected to the
action of the air. Thus, this membrane serves, at first, the
purpose of the chorion or placenta. Next, we find that two
veins, partly new, and partly receiving areolar ramifications,
form on the area, corresponding to the two arterial branches
from the aorta, and carrying back their blood not to the vena
terminalis, but directly to the heart, where the cephalic and
caudal branches enter. These branches, with the vena ter-
minalis now decay, but even so late as when the vitellus is
taken into the belly, some ramifications of the new vessels,
called omphalo-mesenteric, remain. The efiPacement of the
original veins of the area, and the diminution of the omphalo-
mesenteric arteries and veins, mav be expected to follow from
that alteration in the current of blood, which attends the deve-
lopment of the chorion, which now performs entirely the respi*
ratory functions of the placenta. The nutritive department
in the chick is to be found in the blastodermic or umbilical
vesicle, which communicates with the intestine, and conveys
the yolk there bv the vitello-intestinal duct which enters at
the lower part of the ilium.

The cicatricula consists of a clear centre and an opaque
margin, and immediately after incubation commences, certain
changes take place, some of which have already been described.
The middle part becomes more clear, especially toward its
circumference, and is named the area pellucida, or, by Coste,
the internal ellipse. A serous and a mucous layer exist here,
but the former predominates, and scarcely any globules are
seen here. This area is at first circular, but, presently, be-
comes oval, and then pyriform. Around the clear area is an
opaque rim, in which first the mucous, but ultimately the
vascular layer predominates. It is called, by some, the area
vasculosa, because it becomes vascular, by others, the tapis or
the external ellipse, for it surrounds the mtemal, but the two
are in contact at that end where the head is to be formed.
It is farther to be observed, that the outer area is, by a curved
line on each side, subdivided into an inner and an outer part,
in the latter of which, called the vitelline area, the mucous
layer predominates, and this does not become vascular. In
the pellucid area, in a transverse direction with regard to the
egg, there is seen, about the fourteenth hour, a small, opaque
stria, about a line and a half long, supposed to result from the
aggregation of granules in the area. It is called by Baer the
primitive stria. From this, in about three hours, there rises
on each side, a little ridge forming his dorsal folds. These

213

meet and unite} so as to fonn a canal, at the end of which the
cranium is formed. A clear fluid is contained in this canal,
which depouts on its inner surface, where the yertebrae form, a
firmer substance, ultimately constituting the spinal marrow
and its membranes, and in the same manner, the brain is sue*
cessiyely produced. Baer, under the name of dorsal cord,
describes another fold of the stria, shaped like a pin and
lying undermost. It is according to him the rudiments of
me spine. Coste considers it as ^jeu de la lumiere. As the
back is formed by the elevation and shutting in of the dorsal
folds, so the anterior part of the body is evolved by folds
rising in an opposite direction, called the ventral folds, which
ultimately also close. From these, also, the extremities are
seen to sprout, about the middle of the third day. Now it is
to be remembered, that the embryo does not continue to lie
flatly on the yolk or the blastoderme ; but by the end of the
second day it begins to curve, so that the two ends of the
membrane forming it, bend toward one another. These ex-
treme folds or curves are called hoods, cephalic and caudal.
What are called the lateral hoods are the ventral folds. If we
continued, in imagination, this process, we should suppose
the margins of all the folds approximating to a common
point, and then meeting so as when closed to form, from the-
membrane, a figure like a worm. But we must bear in mind
that aU the three layers enter so far into this composition,
and also that as the blastoderme rests on the yolk, the curving
and contraction of this membrane, wUl include a part of th&
yolk on which it is placed. We may therefore say, for the
present, that a little part of the yolk is included in the cavity
of the embryo, while the great bulk is exterior to it in the
blastodermic vesicle. That portion of this vesicle and mem-
brane, taken into the embryo, divides into two, one directed
toward the head, the other toward the tail, the first forming
the ilium, jejunum, &c., all -the way to the mouth ; the second
the c^BcUm, &c., on to the anus ; and hence we clearly under-*
stand the nature of the vitello-intestinal duct already noticed.
The serous layer forming the ventral folds is the founda-
tion on which the cavity is formed. The mucous and vas-
cular layers are taken in as if to line this open cavity. Then,
they are so far detached firom the back, as to form by the
extension of the vascular layer, a mesenteric fold, at the margin
of which the mucous or undermost layer forms a gutter on
which also is extended the vascular one. Both close so as to
form a tube^ the innermost constituting the mucous coat, the

214

outermost the musctilar and yaseolar, on which is next formed
a transparent coreringy converted into peritoneum. For a
length of time, a great part of the intestme is not within the
umbilical aperture, but about the nineteenth day it is taken
in, and along with it, the yitelline duct which dilates a little,
within the cavity, to receive the yolk, so that at this time we
have two dilated sacs containing yolk, one without, another
within.

The embryo about the third day, begins to turn toward the
left, the head turning first; on tne fifth,. it is quite on the
left side, the vitelline duct entering on that side, and the
aUantois proceeding from the right directly toward the shelL
This side is developed more speedily than the other.

The alimentary canal is the origin of the other viscera. Its
vascular layer swells, and gives off detachments in different
parts. From the pharyngeal portion, two little prolonga-
tions go off forming the lungs. In like manner the liver,
pancreas, aUantois, &c., are given off as sprouts, and gradu-
ally developed. All must, and do, originally, communicate
with the canal, and this communication in some continues,
becoming the excretory duct. It is farther to be observed
that the vesicle already described (ovo-urinary vesicle,) being
sent off from the lower part of the alimentary canal, comes to
be subdivided by a contraction into two, one, exterior, forming
the vascular covering, or chorion, another within, forming
the bladder, the pedicle or top of which, analogous to the
uracbus, is at this time glued to the umbilicus.

About the third day, three slits are observed on each side of
the neck, communicating with that part of the alimentary canal
which is afterwards to be the pharynx. They are at first
nearly parallel to one another, and vertical with respect to the
spine. There must of course be septa or bands between the
slits, giving a resemblance to the giUs of fishes. Hence the
name of the ln*anchial arches. Hiese gradually are obli-
terated, so that they are effaced about the sixth day. The
uppermost is converted into tiie lower jaw.

At the margin of the cephalic hood, in the region of the
neck, we observe a deposition of opaque substance, which
within thirhr-six hours becomes clear, and converted into a
canal containing colourless fluid. About the same time we
observe red blood in the area. This cardiac canal, even
whilst shut at both ends, contracts on its contents, exhibiting
slight pulsation. From the anterior and posterior extremities,
two littie prol<»gations go off, birt it can hardly be said that

215

fhey *^ formed after the canal. The poaterii>r» oaUed ali^
laimU reeeire the e&teriiig rein or amtimiatioD of th»
rata terminalis, a skort eammoQ iruoky eatering the heart,
beisw thus formed* From tfaA otiier, or anterior end of fcho
oaoa^ where the bulb of the aorta is formed, the anterior
proJeagatioDS, beeoming small yessels, ajpch backvards, whilst
others foraii heoce called the art^al arches. By them the
blood is sent back to the area. The eanal elongates, but
lieiiq; fixed at its two ends, it must thereby form a cur?e like
a borte riioe. This increasing, the canal doe» not project
iartiier, but coils so as to form first a circle, and then an addi-r
tieiial twist forms. That part of the canal into which the poa«
ierior reins enter, or the common trunk formed by them»
becomes the auricle. The yentricle is formed at the convexity
of the priscipal curve, for a time, separated from the auricle, by
a short diaphanous portion called the canalis auricularis. At
the anterior extremity, the bulb of the aorta is formed, dis->
tiaguished from the ventricle, also, for a time, by a contraction^
Oitted the fretum. Ultimately, the single auricle and ventricle,
are divided, by a septum, and partly by growth, into two*
The same happens to the bulb of the aorta which rose from
^be common ventricle. Thus the heart is constructed, but it
10 necessary to revert to the bulb of the aorta, from which we
find sMGcesaively formed five pair of ardies, the course of
which has been already noticed. These, on each side, meet in
a common trunk called the root of the aorta. The two roots
next unite and form the trunk of the aorta which is distri-*
bated in three ways ; first, to the body of the chick ; second, to
the vascular area, which lessens, as the third, to the chorion,
iacreaaes. At one period the aorta seems almost te end in the
tfeolar or omphalo-mesenteric arteries, afterwards, in the two
attsatoid branches corresponding to the umbilical arteries,
tbe right one of these, in the chick, being at last obliterated.
With regard to the arches we find important changes take
place. The most aaterior pair is obliterated first, then the
second pair, and lastly, the fifth arch on the left side. The
remaining arches change their character, and are converted
inio those going to the head, wing, &c., the carotid being first
developed ; thus the fifth on the right, and the fourth on the.
left side, go to the lungs and form pulmonary arteries ; whilst
the fourth <m the ri^t side forois the descending aorta, the
other root beting effaced. It is the left in mammalia.

For understanding the venous system I would observe, lat,
that the pumitive or terminal veins from the vascular area^

216

going to the heart, obliterate ; 2d, that the second set of
areolar veins called the omphalo-mesenteric, enter the heart
where the first did, and there is therefore stiU a short venous
trunk there, which is converted into the end of the vena cava.
Some way before entering the heart, they, in the process of
incubation, receive the mesenteric veins, and hence their name.
The areolar department of these omphalo-mesenteric veins in
its turn diminisnes also, leaving the mesenteric in full vigour.
3d, Two descending or anterior cavas form, by the union of
the jugular, brachial, and intercostal, but only the left enters
by a proper orifice : the right enters the ascending or poste*
nor cava, which is formed from numerous branches in the
Wolffian body, and, issuing from it, mounts behind the
liver. 4th, The common venous trunk entering the heart
elongates, and, by a change of position, is carried toward the
alimentary canal, from which is formed two hollow pyramids
embracing it, and constituting the rudiments of the liver.
5th, The allantoid or umbilical vein enters ultimately, and
joins the common vein which may be called cava. But besides
this junction, called ductus venosus, a trunk is sent oflT, around
which, the liver is formed ; and again from the liver a vein
arises to enter the common trunk or cava higher. This part
of the venous system, which is greatly involved in the liver, is
both the hepatic vein and vena porta. The omphalo-mesen-
teric veins are tributaries to, and afterwards principals in,
the formation of the porta, and therefore this vena porta
must at early period enter very near the heart. Baer says,
even that its trunk, which is short, is not, at the third day, dis-
tinct from the venous part of the heart. 6th, Groing over these
changes, and connecting them one with another, they shall be
better understood, by recollecting that these permanent veins
elongate, so that the junction of one with another becomes
farther from the heart. We may trace the system from the
heart in the chick. First, there is a short common trunk
receiving the terminal veins, which are efiaced ; second, this
elongates, receiving the cava and the united trunk of the
omphalo-mesenteric veins ; third, if we traced still farther on,
we should go along the umbilical vein, and remark the con*
nexion of this with both the porta and the cava.

The nervous system seems to be formed from canals and
vesicles as already hinted at. According to Baer, the ante-
rior part of the spinal cord dilates into a vesicle, which is
afterwards subdivided for the two hemispheres of the cere-
brum. Behind that another forms for the optic beds, and then

217

anotiher for the medulla oblongata. Serres says that on the
fifth day, the rudiments of the cerebellum appear from the
lateral parts of the medulla oblongata. The nrst nerve seen
is the optic, which shoots out as a tube, and ends in a small
bladder or retina, enclosing the lens on the surface of a globe
of albumen. The ear in like manner shoots out from the
medulla oblongata, and on the third day the olfactory appear.
There is a difference however in the statements of physio^
logists. Serres says the first nerve seen is the optic, on the
fourth day, then, we have the third pair, then the fourth,
sixth, and fifth, in succession, and the seventh so late as the
eleventh day. There is in different classes of animalft increasing
complexity or development of the different parts of the brain,
being lowest in fishes, and progressively higher in reptiles,
birds, and mammalia. In the human embryo, the brain seema
to be successively analogous to the first three, and then is
perfected into the fourth. The nervous system seems to be
formed in two halves, from opposite sides which unite. Some,
as Serres, maintain, that the nerves, and even those which
are ganglionic, are formed in the circumference and go toward
the centre ; that is, are formed in the part which they are to
supply, and go to the spinal cord, &c. Others consider the
central part of the nervous system as their origin. We see
distinctly in the optic nerve, that it extends from the optic
bed.

Attending next to the mammalia, we find the ovum to
consist of tvro layers, the outermost of which is generally con-
sidered to be analogous to the vitelline membrane of oirds;
the innermost, to the granular or blastodermic vesicle, on
which is seen the blastoderme or cicatricula. It contains a
pellucid fluid, within which, at an early period, is seen the
minute vesicle of Purkinje, with its germinal spot. We have
thus a yolk with all its parts, but as yet we see nothing anal--
ogous to albumen. The development goes on as in the chick,
with certain modifications connected with the placentary
system, and the changes undergone by the uterine surface.
In the sheep, the ovum, consisting of these two membranes,
receives, on the thirteenth day, a covering of albuminous sub-
stance, or false membrane as it is called; and about the
fifteenth, the blastoderme exhibits the rudiments of the embryo,
with the areolar vessels, or one omphalo-mesenteric artery..
On the seventeenth, the ovo-urinary sac protrudes between
the vitelline membrane and blastodermic vesicle, to the former
of which its outer layer becomes attached* The embryo

218

rinks more and more into tbs sae, tOl at list it is completelj
enreloped by it^ and this enrelope must eoosist of two layen
formed bjr tue two sides of the flattened sac which is drkwn
like a parse over the embryo and its amnion. These Tascu*
lar layers forming the chorion, are denominated, uidiTidaally,
the exochorion, and endochorion, by Dntrochet ; and about
the fourth week, the vessels, which are die umbilical, concen-
trate or increase at particular parts, corresponding to emi-
nences on the uterine surface. These cotyledons, as they are
called, dip down into depressions, or cayities in l^e mammil-
lary projections from the uterus. In the cow they are large
and numerous, and thus many placentube are formed. But
to confine the dates to the sheep, we find that till the twenty-
ninA day, there is no organic connexion between the ovum
and the uterus. The umbilical Tesicle is small, and in some
animals rather increases for a time than diminishes ; hence it
is inferred, that the ovum must be nourished by absorption.
About this period, viz., the twenty-ninth day, a non-yascular
membrane, which had hitherto been confounded with the inner
layer of the ovo-urinary sac, separates itself from that sac. It
is only in ruminants that this is seen distinctly separate from
the other parts. It forms a bag, and contains urine. About
tiie eighth day, the ovum changes its shape, becoming elon-
gated or prolonged latterly. Now into these two lateral pro*
longations of the membrane this sac extends. The blastoder-
mic reside pressed on by it becomes adherent to it, whilst on
the other hand it becomes adherent to the vitelline membrane.
The two vascular layers of the ovo-urinary sac unite.

In the class rodentia, of which the rabbit is a specimen, the
embryo, endosedinits amnion, sinks in theblastodearmic vesicle,
and IS enveloped at last by it, as the sheep is by the ovo-uri-
naiT >ac. 1^ yesicle which » large in proiibrtioQ in the
rabbit, and has no umbilical pedicle, is not vascular till the
ninth day, when the omphalo-mesenteric vessels ramify on the
inner layer of the double cap or covering formed by it. The
ovo-urinary sac protrudes mm the animal and passes out by
the purse mouth of the envelope alluded to. But it does not
expand, as in the case of the sheep, so as to surround the
whole. It goes to the ut^ne eminences, and forms the fostal
portion of placenta. So far, we see no provision for a cho-
rion, unless we seek for it in the vesicle, or in the layer of
lymph which surrounds the omm.

In women the ovuhun is just visible to the naked eye,
but is so rimilar to that of other mammalia, that I have

219

notlung peeuliar to Temark. A bjer of lymph as in Ihe
sheep, is added in the uterus, or rather in its passage aldDg*
the tube, and this supplies the place of the vitelline mem-
brane which is destroyed. A deciduous coat is formed on
the surftce cS the uterus, independent of the entrance of
the oTum, for it exists in extra-uterine pregnancy. I at
(me time thought that it iras organized before the descent
of the oYidum, but am now mdimd to beUeve that it is still
soft when that takes place. We know that in rabbits the
OYum is not adherent till the fifth or sixth day, and in the
sheep much later. In the human subject, the ovo-urinary sac^
as in the rabbit, seems to proceed durecldy to the uterus, and
form a placenta, but the date of this is not decided. Baer
says he saw the amnion, which is formed as in the chick,,
distinctly, before a placenta existed. Vessels were also seen
on the umbilical Tesicle, which it is well known disappears
about the third month. Every thing is well made out as to
the human embryo, cxceptmg Ihe formation of the chorion,
the OYO-urinary sac, as in rabbits, not expanding over the
OYum. Some suppose that the gelatinous coat which it obtains
in the tube is converted into chorion. The false amnion, if it
existed in the human embryo, or the vitelline membrane, if
persistent, might be converted into chorion ; but as yet we
can merely conjecture. It is only in woman and some simias that
it extends along the cord. At an early period it is separated
from the amnion by a traaaparent jelly, like the vitreous
humour of the eye, contained in a reticulated texture. The
quantity at first is consideraUe, so that the chorion may be
tour or five times larger than the amnion, and therefore ouly
in contact with it at the umbilicus. Even at the full time
a thin layer is interposed. This substance is supposed by
some to be originally the sac, corresponding to the aUantois,
but it is c^tainly, at the earliest period I have examined, very
unlike it*

The blastodermic or umbilical vesicle, which, as in other
mammalia, has the blastoderme, socm shrivels and disappears.
In the Huttterian Museum, ^ess RR No. 290, it is seen,
within the chorimi of 9n early conception, as large as a small
pea, close to the embryo, and entering the caudal extremity
by a short pedicle. In the next number, supposed by Dr.
Hunter to be six weeks, the vesicle is flat like a lintseed
between the chorion and amnion, with a filament going to the
embryo from which it is now considerably removed, h seems
to be of no use beyond the earliest period, and it is generaUy

220

entirely eff'aced in the third month, though sometimes vestiges
are seen later.*

SECTION NINTH.

Immediately after conception, there is formed on the inner
surface of the body, and fundus of the uterus, a yascular layer
called the caducous coat or membrana decidua. The inner
surface of this is smooth, the outer, by which it adheres to the
uterus, is rough and not so dense. Into this last, vessels shoot
from the uterus, and seem to spread on the inner surface. I
have considered these two surfaces as belonging to two differ-
ent layers of decidua, intimately connected, and really form-
ing one coat. This extends a very little way into the orifices
of the tubes, and at the top of the cervix seems to be closed
over the surface of the jelly which occupies that part, forming
thus a shut sac. Now, when the ovum enters the uterus,
one of two things takes place ; either it is checked by what
may be considered as the inner layer, which it does not
mechanically push before it, but that layer grows with it, and
affords a covering to it, or, the ovum enters when the decidua
is yet soft and scarcely organized, becomes involved in it, and
surrounded by it, so that as it grows or enlarges, the envelope
grows with it, and still covers it. From finding the ovum at
the top of the fundus, and not, necessarily, at the earliest
period, just at the orifice of the tube, the last is the most
probable opinion. If we trace the decidua along the uterus
to the ovum, we find it reflected over it as a covering, and
therefore this protrusion or envelope is called the reflected
decidua. There must, for a time, oe a space between the
surface of this, and that of the general cavity, or sac of the
decidua vera as it is called, and this space is filled with fluid,
which after death is of a reddish colour. The Quantity of
this lessens as the ovum ffrows, and at last the reflected and
the true or original • decidu® meet and become blended to-
gether. Till we know more of the formation of the chorion
m the human embryo, we cannot decide that this last mem-
brane is, from the nrst, in contact with the decidua reflexa.
K the conjecture be true, that the chorion is formed by a coat
of lymph, which the ovulum receives in the tube, this covering

' • For farther informmtion on the develapiiient of tbt embijo, see Datrocbct,
In Mem. de la Soc. d* Emulation, T. YiH. p. 47. Pander, in Arcbires Generales,
188S, p. 178, and 840. Baer, in Repertoire Gen. d'Anatomie, T. Till. p. 47.
Recbercbea tur la generation, par Delpecb, et Coete. Velpeau, £mbryolof ie.
Cotte, In Annates dee Scleneee Nat Sd Series, T. ill. Serres, Tiedcman, kc
Alio Wag oor and Valcntlii% In £diii« Joonial, 188ft.

221

must be interposed between tbe ovulum and decidua reflexa,
till it become organized into chorion. One thing is certain,
that whilst the ovulum is exceedingly smaU, the decidua re-
flexa has been found larger than a pea, and apparently empty,
as if a fluid had escaped. Dr. Montgomerie has described on
tbe uterine surface of the decidua vera, small elevations like
bags, which appeared to have orifices toward the uterus, and
to contain a milky fluid.

The decidua is at first, and for a long time, thick and also
vascular; but by degrees it becomes soft, and like a thin
layer of jelly, but still having soft vessels circling in it. The
decidua vera does not terminate at the margin of the placenta,
but is continued beneath it, so that it becomes as it were a
medium of attachment to the uterus, and in which the fra-
gile communicating vessels P&ss- At the full time it is like a
thin stratum of red jelly. The decidua reflexa is best seen
at a comparatively early period. At the second month, for
instance, it is distinctly seen reflected on the chorion, from the
margui of the placraita, and as thick as paper.

SECTION TENTH.

The chorion from the first is covered with shaggy villi,
giving its surface a flocculent appearance. These, when
macerated, are white and solid, so that they can only be con-
sidered as leaders to the small vessels which may pass on them.
The chorion has no red vessels proper to itself. Its tex-
ture is membranous, or like condensed cellular substance, and
as gestation advances, its villi or filaments disappear, or at
least become so obscure that they are lost in the decidua re-
flexa. It adheres slightly to the amnion by the remains of
the albumen which was interposed between them.

SECTION ELEVENTH.

The amnion is thin, pellucid, and totally without the ap-
pearance of red vesselis or regular fibres ; yet, in the end of
pregnancy, it is stronger than the chorion. It lines the
chorion, covers the placenta, and mounts up on the navel
string, affording a coat to it all the way to the umbilicus,
where it terminates.

The sac, formed by the amnion, contains besides the foetus,
a fluid which appears to be composed chiefly of water, with a
very little earth, albumen, saline matter, and a peculiar acid.
As this water is contained within the amnioui it has received
the name of liquor amnii.

Tlte qoantity of witer, upon an average, wliidiiB cootamed
within the anmioo, at the fiiU time, is ahoat two Engliah
pinta; but aometimea it is smdi more, and at other times
scarcely six omices. It is secreted from the inner svarbuse of
the membrane hv pellucid yessds, bat diese haye nerer been
injected or traced to their soox^oe. It has been said that they
were distinct in supposed inflasBmation of this texture. In
the early periods, the quantity is larger in proportion to the
size of me uterus, than afterwards. It has bera said to con-
tain arespirable air, butan bmiof no air is foundin the lungs
of the foetus.

SBCTION TWELFTH.

Tlie formation of the placenta in quadrupeds has been well
made out, and from what has been already said, the source of
its two portions may be understood. In the human subject,
the foetal part seems to form more like that of the rodentia,
than any other class. The maternal part, as it is called, if
not formed from the OTum, is at least deciduous, not an inte-
gral part of the uterus, as in other animals, monkeys excepted.
At the full time, it is a flat circular substance about a span in
diameter, and fiilly an inch thick at Ae centre, but thin at the
circumference. It may however be thin and extended over a
much laiger surface, or it may be divided so as to form
two or more, but generally only one is large, and to this,
the vessels from the other run, m order to join the umbilical
vessels there. The ordinary weight of the placenta has been
already noticed. Although it varies according to the period of
gestation, yet, it also does so, to a considerable extent, at the
lull time. It is sometimes very large and thick, weighing
from a pound and a half to nearly two pounds, or is de-
cidedly under the average, and this does not depend alto-
gether on the size of the child.

That surface of the placenta which is attached to the
uterus, is distinctly divided into lobes, with small sulci be-
tween them. It is covered by a thin laver of decidua, soft,
and resembling clotted blood. The sur&ce.next the child is
imoother, and on it we see the eminent branches of the umbi-
lical vessels, over which are spread the chorion and amnion,
the fmner adherent to the suriaoe.

The umbilical cord may be fixed into any part of the pla-
ocpta, or even into the membranes at a distance fit^m it. In
this case, the vessels run in distinct brandies to the placenta,
along the membrane; usually the oord is implanted about

2S3

half way between the centre and the circninfereiiee. From
this point the Teasels radiate and ramifj on the phicenta, gTad»-
ally dipping into its substance*

If ire inject firom the umbilical cord) we find that the
placenta is rendered tui^id, and vessels are filled in erery
part of it* These are seen, after they enter the placesfta,
rery small, but ramify extremely and nunutely. They do
not, however, go entirely to the uterine surfuse. If we macer-
ate the placenta so as to unravel its texture, we find them
forming a fine shaggy or flocculent tissue ; but there is an
uninjected substance between the vessels, if this has not been
washed away. If, on the other hand, we inject from the
uterine arteries of a female who has died pregnant, we in like
manner render the placenta tm^d, and the injection puses
on, even to the foetal surface, which is coloured by it. If we
unravel this, we find it to be a tissue of small cells, filled with
injection, communicating with one another, and having an
uninjected substance between them. K we inject both sets of
vessels with difierent colours we see the exact etructure at
once, namely, minute vessels from the card ramifying round
cells injected from the uterus. From individual ramificationB
of the umbilical vessels, we may inject the different lobes with
difi^erent coloured wax, showing that they do not communicate
with one another. For obvious reasons, it is more difficult to
inject the cellular or maternal part of the lobes separately*
Some suppose that the maternal and festal vessels, communis
cate directly ; and in the rabbit, it has been maintained Uiat
this is established by injection; but as yet, no conclusive
proof has been brought forward. It is evident that by ruptaire
a communication might be formed; and as for experiments
with odorous substances, they cannot be depended on.

When we speak of foetal and maternal parts of the placenta,
we can only do so in respect to the source whence they are
supplied with blood. We are not, in the human subject,
entitled to speak positively as to the formation. The cells^
or what is called the maternal portion, may be formed by
the ovum. In extra-uterine, especially in ventral pregnancy^
it would be important could we ascertain the exact structure
of the placenta. It has been denied that the placmta was
cellular, or received vessels, directly, or of any considerable
size from the uterus. I believe that the state of the vess^
varies somewhat at different periods ; assuredly the placenta
is not perfected at once, nor am I able yet to say when ceUs
first appear. At the seventh month, and afberwards, we find.

224

after carefully iojecting the uterine vessels, that, on cautiously
separating tne placenta, numerous arteries pass from the
surface of the uterus into the layer of decidua which is inter-
posed. There, they form small coils, the coats of which
resemble the decidua itself in softness and texture. They
open into the placenta, or, it will give a more correct idea to
say, that they open at once into cells, which they fill even to
•the foetal surface. Some pass deep into the sulci between
the lobes, before they open into cells. They are small in the
decidua of the uterus, where the placenta is not attached ; but
at the placenta they are as large as a bell wire.

The uterine sinuses also yary at different parts. Where
the placenta is not attached, they either terminate, at once, by
opening obliquely on the surface of the uterus, or often they
appear as if a slice had been taken out of their side, the trunk
continuing on in the uterine substance. In neither case can
the veins or sinus be traced through the decidua. The
vacancy in the side of the vein or its orifice is covered, and
rendered entire by the decidua. This has been also noticed
by Dr. Lee, who imagines that the foetal blood, is changed
by the maternal, acting on it through the coat. But this
structure exists, not at the placenta, but at the decidua, cover-
ing the membranes, and therefore cannot be intended for this
purpose, even if the venous blood of the uterus could act, as
js tiius supposed, on the foetal vessels. No distinct or even
small veins from the decidua, can be traced into the sinuses ;
and yet we should suppose that blood is sent to them from the
decidua. At the placentary region the case is different.
We there find that the veins, like the arteries, are prolonged
from the uterine surface, and retain both their size and flatten-
ed shape. They pass obliquely through the stratum of
decidua, as if two layers of it formed the coat of their contin-
uation. The tract is very short on the uterine surface of
the placenta ; and thus, lik^ the arteries, the veins terminate
at once, in cells ; so that we can fill these, throughout the whole
thickness of the placenta, from either set of vessels. At the
margin of the placenta, the veins often skirt that, for a consid-
erable length, before communicating with the cells, but even
these long and large canals have coats quite like decidua.
•From this structure of the intermediate vessels, we can easily
see that their great security arises from the apposition of the
uterus and ovum, or the support afforded by the adhesion of
the one to the other. A slight separation must lacerate the
tender vessels, either passing to tne surface of the placenta.

225

or numing along its mai^in ; and as these, especially the
latter, and the veins of the former, are large at the end of
gestation, great hsemorrhage may ensue. We farther under-
stand, firom this fragile texture, how the secundines are easily
thrown off after the child is bom.*

In the Hunterian Museum, Press RR, are several prepara^
tions which illustrate the formation of the placenta, rf o. 1 92,
exhibits the chorion of a conception said to be two weeks old.
It 13 altogether shaggy, with no appearance of placenta.
Then, at a little farther on (209), one spot is becoming denser,
as if the vilU had become more interwoven. It is probable
that by this time the ovo-urinary sac, with the foetal vessels,
has reached that spot. This, and similar preparations, prove
that the placenta is at first small in proportion to the ovum.
It is probable that the cells, or cavities, mto which the mater*
nal vessels open, are formed by the interlacement of the non-
vascular villosities of the chorion, and that their inner surface
is tufted, by the termination of those which project, and con-
duct on them the foetal ramuli. Weber says, that each
minute twig of an umbilical artery ends in a corresponding
vein, forming viUi which project into the cell, and conse-
quently float, or are bathed, in the maternal blood. At two
months, (No. 263), the conception is as large as a small egg^
The placentary portion is large and dense, with decidua going
off from it. The foetus is the size of a bee. No. 180, is a
uterus at four months, with the veins injected black, the arte-
ries red, and the placenta removed. The uterine surface is
rough, from part of the placenta and decidua still adhering;
and all over, from the fundus to the cervix, vessels of both
colours are seen projecting from the surface. At the fifth
month, (No. 340), the juacenta is about three inches in
diameter ; at six months, the placenta is seen to be very large
in proportion to the uterine surface, for, altogether, it covers
a third of that, reaching from the fundus, far down the body.

* Whilst this shMt was |»intin;, I bare examined two additional nteri, one in
tbe fonrthy another in the eichtb month* In the fint, the placenta reached from
the top of the oerTix to within an inch of the fandua. It measured three and a
half Inchet long, and two and three-quarters broad. Its structure resembled that
at the fuU time. The uterine sinuses had orifices as wide as a large pin's head.
The left orarium had no mark ; the right had one corpus luteum» or yellow, some-
what conTolnted msas, five-eighths of an inch long, one-half broad, and equally
thiek. In the second, the yessels were seen yery distinctly entering the plaoenta»
and, as osnal, the cells were filled best from the vein, that Is, the reinous Iniec-
tiott, formed tlie great mass of cells, especially toward the festal surface. Tha
arterial injection was best seen toward the matemaL The foetal ressels rami-
fied minutely amongst and around the eells, in that gelatlooaa solMtanoe which
connects them. The corpus Inteam was thin bat distmctt

22S

hi anoth»* preparation at the same age, (No* 21), the uterus
IB injected with red size, and the placenta is red to the fodtal
surface; the umbilical yessels are injected with white and
hiack.

The placenta being a living part, is liable to disease.* Its
Tcssels may be very much congested^ or eztraTasation may
take place. It is also liable to inflammation, ending m grey
or red induration like that of the lungs,, or m abscess^ or ad^
hesion to the uterus, or, by its fcetal surface, to some part
of the child* We sometimes find it unusually soft. Distmot
tumours may form in its substance ; part of it may be ossified;
or more or less of it may be converted into hydatids* Partial
disease of the placenta does not necessarily destroy the foetus^
but extensive alteration must do so. We cannot, a priori^
detect the existence of such alterations, for even fixed or
local pain may proceed from other causes, and the stethoscope
eannot make us sure of the state of the circulation in the
placenta* In doubtful cases, early venesection is^ I believe
the safest practice.

SECTION THIRTEENTH. 1

The umbilical cord, is an essential part of the ovum, con«»
necting the foetus to its placenta. It is found in oviparous
and viviparous animals, and also in plants ; but in these dif-
ferent classes, it appears with many modifications. In the
human subject it consists of three vessels ; of which two are
arteries, and one is a vein. These are imbedded in gluten^
and covered with a double membranous coat.^ The two
arteries are continuations of the arterise hypogastrics of the
ehild, which, passing out at the navel, run in distinct and
unconnected trunks, until they reach Ae placenta, where ihej
ramify and dip down into its substance. When they reach
the placenta, the one artery, in some cases sends across a
branch to communicate with the oliier. The vein commences
in the substance of the placenta, forms numerous rays on its
surface, corresponding to the branches of the arteries ; and,
near the spot where the arteries begin to give off branches,
iihese rays unite into a single trunk, the area of which is
rather more than that of the two arteries. None of these
vessels are furnished with valves.

The umbilical vessels run in a spiral direction, within the
covering of the cord, and die twist is generally firom right to

Edin. Joarml, 1886.

S27

left* Besides this twisting, we aiso find, that the vesads^
especially the arteries^ foim very frequent eoils, loosely,
lodged in the gluten.

The cord does not consist entirely of vessels, but partly of
a tenacious transparent gluten, which is contained in a cel«»
hilar structure ; and these numerous cells^ together with the
Tflssels, are covered with a sheath, formed by the reflectioa
ef both chorion and amnion from the placenta ; and of neces*^
mtj, the amnion forms the outer coat of the cord. The
oborion adheres firmly to the cord every where, but the
amnion does not adhere to the chorion; it is not even in-
contact with it at the placental extremity, but forms there a
slight expansion, which, from its shape, has been called by
Albinus, the -processus infundibuliformis* It is only in the
hnmim subject and some apes, that the chorion is found oa
the cord. Fleurens says that there are five layers continu*^
ous, successively, from without inwards, with 1. the epidermis^
2. the derma, 3. the subcutaneous cellular tissue, 4. the
muscles and aponeurosis, 5. the peritoneum.

The proportion of gluten is larger in the early, than in the
advanced, stage of gestation ; and tlie vessels, at first, run
through it in straight lines. In some instances, the cells
distend or augment in number, so as to form tumours on tha
cord, which hang from it like a dog's ear.

From the vesicula. alba or umbilicalis, already described^
a small duct proceeds along the cord, but it is soon obliterated*
A small artery and vein pass along the cord from the navel^
to the vesicle. These are the omphalo^mesenteric vessels.

Nerves have been described, and also lymphatics, rising
from the placenta, and said to be easily injected by pushing
a fine tube into the ceUs of the cord. This does not seem to
be the case. Besides the blood vessels^ there is, in brutes, the
nraebus leading to the allantois.

When the ovmn is first visible in the uterus, there is no
cord, the embryo adhering directly to the involucra, but it
soon recedes ; and within the sixth week, a cord of communi-
eation is perceptible.

The cord at the full time varies in length, from six inches*
to four feet,t but its usual length is two feet. When it is
too long, it is often twisted round the neck or body of the

• HiManiu, cent M. obs. 60. ^ ,^ « ^ ..... .

t Maurtceau has wen it a Paris ell and a third, olja. 401 — Hebenttrf it forty
Inches.— Hallrr Disp. Anat. Tom. v. p. 675 — Wrlnberg fortv-elghl inches —
Vida Com. Gotting. Tom. It. p. 60. it has been seen fire and a half feet long.

228

ohild, or occasionally has knots formed on it,* most frequently,

Eerhaps, by the child passing through a coil of it during
kbour.f I have seen them pretty firm.

The vessels of the cord sometimes become varicose and
form very considerable tumours. These, occasionally, so far,
impede the circulation, as to interfere with the growth of the
chUd, or even to destroy it altogether. Sometimes the vessels
burst, and blood is poured into the uterus, which produces
a feeling of distention, and excites pain. There can, how-
ever, be no certainty of this accident having taken place
nntil the membranes burst, when clots of blood are discharged.
If the foetal and maternal vessels should communicate, the
mother is weakened, and may even fiunt; and, in every
instance, the child suffers, but does not always diet Deliv-
ery must be resorted to, either on account of the effects pro-
duced on the mother, or to prevent the destruction of the
child.

The cord may, by a fall, or violent concussion of the body»
be torn at a very early period of gestation. In this case, the
child dies, but is not always immediately expelled. It may
be retained for several weeks ; afterwards the ovum is thrown
off, like a confused mass, enclosing a foetus, corresponding in
size to the period when the accident happened.§ The cord
may be filled with hydatids.

The cord has been found unusually small and delicate, or,
on the contrary, very thick. In the latter case, it is always
proper to apply two ligatures, instead of one, on the portion
which remains attached to the child.! It has happened, that
by the shrinking of the cord under the ligature, the child has
aled from h«morrha«e.5

Two cords have been met with, connected with one placenta,
or with two placentse belonging to one child. In other in-
stances, the vessels are supernumerary or deficient. Stories
have been told of the cord being altogether wanting, but these
are incompatible with the fostal economy.

• Vide MaoricMU, oIm. 193 wad 166. See alio Baadelocqae, who Jattif
remarks, that thev Derer can be drawn ao tight, as to stop the circulation.
Dr. Hunter thinks h« has twice seen these formed prerious to birth.
Vide Baudelocoue TArt, note to section 1064.
Vide Case by M. Anel, in Mem. of Acad, of Sciences, 1714.
_ This was proposed hj Manrioean. in consequence of meeting with an Instance
wliere the child suffered much from Iom of bIood» obe. 256*
1 Vide Case hj M. Degland, in RecusU Period. Tom. r. p. 843.

229

CHAP. XVII.

OfSterilUy.

Sterility depends either on malformation, or imperfect
action of the organs of generation.* In some instances, the
OTaria are wanting, or too small ; or the tubes are imperfo-
rated; or the nterus very small. In these cases, the menses
generally do not appear, the breasts are flat, the external
organs small, or they partake of the male structure and the
sexual desire is inconsiderable.

In a great majority of instances, however, the organs of
veneration seem to be well formed, but their action is imper-
fect or disordered. The menses are either obstructed or
sparing, or they are profuse or too frequent, and the causes
of these morbid conditions, have been already noticed.

It is rare for a woman to conceive, who does not menstruate
regularly ; and, on the contrary, correct menstruation gene-
raUy indicates a capability of impregnation on the part of a
woman.

A state of weakness or irritation of the uterine system,
occasioned by frequent and promiscuous intercourse with the
t>ther sex, is another very common cause of barrenness in..
women, and hence few prostitutes conceive.

A morbid state of the uterus and ovaria, often accom-
panied with fluor albus, may likewise be ranked amongst
the causes of sterility, and this is known by its proper
characters.

Women who are very corpulent, are often barren, for their
corpulence either depends upon want of activity of the ovaria,
spayed or castrated animals generally becoming fat, or it
exists as a mark of weakness of the system.

When sterility depends upon organic disease, we have
it seldom in our power to remove it ; but when there is
no mark of the existence of such a state, and we have
^ound to suppose that it is occasioned by disordered or
imperfect action of the uterine system, we are to employ
such means as are supposed capable of removing this, either
by operating on it along witn the general system of the
body,^ or more directly on the uterus itself. Our first
attention must be directed to menstruation, as the state of

• Dopoytreii^cut off an dong atcd neck of the ntcrni, and, aAer tliat, the woman
eenoeWed.

230

that function is our principal directory in the choice of the
class of medicines to be employed. On this subject I must
refer to what has been said in chap. xii. We will also, alto-
gether independently of the state of menstruation, naturally
consider the constitution and habit of body, with regard to
plethora, irritability, torpor, or debility, and use varied and
persevering means for rectifying these states ; always, how*
ever, taking care that we do not injure the constitution in
seeking for a remote good. In the majority of cases, weak*
ness or imperfection of action, of the uterine system, is die
cause. This may be dependent on the direct condition, of
these parts, or be produced by the sjrmpathetic influence of
other organs. Sea bathing, change of air, and tonics in
various forms, with the use of such laxatives, as invigorate
the action of the bowels, are all more or less useful. The
ancients employed medicated pessaries, which have long
fallen into disrepute, rather perhaps firom the absurdity of
their ingredients, than from any argument respecting the
isefficacy of gentie stimulants acting on the vagina and womb*

A temporary separation from the husband is of service,
especially when the menses are profuse, and, in most cases,
frequent intercourse should be avoided.

Should a woman, who has been for some years barren^
conceive, she must be very careful during gestation, for
abortion is readily excited.

In some cases, the uterine system is capable of being
acted on by the semen of one person, but not of another.

CHAP. XVIII.
0/ JSoBirtMUerine Pregnancy.

SECTION FmST.

It sometimes happens, that the ovum does not pass down
into the womb, but is retained in the ovarium, or stops in the
tube, or is deposited among the bowels. No cause can ia
general be assigned.* Of all these species of extra-uterine
pregnancy, the tubal is the most frequent.

* LaUMamiid, ia ona oatc, ■ttribttlM the accident to a fright or ttart at tlitt
nomeiit of conception, wiilch happened in October. The patient died in Maroh.

I , **• J^ **"S"^ '■* i^ abdomen, and the chorion was adJheriuf to Ibe wboU
pclTia. Kour. Joom. Tom. IL p. 320,

331

The ByaagtjomB of .eatra-uteriiie>pvegiiancy are not, at ?Etr^
very definite. The woman may at first enjoy perfect health,
but, generally, the uaual sympa^etic effects of pregnancy, or
the dbeases «3f gestation, are more distressing than if the
foetus were contained in utero, and often do not cease so
early. In some cases, they e?en increase in yiolence, as
pregnancy adyances.*

The symptoms, though often more violent, are, however,
«milar in kind, to those of common pregnancy. The belly
swells, the uterus itself enlarges, and may be felt to be heavy;
but after some time, it does not correspond in its size, and in
the state of its cervix, to the supposed period of gestation, or
it may return to the unimpregnated size.f The menses are
often obstructed, though in some cases they have continued
to appear for two or three months. The breasts enlarge, the
morning sickness takes place about the usual period,t and the
child quickens at the proper time, but it is felt chiefly in one
side. An obstruction to the free passage of urine is some-
times produced, till the sac rise out of the pelvis.

Occasionally, in the early state of pregnancy, pains§ resem-
bling those of colic are felt, and these have been so severe as
to excite syncope, || or convulsions ;^ and it has happened
that during these pains, the tube or ovarium has burst, and
the person died, owing to the internal haemorrhage,** and

I • Vid« Fm^tT hj Dr. GartlMliore, liood. Mod. Jour. Vol. yiU. p. 844. '
, t Vide Mr. Tucker^ cue, Med. and Phys. Jour. xxix. 448.

f la Dr. Cfairke'a ease the moriiinf eicknees, and other eigne of prtgnuatfp
appeared -rerj regalnrly. At the end of nine monlbs, attemple were made to
«xpel the feBtus- Theee were followed by Inflammation and decline of health.
Then enppuration took pkrae, and the patient eunk. Traoeactions of a Society^
an., VoL ii. p. 1. In Mr. Maiawmring*e caee. In the eaoM work, p. 287, tha
patient euffeved maeh from momlni; eiekneee, and pain at the groini.

^ in the Jonmal de S^avans for 1756, we are told of a woman at LoitTali|«
mho at fivat had eo droadfal nain whan ahe want to atool, that ehe thought her
fcowele ware eomiog out. Jn Fouteau'e gsm the woman Buffered great patn tUl
mftar the aeoaad month. Mahmgee, p. SS9.

|( Bianohi mentione a onae, in wbioh, in the firet months, the woman com-
bined of mat pain in the lower belly, with nausea, and fainting fits. The
■Botioa of the ehild aeasad in the fifth month, and then milk was secreted. l>a
Nat. in Hum. Corp. VUiosa, Morbnsque Oener. p. 166.— In Dr. Mouneey^
aeae, the pain, Yomiting, and faiatinjr ncs, continued till the woman quickened.
Phil. Trans. Vol. sir. p. 1 31. —In Dr. Fern*s case, the person complained af
great pain till the third month ; and from that period till the eighth month, waa
•okgact to eoBvalsions and synoope. PhlL Trans. Vol. xxl. p. 121.

i Vide Dr. Fam's ease, and a ease by Mr. Jaoob, in Lond. Med. Jour. Vdl.
viii. p. 147.

* * in Mr. L8ngitaff*s oase, the patient felt riolent pain in the lower heTly;
•ickness, and faintness, and died in seven hours after being taken ill. Two
quarts of blood were found effused into the pelris, and abdomen, and a foitus
with its membranes jrta found, apparently about eight weeks old. The H{ht
Fallopian tube was as large as a hen's egg, and had burst in two places. The
uterus was rery vasoahr, and oonUined jdfy, hat it ia said had no decidua ; and

232

partly perhaps from inflammation. The paina usually begin
in the sac, and then the uterus is excited to contract, and
discharge the fluid it contains. When these pains either do
not occur, or are removed, or the patient surviyes the rupture
of the sac, we generally find, that at the end of six, eight,
nine, or ten months, from the commencement of gestation,
appearances of labour* take place ; the woman suffers much
from pain, and there may be a sanguineous discharge from
the uterus. The pains go off more or less gradually ,t the
motion of the child ceases, and milk is secreted.^ In a few
instances, very little farther inconvenience is felt, the tumour
of the belly remaining for many years, and the child being

the eerviz wat not tliat up by mucin. The tube wu obliterated at the uterine
extremity, which probably was the cause of the eviL Med. Cbir. Trans. Vol.
yii. p. 497. SaHatier mentions two instances of oyarian preg^nancy, where the

Silent died quicldy after pain and faintlnff. Med. Operat. Tom. i. p. 343.
r. Abercrombie has informed me of a fatal case of hemorrhage of this liind.
JSee also Reyue Med. Tom. i. p. 460. M. Bushell relates a case where the tube
gave way, but the ovum, about half the size of a pea, was found in the tube, be-
tween the laceration and uterus. About two pounds of coaeulum were found in
the pelvis. Med. Chir. Rev. June, 1824. The late Mr. Af oore showed me a
reparation taken from a woman in the sixth month of extra-uterine pregnancy.
Fains, of the bearing-down kind, came on about a fortnight before her death,
ifith sharp pain in the side, where the ovum lay. Bleeding and other means
relieved her, but at the end of a fortnight, they returned, and she sunk rapidly.
On examination, a foetus of the ordinary size at six months, was found m the
ovarium, which liad giren way, and blood was effused into the abdominal cavity.
The uterus was enlarged to the size of the fist, and could have contained a largo
pear. It was lined with decidua. In the first effort the os uteri vras felt open,
nut nothing could be discovered within it. A brownish discharge took place.
In M. Clement's case, the female, who had previously been quite well, suddenly
complained of abdominal tension, and pain so severe, as to make her shriek,
fainting, hiccup, &c., and died in about three hours. TIm tube was the
size of a pigeon's egg, and though lacerated, still contained a small ovum and
embryo, about six weeks old. The uterus was twice its natural size, and lined
with decidua. A great quantity of blood was in the pelvis. Med. Gas. xIt. p. 81.
An unmarried woman, had, for two days, slight dUficultv of making water,
complained, then, of faintishness, followed by pain in the lower belly, so great
as to make her bend forward. In a few hours fatal syncope took plaoe. An
immense clot of blood was found in the abdomen, produced by the rupture of the
tube. 1 receired the uterus for examination. The foetus measured from tho
head to the heel, three inches, and was still connected to the tubal placenta by
the cord. The uterus was three inches five-eighths long; the cavity of tho
fundus one inch seven-eighths broad ; the thickness of the paries five-eighths ; tho
breadth of the oo uteri, externally, at the cervix, one inch firo-eighths. The
fundus and body were coated with a thin layer of decidua, putly like jelly, partly
like fibrin, with red patches in it of small size, and striiB or the same colour.
The cervix and os uteri contained red iellr. The ovaria had nothing unusual
In their appearance. See also a case in Archives, T. z. p. lOS.

* In Dr. Perfect's case, no labourpains came on, but the motion of the child
onaed at the end of nine months. Tne abdomen neither increased nor dimln*-
Ished in size for two years and seven weeks ; but she was afllicfrd with constant
pain in the hypogastric region, attended with fever, and finally sunk under
marasmus. Cases in Midwifery, Vol. 11. p. 164.

t In Mr. Bell's case, the pains continued, though gradually abating, for three
weeks. Med. Comment. VoL 11 p. 78.

_l '? V^' ^^** o«» Biilk continued to be secreted for several yean. In Bfr.
Tufnbulli caa^ a fluid was secreted, rather like pus than milk. .

233

tionyerted into a substance resembling tbe gras des cimetieres^
whilst tbe sac which contains it becomes indurated. More
frequently, however, considerable irritation is produced,* with
nausea, loss of appetite, frequent vomiting, or diarrhoea, or
dysuria, chills, difficulty of breathing, aphthous mouth, and
great debility ; inflammatory symptoms supervene, and hectic
takes place. The sac adheres to the peritoneum, or intes-
tines; and after an uncertain period, varying from a few
weeks or months to several years, it either opens externally,
or communicates with the abdominal viscera. Very foetid
matter, together with putrid flesh, bones, and coagula, are
discharged through the abdominal integuments,t or by the
rectum,} vagina, § or bladder. || Sometimes, almost an entire

* In the eaae of a female maUtto, the outlines of which I was fsvonred with
hj Dr, Chltholm, the pain was so great that it could not be allayed by tbe
stroDjnst opiates. It ended fatally.

f lliis termination Is noticed so long ago as by Albucaais, lib. ii. c. 76. In
the Padnan Commentaries, there Is related a case, where the alidomlnal pHrietea
opened by gangrene, which Is also said to have affected the uterus, and the child
was then expelled, and the patient recovered. In a case latelv related by Mr.
Gunning, tbe patient after having pains like those of lal>oar for three davs, got
better ; in a month the menses appeared ; presently the abdomen became innnmed,
and a foBtus was disehaned through the integuments. She continued to roen<-
stmate, and we are Informed that at each period, a discharge of red fluid took
place by the fistuloos wound» which had not closed. Med. and Phys. Jour.
Oct 1827, p. SI4.

i Vide cases by Langius, In his Epistole, Tom. Ii. p. 670. Tulpius Opera,
lib. iv. e. 89. p. 958.— Pouteau In his Melanges, p. 87a— Mr. Shtever, in Phil.
Trans. No. 903. p. 172.— Winthrop. Phil. Trans. Vol. xliii. p. a04, and Simon,
n. 689— LIndesUple, Vol. xliv. p. 617.— Merely, Vol. xix. p. 486.— Gordon, in
Jdcd. Comment. VoL xvlii. p. SS3. — Cammel, in Lond. Med. Jour. Vol. v. p.
90.— Case by M. Bergeret, In the Recueil Periodique, Tom. xiv. p. 289. Gait*
akelJ, Med. Aep. March 182a

$ Vide MarceL Donatus, de Med. Hist MIrab. lib. Iv. c. 22— Horstii Opera,
Tom. IL p. 536. In this case, the foetus was discharged both by the vagina and
reetam.— Benevoli, in his Dissert, o. 104, gives an instance where the greater
part of the ehild was erpelled bv tne vagina, but the woman died before the
process was completed.— Mr. Smith's case in Med. Comment. Vol. v. p. dI4—
In Bfr. Colman^ case^ pains came on, and tbe head was felt in tbe pelvis at tiie
time of her reckoning, and long afterwards, but the os uteri could not be per-*
ceived. In seme time, hectic fever, with diarrhoea and sore mouth appeared.
Six months after her attempts at labour, an opening was felt in the vagina, but
▼cry onllke the os uteri. The hand was introduced, and a putrid child was
eztraeted. Some feces continued to come by the wound, but at last she got
well. Med. and Phys. Jour. Vol. 11. p. 268.— See also Camper's case, In his
Demonst Anat. Path. lib. ii. p. 16. and Dr. Fothergill's case in Mem. of Med.
Sodety, VoL vl. p. 107.— In Dr. Harder*s case, the foetus piecemeal was extract-
ed from an abseese In the vagina. Much pos flowed, but nothing like placenta
or cord was discharged. The patient recovered. Archives, 2d Series, T. x.
p. 488. In a ease related by Mr. Kankin, two bones were discharj^ed by tbo
T^na. The os uteri was lelt a little open, and something within it. It was
dilated by polypna forecpe, and a foetus extracted. £din. Med. Jour. April*
1887, p. 802. If the extraction really was made through the os uteri, and not by
a new formed opening, the case could not have been extra-uterine. May the
nteroa have been raptored at the time palne were first felt, but tbe foetus not
entirely expelled into the cavity of the abdomen ? We have no Instance, even of
a dead ehlid being Mtained in utero, after natural labour had come on, and being
afterwards expelled pleeemeal.

I Vide Staipart Van der WIel Opera, Tom. I. 80ft. In this case bones cama
away with the urine.— 'In the case of Ronflsos, the child was discharged partly

23ft

fetus fans been brouf^ht away from the .nmhilimH,^ or fay'tthe
rectum.t It is worthy of notice, that the placenta, in .iUs
process, almost always is destroyed^ and discharged among
the putrid fluid. Often, time is not allowed for expulsion to
be accomplished, but the person dies at an early period.
£xtra-uterine has been combined with ordinary pregnan(^*§
Thus it appears, that there are different terminations of the
extrar-uterine pregnancy. The sac may burst, and the person
die speedily of hemorrhage ;|| or the child may escape into
the abdomen, and be enclosed in a kind of cyst of lymph ;^
or the sac may remain entire, the child being retained many
years,** and the parts become hard; notwithstanding this, the

by the bladder, bat chiefly by the anas. EpUt. Med. — A ilmUar instance Is
related by Morlanne, the extraneous matter tormlo|^ « nueleos for a caleuluo.
By an operation similar to that of lithotomy, two stones and fire portions df
cranial bones were extracted. Recueil Period. Tom. xiii. p. 70.— >ln Prof.
Joseph i*s case, the child was found altogether In the bladder. Med. and Phys.
Jour. Vol. xir. p. 519.

• Vide case of Mrs. Staff, In Lond. Med. Obs. and Inqnliios, VoL ii. p. 860;
and cases by Mr. Jacob, Dr. Maclarty, and others.

f in Mr. Gifford*s case, the child was expelled entire by the anm, and tiwvn.
the cord was found hanging out of the intestine. Phil. Trans. Vol. xxxtI. !>.
485. See also Mr. Goodsir'tf case. In Annals of Medicine, Vol. yii. p. 412. Dr.
Albers has a similar case. Jn Julia*s case, bones were discharged by the reotnsa
in the second year. At an earlier period^ pains, with milk fever, &o., had cons
on. llev. Mfd. Tom. x. p. 53.

i In Dr. M* Knight's case, althoogh the Gseearean operation was performed
before any bad effects were produecd on the health, no part of the placenta cooltt
be found.

§ Case by CI let. Nouv. Jonr. Tom. Ui. p. 287. A woman, whilst going on with

an extra- uterine concebtion, became pregnant, and at the full time bore a child,

which lived 15 days. The abdominal tumour bad prerioosly hecome blue ; an

incision was made, and a child 18 inches long extracted, recovered. Archlv«%

T. ix. p. 4^.

y In Dr. Clarke's case, the tube burst in the aeeond month, and the wovnnn
died from loss of blood. Transaetions of a Society, Vol. i. p. SIS. Vide ease by
Duverney, in his wi>rks, Tom. ii. p. 858. and by M. Littre in the Memoirs of
the Acad, of Sciences, for 1703, and by Riolan in hie works. See also Med.

Comment. Vol. 1. p. 429. In Mr. T. Blizard'e case, ruptttre took place at a y9ij
early period, for the woman had miscarried only Ave weeks previons to thta
event. Vide £din. Phil. Trans. Vol. v. p. 189. Mr. TuokeKa case, Med. and
Phys. Jfturnal, xxix. 448.

^ In Vide a case by La Croix, in La Med. Edare^, Tom. iv. p. S40. In Dr.
Bright's case, the fostus lay in a kind of cavity, communicating with the bow<l.
The patient had suffered much from pain, dll&oult breathing, diarrhcea, Ike.
London Med. and Surr. Joum. ii. 65.

** 1 liave known the fsatns retained for twenty years, and tliere are noma
Inatanaes, where it has been retained for thirty, forty, or fifty years. Mre. Rafr,
whose case is related in the Med. and Phys. Jonr. for May 1800, carried the ehlld
fifty years. Middleton's patient carried it sixteen years: Phil. Trans. Vot
zllv. p. 617. Mounsey's thirteen years, Vol. xlv. p. 121. Slolcertohl^ forty^ahc,
i^ars, Vol. xxxi. p. 126. firoomfield*e nine years. Vol. xil. p. 696. Sir P.
okippon*s patient discharfed it by euppuratlon at the groin, after retalnlnr It
twenty years. Vol. xxiv. p. 2070. See also easss by M. Grival, In £din. Med.
Jour. Vol. ii. p. 19, and Dr. Caldwell, p. 82. Sometimes no attempt is made
to expel, but the fsBtus Is converted into a enbstanee which Fovrcroy finde tn
resemble the gras dee cimetleres. System, Tom. x. p. 68. fiandifort relates •
case, where, after attempts at lal>our, no further Ineonvanlenoe was anstalned, bat
the ehUd was found after twanty.twD yean to be Indunted. ObiervaUoneB, lib.

235

mensoB nay retam, and die ^womaa -eoimeiTB agasn.^ fiMk
the most frequent tenoinatian, is tiiat of inflammation, ending
in abaceas, attended with fever and irain, nnder whidi the
patient either sinks, or the foatns is expelled in pieces, and
the cure U slowly accomplished. When the sac adheres tq,
and opens into, the sigmoid flexure of the colon, the bones axe
more easily disclmtged than when it becomes connected to
ihe ilium, unless that open into the colon. From a review of
cases it appears, that a majority ultimately recover, or get
the better of the immediate injury ; of the rest, some have
sunk speedUy, either from hiemorrhage or inflammation, or
exhaustion produced by ineffectual attempts to expel the
-child; or more slowly from hectic fever, or irritation ; or in
consequence of some other disease being called into action,
by the violence which the constitution has sustained.

In some cases the sac soon rises quite out of the pelvis. Txl
others, it remains longer, and falls down between the uterua
and bladder, t or the rectum and vagina, forming a tumour,
accompanied with symptoms of retroversion of the uterus4
In such cases the sac inflames, and bursts into the rectum cr
vagina. Dr. Merriman§ is of opinion, that all these cases,

ii. p. 96. He qaotes Neb«l for a case, where it was retained fifty>foar yeara.
Cbeselden found it emiTcrted into eartliy matter. The late Mr. Hamilton of tlib
place, liad a preparation of a fcetus, covered with calcareous matter, which waa
retained S2 years. This woman had pains at the end of nine monthSt after which
the belly decreased in size. Penker relates a case of extra- uterine pregnancy, aa
4ine in which the child was retained in utero for three years. The result is not
Ifiiren. Archives, Tom. ix. p. I24w In Vol. xvii. p. 8S2, M. Garde relates the
€Bse of a woman 7S years old, in whose abdomen, was found an oaified isBtii%
two Inches long. In the American Med. Jouni. for May, 1828, is the case of m
ocgress, who retained a child in an ossified cyst for fortv years.

* In the 5th Vol. of the £din. Med. flssays, there is related a case in which
the patient aeemed to have a second extra-uterine pregnancy before ahe got quit
4>f the first. See also Primrooe de Morb. Mul. p. d26. Mr. Hope, in the 6th
Vol. of the Med. and Phys. Jour. p. 860, details a case, where the woman in the
aeventh month of pr^^ancy had pains, which continued for three weeks, and
then went off, learing a hard tumour on the left side, which waa somewhat pain-
fal ; she then had another pregnancy, and a fortnight after delivery, began, after
taking a laxative, to vomit, and continued to do so, ultimately throwing up feon^
lent matter. The case ended fatally. See also Turk, in Haller, Disp. Chtr. iv. 798.
Mr. S. Cooper mentions a case, where the patient had a living child, whilst atttl
discharging the bones, of an extra-uterine one. Med. and Surg. Joum. v, 897.

t This happened in Dr. Harries*s case. Dysoria waa a prominent aymptosB.
See Med. Gazette, xiv. p. 880.

i Vide Mr. Mainwaring*s case, in Trans, of a Society, Ac. VoL ii. p. 887.
In Mr. White's case, related in Med. Comment. Vol. xx. p. 254, the aymptoma
ivcre verv like those of retroviersion, and the case was only distinguished by the
result. In Mr. CammelFs case, there was not only a tumour betwixt the v^gl-
na and rectum, but the os uteri was turned upward and forward. Lend. Mad.
Jour. Vol. V. p. 96. Mr. Kelson's case very much resembled retroversion, Ar
in the tenth week both the urine and stools were obatructed. In about a fort-
night the impediment was suddenly removed, and the utcrns felt in aito. She
continued well to the ninth month, when labour ineffectually came en ; but in
process of time, the child was discharged by the aniia. Med. and Phya* Jear*
Vol. xi. p. 293. '

, S Vide Disaert. on Retroyeralon, kc 1810.

236

are instances of retroveried uterus, and not of extrar-utertne
pregnancy ; but, for the present, this must rest entirely on
supposition. The mere circumstance, of the pregnancy being
complicated with suppression of urine, or tumour at the back
part of the pelvis, is no proof, as both of these may arise from
the pressure of the sac on the pelvis.

Sometimes, when parturient efforts are made, the head
descends into the pelvis, though it was not there before ; but
either no os uteri can be felt, or it is felt directed to the
pubis, and it is not affected by the pains.

It is curious to observe, that invariably the uterus enlarges
considerably,* and in every instance, decidua is formed.
The cavity is filled with a fluid, which is often, indeed gene*
rally, discharged when pains come on, but the decidua is not
soon thrown off. f In a remarkable case related by the late
Mr. Hey t of Leeds, the placenta was formed in the uterus,
while the foetus lay in the tube.

Tubal pregnancy, sometimes does not proceed farther than
the second month, the tube bursting at that time; or, to speak
more correctly, I believe the tube slowly inflames, and
sloughing takes place. In many instances, however, the tube
goes on enlarging for nine months, and acquires a size nearly
equal to that of the gravid uterus, at the same stage of gesta-
tion.§ The placenta, differs from an uterine placenta, in

* fioeYimer long ago observed this ; and Dr. Balllle, In the 79th Vol. of the
Phil. Trant. mentions, that Dr. Hunter had a preparation of tnbal prtgnutcy,
in which the uterus was found enlarged to double its natural size and containing
decidua. He also states, that in an oyarian case, the uterus was enlarged, thick,
and spongy, and its vessels enlarged. Dr. Clarice found the uterus, in the
•ecoiid month of an extra-uterine pregnancy, exactly of the same aize as if the
embryo had been lodged within it. The decidua was formed, and the cerrix
filled with gelatinous matter. Transactions of a Society, Vol. I. p. 216. See
also a case by Saviard, in Phil. Trans. No. 222, p. 31i. A case similar to Dr.
Clarke's is related by Mr. T. Bllzard, in the Edio. Phil. Trana. VoL t. p. 189.
See also Annals of Med. Vol. iii. p. 379.

f In Mr. Houston's case the cervix was so closed up that it would not admit m
probe. Phil. Trans. Vol. xxxii p. 887. The decidua would appear sometimee
to enlarge, and form a man like placenta, which In Mr. Tumbull's case waa
expelled with haemorrhage. Mem. of Med. Society, Vol. iii. p. 176. Mr.
Douches has published a case of tubal pregnancy, proving fatal alwut the tenth
week, where there was no decidua, but only a thin coating of mucus within the
uterus, which waa somewhat enlarged. Med. Gazette, vil. p. 11.

1 Vide Med. Obs. and Inq. Vol. ill p. 841.

$ Among many other cases in proof of this, I may refer to one very aGeuratcly
detailed by Dr. Clarke, in Trans, of a Society, Ice. Vol. ii. p. 1. In a case
which the late Dr. Millar showed me, the pat&nt was supposed to become prrg-
nant In January 16SS. Till the eighth month she went on as usual. She, at that
time, had pains like those of labour, for three days, lliese went off, but returned
again, for a short time, in three weeks. Jn the month of May 1888, ahe was pale,
emaciated, with ouick pulse, diarrheea, and aphthous mouth. The abdomen waa
large, like that of a woman about the eighth month, very tender, and with a UnO'
tuatiug prominence to the left side of the navel. She got ao far better aa to be
abU to walk some mUcs, but presently reUpscd, and died November 1888. The

237

being much thinner and more extended. External examina-
tion disooyers little difference, at the full time, between this
and common pregnancy. M. Breschet* has published some
cases, where the ovum got to the very end of the tube, but
not into the uterine cavity. It grew in the substance of the
uterus, t

Ovarian:( is much more rare than tubal pregnancy, and it
is seldom that the ovarium acquires a great size. It either
bursts early,§ or inflammation and abscess take place ; or the
fcetus dies, and is converted into a confused miuss; or it excites
dropsy of the ovarium. | The ovarian pregnancy, until
inflammation have taken place, produces a circumscribed
moveable tumour, like dropsy of the ovarium.

In ventral pregnancy, tne most rare of the three species,
the motions of the child are felt more freely f and its shape
is readily distinguished through the abdominal integuments.
The expulsive efforts come on as usual, and the head of the
child id sometimes forced into the pelvis. It dies, and the

uterus waa found to be sound, snd not adhering to other parts. The left tube
was enlarged, and adhering to the ilium, forming a cavity which contained pas
and bones, some of which bad entered the ilium. I have a cast of the parts, takea
by my son.

* Hepertolre dMnatomie, Tom. i. p. 91. Moreau and Gardien mention a case
where a canal went off from the right tube, through the substance of the uterus,
to open within ito neck, and think this may explain such a case. Revue Med.
Tom. i. p. 567. In the Museum Dupuytren, a good specimen of Breschet's is
seen, llie uterus itself is enlarged to about the sixe it onght to have in the third
or fourth month. This, which has been called interstitial pregnancy, is also
Ulustrated by a case in Archives. T. xl. p. 169.

f Some deny that the ovum gets from the extremity of the tube into the pari-
etes of the uterus. Others mamtain that it does, and has been expelled from the
uterine cavity into the vagina. See a case by Carus, and discussion by Velpeau»
ftc, in Archives, 2d Series, T. ix. 107.

} In a case related by Varocquier, the ovarium did not acquire a larger size
than an ecg. The woman died after suffering violent pain in the left side, low
down. The viscera were slightlv inflamed. Mem. de TAcad. de Sciences, Tom*
cxtll. p. 7S. In the case by L^£veilltf, the foetus was apparentlv betwixt threo
and four months old. Rapport de la Society Pbllomatique, Tom. L p* 146.
See also a ease in the Recueil Period. Tom. xiii. p. 63; and in the ReeueU dea
Actcs de la Society de Lyon.

$ Vide Chambon, Naiad, de la Grossesse, Tom. ii. p. S7a Case by St.
Maurice, in Phil. Trans. No. lAO, p. 2285. In the case related bv La Rocqa«t
the ovarium was found ruptured, and the abdomen full of blood. Jour, de Med.
1683. Boehmer found the ovarium ruptured, and the foBtus half expelled. Obik
Anat fasc. Prim. Dr. Forrester's patient, after violent colic pains, voided
blood by the anus. The haemorrhage and fainting flU proved fatal. The fetua
waa found in the ovarium. Annals of Medicine, vol. ii. p. 379.

B Vide Rcederer, Elemens, c. 16, § 758. In M. Dumas* case, a fluid like
chocolate was drawn off by tapping, which was twice performed. The orarium
contained hair, bones, ftc La Med. EcUre^ Tom. iv. p. 65. Mr. BeU's tubal
ease excited ascites.

f Dr. Zais relates a ventral case, where the motion could scarcelv be mode-
rated, by the force a man could exert ! £ight weeks after the death of the fotost
It was removed by an operation. It was found to have been included in a kind of
cyst. The placento was attached to the spine, and could not be separated. Tba
wound was closed, and the placenta seemed to eome away^ In a broken dowa
•tota. The patient reeovered* Archiv. Geo, zxr* 417»

238

uaual procesB &r its removal is carried on, if tilie woman dip
not sink immediately under the irritation* The placenta is*
found attached to tiie mesentery or intestines,* or, together
with the foetus, contained in a aac.f It has been supposed,.
Iliat the examples of this variety are all in reality instances
of ruptured uteri ; but this is not supported by satisfactory
proof. At the same time, I ha^e- no doubt tiiat many of
tbem are*

SECTION SECOND.

In the treatment of extra^iterine pregnancy, much must
depend on the circumstances of the case* In the early stage,,
if the sac be lodged in the pelvis, we must procure stools,
and have die bladder regularly emptied, as in cases of retro-
verted uterus. Attacks of pain, during the enlargement of
the tube, require blood-letting and anodynes, laxatives and
fimientations. The same remedies are indicated when con*
tnilsions take place* Ovarian, requires a similar management
with tubal pregnancy, except, that if it be complicated with
dropsy, relief may be obtained by tapping.

When expulsive efforts are made, and the head is felt
through the vagina, and the nature of the case distinctly
ascertained, it may be supposed, and some recorded cases
would seem to justify the supposition, that much suffering
may be avoided, by making an incision through the vagina^
and delivering the child; but, as yet, experience has not
fhlly ascertained the utility of this practice4 It has been
proposed, in these and other circumstances, to perform the

* Vide Dr. Kell/s case, in Med. Obs. and Inauiries, Vol. iii. p. ii. In Mr*
C1arke*a case, the placenta was attached to the kidneys and intestines. Mem*
•f Med. Smstety, Vol. iii. p. 170. In the Mem. of the Acad, of Sciences, there
is a case related, where the placenta adhered to the lumbar yertebrs. In the
history by La Coste, it was placed under the stomach and colon. Vide CEuvrea
4b Duvemey, Tom. ii. p. S63. In Mr. TurnbulFs case^ it was very thin, and
adhered to the intestines. Mem. of Med. Society, Vol. iii. p. 176. A rate of
Tcntral pregnaney, complicated with hernia, is related by M. Martin, in the
Reeneil des Actes de la Society de Sant^ de Lyon. Courtial found it adhering
le the stomach and colon.

f In a case related by Dr. Collins, the appearance much resembled, that of
ntroyersion, in some respects, but although the tumour could be raised out of the
palyis, it readily returned again. The bladder was empty, and yet *' a large
elastic tumour" waa felt in its region, which was not found or accounted for oa
dissection. The uterus, tubes, and oraria, were entire, but in the pelvis, was a
SBC, from which a fsrtus two months old, had escaped. This sac is said not to-
Ibave bad any connexion with the uterus, but the particular attachment to the
peWis, was not ascerUined. lliere was no drcidua, but some small escrescence».
ea the Inner surface of the uterufc Dublin Med. Trans. Vol. I. p. 1 IS.

I In a esse probably of this kind, rdated by Lauveijat, and quoted by Ssbatler,
tiie child waa eaEtracted by an incision through the vagina, and the woman re*
oaiTered; Dela Med. Open Tom. 1. p. 196* A similar case is to be mef with
In tlM Jonm. des Sgavans* 1722. A Tcry intarssUng case is related by Delisle»
In tha Bulletin de la Society Med* d'EmulaliMi, for Mar and Joim^ ISJS -, wlMfi»

289

GaaoreMi opentioii,* in Ae usual maimer, upon- the aeces-
8ion of labour ; but there is not only great danger from the
wound, but likewise from the management of the placenta,
which, if removed, may cause haemorrhage, especially in
yentral pregnancy, and, if left behind, may produce bad
^bds. The last, howeyer is the worst alternative, unless it
he strongly adhering to delicate partsw The case, of all others^
which would justify the operation, is that, where the child is
alive, at the time when pain comes on, ^d where the proofs
of the pregnancy being extr&-uterine are unequivocal.

The result of the numerous cases upon record, will certainly
justify, to the fullest extent, our trusting to the powers of
nature, rather than to the knife of the surgeon. If any
exception is to be made to this rule, it is in those cases,
where the child is distinctly felt through the vagina, and
ean be extracted by an incision made there. AUaying pain
and irritation in the first instance, by blood-letting, anodynes^
and fomentations ; and avoiding, during all the inflammatory
stage, stimulants and motion, whilst, by suitable means, we
paUiaie any particular symptom, constitute the sum. of our
practice.

A tendency to suppuration, is to be encouraged by poultices ;
and the tumour, when it points externally, is either to be
epened, or to be left to burst spontaneously, according to
the sufferings of the patient, and the exigencies of the case.f

tbe cbUd was extnujted aliTe, by tn incision throDgh tha Tuina» Tli« mother
died III A oiUD'ter of an liour, and tlie child half an hoar after nor. It haa, in one
inataneo, howerer, been extracted thoa, with eooeeta to both partiee. In Mr*
Kornian*a caae, Med. Chir. Trani. Vol. xiii. p. 2, the child was extracted, after
making an inciaion through the yagina, but the patient died from peritoneal
inSamuMttion. The pregnasoy ivaa Tentral, ftir the placenta was nttaclied exter-
DaUy to the broad ligament of the uterua. Caignon extracted' a living child from
the Tagina. but the mother died. Archives, xxi. 286.

o M. Colomb performed the Cosarean operation, bat it ended fatally. Recneil
deo Actoe de la Soeiet^ de Lyon. Osiander has also failed. Gomey extracted
by opcrstioo. Med. and Phye. Journalt April, 1889. In a late case, we ars
told of the saeeessful extraction of a living child, which was supposed to haw
been in the cavitv of the belly, having the placenta attached to the fandoa uteri
and ovarium* Nonv. Jonm. Tom. xv. p. 52.

t Dr. Madarty rslatea the caae of a ncgreaa, where the brpech of the cfailcl
protruded through an ulcer, at the lowvr part of the abdominal tumour, and tfa»
arm at the upper part of the tumour. The intermediate portion of skin wa»
divided, and the foetus extracted. The head of the child stuck firmly, bnt waa
ItaroQghi out with the forceps. There waa no pkcenta, bnt putrid matter waa
dlschargad with the child. The woman recovered. Med. Comment. Vol. xril.
n. 4CH. Aoothsv eaea ia nUted by Duvemey, where the child waa extracted
mm the groin ; and this is one of the rare inatancea where the placenta waa not
deatruyed. It waa extracted with the child* (Euvraa, Tom. il. p. S67» Cypri*
•Doe givea an inatanea of the child being xvmoved, after having been retained
tnuoty^ona nontha^ Uistan Fsrtus Hum. Sslva Matre ex Tuba Bxciai. Mr.
Biudia anlaifiad. tbar mureUwUb aJanott. PbiL Trauti Vol. xiz. p. flsa Ssa
alio Mr. Baynham*! caiOi in Med. Fact^ Vol. i. p. 7B»- In- Ma BdU'k^ eaie am

240

The passage of the bones, and differ^t parts of the foetus,
may often be assisted ; and the strength is to be supported,
under the hectic, which accompanies the process* After the
abscess closes, great care is still necessary, for, by £fttigue or
exertion, it may be renewed, and prove fatal.*

When no process is begun for removing the foetus, but it
is retained and indurated, our practice is confined to the
palliation of such particular symptoms as occur*

CHAP. XIX.

Of the Signs of Pregnancy.

Some women feel, immediately after conception, a particular
sensation, which apprises them of their situation, but such
instances, are not frequent, and, generally, the first circum-
stances which lead a woman to suppose herself pregnant, are
the suppression of the menses, and an irritable state of the
stomach, commencing often within the first month. She is

Incision, foar inclies in lencth, was made, and the bones of two children extrac-
ted. Med. Comment. VoL ii. p. 72. Dr. Haighton relates an Interesting
que, where some bones were discharced by the ragina, but the tumour also
pointed above the pubis, and through this one of the ribs appeared. The practi-
tioner made an incision, but so great hemorrhage came on, that he was obliged
to apply a bandage till next day, when he extracted the bones. The woman
recovered. Med. Records, p. 260. Dr. M*Knight performed the operation In
the twenty-second month, although the woman enjoyed tolerable health ; ray
dangerous symptoms superrened, but the woman, wno certainly was brought Into
a Terv hazardous state by the premature operation, did recorer. No placenta was
found. Mem. of Med. Society, Vol. It. p. S2. See also a successful cure In Med.
Chir. Rer. for July IS26, p. 275. Mr. Hntcheson has lately published an Interest-
ing ease, In which the child was extracted piecemeal with success. The patient
had the ordinary symptoms of pregnancy, but Increased more rapidly In sixe than
usual, and presently had spasms, so severe as to make her Insensible. At the
ninth month, pains came on, attended with clear discharge, occasionallv bloody,
and at that time she suifered much agony from the restlessness of the child. A
tumour was felt between the rectum and VMina. Afterwards, owlngto swelling,
paracentesis was performed, and six pints of dark fluid drawn off. The aperture
did not heal, but became larger, ano a finger introduced could feel the head of a
child. It was enlarged, and the child extracted piecemeal. The funis was
entire, built was not till some time after that the disorganised placenta was dis-
charged. Mr. Hutcheson argues in favour of early extraction. Med. Gazette,
Ko. 414 and 460.

• In Dr. Morley*s case, this happened two years after the original abscs« had
healed. Phil. Trans. VoL xlx. p. 486. Mr. Moyle details a history, where
the abscess first of all burst, In consequence of leaping over e hedge. Bones
continued to be discharged for a year, without much Injury to the health. The
abscess then healed, but three years aftowards a tumour again appeared, and in
eonscquenee of exertion burst, when about a yard of intestine pretnided. Some
days 2>fP^^ before Mr. Moyle saw her. The intestine was then gangrenous,
^ V Jomf V^L ^1 ^*^ ^°**'' ■"* ^^ portion was thrown off before death.

241

Bick, or vomits in the mornin?, and has returning qualms, or
fits of languor, during the &renoon, is liable to heartburn
through the day, or in the evening, and to that disturbed sleep
through the night, which so frequently attends abdominal
irritation. In some instances, the mind is also affected, becom-
ing unusually irritable, changeable, or melancholy. Occasion-
ally the features become livelier and the complexion better,
but in general the woman becomes paler, the under part of the
lower eyelid, perhaps, of a leaden hue. The features become
sharper, or even the whole body begins to be emaciated,
whilst the pulse quickens. In many instances, particular
sjrmpathies take place, causing salivation, toothach, jaundice,
&c. In other cases, very little disturbance is produced, and
the woman is not certain of her condition, until the period
of quickening.

Some females, at the time of conception, have a slight dis-
charge of blood from the uterus, and in every case the true
menses are afterwards suppressed. It has, however, been
disputed, how far this suppression is an invariable effect of
pregnancy. That some have been regular during the whole
time of gestation is asserted by distinguished practitioners,
whilst others, no less eminent, maintain, that although re-
peated sanmiinous discharges, like menstruation, may take
place, yet these are neither regular, as to the monthly period,
nor, exactly, of the quality of the menses. I have not
known any instance, where menstruation was perfect and
regular, during the whole of pregnancy. But we sometimes
find, that every month, for at least a part of the term of ges-
tation, there is, for a day, a sanguineus discharge with pain,
and occasionally the pain, at each successive period, increases,
whilst the discharge diminishes. Some have, at the period
succeeding impregnation, a degree of haemorrhage rather than
menstruation. This is no indication of a threatened abortion.
The breasts, at first, sometimes become rather smaller, but about
the third month they enlarge, and occasionally become painful.
The nipple is, at all times, surrounded by an areola, more or
less broad and deeper in colour, as the complexion is dark. Its
texture is similar to that of the rest of the skin, containing
glands or little vascular follicles, with excretory ducts. One
set, at the under surface of the corium, for the secretion of
mucus, which, mixing with colouring matter from another set,
more superficial, forms epidermis. A third set, in the sub-
stance of the corium, secrete sweat. Besides these, we also
find, if they be not a modification of the third set in the areola,

from fire to ten little gkndd which appear aa tnberdea on tke
fturface. They secrete aometimes a limpid, sometimea »
milky fluid. It has long been kiKMirn, that occasioiially durmg
menstruation, the areola beeomes more eolovred from inereaaed
action ; hut almost inyariably by the third month af pregaaaey,
it becomes darker, more turgid, and its tubercles more pro-
minent. This condition, whidi ooBtimies during lactatioii»
has been well described by Dr. Moatgonierie. Doubtlaai^
it greatly depends on the increased action which ia exeiled
in the breast in general ; but the difference of cokmr eTineoa
also a change of the secretion, from the appareil ehromotogene
of Breschet, or that which secretes the colouring matter.* This
change is not always confined to the original areola, bat may
extend considerably bey^md its former boundaries.

On the same principle, the skin of the labia or groin aome^
times becomes darker. Jacquimen says, that the mucus-coat
ef the vagina assumes a deeper or purple colour, but thia»
when it exists, must be attributed to me state of the yaacular
system there.

In the conmiencement of pregnancy, the abdomen does not
beciMne tumid, but, on the contrary, is sometimes rather
flatter than formerly, and when it does first increase in size^
it is rather from inflation of the bowels, particularly of the
colon, than from expansion of the uterus. In some instances,
about the time of the first menstrual period, the intestines
distend, from flatus, for several weeks, when they subside,
and the abdomen continues small till the uterus rise out of
the pelvis. As an increase of bulk, together with many of the
other symptoms of gestation, may proceed {tool suppresaioii
of the menses, we cannot positivdy, from these signs, pro>
nounce a woman to be with child. The enlargement of the
belly is at first accompanied with tension or uneasiness about
the navel, which becomes rather prominent, especially toward
the oath month, but it may remain longer depressed.

When women have any doubt with regard to their situA-
tiou, they generally look forward, to the end of the seeond
quarter of j^egnancy, as a period which can ascertain their
condition* For, about the end of the fourth month, or a
little sooner or later, in different women, the uterus aacenda
out of the pelvis, and the motion of the child is first per*
ceived, or it is said to quicken, and, in Bcme eases, a fiev
drops of Uood flow from the uterus at this period. Sons^

iw8diBMiNttaralM^8cvkS. X»abt»^ MStt«q.

243

qpden si Ae end of die tkird, and others, not till the fifth
monlh, winch may depend on the size of the pdns, the
gfowth of die utemsy and quantity of fluid it coirtains. The
SMition 18 first felt in the hypogastriiuB^ and is languid and
indistiDCt, bnt hw degrees it becomes stronger. It is posnble
toF women to nustake the effects of wind, for the motion of a
diild, espedalhr, if they hare noT^ horn children, and be
anxious ror a umily. Bat the sensation, prodoced by wind
in the bowds, is not confined to one spot, and is, Tery often,
referred to a part of the abdomen, where the motion of the
child could not possibly be felt. It must, howerer, be ac-
knowledged that sometimes a sensation, seems to be produced^
distant from the ntems, and higbar than the child can actually
lie. This may be from motion, communicated through the
folds of the intestine, and the result shows, that the woman
was not mistaken in her sensation. It is not to be supposed,
that the child is not aliTe till the period of quickening, though
Ae code of criminal law, is absurdly founded on that idea*
The child is aliye from the first moment that it becomes
lisible, but the phenomena of life must yary much at different
periods. It is seldom felt to move, till after the ascent, of
the ntems, out of the pelvis. Does this arise, from any
diange of the phenomena of life, at that time, in the child
itself, or from tbe muscular power becoming stronger, or from
the uterus now being in a situation, where, there being more
sensibility, the motion is better felt ? All of these probably con-
tribute to the sensation, which becomes stronger, as the child
acquires more vigour, and, as the relative proportion oi liquor
amnii decreases. This foetal motion, however, is not to be
confounded with tbe sensation, sometimes felt by the mother,
from the uterus rising out of the pelvis, and which precedes
the feeling of fluttering. If this elevation shall take place
suddenly, the sensation accompanying it, is pretty strong,
and the woman, at the time, often feels sick or faint, and in
irritable habits, even an hysterical fit may attend it. From
Ae time when this is felt, women are said to have quickened,
and they afterwards eicpect to be conscious of the motion of
the child. This motion in many, soon increases, and becomes
yery vigorous ; in others, it is languid during the whole of
pvegnancy ; and in a few cases scarcely any motion has been
felt, although the child at birth be large and lively. Tbe
morning sickness, and many of the sympathetic effects of
pr^:nancy, generaUy abate after this, and the health improves
mamg the two last qitarters. ^

244

Many women suppose, that by examining the blood drawn
from the reins, their pregnancy may be ascertained. Soon
after impregnation, the blood, in most cases, though not in-
variably, becomes sizy, but, it differs from that of a person
affected with inflammation. In the latter case, the surmce of
the crassamentum is dense, firm, and of a buff colour, and
more or less depressed in the centre. But, in pregnancy, the
surface is not depressed, the coagulum b of a softer texture,
of a yellow, and more oily appearance. It is not possible,
however, to determine positively, from inspecting the blood ;
for, a pregnant woman may have some local disease, giving
the blood a truly inflammatory appearance ; and, on the other
hand, it is possible for the suppression of the menses, accom-
panied with a febrile state, to give the blood, the appearance,
which it has in pregnancy. The chemical qualities have been
said to be changed.

The urine, if allowed to stand for a day, generally deposits
a caseous sediment, easily detected, if the fluid be not dark or
turbid, furnishing other precipitates.

Examination of the uterus itself, is a more certain mode of
ascertaining pregnancy. About the second month of gesta-
tion, the uterus may be felt prolapsing, lower in the vagina
than formerly; its mouth b not direct^ so much forward as
before impregnation ; and the cervix is felt to be thicker, or
increased in circumference. The os uteri has been affirmed
to close, so that the finger could not be introduced even so
far as in the unimpregnated state. The cervix is undoubtedly
shut up by jelly, but there is no diminution of the outward
chink, or opening between the lips, to such an extent as can
enable us to form a judgment. The aperture is sometimes a
little more circular. When raised by the finger, the womb,
is found to be heavier, or more resisting. Some have ad-
vised, that the os uteri should be pressed upward and forward,
so as to retrovert the womb, in order that its body may be
felt, but this is not expedient. Examination, at this period,
is liable to uncertainty, because the uterus of one woman, is,
naturally, different in magnitude, from that of another. But,
in the third month, we can arrive at a surer conclusion, the
womb being then felt, decidedly, to be heavier, so that it may
be, in a manner, balanced on the finger, during which, some-
thinjg can be felt to be floating within the uterus. In the
beginning of the fifth month, it is found to be higher than
when ummpregnated ; and a kind of fluctuation may be per-
ceived, and by placing the hand on the lower part of the belly,

245

so as to press on the fimdas of the womb, it can be made to give
more resistance to the finger, applied per yaginam, and may,
by it, be in some degree, made to roll. After quickening, if
we pat with the finger on the cerviK uteri, we can generally
make the child strike gently, so as to be felt. About this
time, and still more distinctly afterwards, we can, if the ab-
dominal muscles be relaxed, feel the uterus, extending up
from the symphysis pubis, and, in proportion as pregnancy
adyances, can, more readily, distinguish the members of the
child, and feel its jerks or motions. Examination, per yagi-
nam, informs us of those changes of the ceryix and os uteri,
which were noticed in a former chapter.

A simple suppression of the menses, is apt to be mistaken
for pregnancy, nor, is it easy to distinguish, for some time,
between them ; but the doubt is soon cleared up by the state
of the womb, and the want of motion at the proper period.
In pregnancy, the uterus early descends, somewhat, in the
pelyis, and its general bulk and weight are increased, whilst
the OS and ceryix, are, by the third month, somewhat altered.
Simple inflation of the bowels, with suppression of the
menses, cannot mislead, if the state of the uterus be attended
to, and, at an adyanced period, the lower belly is found soft
or pufiy.

Not unfrequently, a diseased oyarium makes the patient
suppose herself pregnant, eyen although she should haye the
counter eyidence of menstruation. For, the abdomen is large,
and the oyarium is felt through the parietes, sometimes
pretty high, like the uterus, or like a prominent part of a
child. The tumour is acted on, so far, by the aorta as to
occasion, at times, a sense of pulsation, which is mistaken for
the motion of the child. Per yaginam, the uterus is some-
times felt to be higher or lower than usual, if the oyarium
act on it. No child, howeyer, can be felt, nor any distinct
expansion of the lower part of the uterus, whilst, exter-
nally, the round and circumscribed tumour of the oyarimn
maybe distinguished.

The stethoscope has been used for ascertaining the existence
of pregnancy, and the life of the child.* If, after the uterus
has ascended out of the peWis, it be applied oyer its reffion,
a particular murmur, or bruit du soufiSet, synchronous with the
piuse of the mother is perceiyed. This has been attributed

• Sc0 » pmr by Dr. KenDedf, in Dublin Hon. Report, t. fiSI, and tha
writinfs of Hamilton, Montgomerie, Velpeao, Itc. Atagendie nyt, tha aoitnd ia
produced bj tha impulae on the thorax.

246

by ^K>iiie to the circidatioa in die plarenlHj aad mwffl kfiik
placeixtaire ; by others, to the utoro-flaoeatary circulatioB, or
to that of the uterus itself^ or to the current in the aorta or
iliac arteries. This souiul has been heard act only afiber the
placenta had been expelled, but also when the uteros had
been enlarged by tumour.

Another sound, the bruit du coeur , or that of the foetal
heart, is heard about the end of the fifth month, and moie
distinctly afterwards. Unlike the other, it is not heard always
in the same place, but Tarying with the posture of the child.
The pulsating sound, or ticking, is so frequent, as 120, some-
times 140 in the minute, and when opportunities hare
occurred, of feeling the cord before labour bi^aa, the pulsa-
tion then has been the same. But in a great many cases»
we find the pulsation not to exceed, perhaps not to extend to,
€0 in the minute. This is to be considered as dq>eadent on
that change which labour produces on the child, for the pul»
sation is slowest during a pain, and then may be aooelerated,
especially if much liquor amnii be retaiaed, and the child
moye. It is not, howeyer, preyed that pressure is the sole
cause of this diminution. If the child be nearly stiU-bomt
we find the pulsation yery slow, until breathing be eatabiaahed.

CHAP. XX.
Of the Diseases <^ Pregnant Women.

SECTION FIRST.

Prbgnanct, produces an efiect on Ihe general system,
mariced, often, by a degree of ferer, and, always, by an altered
state of the blood. This state, is the consequence of local
increased action, induced on the same principle as when aa
organ is inflamed. There would appear to be, likewise, a
tendency to the formation of nuNre blood than fonnerly, and
the aeryous system is often rendered more irritable and aen-
sible. The grayid uterus, also, has an effect, by sympathy,
on other organs or yisoera, and, likewise, on some of theB,
mediaaically, by its bulk and pressure.

The effect of irritation, or changes in the condition, of the
extremities of the abdominal neryes, on the sensorivm com-
mune, and whole neryous system, as well as on the arterial

t43

meiaaa, « so hitf fvoved, Aat it » nxyt neeeBMory to ^aatet^
lannkel;^ hero nto tiutt wAjecL It is, kowever, of greact
importMice, tlnife it Bfaould be borae in mnd, in our pa&olo*
f^eai FeaMoing, altboogh, we be not yefc prmared to explain,
or wbat is imrae, to detail, many mets of practical value.
The origin and daatribatian of the par vaffoxn, and sympatiietic
aerves, might lead to tiie expectation, of very important and
intricate ajvpatUes. Temporary affection, of certain por--
tiona of tliKB intestinal canal, produces pain in one eye or side
af the head; when anotSier portion is raected, or perhaps the
flame pcxrtkm, in adtfereat degree, the opposite side su£Fers,
or Ae whole finrehead is pained, or the upper part of the
spinal' marrcnr sympadtizei, and a secondary, but moat marked,
tRUD of symptoms is thereby produced, cough, feeling of
soffocation, nmnbness, or spasms. Another affection of the
bowels, gives rise to oonvukdve a^tation of the muscles;
whilst, once more, we find irritation, particularly of the small
intestines, sometimes occasions drowsiness, or a feeling of
fiihiess and giddiness in the head, or eyen a temporary insen-
sibility, or paralysds. Hence, some varieties of apoplexy and
paby, are, orisinally, dependent on affection of the bowels ;
and, hence, &e distressing, and, in many cases, injurious
efieets, produced by inefficient doses of laxatives, which irri-
tate, partially, without exciting briskly and universally, or, in
speedy succession, the whole tract of the intestine. Henep^
the impropriety of employing certain mineral waters, in
cephalic affiscticms, more especially, if not aided by exercise,
or an additionid laxative to excite briskly. Hence, the origin
of sick headach, of many hysterical and ancMualous affections,
of chorea, and disorders of the sanguiferous system; and
faenee, the mast valuable, but too often disregarded fact, that
many exmtements, arising clearly from the bowels, or state of
tibe abdomnuil nerves, are, from this indirect influence on the
vascular system, best reheved by resorting to the lancet,
before acting en tiie original seat of the disease by purgatives,
which should be too slow in their operation. The uterus
may dnredfy iniftaence the system, producing much irritation,
aM many disoi^dered actions, and so doubtless may the stomach
and liv^er ; but I qaestion whether these different organs, do
not more frequently cause sympathetic disorders, through the
medium of tiie intestines. Even, in many cases of dyspepsia,
perhaps in most, not dependent on organic disease, the com-
plaint is referrible to tiie intestines; increased secretion of
Dile, acidity in ike stomach, sickness and headach, depending

248

more on the state of the bowels, than on primary disorders of
the stomach. Hence, dyspeptic patients are sure to suffer,
if they take much liqmd, or soups, or acidifiable diet, or
aliment which passes easily out of the stomach, and is pos*
sessed of a gentle laxative quality ; for, thereby, the intestines
are excited to a hurtful, but not to a sufficient degree ; they
are irritated, but not stimulated to efficient action. A diet
too light is, therefore, equally bad, in such cases, with one
which is heavy and indigestible ; and that diet is best, which
neither passes too readily, through the changes to be pro*
duced on it, in the stomach, nor resists too long, nor runs
rapidly into acetous fermentation. Every invalid must, to a
certain degree, regulate his diet by experience ; but, when an
acute attack is brought on, he shall find it still a desideratum,
to obtain a medicine which can, rapidly and briskly, excite
the intestinal action, without occasioning a long interval of
sickness, or being succeeded by debility of the canaL

Effects, both powerful and varied, are often produced by
the uterus in a state of gravidity. These, may be divided^
into those arising from sympathy between the uterus and
other abdominal viscera, and confined to them; into those
exhibited in more remote parts, whether occasioned by sym-
pathy directly with the uterus, or indirectly through the
medium of the sympathizing intestines ; and into those arising
more purely from mechanical pressure.

When we consider the great connexion, which subsists
between the uterus, and other abdominal viscera, by means
both of the sympathetic and spinal nerves, as well as by that
more mysterious sympathy, which exists between one organ
and another, beyond what can be explained by mere con-
nexion of nerves, we need not be surprised, at the powerful
effect, often produced by pr^^nancy, on the different organs
of digestion, particularly on the stomach and duodenum.
These have, in general language, been called dyspeptic, but a
thousand symptoms, many of a very opposite character, have
been included under the name of dyspepsia or indigestion*
It is not my intention, to enter farther into this subject, than
to observe, that nothing can be more unfounded than the
doctrine, that an imperfect and disordered performance of a
function, necessarily, implies a state of debility, far less of
torpor, in the organ affected. There may be a defective
neitormance, from simple weakness, but this does not often
last long ; and in a much greater number of instancy, the
derangementp from the very first, is connected with, if not

249

immediately dependent on, a state either of irritation or ex-
citement. Without discussing the chain of sympathies, which
may lead to the production of particular symptoms, much less,
investigating the causes and varieties of dyspepsia, I would,
from this view, point out the relief which is procured to the
stomachic affection, as well as to the other disorders incident
to pregnancy, by the use of the lancet, and of a soothing, in
preference to a stimulating regimen.

The effects of pregnancy vary much, both in degree, and
in the nature and combination oi the symptoms, according to
the constitution of the woman, and the natural or acquired
irritability and sensibility of different organs. In a few cases,
a very salutary change, is produced on the whole system, so>
that the person enjoys better health, during pregnancy, than
at other times. But in most instances, troublesome or incon*
venient symptoms are excited, which are called the diseases
of pregnancy, and which, in some women, proceed so far, aa
not only to deprive them of all enjoyment and comfort, but
even to produce considerable fear of their safety.

As these proceed from the state of the uterus, it follows,,
that when they exist, in a moderate degree, they neither
admit of, nor require any attempts to cure them, for their
removal implies a stoppage of the action of gestation, which
is their cause. But, when any of the effects, are carried to a^
troublesome extent then we are applied to, and may palliate,
though we camiot take them away. This we do, by lessening-
plethora, or local irritation, or excitement, of the origin of the
nerves, if necessary, by blood-letting, and allaying the in-
creased irritability of the system, by the regular use of laxa*
tives, which remove that particular state of the bowels, which
is so apt to cause restlessness and nervous irritation. If these-
are not altogether successful, the camphorated julap, or musk,
are useful medicines.* Besides this general plan, we must
diminish the febrile state of the system, where such exists, hy
regulation of the diet, and suitable remedies. Individual
symptoms must be treated on general principles.

There is a great diversity, both in the effects of pregnancy,^
and, also, in the period at which these manifest themselves,.
for, whilst some begin to suffer, very early, from the irritatioi»

* Petit, and many after him, haye been of opinion, that opiam b hurtful dur«>
in^ gestation ; and tbere can be no doubt that it generally Is so, when giren fre-
qnentlj. It is detrimental, both by its effects upon the stomach and bowels and
on the system at large. In severe spasms, or great irritation, it may be necessary^
hot it never ought to be often repeated, as it ultimately increases the Irritabilityi
and injnm th« bowels^ as it would do in chorea.

of the utams^ ad arenmoli relieved from dw eflbcts thereof^
after the clnld qmckeas, others, fed Ixttib nicoiipemenoe tiS
towards the end of pregnancy, or the last qnsrtei^ when tli0
womb is greatly enlarged, and the abdominai Tiaoera dia-
turbed.

In the dietetic part of our trestment, we must bear in mind,
tiiat we ought neither to admit of sn(^ reghnen, as shail fiU
the vessels with too mudi fluid, nor throw the organs of
digestion into diaarder. Much liquid, eren of the mildest
mature, ought to be avoided, and the aliment most neither be
too rich nor too acescent. Rerard, however, must be had, in
our directions, to the state of the patient, and the risks to Ire
apprehended, on the one hand, from plethora, and on the
other, from debiiihr. Whatever fruit agrees wilji the patient,
it may be freely allowed, and the same may be said of well
boiled vegetables, but when these occasion acid or flatulence,
they must be refrained from. It is of much importance, to
preserve the bowels in a correct and active state. The'
exercise to be taken, or permitted, must be regulated by the
probable chance of abortion resulting.

SECTION SECOND.

In many cases, the pulse becomes somewhat quicker, soon
after impregnation, and tiie heat of the skin is, at the same
time, a littie increased, especially in the evenings. In the
latter months of pregnancy the febrile symptoms in some
instances are extremely troublesome ; the pulse is permanent-
ly frequent, but in the evenings it is more accelerated, whibt
the dcin becomes hot, and tiie woman restless; she cannot
sleep, but tosses about till daybreak, when she procures
short uxu*efreshing dumber, occasionally accompanied with a
partial perspiration. In the morning, the febnle symptoms
are found to have subsided, but in the afternoon they return,
and the following night is spent alike uncomfortably.

This state is attended with more emaciation, and greater
sharpness of features, than is met with in pregnancy, under
different drcnmstances ; but it is wondeirul how well the
strength is kept up, in spite of the want of rest,, and of Ae
uneasiness which is proceed, from this disease being, some-
times, conjoined with intolerable heat, about the parts of
generation.

Without Altering mto the doctrine of fever, I would mere^
ly remark, that the existence of this state, must be intimately
connected with an excited conditioe, of those portions of the

iwHi«c^BMi^y^
ray a UtM

251

MTTOtts fljrstem, wUcb, diiefly^ niiheiice die actim of iktt
heart, and tlie evolution of animal heat*

In slight degrees of this febrile state, all tliat is

ia aedukmsly to keep Ae hovels open, md take away

bloody in ofder to diminish the excitement of the nervoas

system. But wfa^i it becomes urgent, towards the last

months of gestation, we are under the necessity of taking

away blood more frequently, but not in great quantity at a

time ; and always, in dmng so, hayiug regard to the oonstitift*

tion of the patient. The saline julap is of considerabb

serriee, by {voducing a gentle moisture, but a copious per*

spiration is neither necessary nor usefiil. The julap may

either be given in repeated doses, through the day, or merdy

one or two doses in die morning, cr early part of the nigh^

according to circumstances. The bowels are to be kept open,

by a mild laxative, such as the aloetic pill, <Hr rhubarb and

magnesia. The sulphuric acid is a very good internal medi-

cine. The restlessness is best allayed by sleeping with few

bed clothes ; and sometimes great relief is obtained, by dipping

4he hands in water, or grasping a wet sponge. Opiates very

seldom give relief, and ought not to be pushed mr, as they

make the patient more uncomfortable, and are supposed even

to injure the child ; at all events, if the occasional exhibition,

€01 any onergency, of a moderate dose of c^ium or hyoscyaF-

mns, fail to procure comfort^le sleep, no benefit is to be

expected from increasing the quantity. Frequently, nothii^

does much good, the state continuing until the woman hs

delivered. I need scarcely add, that we must take care not

to confound this, which may be called the fever of pregnancy,

with that arising from local disease, as for instance in the

kmgs or liver.

There is a species of fever, which may affect women
about the middle of pregnancy, and makes its attack
suddenly, like a regular paroxysm of ague. It soon puts
en an appearance rather of hectic, combined with hysterical
symptoms. The head is generally at first pained, or the
patient comf^ins of much noise within it, sleeps little, has
a loathing at food, with a furred dry tongue, and a conskler*
able thirst, whilst the bowds are coostipated. Sometimes
she talks incoherently, or moans mncfa during b^ slumber,
and has frightful dreams : occasionally, a cough, or distress-
ing vomiting supervenes. This disease is very obstinate, and
often ends in abortion, a&er which, if die patient do not sink
speedily, under the effects of the process, she begins to r^

25S

coyer, but remuna long in a cblorotic statOy which, if not
removed, may terminate in phthisis. This disease appears
to originate from the bowels, and beara great analogy to the
infantile remitting fever. It is usually, preceded by costive-
ness, and is sometimes, apparently, excited by irregularities
in diet. We ought, on the first attack of the cold fit, to check
it by warm diluents, with the saline julap. If the proper
opportunity be lost, or these means fail, we must lessen irrita-
tion, by detracting some blood, open the bowels freely, and
afterwards prevent feculent accumulation, keep the surface
moist, and palliate troublesome symptoms. If the tongue be
early loaded, and the patient be sick or squeamish, a very
gentle emetic, such as a cupful of chamomile tea, which may
only operate once, and that easily, will be proper in the com-
mencement. The strength is to be supported. In a state
of convalescence, gentle exercise and pure air are useful, but
every exertion must be avoided.

SECTION THIRD.

Vomiting, is a very frequent effect of pregnancy, and,
occasionally, begins almost immediately auer conception.
Generally, it takes place only in the mominff, immediately
after getting up, and hence it has been called the morning
sickness; but, in a few instances, it does not come on till
the afternoon. It usually continues until the period of
quickening, after which it decreases or goes off, but some-
times it remains during the whole of gestation. Some
women do not vomit, and have very little, if any, sickness ;
others, begin, after the fourth month, to feel an irritation
about the stomach and other viscera ; and some remiun fi*ee
from inconvenience till the conclusion of pregnancy, when
the distention of the womb affects the stomach. The fluid
thrown up, is generally ghury or phlegm, and the mouth,
fills with water, previous to vomiting, but it the vomiting be
severe or repeated, bilious fluid is ejected. Generally, there
is no occasion to prescribe any remedies. Puzos, and others,
even considered vomiting as salutary; but in some cases, it
goes to a very great length, recurring whenever the woman
eats, or sometimes even when she abstains from eating, and
continues for days or even weeks, so obstinate, that she is in
danger of miscarrying, or of suffering from want of food.
Although emetics be apt to cause abortion, yet this s^pa-
thetic vomitinff seldom does so, unless it be long continued*
In this case, ^rtion does take place, and most fortunately^

253

as otherwise the woman would die exhausted. I have never
known, howerer, vomiting, purely dependent on preg-
nancy, end fatally. In some instances, toe vomiting ceases
whenever the ovum perishes; in others, not tm it be
entirely excluded. It is a general rule, in severe cases, to
take away, early, a small quantity of blood, a quantity pro-
portioned to the vigour and fulness of the habit, and state of
the pulse. Of the utility of this practice, the general testi-
mony of practitioners, and my own observation, fully convince
me. It does good, by relieving that state, of the origin of
the eighth pair of nerves, which occasions the irritabuity of
the stomach, just as it would abate vomiting, in other, more
formidable, cerebral affections. It also acts on the sympa^-
thetic nerve, the cceliac plexus of which, sympathizes with the
uterine. Narcotic substances, such as opium, have been tried
internally, either without blood-letting or subsequent to it,
but uniformly without permanent, and, rarely, even with tem-

C>rary advantage. In a few instances, a cloth wet with
udanum, applied to the pit of the stomach, has done good.
The greatest attention, must be paid to the bowels, and most
marked benefit, is often derived, from a gentle dose of Epsom
or Cheltenham salts. The severity of the vomiting, may
also be greatly mitigated, by effervescing draughts, or soda
water, the last of which, if it do not check the vomiting, ren-
ders it much easier. Even cold water, has been employed,
with advantage. A light bitter infusion, as that of chamo-
mile, or lemonade, is sometimes of service. Obstinate vomit-
ing, especially, if accompanied with pain, or tension in the
epigastric region, may be relieved by the application of
leeches to that part. 1 have so often found advantage, from
this remedy, in harassing vomiting, that I strongly advise it*
If these means fail, in procuring speedy relief, it is necessary
to refridn for a time, from eating, and have recourse to
nourishing clysters, or to give, only, a spoonful of milk, soup,
&c., at a time. Sometimes one kmd of food is kept, whilst
another is rejected. When the vomiting is bilious, and accom-
panied with pain in the right side and shoulder, cough, and
other symptoms of hepatitis, blood should be taken, if the
symptoms be acute ; if not, a small issue, by caustic, should
be immediately formed on the side, and a very gentle course
of mercury given, with circumspection, for, if the medicine be
given freely, it produces much debility, or abortion, and
sometimes accelerates the fate of the patient.

In very obstinate vomiting, it has been proposed to induce

354

preottture labour, in order to presenre the patieiit. I kaev
one case where this was twice done. In a subsequent preg*
nanc J the patient died, and a gall stone was foond impacted
an the duct.

When Tomiting is troablesofne, in the conclosion of preg*
nancy, it is proper to detract hbod, and confine the person
to bed« Cloths dipped in laudanum, should be apptied to
the pit of the stomach, and a grain of solid opium may be
given internally ; but if this do not succeed, it is not proper
ta gire larger and repeated doses. Gentle laxatiyes must be
employed.

Vomiting may also come on, from a state of the stomach,
i^proaching to inflammation. In this case, it is obstinate,
and nothing can be long retted* The substance Tomited,
is either green or blackish, according to the extent and
duration of the disease, and there is tenderness of the
epigastrium, with great depression of strength. The former
or hepatic disease is dangerous, but this is much more so.
Leeches, followed by blisters applied to the region of the
stomach, and opiates, with small quantities of nuld nourish-
Btoit, or nutritive glysters, constitute the treatment, unless
we have seen the case so early, as to be able to use the lancet*
It is too often fatal.

Obstinate vomiting, has also appeared to proceed, from a
morbid condition of the uterus, which, after death, has been
found slightly inflamed, or even pus has been found, between
the surface of the uterus and membranes, although, during
life, no pain was felt in the uterine region. The parietes
are soft, the uterus flaccid, with an exudation of fibrin m some
places between the uterus and decidua. The stomach ia
sound, and seldom has been pained. Two cases are related
by M. Dance, where the vomiting began with pregnancy, and
proved fatal at three or three and a half months.* This calls
for minute examination in protracted vomiting, and points out
in all doubtful cases, the propriety of the soothing and gentle
de^etory, rather than stimulating treatment.

Dyspepsia is to be treated more $olito by mild laxative
bitters, along with soda ; the occasional use (h a blue piU, or
if need be, the application of a very small blister to the
epigastrium. The diet rather solid tlum liquid*

• Aniiivn Cuatimkii Jalii, I6t7.

2&&

SECTION FOURTH.

HeaxtbuTB, aftem occurs very -early after oonceptioii, bui
aometimeB Bot tiU aftear the fourth saoiiih. This is a
couqilauit, sg very common, and so generally mitigated hy
afafierbente^ such as ma^eaia, fiod% or chalk, that we ara
seldom eonsulted respecting it* But, when it becomes very
severe and intractable, it is requisite to try the most powerfm
of these means, such as calcined magnesia, combined with
pure ammonia. When these &il, liquor potassse or the chalk
mixture, with a large proportion of mucilage, may give relief.
Laxatives are alwi^ indispensable. In obstmate cases, veni-
section is usefuL Emetics have been proposed by Dr* Des-
man. They are only allowable, where there is a constairt
screatus, of disagreeable phlegm. In every severe case, the
diet must be carefully attended to. A sensation of heat or
burning, scmietimes depends on the mere state of the nerves
of sensation. It is not relieved by antacids, nor is there any
proof of acid being present. It is more permanent, and
obstmate, than heartbium from acid. It is most relieved by
opiiun, in moderate doses, and purgatives, and the application
of a blister, to the back of the neck, or between the shoulders*
We must not confound these affections, with chronic inflamma-
tion of the mucous coat of the stomach and gullet, in wldch
the throat ultimately becomes aphthous. Leeches to the pit
«f the stomach, followed by a small blister, mild laxatives,
bland liquid, and oecaaonally small doses of bine pill, cour
stitute the practice.

Pyrosis is to be relieved chiefly by laxatives, such as the
aloetic pUl, with extract of colocynth, some slight bitter, or
rhubarb and magnesia. If these means fail, antispasmodics
or opium may be useful, and rubbing the cervical region,
with anod^me balsam, or apjdying leeclies to the back of the
neck, for it often depends, on a complicated affection, of the
eighth and the fifth pair of nerves.

SECTION FIFTH.

WomeK dmnng gestation, are subject to many bizarrerie^
in their appetite, and oft^i have a deskte to eat things, they
did mat fivmerly like. This desire, is common, in cases of
abdominal imtatieB, as we see in those, who are afflicted
with wonos, or ha^ve iaidnrated or morbid fieces in the iotes*
Haaa^ These Isnghigs, it has been thought dangerooa ti»
dnf ; fiir, aa it ms sappoeed, liat tibey depeftded upon same

256

peculiar state of the child, affecting the mother, it was imag*
med, that, if this were not removed, the infant should sustain
an injury, or might even hear the mark of the thing longed
for. Into this doctrine, it is now unnecessary to enter ; and
it will he sufficient to add, that when the desire is placed
upon any article of diet, it may he safely gratified, and,
indeed, generally, the inclination leads to some light, and
cooling, regimen.

SECTION SIXTH.

Spasm of the stomach, or duodenum, may often be attri-
buted to some irregularity of diet, to the action of cold,
or the influence of the mind. It is necessary to interfere,
promptljr, not only because the pain is seyere, but, also,
oecause it may excite abortion, or tdll the child. A full dose
of laudanum, with ether, followed immediately by a saline
clyster, is almost always successful; but when the attacks
are renewed, then, we must endeavour to prevent them by
tonics, such as colomba, oxyde of bismuth, or preparations of
iron. It is, at the same time essential, that the bowels be
kept open, and for this purpose, asafoetida, combined with
aloes and colocynth, is well adapted. Blood-letting is of
service, if the attack be prolonged.

When spasm of the stomach, takes place in the end of
pregnancy, or about the commencement of parturition, with
a sense of fulness or uneasiness in the head, it is necessary
to detract blood, lest the patient be seized with convulsions,
which are particularly apt to take place, if there be any spot,
in the spine, tender on pressure. If so, a blister should be
applied to it. Bleeding is likewise proper, when the pain is
accompanied, with tenderness about tne epigastric re^on,
heat of the skin, full pulse, and ruddy face. When pain pro-
ceeds from the passage of a biliary calculus, it is to be treated
mare solito.

SECTION SEVENTH.

Costiveness, is a general attendant on pregnancy, partly
owing to the pressure of the uterus on the rectum, and partly
owing to the mcreased activity of the womb, producing a slug-
gish motion of the bowels. We must not, however, neglect
this state, because it naturally attends gestation, for it may
occasion many and serious evils. It certainly increases the
irritability of the system, as well as some of the stomachic
ailments ; and is apt to cause irritation of the bowels, which

SS7

may either excite premature labour, or give rbe to mucli
inconvenienoe after delivery, or, eren, occasion convulsions
during labour. In considering the effects of costiveness, not
only in pregnancy, but in other circumstances, it will be well
to attend to the effect on the rectum alone, independently of
other consequences, and to recollect the branches, both of the
sympathetic ganglia and sacral nerves, distributed to that gut
and the remote influence thereby exercised.

Magnesia is a very common remedy, because it, at the
flame time, relieves heartburn ; but, wnen it fails, or is not
required for curing acidity in the stomach, the common alo-
etic pill, the compound rhubarb pill, compound extract of
xx)locyndi, or, a piU composed of equaJ parts of carefully pre*

Sared extract of aloes, and that of bquorice, with or without a
ttle oil of peppermint or of cassia, may be employed. Castor
oil is also given, either alone, or made into an emulsion with
mucilage. If a clyster of warm water, be regularly given in
4;he morning, much less medicine will be required. At least
a pint should be thrown up, and it should not be retained
above a few minutes, as it acts on a different principle from
the saline clyster. The mere emptying, of the rectum alone,
has a most beneficial effect on tne system, and must not be
^disregarded, even, if the superior part of the canal, did its
.duty.

It sometimes happens, that indurated faeces, are accumu*
lated in the rectum or colon, producing considerable irritation,
eren of the whole system. This causes, not only pain of the
bowels, but, also, an increased secretion of tne intestinal
mucus, which is passed either alone, or with blood, together
with pieces of hard faeces. This state, like dysentery, is often
accompanied with great tenesmus ; but it may be readily dis-
tinguished, by examining per vaginam, for, the rectum is
-found to be filled with faeces, and sometimes a diverticulum is
.formed, or considerable pressure made, on the top of the
vagina. Our first object ought to be, to remove the uritating
cause, which might ultimately produce abortion. Clysters
are of great efficacy, because they soften the feeces, and assist
in empb^ng, that part of the intestine, which is most distend-
ed. These are to be, at first, of a very mild nature, and
jnust be frequently repeated. It may even be requisite, to
break down the feculent mass, with the shank of a spoon, or
jBcoop. Aflter the rectum is emptied, laxatives, such as castor
oil, or small doses of sulphate of magnesia must be given, to
.evacuate the colon; and when the faeces ^ar^ brought into .tb«

258

f^dtoxa^ clysters nrost be again eiuplvyuil* Afler file bowidi
are emptied, liyoscyamuB sbeuld be ghren, to allay the vriti^
tion ; or if this be not sufficient, and the pain, and aeeretion
sf macuB, with tenessras, stiH oontinne, an <nnato dyater
must be administered, but, neict day, it is to be followed by a
mild laxative. Should there be fever, or oonsideraUe pain in
the abdomen, blood-letting will be neeessaiy. If Ibis coative
state be neglected, near the time of delivery, liie labour m
liften protracted, and after delivery, masses of indnrated
fteces, come down from the colon, attended iriili consideniM^
pain, and frequency of pulse, or, sometimes fctal peritonnrf
inflammation. When there is much irritatien wMi-seoBibifity,
upon pressing on the abdomen, eitbar hetare or after ddiv^^
ary, it will l^ proper to detract blood, at Ibe aame lime that
lw use the nsmedies alrea^ pointed out.

SECTION EIGHTH.

The bowels, instead of beii^ bound, may be Tory tipen ; or
aostiveness and diatrhoea, may alternate with eac^ oAer.
The diarrhosa is of two kinds ; a simple increase df tlie
peristaltic motion, with greater serous secretion; or a
more obstinate disease, depending en deranged action, ff not
texture, of the bowels, in the first lund, which seems to
proceed from the uterine sympathy, the discharge is not alter*
ed from the natural state, esoept m being thinner ; the appe-*
lite is pretty good, and the tongue clean, or only sfightiy
white. This is not to be checked, unless it go to a consicU
arable extent, or eontinue long, or the patient be weakened
bv it, or be previously of a debilitated habit. Anodyne
tipsters, or flie ooufectio catechu, or half-grain opium pills,
will then be of service. Should the puke be frequent, and
ttny degree of heal, or tension, be felt in the abdomen, vene*-
ieetion will be usdul. in the second kind, the function of
Ae digestive organs is more injured, either directly or indi*
Yeody, the appetite is lost or diminicbed, the tongue is fonl,
and the patient has a bitter or bad taste, and oecasiomtDyv
tamits ilUtasted'or bilious matter ; thebreaih is o£fennve, and^
«rflen, the head aefaes. The stools are verr oiEansive, and
generally dark-coloured, b this case, small doses of rhubarb
(^ve great relief, and one grain of ipecacuanha, may oec»-
»ioa>ffly be added, to eadi dose of f4rabarb. A fight bitter
faftaaoa, ib abo a aaefol remedy. Attentbn must be pmd te
"^^> ^i<* » 1» be light, and the food taken in snidi
i|aiiMDat»4faMb <3oBHilenMe beneBl, irderneVftem

259

i whid geaera% abates the siekneea. When the tongue
becomes eleaner, and the stools nore natural, anodyne clysters
he adaHoniatered. Ttn all eases of continued 'dianrheea^ it
naeful to kaye the surface kept warm wiA flamnel ; and
aanwtivies a flannel roUer, hoaad gently nrand the abdomen^
gires great rdief. Pni^ng, from chitnic iniammatien or
ulceration of the mocons coat of the intestine is very danger-
oas and obstinate* It resembles dysentery ; it sdidom proreo
fiilal before, hut often after, (felirery. If we see the patient
esffly, mild lazatiyes should be giren to remote any hardened
ftsees which may be in the bowels. If there be miieh pain,
leeches should be applied* Afterward, anodyne clysters, or pills
of8oftopinni,mustbewed. Blisters have sometimes been ns^iL

SECTION NINTH.

Pregnant womco are very subject to piles. This may be,
portly, owing to <he pressure of the womb, upon die vessels of
the pebris, but is chiefly to be attributed, to a sluggish state
of the intestinal canal, oommunicatiag a similar torpor to the
haemorrhoidal veuis. As liiis state, is attended wit^ costive-
ness, the disease has been oonsidered as dependent on the
ssechanical action of the fssees ; but, whatever truth mav be
in this opinion, in some cases, yet, generally, it is witboot
foundation ; and it is no unusual thing for those who are sub*
ject to piles, to be able to foretel an attack, by the appearance:
of peculiar symptoms, indicating diminished action of the
intestinal canal. The treatment of this disease is twofold.
We are to remote the cause, by such means as give a brisker
action to the bowels, such as bitters and laxa^ivies ; which last)
are ako of great service, by removing the irritation of the
flBsees from & rectum, and* rendering them softer, by which
dbe espula&on gives less pain. For this purpose, ereapa of
tartar alone, or oembined with sulphur, has been generally
en^ployed; but we may, with equal advantage, give small doses
of eastor oil. The effect should never be violent, and much
beeeflt, may be demed, from the daily use of a clyster of
tepid water, cautiously administered, so ae not to irritate the
parts with the pipe. Besides removang the cause, we soust
likewise lessen the effect, by such local means, as abate irrita*
ftion end sen^bility. When the pajn» inflammation, tmd ewellr
ng^ are great, it is ef service to detract blood, topically, by
the application of leeches, or, especially if there be consider-
fthfe fever, blood-letting may be necessary, as in other cases
of local inflanunfttion. The di^t should be spare ; all stimur

360

lants and cordials must be avoided ; cooliog and anodyne ap«
plications to the tumour, are also very proper, sucn as an
ointment, containing a small quantity of tne acetate of lead,
or a weak solution of the acetate of lead, in rose water,
pr a mixture of the acetum lithargyri and cream, or cocoa
nut oil. Sometimes, astringents are of service, such as
the gall ointment; or narcotics, such as opium* or bella*
donna. If these means fail, it will be proper to give an ano-
dyne clyster, and apply fomentations, or emollient poultices
to the tumour, but every practitioner can tell, how often,
all topical applications have disappointed him. In some cases,
the tumour becomes slack, and subsides gradually ; in other
instances it bursts, and more or less blood is discharged. If
the haemorrhage be moderate, it gives relief; but, if profuse,
it causes wealmess, and must be restrained, by pressure and
astringents. Great pain, or much haemorrhage, are both apt
to excite abortion, as the former is apt to act, by sympathy,
on the neighbouring parts. Even in the ummpregnated
state, internal piles are apt to produce symptoms, supposed to
arise from the womb or vagina. The rectum-bougie in such
cases is useful, provided it do not give pain.

Extirpation is not warrantable, in pregnancy, unless, the
severity and obstinacy of the symptoms, be more likely, to
produce premature labour, than the temporary pain, and
excitement, from the operation.

SECTION TENTH.

The bladder is often affected by pregnancy. In some in-
stances, like the intestines, it becomes more torpid than
formerly, so that the woman retains her water long, and ex-
pels it with some difficulty, and in considerable quantity at a
time. This state requires great attention, for retroversion
bf the uterus may, at a certain stage of gestation, possibly, be
occasioned. There is not much to be done, by medicin€»B(, in
this case ; for, although soda, and similar remedies, sometimes
give relief, yet, more reliance must be placed, on the reffular
efforts of the patient. Should these be delayed too long,
then, the catheter must be employed.

More frequently, the bladder is rendered unusually irritable,
especially about its neck, and the urethra participates in this
btate. There is also, in many instances, an uneasmess felt,

• Dr. Jobnwii adTliit tlM foUowinir ointntnt to be *ppUad. uid tbm a
muUIm to be laid oYer the tninour. & OL Amy|d. i . OL Suocini ^ m.
Tlnet. Opn. ^ tj. Jl. System, ^» 125.

261

ia the region of the bladder itself. This state, requires a
yery different treatment, from the former, for, here, it is our
object, to aroid every saline medicine, which might render
the urine more stimulating. Relief is to be expected, by
taking away blood, giving small doses of castor oil, and, occa*
sionally, the extract or tincture of hyoscyamus, and encour*
aging the patient to drink mucilaginous fluids, which, although
they do not reach the bladder as mucilwe, yet, afford a bland
addition to the blood, from which the urme is secreted. This
state of the bladder, is sometimes productive of a slight irrita-
tion, about the symphysis of the pubis, rendering the articu*
lation less firm, and more easily separated. In such circum-
stances, when the pubis is tender, blood-letting and rest, are
the two principal remedies.

A very distressing affection, which is often conjoined with

thb state of the bladder and urethra, but which may also take

place without it, is a tender and irritable state of the vulva,

producing great itching about the pudendum, especially

during the night, and generally the urine is felt xery hot.

This vexatious condition, is often alleviated, by blood-letting

and laxatives ; and when the itching is great, a sponge dipped

in cold water, or in cold solution of cerussa acetata, should be

applied, or the parts may be bathed with emulsion of almonds^

having half a grain of muriate of mercury, added to each

ounce, or with a weak solution of nitrate of silver. * If much

fever exist, the saline julap, combined with a little tincture of

opium, is useful.

• Incontinence of urine, is not uncommon in the end of ges-
tation, and is produced by the pressure of the uterus on the*
bladder, by which the urine is forced off, involuntarily, when-
ever the woman coughs or moves quickly ; or at least she
cannot retain much of it, being obliged to void it frequently,
but without strangury. For tms complaint, there is no cure ;
and many consider it as a favourable omen, that the child's
head is resting on the os uteri. When the uterus is very
pendulous, some advantage may be obtained, by supporting
the belly, with a proper bandage, attached to the shoulders^

SECTION ELEVENTH.

Connected with the state of the alimentary canal, is the
jaundice of pregnant women. This disease appears at an
early period, and is preceded bv dyspeptic symptoms, which
^;enerally increase, aher the vellowness comes on. In some
mstancesy the tinge is very slight, and soon disappears. In

262

otker easesp the yeUaw colour, is deep akid lomg t&atiaamai^
aad the derangevient of the rtonaeh and boweb coneideraUo.
Eknetics, and other Tioknt reoiedies, which are somelnnes
iised in the cure of the jaundice, are not aHowable in tUt
isaee ; and, in every inatanee, when young married women an
aeiaed with jaundice, we should be yery oantioiiiB in onr pr^
acripiioBS* Small doees of blue pill, along whh hixaliTes, and
afterwards, some light bitter infusion, are the most proper
remedies, and, generally, the complaint soon goes off. JanB-
jdice may also lake place, in the end of gestation, and in this
case, it proeeeds, most frequently, firom pressure on the gaU
dnct. Sometimes, howeyer, it is dependent on a disease of
the liyer itself, which insiy occur at any period of gestation^
and is marked by the usual symptoms. In this case, tim
danger is y^y great, and ean only be averted, by taking
eantiouB measures, for remoyii^ the hepatic disease.

SECTION TWELFTH.

In some cases, the skin is partially coloored, the moitthf
ioit instaaee, being surrounded with a ydlow or brown circle,
or irregular patches of these colours, iqvpearing on different
parts of the body. This Is an affection, quite independent of
the state of the bile, and seema rather to be connected, with
eertam conditions of the alimentary canal. It goes off after
^delivery, and does not require any peculiar treatment*

SECTION THIRTEENTH.

The thoracic viscera, not unfrequently suffer, during preg-
nsncy. Palpitation of the heart, is a very common affectiont
aad extremely distressbg. It is a disease so weQ known,
ihat it is neecUess here to describe it ; but it may not be ini->

5>roper to observe, that wcMnen themselves, sometimes misrakft
or it, a strong pulsation of the arteries, at the upper part &l
the abdomen. It may make its attack, repeatedly, in the
course of the day ; or only at night, before falling asleep ; er
at the interval of two or three days; aad is very reaiUly
excited, by the slightest agitation of the nund. It is generally
void of danger; but, in delicate women, and in those who
are disposed to abortion, it sometimes occasions that event ;
and, ir long continued, it may excite pulmonic disease, in
those who are predisposed to it Absolute rest, with anti*
apasmodics, are requisite during the paroxysm. Hartshorn,
^ther, and tincture of opium, may be given separately or com*
bined. Eoderic a Castro prescribes a draught of hot wator^

tomes, such as tincture of muriated iron, and of foetids^ muti
ms Takfiaa aoA aeafiatidli, and ruUbing the ^in^ with a^me
irtimubliqg aiabnooatiDiu Fatigua aad axertiai^ must bp
avoided^ aad the nund k^ traaquiL 4f the patient b^
flktiw/riOf the head be paiaecC or the face flushed, it is usefiil
to tdke atiraj a little blood. The hovels are to be caceful]|r
kept apan. The dki must be attended to» for it is ofteR
.yiiodui4d by a diaordeied stomach.

A mara ftmaidaUa species of palpitation is indepead^it cf
the pregnant state, but is iiM^^aaed by it. It proceeds froiiL
organic affection of the heart, detected by the stethoscope.
Mere palpitation, from this cause, dees not prove fatal ; but,
^en oambined, aa ktoo oftsn ia» with dj^aoBa and dropar, it
la most dai^jeroas, and the patient Buiy die undelivered. The
treatment must be eonducted on the uaual principles. OcGty-
akmal Uesding to a small esteat, light diet» laxatives and
dniretifia, ceBstitute the praetice.

A teadeBcy to BervoHs or hysterical diseases, is to be pre^
^amUilt m tbue who are liaUe to them^ by oocasional blood-
iettiBg, titeuseaf laiatLves, aad camphor, <Hr fntids. Qpiatea
ate mdy to be given^ for the immediate lelief of urgent

SECTION FOUSTEENTH.

Synaopa may tuhe pkMM)» at any period of geatatioB^ \m^
ia most frequei^ im the first three months, or about the tima
of madcariag. it afiaa ooeurs, ia &06e who are otherwiaa
Wealthy, hat it alaa may aceur, daily, for some time, in thoaa
who are waakenad» by a loose state of the bowek, altemaUi^
in&L ceatltaaass, or, bgr want of sleep oeeasioned by toothach;
&c Itms^ aaoeeed some Htiie esertion, or speedy motion
ar eaynia to heat; bot it amy also eome on, when thp
paraan la at aadaet rest The paroxjsm is sometimes eaok-
idete^ aad of loag^ dmmtiDa; at <^er times, the patient does
wet loae bar knofwisdgaof what is going on, and aocm recovers^
A recnmbeBt poslmee, the admission of cold air, or applioi^
tion of cold water to tim £soe, the use of volatile salt, aad the
cautious administration of cordials, constitute the practise
during the attack. Should the fit remain long, we must pre-
serve tbe heat of the body, otherwise, a protracted syncope,
may end in daaA. Those who are subject to famting fits,
Bast avmd &tigua, crowded or warm rooms, fasting, quio&
autioBy and agitatiim of the miad« Tonics are usefiilt vkaa

S64

the system is weak, and tbe bowels must be, strictly, attend-
ed to.

There is a species of syncope, that I have, oftener than
once, found to prove fatal, in the early stage of pregnancy,
dependent, I apprehend, on organic affections of the heart,
that yiscus being enlarged, or otherwise diseased, though

perhaps, so slightly, as not, preyiously, to give rise to any
troublesome, far less, any pathognomomc symptoms. Al-
though, I have met with this fatal termination, most frequent*
ly, in the early stage, yet, I have also seen it take place, so
late, as the sixth month of pregnancy.

SECTION FIFTEENTH.

Sudden attacks of dyspncBa, in those who were previously
healthy, are generally to be considered as hysterical, and are
readily removed by antispasmodics. There is, however, a
more obstinate and protracted symptom, not unfrequently
connected with pregnancy, namely, cough. This may come
in paroxysms, which are generally severe, or, it may be almost
constant, in which case, it is short and teasing. Sometimes
a viscid fluid is expectorated, but more frequently, the cough
is dry. During the attack, the head is generally painful, and
the woman complains much of the shaking of her body, esp^
cially of the belly. All practical writers are agreed, with
respect to the hazard of this disease, for it is extremely apt
to induce abortion ; and it is worthy of remark, that after the
child is expelled, the cough often suddenly ceases. But ex-
posure to cold firequently brings it back, and, should there be
a predisposition to phthisis, that disease may be thus excited.
Blood-letting must be early, and sometimes repeatedly em-
ploved, the bowels kept open, and lozenges, contuning opium
or hyoscyamus, must be occasionally us^ to aUay the cough.
A large nurgundy pitch plaster, applied betwixt the shoulders^
is of service, or a small blister, over the junction of the cervi-
cal and dorsal vertebrae, and kept open, for some time, by
savin ointment. This land of issue, also does good, on the
top of the sternum. Should abortion take place, and the
cough continue, tonics, such as myrrh and oxide of zinc^
ought to be administered.

SECTION SIXTEENTH.

^ In some instances, haeimoptysis or haematemesis takes place
in pregnancy, eroedaUy in the last months. Blood-letting is
tiie remedy, chiefly, to be depended on, and, afterwards, pur-

S66

gatWies should be given. Adds and hjoscyamus may then
be employed, to allay irritation, and a blister applied over the
breast or stomach. If these means do not succeed, the patient
dies. Should the haemorrhage take place during labour, or
should pains come on prematurely, and the os uteri dilate, as
sometimes happens, it will be prudent to accelerate the de>
livery.

SECTION SEVENTEENTH.

Headach, is a very alarming symptom, when it is severe,
constant, and accompanied with symptoms of plethora. If
the eye be duU or suffused, and the head giddy, especially
when the patient stoops or lies down, with a sense of heavi-
ness over the eyes, or within the skull, great danger is to be
apprehended, particularly, if she be far advanced in her preg*^
nancy* This is still more the case, if she complain of ring-
ing m the ears, and see flashes of fire, or have indistinct
vision. I am pretty well satisfied, that in most cases, al-
though the head be pained, yet, the spinal cord is the part
originally diseased, and the nead only suffers in a secondary
way. In some instances, there is a fixed pain in one part ot
the back, along with, or preceding the affection of the head.
Tetanic convulsions, or coma, next take place, sometimes,
attended with paleness, sometimes, with turgid redness of the
visage. These diseases are to be prevented, by having im
mediate recourse to blood-letting and purgatives; and the
same remedies are useful, if either one or other of them, have
already taken place. The quantity of blood which is to be
detracted, must be determined, by the severity of the symp-
toms, the habit of the patient, and the effect of the evacua^
tion ; but, generally, moderate evacuation will prevent, whilst
very copious depletion, is requisite to cure, these diseases. I
shall not, at present, enter, more minutely, into the treatment
of convulsions, but only remark, that the first and most essen-
tial thing, to be done, is to detract blood freely from a vein ;
next, the bowels are to be immediately opened by a clyster,
and, then, a purgative is to be administered. U the headach
be^accompamed with oedema, diurectics are to be afterwards
used. If local uneasiness remain, in one part of the back, or
a vertebra be pamful on pressure, and, particularly, if pres-
sure excite spasm, blood should be t£^en from the part, by
leeches or cupping, and afterwards an issue, over it, may be
required.

If the patient be seized with apoplexy, there is seldom any

^Haaxpkwtdok^mfA Hm tkM,^ imiag ike &, ndis
fywn praoticB, I luuie obI j «iiQe ka»ini Aat event trice plaecL
In eclanmBia, on tbe eonbraDjc, if ti»pavoz¥Bni be protnetod^
but particulariy if the attaoLa be iBptut&if and the patient
bave not been anibject to them, befiore, tiime is, freqnenilj, an
effect produced on the uterus ; its moutii tffeoB, and the cshild
may be expelled, if the patient be not, early, cut ofi^ 1^ a
fatal coma. But much depends on the cause, and the imme-
diate connexion of the disease, with the state of the uterus.
Whenever espulsiye eflSects come on, we iBuat conduct the
labour, accoroing to the rules, hereaftBr, to be noticed* But
in no case, are we to endeavour to bring on labour, or force
delivery .t In some instances, pa^r muier succeeds .an ap^
piectic attack, or follows headach and vertigo. TUa does not
commonly go o£^ until delivery have taken place ; but it magr
be prevented from becoming severe, by mild laxatives and
light diet ; and after the woman recovers from her labour, the
disease often abates, or yields to appropriate remedies.

All beadachsy bowever, do not forebode these dismal events^
for, ofieny they proceed from the stomacb, and evidentijr
depend on costiToness, dyspepsia, or nervous irntation. These
are generally periodical, accompanied with a pale visage ; th^
feel more external than the former, and are often confined to
one side of the head. They are attended with acidity ui tka
stomach, eructations, and sometinies considerable giddiness^
tu: slight sickness, with bitter taste in the mouth. They are
relieved^ by the regular exhibition of laxatives, by sleep, Hm
moderate use of vdatiles, and the application of ether ester*
nally.

Hystarical convulsions, are not uncommon daring ge8tatM»
and, more especially, during the first four months. They
occur in irritd>le and exdtaUe habits, or in dioee, who are^
naturally, disposed to syncope, or who hsfe been exhausted,
by any pain, deprivii^ Uiem of rest, or by ahrine disduorges;
They are distinguxdied, by the face^ usnallv, being pale
during the attacx, the countenanee is very little distorted,
there is no foam issuing from tbe mouth, the patient, far a
time, lies as in a faint, and then has convulsive motions, or
screams and sobs, and the fit is generally terminated by shed-
ding tears. The treatment, in the first instance, consists is

• Mr. Wilflon's out I* an oMplloo t'j this. YMe Mtd. ^Mte, Vd. t. pw 8S»

t Some attribute thie to hypertrophy of the left Tentricle ; otben, to thogfrnvld
^^^ ^nictlog the ooane of the blood U tho lowtr esticBiitiw ; bothopinioiis

«7

.adniaiaieKtttf nnJiiWMiiiMMiiliiH, TuirticMlwlT opiitiii. mmI Tdhiiin
foiUds. Afterwards, ike retenis ara to oe pieffwitod, If
bringiiig the bowds into a eomet alate, aad keeping fhemao.
The eiercige is to be gentle, but token reguiarlj. The ditf;
mild, hut nouriahing. Sleep k to be precared, if nee
b^ opiates ; and tonic medicinet, with the awittaiiee of
niateid tinctore oi yalerian, must complete the eiore* If> how-
eyer, there be a feeling of fulness about the head^ or weigbl,
or headachy it i% even in spare habits, of serviee totahe
a little blood*

SECTIOlf EIGHTEENTH.

Toothach, not unfrequently attends pregnancv, and
times, is a very early symptom of that state. The tooth may
be sound or diseased, but, in neither case, ought we to extract
it, in the early months, if it be possible to avoid the operation.
I have kiiDw£ the estracUtm, ^oUoired inafew>i2i^ bf
abortion. Blood-letting freipiently gives ceUef, and^ aoBi»-
times, a little cold water, taikea into the month, abates the
pain. ' In other cases, wann water gives more rcdief. Cro»-
aote may be tried.

SECTION NINETEENTH.

Salivation, is, with some women, a mnrk of ^ngnanqr* 'it
has been supposed, that there is a sympathy, emtiBg between
the pancreas and salivary glands, and that the phlegm rqecti-
ed by vomiting, proceeded from the femner, wnilst, in numy
instances, the latter, yielded an iaereased qaantity of viseii
saliva. This is a ^mptom, which scarcely demands ai^
medicine, but, when it does, mild laxatives, are tim mort
efficacious, with counter-irritetion on tiie back of the head or
neck.

SECTION TWENTIETH.

Pain and tension of the mammm, freqiiently attend gosti^
tion, and these symptoms are often very distressing. If die
woman have, formerly, had a suppuration of one mannna, that
Vreast, is generally most painful, and she is afraid of absoeas
again forming ; in other instances, the pain being aceompaaied
with increased hardness of the breast, produces apprehension
of cancer. These fears, are generally groundless; but if
auppurati(m do take jdace, it is to be treated on general prin-
dples. Blood-letting often relieves the uneasy feeling in the
breast, which is alM> mitigi^ed, by tepid fomentations, or

266

gentle friction, with wann oil. Nature often gives relief, by
the secretion of a serous fluid, which runs out from the nipple ;
but if this be much encouraged by suction, Chambon remarks,
that the foetus may be injured. This, however, is so far from
being always the case, that many women, who conceive during
lactation, continue to nurse, for some months, without detri-
ment to the foetus. The discharge is, in some instances, so
great about the seventh month, or later, as to keep the woman
veiT uncomfortable. The diet in this case should be dry.

The sudden abatement of the tension, and fulness of the
breasts, with a diminution of size, are unfavourable circum-
stances, indicating either the death of the child,, or a feeble
action of the womb.

SECTION TWENTY-FIRST.

In the course of gestation, the feet and legs, frequently*,
become oedematous, and sometimes the thighs, and labia
pudendi, participate in the swelling. The swelling is by no
means proportioned, always to the size of the womb, for, as
has been remarked by ruzos, those who have the womb
unusually distended with water, and those who have twins,
have, frequently, very little oedema of the feet. This disease,
is partly owing, to the pressure of the uterus, but it also seems
to be, somewhat connected with the pregnant state, inde-
pendent of pressure ; for, in some instances, the oedema is not
confined to the inferior extremities, but affects the whole
body. A moderate degree of oedema, going off in a recum-
bent posture, is so far from being injurious, that it is occa-
sionally remarked, that many uneasy feelings, are removed
by its accession ; but a greater, and more universal effusion,
indicates a dangerous degree of irritation. In ordinary cases,
no medicine is necessary, except aperients; but, wnen the
oedema is extensive or permanent, remaining even after the
patient has been for several hours in bed, and, more especially,
if the pulse be accelerated, and uncomfortable sensations be
felt in the head, or about the eyes, it may be considered as
arising from a particular state of the nervous system, and
dangerous effects, such as convulsions, may succeed ; or, it
may predispose to puerperal diseases. We must therefore
have, instant, recourse to blood-letting and purgatives. These
means are always proper, and are never to be omitted, unless
the strength be much reduced ; in which case, we only employ
the purgatives and cardials prudently, with acetate of potass,
or sweet spirit of nitre. In obstinate cases, we may try the

269

twelfth part of a grain of extract of elaterium, with a drachm of
supertartrate of potass, twice or thrice a day for a short time.
Diuretics, generally, are not successfbl, and many of them, if

g>en liberally, tend to excite abortion. Friction relieves the
eling of tension.

SECTION TWENTY-SECOND.

Ascites, may, like oedema, be excited, in consequence of
some condition connected with gestation, or may be iade»
pendent of it, arising from some of the ordinary causes of
dropsy, especially from a disease of the liver, in the last
case, medicine has seldom much effect, in palliating or re-
moving the disease, and the patient usually dies, within a
week or two after her delivery, whether that have been pre-
mature, or delayed till the full time. When ascites is not
occasioned by hepatic disease, and appears for the first time,
during gestation, it is generally connected with the cedematous
state, above-mentioned, depending on the same condition of
the nerves, and seldom comes on, until, the woman have been,
at least, three months pregnant. If it be not attended with
other bad symptoms, such as headach, feverishness, drowsi-
ness, &c., it abates and goes off, a little before, or soon after,
delivery, which is often premature. But in other instances it
increases, and from the distension produced, very great diffi-
culty of breathing, inability to sleep, and tendency to faint,
are occasioned. I have seen diuretics given, very freely, in
these cases, but, most frequently, without any benefit. On
this account, and also from the danger of these exciting abor-
tion, or premature labour, I am inclined to dissuade from
their use, except in urgent cases. Then, the mildest ought
to be employed, such as cream of tartar, juniper tea, acetate
of potass, &c. If any of these produce much irritation of the
urinary organs, they must be exchanged for others. Purga-
tives and blood-letting are more useful, and ought rarely to
be omitted. Elaterium in minute doses is safely to be
tried. The lancet, in many cases, if early employed, and to
a moderate extent, will supersede the necessity, of resorting
to any other remedy, beyond that of a purgative, for, this is
an acute disease, more easily remedied by depletion, than by
any other means. If, in spite of this treatment, the .swelling
increase, paracentesis must be performed, and I am surprised
that there should ever have been a moment's doubt, as to its
wopriebr, for there certainly can be none as to its safety*
When the navel jn-pjects much, and is very thin, it has been

270

papoMd to pmictare it with a kneet. " In one cace, rented
qr M. Olivier, the iuid ccMitiniied to bediseharged for twelve
daye, a&w which the punctHre doaed. In another, the patient
herself pierced the navel fifteen or twenty tines with a needle*
Ascites may have existed previously to fregQamcjy and the
two causes combined, can produce a very great enlargement
of the belly. In this case, tne nterus may be felt through the-
parietes, eonetimes very much compressed, aa if the child
lay acrass» Mild diur^ics tend to keep the disease at bay ;
and if the distensioB be very great, especially at an early
Stage, my experience leads me to oonefaide, that after quick-^
ening, a §^reat part of the fluid may, as in the former case, be
drawn off safely, provided* during the operation and afterw
wards, the abdomen be carefully md uniformly supported by
a bandage. It is useful to know this, as the distension is
sometimes ao great, that life could not go on, without much
distress, till the end of geataticm. The operation, I think, ia
more apt to be succeed^ bv labour, if p^ormed in the last
month, than earlier. In all cases where the patient is weak^
we maat take great care that the puncture be eorreetly ck>0ed;
for, if its lips inflame, instead of adhering, fotal peritonitis is
the invariable result. When the dropsy is very general, and
the symptema uigent, it haa been propoaad to induce pramsK
tnre labour.

SECTION TWENTY-THIRD.

When the Inpior anmii is in too great quantitT, much
ineonvenienoe is produced, and not nnfreqnently the child
perishes* This disease is known, by the abdamen being un*
uanally large, at an early period of gestation, for generally by
the seventh month, it is as big as it ought to be in the ninth*
k is distinguished firora aaoiteB, by motion of the child being
fcit, though obscurely, by the mother, and the breaata enlarge
iDg. Per vaginam, we can ascertain that the uterus eontaine
a substance, which ahematdy recedes and descends, sm the
ittger strikes on the lower part of the womb. TUs is to be
nonsidered as a dropaical affection of the ovum, but tlM heakh
af the woman seldom aaffers ao much as in ascites: the
tongue, however, is white, and the nrtne la

fuantity. The legs ore less apt to swell, than in a enmneai
pr^guauey. The diatantion may, in the advaneed stage,
prove tfouUeaarae. When die qnantibr of water ia giveady
Mreaaed,dM5 AM is aeldom kcfit tall the foil tim^ bui ia
gsMiwMy eapaied m the eighth nmath, or mmmt, and the

S71.

Uxmr 18 aft to. \m aaampaiied, or anoBBBded, Iqr vieriiift
bflBBBOcrfaiga. hiwaoB iimiamwiij. the child ooeiipie« the upper
part of ibi utemfl^ snd the irater tbe under, at laaat dnrmg
Ubour* Twiee in the aaiae imaan, in Baooeeding piegnaii^
aiea, I foand tiie cfaiid eontaBned ia Ihe vgpper part of the
utenis, and emhsaaed ^ it, aa if it were in a ejst, whilst
aewral pints of iviater lay between it and tiie ob uteri,
mien the water cmmB awaf^ filling seme basins, Aen the
ehild deaesnded to the job uteri, but was^bom dead, with the
tiiigha tamed finnljr up, aver the abdomen^ jmd other maska
of deformity.

We know llie water to be oontadned in the utems, and not
in the abdominal caiil^, by feeling ibe shape and firnmess of
theutems, and by the greater obsinirity of the fluctuation. In
amatteBf canq>licated wm pregnancy, the fluid is more distinct,
and the siu^pe ef the utems cannot be peroeiyed till after
tapping. This is a disease of &e onm, and not of the
mother, for even the fiostus itself is often malformed, or at
least blighted. The aflSsotion, may be considered, as a species
«f nonstrans eonoq»tion. It has also been looked on as the
result of inflaransation of the amnion. Some particular coa»
dition of the paiBsnt, in csertain cases, occaiUionB this state*
For nifitanoe, it magr be oonneotad with a syphilitic taint in
ectbor tbe fiither or moliier ; or with some less obvious cause
impairing the aetiim of the wmid), but not directly produeinr
a miscarriage; wiiii famacy or iiUotism ; or with an original
anaditioii m the ormn in the ovarium : for a woman may,
mthout any appasent cause, hare repeatedly [this kind of
prBgnancy* i&E of these oanses do net operate, uniformly, te
we same extent, bot the fetns suffers in proportion to their
i^raluniu. It. is i^fibar bora very feeble md laDguid, and is
reared with difficulty, or it dies almost immediately, or it
perishes before labour commences ; and this is generally the
case, when the diseased state, exists to any great degree. The
period of tbechild^ deefh, m usually marked, by a sfaiyering
it, and ccsaatioa of motion in utero, at the same lime thai
thfyfareaate beoome flaccid. Afterwards, irregular pains come
an, with or without a watery discharge. Sometimes the
aaaaiis ndL-er-ieveiaafa, for a-few days, before labour begin*
If tiiefiqunr amnii be^oidy moderately increased, beyond tibe
nal tfoaaiitfj iSae eiiiieaii mi^ ge the full time, but, from
the distention of the uterus, is apt to haye a lingering labour.
Tomes, the coQ bath, dry met, with occasional yenesec-
tioni and the use of lazatiyes, during pisgiMimnyyJMy be of

273

service, but frequently fail. Diuretics do no good. If in the
early stage, there be febrile symptoms, along with any peculiar
feeling in the uterine region, blood-letting 'and laauUives are
proper, or leeches may be applied to the belly or back. A
course of mercury conducted prudently, preyious to concep-
tion, is the only remedy, when we suspect a syphilitic taint.
It may be necessary to prescribe it to both parents. When it
proceeds from some more latent cause, I think it useful, for
preventing a repetition of the disease, to make the mother
nurse, even although her child be dead. Mercury ought also
to be tried.

When this distention produces much distress, it has been
proposed to draw off the water by the os uteri ; or this has
been done, in one case, by the common operation of paracen-
tesis, the woman surviving, and labour taking place on the
twenty-first day.* I can conceive no one advantage which
can result from tapping the uterus, rather than perforating
the membranes from the os uteri, which must be done if the
symptoms be urgent, but very often the uterus, in that case,
spontaneously expels its contents. When the os uteri is
considerably dilated by the pains, it may be proper to rupture
the membranes, as has been advised by Puzos.

This disease may be complicated with alterations of the
placenta, which may also exist without it. In some cases,
we have cysts formed in the placenta, or more solid tumour,
or induration, or wasting and shrivelling of a part, whilst the
rest is healthy. We have no control over these diseases, when
they take place, neither, indeed, can we be sure of their
existence, even when we have the uterus ceasing to enlarge,
or repeated haemorrhage. One part, may be much diseased
or wasted, and the rest may be sufficient to presferve the
foetus.

SECTION TWENTY-FOURTH.

Discharges of watery fluid from the vagina are not unfre-
quent during pregnancy, and generally depend upon secretion
from the glands about the cervix uteri. It has been supposed,
that, in every case, they proceeded from this cause, or from
the rupture of a lymphatic, or the evacuation of a fluid collec-
ted between the chorion and amnion, or the water of a blight-
ed ovum, in a case of twins ; for in most instances, where the

• vide ease by Noel Desroamls, in Recaell Period. Tom. tL p. 940L M.
Baudelocaae f tyee a nemolr on this lubjeot, In the lame volume, ootfpiki abo^
•eema to defond Iht paraeeiitoalt.

273

liquor amnii has been artificially evacuated, labour has taken
place* But we can suppose, uiat the act of gestation may,
m some women, be so strong, as not to be interrupted, by a
partiail eracuation, of the liquor amnii. Even granting the
water to be collected, exterior to the chorion, there must be
a strong tendency to excite labour, if the quantity discharged
be great ;* and if the uterus can resist this, it may also be
unaffected, by the evacuation of liquor amnii. I have, known
instances^ where, after a flight or exertion, a considerable
quantity of water has been suddenly discharged, with subsi-
dence of the abdominal tumour, or feeling of slackness, and
even irregular pains have taken place, and, yet, the woman
has gone to the rail time.t • These circumstances prove, as far
as the nature of the case will admit of proof, that the water
bad been evacuated. Sometimes only one discharge has
taken place, but oftener the first has been followed by others,
and these are often tinged with blood. The aperture seems
to close, if gestation ffo on, for, during labour, a discharge of
water takes place. Much more frequency, labour does take
place. Even, when the discharge proceeds, only, from the
glands about the cervix uteri, if the woman be not careful, a
hemorrhage may take place, followed by labour. This is
most likely to happen, if there have been a copious discharge.

The practice, in these cases, is to confine the patient for
some time to bed. An anodyne ought also to be given, and
may be repeated occasionally, if she be affected either with
irregular pain or nervous irritation ; previous venesection
ahxn renders this more useful. The bowels are to be kept
open. If we suppose the discharge, to be from the ^ands
about the cervix uteri, we may, with advantage, inject some
astringent fluid, such as a solution of sulphate of alumine, or
decoction of oak bark.

It sometimes happens, that a large hydatid, is lodged
between the ovum and the os uteri, and it may be expelled,
several weeks before parturition. . If care be not taken, this
may be followed by h«emorrhage. The existence of smaller

• Vld0 Dr. Aleanmdcr'f oMe, in Med. Commttt. Vol iU. ^ 187.

f Dr. Pentlaofl reUtM a very distinct case, where the liqaor wme, In the third
or fourth month discharged in a lit of ooaghing. The belly fell, bat the stiU
w«nt on to the fall time, and had a good bboar. DabUn Med. and Phyi.
Sasajnii, No. 1. art. a^l hare known a discharge of water take pb^e, at abort
interrals, for some weeks ; and then the funis nmbilicalls protraded, withoat any
exertion, or any pains to rapture the metthianes, whieh Is a demonstration thai
the membranes nad been preriooBly open, and tbat the discharge of liquor did
not speedUy excite labour.

jiySatids, nith pr^aaejr^ may also take plaeci, tiditrm tife
deeidiia or part, of the placQ&ta*

SECTION TWENTY-FIPTH.

Varioose tumours sometimes appear on the legs. Th^
are not daDgerous, bat are often painful. By pressure^ they

. can be r^aioTed ; but I am not sure, that it is altogether safe»
to apply a bandage round the legs, so tight, as to prerent

.their return. It is better, in ordinary case% to do notning at

>all; but where there is much piun» a recumboit posture and

.moderate pressure giye relief.

SECTION TWENTY-SIXTH.

' From die distention of the abdominal muscles, pain may
be prodoced, either about the extremities of the recti muscles^
jDr die origins of the oblique or transverse muscles. These
pains are not dangerous, but give unnecessary alarm if the
cause be not known« It is impossible to remove them, but
they may be mitigated by anodyne embrocations* If the pain
be severe along the edge of the ribs, relief may be obtained^
by applving round the upper part of the abdomen, a narrow
band of leather, spread with adnesive plaster.

There is another cause of pain, which sometimes affects
these muscles, but eftener those about the pelvis and hips*
This seems to proceed from the state of the spinal nerves^
going to the muscles. A long walk, or some little fatigue^
may produce such an effect, aa to render them painful for a
long time ; or, even without any unusual degree of motion^
the muscles ache, and produce the sensation of weariness.
'These pains have been supposed to be most frequent, when
the woman has twins ; but this is far from being a general
rule. They may occasion an apprehension, that' ^e is going
to miscarry. Reit is the principal remedy; but if they be
aevere, relief may often be obtained by venesectioB, and
robbing the back, with a stimulating embrocation.

Pain in Ae side, particularly the right side, is sometimes^
at an advanced period of gestation, both muscular, and also
connected with the state tiS the bowels, especially of the colon.
It Is frequently most severe, and may be rendered still more
diBtressing, by being combined with violent heartburn, or
water-brash. It comes on chiefly at night, and instead of
being relieved by lying down, is often increased on going to
bed. It is usually accompanied, with much motion of the

, »7»

cbiUU Veneseotion, sometuDes gires relief bat generiAy
Bictre advantage is demed, from rubbbg with aooiodyiie bakaiot
stten^ng to 1^ state of the boweh, and Tegulatmg the diet.
Aldiongfa the pain be Tery severe, it seldom brings an labour*
In certain cases, there is a complication of pleuritic pain of
the side, spaan of the ureter, and some portion of ttie intefrr
tines, with sensibility of part of the abdominal mnades. Blood*
-letting and purgatives, followed by anodynes, and rubefacient
Applications, form the practice. If tiiese fail, a blister applied
lo that part of the back, which is on a line with, or a little
above, the seat of the pain, may be use&l^ heis, and in mosfc
of the cases, noticed in this section.

SECTION TWENTY-SEVENTH.

Spaam of the ureter, or some violent nephritio affection^
may occnr during gestation. The paia is ^evere^ tte pulse
dow and soft, and the stomach often filled with wind. The
symptomB are attended with distressing strangury, and if not
soon removed, may cause premature labour. Decided relief
is obtained, by giving a saline clyster, and after its operation,
injecting eighty drops of laudanum mixed with a little starch*
A sinapism is to be applied to the loin, and if these means
£iil, blood must be taken away.

SECTION TWENTY-EIGHTH.

Spasms in the inferior extremities, are often very distresfih
ing. These may come on suddenly, but, occasionaUy, they
are preceded 1^ a sense of coldness, and accoiiq>anied with a
feeling of heat. They are removed by change of posture and
.gentle friction. They have, by some, been thou^t to indi-
cate a wrong presentation of the child ; but this opinion i^
not supported by experience. They proceed from the pres*
sure of the uterus on the nerves in the pelvis.

SECTION TWENTY-NINTH.

The gravid uterus itself^ at various periods of gestation, is
liable to become pretematurally sensible, and even to be
affected with spasm. This state, is marked by great pain, in
the region of the uterus, subject to exacerbations, but Aever
going entirely o£ It is presently succeeded by inflammation^
marked by frequency of pulse, thirst, beat of skin, sometimes
sickness, constipation, more or less tenderness of the hypo-
gastric region, with severe pain, stretching to one or both
gtoinsy and'occaaibnally in the bacic. In every instance I have

276

known, the ovum has been enpelled, and, in some, the patient
has sunk soon afterwards. The practice, even when the case
is clearly spasmodic, consists in detracting blood, and, after
opening the bowels, giving e£Pectiye doses of opium, either by
the mouth, or as clysters ; and this remedy must be repeated
as often as necessanr. When inflammation has taken place^
the detraction of blood must be pushed farther, warm fomen-
tations employed, stools procured, and anodyne clysters ad-
ministered. When abortion takes place, the strength must
be supported, and irritation allayed by the free use of opium;
but the patient is in a dangerous state.

SECTION THIRTIETa

Some children, are scarcely perceived to move, in the
nterus, whilst others are disagreeably active. But there is a
state, in which, the motion amounts to an actual disease*
This generally arises from an increased sensibility of the ute-
rus, and abdominal muscles, proceeding, I apprehend, from
the condition of the nerves supplying them, one of the effects
of which, I have noticed in the last section. The motion,
whether it be actually stronger, or more frequent, than usual,
produces a sense of pain in the uterus, with a feeling of sink-
ing or sickness, and, often, spasmodic contractions of the abdo-
minal muscles, and sometimes slight convulsive motions, of
those of the trunk or extremities. Such patients, seldom go
to the ftill time, and after delivery, are more liable, than others,
to s^cope, with or without haemorrhage. The treatment
-consists in venesection, if the circumstances permit it, the use
of laxatives, the application of irritants to the back, and if
-these do no good, an opium plaster should be applied there,
and cloths wet with laudanum laid on the abdomen.

SECTION THIRTY-FIRST.

In a first pregnancy, the abdominal muscles, generally pre-
serve a greater degree of tension, than they do afterwards ;
and, therefore, the belly is not so prominent, as in succeeding
pregnancies. Sometimes the muscles and integuments, yield
«o readily to the uterus, that it falls very much forward, pro-
ducing a great prominence in the shape, inconvenience irom
the pressure on the bladder, and pain in the sides, from the
increasing wdght of the projecting .uterus. In such cases
benefit may be derived, from supporting the abdomen, with a
bandage, connected mitt the shoulders. In other instances,
the muscles and integuments do not yield freely, but the belly

277

ig hard and tense ; the patient feels shooting pains about the
abdomen, and sometimes miscarries. This state is relieved
by blood-letting and tepid fomentations. When the skin does
not distend freely, and becomes tender and fretted, or when
these effects are produced, by very great distention, benefit is
derived, from fomenting with decoction of poppies, and, after-
wards, applying a piece of soft linen, spread very thinly with
some emollient ointment.

There is sometimes a disposition to distend unequallv, so
that one side, yields more than the other, or even part of one
side, or one muscle more than the rest, producing a pecuHar
shape. This is attended with no inconvenience.

SECTION THIRTY-SECOND.

' The navel of pregnant women generally becomes prominent^
even at an early stage. In some instances, such a change i^^

iiroduced, as to allow the intestine or omentum to protrude,
brming an umbilical hernia; or, if the woman have been
formerly subject to that disease, pregnancy tends to increase
it, whilst on the other hand, the intestines beiug soon raised
lip by the ascending uterus, inguinal and femoral hemi»
are not apt to occur, or, are even removed, if they formerly
existed. Umbilical hernia ought to be either kept reduced, .
by a proper bandage, or at least prevented, by due support, .
from increasing; and during deh very, we must be careful^
that the intestine be not forcibly protruded, as it might'
be difficult to replace it. After delivery, a truss must be ^
applied with spring wings, which come round by the side of
the belly.

I have seen the linea alba give way, just below the umbili-
cus, so as to aUow a portion of the uterus to project, forming
thus a painful tumour of a flattened form, and too tender to
permit of pressure. Leeches relieved the pain, probably by
their effect on the cellular substance ; and, when the child
was bom, the tumour disappeared.

In some cases, during gestation, the fibres of the abdominal
muscles, elsewhere, separate, so that a ventral hernia is formed,
either by a portion of the parietes of the uterus, or by intes-
tine. The same circumstance may take place during partu-
rition ; and the laceration is sometimes so large, that after-
wards, whenever the muscles contract,^.as,for instance, in the
act of rising, a quantity of intestine is forced out, forming a
hard tumour like a child's head. It is necessary in this, and
in all other cases of large hemise, to be careful that compres-

sum be applied tmmediatdy after delivety, and aho dariaff
the expolnon of the child* By negleeting this, syncope aad
uterine hsemorriiage have been occasioned.

Hernia of the bladder should always be reduced in the
oommeneement of labour, for it may interfere with the
process ef parturition, or the bladder may be exposed ta
injury.

SECTION THIRTY-THIKD.

' It is not uncommon, to find women very desponding during
pregnancy, and much alarmed respecting the issue of their
confinement. . This apprehensive state, may be the conse-
quence of accidents befalling others in parturition ; but not
unfrequently it proceeds from a peculiar state of the mind,
dependent on gestation, and mtimately cimnected with
sympathetic effects produced on the medulla spinalis and
gblongata. These may arise directly from the uterus, or
mediately through the state of the bowels ; nor is it easy, or
perhi4>s always possible, to determine which of these operate,,
primarily, on the nervous system. Some, who at other times
WJoy good sfurits, become always melancholy during preew
sanoy, whilst others suffer chiefly during lactation. If this
state be preceded by excitement, marked by heat of skin and
frequency of pulse, or by congestion at the base of the brain«
marked by w>w pulse, and feebleness or languor, venisec-
tion will be proper ; and in determining on this, no attention
is to be paid to the paleness of the visage. If there have been
BO indication for bleeding, then we go on, at once, to the
plan which in the former case we would follow, after die use
of the lancet, namely, the regular use of purgatives, and the
exhibition of the mist, camph. in the dose of half a wine glass-
Jill every three hours, either alone or with a taUe spoonful
of saline julap. Little more can be done bv medicine, except
to obviate all causes of disease, or uneasmess of the body;
the mind is to be cheered and supported, by those who hav^
most influence with the patient. The disease is not perma-
nent, and when it commences early in gestatioiit usually goea
off before delivery.

A similar affection of the mind, may occur near the men^
strual period, for a length of time in the unmarried, and it
seems to depend on the same cause, namely, the effect of th^
uterus on the nerves.

Some during the early period of pregnancy, imagine that
they see a jAantom continually present, or are under otbor

dduiiaB& In gcbenl, after g^Uiag fiirther an, die mind
lewcomes oerreeU

SECTION THniTY.FOUETHL

RetroYersion of the uterus was described^ but not ex*

Jlained^ by j£tius, Rod* a Castro,* Maurieeau, and La
{otte, and afterwards demomtrated by Gregoire, and hia
pupil Levrety but was, in this country, first, aocurately illu»*
trated by I^. Hunter in 1754. It is an accident which is
always attended with painfiil, and sometimes fatal conse^
quences, ehiefly owing to the effect produced on the Uadder.
If the pelvis be of the usual size, it may take place at anjr
time^ during the third and fourth months of pregnancy : or if
the pelris be large, or the orum not much distended with
water, it may /OCcur in the fifth month* It may also be pro*
duced, when the womb is enlarged to a certain degree, by
disease-t A peculiar kind of displacement is described by
Mr> Ingleby^t where a tumour of the fundus seems to have
earried the Jbody of the impregnated uterus deep into flid
pelvis, so as to resemble retroversion. It was pushed up, bui
the patient died after delivery.

We recomise retroversion of the uterus, diiefly, by Ha
effects on uie bladder, and, also, by difficulty in voiding the.
faeces ; for, whilst, the natient mav be distressed sometimes
with tenesmus, she ususdly passes httle at a time« Although^
it have been maintained, by some, that no effect is produced
^)n the rectum, yet, nevertheless, the obstruction, in certaia
oases, is so great, that feculent vomiting is produced. And
on dissection, we find the rectum stretched over the fundus
uteri. When the retroversion is completed, bearing-down
pains may be excited^ as if an attempt were made, to exjpel»
or force down, the uterus itself, and in some instances they
^^c^ual the pains of labour. These are much connected, also^
With the state of bladder, being most severe when it is dis^*
tended, and generally abating, in frequency and force, when
the urine is evacuated. In some cases, the retention^ is,
from the first, complete, and the symptoms go on increasing*

* Lib. U. c. 17. De Uteri Awsenia et Raeona. He gives a yery imperfect
.Meoont, bat 9Mm» ndnodon to be eilseted by tiie ftDger in Mie.

4 Mr. PeuioD relates a case^ where the ntenis was retroTerted, in oenseqiieiMa'
of beiof seirrhoas. Vide Feanon on Caneer, p. lia Dr. Mareet gives aa'
UMtaoee whne the uterus wss retrorerted without pregnaney, producing oon.*
stipation and vomiting. Vide Cooper on Hernia, Part ii. p. SO. I>esaulf
^bserrcSjithasbesncausedbvaaterijiepolyptts. See also Dr. vVeir in GJasgofW
Joomal, i. 269. — © .

>|. ShG|a and Cases, f. 7S.

280

In others, after a day or two, the urine be^ns to dribble
away, but the bladder is never emptied ; or, there may for
some time, at first, be a little discharged, by stnuning, and
afterwards the retention becomes total. This condition is
attended with either acute pain, or tenderness of the lower
part of the belly, so that sometimes, the patient cannot bear
to have it touched. It is also tumid. The loins are pained,
and there is more or less desire to strain, according to the
state of the bladder, and the position of the uterus. There
is tenesmus, and even the rectum may be everted, and the
orifice of the vagina protruded. The degree to which the
bladder may be distended, in the living subject, is much
neater than could be supposed, from trials to mflate it after
death. Fourteen pints have been drawn off at once, and the
bladder has been found as large as the gravid uterus, at the
full time.

The acute symptoms, produced by the distention of the
bladder, or the inability to pass the urine freely, first of all,
call the attention of the patient, to the disease. When we
examine her, we find a tumour betwixt the rectum and
vagina,* formed by the fundus uteri, which is thrown back-
wards and downwards, whilst the os uteri is directed forward,
and sometimes so much upwards, as not to be felt by the
finger. The back part of the vagina, has been pressed, 80
forward, as to make it difficult to introduce the finger.

This is a disease, which we should think cannot be
mistaken, and, yet, it is sometimes difficult to distinguish it ;
for, in extra-uterine pregnancy, it has happened, that the
symptoms have been nearly the same, with those of retrover*
sion ;t and tumour of the ovarium has sometimes produced
similar effects. Perhaps, the diagnosis cannot, in every case,
be accurately made, but this is of less immediate importance,
as the indications, in such instances, must be the same, namely,
to draw off the urine, and procure stools.

Retroversion may take place, under two different circum-
stances, and from two causes. In the one, it takes place
more slowly, and its progress, in some instances, may be
ascertained from day to day ;t in the other, it occurs pretty

* M. BaudelocqiM relatM a mm, when the fnados ntcrl motrodcd at tbe m
externum, the patient at the lame time haTinc Tiolent inelinatlon to expel tom*.
thing. He was, howerer, abie epccdilj to reoace the womb to the proper etat^
Vide I' Art, ke, § 125. In Dr. fie)l*e caee, a portion of the rcetam waa protrudtd
by the uterne. Med. Facts, Vol. riii. p. ^

t Vide Mr. Glibrd*e caee in PhU. Trani. Vol. xxxtL p. 485, and Mr. Whlte*a
rery inetructive caee, in Med. Comment. Vol. xx. p. 854.

I M. BaadtlooqiM |lv«t a oaic of Uiis kind, S m. Jn Dr. B«U*a OM^ m tht

381

quickly, and occafiionally the woman has been sensible, at the
thne, of a tumbling, or motion, within the pelvis.

That the student may, the better, understand retroversion,
I remark, first, that the uterus, in the unimpregnated state,
lies obliquely, sometimes almost horizontally, in the bottom of
the pelvis. If it remain long in this position, after its fundus
has enlarged in consequence of pregnancy, more especially, if
there be Uiat relaxation which attends prolapsus, retroversion
is endangered, if not actually produced. But, if along with this,
the rectum should be lax, and curl or hang much to one side,
as it often does, particularly to the left side, it is evident, that
should this fold or curve of the rectum, become loaded with
faeces, pressure will be made on the fundus uteri, which there^
by, is not only prevented from rising, but is actually pressed
lower, the cervix is carried forward, and a certain degree of
prolapsus takes place. Then, pressure is made, against the
M>wer part of the bladder, just at its orifice. The urine thus
comes to be retained, the bladder is distended, and the cervix
is carried still higher, and the fundus pushed somewhat back-
ward, and also pressed lower, partly, by this cause, and partly,
by bearing-down efforts, which are excited. If the size of the
pelvis have any influence, I should say, that one too large,
rather than too small, was favourable to its production.
Now, if this view be correct, it is evident that retention of
urine, though it may increase the retroversion, is at first an
effect, and not a cause. Nay, farther, it follows, that even
in the unimpregnated state, the uterus may be partially
retroverted, or retroflected, by this state of the rectum, and
yet no retention of urine be produced, but only an obstruc*
tion to the passage of the stools, the uterus being too short
to act, mechanically, both on the bladder and the rectum,
and thus the symptoms of this species will vary, according as
the uterus is, or is not enlarged. Secondly, if the urine be
too long retained, in the unimpregnated state, the distention'
of the Uadder raises the uterus somewhat ; but the peritoneal
coat reflected from the bladder, is raised as that viscus dis-
tends, and makes the uterus, cling closer, to its posterior sur*
face. Retroversion cannot therefore take place, from this

wonum emnplaiDcd for Hre treelu of dTiurla only, It It likely that for that jwrlod^
tb« retroTcrsion wa« not complete. Med. Facts, Vol. riii. p. 82. Dr. Hanter
•upMoed that it might take place in Tarious degrees ; it might be complete, or
aomi^eomplcte, or eren the os ntol might remain in its natural sltoatlon. He
saya that Dr. Combe and he saw a case, where the os uteri was pushing out as ia
« vroddentia; bat this, perhaps, will not be admitted to have been retrorersioa.
Med. Obs. and Inq. Vol. t. p. 88S. In the same volume, p. 9d2^ Dr. Garthshorv
vristcsaniBttanceofaraiii-retroTertion. . .

oMiBe, and if it GMld, it wooUl immediate^ oeaae^ ea emptif-
ing the bladder. Bu^ if tbe fundus be enlarged, and <u»
whole uterus be longer, as in pr^gnaney, then, the heaivy
fundus may, in certain positions, incline a little more back-
ward, when the bladder is full, or it may be acted on, by iim
state of tbe rectum already notieedy whidi may thus greatl j
contribute, to the production, or increase^ of xetroyersioo, or.
may be the principal cause* Any unusual oantBadion, of the
abaominal muscle% may. also 10*688 (he fundus downwards and
backwards. Still, even m this yiew of the subject, a dia*
tended bladder, does not seon oapable of caosing, of itself a
retroversion of the uterus^ It cam -only, at the most, faring
the uterus into positions, more finronrabla for its ^rodnctiaBt
by jNressure,* or other causes* From the description already
given, of the relatiye intuation of the bladder, and its oon*
nexions, it appears, that it is attached, both to the yagiaa aad
uterus. In die third month of pregnancy, if the bladder be
folly Uown up, we find that it is connected, to tbe fisMse of
the cervix uteri, for nearly 2| inches above the lip of the os
uteri, and the peritoneum is reflected firom the Uadd^, te
the uterus, at about three inches from tbe top of ihe fundusy
and the vesical fascia a little lower, ibe whole length of the
uterus being at this time about 5| inches.t If the finger be
introduced into the vagina, we feel at its end, the di^iended
bladder, which is attacmed to it, for abont two inches and a
half. At this period, the top of the fundus, rises above the
brim of the pelvis. Now, granting the uterus, to be a littlo
more raised, it cannot be tborown much more backward, for it
meets the rectum, and is supported by it. But, if, in this
distended state of the bladder, when it is, perhaps, mx inches
and a half long, and its antero-poslerior diameter six, any
pressure be made by the abdominal nmsdes, the bladdor
may be forced back, and the intestines down, on the utaras,
and its fundus pressed a little lower, whilst the cervix curves
or bends backward, so that the vteras is more op less retro*
fleeted.^ And it is not till a more advaoeed stage ef the

* I hsre itadied tiiis poiat cs«fiilly» tymaalaaUaa la Ikepii^fiiant

and my son, Blr. Allan Bumsy hM fiuther ooofirmed, ilia aereral opiniona I haTV

^ren, by so^armta obaenratiooiv in diwafUng a feoaala in IIm third month. Jkw

Hunter mautained that ratroTcnion ia tha caiiae. Dr. DanauDt tha effaet aC

ntention of urina. WhoaTcr triaa ta ntrarert tha olenia, ia pnfoaney, ahaU

find it moi^eMilyacoomidiahed, whan tha hUddaria empty ar flaccid, thaa '
it MxreaUy distended.

^ ^*.K "• f*y' '^**k»«»* mush Tialanec^ be aa bant bacfc at retroflaetad, by
I In Mr. Bird.caaa, the accident aooojadad to ftoapiogp la waahiflf «Wthi%.

cumog

tinfc M Itovte tfas 08 nteri) diccatadm tiie liaftcl airaiof
the uterOfl^ or conralete^ and actool jEotromeraioiiy or tiiniiiig
the womb, obliqimy, upside down^^esteiblidied. TUb^ how-
ever will be soiBAwluEt wpendei^ ok tbe period of ffestsinoB,
for, if beyond the tkird month, and the body and nrndoa of
the nl^rus, be more globular and ku^et, tine retvoflection ia
IflOB likeiy to be conaiderahle. The uterus may alao lie, for a
tiaoe, man directly back, its anterior face placed upward.
Farther, wehoiKe formerly aaen, that a fold of the peritoneum,
goes off, on each mde, from the uterus, to the aide o£ the
rectum, formiag, thus, a kind of col de sac between them, aA
the upper part of the vagina. Now, the uterus, though it
Hny go by the side of this, obliquely, is more likely to be
relCDvertod into it, enlarging it, and carrymg it down before
it. Thus, a kind of cavity or pouch ia &rm^, for the reeep-
tioa of the findiis vteri, which is thereby more firmly fixed.
When the cervbL uteri is curved back, the os uteri is not
fimnd to be directed upward, or to be so high, as it afiterwards
is. It presses on the neck of the bladder, andj obstructs,
more or less, the flow of urine. But if the retroversion bo
complete, and more especially, if it have been of consider-
able duration, the os uteri is sometimes carried, even, above
the pubis. It presses against the back part of the bladder.
Some of the urine may escape, or ooxe beyond the point of
pressure, and either come dribbling away, or, as tiie urethra
IS directed more upward, it may be so stretched and tightened)
or the orifice ef the bladder, may be drawn, so c^liquely,
against the vagina, that a coUection, to a certain degree, may
tiika place just above the neck,.aod if the catheter be intro«>
duced, only thus far, we may empty this, without relieving the
bladder, and suppose that we have got away all the urine,
when Bsuch still remains. It is also possible, f<»r the impacted
uterus, to be so affected in its shape, and so bent at its cer-
vix, as to make pressure on two points.

If the patient die, without having the uterus replaced, we
find it firmly impacted in tbe pelvis. The fundus is in the
hoUow of the sacrum, with the rectum stretched on it, so as
to be almost flat, and the os uteri directed forward, sometimes
to the arch of the pubis, pressing on the urethra, sometimes

Hf ed. Obe. and Inq. VoL r. p. 100. In Mr. Hooper's case, the womait was
fiifhcened bf an ok, and in attempting to escape, reU down, after which the
^aptoaao appeand. Mr. Evan's patient ascribed it to lifting a burden. Med*
Comment. VoL vi. p. 215 ; and Mr. Swan's patient to a fall, p. 217 ; Br. Mev-
iiMim1>pnrtent first oonplainiid after being suddenly terrified ;. and Mr.^ Wllmtr's
patient had the uterus retroverted, after being fatigued with weeding.

284

higher^ toward, or even aboye, the upper part of the symphy-
sis, pressing on the bladder. In most cases, the cervix will
be found more or less curved, so that the os uteri is not
directed so much upward, as it otherwise should be. The
peritoneum and vesical feiscia, instead of being reflected upon
the face of the uterus, evidently, must run directly down*
The uterus, may be, altogether in the cavity of the pelvis, or
part, of what ought to have been its anterior surface, projects
above the brim. The urethra is placed more directly up-
wards. In drawmg out the uterus, it comes with a sound,
like that of a piston, from a syringe, and part of the difficulty
of raising it, is undoubtedly from its being like a sucker.

The same woman has been known, to have the uterus re-
troverted, in two successive pregnancies. Retroversion may
also take place after delivery.*

The dmger of retroversion arises, more immediately, from
the distentionf of the bladder, which inflames,! <^d an open**
ing, generally small and irregular, may take place, in conse-
quence of gangrene ;§ or the bladder adheres to the abdominal
parietes, its coats becoming thickened and diseased*! If the
urine cannot be drawn off, of which I have never yet met
with an instance, death is preceded by abdominal pain, vomit*
inff, hiccup, and sometimes convulsions. These effects are,
chiefly, produced, by mistaking the nature of the complaint.
Their duration is variable.^ Inflammation and gangrene of
the vagina, and external pa^, have also been produced. If
the disease do not prove rapidly fatal, so much urine escaping
as to prevent a speedy termination, it occasionally happens,
that hectic fever is produced. The pulse becomes frequent,

• Vide c«M by Dr. Scoter, in Trans, of Fbyi. aX Pliiladdphia, p. ISO. Both
timet it was reduced by tbe band.

f In the case described by Dr. Hunter, Med. Obe. and Inq. Vol. ir. p. 400»
tbe bladder after death was A»und to be amazingly distended* but not ruptured.

I In Mr. Wilmer*s case, the belly was greatly distended ; six pints of urine
were drawn off, but the woman soon died. On lospeetinf the body, tbe bladder^
from tbe disease of its surfim^ was found to contain a quantity of coagulated
blood, and the inflammation had spread to the colon. In this case, tbe umbtUcua
was protruded like half a melon, and the disease, was, at one time, taken for
hernia. The uterus was found to be so flrmly wedged in the pelvis, that it
could not be raised up, till the symphysis pubis was sawed away. M* timer's
Caaes,p.S8i.

§ In Mr. Lynn's ease, the bladder burst, or sloughed, and Immediately after-
wards the woman miscarried, but the uterus after death was found to be stlU dis-
J»laced. Med. Obs. and Inq. Vol. ▼. p. 988. Dr. Squires relates an Instance
n which the bladder gave way. Med. Review, for 1601.

Iln Dr. Koes's patient, alter the uterus waa rsduoed, abortion took vlaee;
tbe woman dying, the bladder was found to be thiekenedt and adhering to
the navel. Annals of Medicine, VoL Iv. p. 284.

5 Dr. Perfect's paUcnt died thus on the sixth day. Caaet In Midwifery, Vol.
i« p* 9M.

S85

the body wasteSi and purdlent urine is ' Toided ;* or the
person may become (Boematous, and the disease pass for
dropsy .t Occasionally the water is not quite obstructed,
but it is voided with difficulty, for a week or two, when the
symptoms become more acute, and forcing pains are excited.
Our first object is to relieve the bladder, by introducing a
catheter. We may tiv either a gum catheter, or a male silver
«ne, which is only sightly curve(]^ toward the extremity. The
bladder being turned a little over the pubis, we introduce the
instrument, more directly upward, than in ordinary cases, and
turn its concavity, toward the symphysis. Should we, how-
ever, in a rarer case, find that the os uteri is so situated, that
the lower part of the bladder, bends backward over it, then,
the handle of the instrument, must be directed back, between
the thighs and the concavity, at its end, turned toward the
sacrum. By introducing a finger, or if necessary even the
hand, into the vagina, we, not only, may, the better guide the
catheter, and ascertain its course, as well perhaps as the seat
of the obstruction, but can depress the os uteri, and push
back the tumour in the vagina^ and thus get, altogether, the
Instrument better on. If we direct the catheter obliquely
backward and use force, the urethra may be ruptured,- and
even the uterus entered.§ We must remember that the os
uteri or the neck, may in one case press only on the urethra,
and in another when raised higher, it may press on or above
the neck of the bladder. In this last case, the obstacle to the
passing of the catheter is likely to be greater from the uterus
pressing the bladder more forward, perhaps even over the

« This it lUmtntcd by Dr. Guthahon*i patient, wbo^notwithstandinf these
STrnptonSt nltimately did ^eU. After the redaction of the womb, she miscarried,
and feetld lumps were, for some time, discharged from the biadder. Med. Obe.
and loq. VoL ▼. n. 302.

f In Mr. Croit's ease, the disease was of a month's standing, the woman waa
esdematoQs, and she was supposed to have dropsy; but by introducing the
cstheter, aeren quarts of urine were drawn off. The introduaion was daily
repeated for some time, and then, occasionally as eircumsUnces required, for
three weeks. The swelling of the legs went off, and the uterus gradually rose.
Med. Jour. VoL x\. p. 981.

Jin Mr. Hooper's case, whenever the tumour was prened back, the woman
led out that she could now make water. Med. Facts, Vol. I. p. 96.
$ In a case related by Mr. Baynham, the catheter was supposed to pass ^^7»
bal» only onoe, had it entered the bladder, and drawn off urine; only blood foU
lowed. The patient died exhausted on the ISih day ; on dissection, two tumours
were found, into the posterior of which alone, the catheter entered. This was
found to be the uterus, llie instrument had pierced, during life, the urethra
and Ytgiaa, and entered the oe uteri, passing on between the parletes of the ute-
rus, and the membranes, without rupturing them. The bladder had not been
emptied, and contained three pints of bloody urine. Its mucous coat was highly
inflamed. The ptfitooeoniy and whole abdominal yisoera were healthy. £din.

rtpliysb, aad opposiag itself as « baitier to die iiisfraihenl.
uiis case preasiiig up die fundus, tboogb it may not
rednoe the retroverrion, yet so far diffplaccH tlw o6 uteri and
relieves the bladder, as to allow the catheter to be tntroduoedi
It is even sometimes followed by the spontaneous discharge
of a little urine. When the catheter camiet be introduora,
-we have been advised to ts^f the bladder,* or the uterus, from
the rectum or vagina, but I have never met, under any ckcum*
stance, wiA a case reqiuring either of these <Mperation8.t

We must not be deceived with regard to the state of the
Madder, by observing that the woman is able to pass a amaH
.quantity of water,' fin* it may, nevertheless, be much distended.
We must examine the beHy, and- attend 1» the sensation, pro*
dnced by pressure, on the hypogastric region. Even although
the catheter have been employed, only part of die urine psay
have been drawn off, particularly, if the complete evacuation,
have not been assisted, by moderate pressure, over the blad*
der. It has happened, that only se much has bean taken
away, as to give a little r^ef, and merely alter the position
of the*utems, so as to lessen the pressure, on the orifiee of the
bladder. In this case, cm getting up, a great quantity of
nriue has flowed spontaneously^ ioA the womb immediately
returned to its propo* stote.

The urine being evacuated, and the most immediate source
of alarm being thus removed, we must, in the next place,
procure a stool, by means of a clyster, or otherwise unload
the rectum ; detract blood, if there be fever or restlesmess ;
and give an anodyne injection, if there be strong bearing-
down efforts. This is, often, all that is requisite ; and I wish
particularly to inculcate the necessity, of directing the chief
attention to the bladder, which ought to be emptied, if possi-
ble four times in the twenty-four hours, but at least morning

* This was done by Dr. CbettoD. The wvmMi remained lonf ^err lUf bat
•be carried ber child to the full time, and reeorered. Med. Commun. V«l. U. p.
96. In one initance, bj mfaii^ a long^ trocar, the Meme wm wmwied, aad the
woman died.

t Mr. Baynham f^m the very interesting^ case of H. Martin, who amlied for
relief, in the 6th montih of pre^ancy, baring six iredts before, had the atema
rctroTerted, in moving a heavy weight. The os uteri, was pointed directly in-
ward, and raised above the pubis, the fiiudns vras ]#sa than ait Ineb, from the
anus, the vagina prolapsed, and the cHtoris (prepooe ?) and symphse eolaifeS.
The urine otrald l>e drawn off by the catheter, which had been used morning aad
evening. Evi^ry attempt to reduce failed; and as slM seemed moribiiim, an
endeavour Was made to introduee a eurvod instrument; into the oe utati; bat it
failed, llie uterus was therefore punctured from the rectum, but ue dlscham

tahinc place, the trocar was introduoed a second time» and IS os. of Itquor ammi
flowed. Then the uterus oonid be replaced. Abortion took plaoe at the end of
twenty.flve houn. fThii tai*|d niuoh irftoffwHfc hwtt msiwiid. £dfai. Jeom*
zi3dU.257.

'OKr

tremogf or a girai*ca&oler insf be Iflft m tlie>)hddep.
By this plan* wc often find* that the uterus resumes its proper
situation, in the eouise of a short time, perhaps in forty-eight
hours ;* and the retroTereion is sehlom continued for more
•than a week, mless the dispkoement hare been very complete.
The precise time, however, required for the ascent of the
womb, will be determined, oc^^ris paribus, by the degree to
which it has been retroverted* and the attention which is paid
to the bladder* If the fundus be very low, the ascent may be
tolious ; but I consider myself as warranted from experience
to say, that in every moderate degree of retroTorsion, in
^▼ery recent case, we may be satisfied with emptying the
bladder regularly, without making any attempt to push up the
womb, unless from its position, and the partial retroversion,
•we HsB^ reaaon to expect, that by introducing the hand, we
can with Utde difficulty and small &rce replace it. But if
-the uterine tamoUr be v«ry low, and near the perinsenm, or if
^there be a tendency to an increase of degree, then, what in
ihis last case, was rather optional than imperative, may, in
tiiis one, be more necessary, and we endeavour to replace the
womb. This is abo proper, if there be much irritation ex-
oited, by the state of the womb, and which does not give way*
to the use of the catheter, and of anodyne clysters. I fear*
however* thai these efiorts are aomettmes too keenly made,
and that, often, more harm than good is done by them. It
-may be said, tlmt although tire inOniBdiate danger, be done
away with, by the regular use of the catheter, yet, the womb
may remain, for the rest of the term of gestation, in its mal-
position, and give rise to great difficulty in labour, or to the
same event as in extra-uterine pregnancy. I can only reply,
tiiat in so many instances, where the bladder has been regu-
larly emptied, has the case done weU, that I feel justified,
when there is no particular urgency, in ascertaining what
nature can do^ before having recourse to efforts that must be
both strong and painful.

The attempt to replace the uterus, may be made, by placing
ibe patient on her knees and elbows, so as to elevate the
breech. Two fingers are then to be introduced, into the
rectum* and the uterine tumour is to be pressed slowly,
firndy* and steadily, either directly up, or obliquely toward
a 8nde» We may*, at the same time, try, with the finger in

* Br. Hunter mentions a eMt, in wkfek thv nttmi TMOvcnd itnlf inune-
difltaljK after theUaOder waa enpUed. Med. Obe. Vet W. p. 409. And in
Hr. Craft's secend cas% the ivatcr bavlnf hecn dr»wa aff for lia daja, thautenia
suddenly rose. liond. Med. Jour. VoL iU F^ Mk

288

the Taginay to turn down the ob uteri, but the proposal to oae
a lerer for this purpose, is not only fraught with danger, but
absolutely useless. Forcible and Tiolent attempts, are to be
strongly reprobated; they giro great pain, aod may erea
excite inflammation, or conyulsions. They can only be justi-
fied, on the principle of preyenting a great danger. Now,
we know that the chief risk, proceeds mm the Sstention of
the bladder ; if, therefore, it can be emptied, the danger is
usually at an end. Some propose, to introduce the one hand»
into tne rectum, and the other, into the yagina, and thus,
more effectually, raise up the uterus ; but this is most seyere.
One fveat obstade to reduction, arises from the fundus^
adjustmg itself, to the hollow of the sacrum, and filling tightly
the cul de sac, into which I haye said it was thrown. The
abdominal muscles, reacting against us, press down the intes-
tines, and also the bladder, if it be not quite empty, on the
ntents, and our efforts, tend rather to press the os uteri farther
up, than to raise the frindus into its place. We shall succeed
best, if we can relax the muscles. Retroflection, is more
easily reduced than retroyersion, and, owing to the relation of
the hollow of the sacrum to the tumour, pressure fit>m the
rectum, is more likely to be efficient, than frt>m the yagina
alone* The practitioner must judge, ftt>m the situation of
the tumour, how, and from whence, he can best direct hia
«hief pressure.

When the retroyersion ceases, the uterus usually resumea
completely its proper situation; but it sometimes happens,
especially if the yagina haye been much relaxed, that when
the retroyersion is remoyed, the uterus is found yery low,
forming a prolapsus, which continues for some time* It
requires, chiefly, attention to the urine and stools ; for it may
occupy the pelyis fully, and pretty firmly ; and almost the
whole foetus can be felt, by the finger, through the uterus*

When the uterus ascends, occasionally a little blood is
discharged ;* but abortion does not take place unless much
injury haye been sustained. Thus, the woman has miscarried,
quickly, after the bladder had burst, or rather slouffhed, as in
Mr. Lynn's patient; or when inflammation had twen place,
as in the cases related by Drs. Bell and Ross. When this
happens, the uterus rises indeed, but the patient is cut off by
peritonei ]nflammation,t accompanied by ycwiiting of dark

« • M. Rom*! CMC, in Act HtTn. K. art 17.

t Both Dr. IUMs*t padent, and Dr. ChfltlOD't wUieDt, the Isttorof wfama
rMovcred, oonpUiiMd of noMsiiicM in the throat, which Dr. C ooMltei M a
Biark of alow poritoMeal inflammation.

289

coloured stuff. Abortion shall generally take place, if the
liquor amnii haye been discharged. The presentation of the
child is not altered.

That the uterus does generally rise spontaneously, if the
urine be regularly eracuated, ana the rectum emptied, is a
fact of which I am fully convinced, from my own^ experience^
as well as from the observations of others. But it is never-
theless possible for it to continue, in a certain degree of
malposition, even to the end of gestation.* In this case, the
uterus cannot, indeed, at last be said, exactly, to be retro-
verted ; for, it has enlarged so much that it occupies nearly
as much of the abdomen as usual : but it has enlarged in a
peculiar way, the os uteri being still directed to the symphysis
pubis, or even perhaps raised above it. In such a case,
which is exceedingly rare, the labour must be very tedious
and severe. The os uteri shall be very long of being felt,
and be first perceived at the pubis.f We are indebted to
Dr. Merriman for an explanation of this fact, and likewise
for the observation, that it is possible for the termination, to
be similar to that, of extrsruterine pregnancy, namely, by
suppuration. A case of this kind, well marked in all re-
spects, except suppression of urine, is related by Dr.
Barnurn,! as an instance of extra-uterine gestation. In the
fifth month, after some imprudence, the patient had pain,
accompanied with a discharge of water and some blood, a
mark that the ovum was in the uterus. She got relief at
this time ; but next month, (Nov.) she had a return of pain,
and the os uteri was felt directed to the pubis, and the fun-

* This circumstance boa been mentioned by different writers, and a distinct
case is related by Dr. Merriman, in the Med. and Phys. Jour. Vol. xvi. p. 988.
Mrs. F. being about five months pregnant, was suddenly terrified, and felt as if
her inside were turned upside down. The symptoms, however, were not very
aeate, for she roidcd the urine in the last month of gestation, though with pala
and some difficulty. On the 16th of June, she had some pains, and a discbarge
of serous fluid ; no os uteri could be felt, but a large semi- globular tumour at the
back part of the Tagina, bearing down toward the perinasum. The nains brought
on fever, and at last delirium and convulsions. She was bled, and nad a clyster,
after which she got some sleep, and the pains contiMwd moderate, though regular,
for two or three days, and she passed both urine and stools. On the SOtn, nothinr
Itlce OS uteri could be felt i but on the 21st, there was perceived a thick flattened
fleshy substance descending Into theWagina, and very soon the uterus was restored
to iu natural situation. The substance was found to be the scalp of the child,
containing loose bones. The child and placenta were delivered, and the mother
recovered. Dr. Dewees has published a criticism on this opinion, and strongly
naintafns, that in all snch cases as Dr. Merriman describes, or refers to, the
child was extra- uterine. Fhiliid. Jour. Vol/ii. p. 76.

t A ease of this kind has been lately published in the 4th No of the Edin.
Journal of Medical Science, by Mr. Wyse. The feet were felt at the os uteri,
which was directed to the pubis, and the head occupied tlie pelvis. The feet were
drawn down, and the heail pushed up by pressing from the rectum.

t Vide New York Med. ilep. v. 40.

290

dus to the sacnim. All attempts to reduce it fiuled, sappo-
ration took place, and foetal bones were discharged by the
anus. She died in March.

Retroflexion of the uterus, or that state produced b^ bend-
ing back the fundus and body on the neck, and in which the
6s uteri is thrown less forward, and not much elerated, is
rare during pr^nancy, but has oftener occurred after labour.
It is to be treated on the general principle of rectifying the
position.

SECTION THIRTY-FIFTH.

The uterus is also sometimes antiverted, that is, the fundus
is thrown forward, so as to compress the neck of the bladder,
and its mouth is turned to the sacrum.* Of this accident I
have never seen an instance during gestation, and, from the
nature of the case, it must be very rare ; but I have met with
it, from enlargement of the fundus uteri, in the unimpregnated
state. The symptoms are, weight in the lower part of the
belly, a desire to make water, but difficulty in doing so, the
existence of a tumour near the pubis, the direction of the os
uteri to the sacrum, and sovie impediment to the passage of
the faeces, with bearing-down pains. The urine should be
evacuated, and the fundus raised up ; but unless the cause of
misplacement be removed, we can only do temporary good
by this. We have little control over tumours seated in, or
acting on the fundus uteri, but time often effects a change
attributed to the physician. Dr. Granville says, he cured
one case, by astringent injections thrown into the vagina, and
applying a compress above the pubis. The French seem
fond of pessaries.

There is a case of antiflexion described by M. Duges, but
the result is not mentioned, only he supposes that as the
cervix was developed, it would be rectified. Flexions, later-
ally, are also met with, the os uteri and fundus being both
directed to one side. Even in the unimpregnated state, the
uterus has been found curved backward or forward, either
congenitally, or from inflammation.

. SECTION THIRTY.8IXTH.

Rupture of the gravid uterus, may take place at any period

* Vid€ ChamboD. Malad. d« la Groncm, p. 16. M. Baudelooqne relatei a
cue from the practice of Cboppart, where it wae produced in the aeoond month
of prenianev, hj the action of an emetic L* Art, lie. § 266. Levrct noticea a
caae where the diaeaie was mistaiien for calculiia, and the operation of lithotomf
actually performed. Journ. de Med. Tom. !▼. p. 260.

291

of gestation. The moment of the accident, is generally
marked by severe pain, occasionally by vomiting, and fre>
quently by a tendency to syncope, which, in some instances,
continues, for a length of time, to be the most prominent
symptom.* The pain sometimes resembles labour, but more
frequently colic, and its duration is variable. In some cases,
haemorrhage tdces place from the vagina, but the greatest
quantity of the bloodf flows into the abdomen, and may prove
fatal without any inflammation. At the time of the accident,
and for a little thereafter, the child is felt to struggle violent-
ly. Then, the motion ceases, the woman feels a weight in the
belly, and if the pregnancy be far advanced, the members of
the child can be traced through the abdominal parietes.t If
death do not speedily take place, the tumour of the belly
generally§ lessens, and milk is secreted, indicating the deatn
of the child. The placenta is usually retained in the uterus,
and, in that case, is expelled more or less entire, or in a
dissolved state, by the vagina, whilst the foetus is surrounded
by displaced mesentery, matted intestines, and a laver of
lymph, so as presently to exclude it, from what, strictly, can
be called the cavity oi the abdomen.

. If haemorrhage, or peritonaeal inflammation, do not, as usu-
ally happens, quickly carry off the patient, we find, that at
the end of some time, occasionally, but not necessarily, of the
nintb month of gestation, pains like those of labour come on,
which either gradually go off, and the child is retained for
many years, || being enclosed in a kind of cyst, or inflamma-
tion and abscess take place, and the child is discharged
piecemeal,^ but some deny this, maintaining that in all such
cases the ovum had been extra-uterine.

* Vide Dr. Underwood's case, in Lond. Med. Joam. Vol. Tii. p. 921.

t A einffuUur cate is to be met with in Medical Facts, VoL iii. p. 171, by Can-
cstrini, wnere the woman had a double uterus. One of the uteri, after some
pains, burst in the fourth month. The ornm was found entire in the abdomen,
and much blood was effused.

I A twin case is related by Dr. J. Hamilton, where the uterus was so thin.
Chat even the sutures of the head could be felt through the abdominal parietes.
Violent pains were produced by the motion of the child, the uterus felt very light,
and the woman had been easposed to a degree of Tiolence. This case had a very
considerable resemblance, in some respects, to a ruptured uterus, but she was de-
livered safely of two children. Cases, p. 124.

$ Sometimes the tumour rather increases. In Dr. Fercival*s case, the belly
became much larger after the accident,'and continued so for about a year. Then
it subsided all at once, when the ^woman was in a recumbent posture. Med.
Comment. VoL ii. p. 77.

B In Dr. Percival's case, the feetus was retained for 22 years, and then dis*
charged by the rectum.

1 Dr. Drake's case, where the uterus seemed to bur»t in the fourth month,
terminated by suppuration at the navel. Excrement was for some time dis*

292

Although, generally, the foetus be expelled into the abdo*
men, and the placenta remain in utero, yet it would appear,
that the ovum may be expelled entire into the abdomen; and
in that case, it is possible for the child to live for a short
time, although out of the uterus. When this happens, its
motions are felt more freely and acutely than formerly.

As the OS uteri opens a little after the expulsion, and a
sanguineous discharge takes place, with or without por-
tions of the placenta, the woman has sometimes been sup-
posed to miscarry. If she survive, the womb slowly decreases
in size, and returns to the unimpregnated state,* which will
assist matmally in the diagnosis, between this and extra-
uterine pregnancy existing from the first. The menses re-
turn, and though the belly do not subside completely, yet,
the person continues tolerably well, unless inflammation come
on. She may even bear children before the extra^uterine

charged it the opening. FhU. Trans. VoL zW. p. 121.— A waahenroman at
Brest had the uterus ruptured by a fall in the scTentb month, and ultimately
expelled the foetus at the naveL Mem. of Acad, of Sciences for ITUP.^Gaillcrm,
in the same work for 1706, mentions a woman who had the womb ruptured bf a
faU in the sixth. month. She immediately fainted, and a discharge took place
from the vacina. The chUd was expeUed by the anus. — See also the cases by Dr.
Percival, Mr. Wilson, &c. If this accident have not been confounded with
extra-uterine pregnancy, it has happened so early as at ten weeks. Rev. Me^.
IS25, D. 155. It is probable that the irase related by Bertrand. was rather rup<>
ture tnan extra-uterine pregnancy. The symptoms came on in the eighth montJi»
and ended in gangrene of abdominal parietes. The child was thus discharged,
and the patient recovered. Nout. Journ. Tom. xt. p. 381.

* In the Journ. de Med. for 1780, there is the case of a woman who had the
uterus ruptured in the fourth montli of pregnancy. The action was followed by
uterine hemorrhage, which continued for some time, llie menses returned, but
the belly did not subside, in the ninth month she died. The uterus was found
of the natural size, but the rent was still perceptible.

The uterus for some time does not return to its unimpregnated state, aa is trU
dent from the following case, which I lately saw. Anne Nealson, aged 24 years,
fell on the ground about a month before this note was written, lieing then in the
ninth month of her first pregnancy. She felt at the time, as if something had
burst near the naTel, and perceived more fluttering of the child than usuaL lliis
oontinued in a certain degree for two days, after which she felt no more motion.
In the course of two or three days after the accident, she was seised with irregu-
lar pains, chiefly about the belly, and these are rather increaaing than diminish-
ing in severity. The belly has subsided considerably in size, is hard, partJculariy
above the navel, toward the stomach. The umbilicus itself is soft and prominent
The bowels are regular, urine proper, tongue clean, heat natural, pulse 84, has
occasional shivering. On examining per vaginam, the lower part of the uterus
is felt soft and tubulated, very unlike either the gravid or unimpregnated womli.
It hangs into the vagina like a fleshy inverted cone* By some degree of atten-
tion the OS uteri Is discovered at the lower part, or rather a little backward. It
has no distinct pnyjecting lips as in the unimpregnated state, but bv pressure
with the finger, the aperture is felt with thin margins, and the point of the
finger mav be introduced a very little way within it. The head of the child Is
discovered between the utrrus and pubis. No disUnct member can be felt
through the abdominal parietes.

Dr. Jeffray possesses a preparation of a fcetus contained in a kind of ryst taken
from a woman who had rarHcd th^ child above 90 vrsr* ; the rupture was occa-
sioned by n fall.

293

ftBtus be got rid of/ If the case be to prove fatal, the pulse
becomes quick and small, the belly painful, the strength sinks,
and sometimes continued vomiting ushers in dissolution.!

Cases have occurred where the rupture was not complete,
but confined to the peritonaeal coat, and outer surface of the
uterine tissue. This may be produced by external causes,
but rather by the contraction of the uterus itself in the very
commencement of labour. Haemorrhage into the abdomen,
alone, or followed by inflammation proves fatal.

Rupture of the uterus may be the consequence of mental
agitation,:^ but in most cases it is owing to external violence,$
sometimes of exertion,! or of convulsions.

Three modes of treatment present themselves, when the
uterus is ruptured during gestation, and previous to labour.
To deliver per viae naturales ; to perform the Cesarean
operation ; and to leave the case to nature. To dilate the os
uteri forcibly, and thus extract the child, is a proposal so
rash and hazardous, that I know none, in the present davy
who would adopt it. I question if the woman could live, till
the delivery were accomplished. But assuredly, if the lacera^
tion communicated with the vagina, or any other circumstance
existed, or any change of the os uteri took place, rendering
the delivery by the vagina, practicable without violence or

* Vide Journ. de Med. Toin. y. p. 4S2.

•)■ In the Journ. de Med. for 17B0, a case is detailed of a woman, who, in the
month of Jaoniiry, being then seven months pregnant, was squeezed betwixt the
wall and a carriage, and had the uterus ruptured. She instantly felt violent
pain Id the belly, and a discharge took place from the vagina, which continued in
variable quantity for six weeks. 7'he strength graduaUy sunk, and in June sha
began to vomit, snd continued to do so for several days, when she died, llie
abdomen was found inflamed, and contained the remains of a putrid child. The
rent was visible in the womb.

i Dr. Percivnl's patient attributed her accident to a fright ; Dr. Underwood's
referred hers to mental sgitation ; M. Dabarqne's to anger.

§ In Mr. Wilson's oatient, the accident was produced by being kicked. She
romplsined of pains ail night after the injury, and next dav had a sanguineous
discbarge from the vsgina, and soon afterwards was attackea with violent griping
pain. The fcetus was ultimately discharged by an abscess, bursting externally.

Annals of Med. Vol. ii. p. 317, and Vol. Iv. p. 401 Dr. Garthshore's patient

ascribed it to violent exercise^ Med. Journ. Vol. viii. p. 8S4. — Mr. Goodsir*s
patient to exertion. Annals of Med. Vol. vii. p. ilS.— In the 6th and 6th vol-
umes of the Journal de Med. are two cases, the first produced by a fall from a
tree, the second by a bruise from a waggon. Other instances, if necessary might
be added.

fl In Mr. Shlllito*s case, symptoms of labour came on after exertion in the 7th
month. Next morning she hnd two severe pains and no more. On the third
day she had rigor, fever, and abdominal inflammation, with profuse discharge of
dark offensive stuff from the vagina, which continued till the fourteenth, when
she discharged water, pus, and the membranous part of the placenta : and on
examination the os uteri was found gone, and an opening in its place which com*
municated with the abdomen. The child was felt there, afid extracted. She
died in twelve days after this, or twenty-five days after the rupture. The child
was found to have been included in a new formed sac.

294

great irritation, it ought to be performed. The Cesarean
operation is safer where the os uteri is rigid, and in every
respect preferable to violent endeavours to open it : but we
cannot yet, from experience, determine its advantages, and
certainly it ought not to be performed, unless we can thereby
save the child, or the patient have reached an advanced
period of pregnancy. The third proposal, to leave the case
to nature, like an extra-uterine pregnancy, is most likely to
be successful, more especially, when the rupture happens in
the early months of gestation, and ought therefore to be pre-
ferred, unless circumstances invite us to deliver otherwise.
We find from the result of cases, of ruptured uterus previous
to the accession of labour, and where the os uteri has not
dilated, or been involved in the rent, that the patient has the
best chance of recovery^ if we be satisfied with obviating
symptoms, and removing inflammation in the first instance ;
supporting the strength of the patient through the progress
of the disease, should it not prove rapidly fatal ; enjoining
rest, giving mild diet, and favouring the expulsion of the
bones, by poultices and fomentations, and, if necessary, by
enlarging the abscess, if it point externally.* When much
blood is effused into the abdomen, there is little room for
treatment The patient sinks speedily.

The uterus, sometimes^ in the early months of gestation, is
opened by a kind of ulcer, and, occasionally, by a species of
slough ; either of which states, proceeds from previous disease
in a part of the womb. There may be pain attending this
process ; but in such instances as I have known, there has
been none. The patient, without any evident cause, has
been seized with great sickness, and fits of fainting, which,
in a few hours have proved fatal. On examination, there
will be found much blood efiused in the pelvis or cavity of
the abdomen, and perhaps a foetus among the clots. But
this oftener proceeds from an opening of the tube, than of
the uterus.

SECTION THIRTY-SEVENTH.

The usual period of utero-gestation is nine months, but the
foetus may be expelled much earlier. If the expulsion take
place within three months of the natural term, tne woman is

u* u j^®™*" '•M in the adT»noed lUgv of pr^^naney. Four weeki afterwmnit
•no iiMi tymptoina of labour. The oe uteri xnm puffy and open, and a bloody
KS^JT*' **••«?"'«««*• She bad tlekneM, debility, and hectic. Then the narei
JNmJS XM? uJ"* **'"" extracted from It a child in a putrid state. Edin.

295

said to have a premature labour ; if before that time, she is
3idd to miscarry, or have an abortion. The process of abor-
tion, consists of two parts, detachment and expulsion ; but
these do not always bear an uniform relation to each other, in
their duration or severitj'. The first, is productive of haemor*
rhage, the second of pain ; for the one is attended with rup-^
ture of vessels, the other with contraction of the muscular
fibres. The first may exist, without being followed by the
second, but the second always increases, and ultimately com-
pletes the first. The symptoms then of abortion, must be
those produced by separation of the ovum, and contraction of
the uterus. To these which are essential, may be added
others more accidental, induced by them, and varying accord-
ing to the constitution and habits of the patient.

The ovum may be thrown oiF at different stages of its
growth ; and the symptoms, even at the same period, vary in
duration and degree. The process of gestation may be
checked, before the ovum can be readily detected, and when
the decidua only is distinct. ' In this case, which occurs within
three weeks after impregnation, the symptoms are much the
same with those of monorrhagia. There is always a con*
siderable, and often a copious discharge of blood, which
coagulates or forms clots. This is accompanied with marks
of uterine irritation, such as pain in the back and loins,
freauently spasmodic affections of the bowels, and occasionally
a slight febrile state of the system. In plethoric habits, and^
when abortion proceeds from over-action, or hsemorrhagic
action of the uterine vessels, the fever is idiopathic, and
precedes the discharge. In other circumstances it is either
absent, or, when present, it is symptomatic, and still more
inconsiderable, arising merely from pain or irritation. As
the deciduous coat is thin, and easily disorganized, it cannot
be readily detected in the discharge. Nothing but coag*
ulum can be perceived; and this, as in other cases of
uterine hsemorrhage, is often so firm, and the globules and
lymph so disposed, as to give it, more, especially if it have
been retained for some time about the uterus or vagina, a
streaked or fibrous appearance, which sometimes gives rise to
a supposition, that it is an organized body.

The only interruption to the discharge, in this case of
abortion, proceeds from the formation of clots, which, how-
ever, are soon displaced. Women, if plethoric, sometimes
suffer considerably, from the profusion of the discharge; but,
in general, they soon recover.

296

If the ovum have acquired the size of a nut, the symptoms
are somewhat different. We have an attempt in the uterus
to contract, which formerly was not necessary ; we have pains,
more or less regular, in the back and hypogastric region ; we
have more disturbance of the abdQminal viscera, particularly
the stomach. The discharge is copious, and small bits of
fibrous substance can often be observed. Sometimes the
vesicle may be detected, in the first discharge of blood, and
will be found to be streaked over with pale vessels, giving it
an appearance as if it had been slightly macerated. In other
instances, it comes enveloped in the vascular portion, or it is
destroyed, and we only discover the decidua torn open, but
still shaped like the uterine cavity. When all the contents
are expelled, a bloody discharge continues for a few hours,
and is then succeedett by a serous fluid. At this time, and
in later abortion, if the symptoms take place gradually, we
may sometimes observe a gelatinous matter to come away,
before the hemorrhage appears.

If the uterus contain more vascular and organized matter,
as in the beginning of the third month, the vesicle never
escapes first ; but we have for some time a discharge of blood,
accompanied or succeeded by uterine pain. Then, the infe-
rior part, or short stalk, of the ovum may be expelled, gorged
with blood, and, afterwards, the upper part equally injured.
Sometimes the whole comes away at once and entire ; but
^this is rare. As considerable contraction is now required in
the uterus, the pains are pretty severe. The derangement
of the stomach is also greater than formerly, giving rise to
sickness or faintness, which is a natural contrivance for
abating the haemorrhage.

When the membranes come to occupy more of the uterus,
and a still greater difference exists betwixt the placenta and
decidua, we have again a change of the process ; we have
more bearing-down pain, and a greater regularity in its
attack ; we have a more rapid discharge, owing to the greater
size of the vessels ; but there is not alwavs more blood lost
now than at an earlier period, for coagula form readily, from
temporary fits of faintness, and other causes, and interrupt
the flow until new and increased contraction displace them.
Often the membranes give way, and the foetus escapes with
the liquor amnii, whilst the rest of the ovum is retained for
some hours or even days,* when it is expelled with coagulated

i^Mj'" "u •*?" *^* plucenta fiirHaioed moch longrr, aftw the rxpulsion of the
child in abortion, than In labour at tbc full time.

■

297

blood perhaps separating and confoundmg its diflPerent parts
or layers. Retention of the secundines, when accompanied
with considerable or repeated haemorrhage, very generally is
dependent on, or connected with, spasmodic contraction of
the uterus, which embraces a very small bit of the upper part
of the placenta. At other times the fcetal and maternal

{>ortions separate, and the first is expelled before the second,
brming a very beautiful preparation. In some rare instances,
we find the whole ovum expeUed entire, and in high preserva^
tion. After the expulsion, the haemorrhage goes ofi; and is
succeeded by a discharge, somewhat resembling the lochia,
and often the abdomen rather enlarges for a time, the morn-
ing sickness continues, the breasts increase, and milk is
secreted, so that if the conception have not been seen, or
exanained, it is difficult for some time to say, whether abor-
tion have been completed. When the uterus at an early
period is emptied, it often feels per vaginam, like a gravid
uterus at a much more advanced stage, and if the abdominal
muscles be hard, and the hypogastrium tense or fttU, an in-
attentive practitioner may make a very great mistake.

In cases of twins, after one child is expelled, either alone
or with its secundines, the discharge sometimes stops, and
the woman continues pretty well for some hours, or even for
a day or two, when a repetition of the process takes place,
and if she have been using any exertion, there is generally
a pretty rapid and profuse discharge. This is one reason,
amongst many others, for confining women to bed for severid'
days after abortion. The second child, may be retained, till
the full time.

There are frequently, for a longer or shorter time before
the commencement of abortion, pain and irregular action in
the neighbouring parts, which give warning of its approach,
before either discharge or contraction t^d^es place ;* unless
when it proceeds from violence, in which case the discharge
may instantly appear. This is the period, at which we can
most effectually interfere, for the prevention of abortion. I
need nA be particular in adding, that we are not to confound
these symptoms, with the more chronic ailments, which ac-
company pregnancy.

A great diversity obtains, in different instances, with regard
to the symptoms and duration of abortion. In some cases
the pains are very severe and long continued; in others short

, • In some eases, shooting pains and tension nrc felt in tlio breasts before abor-
tion, and the patient la feverish.

298

and trifling ; nor is the degree of pain always a correct index
of the force of contraction. Sometimes the haemorrhage is
profnse* and alarming: at other times, although circum-
stances may not be apparently very different, it is moderate or
inconsiderable. Often, the sympathetic effects on the stomach
and bowels, are scarcely productive of inconvenience, whilst
in a greater number of mstances, they are very prominent
symptoms. Spasmodic contraction of the womb, is generally
attended with sickness, vomiting, and faintness.

The OS uteri always becomes soft, and opens during abor*
tion. Sometimes it is felt very high and far back, and in
that case, the anterior surface of the uterus, is felt often press-
ing into the vagina, like a degree of anti version.

I may only add, that, OBteris paribus, we shall find that the
farther the pregnancy is advanced beyond the third month,
and the nearer it approaches to the end of the sixth, the less
chance is there of abortion being accompanied, but the greater
of its being succeeded by nervous affection.

As there is a diversity in the symptoms, so is there also in
the duration of abortion ; for, whilst a few hours in many,
and not above three days in the majority of cases, is sufficient
to complete the process, we find other instances in which it is
threatened for a long time, and a number of weeks elapse
before the expulsion take place.

In some cases, the child appears to be dead for a consid-
erable time, before the symptoms which accompany expulsion
occur. But in a great majority of cases, it is living, when the
first signs of abortion are perceived, and in some instances is
bom alive. The signs by which we judge that the child in
utero is dead, are the sudden cessation of the morning sick-
ness, or of any other sympathetic sjonptom, which may have
been present. The breasts become flaccid. If milk had been
formerly secreted, it sometimes disappears, but in other
instances the contrary happens, and no evident secretion takes
place, until the action of gestation, or at least the life of the
child be lost. In almost every case, however, the breasts
will be found to have lost their firmness. If the pregnancy
had advanced beyond the period of quickening, the motion of
the child will be lost, and a feeling of heaviness will be felt
about the pelvis. When all these signs are observed, and
when they are followed by discharge, and especially when this

uJt7h!^Z^Z •"• P'«^'»®''*c K^ntnWf Iom much blood, unlm the eontraction
feVr bourl "•"• **^ "'* »' ••^«n P«"n«*» of •»»««> •"•▼' bwn lort In a

299

is attended with pain, there can be no doubt that expulsion
will take' place, and it would be improper to preyent it. We
are not, however, to conclude that the child is dead, merely
because it does not move ; and when abortion is threatened
before the term of quickening, this sign cannot enter into our
consideration. The stethoscope can only be of use after the
fifth month, in discovering the bruit du coeur.

When the ovum perishes at a very early period, and is not
imme^ately discharged, we find that the sympathetic signs of
pregnancy disappear, and not unfrequently a serous or
milky fluid comes from the nipples. The woman feels languid
and hot at night, or has fits of sickness, or hysterical symp*
toms ; a discharge of foetid dark coloured fluid takes place
from the vagina, and is often mixed with particles like snufi^.
This continues till all the remains of the ovum have come
away, and then the health and spirits are restored.

If, at a more advanced period, the ovum remain after the
child dies, it is converted either into a mole or hydatids; and
this may also happen, even, at a very early stage of pregnancy.
These cases have already been considered. It is generally
most prudent to obviate symptoms, and wait until the os uteri
open and pains come on. Then we are to be directed by
existing circumstances. Whether the ovum become putrid,
or undergo a change into hydatids, it is reasonable to expect
that the vessels of the uterus, being no longer employed in
the growth of the foetus, should diminish, and become, in the
first case, merely sufficient to nourish the uterus, and, in the
second, to supply the necessities of the substance attached to
the inner surface of the womb ; for, there is a communication
between them, and a discharge of blood attends the expulsion
of either a mole or hydatids, whereas, on the other hand, if
the ovum have perished completely and become putrid, the
discharge is rather a foetid sanies than red blood.

Abortion may, very properly, be divided into accidental
and habitual. The exciting causes of the first class may, in
general, be easily detected ; those giving rise to the second,
are often more obscure ; and, without great attention, the
woman shall go on to miscarry, until either sterility, or some
fatal disease, be induced.

In many cases, there can be no peculiar predisposing cause
of abortion, as, for instance, when it is produced by blows,
rupture of the membranes, or accidental separation of the
decidua; but, when it occurs without any very perceptible
exciting cause, it is allowable to infer, that some predisposing

300

state exists, and this, frequently, consists in an imperfect mode
of uterine action, induced by age, former miscarriages, and
other pauses. It is well known, that women can only bear
children until a certain age, after which, the uterus is no
longer capable of performing the action of gestation, or of
performing it properly. Now, it is observable, that this
incapability or imperfection, takes place sooner in those, who
are advanced in life before they marry, than in those, who
have married and begun to bear children earlier. Thus we
find, that a woman who marries at forty, shall be very apt to
miscarry; whereas, had she married at thirty, she might
have born children, when older than forty ; from which it
may be inferred, that the organs of generation lose their
power, of acting properly, sooner, if not employed, than in
the connubial state. The same cause which tends to induce
abortion, at a certain age, in those, who have remained
until that time single, wiU also, at a period somewhat later,
induce it in those, who have been younger married ; for, in
them we find, that, after bearing several children, it is not
uncommon to conclude with an abortion ; or sometimes after
this incomplete action, the uterus, in a considerable time,
recruits, as it were, and the woman carries a child to the full
time, after which she ceases to conceive.

In the next place, I mention that one abortion paves the
way for another, because, setting other circumstances aside,
it gives the uterus a tendency to stop its action of gestation at
an early period after conception, and therefore it is diflicult
to make a woman go to the fiUl time, after she has miscarried
frequently. This fact has also been explained upon the
principle of repeated abortion weakening the uterus,* and this
certainly may have some influence. The renewed operation
of those causes, wliich formerly induced abortion, may like-
wise account, in many cases, for its repetition. But I am
also inclined, to attribute the recurrence, sometimes to habit
alone, by which I understand that tendency, which a part has,
to repeat, or continue, those modes of acting, which it has
frequently performed, as we see in many diseases of the
stomach and windpipe, spasmodic a£fections of these, and
other organs, being apt to return at the same hour, for a long
time. With regard to the uterus, one remarkable instance is
related by Schubsius, of a woman, who, in spite of every

* ** Per banc Tero contuetudinam nihil iillad inteUigo, quam pmTam Taaorum
uteri laxitatemet indeprovrnienCein humorum Ktagnailonenii ex abortlend Habere
lueplui repetlto inductam-** HoffmAn. Tom. iii. p. 180.

301

remedy, miscarried, twenty-three times, at the third month.
In this, and similar cases, slighter causes applied at the period
when abortion formerly happened, will be sufficient to induce
it, than would be required at another time.

We also find that an excessive or indiscriminate use of
venery, either destroys the power of the organs of generation
altogether, making the woman barren, or it disposes to abor
lion, by enfeebling these organs.

Some slight change of structure in part of the uterus, by
influencing its actions, may, if it do not prevent conception,
interfere with the process of gestation, and produce prema-
ture expulsion. If, however, the part affected be very small,
and near the os uteri, it is possible for pregnancy to go on to
the full time. Indeed, it generally does go on, and the
labour, as may be foreseen, will be very tedious. I knew one
instance, where a very considerable part of the uterus, I may
say almost the whole of it, was found, after delivery, to be
extremely hard, and nearly ossified ; but this state could not
have existed before impregnation took place, for, I cannot
conceive that so great a proportion of the uterus, should have
been originally diseased, and, yet, that conception, and its
consequent actions, should take place. There is less diffi-
culty in supposing that, during the enlarging of the uterus,
the vessels deposited osseous or cartilaginous matter, instead
of muscular fibres.

A general weakness of the system, which must afiect the
actions of the uterus, in common with those of other organs,
is likewise to be considered as giving rise to abortion, though
not so frequently as was at one time supposed.

A local weakness of the uterus, sometimes exists, when the
general system is not very feeble ; or, when the constitution is
delicate, the uterus may be weaker, in proportion, than other
organs. Simple debility, however, is seldom the sole cause
of abortion, for, in most cases, it is conjoined with a state,
prone to irregularity of action, and morbid irritability. In
neither case, can it perform its functions, with the necessary
activity and perfection, but it is very apt, after a time, to flag.
We cannot operate, with medicines, directly upon the womb,
for the purpose of strengthening it, but must act on it, by
invigorating the general system, and attending to all the
functions, performed by other organs, and, more especially,
those of digestion. Sea-bathing is of great service ; and
after impregnation, every exciting cause of abortion must be
guarded against. Women of this description; are generally

302

pale, of a weakly, flabby habit, and subject to irregular, often
to copious menstruation, or fluor albus. When they conceive,
the cold bath, light digestible food, regular bowels, and free
air, should be enjoined; and, if any uneasy sensation be
felt about the uterus or back, or the pulse throb, a little blood
should be slowly taken away, and the woman keep her room
for some days/ Bleeding prevents the womb /om being
oppressed, and it is as necessary to attend to this, as it is to
prevent the stomach from being loaded, in a dyspeptic patient.
On the other hand, were we to bleed copiously, we night
injure the action of the uterus, and destroy the child.

It has been supposed, that abortion mignt arise from rigi-
dity of the uterus, which prevented its distention. But the
uterus does not distend like a dead part, unto which pressure
b applied, but it grows, and therefore I apprehend that an
effect is, here, considered as a primary cause.

The uterus, is not only affected, by the general conditions
of the system, more especially with regard to sensibility, and
the state of the blood vessels, but it, likewise, sympathizes
with the principal organs, and may undergo changes in con-
sequence of alterations in their state.

Thus, we often find that loss of tone, or defective action
of the stomach, produces amenorrhoea, and it may also on
the same principle induce abortion ; on the other hand, the
action of the uterus, may influence that of other viscera, as
we see in pulmonary consumption, which is sometimes in its
early stage, suspended in its progress, during pregnancy; or,
if there be any disposition in an organ to disease, frequent
abortion, partly by sympathy betwi&t the uterus and that
organ, and partly by the weakness which it induces, and the
general injury which it does to the system at large, may
excite the irregular or morbid action of the organ so disposed.

As the action of the uterus is increased, during pregnancy,
it must require more nervous energy, an4 although the size of
the nerves of the uterus be increased, yet we must, to a certain
degree, depend for the increased supply upon the trunks, or
larger portion of the nervous substance from which they
arise ; tor we well know that the quantity of energy expended
in an organ, does not depend upon the size of the nerve in its
substance, but on the trunk which furnishes it. Whenever
action is increased in an organ, it must either perish, or the
larger nerves must send the branches more energy, for, the
branches, themselves, cannot form it, their extremities being
only intended for expending it ; from which it follows, that,

303

in pregnancy, there must be more energy sent to the uterus,
and, most likely, less to some other part. We also find that
increased action, in one organ, may be productive of dimin-
ished action in another, unless excitement, raise general
action, above the natural degree, the consequence of which is,
tbat the power is not sufficient for the action, which becomes
irregular, and the system is exhausted, as we see in febrile
conditions.

There being increased action of the uterus, in gestation,

requiring an increased quantity of energy to support it, we

find that the system is put, pro tempore^ into an artificial state,

and obliged, either, to form more energy, which cannot be so

easily done, or to spend less in some other part. Thus the

function of nutrition, or the action by which organic matter

is deposited, in room of that which is absorbed, often yields,

or is lessened, and the person becomes emaciated, or the

stomach has its action, diminished, or the bowels, producing

costiveness and inflation. If no part give way, and no more

energy than usual be formed, gestation cannot go on, or goes

on imperfectly. Hence, some women have abortion by being

too unsusceptible, that is to say, all the organs persist in

keeping up their action, in perfection and complete degree.

A tendency to abortion, also, results from a contrary cause,
from organs yielding too readily, allowing the uterus to act
too hurriedly. In this state, it is as liable to go wrong, as
the general system is, when it is at the highest degree of
action compatible with health ; the most trifling cause de-
ranges it. Thus sometimes, the intestines yield too readily,
and become almost torpid, so that a stool can with difficulty
be procured. Here costiveness is not a cause of abortion,
though it may be blamed. In like manner, the muscular
system may yield and become enfeebled : and in this instance,
debility is accused as the cause of abortion, although it be»
indeed, only an effect of too much energy being destined for
the uterus. In this case, the woman is always weaker during
menstruation, and gestation, than at other times.

If the neighbouring parts, do not accommodate themselves,
to the changes in the direction of energy, and act in concert
with the uterus, their action becomes irregular, and conse-
quently painful. In this state, the uterus may have its just
degree of power and action ; but other parts may not be able
to act, so well, under the change of circumstances. This is
chiefly the case in early gestation, for, by time, the parts come
to act better. It often gives rise to unnecessary alarm, being

304

mistaken for a tendency to abortion ; but the symptoms are
different. The pain is felt chiefly at night, a time at which
weakened parts always suffer most ; it returns pretty regu-
larly for several weeks, but the uterus continues to enlarge,
the breasts to distend, and all things are as they ought to be,
if we except the presence of the pain. This may be allevi-
ated by bleeding, and sometimes by anodynes ; but can only
be cured by time, and avoiding, by means of rest and care,
any additional injury to parts, already, irregular and ticklish,
in the performance of their actions. If this be neglected,
they will re-act on the uterus at last, and impede its function.
It is therefore highly necessary, especially in those disposed
to abortion, to pay attention to pains about the back, loins, or
pubis : and to insist upon rest, open bowels, and detracting
blood, if the state 6f the vascular system indicate evacuation.

I have already considered the sympathetic effects, produced
on other organs by the state of the uterus, and bave here only
to remark, that when any of these go to an extreme degree,
an injurious effect may be produced on the uterine system.
To avoid repetition, I refer to what I have said, when con-
sidering the disorders of menstruation.

Even although the different organs, both near and remote,
may have accommodated themselves, to the changes in the
uterine action, in the commencement of gestation, the proper
balance may yet be lost, at a subsequent period ; and this is
most apt to take place, about the end of the third, or begin-
ning of the fourth month, before the uterus rise out of the
pelvis : and hence a greater number of abortions take place at
that time, than at any other stage of pregnancy. There is
from that time, to the period of quickening, a greater suscep-
tibility in the uterus to have its action interrupted, than either
before or afterwards ; which points out the necessity of re-
doubling our vigilance, in watching against the operation of
any of the causes, giving rise to abortion, from the tenth to
the sixteenth week.

If the action of gestation go on under restraint, as, for
instance, by a change of position in the uterus, or by its pro-
lapsing too low in the vagma, it is very apt to be accompanied
by uneasy feelings, for, whenever any action is constriuned,
sensation is produced. The woman feels irregular, and pretty
sharp pain in the region of the uterus, and from sympathetic
irritation, both the bladder and rectum may be affected, and
occasionally a difficulty is felt in making water, by which a
suspicion is raised that retroversion is takin^^ place. Some-

395

times the cervical vessels, in these circumstances, yield a little
bloody as if abortion were going to happen ; but, by keeping
the patient at rest, and attending to the state of the rectum
and bladder, no harm is done ; and when the uterus rises out
of the pelvis, no farther uneasiness is felt. Occasionally, a
pretty considerable discharge, may take place under these cir-
cumstances, if the vascular system be full, or the vessels about
the cervix large. But, by care, gestation will go on; for
-discharge alone, does not indicate that abortion must neces-
sarily happen. It, indeed, often causes abortion, and is
almost always an attendant upon it ; but we form our judgment,
not from this symptom alone, but also from the state of the
muscular fibres, and the vitality of the child.

Retroversion of the uterus likewise constrains very much
its action, and may give rise to abortion, though in a greater
number of instances, by care, gestation will go on, and the
uterus gradually ascend. The bowels are to be kept open,
and the urine regularly evacuated.

Sometimes in irritable or hysterical habits, the process of
gestation, produces a considerable degree of disturbance, in
the actions of the abdominal viscera, particularly the stomach;
exciting frequent and distressing retching or vomiting, which
may continue for a week or two, and sometimes is so violent
as to invert the peristaltic motion of the intestines near the
stomach, in which case feculent matter, and, in some instances,
lumbrici are vomited.

This affection, is often accompanied by an unsettled state
of mind, which adds greatly to the distress. We sometimes,
in these circumstances, have painful attempts made by the
muscles to force the uterus downward, and these are, occasion-
aUy, attended by a very slight discharge of blood. We have,
however, no regular uterine pain ; and, if we be careful of
our patient, abortion is rarely produced.

The best practice is to take away a little blood at first, to
keep the bowels open, to lessen the tendency to vomit, by
applying leeches, or an opium plaster, or a small blister, to the
region of the stomach, and to allay pain, by doses of hyoscya-
mus or opium, conjoined with carminatives. Wlien the mind
is much affected, or the head painful, it is proper to shave the
head, and wash it frequently with cold vinegar, or apply
leeches to the temples ; at the same time we keep the patient
very quiet, and have recourse to a soothing management, or
may even use the lancet.

The uterus being a large vascular organ, is obedient to the

306

laws of vasculdr action, whilst the ovum is more influenced by
those regulating new formed parts ; with this difference, how-
ever, that new formed parts or tumours, are united finnly to
the part from which they grow, by all kinds of vessels, and
generally by fibrous or cellular substance, whilst the ovum is
connected to the uterus, chiefly by very tender and fragile
arteries and veins. If, therefore, more blood be sent to the
maternal part of the ovum, than it can easily receive, and
circulate, and act under, rupture of the vessels will take
place, and an extravasation and consequent Separation, be
produced; or, even when no rupture is occasioned, the action
of the ovum may be so oppressed and disordered, as to unfit
it for continuing the process of gestation. There must, there*
fore, be a perfect correspondence betwixt the uterus and the
ovum, not only in growth and vascularity, but in every other
circumstance connected with their functions.

Even when they do correspond, if the uterus be plethoric,
the ovum must also be full of blood, and rupture is very apt
to take place. This is a frequent cause of abortion, more
especially in those who menstruate copiously. On the other
hand, when the uterus is deficient in vascularity, which often
happens, in those, who menstruate sparingly or painfully, or,
who have the menses pretty abundant, but watery, the child
generally dies before the seventh month, and is expelled.
The process is prematurely and imperfectly finished.

The existence of plethora is to be considered as a very
frequent cause of abortion, and requires most particular
attention. It more especially obtains in the young and
vigorous, or in those who live luxuriously, and sleep in soft,
warm beds. It renders the uterus too easily supplied with
blood : the increase is not made in the regular degree, corre-
sponding to the gradual increase of action, and augmentation
of size ; but it is, if I may use the expression, forced on the
uterus, which is thus made, for a time, to act strongly and
rapidly. It is not, however, to be supposed that plethora
acts mechanically, for the evil arises, rather, from the effect it
produces on the nervous system, and when this is excited
either by this state of the vessels, or by any accidental or
concurrent cause, the re-action on the vascular system is
powerful, and we have hemorrhage, or inflammation, &c.,
produced. Or if an organ be, alreaidy, in a state of increased
activity, it is apt to be disordered. The action of the uterus
thus excited, is sometimes so great, that the person feek
weight, throbbing, and shooting pains about the pelvis ; but.

307

in other instances, the vessels suddenly give way, without
previous warning, and the blood bursts forth at the os uteri.
This cause is especially apt to operate, in those who are newly
married, and who are of a salacious disposition, as the action
of the uterus is thus much increased, and the existence of
plethora rendered doubly dangerous. In these cases, when-
ever the menses have become obstructed, all causes tending
to increase the circulation must be avoided, and often a
temporary separation from the husband is indispensable*
Often do we find, that slight exertion, within a fortnight
after the menses stop, will produce a speedy and violent
eruption of blood, which continues until the vessels be fully
unloaded, and until all that part of the process of forming an
ovum, which had been effected, be undone.

It is not difficult to conceive, how an excitement of the
origin of the spinal nerves, whether produced by some cause,
mental or corporeal, acting immediately on them, or, by such
causes, as occasion turgescence of the vessels, in their vicinity,
should have a powerful influence on the uterus. The state
of the nervous system, has therefore, often, even a more de-
cided effect in predisposing to, or actuallj/^pro'ducing abortion,
than the condition of the vascular system. Those who are
peculiarly excitable, or who have any deviation from the
nealthy state of action, or susceptibility of the medulla spinalis
or sympathetic nerve, are thereby liable to abortion. This
concuiipn, often passes for one of mere debility, and the error
is canrnmed, by sometimes finding that tonics and cold bathing
lessen it. When they do so, it is by diminishing the morbid
susceptibility of the nervous system, and rendering it more
perfect in its function. Many causes which are capable oS
acting also, in another way, on the uterus, do often produce
their effect in this manner, by affecting Uie nerves supplying
the uterus ; surprise, fatigue, &c., are of this kind. A state
of plethora, which I have already noticed, as giving a strong
predisposition to abortion, is greatly more hazardous, when
combined with increased susceptibility of the nervous system,
or of its uterine portion.

Abortion necessarily implies separation of the ovum, which
may be produced mechanically, or by spontaneous rupture of
the vessels, or by an affection of the muscular fibres. It
unavoidably requires for its accomplishment, contraction of
those fibres which formerly were in a dormant state. A natural
and necessary effect of this contraction, is to develop the
cervix uteri. This, when gestation goes on regularly, is

308

accomplished gradually and slowly, by the extension and
formation of fibres. In abortion no fibres are formed, but
muscular action does all, except in those instances, where the
action of gestation goes on irregularly and too fast ; in which
case, the cervix distends, sometimes by the third month, by
the same process which distends the fundus. But, much more
frequently, the cervix only relaxes during abortion, as the os
uteri does in natural labour, and yields to the muscular action,
of the fundus and body, or distended part.

The existence and growth of the foetus, depend on the foetal
portion of the ovum. The means of nourishment, and the
accommodation of the foetus, in respect of lodgement, depend
on the uterus; and these circumstances requiring both foetal
and maternal action, are intimately connected. The condi-
tion of thq uterus qualifying it to enlarge, to continue the
existence and operation of the maternal portion of the placenta
or ovum, and to transmit blood to the ovum, exactly in the
degree correspondent to its want, constitutes the action of
gestation. When the action of gestation ceases, pniversally,
in the uterus, another action, namely, muscular contraction^
begins, and then all -hope of retaining the ovum any longer is
at an end.* I am aware that there are cases, where pain has
come in paroxysms, and even the os uteri has been afiected,
and yet no expulsion has taken place. But it is not proved
labour bad actually begun. We know that pain, like that of
labour, is often felt long before the patient is confined, but we
have no evidence, that, in any of these cases, the uterus be-
comes, universally, hard during the pain, '^indicating general
muscular contraction. I do not deny the possibility of partial
muscular action occurring, without expulsion following. The
OS uteri may be prematurely developed ; it may be open for
some weeks even without pain ; but no man will say that, in
this case, labour or uterine contraction has begun. We may
even have partial muscular action, in a few cases, about the
cervix uteri, which has less to do with the action of gestation,
than the rest of the uterus ; and this action is often attended
with considerable pain or uneasiness. Sometimes it is con-
nected, with convulsive agitation, of several of the external
muscles of the body. Even in this case, expulsion does not
always immediately take place, for, by bleeding, and rest, and
opiates, the motion may sometimes be checked ; but regular

• It may appear to be • ttrong arfument Bgaintt thit, that in cases of t'jjnj'
one child inav be expelled, and another retained. But in such, the one expelled,
U generally blighted, and there is no eridence that the whole uterus had eontractod.

>l^

309

and universal action of the muscular fibres of the uterus, tiever
yet has been stopped. It may, like other muscular actions,
be suspended, by anodynes or artificial treatment; but it never
has, and never can be stopped, otherwise than by the expul-
sion of the ovum, when a new train of actions commences.
Whenever, then, at any period of pregnancy, we have parox-
ysms of pain in the back,* and region of the uterus, attended
with feeling of weight in that region, tenesmus, micturition,
descent of the uterus in the pelvis, and opening of the os
uteri, we may be sure that expulsion, though retarded, must
soon take place. This fact is not always attended to, in
abortion, for, many think, that if by anodynes, they can abate
the pain, they shall make the woman go to the full time.
This is true with regard to many painnil sensations, which
may attend a threatened abortion, or which may be present,
although there be no appearance of abortion ; and when the
OS uteri is not opened, we do not despair, although, the
sanguineous discharge be considerable, if the liquor amnii be
not evacuated, or the child dead ; but it does not hold with
regard to those regular pains, proceeding from universal
action of the uterine fibres, and accompanied with dilatation
of the OS uteri. We may save, both ourselves and our patients,
some trouble, by keeping this in remembrance.

Seeing, then, that uterine contraction is brought on^ by
stopping the action of gestation, and that, when it is brought
on, it cannot be checked, nor the action of gestation restored,
we must next inquire how this action may be stopped. I
have already mentioned several circumstances, affecting the
uterus, and likely to injure its actions ; and these I shaU not
repeat, but go on to notice some others, which are often more

Eerceptible : and first I shall mention violence, such as falls,
lows, and much fatigue, which may injure the child, and
detach part of the ovum. If part oi the ovum be detached,
we have not only a discharge of blood, but also the uterus, at
that part, suffers in its action, and may influence the whole

* It may not be improper to mention, that in some febrile affcctloaa we have
pain in the ImicIc and loins, occasionally remitting, or disappearing altogether, for
a short mee, and then returning. Sometimes along with this, we have, owing
Co the affection of the circulation, and in some instances to previous exertion, a
•light discharge from the vessels about the os uteri. The state is distinguished
ftom uterine contraction, bv our finding that the cervix is unaffected, that the
pains are increased by motion or pressure, and are more irregular than those
attending labour. This state may he prevented from inducing abortion, by rest,
by keeping the bowels open, by anodynes preceded bv venesection, if the pulse
Indicate it. Frictions, with camphorated spirits or wine, or laudanum, give
relief. Any exertion) during the remaining period of gestation, will renew the
pain in the back.

310

organ, so as to stop the action uniyersally. But the time re-
quired to do this is various : an opportunity is often given to
prevent the mischief from spreading, and to stop any farther
effusion — perhaps to accomplish a re-union.

Violent exercise, as dancmg, for instance, or much walking,
or the fatiguing dissipations of fashionable life, more especially
in the earlier months, by disordering the nervous system, and
affecting tiie circulation, may vary the distribution of blood
in the uterus, so much, as to produce rupture of the vessels,
or, otherwise, to destroy the ovum. There is also another
way in which fatigue acts, namely, by subducting action and
energy from the uterus : for the more energy that is expended
on the external muscles, or those of the inferior extremities,
the less can be afforded, or directed, to the uterus ; and hence
abortion may be induced at an early stage of gestation.*
Fatigue also, by the effect produced on the medulla spinalis,
may directiy injure the nerves of the uterus. Even, at a more
advanced period, inconvenience will be produced upon the
principle formerly mentioned; for, the nerves of the loins
conveying less energy, in many instances, though not always,
to the muscles, they are really weaker than formerly, and are
sooner wearied, producing pain, and prolonged feeling of
fatigue for many days after an exertion, which may be consid^
ered as moderate. This feeling must not be confounded with
a tendency to abortion, though it may sometimes be combined
with it, for generally by rest the sensation goes off. Neither
must we suppose that the child is dead, ft'om its being unusu-
ally quiet during that period, for as soon as the uterus, which
has been a littie impaired in its action, recovers, it moves as
strongly as ever.

In the next place, I mention the death of the child, which
ma;^ be produced by syphilis, or by diseases perhaps peculiar
to itself, or, by that state, which produces too much liquor
amnii, or by injury of the functions of the placenta, which may
arise from an improper structure of that organ itself, or
aneurism, or other diseases of the cord. But in whatever way
it is produced, the effect is the same in checking the action of
gestation, unless there be twins, in which case it has been
known, that the uterus, sometimes, did not suffer universally
but the action went on, and the one child was bom of the

* The aame effect is obscTTsble in the etomach and other orftnt. If a delioUe
person, after a hearty meal, use exercise to the extent of fatigue, ha feels that
the foo4) is not digested, tlie stomach having been weakened or injured In Ita
Actions.

311

fiill size, the other small and injured.* The length of time
required for producing abortion, from this cause, is various ;
sometimes it is brought on in a few hours ; at other times not
for a fortnight, or even longer. In these and similar cases,
when the muscular action is commencing, the discharge is
trifling, like menstruation, until the contraction become greater,
and more of the ovum be separated. When symptoms of
abortion proceed from this cause, it is not possible to prevent
its completion ; and it would be hurtful even if it were possi-
ble. When, therefore, after great fatigue, profuse evacua-
tions in delicate habits, violent colic, or other causes, the
motion of the child ceases, the breasts become flaccid, and the
signs of gestation disappear, we need not attempt to retard
expulsion, but should direct our principal attention, to con-
duct the woman, safely, through the process.

Another cause is, any strong passion of the mind. The
influence of fear, joy, and other emotions, on the nervous
system, is well known, and the nerves of the uterus, are not
exempted from their power ; any sudden shock, even of the
body, has much effect on this organ. The pulling of a tooth,
for instance, sometimes suddenly produces abortion. A
thunder storm or violent cannonade, has been supposed to
cause abortion by the concussion of the air ; but when they
have that effect, it is owing to mental trepidation.

Emmenagogues, or acrid substances, such as savin and
other irritating drugs, more especially those, which tend to
excite a considerable degree of vascular action, may produce
abortion. Ergot does not seem to have the power.

Such medicines, likewise, as exert a violent action on the
stomach or bowels, will upon the principle formerly men-
tioned, frequently excite abortion ; and very oflen are taken
designedly, for that purpose, in such quantity, as to produce
fatal effects ;t hence emetics, strong purgatives, diuretics, or
a fuU course of mercury, must be avoided during pregnancy.

* I lutTe already noticed, that, sometimes in consequence of the death of one'
child, the uterus has suffered partially, and expulsion taken place ; but the other
child continuing to live, iias preserved the action of gestation in that part of the
uterus, which, properly speaking* belonged to it, and pregnancy has still gone on.
This, however, is an extremely rare occurrence ; for in almost everjr instance,
the death of one child, produces an affection of the action of gestation, in the
whole uterus, and the consequent expulsion of both children. In Mr. Chalmers*
case, a blighted fsetus and placenta were expelled In the seventh month, whilst a
living child, which had been retained, was bom at the full time. Med. Reposit.
ix. IM.

t It is an old observation, that those purgatives which produce much tenes-
mus, will excite abortion : and this is certalnlv true, if their operation be carried
to a considerable extent, and continue long violent. Hence dysentery is also apt
U% bring on a nuscarriage. Those strong purges, which are sometimes taken, to

312

If any part with which the uterus sympathizes, have its
action greatly increased, during pregnancy, the uterus may
come to suffer, and abortion be produced. Hence, the
accession of morbid action or inflammation, in any important
organ, or on a large extent of cuticular surface, may bring
on miscarriage, which is one cause, why small-pox often
excites abortion, whilst, the same degree of fever, unaccom-
panied with eruption, would not have that effect. Hence,
also, increased secretory action in the vagina, if to a great
degree, though it may nave even, originally, been excited in
consequence of sjrmpathy with the uterus, may come to in-
capacitate the uterus, for going on with its actions, and,
therefore, it oug^t to be moderated, by means of an astringent
injection. Even, when there is no immediate and natural
sympathy, a violent local ulment may disorder the whole frame,
so as to injure the uterine action. An obstinate pleurisy, for
instance, particularly if we require to bleed, freely, to subdue
it, generidly is followed by premature labour. Typhus fever
frequently causes abortion, and a very considerable proportion
of these cases end fatally, owing to peritoneal inflammation.

Mechanical irritation of the os uteri, or attempts to dilate
it, prematurely, will also be apt to bring on muscular con-
traction. At the same time, it is worthy of remark, that the
effect of such irritation is generally, at first, confined ta the
spot on which it acts, a partial affection of the fibres in the
immediate vicinity of the os uteri being all that is, for some
time, produced ; and therefore^ slight uneasiness at the lower
part of the belly, with or without a tendency in the os uteri
to move or dilate, whether brought on by irritation at the
upper part of the vagina or os uteri, or by the affection of
the neck of the bladder, &c., may be often prevented from
extending farther, by rest, anodynes, and having immediate
recourse, to such means, as the nature of the irritation may
require, for its removal.*

J promote pmoatare ezpulsion, not only act by excHing tenesmat, bat likewiae by
nflaming the ttomacn and bowels, and thus affect the uteraa in two ways. Ic
cannot be loo generally known, that when these mediclnea do produce abortion^
the mother can seldom surviTS their effect. It ia a mistaken notion, that abor-
tion can be most readily excited by drastic purges, frequent and copious blecdingt
ftc, immediately after the woman discorrrs herself to be pregnant: on the con-
trary, the action of the uterus is then more independent of tnat of other organs,
and therefore not so easily injured by changes in their condition. I have already
shown, that abortion more frequently happens, when the pregnancy is farther
advanced, because then, not only the uterus is more easily affected, but the fsBtus
seems to suffer more readily. It is apt, either from diseases directly affecting
Itself, or from changes in the uterine action, to die about the middle or the third
month, in which case expulsion follows witliin a fortnight.
* Chronic inflammation of the heart is frequently attended with pain at tb«

313

The irritation of a prolapsus ani, or of inflamed piles, with
or without, much sanguineous discharge, may excite the uterus
to contract; and if the bleeding from the anus have been
profuse, and the woman weakly, it may destroy the child,
riles ought, therefore, never to be neglected.

Tapping the ovum, by which the uterus collapses, and its
fibres receive a stimulus to action, is another cause by which
abortion may be produced ; and this is, sometimes, with great
propriety, done at a particular period, in order to avoid a
greater evil. It is now the general opinion, that contraction
will unavoidably follow the evacuation of the waters. But
we can suppose the action of gestation to be, in some cases, so
strong, as not, at least for a very considerable time, to stop in
consequence of this violence, and, if it do not stop, contrac-
tion will not take place. I do not, however, mean to say, that
all discharges of watery fluid from the uterus, not followed by
abortion, are discharges of the liquor amnii. On the contrary,
I know, that these are, often, the consequence of morbid
action about the os uteri, the glands yielding a serous, instead
of a gelatinous fluid, and this action may continue for many
months.

In all these cases, the woman must be confined to bed, and
have an anodyne every night at bedtime, for some time,
premising venesection if the pulse indicate it, and conjoining
gentle laxatives. There is just so much probability of ges-
tation going on, as to encourage us to use endeavours to
continue it. In those instances where the discharge is small,
and the oozing pretty constant, we conclude that it is yielded
chiefly by the glands about the os uteri, and may derive
advantage from injecting, three or four times a-day, a strong
infusion of galls, or solution of alum. The woman ought to
use no exertion, as the membranes are apt to give way.

It is sometimes necessary to lay down rules for the manage-
ment of pregnant women, even although they may not have
been liable to abortion. These are to be drawn, from the
remarks already delivered, and it is only requisite to add, that
in all cases, it is proper to attend to the efiects of utero-gesta-
tion, or the diseases of pregnancy, which are to be mitigated,
when severe, by suitable remedies.

The danger of abortion, is to be estimated, by considering
the previous state of the health, by attending to the violence
of the discharge, and the difficulty of checking it; to its

bottom of the abdomen, wbich is Mmetimet miitaken for lymptoms of calcului.
Jn one ease abortion seemed to proceed from this diteate of the heart.

314

duration, and the disposition to expulsion, which accompanies
it ; to the effects which it has produced, in weakening the
system, and to its comhination with hysterical or spasmodic
affections. In general, we say that abortion is not dangerousi
yet, in some cases, even at a very early period of gestation,
and under vigorous treatment, it does prove fatal very speedily,
either from loss of blood, or spasm in the stomach, or convul-
sions. I knew one instance, and have heard of more, which
proved fatal, so early, as the end of the second month. It is
satisfactory, however, to find, that this termination is rare,
that these dangerous attendants are seldom present, and that
a great haemorrhage may be sustained, and yet the strength
soon recover. But if there be any disposition in a particiuar
organ to disease, abortion may make it active, and thus, at a
remote period, carry off the patient. Miscarriages, if fre-
quently repeated, are also very apt to injure the health, and
break up the constitution. Severe or fatal inflammation of
the uterus, or peritoneum, may follow abortion at a very early
period, especially, if any puerperal epidemic exist.

When abortion is threatened, the process is very prone to
go on to completion ; and it is only by interposing, before
the expulsive efforts have begun, that we can be successful in
preventing it; for, whenever the muscular contraction is
universally established, marked by regular pains, and attempts
to distend the cervix and os uteri, nothing, I believe, can
check the process. As this is often the case before we are
called, or, as in many instances, abortion depends on the
action of gestation, being stopped by causes, whose action
could not be ascertained, until the effect be produced, we shall
frequently fail in preventing expulsion.

This is greatly owing to our not being called, until abortion,
that is to say, the expulsive process, have begun ; whereas,
had we been applied to upon the first unusual feeling, it might
have been prevented. What I wish then particularly to
inculcate is, that no time be lost, in giving notice of any
ground of alarm, and that the most prompt measures, be had
recourse to, in the very beginning ; for, when universal uter*
ine contraction has commenced, then all that we can do, b to
conduct the patient safely through a confinement, which the
power of medicine cannot prevent.

The case of threatened abortion, in which we most fre-
quently succeed, is that arising from slipping of the foot, or
from causes exciting a temporary over-action of the vessels,
producing a slight separation : because here the haemorrhage

315

immediately gives alarm, and we are called before the action
of gestation be much affected. Could we impress upon our
patients, the necessity of equal attention, to other preceding
symptoms and circumstances, we might succeed in many cases,
where we fail from a delay, occasioned by their not under-
standing that an expulsion can only be prevented, by inter-
fering before that process begins ; for when sensible signs of
contraction appear, the mischief has proceeded too far to be
checked. Prompt and decided means, used upon the first
approach of symptoms, indicating a hazardous state of the
uterus, or on the earliest appearance of haemorrhage, may,
provided the child be still alive, be attended with success.

In considering the treatment, I shall, first of all, notice the
most likely method, of preventing abortion, in those who are
subject to it ; next, the best means of checking it, when it is
immediately threatened; and, lastly, the proper method
of conducting the woman through it, when it cannot be
avoided.

The means to be followed, in preventing, what may be
called habitual miscarriage, must depend on the cause, sup-
posed to give rise to it. It will, therefore, be necessary to
attend to the history of former abortions ; to the usual habi-
tudes and constitution of the woman ; and to her condition
when she becomes pregnant.

In many instances, a plethoric disposition, indicated by a
pretty fiiU habit, and copious menstruation, will be found to
give rise to it. In these cases, we shall find it of advantage
to restrict the patient, almost entirely, to a vegetable diet,
and, at the same time, make her use considerable and regular
exercise.

The sleep should be abridged in quantity, and taken, not
on a bed of down, but on a firm mattress, at the same time
that we prevent the accumulation, of too much heat, about
the body. The bowels ought to be kept open, or rather loose,
which may be effected by drinking Cheltenham water, or
taking some other laxative. We must not, however, carry
this plan too far, nor make a sudden revolution in the con-
stitution, as this may be productive of permanent mischief,
and occasion the diseases which proceed from a broken habit.
Whenever the strenffth is diminished, the appetite impaired,
or any other bad effect is produced, we have gone too great
length.

There is, in plethoric habits, a weakness of many, if not
all of the functions ; but this is not to be cured by tonics,

316

but by continued and very gradually increased esercise, laxar
tives, and light diet, consisting chiefly of vegetables. This
plan, however, must not be carried to an imprudent length,
nor established too suddenly, but, regard is to be had to the
previous habits. It is a general rule, that exercise should not
be carried the length of fatigue, and that it should be taken,
if possible, in the country, whilst late hours, and many of
the modes of fashionable life, must be given up. We must
remember, that an excitable state of the nervous system, is
apt to take place, and must endeavour, to lessen this, by strict
attention to the bowels, friction, with some stimulating embro-
cation, on the spine, and the use of the shower bath, or sea
bathing, if they do not produce chillness or languor. There
is, I believe, no remedy more powerful, in preventing abor-
tion, than the cold bath, and the best time for using it is in
the morning. By means of this, conjoined with attention
to the vascular system, and prudent conduct on the part of
the patient, I suppose that nine-tenths of those who are
subject to abortion, may go on to the full time. If the
shower bath be employed, we must begin with a small quan-
tity of water, and, in some instances, may, at first, add so
much warm water, as shall make it just feel cold, but not to
give too great a shock. If the cold bath cause headach, this
may, often, be prevented, by premising one or two doses of
physic. Sea water can often be borne, when fresh water
disagrees.

After conception, the exercise must be taken with circum-
spection : but the diet must still be sparing, and the use of
the cold bath continued. If the pulse be at any time full, or
inclined to throb, or if the patient be of a vigorous habit, a
little blood should be taken away, at a very early period. In
some cases, where the action is great, we must bleed, almost
immediately, after the suppression of the menses. It is not
necessary to bleed copiously ; it is much better to take away
onlv a few ounces, and repeat the evacuation when required,
and we should matiage so as to avoid fainting. The cold
bath should be conjoined.*

When there is much aching pain in the back, it is of
service to apply occasionally cloths to it, dipped in cold water,

T J^^ uetat« of iMid, has been recommended by the late ingenloui and justly
celebrated Dr. Uueh of Philadelphia, in doeet of from one to diree grains, given
Iw.T^rll'"? ^^f' Of this practice I cannot apeak from mrown cxperienea;
suacwT' informed me, that in his hands it had been attended filth great

317

or gently to dash cold water on it ; or employ a partial shower
bath, by means of a small watering-can.

In this, as in all other cases of habitual abortion, we. must
advise, that impregnation shall not take place, until we have
corrected the system : and after the woman has conceived, it
is proper that she live absque marito^ at least until gestation
be well advanced. I need hardly add, that when consulted
respecting habitual abortion, the strictest prudence is required
on our part, and that the situation of the patient, and many
of our advices, should be concealed from the most intimate
friends of the patient.

In other cases, we find that the cause of abortion, is con-
nected with sparing menstruation. This is often the case
with women, whose appearance indicates good health, and
who have a robust look. This is not often to be rectified by
medicine, but it may by regimen, &c. Here, as in the former
case, we find it useful to make the greatest part of the diet
consist of vegetables ; but it is not necessary to restrict the
quantity.

When, on the other hand, the patient has a weakly, deli-
cate, appearance, it will be proper, to give a greater pro-
portion of animal food, and two glasses of wine, in the after-
noon, with some mild bitter laxative, so as to strengthen the
stomach, and, at the same time, keep the bowels open.

We also derive, in both cases, advantage from the daily
use of the salt water bath, made of a pleasant temperature ;
but this is to be omitted after conception, at least for the
first ten or twelve weeks, after which, if there be symptoms
of irritation, or feeling of tension about the belly, or pain
about the groins or pubis, it may be employed, and is both
safe and advantageous. But when the patient is of a phleg-
matic habit, or subject to profuse fluor albus, it is not indi-
cated, and sometimes is pernicious. The internal use of
Bath water, previous to conception, is often of service.

I have already mentioned, that abortion is sometimes the
consequence of too firm action, the different organs refusing
to yield to the uterus, which is thus prevented, from enjoying
the due quantity of energy and action. These women, have
none of the diseases of pregnancy, or they have them in a
slight degree. They have good health at all times, but they
eiuier miscarry, or have labour in the seventh or eightn
month, the child being dead ; or if they go to the full time, I
have often observed the child to be sickly, and of a constitu-
tion unfitting it for living. Blood-letting is useful, by making

318

the organs more susceptible. The tepid (not hot) bath is, in
general, of advantage, and may be employed every second
evening for some time.

There is another case, in which, all the functions are
healthy and firm, except the circulation, which is accelerated
by the uterine irritation. This is more or less the case, in
every pregnancy, but here, it is a prominent symptom. The
woman is very restless, and even feverish, and apt to miacacry,
especially if she be of a full habit. I am satisfied that, in
many, instances, this state is produced, by irritation of the
origin of the cardiac nerves, and is quite independent of
plethora. Immediate relief ia ^ven by venesection, which is
the only effectual remedy, but must not be carried to an
extreme degree. The bowels are also to be kept regular.

When, on tfae contrary, abortion arises from too easy
yielding of some organ, we must keep down uterine action,
by avoiding venery, and pouring cold water, every morning,
from a watering-can, upon the loins and ilia; at the same
time we must attend, to the state of the organ, sympathizing
with the uterus.

system
weaknee
bedtime

It is
history
causes:
case, it
yielded <
with pre

Gene
abortion

exhibitio
wearing
practice.

319

SypbiE* ii likense a caaae of abonioa. niwa it «ec^rs
in the mother, it oA^ miiB ibe ucras. for emus on vith
its actioiis. At otlwr times, Bbarv especuUr, whea die &tb«r
taboon mdcr Ttncnmi hierac^ or bAS du* be«n cwpletelT
cored, ibe child is c^ideotlv af«ci^ and ofiea dies, beAire
tbe procejB of ee:itatk»a can be cooipleted. In these cases,
A coorae of iDeTcarT, ak>oe, can effect a mre- Bot ve are
not to snppoee tbat ererr cbUii, bom viihoui tbe cutk-te, in
an emi^ stale of presnancy. ha^ fodered from tbij cause ; oo
the eoutiarr, as some of these instances, depend on causes
already aentianed, and which cannot be cured bv merrurr. I
wish to 'TTtiTFit tbe student asain^ too ba^tilT concludinsr,
that one of tbe {nrents has been diseased, becanse the child is
bom dead, or putrid, at an eaHv period. It b not always
ean to form a correct jod^menl ; bat we may be asasted by
fnding tbat tbe other causes, which I bare sientitHied, are
absent, that we bare appearances of ulceration on tbe <^d,
and that there are sane sospicioos circumstances, in tbe former
histivy, and |geagnt health, of tbe parents. A child may
be bom dead, and even putrid, not only in consequence of
syphilis, but alao of some malfwinaticm of the ftetus itself, or
<^ its appendages ; or, of a general imperfectiMi ot the ovum,
osoaDy, comlNned with an increased quantity ot liqwu- amnii ;
or, of crigiual detnlity of constitution, unfitting the child for
conung to uiatuiitj ; or, of &tal doangement ^ stracture, m-
action, taking fdace in utero, from causes not rerj obrioaF ;
or, frmn weakneaa w imperfect action of the uterus itBclL or

318

the organs more susceptible. The tepid (not hot) bath is, in
general, of advantage, and may be employed every second
evening for some time.

There is another case, in which, all the functions are
healthy and firm, except the circulation, which is accelerated
by the uterine irritation. This is more or less the case, in
every pregnancy, but here, it is a prominent symptom. The
woman is very restless, and even feverish, and apt to miscasry,
especially if she be of a full habit. I am satisfied that, in
many ^instances, this state is produced, by irritation of the
origin of the cardiac nerves, and is quite independent of
plethora. Immediate relief is given by venesection, which is
the only effectual remedy, but must not be carried to an
extreme degree. The bowels are also to be kept regular.

When, on the contrary, abortion arises from too easy
yielding of some organ, we must keep down uterine action,
by avoiding venery, and pouring cold water, every morning,
from a watering-can, upon the loins and ilia; at the same
time we must attend, to the state of the organ, sympathizing
with the uterus.

Sometimes, it is the stomach which is irritable, and the
person is often very sick, takes little food, and digests ill. A
small blister, or leeches applied to the pit of the stomach
often relieves this ; a little of the compound tincture of bark,
taken three or four times a-day, is serviceable ; or a few drops
of the tincture of muriated iron, in a tumbler glassful of
aerated water. At other times, the bowels yield, and the
patient b obstinately costive. This is. cured by aloe tic pills,
or manna, with the tartrate of potass. When the muscular
system yields, producing a feeling of languor and general
weakness, the use of the cold bath, with a grain of opium at
bedtime, will be of most service.

It is evident, that it is only by attending, minutely, to the
history of former miscarriages, that we can detect these
causes : and we shall generally find, that in each individual
case, it is the same organ, in every pregnancy, which has
yielded or suffered. Previous to future conception, we may,
with propriety, endeavour to render it less easily effected.

General weakness, is another condition, giving rise to
abortion ; and upon this I have already made some remarks.
I have here only to add, that the use of the cold bath, the
exhibition of quinine alone, or with sulphate of iron, and
wearing flannel next the skin, constitute the most successful
practice.

319

Syphilis is likewise a cause of abortion. When it oecurs
in the mother, it often unfits the uterus, for going on with
its actions. At other times, more especially, when the father
labours under venereal hectic, or has not been completely
cured, the child is evidently affected, and often dies, before
the process of gestation can be completed. In these cases,
a course of mercury, alone, can effect a cure. But we are
not to suppose that every child, bom without the cuticle, in
an early state of pregnancy, has suffered from this cause ; on
the contrary, as some of these instances, depend on causes
already mentioned, and which cannot be cured by mercury, I
wish to caution the student against too hastily concluding,
that one of the parents has been diseased, because the child is
bom dead, or putrid, at an early period. It is not always
easy to form a correct judgment ; but we may be assisted by
finmng that the other causes, which I have mentioned, are
absent, that we have appearances of ulceration on the child,
and that there are some suspicious circumstances, in the former
history, and present health, of the parents. A child may
be bom dead, and even putrid, not only in consequence of
syphilis, but also of some malformation of the foetus itself, or
of its appendages ; or, of a general imperfection of the ovum,
usually, combined with an increased quantity of liquor amnii ;
or, of original debility of constitution, unfitting the child for
coming to maturity ; or, of fatal derangement of structure, or
action, taking place in utero, from causes not very obvious ;
or, from weakness or imperfect action of the uterus itself, or
such a condition as sometimes produces epilepsy ; or, it is in
certain cases occasioned by a convulsion. Most of these
causes are not under our control ; and indeed, with the excep-
tion of the case of syphilis, we can only propose to prevent
the death of the child, by the use of such general means, as
invigorate the constitution of the parent, or, as obviate palpa-
ble, predisposing causes of injury, to the uterine functions.
I believe tnat the health of the father has a material influence
on the p^fection of the ovum, and that it is too much over-
looked in considering both sterility and abortion. Males
subject to insanity, or epilepsy, may be referred to.

Advancement in life, before marriage, is another cause of
frequent abortion, the uterus being then somewhat imperfect
in its action. In general we cannot do much in this case,
except avoiding carefully the exciting causes of abortion;
and, by attending minutely to the condition of other organs.

320

during menstruation or pregnancy, we may, from the princi-
ples formerly laid down, do some good.

It is satisfactory to know, that although we may fail once
or twice, yet, by great care, the uterus comes, at last, to act
more perfectly, and the woman bears children at the full
time.

After these observations, it is only necessary to add, that
in every instance of habitual abortion, whatever the condition
may be which gives rise to it, we find it is essential, that the
greatest attention be paid, to the avoiding of the more evident,
and immediate, exciting causes of miscarriage, such as fatigue,
dancing, &c. In some cases, it may even be necessary to
confine the patient to her room, until the period at which she
usually miscarries is past.

When abortion is threatened, we come to consider whether,
and by what means, it can be stopped. I have already
stated my opinion, that when the action of gestation ceases,
it cannot be renewed, and, that universal contraction of the
uterine fibres, is a criterion of this cessation.

But there are many cases, where it must be doubtful, if this
universal contraction have taken place, and, therefore, where
it is necessary, that we proceed on the most favourable suppo-
sition. Farther, as some of the means which may be supposed
useful in preventing a threatened abortion, are also useful in
moderating the symptoms attending its progress, we may
properly have recourse to them. Some causes giving rise to
abortion do not immediately produce it, but give warning of
their operation, producing uneasiness in the vicinity of the
uterus, before the action of that organ be materially affected.
The detraction of a little blood at this time, if the pulse be in
any measure full or frequent, or, if the patient be not of a
habit forbidding evacuations, and the subsequent exhibition
of an anodyne clyster, or a full dose of opium,* together
with a state of absolute rest, in a recumbent posture, for some
days, will often be sufficient to prevent further mischief, and
constitute the most efficacious practice. The patient should
be strictly confined to bed, sleeping with few bedclothes,
and without a fire in her apartment. Indeed, the very first
thing to be done, on entering her room, is to order the
patient to bed. The diet should, in general be low, consist-

• Opiatet are of tignal benefit In t)iU •ituation, and should seldom be omitted
after venesection.

321

ing of dry toast, biscuit, and fruit ; and much fluid, especially
warm fluid, should be avoided.

This is the time, at which we can interfere, with the most
certain prospect of success, and the greatest attention should
be paid to the state of the rest of the system, removing uneasi-
ness, wherever it is present, and preventing any organ from
continuing in a state of undue action. It is difficult to per-
suade the patient, to comply with that strict rule, which is
necessary at this period; but, being persuaded, that if this
period^ be allowed to pass over with neglect, and contraction
begin, nothing can afterwards prevent abortion, I wish, par-
ticularly, to impress the mind ot the student, with a due sense
of its importance ; and I must add, that as after every appear-
ance of morbid uterine actioti is over, the slightest cause will
renew our alarm, it is necessary great attention be paid for
some time to the patient.

Often, instead of an uneasy feeling about the loins, or
lower belly, we have, before the action of gestation stop, a
discharge of blood, generally in a moderate, sometimes in
a trifling degree. This is more especially the case, when
abortion is threatened, owing to an external cause ; and, if
immediately checked, we may prevent contraction from
b^inning.

Even in those cases, where we do not expect to ward off
expulsion, it is useful to prevent, as far as we can, the loss of '
blood ; for as I cannot see that the haemorrhage is necessary
for its accomplishment, although it always attends it, I con-
clude, that our attempts to prevent bleeding, can never do
harm : if they succeed in checking abortion, we gain our
object, if they fail, they do not increase, but diminish the
duger. It should be carefully remembered, that the more
we can save blood, the more do we serve our patient. As the
means for checking the discharge, will be immediately pointed
out, it is unnecessary here to enter into any detail.

Sometimes the vessels about the cervix and os uteri yield,
po8i coiiumy a little blood ; and this may occur either in those
who have the uterus in a high state of activity, or, more
frequently, where it is irritaUe and feeble in its functions.
The same discharge may sometimes appear in rather greater
quantity after impregnation, passing perhaps for the menses,
and making the woman uncertain as to her situation ;* but it

* On tbe other hand, women who are not with child, may, from some Imper-
fection of nterine action, diecharge smnll clots, along with red fluid, at the
menetrual period, teTeral times in succession, and are thus erroneously supposed,
to he threatened with abortion.

322

is generally, though not always, irregular in its appearance,
and seldom returns above once or twice. In some instances,
however, it becomes greater and more frequent in proportion
as the vessels increase in size. It is now apt to pass for
menorrhagia. If it be allowed to continue, it tends to injure
the action of the uterus, and produces expulsion, which
sometimes is the first thing which shows the woman her situa*
tion. The discharge is best managed bv rest, the frequent
injection of saturated solution of the sulpoate of alumine, or
decoction of oak bark, and the internal use of tincture of kino.

When a slight discharge takes place, in consequence of a
slip of the foot, or some other external cause, we may also
derive advantage from the use of the injection : but if the
discharge be considerable, it will often fail. It is better, in
such a case, to trust to the formation of a coagulum.

When, in a plethoric habit, abortion is threatened, from a
fright, or mental agitation, we have often palpitation, rapidity
of the pulse, headach, flushed face, and pain about the
back or pubis; blood-letting relieves inunediately the un«
easiness in the head, and often the pain in the back; after-
wards, the patient is to be kept cool and quiet, and an ano-
dyne administered.

In those cases, where regular uterine pain, precedes or
accompanies the discharge, expulsion cannot be prevented;
but when the discharge precedes the pain, it sometimes may,
nay, if the child be stul alive, it frequently may. Rest is
absolutely necessary, if we wish the person to go to the full
time ; and it is occasionally necessary to confine her to bed
for several weeks, and give an anodyne at bedtime, taking
care also to keep the bowels in a proper state by gentle medi-
cine. Blood ought also, unless the pulse and habit of the
patient forbid it, to be detracted, but it is never to be taken
m a large quantity ; if so, we bring on palpitation and great
debility, and destroy every chance of avoiding abortion.

This is a very critical situation ; much depends on the
vigour and promptitude of our practice, and much, very much,
upon the prudence of the patient. It is teasing to find, that
sometimes, after all our care and exertions, one rash act,
destroys, in a single day, the effect of the whole.'

When we cannot prevent abortion, the next thing is to
conduct the patient safely through the process, by lessening
the effects or separation, or detachment of the ovum, and
accelerating the contraction. The first point, which naturally
claims our attention, is the haemorrhage. Many practitioners.

323

upon a general principle, bleed in order to check this, and
prevent miscarriage ; but miscarriage cannot be prerented, if
the uterine contraction have universally commenced ; and the
discharge cannot be prudently moderated by venesection,
unless there be undue or strong action in the vessels, or much
blood in the system ; if so, a vein may be opened with advan-
tage. This is not always the case, and, therefore, unless
the vessels be at, or above, the natural force or strength of
action, the lancet is not at this stage necessary. The fulness
and strength of the pulse, are lost much sooner in abortion,
than can be explained, by the mere loss of blood. This
depends on an affection of the stomach, which has much
influence on the pulse ; and the proper time for bleeding is
before this have taken place. When abortion has made so
much progress before we are called, as to have rendered the
pulse small and feeble, or when this is the case from the first,
bleeding evidently can do no good. I cannot hold out advan-
tage from the use either of digitalis or of nauseating doses of
antimony. Internal astringents have been proposed, but they
have no effect in copious hemorrhage, unless they excite
sickness, which is a difierent operation from that which is
expected from them. They are more useful in protracted,
but moderate haemorrhage. The injection into the vagina,
two or three times a^ay, of decoction of oak bark, or some
other astringent, is of great benefit in such cases. If the
cold injection give pain in the belly, it may be used tepid.

The application of cloths, dipped in cold water, to the back
and external parts, ought generally to be had recourse to.
The introduction of a very small piece of smooth ice, or a
little snow wrapped up in a bit of linen, into the vagina, has
often a very speedy effect in retarding the haemorrhage,
whilst it never, if properly managed, does any harm ; but we
must not continue either of those, so long as to produce pain,
or much and prolonged shivering. The heat of the surface
is also to be moderated, if there be no pulmonic or rheumatic
affection, by having few bedclothes, and a free circulation of
cool air.

But, the most effectual local method, of stopping the
haemorrhage, is by plugging the vagina. This is best done,
by taking a pretty large piece of soft cloth, and, after dipping
it in oil^ wringing it gently. It is, then, to be introduced
with the finger, portion after portion, until more or less of the
vagina, according to the urgency of the case, be filled. Any
portion which remains out, is to be pressed firmly on the

324

orifice. This acts by allowing the effused blood, time to
coagulate. It gives no pain ; it produces no irritation ; and
those who condemn it, surely, must either have not tried, or
have misapplied, it. If we believe that abortion requires for
its completion a continued flow of blood, we ought not, in
those cases where the process must go on, to have recourse
to cold, or other means of restraining haBmorrhage. If we do
not believe this, then, surely, the most effectual method of
moderating it, is the best. Plugging, can never retard the
process, nor prevent the expulsion of the ovum, for, when the
uterus contracts, it sends it down into the clotted blood in the
upper part of the vagina, and the flooding ceases.

Faintness, operates, also, in many eases, by allowing coag-
ula to form, in consequence of the blood flowing more slowly ;
and, when the faintness goes off; the coagula still restrain the
hsemorrhage, in the same way, as when the plug has been
used. This, naturally, points out the advantages of usinff the
plug, as we thus, produce coagulation at the mouths of the
vessels, and, also, diminish the vascular action. It will, like-
wise show the impropriety of using injections at this time ;
for, by washing out the coagula, we do more harm, than can
be compensated for, by any astringent effect produced on the
vessels.

The principal means, then, which we employ for restrain-
mg the hemorrhage, are bleeding, if the pulse be full and
sharp ; if not, we trust to stuffing the vagina ; to the applica^
tion of cold to the external parts ; to keeping the heat of the
body, in general, at a low temperature ; and to enforcing a
state of absolute rest, which must be continued during the
whole process, however long it may, in some cases, be. The
drink should be cold, and the food light, and taken in small
portions.

Opiates have been advised, in order to abate the discharge,
and are by many, used in every case of abortion, and in every
stage. But as we cannot finish the process, without muscular
contraction, and as they tend to suspend that, I do not see,
that their constant exhibition, can be defended on rational
principles. If ffiven in small quantity, they do no good in the
present point of view ; if in larger doses, they only postpone
the evil, for they cannot check n^ortion after contraction has
begun. When the process is going on regularly, opiates only
tend to interfere with it and prolong the complaint. But 1
wiU not argue against the use of opiates from their abuse.
1 ney are very useful in cases of threatened abortion, more

325

especially in accidental separation, of the membranes and
consequent discharge. They do not directly preserve the
action of gestation, but they prevent the tendency to muscu-
lar contraction, and thus do good. In weakly or emaciated
habits, opiates alone, if given upon the first appearance of
mischief, are often sufficient to prevent abortion ; and in op-
posite conditions, when preceded by venesection, they are of
great service. Opiates are likewise useful, for allaying those
sympathetic pains about the bowels, and many of the nervous
fldfections which precede, or accompany abortion. They are
abo of much benefit in cases where we have considerable and
protracted discharge, with trifling pains, as the uterus is not
contracting sufficientiy to expel the ovum, but merely to sepsr-
rate vessds, and excite haemorrhage. They either at once
render the pain brisker, or by suspending, for a time, the
action, it returns afterwards with more vigour and perfection,
and finishes the process. In cases of irregular or spasmodic
contraction, a fuU dose is useftd.

It was at one time, a very frequent practice to endeavour,
with the finger or small forceps, to extract the foetus and
placenta, in order to stop the discharge. Puzos strongly
opposed this practice, and it is now very properly given up as
a general rule. I do not wish, however, to be understood as
altogether forbidding manual assistance, but it is a useful

•recept, not to be hasty in attempting to extract the ovum.

f the discharge be protracted, and the membranes entire, we
may, if the situation of the patient require it, sometimes
accelerate expulsion, by evacuating the liquor amnii. But if
the pregnancy be not advanced beyond the fourth month, it
will be decidedly better, to trust to a smart clyster, and re-
straining the hsemorrhage by means of the plug. We thus
have a greater likelihood, of getting all the ovum off at once,
and, if the hsemorrhage be stUl protracted, we may excite the
action, by gently dilating the os uteri, and moving the finger
round it. If the membranes have given way, and the fcetus
be still retained, we may, by insinuating a finger within the
uterus, cautiously, hook it out ; or, in many cases it will be
found, partly, expelled through the os uteri, and may easily
be helped away. But the most tedious and troublesome case,
generally, is tnat in which the foetus has been expelled, but
the secundines are still retained, under one of two circum-
stances ; namely, either they are only partially detached, and
still adherent to a certain extent, or there is a circular and
spasmodic contraction of the uterine fibres around a portion

326

of them, a state which may occur even before the foetus itself
be expelled. Now, we never can consider the patient as
secure from haemorrhage, until these be thrown off, and
therefore, she must be carefully watched, especially when
gestation is considerably advanced. In a great majority of
instances, the uterus within a fbw hours, contracts and expels
them. But in some cases, the haemorrhage does become pro*
fuse, and there is little disposition to throw them off. By
stuffing the vagina, we shaU often find, that the discharge is
safely stopped, and the womb excited to act, in a short time;
or, a warm saline clyster is to be given, of such strength as
shall briskly stimulate the rectum, and excite sympathetically
the uterus, or we may try the ergot, which sometimes has
been of service, but, in other instances, has failed, and even
produced distressing sickness. If we be disappointed, or the
symptoms urgent, the finger must be introduced within the
uterus,* and the remains of the ovum slowly detached by very
gentle motion. But we must be very careful not to endeavour
to pull away the secundines, until they be fully loosened, for
we thus leave part behind, which sometimes gives a great
deal of trouble ; and further, if we rashly endeavour to ex-
tract, we irritate the uterus, and are apt to excite inflammar
tion, or a train of hysterical, and sometimes fatal symptoms.
It is these two circumstances, which make me cautious in
advising manual assistance ; and, fortunately, the proportion
of cases requiring it, is not great in abortion at an early
period. If we have an opportunity of opening the uterus,
after the foetus has been expeUed, we find the under part of
the secundines detached ana bloody, whilst the portion near
the ftmdus, perhaps also the body, is adherent. When there
is retention of the secundines, with repeated or continued
discharge, and frequent but useless pains, with feeling of sick-
ness or sinking, we may suspect that part of the uterus is
contracting, spasmodicaJly, round the upper portion of the
placenta, whilst all the rest is detached. This state of the
womb, known under the name of the hour-glass contraction,
is frequent after delivery at the full time ; but it is perhaps
scarcely less so after abortion, and may be met with even at a
very early period, and most probably is the cause of every
obstinate, and especially every fatal case. There are few

.«.* lu *<*»• joitenops the h«ir of tb« Mcundiow wlU be ftMiiid in the vhiml mmI
M^UrS '^^ *^^ ^" ^^^ uterus. In this caee, aU that ia neceeesry it gcotlx to
flngw* ^"** ' *■ ^^ P«'««*n« t^em <Jown, or hooking them between two

327

instances of faintness or sinking, unless from extreme hsmor-*
rbage, which do not proceed from uterine spasm. If a smart
clyster do not excite regular and efficient contraction, it is
necessary to introduce the hand into the vagina, and with one
or more fingers remove the secundines, and excite the womb
to proper action. The part of the placenta retained in the
upper division by the constriction, is sometimes not larger
than a walnut, although the patient be three or four months
pregnant. I most decidedly, in such cases, advise cautious
Olfaction.

When part of the ovum is left, or the whole of the secun-
dines are retained for a considerable time, we have another
danger besides haemorrhage ; for, within a few days, putrefac-
tion comes on, and much irritation is given to the system,
until the foetid substance be expelled. Sometimes, if gesta-
tion have not been far advanced, or the piece which is left be
not very large, it continues to come away in small bits for
many months, during the whole of which time, the woman is
languid, hysterical, and subject to irregular sanguineous dis-
charge, or often to obstruction.* But? more frequently, the
svmptoms are very acute ; we have loss of appetite, prostra-
tion of strength, tumid or tender belly, frequent, small, and
sharp pulse, hot and parched state of the skin of the hands
and feet, nocturnal sweats, and various hysterical symptoms.
The discharge from the vagina is abominably foetid, and
haemorrhage sometimes occurs to a violent degree. The
treatment of this will hereafter be pointed out.

When abortion follows severe vomiting, depending on preg-
nancy, that symptom may continue urgent till after the secun-
dines are thrown off.

From these observations we may see, upon the one hand,
the impropriety of allowing the secundines to remain too
long in ^the uterus ; and, on the other, the danger of making
rash or unnecessary attempts to extract, by which we irritate
the uterus, and tear the placenta, which is almost always
productive of troublesome consequences. The mechanical
removal of the placenta, is effected with least trouble and
smallest irritation, in those cases in which it is most required,
namely, where it is entirely or nearly detached, but still
retained by a spasmodic contraction round the upper part,

• i have been tnformed by Mr. Ang oi, of a cbm, where, in the third month,
the fcBtus was diecfaarged, but the placenta was retained, and conrerted into
hydatids. This did not prevent the woman from becoming again pregnant, and
the second conception, apparently sound, at the fourth month was expelled, along
with a great quantity of hydatids, and most alarming hemorrhage.

328

whilst in those, where there is adhesion, there is generally
less occasion to interfere, in the way of extraction, on account
of the severity of the hsemorrhage.

I now return to the consideration of the usual progress of
abortion. The stomach very soon suffers, and becomes debili*
tated, producing a general languor and feebleness, with a
disposition to faint, which seems in abortion, to depend more
upon this cause, than directiy upon loss of blood. Indeed,
the haemorrhage produces both slighter, and less permanent,
effects in abortion, than at the full time, although, less blood
may hare been lost in the latter, than in the former case, for
the vessels are smaller, and the discharge is not so sudden.
There is still another cause for this, namely, that the action
of the uterus is less, in the early than in tiie late months*
Now, we know that the effect of bsmorrhage from any organ
is, ccBteris paribus^ in proportion to its degree of action. Hence
the discharge is less dangerous' than at the full time, and still
less in monorrhagia than in abortion.

The effect of abortion on the stomach, seems to be in
proportion to the period at which it takes place, being greater
when it occurs before the fourth month than after it. The
effect, though distressing, and often productive of alarm, may
lessen the action of the vessels* The strength of the pulse is
much abated ; sometimes it becomes slower, but in general it
remains mudi as formerly, in point of frequency ; we are,
therefore, not to be too anxious in removing this condition,
which restrains haemorrhage, yet, as it may go beyond due
bounds, and produce dangerous syncope, we must check it in
time. We must likewise be very attentive to the state of the
discharge, when this affection is considerable, for, if, notwith-
standing this, the hcemorrhage should continue, it will produce
greater, and more immediately hurtful effects, than if this
were absent.

The best method of abating this sinking and feebleness, is
to keep the body perfectly at rest, and the head low. If
necessary, we give small quantities of stomachic cordials, such
as a littie tincture of cinnamon, or a few drops of ether in a
glass of aerated water ; or we may give a little peppermint
water, widi twenty drops of tincture of opium. In urgent
cases, Madeira wine, or undiluted brandy may be given ; but
these are not to be freouentiy repeated, and are very rarely
necessary. Full doses of opium are also useful.

Sometimes, instead of a feeling of sinking and faintness,
the fibres of the stomach are thrown into a spasmodic con*

329

traction, producing sudden and violent pain. This is a most
alarming symptom, and may kill the patient yery unex-
pectedly* it 18 to be instantly attacked, by a mixture of sul-
phuric ether and tincture of opium, in a full dose, whilst a
ginapism is applied to the epigastric region ; but if, when this
pain occurs, there be symptoms of approaching convulsions,
then, bleeding should precede the anodyne, and no ether
shoidd be given.

Spasms about the intestines are more frequent, and much
less dangerous. They are very readily relieved, by thirty
drops of tincture of opium, in a dessert-spoonful of aromatic
tincture, or of the compound tincture of lavender, with a little
water.

These disagreeable symptoms, which I have described,
fortunately, do not often attend abortion, but the process goes
on safely, and without disturbance. In this case, after it is
over, we only find it necessary, to confine the person to bed,
for a few days, as getting up too soon, is apt to produce
debilitating discharge. We must also, by proper treatment,
remove any morbid symptoms, which may be present, but
which, depending on the peculiarities of individuals, or their
previous state of health, cannot here be specified. When
the patient continues weakly, the use of the cold bath, and
sometimes of quinine, will be of much service in restoring
the strength ; and, in future pregnancies, great care must be
taken, that abortion may not happen again, at the same
period.

SECTION THIRTY-EIGHTH.

Of all the incidents to which a pregnant woman is exposed,
none is more alarming or troublesome than uterine haemor-
rhage, when it occurs in the advanced stages of gestation, or
after the delivery of the child. This, from its extent, and
impetuosity, has aptly been called a flooding ; and from the
frequency of its occurrence, it must be extremely interesting
to every practitioner.

- I have, (p. 224,) when describing the sinuses which skirt
the placenta, and the fragile vessels passing between it and
the uterus, noticed how easily they may be ruptured, and, how,
great hsemorrhage may result, even if only the mere edge ojf
the placenta be detached ; for, it is evident that the discharge
is not, necessarily, proportioned to the extent of separation.
Dr. Hamilton thinks that the blood proceeds chiefly from the
placenta, which, receiving blood from the uterus, pours it out

330

from the detached surface. That blood flows from that
surface, as well as from that of the uterus, is doubtless true,
for the vessels, whether they be the large marginal sinuses, or
veins going directly from the uterine face of the placenta to
the uterus, must, when torn, allow their contents to escape*
But it is equally clear, that if vessels do pass from the uterus
to the placenta, these must also directly pour out blood, and
we know how freely the uterine sinuses or veins communicate.
If no laceration of placentary substance exist, no blood can
come from the foetal vessels, nor even directly from the cells,
but from them, onlv, bv the returning veins. Farther, if the
maternal, like the loetai vessels, do not communicate from one
lobe to another, the blood from these veins must be from the
detached lobe. In my opinion, the marginal sinuses, which
being extensive, may receive blood from more than one lobe,
and perhaps emptv many, will furnish a great discharge.
The uterine vessels also pour out blood directly, and how
much they can yield in a short time, is seen in flooding, after
the placenta is delivered.

As the ovum corresponds exactlv to the inner surface of
the uterus, and is in close and intunate contact with it, we
find, that as long as this union subsists, the vessels, notwith-
standing their delicacy, are enabled to transmit blood without
effusion. But, whenever a separation of the one from the
other takes place,'^then, these vessels are either directly torn,
or, even supposing them to extend a little, they must be
ruptured by their own action, or by the force of the blood
which they receive and circulate.

The membranes are never so frdl of water, as to be put
upon the stretch, and therefore they cannot forcibly distend
the womb, and make pressure on its inner surface. The
womb again during gestation, does not embrace the mem-
branes tightly, so as to compress them. Hence it is evident,
that when rupture first takes place, no resistance can, by the
action of the one upon the other, be afforded to the flow of
the blood. The consequence of uterine hcemorrhage, when
considerable, ia, that the force of the circulation is diminished,
faintness, or absolute syncope, being induced. The blood in
this state flows more feebly ; coagulation is allowed to take
place, on the exposed surface of the uterus, placenta, or in
the delicate marginal sinus, and the paroxysm is for the
present ended. This coagulation, in slight cases, may take
place, even without the intervention of faintness. Re-union,
however, when the separation is extensive, and the coagulum

331

considerable, cannot be expected to take place, and therefore
when the clot loosens, a return of the hsemorrhage, is in
general to be looked for*

One or more copious discharges of blood, must injure the
functions of the uterus, and ultimately destroy, altogether,
the action of gestation. This tends to excite the muscular
action of the uterine fibres, and by their contraction two
effects will be produced. The uterine vessels will be dimin*
ished in their diameter or capacity, and by the whole surface
of the womb, pressing more strongly upon the ovum, a greater
resistance will be given to the flow of the blood, from the
sinuses, arteries, and placenta or decidua.

Thus it appears, that nature attempts to save the patient
in two ways. First, by the induction of a state of faintness,
or sometimes of complete syncope, which tends to check the
present attack. Secondly, when the haemorrhage is so great
or obstinate, as to prevent any possibility of the woman going
safely to the full time, such effects are produced, as tend to
establish muscular contraction, and accelerate expulsion.
This double process, ought, in all our reasonings, to be held
in view.

Uterine contraction is of two kinds, which may be called
permanent and temporary. The permanent, is that con-
tinued action of the individual fibres, by which the uterus
is rendered more or less tense, so that it feels firm if the
hand be introduced into its cavity. The temporary, is that
greater contraction, which is excited at intervals, for the
expulsion of the foetus, producing what are called the pains of
labour.

In those cases, where nature effects a cure by expulsion, or
the production of labour, it is chiefly, to the permanent or
tonic contraction, that we are indebted for the stoppage of
haemorrhage ; because, this contraction lessens the size of the
vessels, and keeps up a regular pressure, of the uterine
surface, upon the ovum, until the pains have accomplished
the expulsion or delivery, of the child. The pains, alone,
could not do this good, for, coming onlv at intervals, their
effect would be fugacious. On the other hand, the permanent
contraction should not be adequate to the purpose, without
the pains, for these temporary paroxysms, excite this action
to a stronger degree, and, by ultimately forcing down the
child, accomplish delivery before the powers of the uterus be
worn out-
Such are the steps by which the patient is naturally saved.

332

But we are not to expect that these shall, in every instance,
or in a majority of instances, take place at the proper time,
or in the due degree. The debility and syncope may go too
far ; or the clots may not form in proper time, or may come
away too soon, or too easily. The action of gestation may
continue, notwithstanding the violence of the haemorrhage,
thus preventing the accession of muscular contraction ; or
before this contraction be established, and the child expelled,
the discharge may have been so great and constant, as to
render the efforts of the womb, weak and inefficient, and, by
still continuing, may destroy them altogether.

These circumstances bemg considered, it is evident, that,
although when the injury is small, and the discharge trifling,
nature may permanently check it, or in more serious cases,
may preserve the woman by the expulsion of the child, yet
we cannot, with prudence, place our whole reliance on her
unassisted operations.

There is also another circumstance, relating to a particular
species of flooding, which renders the accomplishment of a
natural cure, or escape, still more doubtful. This is, that
the placenta is sometimes attached to the os uteri, which,
necessarily, must produce a haemorrhage, whenever the cervix
comes to be fully developed, and the mouth to open.

The vessels going to, and returning from the placenta, are
much larger than those which belong to the decidua ; there-
fore, if part of the placenta be detached, the quantity and
velocity of the discharge must be greater, and the effects more
to be dreaded, than when a part of the decidua alone is sepa^
rated. If the placenta be fixed near the cervix uteri, and a
part of it be detached, then, the blood which is efiused, will
separate the membranes down to the os uteri, and a profuse
haemorrhage will appear. But sometimes, if it be fixed high,
or near to the fundus uteri, the blood may be confined, espe-
cially if the separation have been trifling, and a coagulum
will be formed, exterior to the membranes, the lower part of
which will still adhere to the uterus ; or if, the central portion
of the placenta have been detached, a collection of blood may
be formed behind it, but may not extend beyond its circular
margin. Such cases are rare. But if the placenta be placed
over the os uteri, nothing can retain the blood ; profuse dis-
charge must take place, sinking the whole system, and very
much enfeebling the uterus itself, so that, most likely, when
uterine contraction does come on, it will be weak, and incapa-
ble of speedily effecting expulsion. Even although the con-

333

traction should be brisk and powerful, it cannot, owing to the
vascularity of the placenta, do the same good as in other
cases of flooding; and therefore, in every instance, much
blood will be lost, and in many, in very many, the patient, if
we trust to this contraction alone, shall perish. Contractiou,
can only be expected, in this case, to do good, when it is
powerful, and tne pains come on, so briskly, as speedily to
empty the uterus, at the same time that coagula shut the
moutns of the placental vessels, at the unsupported part.

It has been a common opinion, that flooding proceeded
always from the detachment of a part of the placenta ; but
this point is not established.* In several cases, of uterine
hemorrhage, the placenta is found to be attached to the
fundus uteri, and we cannot suppose, that in all of these, the
whole extent of the membranes, from the placenta to the os
uteri, has been separated ; yet, this must happen before the
discharge, can, in these circumstances, appear. We can
often account for the hsmorrhage, by suppodng a portion of
the decidua to be detached ; and we know that the vessels
abotit the cervix, are sufficiently able, to throw out a con-
siderable quantity of blood, if their mouths be open. Still,
in most ccues of profiue hamorrhage^ we shall find, that the
placenta is attached near the os uteri, and more or less of it
separated.

li is possible for blood to be effused, in consequence of
detachment of part of the ovum, and yet it may not be dia-
chai^ed by the os uteri.f This detachment may be produced
by fatigue, falls, blows, &c., and the effusion is accompanied
with dull internal pain at the spot where it takes place.
This pain is sometlung like colic, or, like pain attending the
approach of the menses. The part of the womb where the
extravasation takes place, swells gradually, and the uterus in
a short time feels larger. If the quantity be considerable,
the size increases, the uterus is felt to be firmer and tenser,
as well as larger, the strength diminishes, and even faintings

* Lone af o, Andrea JPtota qantioned tbe OBinron, that flooding was always
prodaeed by separation of tbe placenta.— Vide Uiscorso del flusso dl sangue, &c.
We are not, boweTer, to suppose, that b^morrhage does not proceed from detacb-
ment of tbe placenta, in anv instance wben it is placed bigh up, but only that it
is a rare occurrence. When tlie stream is rapid and profuse, we have erery
reason to suppose, that part of tbe placenta is separated ; but if we have occasion
to deliver, it will generally be found that it is placed close by tbe cerrix uteri, or
At least not very far from it

t Vide Albinus Acad. Annot. lib. i. p. 58. Recuell Periodlque, torn. ii. p. 15,
and torn. iii. p. 1.

334

may come on. In course of time, weak slow pains are felt,
but if the injury be great, these decline, as the weakness in-
creases. They may, or may not, be attended with the dis-
charge of coagula from the os uteri. In such a case, it is
eyident, that nothing but deliyery, can save the mother.
But, in slighter cases, where the separation is not very exten-
sive, it may not be discovered or suspected, at least, till the
child is born, when often a quantity of dark, or even grumous
blood is evacuated, without affecting the pulse or strength,
which it would be likely to have done, had it come recently,
from the vessels of the uterus.

Let us next consider the causes, giving rise to hemorrhage,
in various degrees ; and the first that I shall mention is
external violence, producing a separation of part of the ovum.
As the ovum and uterus correspond exactly to each other, and
are, in the advanced stages of gestation, composed of pretty
pliable materials, falls or blows do not produce laceration, so
frequently as might be supposed. In a majority of instances,
the effect is produced, chiefly by the operation on the vessels,
their action being violently and suddenly excited, and rup-
ture of their coats thus produced. When the ovum is
mechanically detached, the injury must have been considerable,
and in general tiie foetus is destroyed.

Fatigue or much exertion, may injure the action of the
uterus, and give rise to premature expulsion, which, in this
case, is generally attended with considerable discharge. Such
exertions are likewise apt, by their effect on the circulation,
to operate on the vessels passing to the ovum, and produce,
in tnem, a greater degree of activity, than they are capable
of sustuning without rupture. It is, therefore, very properly
laid down as a rule of practice, to forbid pregnant women to
undergo much fatigue, or exert any great muscular action ;
and wherever this rule has been departed from, especially, by
a patient of an irritable or of a plethoric habit, it behoves the
practitioner to attend, carefully, to the first appearances of
injury, or, to the first symptoms of decay, in the uterine
action. Rest, and an opiate, upon general principles, are
indicated, and when the circulation is affected, or we appre-
hend increased action, about the uterine vessels, venesection
must be premised, and the patient kept cool and tranquil.

Violent straining at stool, or strong exertion of the abdo-
minal muscles, made in lifting heavy bodies, or in stretching
to a height, or frequent and continued stooping, may all, by

335

eompressing the womb» cause separation. For, the ^eatest
efeet will be produced where the resistance is least, or the
support smallest, which is at the under part of the uterus, and
there, rupture will be apt to take place.

A preternatural degree of action, in the vessels going to
the placenta or decidua, must be dangerous, and likely to pro-
duce rupture and extravasation. This, may either be con-
nected with a general state of the vascular system, marked by
plethora, or by arterial excitation, or, it may be, more imme-
diately dependent on the state of the uterus itseV.

When the patient is plethoric, or, when the action of the
vascular system is increased, it is natural to suppose, that the
effect will be greatest, on those parts of the womb, which are
in the highest state of activity. These are chiefly two ; the
part to which the placenta is attached, for, there, the vessels
are large and numerous ; and near the cervix uteri, because,
there, the greatest changes are going forward. At one or
other of these two places, rupture is most likely to take place,
and it will happen, still more readily, if the placenta be
attached at, or near to, the cervix. It may be excited either
by too much blood, circulating permanently in the system, or,
by a temporary increase of the strength and velocity of the
circulation, produced by passion, agitation, stimulants, &c.
A plethoric state, is a frequent cause of hsemorrhage, in the
young, the vigorous, and the active ; the decidua is separated,
and a considerable quantity of blood flows, perhaps, the
placenta is detached, and the haemcNrrhage is more alarming.
In some cases, the rupture is preceded by spitting of blood,
or bleeding at the nose, and, in these cases, the lancet may
be of much service.

We sometimes find, that extravasation is produced, by an
increased action of the uterine vessels themselves, existing as
a local disease. In this case, the patient, for some time
before the attack, feels a weight and uneasy sensation about
the hypogastric region, with slight darting pains about the
belly or back. These precursors have, generally, been
ascribed to a different cause, namely, rigidity of the ligaments
of the womb, or of the fibres of the uterus itself.

Spasmodic action about the cervix uteri, must produce a
separation of the connecting vessels. The causes giving rise
to this, in the advanced period of gestation, are not always
obvious, neither can we readily determine the precise cases, in
which this action excites flooding. We should expect, that
the discharge ought, always, to be preceded by pain, biit, we

336

know that motion, may take place, in some instances, about
the cervix uteri, without much sensation ; and, on the other
hand, many cases of flooding, not dependent on motion of
the uterine fibres, are attended with uneasiness or irregular
pain about the abdomen. This spasmodic action is not
unfrequently produced, by hanging pregnant animals.

Whatever stops, prematurely, the action of gestation, may
give rise to a greater or less degree of haemorrhage. For, in
this case, the development of the cervix takes place quickly,
and the ovum must be separated. The quantity of the dis-
charge* will depend upon the state of the circulation — the
magnitude of the vessels which are torn — ^the contraction of
the uterus — and the care which is taken of the patient.
Hence, it follows as a rule, in every premature labour, more
especiallv in its first stage, that we prevent all exertion,
refrain nrom the use of stimulants, and confine the patient to
a recumbent posture.

It sometimes happens, that eflPective contraction does not
take place, speedily, after the action of ffestation ceases, but
a discharge appears. This may stop, by the induction of
syncope, or tne formation of clots. The blood, which is
retained about the cervix and os uteri, putrefying, produces a
very offensive smell. Milk is secreted, as if delivery had
taken place, and, sometimes, fever is excited. In this state,
the patient may remain for some days, when the haemorrhage
is renewed, and she may be lost, if we do not interfere.

Some undue state of action about the os uteri, removing,
or stopping the secretion of that jelly, which, naturally, ought
to be lodged within it, is another cause.

This, IS generally productive of a discharge of wateiy fluid,
tinged with blood, and, if the patient be not careful, pure
Uood may be thrown out in considerable quantity. It may
even happen, that the haemorrhage, under certain circum-
stances, may prove fatal ; and yet, upon dissection, little or
no separation of the ovum be discovered, the discharge taking
place from the vessels of the os uteri itself.f

In some instances, where a portion of the placenta has been
detached, I have observed, that near the separated part, the
structure of the placenta was morbid, being hard ana gristly.

* In thote CMCS where the contraction hecomei uniremi and effectlTe, we haTt
little diacbarge, and the patient is merely said to have a premature labour ; but
'■ .^■■^fpntractlon be partial, and do not toon become effeinlTe, then we hare eon-

/ vri^ diacbarge. and the patient it nald to have a flooding.
Bibli tb gJ^ *" ****'"*' ^ ^* ^**"*«''*» ^^ *••« *"* volume of Brewer't

337

In these cases, I could not detect any other cause of separa-
tion, and suppose, that by the accidental pressure of the child,
upon the indurated part, the uterus may nave been irritated."

The insertion of the placenta over the os uteri,* may give
rise to flooding in difierent ways.

The uterus and placenta, may remain in contact, until the
term of natural labour, the one adapting itself to the other ;
but whenever the os uteri begins to dilate, separation, and
consequent haemorrhage, must take place. But, often, at an
earlier period, in the eighth, or by the middle of the ninth
month, we find, that, either, the uterus and placenta no
longer grow equally, in consequence of which the fibres about
the 08 uteri are irritated to act, or, so much blood as must
necessarily, in this situation, circulate about the cervix uteri,
interferes with its regular actions, and induces premature
contraction of its fibres, with a consequent separation of the
connecting vessels.

In order to ascertain, whether the hemorrhage proceed from
this cause, we ought, in every case, to which we are called,
carefully, to examine our patient. The introduction of the
finger is sometimes sufiicient for this purpose, but frequently
it may be necessary, to carry the whole hand into the va^na.

If the placenta present, we shall feel the lower part of the
uterus thicker than usual, and the child cannot be so dis-
tinctly perceived to rest upon it. This is ascertained, by
pressing with the finger, on the forepart of the cervix,
Detwixt the os uteri and bladder, and also a little to either
side.f ^

If the 08 uteri be a little open, then, by insinuating the
finger, and carrying it through the small clots, we may
readily ascertain whether the placenta or membranes present,
by attending to the diflPerence which exists betwixt them.
But in this examination, we must recollect, that if only a
small portion of the edge of the placenta present, this may

* So far as I hare obscrTed, uterine hsmorrbage, when profuae, it produced
meet frequentlf hj this cause ; at least two-thirds of those cases requiring de-
livwf, prseeed, 1 chink, from the presentation of the placenta ; and in the majo-
ritjr of the remaining third. It will be found attached near to the cervix. Most
of those hsmorrhages, which are cured without deliyery, proceed from the detach-
ment of the decidna alime, or of a rery small portion m the placenta, which has
been separated under circumstances fayourable for firm coagulation.

t When a large coagulum occupies the lower part of tne uterus, we may be
deceived, if we trust to asternal feeling alone, without introduelnc the finger
within the os uteri. If the uterus have ite usual feel, and the child be felt dln-
tlnctly through It, then we are sure that, howerer near the placenta may be to
the as atari, it is not fizrt exactly over it.

338

not readily be felt at first, especially if a coagulum fill the
upper part of the os uteri.

To conclude this part of the subject, I remark in general,
that haemorrhage from the uterus, is not merely arterial, but
also venous, and the orifices of these latter vessels, are
extremely large. Almost immediately after conception, the
veins enlarge and dilate, contributing greatly to give to the
uterus, the doughy feel which it possesses. In the end of
gestation, the sinuses are of immense size, and their extremi-
ties so large, that, in many places, they will admit the point
of the finger. Now, as all the veins communicate more
freely than the arteries, and as they have in the uterus no
valves, we can easily conceive the rapidity, with which dis-
charge may take place, and the necessity of encouraging
coagulation, which checks venous, still more readily, than
arterial, haemorrhage. The discharge from the marginal
sinuses, at the placenta, is venous.

In whatever way flooding is produced, it has a tendency
to injure or disturb gestation, and to excite expulsion ; but
these effects may be very slowly accomplished, and, in a
great many instances, may not take place, in time to save the
patient, or her child. Having already noticed those changes,
produced on the womb itself, by haemorrhage, and the danger
of trusting to them, for the recovery of the patient, I will
not recapitulate, but proceed, very shortly, to mention the
effects, produced on the system at large.

During the continuance of the haemorrhage, or, by the
repetition of the paroxysms, if this be allowed to occur,
eertain alterations, highly important, are taking place. There
is much less blood circulating than formerly ; and this blood,
when the haemorrhage has been frequently renewed, is less
stimulating in its properties, and less capable of affording
energy, to the brain and nerves. The consequence of this is,
that all the actions of the system, must be performed more
incorrectly, and with less strength. The body is much more
irritable than formerly, and slight impressions produce
greater effects. This gives rise to many hysterical, and
sometimes even to convulsive affections. The stomach can-
not so readily digest the food — the intestines become more
sluggish-^the heart beats more feebly — the arteries act with
little force — the muscular fibres contract weakly — the whole
system descends in the scale of action, and must, if the ex-
pression be allowable, move in an inferior sphere. In this
state very slight additional injury, shall sink the system irre-

339

parably — yery trifling causes shall unhinge its actions, and
render them irregular. If the debility be carried to a farther
degree, no care can recruit the system — no means can renew
the yigour of the uterus. We may stop the haemorrhage,
but recovery cannot take place. We may deliver the child,
but the womb cannot contract. When much blood has
been lost, particularly, if some irritation be conjoined, an
approximation is made to a state of fever, which I have ex-

Elained at the article ^' monorrhagia." The pulse is feeble,
»ut sharp, the skin rather warm, and the tongue more or less
parched. This state of the vascular system is dangerous,
Doth as it exhausts, still more, a frame already very feeble,
and, also, as it tends to renew the haemorrhage. It will often
be found to depend, upon slight uterine irritation, upon
accumulation in the bowels, upon pulmonic affections, upon
muscular pain, or, upon the injudicious application of stimuli.
But, as has been explained in a former section, the mere loss
of blood can, of itself, produce a febrile state.

Such organs as have been previously disposed to disease,
or have been directly or indirectly injured, during the con-
tinuance of protracted flooding, may come to excite irritation,
and give considerable trouble.

An acute attack of haemorrhage, generally leaves the
patient, in a state of simple weakness ; but if the discharge
be allowed to be frequently repeated, and the case thus pro-
tracted, the state of the vascular system which is produced,
adds to the danger, and excites, if the patient be not delivered,
more speedy returns.

A woman seldom suffers much, or at least, evidently, in a
first attack of haemorrhage. If she be stout and plethoric,
she may lose a large quantity of blood, and yet, to appearance,
not be greatly injured, although she, in reality, be in that
state, in which a very little farther discharge, may produce
alarming symptoms. The haemorrhage may come on in
every different situation. She may have no appearance of
it, tUl labour begin, and then it may either break out at once
with impetuosity, or, slight at first, it increases rapidly as
labour aulvance^. Or she may be attacked, long before her
confinement is expected. She may awake, suddenly, from a
dream, and feel herself swimming in blood; or, it may
take place when walking ; or may be preceded by a desire
to make water, and she is surprised to find the chamber-pot
half filled with blood. If the attack be not very severe, and
be soon checked, and there be no labour, she recovers from

340

her consternation ; perhaps, in spite of every injimction, she
walks about as usnal, and finds no bad effect from motion ;
the feeling of heaviness which may have preceded the acci-«
dent is gone, she is lighter and better than she was before it,
and hopes all is well ; but, in a few days, the haemorrhage is
repeated, and again stops ; at last, after one or two attacks,
for the time is uncertain, the os uteri becomes soft, and opens
a little, perhaps without pain, or she feels dull sUght pains,
which, however, give her very little uneasiness. This state
may take place early, and without dangerous debility; it
may take place in the second or third attack ; or possibly the
haemorrhage may never have entirely ceased, continuing for
a day or two like a flow of the menses, and then it is sud-
denly increased, or flows in a torrent. But although this
state of the uterus, whether it be induced before the end of
gestation, or in the natural course of labour, may take place
without alarming debility, it may also, and that very sud*
denly, be attended with the utmost danger, or may be accom--

!ianied with so much haemorrhage, as to prove absolutely
atal. The patient is found without a drop of blood in her
face, the extremities cold, the pulse almost gone, the stomach
unable to retain drink. She is in the last stage of weakness,
but it is not the weakness produced by fever or disease, for
we, often, find her voice good, and, generally, the intelleet
clear. The haemorrhage has, perhaps, stopped, and a young
man would suppose it still possible for her to recover. But
although not a drop of blood be afterwards lost, the debility
increases, the pulse is quite gone, she breathes with difficulty,
and gives long sighs, wavers in her speech, and in a short
time expires.

We may lay it down as a general observation, that few
cases of profuse haemorrhage, occurring in an advanced stage
of gestation, can be cured without delivery, or the expulsion
of the child. For, when the discharge is copious or obstinate,
the side of the placenta is generally separated, sometimes to
a very considerable extent, and a re-union, without which,
the woman can never be secure against another attack, can
rarely be expected. If the placenta present, the haemorrhage,
although suspended, shall, yet, to a certainty return, and tew
survive, if the child be not delivered.

]But in those cases^ where only a portion of the decidua has
been detached, and the communicating vessels opened, either,

\*M*^ °C o?er-action in the vascular system, or, by too
much blood iu the vessels, or, by some mechanical exertion,

341

if proper eare be taken, the haemorrhage may be completely
a&d permanently checked ; or if it should return, it may be
kept 80 much under, or may consist so mueh of the watery
discharge from the glands, about the os uteri, as neither to
interfere with gestation, nor injure the constitution ; yet, it is
to be recollected, that even these cases of hooding, may some*
times proceed to a dangerous degree, requiring very active
and decided means to be used, and in no case, can the patient
be considered as safe, unless, the ujtmost care and attention
be paid to her conduct.

It vould thus appear, that some haemorrhages almost
inevitably end, either in the delivery of the child, or the death
of the parent whilst others, may be checked or moderated^
without an operation. A precise diagnostic line, liable to no
exceptions, cannot be drawn betwixt these cases ; and, there^
fore, whilst we brieve that rapid and profuse haemorrhages,
which indicate the rupture of large vessels, can seldom be
permanently checked, we still, provided the placenta dp not
present, are not altogether without hopes of that termination!
which is more desirable for the mother, and safer for the
child, than premature delivery. In slighter cases, our hope
is joined with some degree of confidence.

A second attack, especially if it follow soon after the first,
and from a slight cause, or without any apparent cause, greatly
diminishes the chance, of carrying the woman to a happy
conclusion, without manual interference.

In forming our opinion, respecting the immediate danger
of the patient, we must consider her habit of body, and the
previous state of her constitution. We must attend to the
;state of the pulse, connecting that, in our mind, with the
quantity and rapidity of the discharge. A feeble pulse, with
a haemorrhage, moderate in regard to quantity and velocity,
will, if the patienl; have been previously in good health,
generallv be found to depend on some cause, tlie continuance
of which IS only temporary. But, when the weakness of the
pulse, proceeds frcMu promse or repeated haemorrhage, then,
although it may sometimes be rendered still more feeble, by
oppression, or Reeling of sinking at the stomach, yet, when
this is relieved, it does not become firm. It is easily com-

Eressed, and easily affected by motion, or, sometimes, even
y raisifig the head.

U the paroxysm be to prove fatal^ the debility increases —
the pulse flutters and becomes imperceptible — the extremities
first, and then the whol^ body, necome cold and clammy —

342

the breathing is performed with a sigh — the patient desires to
be raised, and have the windows opened — is in constant
motion, with great anxiety, perhaps vomits — and syncope
closes the scene.

If irritation be conjoined with haemorrhage, or the vascular
system be excited, then the pulse is sharper, and although
death be near, it is felt more distinctly, than when irritation
is absent.

The termination, in this case, is often more sudden than a
person unacquainted with the effect of pain and irritation, on
the pulse, would suppose. For, when the pulsation is distinct,
and even apparently somewhat firm, a slight increase of the
discharge, or sometimes an exertion without discharge,
speedily stops it, the heat d^arts, and the patient never gets
the better of the attack.

We must likewise remember, that a discharge which takes
place gradually, can be better sustained, than a smaller
quantity, which flows more rapidly. For, the vessels in the
former case, come to be accustomed to the change, and are
able, more easily, to accommodate themselves, to the decreas-
ed quantity. But when blood is lost rapidly, then, very
speedy and universal contraction, is required in the vascular
system, in order that it may adjust itself to its contents, and
this is always a debilitating process. The difference, too,
betwixt the former, and the present condition of the body,
is rapidly produced, and has the same bad effect, as if we
were instantly to put a free liver, upon a very low and ab-
stemious diet.

In all cases of considerable flooding, we find, that during
the paroxysm, the pulse flags, and the person becomes faint.
Complete syncope may even take place ; but this, in many
cases, is more dependent on sickness, or oppression at the
stomach, than on direct loss of blood. In delicate and irri-
table habits, the number of fainting fits may be great, but
unless the patient be much exhausted, we generally find, that
the pulse returns, and the strength recruits. The prognosis,
here, must depend, greatly, on the quantity and velocity of
the discharge, for, it may happen, that the first attack of
haemorrhage, may produce a syncope, from which the patient
is never to recover.

When we are called to a patient, recently, attacked with
flooding, our most obvious duty is immediately to restrain the
violence of the discharge; after which, we can take such
measures, as the nature of the case may demand, Pither for

343

preserving gestation, or for hastening the expulsion of the
child.

A state of absolute rest, in a horizontal posture, is to be
enforced with great perseyerance, as the first rule of practice.
By rest alone, without any other assistance, some haemor-
rhages may be cured, but without it, no patient can be safe.
Even, after the immediate alarm of the attack is over, she
must still recollect her danger. She should be confined to
bed, upon a firm mattress for several days, and ought not to
leave her apartment, for a much longer period.

In general, the patient has gone to bed before we are called,
and, perhaps, by the time that we arrive, the bleeding has in
a great measure ceased. The partial unloading of the vessels,
produced by the rupture, the induction of a state approaching
to syncope in consequence of the discharge, the fear of the
patient, and a horizontal posture, may all have conspired to
stop the haemorrhage.

The immediate alarm from the flooding having subsided,
the patient often expresses herself as more apprehensive of a
premature labour, than of the haemorrhage, which she considers
as over. If the attack, have been accompanied with slight
abdominal pain, her fears are increased. But we are not to
enter into these views of the case ; we are to consider the
discharge as the prominent symptom, as the chief source of
danger. We are to look upon the present abatement, as an
uncertain calm, and whatever advice we may give, whatever
remedies we may employ, we are not to leave our patient,
until we have strongly enforced on her attendants, the danger
of negligence, and the necessity of giving early intimation,
should the haemorrhage be renewed. There is no disease to
which the practitioner can be called, in which he has greater
responsibility, than in uterine haemorrhage. The most prompt
and decided means must be used ; the most patient attention
must be bestowed ; and, whenever he undertakes the manage-
ment of a case of this kind, whatever be the situation of the
patient, he must watch her with constancy, and forget aJl
considerations of gain and trouble. His own reputation, his
peace of mind, the life of his patient, and that of her child,
are all at stake. I am doing the student the most essential
service, when I earnestly press upon his attention these
considerations. And, when I entreat, implore him, to weigh
well, the proper practice to be pursued, the necessary care to
be bestowed, I am pleading for the existence of his patient,
and for his own honour and happiness. Procrastmation,

344

irresolution, or timidity, hare hurried innumerable victims to
the grave; whilst the rash precipitation of unfeeling men,
has only been less fatal, because, negligence is more common
than activity.

I shall endeavour to point out the proper treatment, in
the commencement of uterine hemorrhage, and the best
method of terminating the case, when the patient cannot be
conducted, with safety, to the full time. Aner the patient is
laid in bed, it is next to be considered, how the haemorrhage
b to be directly restrained, and whether we may be able to
prevent a return. It is at all times, proper to ascertun,
exactly, the situation of the patient by examination, as we
thus learn, the state of the cervix and os uteri, and whether
there be any tendency to labour ; whether the discharge be
stopped by a coagulum in the mouths of the vessels,* or by a
large clot in the upper part of the vagina ; whether the pla-
centa be attached to the os uteri, or whether the membranes
E resent. We likewise endeavour to ascertain the quantity of
lood which has been lost — the rapidity with which it flowed
— the effect which it has produced upon the mother or child —
and the cause which appeared to excite the haemorrhage.

The first remedy which, upon a general principle, offers
itself to our attention, is blood-letting. In those cases, where
the attack has been produced, by over-action of the vessels of
the decidua, or a plethoric condition, or where it seems to be
kept up by these causes, this remedy, employed early, and
followed by other means, may be effectual, not only in check-
ing the present paroxysm, but, also, in preventing a return.
But, we are not to apply the remedy for this one state, to
every condition ; we must have regard to the cause, and con-
sider how far the hemorrhage is kept up by plenitude or
morbid activity of the vessek. In those cases where the
attack is not excited by, or connected with, plethora, or undue
action in the vascular system, venesection is not indicated,
nay, may be positively hurtAil. We have in these cases,
"which are, by far the most numerous, other means of safely
and powerfully moderating vascular action, without the
detraction of blood, which, in this disease, it ought to be a
leading principle, to save as much as possible ; imd it must be
impressed on the student, that venesection is rarely required,
and its use limited to a single case. Whatever lessens,

* "We may OMJaeturc that this U the omc, if wc iiWI do dot in tbo ^ff'^
ploMiiif tli« ot uicri. We are not wamntcd to Uiriut tke Sagtr, foreiUy,
wItDin tae oe uteri, in tbii eaaunination ; or to rub away the miaU ooa^ola which
May he forwA within it, aad whkh may he rettralnlng the hamotrh^e.

345

materially or suddenly) the quantity of blood, mufit directly
enfeeble, and call fur a new supply, otherwise the system
suflPers for a long time.

We shall find, that except under those particular circuoK
stances which I have specified, and where we hare ground to
believe, that the placenta is entirely adherent, that the rup-
ture of vessels of the decidua has been directly dependent,
on their plenitude or over-action, the circulation may be
speedily moderated, by other means, and, especially, by the
application of cold. This is to be made, not only by apply-
ing cloths, dipped in cold water, to the back and vulva, but,
also, when the heat is increased, by cold-sponging over the
legs, arms, and even the trunk, covering the patient only
very lightly with clothes, and promoting a free circulation of
cold air, until the efiect upon the vessels be produced. After
this, we shidl find no advantage, but rather harm, from the
further application of cold. All that is now necessary, is
strictly, and constantly, to watch against the application of
heat, tJiat is, raising the temperature above the natural
standard.

The extent to which this cooling plan is to be carried,
must depend upon circumstances. In a first attack, it is in
general to be used freely ; but, where the discharge either
towards the end of this attack, or in a subsequent paroxysm,
has gone so far, as to reduce the heat, below the natural
standard, the application of cold, must sink the system too
much. In some urgent cases, it may even be necessary, to
depart from our general rule, and apply warm cloths to the
hands, feet, and stomach. This is the case, where the dis-
charge has been excessive, and been suffered to continue
profuse, or for a long time, and where we are afraid that the
system is sinking fast, and the powers of life giving way.
There are cases, in which some nicety is reqidred, in deter-
mining this point, and, in these circumstances, we must never
leave our patient, but must watch the effects of our practice.
This is a general rule, in all haemorrhages, whatever their
cause may have been, or from whatever vessel the blood may
come. A cold dun and a feeble pulse, never can require the
positive, and vigorous, application of cold ; but, on the other
hand, they do not indicate the application of heat, unless
they be increasing, and the strength declining. Then, we
cautiously use heat, to preserve what remains, not rashly and
speedily to increase action, beyond the present state of power.
In the application of cold, regard must also be paid, to the

346

previous condition of the patient, and her tendency to
rheumatism or pectoral complaints.

When an artery is diyided, it is now the practice, to trust
for a cure of the haemorrhage, to compression, applied by a
ligature. We cannot, however, apply pressure directly, and
mechanically, to the uterine vessels, but we can promote
coagulation, which has the same immediate effect. Rest and
cold, are favourable to this process, but ought, only in slight
cases, to be trusted to, alone. In this country, it has been
the practice to depend, very much, upon the application to
the back or vulva, of cloths dipped in a cold fluid, generally
water, or vinegar and water; but these are not always
effectual, and sometimes, from the state of the patient, are
not admissible. Astringent injections are seldom of benefit,
in any discharge, which deserves the name of haemorrhage.
They commonly do good in a stillicidium, rather trouble-
some from its duration, than hazardous from its extent.
In urgent cases, thev are hurtful, by washing awav coagula.

Stuffing the vagma with a soft handkerchief,* answers
every purpose, which can be expected from them, in
producing coagulation of the blood at the mouths of the
vessels; and whenever a discharge takes place, to such a
degree, as to be called a flooding, or lasts beyond a very
short time, this ought to be resorted to. The advantage is
so great and speedy, that I am surprised that it ever should
be neglected. I grant that some women may, from delicacy
and other motives, be averse from it, but every consideration
must yield to that of safety; and it should be impressed,
deeply, on the mind of the patient, as well as the practitioner,
that blood is most precious, and not a drop should be spiUed,
which can be preserved. Unless the flooding shall, in the
first attack, be permanently checked, which, when the
separated vessels are large and numerous, is rarely accom-
plished, we may expect one or more returns, before expulsion
can be accomplished. The more blood, then, that we allow
to be lost at first, the less able shall the patient be, to sup-

* The iniertion of a smaU piece of ice in the first fold of the napkin, i«

attended with great adTantace, and has often a very powerful effect. Dr.

Hoffman employed the introduction of lint, dipped in solution of ▼Itriol, but

this was rather as an astringent than a plug, and he docs not propose it as a

general practice. He considers that he was obliged to have recourse ad anemt

et extremum auxilium. Vide Opera Omnia, Tom. iv. Leroux employed toe

** if ^l^. frttAf. Vide Obsermtions sur les Pertea, 1776. Some modern

r.t.!!^^'^ *^ ^" '^'^1« estimation ; and Gardien says, that when the placenta is

«!».#K aV*'' ^^"^ ®« "t**" it in injiiriouii, by exciting the uteiiM to dilate Its
mntith. Inm. !l. p. 404. * y j m

347

port the course of the disease, and the more anfavourable
shall delivery, when it comes to be performed, prove to her
and to the child. It is of consequence, to shorten the
paroxysm, as much as possible, and, , therefore, when
circumstances will permit, we should make it a rule, to have,
from the first, a careful nurse, who may be instructed in our
absence, to use the napkin without delay, should the
haemorrhage return.

But whilst I so highly commend, and so strongly urge the
use of the plug, I do not wish to recommend it, to the
neglect of other means, or in every situation. In the early
attacks of hsemorrbage, when the os uteri is firm, and
manual interference is improper, I know of no method more
safe, or more efiectual, for restraining the hsemorrhage, and
preserving the patient. But, when the haemorrhage has
been pronise, or frequently repeated, and the circumstances
of the patient, demand more active practice, and point out
the necessihr of delivery, then, the use of the plug cannot be
proper.* if trusted to, it may be attended with deceitful
and fatal effects. We can, indeed, restrain the hsemorrhage,
from appearing outwardly; but there have been instances,
and these instances, though comparatively few, ought to be
constantly remembered, where the blood has collected within
the uterus, which, having lost all power, has become relaxed,
and been slowly enlarged with coagula — the strength has
decreased — the bowels become inflated — the belly swelled
beyond its size in the ninth month, although the patient may
not have been near that period ; and, in these circumstances,
whilst an inattentive practitioner, has perhaps concluded that
all was well, with regard to the haemorrhage, the patient has
expired, or only lived long enough, to permit the child to be
extracted. AU practical writers, warn us against internal
flooding, nay, so far do some carry their apprehension, that
they advise us to raise the head of the child, and observe
whether blood or liquor amnii be discharged ;t an advice,
however, to which I cannot subscribe, because, in those cases
where the membranes have given way, or been opened, the
head cannot be thus moveable, nor these trials made, unless

* Mr. Ingleby, in hit work on uterine hsmorrhage, seems to think that I
object to the use of the plag in profuse hsmorrbage. Quite the contrary, if
delivery be not practicable. But in those cases, where the discharge has l>een
profuse, or repeated, the os uteri is generally dilatable, and then, to the delirery
of the mother, we must look for safety.

t Vide Dr. Johnson's System of 5lidwifery, p. 157, and Dr. Leak's Diseases
of Women, Vol. ii. p. 2«0.

348

we hare waited, until a dangerous relaxation, hare taken place^
in the uterine fibres; and if, on the other hand, we have
delivery in contemplation, it is our object to confine the
liquor amnii, as much as possible, until we turn the child.
Blood may also collect in the upper part of the vagina, to a
dangerous quantity, when the plug has been trusted to, too
late, for then a small loss is of much importance. At an
early period, I do not think there is ground for fear on this
point, but still it is well to remember the possibility of the
occurrence, and examine the actual state of the patient, at
proper intervals. If the vagina have been not merely stopp<Ml
at, or near its orifice, but stuffed as it ought to be, there is
little room for much blood. The upper part of the vaginay
no doubt, may distend, but not to a great degree, in ffeneral^
as the coagulum restrains, like a continuation of the Jnug, the
haemorrhage. The feeling of distension, or weight, and the
pressure on the bladder, would warn us of the inefficiency of
the plug. It will be very diffimlt to prove, that it has ever
caused efiusion between the membranes, or placenta, and the
uterus, at an early stage of the disease.

Besides using these means, it will also, especially in a first
attack, and where we have it not in contemplation, to
deliver the woman, be proper to exhibit an opiate, in order
to allay irritation, and this is often attended with a very
happy effect. On this subject, long experience enables me
to speak with decision, and to recommend, in every instance,
where the haemorrhage does not depend on plethora, the
exhibition of a full dose of laudanum, which tranquilises the
patient, allays irritation, and checks, for a time, the dis-
charge.

Such are the most effectual methods of speedily, or
immediately, stopping the violence of tlv9 haemorrhage.
The next points for consideration are, whether we can
expect to carry the patient, safely, to the fiill time, and,
by what means, we are to prevent a renewal of the dis-
charge.

It may, I believe, be laid down as a general rule, that when
a considerable portion of the decidua has, in the sevenlli
month, or later, been separated, the haemorrhage, although it
may be checked, is apt to return. When a part of the pla*-
centa has been detacned, and, more especially, if that organ
be fixed over the os uteri, gestation cannot continue long ;
for, either such injury is done to the uterus, as produces
expulsion and a natural cure, or, the woman bleeds to death,

349

or, we must deliver, iu order to prevent that dreadfbl termi-
nation.

If the discharge be in small quantity, and have not flowed
with much rapidity — if it stop soon or easily-^if no large clots
be formed in the vagina — if the under part of the uterus have
its usual feel, showing that the placenta is not attached there,
and that no large coagula are retained within the os uteri —
if the child be still alive — if there be no indication of the
accession of labour — and if the slight discharge which is still
coming away, be chiefly watery, we may, in these circumstan-
ces, conclude, that the vessels which have been ruptured, are
not very large, and have some reason to expect, that by care
and prudent conduct, the full period of gestation may be
accomplished. It is difficult to say, whether, in this event,
the uterus form new vessels, to supply the place of those
which have been torn, or whether re-union be effected by the
incorporation of those, with corresponding vessels from the
chorion. In the early months we know that reunion may
take place ; but when, in the advanced period of pregnancy,
the decidua has become very thin, soft, and almost gelatinous,
it is not probable that the circulation may be renewed. At
all events, we know that the power of recovery or reparation,
is very limited, and can only be exerted, if at all, when the
injury is not extensive. But although no reunion may take
place, yet, the vessels at the spot, may contract and come
rather to furnish a serous secretion, than pour out pure
blood.

When the placenta is partly separated, all the facts of which
we are in possession, are against the opinion that re-union
can take place. If the spot be very trifling, and the vessels
not large, we may have no return of the bleeding, a small
coagulum may permanently restrain it ; but if the separation
be greater, and the placenta attached low, or over the os
uteri, the patient cannot go to the full time, unless that be
verj near its completion. We judge of the case, by the pro-
fusion and violence of the discharge, for, all great hssmorrha-
ffes proceed from the separation of the placenta, and by the
xeel of the lower part of the uterus — by tne quantity of clots,
and the obstinacy of the discharge, which may perhaps require
even actual syncope to stop the paroxysm-^a circumstance
indicating great danger.

The best way, \^ which we can prevent a return, is to
moderate the circulation, and keep down the action of the
system, to a proper level with the power. The propriety of

352

her ; it is by giving mild food, so as, gradually, to restore the
quantity of blood and the strength; it is by aroiding the
stimulating plan on the one hand, and the starving system on
the other, that we are to carry her safely through the
danger.

Some medicines, possess a great power, over the blood-
vessels, and may therefore be supposed to enable us in
haemorrhage, to cure our patient with less expense of blood,
than we could otherwise do. Digitalis is of this class*
Acetate of lead has also been proposed, in doses of two grains
everv hour, till at least twelve grains were taken ; but I can-
not hold out any reliance on either of these, neither would I
advise tartrate of antimony.

Whilst we endeavour, to diminish the action of the vascular
system, we must also be careful to remove, as far as we can,
every irritation. I have already said all that is necessary,
with regard to heat, motion, and diet. The intestinal canal
must also be attended to, and accumulation, within it, should
be carefully prevented, by the regular exhibition of laxatives.
A costive state, is generally attended with a slow circulation,
in the veins belonging to the hepatic system, and, of these,
the uterine sinuses form a part. If the arterial system, be
not proportionally checked, this sluggish motion is apt, by
retarding the free transmission along the meseraic veins, to
excite the haemorrhage again.

Uneasiness about the bladder or rectum, or even in more
distant parts, should be immediately checked ; for, in many
cases, haemorrhage is renewed by these irritations. In these
cases, or where the patient is troubled with cough, or affected
with palpitation, or an hysterical state, much advantage may
be derived from the exhibition of opiates. In many instances,
where an attack of flooding, is brought on, by some irritation,
affecting the lower part of the uterus in particular, or the
system in general, or, where the bowels are pained, and the
pulse not full nor strong, rest, cool air, and a moderate dose
of tincture of opium, may terminate the paroxysm, and per-
haps prevent a return. This is especially the case, if only a
mrt of the decidua have been separated, and the discharge
nave not been profuse. When the vascular system is full,
venesection, as formerly explained, may, though rarely, be
proper, before the anodyne be administered.

It may happen, that we have not been called, early, in a
first attack, and that some urgent symptom has appeared.
The most frequent of these, is a feeling of faintness or com-

353

plete syncope. This feeling often arises, rather, from an
affection of the stomach, than from absolute loss of blood, and
in this case, it is less alarming, than when it follows copious
haemorrhage. In either case, however, we must not be too
hasty in exhibiting cordials. When the faintishness depends,
chiefly, upon sickness at the stomach, or feeling of failure,
circumstances which may accompany, even a small discharge,
it will be sufficient to ^ve a few drops of hartshorn in cold
water, and sprinkle the face with cold water : a return is pre*
vented by an anodyne draught, or opium pill. When it is
more dependent on absolute loss of blood, we may find it
necessary to give a full dose of opium or laudanum, with the
addition of small quantities of wine warmed with aromatics,
but the latter, even in this case, must not be given with a
liberal hand, nor too frequently repeated.* It is scarcely
necessary for me to add, that we are also to take immediate
steps, by the use of the plug, &c., for restraining the dis-
charge* This I may observe once for all;

Sickness and faintness also may depend on spasm of the
uterus, which ought to be checked, immediately, by laudanum.
It also is a ground for delivery, earlier than would be other-
wise required. It is recognised by the continued pain in the
back and belly, with much greater sinking, than can, from
the mere discharge, be accounted for.

iComplete syncope is extremely alarming to the by^-standers,
and, if there nave been a great loss of blood, it is, indeed, a
most dangerous symptom. It must at all times be relieved,
for, although faintness, be a natural mean of checking haemor-
rhage, yet, absolute, or prolonged syncope is hazardous. We
must keep the patient at perfect rest, in a horizontal posture,
with the head low, open the windows, sprinkle the face
smartly with cold vinegar, apply volatile salts to the nostrils,
and give 6fty or sixty drops of laudanum internally, and occa*
siondly a spoonful of warm wine.

Universal coldness, is also a symptom, which must not be
allowed to go beyond a certain degree, and this degree, must
be greatly determined, by the strength of the patient, and the
quantity and rapidity of the discharge. When the strength

* At lyneope and lota of blood biTt both the effect of relaxing the motcolai'
fibre, at it well known to turgeont, it mav be tupposed that thev should increato
the flooding bv diminishing the contraction of the uterus, if that have already
taken place. But the contrary is tlie case, for by allowing coagula to fonui syn-
cope restrains hemorrhage, and therefore ought not to be too rapidly removed In
a flrtt attack, and before the ot uteri have beoome dilatable.

2 A

354

is not previously much reduced, a moderate degree of cold-t
ness, is, if the hssmorrhage threaten to continue, of serrice ;
but when there has been a great loss of blood, then, uniTersal
coldness, with pale lips, sunk eyes, and approaching deli-
rium, may, too often, oe considered as a forerunner of death.
When we judge it necessary to interfere, we should apply
warm cloths to the hands and feet, a bladder half filled witn
tepid water to the stomach, and give some hot wine and water
inwardly.

Vomiting, is another symptom which sometimes appears.
When it proceeds from excessive discharge, it is an alarming
sjrmptom. It is less so, when it is caused by the attendants
having given more nourishment or fluid than the stomach can
bear, or from a gush of blood taking place soon after the
patient has had a drink. It, in this case, is commonly pre-
ceded by sickness and oppression, which are most distressing,
and threaten syncope, until relief be obtained by vomiting.
Sometimes, it is rather connected with an hysterical state, or
with uterine spasm. If frequently repeated, it is a debilitat-
ing operation, and by displacing clots may renew haemorrhage;
but, sometimes, it seems fortunately, to excite the contrac-
tion of the uterus, and give it a disposition to empty itself.
For abating vomiting, we may apply a cloth, dipped in lauda-
num and camphorated spirits of wine, to the whole epigastric
region; or give two grains of solid opium, or even more,
if the weakness be great. Sometimes a little infusion of
capsicum is of service: it should just be gently pungent.
In flooding it is of importance, to pay much attention to the
state of the stomach, and prevent it from being loaded ; on
the other hand, we must not let it remain too empty, nor
allow its action to sink. Small quantities of pleasant nourish-
ment, should be given frequently. We thus prevent it from
losing its tone, without oppressing it, or filling the system too fast.

Hysterical aflfections, often accompany protracted floodings,
such as globus, pain in the head, feeling of sufibcation, palpi-
tation»* retching, in which nothing but wind is got up, &c.
These, are best relieved, by some foetid or carminative sub-
stance, conjoined with opium. Laxatives are also of essential
service. The retching, sometimes requires an anodyne

* Th€ quMitlty of blood lost, it lometinefi to great, m to do irreponblo injnry
to tbo bcBTtf and OTor aftor to Impair Its action. On« well marlced Instance of
tbb it related by Van Swieten, in bit commentanr on Apb. 1904, wbere for
twelTe years tbe woman, after a ssTcre flooding , eotud not sit op In bed .wltbout
Tiolent palpitation and anxiety.

355

clyster, or the application of a camphorated plaster* to the
region of the stomach.

After haying made these observations, on the management
of flooding, and the best means of moderating its violence, of
preventing a return, and of relieving those dangerous symp-
toms, which sometimes attend it, I next proceed to speak of
the method of delivering the patient, when that is necessary.
I have separated the detail of the medical treatment of a
paroxysm, from the consideration of the manual assistance,
which may be required, because, however intimately con-
nected the different parts of our plan may be, in actual prac-
tice, it is useful, in a work of this kind, in order to avoid con-
fusion, that I lay them down apart*

As some peculiarities of practice, arise from the implanta-
tion of the placenta, over the os uteri, I shall confine my
i^resent remarks, to those cases, in which the membranes are
bund at the mouth of the womb, desiring it to be remem-
bered, however, that this circumstance shall not necessarily
indicate, that the hiemorrhage does not proceed, from separa-
tion of die placenta, which may be fixed very near the cervix,
although it cannot be felt.

The operation of delivering the child, is not difficult to
describe or to perform. I am generally in the practice of
giving, a quarter of an hour before I begin, if the case admit
of this delay, fifty drops of tincture of opium. The hand,
previously lubricated, is then to be slowly, and gently, intro-
duced completely into the vagina. The finger is to be intro-
duced into the os uteri, and cautiously moved so as to dilate
it ; or» if it have already dilated a little more, two fingers
may be inserted, and very slow and gentle attempts made, at
short intervals, to distend it without injuring the mem-
branes ; and the practitioner shall succeed best, when he acts,
80 as rather to stimulate the uterus, and make it dilate its
mouth, than forcibly to distend it. On the part of the opera^
tor, is demanded much tenderness, caution, firmness, and
composure; on the part of the patient, is to be desired
patience and resolution. The operator is to keep in mind,
that piunful dilatation is dangerous, it irritates and inflames
the |Nirt8, and that the woman should complain rather of the
tttenne pains which are excited, than of the fingers of the
{Mractitioner., More or less time will be required, fully, to

* This may be made bjr melting a little adhcsiTe plaster, and then adding to it
a large proportion of camphor, preyiously made into a thick liniment by rubbing
UwUhoUT7oll.

356

dilate the os uteri, according to the state in which the utems
was, when the operation was begun. If the os uteri be soft
and pliable, and have already, by slight pains, been in part
distended, a quarter of an hour, perhaps only a few minutes,
will often be sufficient for this purpose; but, if it hare
scarcely been affected, before, by pains, and be pretty firm,
though not unyielding, then, half an hour, may be required.
I speak in general terms, for no rule can be given applicable
to every case, and we rarely require to deliver, where the 09
uteri is not already partially dilated, and dilatable. . Not
unfrequently, although the patient have felt scarcely any
pains, and certainly no regular pwis, the os uteri will be
found as large as a penny piece, and its margin soft and thin.
The OS uteri being sufficiently dilated, the membranes are to
be ruptured, the hand introduced, the child slowly turned and
delivered, as in footling cases, endeavouring rather to have
the child expelled, by uterine contraction, than brought away
by the hand. Hasty extraction is dangerous, for the uterus
may not contract after it. And, therefore, if when we are
turning, we do not feel the uterus acting, we must move the
hand a little, and although we turn, yet we should not begin
to deliver, until we perceive that the womb is contracting.
The delivery must be but slow until the breach be passing;
then, we must be careful, that the cord be not too long com-
pressed, before the rest of the child be born. The child
being removed, and the belly properly supported, and gently
pressed on, by an assistant, the hand should a^ain be cautiously
mtroduced into the womb, and the back 01 it placed on the
surface of the placenta, so as to press it a little, and^excit^
the uterus to separate it. The band may also be gently
moved, in a little time, and the motion repeated at intervals,
90 as to excite the uterus to expel its contents ; but if the
placenta shall adhere, upon no account are we to separate it.
This must be done by the uterus ; for we have no other sign,
that the contraction will be sufficient to save the woman from
ftiture haemorrhage. If the placenta be detached, and the
uterus contracting, we may safely extract it, if we only bring
it away without the smallest force ; we then reintroduce gently
the hand, and retain it for some time, for reasons to be pre*
aently mentioned. The whole process, from first to last,
must be slow and deliberate, and we are never to lose sight
of our object, which is to excite the expulsive power of the
uterus. It is not merely to empty the uterus — it is not
merely to deliver the child, that we introduce our head : aU

357

this we may do, and leare the woman worse than if we had
done nothbg. The fibres must contract and press upon the
vessels, and as nothing else can save the patient, it is essen-
tial that the practitioner have clear ideas of his object, and be
convinced on what the security of the patient depends.

But to teach the method of delivery, and say nothing of
the circumstances under which it is to be performed, would
be a most dangerous error. I have, in the beginning of this
section, pointed out the effect of hssmorrhage, both on the
constitution and on the uterus ; and I have stated, that the
action of gestation is always impaired, by a certain loss of
blood, and a tendency to expulsion brought on. But before
the uterine contraction can be fully excited, or become effec-
tive, the woman may perish, or the uterus be so enfeebled as
to render expulsion impossible. Whilst then we look upon
the one hand to the induction of contraction, we must not on
the other, delay too long. We must not witness many and
repeated attacks of haemorrhage, sinking the strength, bleach-
ing the lips and tongue, producing repeated fainting fits, and
bringing life itself into immediate danger. Such delay is
most inexcusable and dangerous ; it may end in the sudden
loss of mother and child ; it may enfeeble the uterus, and
render it unable afterwards to contract ; or it may so ruin
the constitution, as to bring the patient, after a long train of
sufferings, to the grave.

Are we then uniformly to deliver upon the first attack of
flooding, and forcibly open the os uteri? By no means:
safetv is not to be found, either in rashness, or procrastination.

The treatment which I have pointed out, wUl always seciu'e
the patient, until the delivery can be safely accomplished.
As long as the os uteri is firm and unyielcQng — as long as
there is no tendency to open, no attempt to establish con-
traction, it is perfectly safe to trust to the plug, rest, and
cold. But I must particularly state to the reader, that the
OS uteri may dilate without regular pains; and in almost
every instance it does, whether there be or be not pains,
become dilatable* Did I not know the danger of establish-
ing positive rules, I would say, that as long as the os uteri is
firm, and has no disposition to open, the patient can be in
littie risk, if we understand the use of the plug ; we may even
stuff the OS uteri itself, which will excite contraction. But if
the patient be neglected, then I grant, that long before a
tendency to labour or contraction be induced, she may perish.
I am not, however, considering what may happen m the

358

hands of a negligent practitioner, for of this there would be
no end, but whiEit ought to be the result of diligence and care.

It is eyident, that when the uterus has a disposition to
contract, and the os uteri to open, delivery must be much
safer and easier, than when it is still inert, and the os uteri
hard.

We nuLj, with confidence, trust to the methodical stuffing
of the yagina, until these desirable effects be produced, and,
in some instances, we shall find, that by the plug alone, we
may secure the patient : the contraction may become brisk, if
we have prevented much loss of blood, and expulsion may
naturally take place. Who would, in these circumstances,
propose to turn the child, and deliver it ? Who would not
prefer the operation of nature, to that of the accoucheur ?
To determine in any individual case, whether this shall take
place, or whether delivery must be resorted to, will require
deliberation on the part of the practitioner. If he have used
the plug early and effectually, and the pains have become
brisk, he has good reason to expect natural expulsion ; and
the labour must be conducted on the general principles of
midwifeiT- But if the uterus have been enfeebled by loss of
blood — if the pains be indefinite — if they have done little
more than just open the os uteri, and have no disposition to
increase, then he is not justified in expecting, that expulsion
shall be naturally and safely accomplished, and he ought to
deliver. When he dilates the os uteri, he excites the uterine
action, and feels the membranes become tense. But he must
not trust to this ; he must finish what he has begun.

Thus it appears, that by the early and effective use of the
plug, by filling the vagina with a soft napkin, or with tow,
we may safely and readily restrain the haemorrhage, until
such changes have taken place on the os uteri, as to render
delivery easy ; and then, we either interfere, or trust to
natural expulsion, according to the briskness and force of the
contraction, and state of the patient.

By this treatment, we obtain all the advantage that can be
derived from the operations of nature ; and, where these fail,
are enabled to look with confidence, to the aid of artificial
delivery.

But it may happen, that we have not had an onp<Mrtumty
of restraining the hemorrhage early ; we may not have seen
tile patient, until she have simered much from the bleeding.*

* Wc an not t« eMiftnc our alteiiti«n to the quAotStv whicb bas beoi lost, b«t
to the effect it bee produced ; end thb will cettrU parAm$ be f rcftt ia proportioA
as the hginotiheye bee bven sadden.

359

la this case, we shall generally be obliged to deliver, and
must, upon no account, delay too long ; yet, if the os uteri be
Yery firm, without disposition to open, and require hazardous
force to dilate it, we shall generally find that the sinking is
temporary : we may still trust, for some time to the plug, and
give opiates to support the strength.

Haemorrhage is naturally restrained by faintness. A
repetition is checked in the same way ; and faintness takes
place sooner than formerly. In one or two attacks the
uterus suffers, and the os uteri becomes dilatable. Slight
pains come on, or are readily excited, by attempts to dis-
tend the OS uteri. Syncope then wiU, in general, eyen when
the plug has not been used, and the patient has been neglected,
restrain haemorrhage, and prevent it from proving fatal, untU
the OS uteri have relaxed; but a little delay beyond that
period will destroy the patient, and it is possible, by giving
wine, and otherwise treating her injudiciously, to make
haemorrhage prove fatal, even before this take place. But
although I have considered it as a general rule, that where
the OS uteri is firm and unyielding, we may, notwithstanding
present alarm, trust some time to the plug, yet I beg it to be
remembered, that there may be exceptions to this rule ; for
the constitution may be so delicate, and the haemorrhage so
sudden, or so much increased by stimulants, as to induce a
permanent effect, and make it highly desirable that delivery
should be accomplished ; but such instances are rare ; and,
although I have spoken of the effects of syncope in restraining
haemorrhage, I hope it will not be imagined by the student,
that I wish to make him familiar with this symptom. It is
very seldom safe, when we have our choice, to wait till
syncope be indbced ; and if it have occurred, it is not usually
prudent to run the risk of a second attack.

The old practitioners, not aware of the value of the plu^,
endeavoured to empty the uterus early ; but it was uniformly
a remark, that those women died who had the os uteri firm
and hard.* It was the fatal consequence, of this practice being
sometimes prematurely and rashly resorted to, that suggested
to M. Puzos, the propriety of puncturing the membranes,
and thus endeavouring to excite labour. His reasoning
was ingenious ; his proposal was in one respect, an improve-

• Gailimeaii distinctly rccommeDds turning, and eztrketinf the child, and f ivn
the history of th« ease of Park's daughter, (1699,) whoee life he saved In thle
way, haying heen taught hy her latefatncr to do so. Maoriceou explicitly saya*
we must not always expect nains to forward lahour, neither defer turning, till the
04 uteri be opened enough, for it is relaxed, and easily dilated^

360

inent on the practice which then prevailed. The ease of the
Operation, and its occasional success, recommend it to our
notice ; but experience has now determined, that it cannot be
relied on, and that it may be dispensed with. If we use it
early, and on the first attack, before any tendency to labour
exist, we do not know when the contraction may be establish-
ed ; for, even in a healthy uterus, when we use it on account
of a deformed pelvis, it is sometimes several days before
labour be produced. We cannot say what may take place in
the interval. The uterus being slacker, the haemorrhage is
more apt to return, and we may be obliged, after all, to have
recourse to other means, particularly to the plug. Now we
know that the plug can, without any other operation, safely
restrain hemorrhage, until the os uteri be in a proper state
for delivery.* The proposal of M. Puzos then is, I appre-
hend, inadmissable before this time. If after this, there be
occasion to interfere, it is evident, that we must desire some
interference, which can be depended oq, both with respect to
time and degree. This method, can be relied on in neither ;
for we know not how long it may be of exciting contraction,
nor whether it may be able to excite efiective contraction,
after any lapse of time. If it fail, we render delivery more
painful, and consequently more dangerous to the mother, and
bring the child into hazard. It has been observed, in objec-
tion to this, by Dr. Denman,t that if turning be difficult, the
flooding will be stopped by the contraction of the womb. But
we know that the uterus, emptied of its water, may embrace
the child so closely as to render turning, if not mfficult, at
least painful, and more dangerous, and yet not be acting so
briskly, and universally, as to restrain flooding : nothing but
brisk contraction can save the patient in flooding, if the
vessels be large or numerous. Spasmodic action may also
take place.

The only case then which remains to be considered, is that
in which pains come on, and expulsion is going forward.
Now, in this case, the flooding is stopped, either by the

* The late Alphonie Le Roy seems much IneliDed, to trust almost entirely
to the plug, and sappooes that the blood will act as a forei^ body, and ezdie
eontraction ; but thisl as a general doctrine must be greatly qualified. Respect-
ing the proposal of M. Puzos, he obserres, •• Pnsos, en conseilant asses hardi-
ment de peroer Ice eanz, n*avoit d'autres Tues que la contraction de la matrioe,
qoleet la suite de cetU operaUon et la cessation de la perte, et ilia conselUa memo
WIS ics eas dee pertes qu'arrivent avant terme. Mais on grand nombre de
miTp' S* '**'*** *" ^'**^ *** ***** "*"** pmtique." Lemons snr Ics pertes dt

t IntroducUon to the JPractioe of Midwifery, Vol. li. p. Sia

361

contraction or by the plug, and the membranes burst in the
natural course of labour. Here then, it is true, interference
is not required ; but if, after going on in a brisk way, for some
time, the membranes being yet entire, the pains abate a little,
which often happens, eyen in a natural labour, it may be pro*
posed to rupture them, in the hope that this shall proye a
stimulus to the uterus, and renew its action. In deciding on
this, the practitioner must be somewhat influenced, by the
preyious discharge. Certainly, if the uterus haye been much
reduced by that in its yigour, it will be less under the influ-
ence of a stimulus ; and if, upon the present diminution of
the pains, the flooding be disposed to return, I should think
that we surely ought to trust rather to the hand, which can
finish the process with safety, than to a method which is much
more uncertain, and less under our command.*

The proposal of M. Puzos is yery limited in its utility*
Its simpucity gaye me at first a strong partiality in its fayour ;
but I soon found cause to alter my opinion. I consider that
we are only warranted in trusting to it in those slighter cases
which would almost do well without it. I must not, howeyer,
conceal, that many eminent men are still fayourable to the

Elan, yet, so far as may be judged of, by cases recorded by these
igb authorities, a larger proportion of women die m this
species of haemorrhage, than in that where the placenta is
attached to the ceryix uteri. Dr. Clarke has four out of ten,
Dr. Ramsbottom seyen out of sixteen. Dr. Collinsf has a
somewhat different result, for out of thirteen, only two women
died, but the loss of children was great, only one being bom
aliye. In the placental presentations, only two women died,
but there were six liying children bom. Dr. Hamilton,} who
argues strongly against the plan of Puzos, says he has seen
fully as many fatal cases in accidental, as in unayoidable,
haemorrhage. On the other hand. Dr. Merriman says, that
thirty cases of the former, all did well.

There still remains a most important question to be
answered. In those cases, where the patient has been allow-
ed to lose a great deal of blood, frequently and suddenly,

* In tboM caan when the placento proenta, few pimctitionen would think of
trueting to the CTacuAtion of the liquor amnil ; they would delWer. If then
delirerj bo considered ai safe and proper in one spedea of flooding, it cannot be
dangorona in the other ; and wheneyer interference in the war of operation is
necessary, the security afforded by the introduction of the liand wiU much more
than compensate for any additional pain. But CTcn in this respect, the two
operations are little diffnrent, if properly performed.

f Praetieal Treallae^ p. 112.

I Practical Obocrrations, Vol. ii. p. 2S9.

trfaen the strength is gone, the pulse scarcely to be felt, the
extremities cold, the lips and tongue without blood, and the
eye ghastly, shall we venture to deliver the woman ? Shall
we, by plugging, endeavour to prevent farther loss, and by
nourishment and care, recruit the strength ; or einpty the
uterus, and then, endeavour to restore the loss ? We have
only a choice of two dangers. The situation of the patient is
most perilous, and I have, in practice, weighed the argument,
with that attention, which the awful circumstances of the case
required. I think myself justified in saying, that we give
both mother and child, the best chance of surviving, by a
cautious delivery. For in these cases, the uterus is almost
torpid, it possesses no tonic contraction.* The general aystem
is completely exhausted, and cannot support its condition
long. The very presence of the ovum witnin the uterus is a
cause of danger. I have never known a woman live twenty-
four hours in these circumstances.

On the other hand, I grant, that it ia possible the woman
may die in the act of delivery, or very soon after it; but if
she can be supported for one day, we may have hopes of
recovery. By a very slow and cautious delivery, and by
endeavouring thereafter, by retaining the hand for some time
in the womb, to excite its action, so as to prevent discbat^e
afterwards, we not only remove the irritation of the distended
womb, hut we likewise take away a receptacle of blood.
During the contraction of the uterus, the blood in its sinuses,
will be thrown into the system, and tend to support it. Part,
no doubt, will escape ; but by keeping the band in the uterus,
by supporting the abdomen with a compress, and exciting the
uterine action by cold applications to the belly, or pressing
firmly on the uterus, witb the expanded hand, or moving the
abdominal parietes over it, we may excite the uterine action ;
or, if the application suddenly to toe belly of cloths wrung out
of iced water, do not produce distressing shivering, it may be
used for a short time, if we find that it makes the uterus coo-
tract; or the loose coaeula ought to be extracted, and the
en to these considerations, we
lich the child has for life, our
a this very hazardous case, be
ecumes firmer, and fuller, upon
the risk from debility is dimin-

363

ished. A full dose of laudanum ought, uniformly, to be given
previous to delivery, as I have uniformly advised ; and, after-
wards, twenty drops of the same medicine are to be given, if
necessary, at intervals, longer or shorter, according to the
urgency of the case, in order to allay restlessness and irrita-
bility. But I do not wish to give more than is absolutely
necessary, for if given, so as to affect either the stomach or
nervous system much, we find that detriment results. If the
stomach be irritable, solid opium may be given, or an opiate-
clyster is to be administered. Small quantities of light
nourishment, must also be given frequently, and a state of
rest strictly enforced, in so much, that the patient, for some
time after delivery, ought not even to be shifted, but only
have a firm bandage applied over the abdomen, in order to
support the muscles and contained viscera, a precaution which
never ought to be omitted. It has been proposed, in cases'of
extreme debility, from haemorrhage, to inject slowly, by
means of a small syringe, into a vein of the arm, blood recently
drawn from another person. But, as yet, we have too few
cases, to enable us to determine the value, of the proposal.

Having already taken notice of the effects of haemorrhage,
and the management of these, I shall refer, on this important
subject, to the section on menorrhagia, which the student is
requested to reconsider at this place.

At one time it was supposed, that the placenta was, in
every instance, attached originally to the fundus uteri, and
that it could only be found presenting, in consequence of
having been loosened, and falling down. This accident was
supposed to retard the birth of the child, by stopping up the
passage, and also, was considered as dangerous, on account
of the flooding which attended it. On this account, Daventer
endeavoured to accelerate the delivery, by tearing the pla-
centa, or rupturing the membranes when they could be found.
This was a dangerous practice, and very few survived when
it was employed. Dr. Smellie, Mr. Gifford, and M. Levret*
were among the first, who established it as a rule, that the
placenta did not fall down, but was originally implanted over
the OS uteri ; and the last gentleman, published a very con-

* J« m'engage a prouTer, Imo. Qa« 1e plnoenta •*impIanUs quelquefois, tur la
cireonfctrenoede I'orifioe de lamatrice ; c«*st-a.dire, tur celui qui da col ra Juludre
rioterieur de oe Tiaccre, et non sur celui qui rcgarde de la Tigin.

8do. Qu'en ce cae la perte de sanf est intvitabU dans let dernier temi de la

fit Stio. Qtt'il n*y a pat de Toye plut ture, pour remedier a eet accident urgent^
que de fair l*accottcheraent forc^ L*Art det Accouchement, p. S4S.

else, and accurate Tiew, of the treatment to be pursued. Mr.
Rigbj, of Norwich, afterwards, published an abstract of the
doctrine of Puzos and Levret, with the addition of some
cases from his own practice.

We know, that during the eighth month of gestation, Terr
considerable changes take place, about the cerrix uteri. It
is more developed and expanded, and its lower portion near
the month, comes in contact with that part of tne placenta
which was above it, bnt being destitute of decndua, and
furnishing only jelly, no firm union can take place. Farther,
either the placenta does not in its growth adapt itself, to the
changes in the shape of the cervix, or, which happens more
frequently, some slight mechanical cause, or action of the
fibres above the os uteri, produces a rupture. This seems
more likely to occur, and to be more serious, when the edge
of the placenta is attached there. When the placenta stretches
fairly across the cervix, it is possible for union to continue,
till labour cause detachment.

This rupture, may, doubtless, take place, at any period of
pregnancy,* but it is much more frequent, in the end of the
eighth, and beginning of the ninth month, than at any other
time, though it may be postponed, till the commencement of
labour, at its full time. But whether the separation happen
in the seventh, eighth, or ninth month, the consequent
hemorrhage is always profuse, and the efiect most alarming.
The quantity, but especially the rapidity of the discharge,
very frequently produce a tendency to faint, or even complete
syncope, during which the heemorrbage ceases, and the
woman may continue, for several days, without experiencing
a renewal of it. In some instances, she is able to sustain
many, and repeated attacks, which may take place, daily, for
some weeks. These, however, it is evident, cannot be very
severe, and the strength must, originally, have been great.
In other instances, she never gets the better of the first
attack. It indeed diminishes, but does not altogether leave
her, and a slight exertion renews it in its former violence.
But whether the patient sufier much or little in the first
ist, the practice must be
I made upon the practi-
it a discharge oi blood

ii^ t^

365

takes place, he ought to ascertain, by careful examination,
the precise nature of the case, and must take instant steps for
checking it, if nature have not, already, accomplished that
event.

If the OS uteri be firm and close, in a first attack, we ought
to use the plug, which will restrain the haemorrhage, and
ensure the present safety of the patient. If this practice have
been immediately followed, she shall in general soon recover |
and the length of time, which she shall remain free, from a
second attack, will depend, very much, upon the care which
is taken of her ; but sooner or later, the attack must and
will return. If the uterus have been injured in its action, by
the first attack, this, will generally be attended with very
slight dull pains, and we shall feel the os uteri, more open,
and laxer than usual. But if the first and second discharges,
have been promptly checked, it may be later, before these
effects be perceived ; the moment, however, that they are pro*
duced, we ought to deliver. It should even be a rule, that,
where they are not likely soon to take place, and the discharge
has been profuse and rapid, and produced those effects on the
system, which I have already pointed out, as the consequences
of dangerous haemorrhage, we must not delay, until pains
begin to open the os uteri. Fortunately, we are not often
obliged to interfere thus early, for, by careful management,
and the use of the plug, we can secure our patient, till some
effect, be produced, on the os uteri.

Although, I have said that we may wait, safely, until the

OS uteri begin to open, and asserted, that no woman can die

from mere haemorrhage, before the state of the os uteri admit

of delivery, I must yet add, on this important subject, that

this state does not consist merely in dilatation, for it may be

very little dilated, but in dilatabUity. We may safely deliver,

whenever, the hand can be introduced, without much force*

A forcible introduction of the hand, on the first attack of

hemorrhage,- would, in many cases, be attended with the

greatest danger, and, in almost every case, is improper and

unnecessary. I have never yet seen an instance, where.

delivery was required during the first paroxysm, if the

proper treatment were followed. Whether it may be required

in a second or third attack, or even later, must depend upon

the quantitv and rapidity of the discharge, its effects, and

the strength of the patient. But, whenever we find the os

uteri more open, than in its usual state, before labour, admit-

hng the finger to be introduced, easily, beyond it, and feel

366

no rigid resistance, we may safely deliver, and, if the h»mor*
rhage be continuing, ought not to delay. This state, will,
generally, be found accompanied with obscure pains, but we
attend less to the degree of pain, than of discharge, in deter«
mining on delivery. The pains, gradually, increase for a
certain period, and then go off. During their continuance,
the OS uteri dilates more ; but if the haemorrhage have been,
or continues to be, considerable, we must not wait until the
OS uteri be much dilated, as we thus reduce the woman to
great danger, and diminish the chance of her recovery. A
prudent practitioner will not, on the one hand, violently open
up the OS uteri, at an early period, but will use the plug,*
until the os uteri become soft and dUatable. If the hemor-
rhage be not considerable, he will even, if the state of the
patient allow him, wait until the os uteri begin sensibly to
open without them, for, the more violence that is done to the
OS uteri, the greater is the risk of bad symptoms supervening.
It is an error, into which some have fallen, to look upon
debUity from discharge, as the only barrier to recovery.
Violent delivery may produce inflammation, or a very
troublesome fever. On the other hand, he wUl not allow
his patient to lose much blood, or have many attacks; he
will deliver her immediately, for he knows that whenever this
is necessary, it is easy, the os uteri yielding to his cautious
endeavours.

But we may not be called, until the patient have had one
or two attacks, and been reduced to great danger. We
find her with feeble pulse, ghastly countenance, frequent
vomiting, and complaining, occasionally, of slight pains. On
examination, the vagina is so filled with clotted blood,
adhering firmly, by its fibrin, to the uterus, that, at first, we
find some difficulty, in discovering the os uteri. We cannot
here hesitate, a moment, what course to follow. If the patient
is to be saved, it is by delivery. The os uteri will he in part
dilated ; it may, easily, be fully opened. We perhaps find
an edge of the placenta projecting into the vagina, perhaps
the centre of the placenta, presenting or protruding like a
cup into the vagina ; but, in both cases, the rule is the same.
We pass bv the placenta, to the membranes, rupture them,!
and turn tne child, delivering according to the directions

-•!L£*?**7 thinki, that In tach cmm, the plug wlH do harm by czciUnc th«
Tmbi/IL iaiL^ ""^"^ ^ ^* plaeenta, and thut lncr«aae the fa«moiTliage.

Mi^ V'^^ll^M ^^^ ^^ ^^* cl>"<l than puahinc the hand throagh tbeplaoanU ;
•^'"''*5^ •-•▼witufeoua for the mother, andTeasy to th« operitor.

367

which I have already given, and treating the patient, in all
other respects, in the exhibition of opiates, and cordials, and
nourishment, and exciting the subsequent contraction of the
womb, as in the case formerly considered.

It may be supposed, that as the treatment is so nearly the
same, it is not material, that we distinguish, whether the
placenta or membranes present. But it is convenient to
make a distinction, because in those cases where the placenta
does not present, it is possible, in certain circumstances, to
check the flooding, and carry the patient to the full time ; and
in those cases, which are indeed the most numerous, where
this cannot be done, we always look to uterine contraction as
a very great assistance, and expect that where that is greatest,
the danger will be least But when the placenta presents,
we have no hope of safety to the woman, from the accession
of labour. We have no ground, to look to contraction, or
labour, as a mean of safety, for, on the contrary, every effort
to dilate the os uteri, separates, still more, the placenta, and
increases the haemorrhage.* The very circumstance, which,
in some other cases, should save the patient, shall here, in
general, increase the danger. I say in general, for there
are doubtless examples, where the patient has, by labour,
been safely» and without assistance, delivered of the child,
when part of the placenta has presented. Nay, there have
been instances, where the placenta has been expelled first,
and the child aiter it.f These examples are to be met with,
in collections of cases by practical writers, and some solita^
instances, are likewise to be found, in different journals. It
would be much to be lamented, if these should ever appear,
without having, at the same time, a most solemn warning,
sent, along with them, to the accoucheur, to pay no attention
to them in his practice. I am convinced that they may do
inexpressible mischief, by affording argument for delay, and
excusing the practitioner, to himself for procrastination.
There is scarcely any malady, so very dreadful, as not to

* llic sreatett niimber of profaae or alarminf bemorrham proceed from the
preeenUnon of the placenta, or the implantation of its margin orer the os ateri ;
and eonaeqoently tne greatest namber of caaee reqairing deUyery are of thia
kind.

f Eren in tboee cases where the placenta is expelled first, the flooding maj
ncnr, and the woman die, if she be not assisted. Vide La Motte, Obs. eczzxriii.
and ccaczziz. In two cases related hj Dr. Collins, the luemorrhage ceased on
the ezpnlsion of the placenta before the child. Similar instances are met with,
and it is easT to explain these ; for the placenta being entirelT separated, the
bmnorrhage fnm ita veins^ both marginal and from the disc, ought to cease ; and
if thei action of the uterus be strong, the uterine orifices may be diminished, and
the circulation confined to the substance of the uterus.

368

ftfford some exampleB, of a cure effected by the powers of
nature alone: but ought we, thence, to tamper with the
safety of those, whose lives are committed to our charge ?
Ought we to neglect the early, and vigorous, use of an
approved remedy, because the patient has not, in every
instance, perished from the negligence of the attendant ? it
is highly proper, to publish the case of a patient who, from
hernia, has had an anus formed at his gfoin, because it adds
to our stock of knowledge : but what should we think of a
surgeon, who should put such a case, into the hands of a
young man, without, at the same time, saying, ^^ Sir, if such
a case ever happen in your practice, either you, or your
patient, must be very much to blame." I do not mean from
this to say, that we are to censure, in every instance, the
accoucheur who has attended a case, where the placenta has
presented, and the patient been delivered by nature; far
from it, for by the use of the plug, he may have restrained
the haemorrhage, pains may have come on, and the child,
descending, may have carried the plug before it ; or when
he was called to his patient, he may have found her already
in labour, and the process going on so well and so safely, that
all interference would have been injudicious. But these
instances, are not to be converted into general rules, nor
allowed to furnish any pretext, for procrastination. They
happen very seldom, and never ought to be related to a
young man, without an express intimation, that he is not
to neglect delivery, when it is required, upon any pretence
whatsoever.

SECTION THIRTY-NINTH.

Many women are subject, in the end of gestation to pains
about the back or bowels, somewhat resembling those of
labour, but which, in reality, are not connected with it.
These, therefore, are called false pains. They sometimes
only precede labour a few hours, but in many cases, they
come on several days, or even some weeks before the end of
pregnancy, and may be very frequently repeated, especially
during the night, depriving the woman of sleep. They are
often confined altogether to the belly, though shifting their
place, and are very irregular both in their attacks and continue
ance. In some cases they affect the side, particularly the
right side, in the region of the liver, and are exceedinglv
severe, especially in the evening ; they are accompanied with
acidity or water-brash, or retching, and generally the child is

369

at that time very restless* These pains may doubtless occur
in any habit, but they most frequently harass those, who are
addicted to the use of cordials. On other occasions, the
false pains occupy, chiefly, the back or hips, or upper part
of the thighs. They even, sometimes, resemble still more
nearly, parturient pains, in being attended with an involun-
tary effort, on the part of the abdominal muscles, to press
down, so as to make the woman suppose that she is about to be
delivered ; and this is occasionally accompanied with tenesmus,
or, with protrusion of the bladder into the vagina, very like
the membranes of the ovum. In other cases, they are
attended with a discharge of watery fluid from the vagina.
False pains may be occasioned by many causes: the most
frequent are flatulence; a spasmodic state of the bowels,
resembling slight colic ; or irritation, connected with costive-
ness or diarrhoea ; or nephritic affections, often accompanied
with strangury. A sudden motion of the back, or unusual
degree of fatigue, may cause a remitting pain in the back and
loins; or getting suddenly out of bed when warm, and
placing the feet on the cold floor, may have the same effect.
A slight degree of lumbago may also resemble the parturient
pains. Agitation of mind, or a febrile state of the body, or
some irritation in the neighbourhood of the uterus, or some
unusual motion of the child, may produce an uneasy sensation
in the uterus ; and sometimes this is accompanied by a dis-
charge of watery fluid from the vagina. Other uterine irri-
tations may excite painful action in the uterus itself, or sym-
pathetically in other parts, as the intestines or muscles of
the abdomen. Amongst these irritations, may be mentioned
that, which sometimes attends the full development of the
cervix, in the last week of gestation, or the expansion of the
portion immediately adjoining the os uteri. Excitement of
the origin of some of the spinal nerves may cause pain —
relieved by bleeding and gentle friction. It is not uncommon
for pains, very like those in the commencement of labour,
to come on either a month, or a fortnight, before true labour.
They are apparently dependent on some change in the action,
or condition, of the uterus itself.

False pains may often be distinguished by their situation,
as for instance, when they affect the bowels or kidneys ; by
their shifting their situation; by their duration; by their
irregularities; and by the symptoms with which they are
attended. But the best criterion is, that they are not attend-
ed with any alteration in the uterine fibres, which, during

370

true or efficient labour pains, contract so as to render the
uterus more compact, and make it feel harder, when the
hand is placed, over it, on the abdomen. They also seldom
affect the os uteri, that part, not being dilated'during their
continuance. It is necessary, however, to observe, that a
dilated state of the os uteri, does not always prove, that the
pains are those of labour ; for, it may be n>und prematurely
dilated to a slight degree, before the proper term of labour,
without any pain. In this case, if the puns proceed from
affections of the bowels, no effect is produced during the
pun, in rendering the os uteri tense, or making it larger.
On the other hand, it sometimes happens, that the fibres
about the os uteri are prematurely irritated ; and this state
may be accompanied with pain, and with a perceptible change,
on the OS uteri, during a pain. This is a very ambiguous
case, but we may be assisted in our judgment, by discovering,
that the term of utero-gestation is not completed, that the
OS uteri is hard or thick, and the pains irregular, both in
severity and duration, coming on at long intervals, or being
frequently repeated for some hours, and then going off altO"
ffether for so many more, and thus, perhaps, continuing even
tor several days. This seems sometimes to depend, on pre-
ternatural sympathy, of the neighbouring parts with the os
uteri, so tliat when it begins to dilate, the abdominal or
perinasal muscles, &c., are excited to painful action, which, on
the principle of the sympathy of equilibrium, which I have
elsewhere explained, immediately calls off the uterine action,
which, for a long time, rather excites those other parts to
unprofitable pain, than establishes itself into regular labour.
In all such cases it is best to proceed on the supposition, that
the woman is not actually in labour, and use means for
relieving her. By letting her alone, she most likely shall
have a continuance of pain, terminating perhaps in labour,
but the process will be tedious and fatiguing ; whereas, by
suspending the action by an opiate, and if necessary by vene-
section, or a laxative, or a Oyster, she may go on, for some
time longer, and shall, at all events, have an easier delivery.
When the false pains are accompanied with a febrile state,
or are very distressing during the night, it will be proper to
detract blood, and afterward if the bowels be regular, give
an anodyne. In all other cases, it is generally sufficient to
keep the woman in a state of rest ; open the bowels by means
of a clyster, if there be no diarrhoea, and, afterwards, give an
<*Fate to be succeeded by a laxative. Rubbing with anodyne

271

balsam is also useful, or gentle friction with the flesh brush.
Motion also often relieves the muscular pain, whilst a quies-
cent state increases it, and hence, it is, m many cases, worst
during the night. In other instances, the erect posture, or
walking, probably from irritation of the cervix and os uteri,
by pressure of the child's head, excites pain.

Nephritic pain, is known by its situation, by the restless-
ness it produces, the frequent desire to make ^ater, the sick-
ness, and soft, perhaps, slow pulse. An anodyne clyster is
the best remedy.

Shivering and tremor, occur in some cases, in the end of
pregnancy, and as they also occasionally precede labour, they
often give rise to an unfounded expectation, that delivery is
approaching. They appear to be connected sometimes with
the state of the stomach, or alimentary canal; in other
instances, with some change in the os uteri itself, which even
without pidn, may be so far opened and relaxed, as to allow
the finger, very easily, to touch the child's head, through the
membranes. It is usually in the evening, or through the
night} that the shivering is felt ; and it is occasionally pretty
severe, and may be several times repeated* Nothing, how->
ever, is required, except a little warm gruel, or a moderate
dose of laudanumi which is always effectual*

BOOK II.

OF PARTURITION.

CHAP. I.

Of the Classification of Labours.

Labour, may be defined to be, the expulsive effort made by
the uterus, for the birth of the child, after it has acquired
such a degree of maturity, as to give it a chance of living,
independently of its uterine appendages.

I propose to divide labour into seven classes ; but I do not
consider the classification to be of great importance, nor one
mode of arrangement much better than another, for the
purpose of practice, provided proper definitions be given, and
plairi rules delivered, applicable to the different cases.

The classes which I propose to explain are,
Class I. Natural Labour, which I define to be, labour taking place at
the end of the ninth month of pregnancy ; the child at first presenting
the upper and lateral part of the parietal bone, and the forehead being
directed, at first, toward the back part of the linea ilio-pectinea, and
the vertex toward the opposite or left acetabolum ; a due pro-
portion existing, betwixt tne size of the head, and the capacity of
the peWis : the puns being regular and effective ; the process not
continuing, beyond twenty-four hours, seldom, above twelve, and
very often, not for six ;* no morbid affection supervening, capable
of preventing delivery, or endangering the life of the woman.
This comprehends only one order.
Class II. Premature Labour, or labour taking place considerably before
the completion of the usual period of utero-gestation, but, yet, not
so early, as, necessarily, to prevent the child from surviving.
Class III. Preternatural Labours, or those in which the presentation,
or position of the child, is different from that, which occurs in natu-
ral labour ; or, in which the uterus contains a plurality of children,
or monsters.

» Dr. Merriman states, that out of ISl caws, ] 1 1 were delivered within IS, and
70, beCweeo Chat and 124 hours. See also note to page 380.

373

This comprehends seven orders.
Order ]. Presentation of the breech.
Order 2. Presentation of the inferior extremities.
Order 3. Presentation of the superior extremities.
Order 4. Presentation of the back, belly, or sides of the child.
Order 5. Malposition of the head.
Order 6. Presentation of the funis.
Order 7. Plurality of children, or monsters.
Class IV. Tedious Labour, or labour protracted beyond the usual dura-
tion ; the delay, not caused, by the miUposition, of the child, and
the process, capable of being finished safely, without the use of
extracting instruments.*

This comprehends two orders.
Order 1. Where the aelay, proceeds from some imperfection, or

irregularity, of the muscular action.
Order 2. Where it is dependent, prindpally, on some mechanical
impediment.
Class V. Laborious or Instrumental Labour ; labour which cannot be
completed, without the use of extracting instruments ; or altering
the proportion between the size of the child, and the capacity of the
pelvis.

This comprehends two orders.
Order 1. The case admitting the use of such instruments, as do

not, necessarily, destroy the child.
Order 2. The obstacle to delivery being so great, as to require
that the life of the child, should be sacrificed, for the safety of the
mother.
Class VI. Impracticable Labour ; labour in which the child, even when
reduced in size, cannot pass through the pelvis.
This comprehends only one order.
Class VII. Complicated Labour ; labour attended with some dangerous
or troublesome accident or disease, connected, in particular instances^
with the process of parturition.

This comprehends six orders.
Order 1. Labour complicated with uterine hemorrhage.
Order 2. Labour complicated with haemorrhage from other organs.
Order 3. Labour complicated with syncope.
Order 4. Labour complicated with convulsions.
Order 5. Labour complicated with rupture of the uterus.
Order 6. Labour complicated with suppression of urine, or rupture
of the bladder.

This classification, necessarily prevents my considering the
different presentations of the head, as varieties of natural
labour, which some have done* Baudelocque enumerates six
positions, marked by the vertex, Ist, to the left, and 2d, to
the right acetabulum; 3d, behind the pubis ; 4th, to the right,
«n^ K¥U ^ |.jjg jgjj. gacro-iliac articulation; 6th, to the

Some of these are so unfavourable, that they require

nan states that out of 45 cases, of tedious labour, 12 were deHrered
ind SO houn ; 16 in between SO end 40, and eo on decreasing In
rere between 70 and SO hours. All the women did well.

374

to be changed, in order to facilitate delirery. On no correct
principle, then, can they be retained as varieties of natural
labour.

Calculations have been made, of the proportion which these
different kinds of labour, bear to each other in practice.
Thus, Dr. Smellie supposes, that out of a thousand women in
labour, eight shall be found to require instruments, or to
have the child turned, in order to avoid them ; two children
shall present the superior extremities ; five the breech ; two
or three the face ; one or two the ear ; and ten shall present
with the forehead turned to the acetabulum.

Dr. Bland has, from an hospital register, stated the pro-
portion of the different kinds of labour, to be as follows : of
1807 women, 1792 had natural labour. Sixtv-three, or one
out of 20, had unnatural labour; in 18 of tnese, the child
presented the feet ; in 36, the breech ; in 8, the arm : and in
1, the funis. Seventeen, or one out of 111, had laborious
labour ; in 8 of these, the head of the child required to be
lessened ; in 4, the forceps were employed ; and m the other
5, the face was directed toward the pubis. Nine or one in
210, had uterine hsemorrhage before, or during labour. It is
evident, however, that this register cannot form a ground for
general calculation ; and the reader will perceive, that the
number of crotchet cases, exceeds those requiring the forceps,
which is not observed in the usual course of practice.* Dr.
Merriman, says, the breech presents once in 86, the feet
once in 80, and the arm once in 170 cases; Dr. Nagele, in
the hospital of Heidelberg, says, out of 263 cases, there were
four twins ; 256 children presented the head, and two of
those the face; 5 the breech; 3 the feet; 1 the arm;
1 the breast ; 1 the hip. Hence, 1 in 26 cases was preter-
natural.

• Ftrther infonaatioo may be obtained br coDsiimnf the ftefort of the
Dublin Lying-in Hoepital, by Dr. ClarlLe. From thii It appean, that out of
10^887, only 184 had tWina— 9746 bad natural hibour, that ia presentation of the
head, and the hibonr terminating within 84 hourt; of these 71 died ; IS4 bad
tediova labour, but in what number of these, the foroepe were used, is not men-
tioned ; 21 died ; 49 appear to hare bad the crotchet used, of these 16 died : 184
praentcd the feet, 1 died ; 61 the breeeb, 4 died ; 48 the eaperlor extremity, 6
died ; 14 cases of uterine hemorrhage preTious to deiivsry, in 4 of whloh the
placenta presented ; 17 cases of conyuTsions before deliTcrv ; 66 cases of presenta*
tion of the chord, 17 of these chUdren were bom alive, 1 ncre were 17 footanelle,
and 44 face preeentotions, neither of these» be' says, gave rise to tedious parturi-
tion. Vide Trans, of the Assoc Ac, toI. 1st, p. 867. See farther, the Report
of the Westminster Hospital, by Dr. GranTUle^ and Dr. CoUM* Talunble l¥ao-
tieal Treatise.

At Dreeden, out of 231 labours, the Tertex presented in 811, the hot In 6, the
brneeh in 8, and the Ibet in I. At Wurtembei^, the proportioa of easss nquir-
ing artiSelal aid, was 8^ per cent. In 1000 of these artlflcini deliTtrics, the
forceps were uMd 844 times.

375

We cannot form an estimate of the proportion of labour^,
with much accuracy, from the practice of individuals, as one
man may, from particular circumstances, meet with a greater
number of di£Eicult cases, than is duly proportioned to the
number of his patients. Thus Dr. Hagen of Berlin says,
that out of 350 ^tients, he employed the forceps 93 times,
and the crotchet in 28 cases ; 26 of his patients died. Dr.
Dewees, again, of Philadelphia, says, that in more than
3000 cases, he has not met with one requiring the use of the
crotchet.

CHAP. II.
Of Natural Labour.

SECTION FIRST.

Previous to the accession of labour, we generally have some
precursory signs, which appear, perhaps, for several days,
oftener, only, for a few hours, before pains be felt. The
uterine fibres begin slowly, and gradiudly to contract, or
shorten themselves, by which the uterus becomes tenser
and smaller. It subsides in the belly ; the woman feels as
if she carried the child lower, than formerly, and thinks
herself slacker, and less, than she was before. For some
days, before gestation be completed, she, in many cases,
is indolent and inactive, but, now, often, feels lighter and
more alert. At the same time that the uterus subsides,
the vagina and os uteri are found to secrete a quantity
of glairy mucus, rendering the organs of generation moister
than usual, and these are somewhat tumid and relaxed,
the vagina, especially, becoming softer and more yielding.
These chimges, are often attended with a slight irritation,
of the neighbouring parts, producing an inclination to ^o to
stool, or to make water frequently, and, very often, griping
precedes labour, or attends its commencement.

The intention of labour, is, to expel the child and secun-
dines. For this purpose, the first thing to be done, is to
dilate, to a sufficient degree, the os uteri, so that the child
niay pass through it. The next step, is to expel the child
itself: and, last of all, the foetal appendages are to be
thrown off. The process may therefore be divided into

376

three stages. The first stage is generally the most tedious.
It is attended with frequent, but usually short pains, which
are described as being sharp, and sometimes so severe, as to
be called cutting or grinding. They, commonly, begin in
the back, and extend toward the pubis or top of the thighs,
but there is, in this respect, a great diversity with different
women, or the same woman, at different times. Sometimes,
the pain is felt, chiefly, or entirely, in the abdomen, the
back being not at all affected, during this stage ; and it is
generally observed, that such pains, are not so effective, as
those which affect the back. Or, the pain produced, by the
contraction of the womb, may be felt in the uterine region ;
and when it goes off, may be succeeded by a distressing
aching in the back. In other cases, the pain is confined to
the small of the back, and upper part of the sacrum, and is
either of a dull aching kind, or sharp and acute, and, in
some instances, is attended with a considerable degree of
sickness, or tendency to syncope. The most regular manner
of attack, is, for pains to be at first confined to the back,
descending lower by degrees, and extending round to the
belly, pubis, or top and forepart of the thighs, and gradually
stretching down the backpart of the thighs, the forepart
becoming easy : occasionally one thigh alone is affected.
At this time also, one of the legs is sometimes affected with
cramp. The duration of each pain is variable ; at first it is
very short, not lasting above half a minute, perhaps not so
long, but by degrees it remains longer, and becomes more
severe.* The aggravation, however, is not uniform, for
sometimes in the middle of the stage, the pains are shorter,
and more trifling, than in the former part of it. During
the intermission of the- pains, the woman, sometimes, is
either very drowsy, or particularly irritable and watchfuL
The pains are early attended, with a desire to grasp, or
hold by the nearest object, and, at the same time, the cheeks
become flushed, and the colour increases with the severity of
the pain. The hand being placed on the abdomen, the
uterus is felt to become hard during a pain, and more com*
pact or contracted.

The pains of labour, often, begin with a considerable
degree of chilness, or an unusual shaking or trembling of the
body, with or without a sensation of coldness. These

* Dr. Merrlmui quotes from M. Saeombe, a detail of the iDterral betwem
the palne^ and their duration. The interval dlminiehcd from 15 to 4 ralnutea*
aiid the duration increaii^ from 21 to 93 lecondt. This U on)f a particular case,
and affords no general rule.

377

tremors may take place, however, at any period of labour ;
they may usher in the second stage, and be altogether
wanting during the first; or they may not appear at all,
even in the slightest deojee, or they may be present only
for a very short time. They can scarcely be said to precede
the uterine pain, but are rather almost synchronous m their
attack; in other cases they do not appear until the pains
have lasted for a short space of time, and then, it is usual
for the uterine pain to be speedily 'removed. Hence, it
might be supposed, that they should materially retard labour,
but this is far from being always the case. In degree, they
vary from a gentle tremor to an agitation of the frame, so
violent, as to shake the bed on which the patient rests, and
even to bear some resemblance to a convulsion. The
stomach also sympathizes with the uterus, during this stage,
the patient complaining of a sense of oppression, sometimes,
of heartburn or sickness, or even of vomiting, which is con*
sidered as a good symptom, when it does not proceed from
exhaustion ; or a feeling of sinking or faintness, but the pulse
is generally good. When there is, in a natural labour, a sudden
attack of sickness, faintishness, and feeble pulse, the patient
is generally soon relieved by vomiting bile. These symptoms,
however, are often wanting, or attack at different periods of
labour; like the rigors, they may be absent during the
greatest part of the first stage, or until its end, ushering in
the second ; but in general, they are confined to the first
stage, going off when the os uteri is fully dilated. That
sickness and feeling of depression, depend on sympathetic
connexion of the nerves of the os uteri, with those of the
stomach, is confirmed by observing, that touching the os
uteri, with the finger, at this stage, sometimes induces them.
In consequence, partly of these feelings, Partly of the
anxiety and solicitude connected with a state of su£^ring and
danger, and partly from the pains being free from any sensa-
tion of bearing-down, the woman, during this stage, some-
times becomes desponding, or fretful. She supposes that the
pains are doing no good ; that she has been or is to be, long
in labour : that something might be done to assist her, or has
been done, which had better have been avoided; and that
there is a wrong position of the child, or deficiency of her
own powers.

When the pains of labour begin, there is an increased
discharge of mucus from the vagina, which proceeds from the
vaginal lacunae;, and from the os uteri. It is glairy, clear.

376

three stages. The first stage is generally the most tedious.
It is attended with frequent, but usually short pains, which
are described as being sharp, and sometimes so severe, as to
be called cutting or grinding. They, commonly, begin in
the back, and extend toward the pubis or top of the thighs,
but there is, in this respect, a great diversity with different
women, or the same woman, at different times. Sometimes,
the pain is felt, chiefly, or entirely, in the abdomen, the
back being not at all affected, during this stage ; and it is
generally observed, that such pains, are not so effective, as
those which affect the back. Or, the pain produced, by the
contraction of the womb, may be felt in the uterine region ;
and when it goes off, may be succeeded by a distressing
aching in the back. In other cases, the pain is confined to
the small of the back, and upper part of the sacrum, and is
either of a dull aching kind, or sharp and acute, and, in
some instances, is attended with a considerable degree of
sickness, or tendency to syncope. The most regular manner
of attack, is, for paiQS to be at first confined to the back,
descending lower by degrees, and extending round to the
belly, pubis, or top and forepart of the thighs, and gradually
stretching down the backpart of the thighs, the forepart
becoming easy : occasionally one thigh alone is affected.
At this time also, one of the legs is sometimes affected with
cramp. The duration of each pain is variable ; at first it is
very short, not lasting above half a minute, perhaps not so
long, but by degrees it remains longer, and becomes more
severe.* The aggravation, however, is not uniform, for
sometimes in the middle of the stage, the pains are shorter,
and more trifling, than in the former part of it. During
the intermission of the- pains, the woman, sometimes, is
either very drowsy, or particularly irritable and watchful.
The pains are early attended, with a desire to grasp, or
hold by the nearest object, and, at the same time, the cheeks
become flushed, and the colour increases with the severity of
the pain. The hand being placed on the abdomen, the
uterus is felt to become hard during a pain, and more com-
pact or contracted.

The pains of labour, often, begin with a considerable
degree of chilness, or an unusual shaking or trembling of the
body, with or without a sensation of coldness. These

* Dr. Mcrrlman quotM from M. Saoombe, n deteil of th« iolcrYal betwcra
tb« InUoM and their duration. The interval diminished Irom 15 to 4 minulee,
and the duration increaiied rn>m 21 to 99 second*. This is onlj a particular case,
and affords do general rule.

377

tremors may take place, howeTer, at any period of labour ;
they may usher in the second stage, and be altogether
wanting during the first; or they may not appear at all,
even in the slightest degree, or they may be present only
for a very short time. They can scarcely be said to precede
the uterine pain, but are rather almost synchronous in their
attack; in other cases they do not appear until the pains
have lasted for a short space of time, and then, it is usual
for the uterine pain to be speedily* removed. Hence, it
might be supposed, that they should materially retard labour,
but this is far from being always the case. In degree, they
vary from a gentle tremor to an agitation of the frame, so
violent, as to shake the bed on which the patient rests, and
even to bear some resemblance to a convulsion. The
stomach also sympathizes with the uterus, during this stage,
the patient complaining of a sense of oppression, sometimes,
of heartburn or sickness, or even of vomiting, which is con-
sidered as a good symptom, when it does not proceed from
exhaustion ; or a feeling of sinking or faintness, but the pulse
is generally good. When there is, in a natural labour, a sudden
attack of sickness, faintishness, and feeble pulse, the patient
is generally soon relieved by vomiting bile. These symptoms,
however, are often wanting, or attack at different periods of
labour; like the rigors, they may be absent during the
greatest part of the first stage, or until its end, ushering in
the second ; but in general, they are confined to the first
stage, going off when the os uteri is fully dilated. That
sickness and feeling of depression, depend on sympathetic
connexion of the nerves of the os uteri, with those of the
stomach, is confirmed by observing, that touching the os
uteri, with the finger, at this stage, sometimes induces them.
In consequence, partly of these feelings, partly of the
anxiety and solicitude connected with a state of suffering and
danger, and partly from the pains being free from any sensa-
tion of bearing-down, the woman, during this stage, some-
times becomes desponding, or fretful. She supposes that the
pains are doing no good ; that she has been or is to be, long
in labour : that something might be done to assist her, or has
been done, which had better have been avoided; and that
there is a wrong position of the child, or deficiency of her
own powers.

When the pains of labour begin, there is an increased
discharge of mucus from the vagina, which proceeds from the
vaginal lacunaB, and from the os uteri. It is glairy, clear.

378

and possesses a peculiar odour. When the os uteri is con-
siderably dilated, though sometimes at an earlier period,
there is, in consequence of the separation of the decidua, a
small portion of blood discharged, which gives a red tinge to
the mucus.

The distention of the os uteri, is often attended with
irritation of the neighbouring parts, the woman complaining
of a degree of strangury ; or having one or two stools wit£
or without griping, especially in the earlier part of the
stage. The pulse is sometimes accelerated, more frequentiy
not.

The OS uteri being considerably dilated, the second stage
b^ns. The pains become different, thev are felt lower,
are more protracted, and are attended with a sense of bear-
ing down, or an involuntary desire to expel or strain with the
muscles ; and this desire, is very often accompanied, with a
strong inclination to go to stool. A perspiration breaks out,
and tiie pulse, which, during the first stage, beat perhaps,
more frequentiy than usual, becomes still quicker, during tiie
exertion ; the patient complains of being hot, and, generally,
the mouth is parched. Soon after the commencement of
this stage, it is usual for the liquor amnii to be discharged.
This is often followed by a short respite from pain, but
presently the efforts are redoubled. Sometimes there is no
cessation, but the pains immediately become more severe,
and sensibly effective. The perinieum now begins to be
pressed down, so as to feel full or protruded, and the labia
are put upon the stretch. The protrusion of the perinsum
gradually increases. The labia are more stretched, and, at
last, extended downward, like an inverted arch or hoop, on
the head. The nymph® are unfolded, so that the inside of
the labia projects a little, like a narrow rim, beyond the
outer skin. The coccyx is pushed a littie back, and con-
sequentiy downward. The anus is carried directiy down-
ward, and its anterior lip or nuirgin, somewhat forward, so
that even a little of the inner surface, of the orifice or
extremity, is seen in fronts Sometimes the whole anus is
carried forward. The perinsBum is stretched both down-
ward and forward, and becomes very thin. Together with the
front of the extremity of the rectum, or anus, it is spread
over the head of the child. Then, as the head passes out, it
glides back, over the brow and face of the child, becoming
narrower, as it is distended laterally. The extension of the
parts is gradual, and at intervals ; for, when the pain goes

879

off, the head recedes, and the perimeum is relaxed, but at
last the head is fixed, and does not recede ; for a short tame
the perinsum is permanently distended, and then, as mentioned,
moves backward, which diminishea the risk of its being lace-
rated. As the head passes out, the vertex either turns up,
toward the pubis, so as to cover the orifice of the urethra,
and sometimes nearly touch the clitoris, and then after a
pain, sweeps round with the face to the thigh, or, it does so
at once. Delivery of the head, is accomplished with very
severe suffering, but immediately afterwards, the woman
feels easy, and free from pain. In a very little time,
however, the uterus again acts, and the rest of the child is
expelled, which completes the second stage of labour. The
one shoulder, usually the right, is found at the arch of the
pubis, the other at the perin»um; they are often both
expelled nearly at the same time, but the top of the one at
the pubis, ffenerally passes forward, a little from under the
arch, and, then, the one behind, clears the perinseum, and
taking the lead, as it were, may be said to be delivered first.
Next, both elbows pass nearly at once, and after a short

Eause, the breech, which had been diagonal, passes, with one
ip to the pubis, the other to the sacrum. The expulsion of
the body is generally accomplished very easily, and quickly ;
but sometimes the woman suffers several strong and forcing
pains, before the shoulders be expelled. The birth of the
child is succeeded, after a short calm, seldom exceeding
twenty minutes, by a very slight degree of pain, which is
consequent to that contraction, which is necessary for the
expulsion of the placenta. It comes down edgeways, and
folded, and the membranes going off from it are inverted, so
as to form a kind of pouch, which receives, at least, part of
the fluid or clotted blood, which may have been discharged
from the uterus. This expulsion is accompanied, and suc-
ceeded, by a moderate discharge of blood, which is continued,
but in decreasing quantity, for a few days, under the name of
the red lochia.

The particular changes, in the position of the head, in its
passage, will be noticed in the third section.

SECTION SECOND.

The duration of this process, and of its stages, varies not
only in different women, but in the same individual in succes-
sive labours; for, although some, without any mechanical
cause, be uniformly slow or expeditious, others, are tedious

380

in one labour, and, perhaps, eittremely quick, in the next, and
this Tariation cannot be foreseen, from any previous state of
the system. A natural labour ought to be finished within
twenty*four hours after the first attack of pain, provided the
pains be tmly uterine, and be continued regularly ; for occa-
sionally, after being repeated two or three times, they become
suspended, and the woman keeps well for many hours, after
which, the process begins properly. In such cases, the
labour cannot be dated from the first sensation of pain, nor
deemed tedious. The greatest number of women, do not
complain for more than twelve hours; many, for a much
shorter period ; and some, for not more than one hour.* Few
women call the accoucheur, until, from the regularity and
frequency of the pains, they be sure that they are in labour,
and feel themselves becoming worse. As the celerity of the
process cannot be previously determined, many thus bear
their children alone, becoming rapidly and unexpectedly
worse. On an average it will be found, that, in natural
labour, the accoucheur is not called, above four hours, pre-
vious to delivery.

The reffularity, and comparative length, of the different
stages is also various ; but it will, generally, be observed, that
when the woman has a natural labour protracted to its
utmost extent, the delay takes place in the first stage ; and,
in those cases, where the second stage is protracted, the delay
occurs, in the latter end of that stage. In most cases, the
first stage, is triple the length of the second. The first stage,
may be tedious, from the pains not acting freely on the os
uteri, or being weak, and inadequate to the effect intended,
or becoming, prematurely, blended with the second stage,
that is to say, bearing-down efforts being made, before the os
uteri be much dilated. Various circumstances may conspire
to produce this delay, such as inactivity of the uterus, ri^dity
of its mouth, premature evacuation of the* water, improper
irritation, injudicious voluntary efforts, &c« The second
stage may be tedious, from irregularity of the uterine con-
traction, or from a suspension of the bearing-down efforts, or
from the head not tummg into the most favourable direction,
or from the rigidity of the external organs.

These, and other causes, which will hereafter be con-

• Dr. Collins sayt, thst out of 16,850 ciuet, I5,08i were deliTered wicbin 12
n«ur». The grentest number, rla., 10,967, were from 1 to i hours in labour; of
^"^ 9.513 were only one hour. No certain ealeulatlan can however be made, as
2^ nnd 166 women delirered in 2i hours, and only S in ^5 ; tin 44 hours, and
♦ ' in 46 hours ; 161 were only ill a quarter of an hour j 156 nine hours.

381

ridered, may not only protract the labour, but may even
render it so tedious, as to remove it from the class of natural
labours altogether. * It is a general opinion, that a first labour
is always more lingering, than those which succeed. We
should be led, however, to suppose, that parturition, being a
natural function, ought to be as well and as easily performed
the first time, as the fifth, the process not depending upon
either habit or instruction. But we do find, that here, as in
many other cases, popular opinion is founded on fact, for
although in several instances, a first labour foe as quick as a
second, yet, in general, it is longer in both its stages. This,
perhaps, depends chiefly on the facility, with which the
different soft parts dilate, after they have been once fully
distended. Some have attributed the pain of parturition, to
mechanical causes, ascribing it to the shape of the pelvis,
and the size of a child's head. But in a great majority of
cases, the pelvis is so proportioned, as to permit the head to
pass with facility. The pain and difficulty, attending the
expulsion of the child, in natural labour, are to be attributed,
to the strong contraction, of the muscular fibres of the uterus,
and to the dilatation, of the os uteri and vulva, in consequence
thereof, together with the effect thus produced on the nerves,
and, perhaps, the temporary excitement of the nerves them-
selves. Women will, therefore, ceteris paribus^ suffer accord-
ing to the sensibility of the organs concerned, and the
difficulty with which the parts dilate. In proportion as we
remove women, from a state of simplicity, to luxury and re-
finement, we find that the powers of the system become im-
J paired, and the process of parturition is rendered more pain-
iil. In a state of natural simplicity, women, in all climates,
bear their children easily, and recover speedily ;* but this is

* *• The GreenUnders, mostly do all their common husinees jiut hefore and
after their delivery; and a 8till>horn or deformed child is seldom heard of.'* —
Crantz't History of Greenland, Vol. i. |». 161.

Long tells os, that the American Indians, as soon as they hear a child, to into
the water and immerse it. One evening he asked an Indian where his wife
was; ** be supposed she had gone into the woods, to set a collar for a partridge.**
in about a hour she returned with a new-born infant in her arms, and, coming
up to me, said, in Chippoway, *' Oway saggonash payshik shomagonish ;** or,
** Here, Englishman, is a young warrior.** fravels, p. 69.

" Comme lea aoeouchemens sons tres-ais^s en Perse, de meme que dana lea

-autres pais chaods de TOrient, il n*v a point de sagea femmes. Les parentes

ag^es et les plus graves, font cet office, mats comme 11 n*y a gueres de vieilles

matronea dans le harum, on en fait venir dehors dans le besoin.** Voyages de M.

Chardin, Tom. iv. p. 890.

Lempriere says. ** Women in this country (Morocco) suffer but little incon-
▼enlenee ft-om child-bearing. They are frequently up next day, and go through
all the dutica of the house with the infant on their back.** Tour, p. 828.

Winterbottom says, that <*with the Africans, the labour is very easy, and

382

more especially the case in those countries, where heat con-
spires to rehuL the fibres. The quality or quantity of the
food, has much less Influence, than the general habit of life,
upon the process of partiu*ition« In a savage state, women,
though living abstemiously, and often compelled to work more
than men, bear children with facility ; whilst in this country,
women who live on plain diet, are not easier than those, who
indulge in rich viands. In all ranks, we often find the os
uteri considerably dilated, and occasionally meet with
instances of labour making great progress, wiUi scarcely any
pain, and I have known cases, where the patient declared, she
nad no pain, even at the last, but only a sensation of strong
pressure, so that she expressed her amazement that the child
was bom. A knowledge of this fact, of which I am well
assured from my own observation, m^ prove of importance
in some questions of jurisprudence. On the same account, I
add, that the pains sometimes become suddenly, and very
unexpectedly, bearing-down, whether severe or not, and the
child ^ay be bom before the patient can be got into bed, or
removed from the night-chair, if she had been at stool. A
strong desire to go to stool, may predominate over the feeling
of uterine pain, and be the immediate precursor of delivery.
We, thereiore, never, in an advanced stage of parturition,
allow the patient to rise, at least, if the process have been
going on regularly, and, at no ^ime. without due precaution.

SECTION THIRD.

The existence and progress of labour, and the manner in
which the child is placed, are ascertained by examination per
vaginam. For this purpose the woman ought to be placed
in bed, on her left side,* widi a counterpane thrown over

tnutod MleW to mtare, nobody knowlpg of It till Ibo wonon ftpvcan At Um 4oor
of Ibo bat witb tbe eblld." Aoooant of Motivo Afrioont, Iw., Vol. IL |k. SM.

The Sbangallo women ** brings forth children witb the utmoot mm, and noror
net or eonSne tbemeelyce 'after deliTerjr ; bat, wwhlnf thenMelveo and the child
with odd water, tliey wrap it op in a ioft dotb, made of the bark of Creea, and
hanf it ap on a branch* that the large anu with which they art infeacod, and the
aorpenta, may not derour it.** Bruoe'o TroYela, Vol. ii. p. 6ftS.

In Otaheico, New South Walea, Sarlnam, &&« partorition is ▼err eai^, and
many more inetaneet micht* if neeeiaary, bo addaoed. Wo are not, however, to
oappoae that in warm dimatce women do not aomotimea aalliBr matarldly. In
the £aet Indies, *• many of the women loee their liTot the ftrat time they bring
forth.** Banolomeo*a Voyage, chap. II.

Undomestlcated animala mcrdly bring forth thdr yoong with conaid«nble
loM thd* |J»""*I"« *l>«y •»»» much pain, and, when domorticalod, oooadonally

Ai«fcS-i*5^^"' ?* hallLdttin* Mdtion baa been propoaed by aomo, and
ll^e^hir :!?!?* ^Ir^ o^ttTnteru^ be proper, tCatIt nUy^la weight,
oome within reach. Somotimea in the early JmS^oi pregnancy, ft la dhmable

383

her, if she be not undressed. The hand is to be passed,
along the back part of the thighs, to the perinieum, and
thence, inunediately to the vagina, into which the forefinger
is to be introduced. It never ought to be carried, to the
forepart of the vulva, and from that, back to the vagina.
The introduction is to be accomplished, as speedily and
gently as possibly, and the greatest delicacy must be observed.
The information which we wish to procure, is then to be
obtuned, by a perfect, but very cautious examination, of the
OS uteri, and presenting part of the child, which fives no
pain, and consequently removes the dread, which many
women, either from some misconception, or from previous
harsh treatment, entertain of this operation. The application
of the hand to the abdomen, during the continuance of the
pain, may ascertain, from the temporary hardness of the
uterus, that its fibres are contracting universally, and this is
an evidence that we should never overlook.

When a woman is in labour, we should, if the pains be
regular, propose an examination, very soon, after our arrival.

It is of importance, that the situation of the child, be early
ascertained, and most women, are anxious to know, what
progress they have made, and if their condition be safe. As
it is usual to examine during a pain, many have called this
operation "taking a pain;" but there b no necessity for
giving directions, respecting the proper language to be used,
as every man of sense and delicacy, must know how to
behave, and can easily, through the medium of the nurse, or
by turning the conversation to the state of the patient,
propose ascertaining the progress of the labour. Some
women, from motives of false delicacy, and from not under-
standing the importance, of procuring early information of
their condition, are averse from examination, until the pains
become severe. But this delay is very improper ; for, snould
the presentation require any alteration, this is easier effected
before the membranes burst, than afterwards. When the

Jiresentation is ascertained to be natural, there is no occasion
or repeated examinations in the first stage, as this may prove
a source of irritation, and, should the stage be tedious, may
be a mean of excitins impatience, sometimes, merely
touching the os uteri, with the finger, produces sickness and
faintness. In that case it must not be repeated, as even the
natural dilatation, renders these effects distressing, for a time.

from the Mine motiyes ; but, daring laboar. it U not often that the ntenit is to
higli, thiit the examlniition eannot be performed in a recumbent poeture.

384

In the second stage, the frequency of examination, must be
proportioned, to the rapidity of the process.

In order to avoid pain and irritation, it is customary to
anoint the finger ^ith oil or pomatum; but, unless this
practice be used as a precaution, to prevent the action of
morbid matter on the skin, it is not very requisite, the parts
being, in labour, generally, supplied with a copious secretion
of mucus. It is usual for the room to be darkened, and the
bed curtains drawn close, during an examination, and the
hand should be wiped with a towel, under the bedclothes,
before it be withdrawn. The proper time for examining, is
during a pain, and we should begin, whenever the pain
comes on. We thus ascertain, the effect produced on the os
uteri, and by retaining the finger until the pain go off, we
determine the degree, to which the os uteri collapses, and the
precise situation of the presenting part, which we cannot do
during a pain, if the membranes be still entire, lest the
pressure of the finger should, were they thin, prematurely
rupture them.

An examination should never, if possible, be proposed or
made, while an unmarried lady is in the room, but it is
always proper that the nurse, or some other matron be
present.

The existence of labour, is ascertained by the effects of the
pains, on the os uteri ; and its progress, by the degree to
which that is dilated, and the position of the head with regard
to different parts of the pelvis. A preliminary question may
here be put, does the development of the os uteri, or its
opening to an evident degree, imply the actual existence of
labour? The answer must depend somewhat on the definition
of labour. If we understand by it, the universal and regular
contraction, of the uterine fibres, I would say, that the mere
opening of the os uteri, with or without pain, does not prove
the actual existence of labour, for it may open considerably,
for a week or two, before universal and expulsive efforts be
made, and this partial effect may be attended with pain ; I
doubt, very much, if it be attended with hardness, and con-
traction, of the body and fundus, of the uterus. If in an^ one
case of this kind, the whole uterus ^ere felt, during a pain, to
become hard, then, we must admit that labour, in the strictest
sense of the word, may begin, and afterwards be entirely sus-
pended, for a fortnight or longer.

Before labour begins, the os uteri is generally so closed,
that the finger cannot, without force, be introduced far within

385

it, and it is directed more or less backwards towards the
sacrum. The os uteri, is, in one respect, an appendage to the
uterus, and hangs down in a cylindrical form. It is not
muscular, but is somewhat elastic, for, after being dilated, it
contracts again if the force be suspended. The case is
different with the cervix, for it is muscular, and the fibres
may act, either circularly, or longitudinally. But at first
they act on the os uteri alone. If they early acted circularly,
they should operate as a sphincter. If the finger be intro-
duced, during labour, into the os uteri, not yet quite dis-
tended, then, although its own proper substance may yield
more or less, yet, the hard boundary of the lower margin of
the cervix is lelt, as a resisting circle within, or higher, and
this must relax, and the fibres act in no farther degree
circularly, than is necessary to keep the longitudinal fibres
together, otherwise the head cannot pass. The first effect
of the pains is to develop the os uteri, that is, to destroy its
projection or protuberance, and next to open it. Sometimes,
the development goes on quickly, and the os uteri becomes
thin, and expanded like a funnel. In other cases, it remains
thick and flabby, and circle after circle, expands abruptly,
from above downward, and at last a mere hard orifice,
admitting only the tip of the finger, and quite flat, is felt.
Even when the os uteri is considerably dilated by the pains,
it, from its elasticity, falls together again in the absence of a
pain ; and although at this stage, it may be re-distended by
the finger, yet the finger cannot, as I have just noticed,
distend the cervix. When we examine in the commence-
ment of labour, the os uteri is to be sought for, near the
sacrum, at the back part of the pelvis, whilst between that
spot and the pubis, we can pass the finger along the fore-
part of the cervix uteri. On this, the presenting part of the
child rests, so that in natural labour, it assumes somewhat
the shape of the head ; and, for the sake of distinction, I
shall call it the uterine tumour. In some, it is so firmly
applied to the head, and so tense, that a superficial observer
would take it for the head itself. In this case, the labour
often is lingering, when the os uteri is high and far back ;
but if it be more forward,, and soft, and thin, it is rather a
good sign. This tumour, or portion of the uterus, is broad
in the beginning of labour, but becomes narrower as the os
uteri dilates, until at last it be completely effaced, the head,
either naked or covered with the membranes, occupying the
vagina. The breadth of this portion of the uterus, therefore,

386

as well as the examination of the os uteri, will serve to a8cer<-
tain the state of the labour.

The OS uteri gradually dilates by the pains of labour, but this
dilatation is more easily effected, in some cases, than in others.
In some, though the pains have lasted for many hours, and
have been frequent, the os uteri will be found still very little
opened. In others, a very great effect is produced in a short
time ; nav, we find, that the os uteri may be partly, even
ffreatly dilated, without any pain at all. We cannot exactly
foretell the effect, which the pains may have, by any general
rule,* nor estimate the progress and probable duration, alto-
gether, by the sensation.

We find in different women, the os uteri in very opposite
states. In some, it is thick, soft and dependent like a
cylinder ; in others, thin and infundibuliform ; sometimes it
is not very early dependent, but the edges of the mouth are
on the same plane, like the mouth of a purse ; these edges
may be thin or thick, and either of these states, may exist with
hardness or softness of the fibre. In some cases, they seem to
be swelled, as if they were oedematous, and this state is often
combined with oedema of the vulva, or it may proceed from
ecchymosis. Now, of these conditions, some are more favour-
able than others : a rigid os uteri, with the lips either flat or
prominent, is generally a mark of slow labour, for, as long as
this state continues, dilatation is tardy ; a thick oedematous
feel of the os uteri is also unfavourable; and usually a project-
ing or tubulated mouth, especially if the margin be thick and
hard,* is connected with a more tedious labour, than where the
OS uteri is flat. In some cases of slow labour, after the pro-
jection of the OS uteri is developed, its orifice for many hours
is scarcely discernible, resembling a dimple or small hard ring,
perfectly level with the rest of the uterus. But although these
observations may assist the prognosis, yet we never can form an
opinion perfectly correct ; for a state of the os uteri, apparently
unfavourable, may be speedily exchanged for one very much
the reverse, and the labour may be accomplished with unex-*
pected celerity. Our prognosis, therefore, should be very
guarded. When the pains produce little apparent effect on
the OS uteri ; when they are slight and few ; and when the orifice
of the uterus is hard and rigid, or thick and puckered during
a pain ; or hangs flabby and projecting during a pain, whilst
the lower fibres of the cervix, feel, when the finger is introduced

* if the margin be thin and Mft, the oa uteri ■ometimea, in the ooorae of an
hmir, laaca ita projaeting form, and beooniea conaiderably dilated.

387

Within the oa uteri, firm aad contracted ; or when the os uteri
does become flatter during a pain, but falls together and
projects when it goes off, and especially if the cervix be
rigid, there is much ground to expect that the labour may be
lin^ring. On the other hand, when the pains are brisk, the
OS uteri thin and soft, we may expect a more speedy delivery ;
but, as in the first case, the unfavourable state of the os uteri
may be unexpectedly removed, so, in the second, the pains may
become suspended or irregular, and disappoint our hopes.
The OS uteri seldom dilates equally, in given times, but is
more alow at first in opening than afterwards. It has been
supposed, that if it require three hours to dilate the os uteri
one inch, it will require two to dilate it another inch, and
other three to dilate it completely. This calculation, how-
ever, is subject to great variation, for, in many cases, though
it require four hours to dilate the os uteri one inch, a single
hour more, may be sufficient to finish the whole process.

The OS uteri is, in the beginning of labour, generally pretty
high; but as the process advances, the uterus descends in
the pelvis, along with the head, and, in proportion as it
descends, the os uteri dilates, whilst the uterine tumour dimi-
nishes in breadth. Should the os uteri remain long high,
even although it be considerably dilated, but more especially
if it be not, there is reason to suppose that the labour shall be
continued still, for some time. On the other hand, should the
uterus descend too rapidly, there may be a species of prolapsus
induced, the os uteri appearing at the orifice of the vagina.
This state is generally attended with premature bearing^down
pains, and indicates a painful, and raUier tedious labour.

The protrusion of the membranes, and discharge of the
liquor amnii, ought to bear a certain relation to the advance-
ment of labour. Whilst the os uteri is beginning to dilate,
the membranes have little tension; they scarcely protrude
through the os uteri, until it be considerably opened. But in
proportion as the dilatation advances, and the pains become
of the pressing kind, the membranes are rendered more tense,
protruding during a pain, and becoming slack, and receding,
when it goes off. In some cases, by examination, we find tbe
membranes forced out, very low into the vagina, like a portion
of a bladder, tense and firm during a pain, but disappearing
in its absence. Sometimes although the head be so high as
not to touch the perinsum, the membranes protrude the
perinieum, and the lasces are evacuated or pressed out, as if
the head were about to be expelled. When the membranes

388

burst, the head is, in such cases, often delivered in a few
seconds, but the pains may remit, for a short time, and the
woman be easier than formerly. The protrusion of the mem-
branes, which has been described by some as constituting a
part of a natural labour, is by no means an universal occur-
rence ; for, in numerous instances, the membranes protrude
very little-and scarcely form a perceptible bag in the vagina.
When the pains have acted some time on the membranes,
pushing the liquor amnii against them, and especially when
they become pressing, the membranes burst, and the water
escapes, sometimes in a considerable quantity ; but, in other
cases, very little comes away* the head occupying the pelvis
so completely, that most of tne water is retained above it, and
is not discharged until the child be bom. If there be great
irregularity in the degree to which the membranes protrude,
there is no less in the period at which they break. In some
cases, from natural feebleness or thinness, they break very
early, and the liquor amnii comes away slowly. Sometimes
they break in the middle or latter end of the first stage, in the
commencement of the second, or not until the very end, when
the head is about to be bom. The opening is sometimes
very large, and the head enlarging it, passes through it ; at
other times it is small, and the membranes are not perforated
by the head, but they come along with it like a cap or cover.
By examination, we ascertain the state of the membranes, and
may be assisted in our judgment of the progress of the labour.
When the membranes feel tense, and are protruded during a
pain, we may be sure that the action of the uterus is brisk
and good. When much water is collected beneath the head,
forming a pretty large bag in the vagina, or, when, during
the pain, there is a tense protrusion of the membranes, though
they be flat, forming a small segment of a large circle, we may
expect, that if the pains continue as they promise to do, the
membranes will soon burst, and the pains become more press-
ing. If, during each pain, after the mpture, a quantity of
water come away, it is probable, that whenever the uterus is
pretty well emptied of the fluid, it will contract more power-
fully. Should the membranes break, when the os uteri is not
fully opened, perhaps only half dilated, we may, if there be
a large discharge, expect a brisker action, and that the full
dilatation of the os uteri will be soon accomplished ; but if the
water only ooze away, and the pains become less frequent,
and not more severe, the labour may probably be protracted
for some hours.

389

In the first stage of labour, the head will be found placed,
obliquely, along the upper part of the pelvis, with the vertex
directed toward one of the acetabula, generally to the left.*
In an examination, at the commencement of labour, we touch,
through the os uteri, a part of the upper portion of the
parietal bone, a little above its protuberance. If we carry
the finger backward, we feel the sagittal suture, and tracing
that, in the direction of the left acetabulum, we feel the
posterior fontanelle. The position is oblique, in a two-fold
way ; the vertex is lower than the forehead, and the head also
enters, somewhat sideways, into the brim of the pelvis, the one
parietal, that which is toward the pubis, being the lowest,
BO that the diameter of the entering part, is not so great, as
the space between the one protuberance and the other, by
about a quarter of a inch. The head continues to descend
obliquely, with the vertex, lower than the forehead, and the
chin directed toward, or pressed on the breast, or throat, of
the child, and it is not until the act of expulsion, that it rises or
departs from that position. As the head continues to descend,
it is still the parietal bone, near the protuberance, which meets
the finger, and even when the head is so low, as to press on
the perinseum, and be felt at the orifice of the vagina, it is
usually that part of the bone which directly presents. At
this time the ear is behind the pubis, and nearly on a line
with its upper margin, and the brow is level with the linea
ilio-pectinea, from behind the acetabulum, back to the sacro-
iliac junction. When the whole of the cranial portion of
the head, has entered the cavity of the pelvis, the chin and
th^ checks, are still above the brim. The end of the nose,
is on a line with the brim, or a very little above it, and
scarcely farther forward, than the sacro-iliac junction. The
ear is felt still behind the body of the pubis, the parietal pro-
tuberance has moved a little more round, to the right side, so
that it has got nearer the pubal margin, of the foramen thyroid-
eum, and the vertex ha^ come more forward, toward the left
ramus, of the pubis aiid ischium. The forcing pains continu-
ing, the perinseum is more distended, and the head brought
lower; but it is not the vertex which we feel, at the orifice of
the vagina, for, till the last, the head is more or less diagonal,
and is not turned, with the vertex, completely forward, till
in the very act of expulsion, when the vertex sometimes

* Two TOMra nuiy be conralted on tbe tubjcet of the notion of the bead, one
by Naegele in Journ. Comp. T. ix. Another by Gcrdy, in Archivea, xxvlii.
851.

390

comes out, and turns directly up between the labia, and then
round to one side. At other times, the vertex, does not come
quite round, but passes out obliquely, and the face, when ex-
pelled, is directed to the right thigh of the mother. By attend-
ing to this account, of the progress of the head, we can ascertain
the advancement of labour. If we feel the parietal protub*
erance presenting, the sagittal suture a little farther back^
and the posterior fontanelle toward the acetabulum, especiallv
if to the left one, we look on the presentation as natural. If,
on the other hand, we can feel the anterior fontanelle, the
vertex is generally directed to the sacro-iliac junction, and,
particularly if we feel also the forehead, if we be not careful,
we may have a face presentation. The ear merits particular
attention, as its higher or lower position, determines the
degree to which the head has advanced, and the direction of
the cartilage, wiO, if we have any doubt, decide the position
of the vertex.

When the pelvis is well formed, and the cranium of due
size, the head may commonly be felt in every stage of labour;
but there are cases in which, even although the pelvis be
ample, it is not easily touched for some time. Such instances,
however, are rare ; and whenever we are long of feeling the
presentation, and do not discover a round uterine tumour,
we may suspect that some other part of the child, than the
head, presents. Even in the end of pre^ancy, and long
before labour begins, the head can usually be discovered,
resting on the distended cervix uteri : but different circum-
stances may, for a time, prevent it from being felt; the head,
perhaps in some cases, as from a fall for instance, being for a
short time displaced towards one side.

When the head comes to present, at the orifice of the
vagina, or passes a line drawn from the under edge of the
symphysis pubis back to the sacrum, the perineum and skin,
near the tuberosities of the ischia, become full, as if swelled,
but not tense. This at first proceeds from relaxation of the
muscles, and some degree of descent of the vagina and
rectum. Whenever this is felt, we may be sure thi^ the
head is descending ; but, although, a few pains mav distend
the perinoeum, yet it may be some hours before this
take place, the pains, for all that time, appearing to produce
very little effect, although the pelvis be well formed. Should
the perinsum become stretched, and the anus be carried
forward a littie during the pain, we may expect that delivery
is at hand. If the woman have already bom children, the

391

tihild is sometimes delivered, within a few minutes, after the
periniBum is first felt to become full.

When the pelvis is well formed, the head generally
descends without much change of the scalp; but when it is
contracted, or the head rests long on the perinieum, the
scalp is either wrinkled, or protruded from the parietal bone,
like a tumour filled with blood.

By examination, we ascertain the presentation, and the
progress which the labour- has made; but, in forming an
opinion, respecting the probable duration of the process, we
must be greatly influenced, by the state of the pains, and, in
part, also, by our knowledge of former labours, if the woman
have bom many children. The different stages of labour,
are generally marked, by a different mode of expressing
pain. In the first stage, the pains are sharp, and the woman
either moans or frets, or sometimes bears in silence. The
second stage, is mariied by a sound, indicating a straining
exertion, a kind of protracted groan, so that, by the change
of the cry, a practitioner may often determine the stage of
the labour. Sometimes in this stage, the woman clinches her
teeth, or holds in her breath, so that she is scarcely heard to
complain. In the moment of expelling the head, some women
are quite silent, or utter a low groan, others scream aloud.
When the pains, in the first stage, are increasing in frequency,
in severity, and in duration, and when they are accompanied,
with a corresponding dilatation of the os uteri, and, especially,
when the head, along with the undilated portion of the os and
cervix uteri, gradually descends, the prognosis is very favour*
able. When the pains, after the os uteri is considerably
dilated, become forcing, with an inclination to void the urine
or feces, and when these pains are accompanied with a full
dilatation of the os uteri, the head at the same time descend-
ing lower, and the vertex beginning to turn a little more
forward, we may look for a speedy delivery. But if the pains
in the first stage, be weak and few, and occur at long inter-
vals, or, though not unfrequent, if they last only for a few
aeconds, and, especially, if, at the same time, the os uteri be
high up, or hard, or thick, we may conclude that the process
is not likely to be rapid. If, when the os uteri is little dilated,
there be an inclination to bear down, the labour is generally
slow, and hence all attempts, at this time, to press with the
abdominal muscles, are improper ; for, whether these be made
voluntarily or involuntarily, they, during this stage, add to
the suffering, fatigue the woman, produce a tendency to pro-

392

lapsus uteri, so that, in some instances, the os uteri is forced
to the orifice of the vagina, and render the labour slow and
severe.

When the head is brought so low, as to protrude the
perinaeum, the pains generallv become more frequent and
severe, and very soon effect tne expulsion. But u they be
forcing, and propel the head considerably each time, and it
recede completely thereafter, the soft parts being rigid, it
is likely that the delivery of the head, shaU be difficult and
painful; for, in some cases, the external parts are long of
yielding, and require repeated efforts to distend them, before
the head can safely be expelled.

Sometimes the pains, ailer beginning regularly and briskly,
become suspended, or less effective, and thb alteration cannot
be foreseen. It is a popular opinion, that if a woman be not
delivered, within twelve hours, after she is taken ill, the
labour will become brisker, at the same hour, at which it
began, that is to say, twelve hours afl;er its commencement ;
and this opinion, is in many instances, countenanced by fact.
In other cases, the labour becomes decidedly brisker, six
hours after its commencement. Most women begin to cod^
plain during the night, or early in the morning, and a great
majority are delivered, betwixt twelve at night, and twelve
o'clock noon.

SECTION FOURTH.

Different attempts have been made, to expkun why labour
commenced, at the end of the ninth month of pregnancy.
The mysterious power of numbers, the influence of tne
planets, the distention of the uterine fibres, the pressure of
the child upon the developed cervix and os uteri, have all in
succession been enumerated, as affording a solution of the
question. It can serve no good purpose to enter into the
investigation, for the purpose of refuting these opinions,
which might be easily done, especially as I have no satisfac^
tory explanation to offer. We know, that whenever the
process of utero-gestation is completed, the womb begins to
contract. If, by any means, this process could be protracted,
then, labour would be kept off; and, on the other hand, if
this process be stopped prematurely, either from some pecu*
liarity connected with it, by which it is completed earlier than
usual, or, from being interrupted by extraneous causes, acting
either on the uterus, or by killing the child, then, contraction
does very goon commence. The immediate cause of the

393

delivery of the child, has been attributed to efforts made by
the fcBtus itself, the expulsive force of the abdominal muscles,
or the contraction of the uterus. The first, is fully set aside,
by our finding, that the foetus, when dead, is bom, ceteris
paribus, as easily as when it is alive and active. That the
muscles, alone, cause the expulsion of the child, is disproved,
by observing, that in the early part of labour they are perfectly
quiescent, and no voluntary effort made with them, is attended
with any good effect. That the delivery is, in a great mea-
sure, owing to the action of the uterus, is proved by observing,
that the uterus contracts, in proportion, as the delivery advan*
ces, and when the child is bom, it is found to be very greatly
diminished in size. But we have still a more positive proof
of this, in attempting to turn the child, for we then feel, very
powerfully, the action of the uterus, and the efforts which it
makes, to expel its contents. It is not just, however, to con-
sider the action of the womb itself, as the sole agent in partu-
rition ; for in the second stage, the abdominsd muscles do
assist in the expulsion, not only by supporting the uterus, and
thus enabling it to contract better, but also directly, by
endeavouring to force the uterus, and consequently its con-
tents, down through the pelvis. Two purposes are intended,
by the uterine action ; the first, is to open the os uteri, the
second, to propel the foetus through it. Whilst, then, the
fibres of the uterus itself contract, those of the os uteri must
relax and dilate, and in proportion as the foetus advances
through the pelvis, the uterine fibres must shorten themselves.
Thus, the uterine cavity is gradually diminished, so that the
placenta can very easily, by a continuation of the same pro-
cess, be thrown off; and the uterine vessels having their
diameter greatly lessened, hsemorrhage is prevented, after the
separation of the placenta. There are then two processes
taking place, during parturition, contraction and relaxation,
and these are, in natural labour, proportionate to each other.
As the OS uteri relaxes, the rest of the uterus, increases in the
activity, of its contraction. This fact, I fear, has not been
sufiiciently attended to, and a very great mistake has often
been made, in supposing that there is greatest contractive or
expulsive effort made, when the resistance is greatest. This
is no doubt true if we look to duration, but not if we attend
to the degree, exhibited in a given time. Were there no
resistance offered, the uterus would contract at once, and
expel the foetus by a single effort ; and this, or nearly this, in
a few cases has taken place, and almost no pain has attended

394

the process. On the other hand, even a very slight resistance
does, in many cases, diminish the degree of contraction, or
expidsive effort, and in proportion as this resistance is re-
moyed, so does the contraction increase. Hence, as the os
uteri relaxes or opens, so does the expulsive power augment,
and it is experience alone, which can convince us how small
a resistance, may be the mean of parrying, if I may use the
expression, the contraction of the fibres, or preventing them
from acting briskly and quickly. Labour, therefore, is more
certainly shortened, by promoting relaxation, and diminishing
resistance, than by means intended to stimulate to action. At
the same time, it must not be forgotten, that continued resis*
tance, does, at last, rouse up the uterine action, and call forth
frequent and powerful efforts, often accompanied with great
pain. These are more easily excited, when the resistance
proceeds from the pelvis or perinseum, and orifice of the
vagina, or the position of the child, than when it arises from
the state of the os uteri, or even of the membranes, in which
case the uterine action is long feeble or inefficient. It is
necessaiT farther to remark, that often a mistake is com-
mitted, by confounding frequent and painful contraction of
the uterus, with powerful and efficient action.

Parturition is a muscular action, and we might in one view
conceive, that it should be most speedy and easy, in those
who possessed a powerful muscular system, and great vigour.
But this is far from being the case, for the process is tedious
or speedy, easy or difficult, according to the relation, which
the power bears, to the obstacle to be overcome. Now, in
many weak and debilitated women, the parts very easily relax
and dilate, and a very small power is required to complete
the expulsion ; whilst we often find, that those who possess
a tense fibre, and great strength of the muscular system,
accomplish the dilatation of the os uteri, not without much
pain, and repeated efforts.

A fundamental principle, then, in midwifery is, that
relaxation, or diminution of resistance, is essential to an easy
delivery : and could we discover any agent, capable of effect-
ing this rapidly and safely, we should have no tedious
labour, excepting from the state of the pelvis, or position of
the child. This agent has not yet been discovered. Blood-
letting does often produce salutary relaxation, but it cannot
always be depended on, neither is it always safe.

395

SECTION FIFTH.

WomeQ) in a state of nature, make little preparation for
their delivery, and conduct the process of parturition, without
much ceremony. They retire to the woods, or seclude them-*
selves in a hut or bower, until they bear the child; after
which, if the religious customs of their country, do not require
their separation for a time, they return to their usual mode
of living.

In Europe, we find that the process of parturition is con-
ducted with more care, and is supposed to require greater
preparation. Different countries, have different customs, in
this respect. In some, women are delivered upon a chair of
a particular construction ; in others, seated on the lap of a
female friend. Some women use a little bed, on which they
rest, until the process be completed ; and others are delivered
on the bed on which they usually sleep. This last, for many
reasons, is the best and most proper practice ; but in order
to prevent the bed from being spoiled, or wet with the liquor
amnii er blood, and also from other motives of comfort, it is
usual to make it up, in a particular manner. The mattress
ought to be placed uppermost, and a dressed skin, or folded
blanket, placed on that part of it, on which the breech of the
woman is to rest. The bed is then to be made up as usual ;
after which, a sheet folded into the breadth of about three feet,
is put across the under fold of the bed-sheet. This is intended
to absorb the moisture, and, after delivery, if not during
labour, that part which is wet, is to be drawn completely away»
so that a dry portion, may be brought under the woman*
This arrangement, is generally attended to by the nurse,
whenever labour begins. When the pains begin, the patient
generally dresses in dishabille ; but when the process is con-
siderably advanced, it is necessary to undress, and lie in bed.
Some, at this time, put on a half shift, that is to say, one
that does not reach below the waist, so that it is not liable to
be wet. Others, are satisfied with having the shift, pushed
up over the pelvis, so as to be kept dry ; its place, in either
case, is supplied with a petticoat. These, and other circum-
stances relating to dress, and to the quantity of bedclothes,
must be determined by the patient herself, and the season of
the year.

It is of consequence, that the room be not overheated by
fire, or the patient kept too warm with clothes. Heat makes
her restless and feverish, adds to the feeling of fatigue, and

396

often, by rendering the pains irregular or ineffective, protracts
the labour. No more people, should be in the room, than are
absolutely necessary. The nurse and one female friend, are
perfectly sufficient, for every useful purpose, and a greater
number, by their conversation, disturb the patient, or by
their imprudence, may diminish her confidence, in her own
powers, and, also, in her necessary attendants. The mind,
in a state of distress, is easily alarmed ; therefore, whispering,
and all appearance of concealment, ought to be prohibited in
the room.

If the patient be disposed to sleep, betwixt the pains, she
ought not to be disturbed, but allowed to indulge in repose.
If she have not this inclination, and be not fatigued, cheerful
conversation, upon subjects, totally, unconnected with her
situation, will be very proper.

Women have seldom an inclination for food, whilst they are
in labour, and, if the process be not long protracted, there is
no occasion for it. If, however, the patient have a desire to
eat, she may have a little tea or coffee, with dry toast, or a
little soup, or some panado ; but every thing which is heavy
or difficult of digestion, must be avoided, lest she be made
sick and restless, or have her recovery afterwards interrupted.
Even very light food, is apt at this time to sour, and cause
heartburn.

Stimulants and cordials, such as spiced gruel, cinnamon
water, wines, and possets, were, at one time, very much
employed, but now are deservedly abandoned, by those who
follow the dictates of nature. Given in liberal doses, they
are productive of great danger, disposing to fever or inflam-
mation after delivery ; and in smaUer doses, they disorder the
stomach, and often, instead of forwarding, retard the labour.
If, however, the woman be weak, or the process tedious, then
a small quantity of wine, given prudently, may be of consid-
erable advantage.

Some women, wish to keep out of bed, as much as possible,
in order that labour may be forwarded, by walking about ;
others, have the same desire, from feeling easier, when they
are sitting. In this respect, they may be allowed to please
themselves, but they ought to be, as much as possible, out of
bed, provided, they do not feel tired.

The urine ought to be regularly, and frequently evacuated ;
and, on that account, the practitioner should, occasionally,
leave the room. If the patient be costive, or the rectum con-
tain fences, a clyster ought always to be given early, which

397

facilitates the labour. On the other hand, if the bowels be
very loose, a few drops of tincture of opium, may be given,
with much advantage.

It is immaterial in what posture, the patient place herself,
during the first stage of labour, when it is brisk ; but, in the
second stage, when delivery is approaching, it is proper that
she be placed on her side, and it is usual for her to lie on
the left side, as this enables the practitioner to use his right
hand. If the vertex be directed to the right side, it is often
useful to place the patient on her right side, unless the pains
be efficient, and the process advancing. In that case, it is
not material on which side she lies. The knees are a little
drawn up, and generally towards the end, kept separate, by
means of a small pillow, placed between them. Many women,
wish to have their feet supported, or pressed against, by an
assistant, and it is customary to give a towel, to grasp in the
hand. This is either held by the nurse, or fastened to the
bed-post. We must, however, be careful that these con-
trivances, do not encourage the woman to make premature,
or too strong and exhausting efforts, to bear down.

Wlien the patient is in bed, it is proper to have a soft
warm cloth applied to the external parts, in order to absorb
any mucus, or water, that may be discharged, and this is to
be removed when it is wet.

Attempts to dilate the os uteri or the vagina, and the ap-
plication of unctuous substances, to lubricate the parts, are
now very properly abandoned, by well instructed practi-
tioners.

The membranes ought, generally, to be allowed to burst,
by the efforts of the uterus alone, for this is the regular
course of nature ; and a prematture evacuation of the water,
either disorders the process and retards the labour, or, if it
accelerate the labour, it renders it more painful. I cannot,
however, go the length of some, who say, that the artificial
evacuation of the water is always hurtful ; for there are cir-
cumstances, in which, it may be allowable, and is beneficial.
It is allowable, when the os uteri is, fuUy dilated, and the
membranes protruded, perhaps even out of the vacina. In
such a case, they would, in a very few pains at fartibest, give
way, but by rupturing them^ we can take precautions, to keep
the person dry, and more comfortable, than she should other-
wi%s have been. Even if the membranes be not considerably
protruded, if the os uteri be completely dilated, no injury
can arise from rupturing them, for they ought, in the natural

398

course of labour, to gire way at this time. But, although
the practice be not detrimental, yet, it does not thence follow,
that it is always expedient ; and it will be an useful rule to
adhere to, that the seldomer we interfere, in this respect, in
natural labour, the more prudent shall our conduct be.

Examination ought, in the first stage of labour, to be
practised seldom; but in the second stage, we must hare
recourse to it more frequently; and, when the pains are
becoming stronger, and the head adrancing, we must not
leave the bedside. At this time, we should be prepared for
the reception of the child. A pair of scissors, with some
short pieces of narrow tape, must be laid upon the bed or
chair, and a warm cloth or receiver, must be at hand, or
spread under the clothes, to wrap the child in. As the
faeces are generally passed, at this time, involuntarily, a soft
doth is to be laid on the perinaeum, and when the second
stage of labour is drawing to a conclusion, the hand is to be
placed on this, in order to prevent the too rapid delivery of
the head, and the consequent laceration of the perinseum*
This is a point of very great unportance, and which requires
to be, carefully, considered by the practitioner. There are
several arguments, against this practice; for we should, a
priori, conceive, that as parturition is a natural process, it
ought not, in any part to be defective, or to require the
regulation of art. Kext, we should strengthen thb doctrine,
by finding, that, in the savage state, a lacerated perinieum is
rarely discovered, and in all those women, who are speedily
delivered by themselves, the recto-vaginal septum is seldom
torn. But, on the other hand, the fact is ascertuned, beyond
all dispute, that the perinsum is sometimes lacerated, not*
withstanding these presumptive proofs, against the occur-
rence of the accident. This being ascertained, it becomes
our duty, however rare the case may be, to determine its
causes, and prevent its occurrence in eveir instance ; for we
cannot exactly say, who the unfortunate individual may be,
to whom it is to happen. We may decidedly say, that the
perinsum is torn in consequence of distention ; but in every
deliverv, the perinsum must be distended, and in some to a
great degree. In proportion to the facility of the distention,
and the ease with which the orifice of the vagina dilates, is
the risk of laceration diminished. It has, therefore, become
a practical rule, to resist, with the hand placed on the
pennsum, the delivery of the head, until the parts be
sujficiently relaxed ; and this pressure ought to be exerted

399

over the whole tumour, but especially at the fourchette ; for,
although the perinseum have been perforated by the head,
which did not pass through the orifice of the ragina, but
through it, yet, usually, the rent begins at the fourchette ;
and proceeds backwards, to a greater or less degree. Till
the relaxation be such as to allow the head safely to pass by
the existing pressure, we must steadily support the pennseum,
and especially at that part where the effect is greatest. This
is generally at the margin or fourchette. But it may also be
between the ragina, and anus, or, the face of the rectum, may
even by the expansion of the anus become extended over the
head. In this case, whilst we attend to the margin, we also
^pay peculiar attention to the whole distended tumour, else we
might hare a perforation of the perinseum. At this stage,
the direction ot the pressure or support, is not only upward,
but somewhat forward. In every case, the fourchette, often,
a small part of the posterior surface of the vagina, is lace*
rated, though the integuments of the perineum remain sound.
By firmly supporting the perinaeum, and, at the same time,
exhorting the patient not to force down, during a pain, and
thus retarding the delivery of the head, until we feel the
vulva, as well as the perinseum relaxing, we may generally
prevent laceration ; and therefore, this accident shall seldom,
if ever, happen in the hands of a prudent practitioner. Still,
it is possible, for the perinseum to be torn, under good man-*
agement. A little bit of it is not unfrequently lacerated,
notwithstanding all our precaution; and although, in this
slight degree, it be of no consequence, yet, we thus see, that
art cannot, completely prevent the accident. Sometimes,
the restlessness of the patient, almost inevitably^ prevents the
necessary precautions from being used ;* and it may happen,
that the frame is so veiy irritable, that the perinieum, unex-*
pectedly, lacerates, at the time when it is supposed, to be in
a favourable state. As there must be some point, where the
resistance ought to stop, else the labour should be unneces-
sarily protracted, or perhaps even the uterus injured, it is
possible that such resistance may be made, as generally is
sufficient to prevent the accident, but, which may not, in
some particular case, owing to the irritable state of the peri-
nsum, be adequate to the intended purpose ; or, the power
of the uterus may be so strong, as to expel the head, in spite

* Dr. Denman, with a candour whieh doea him honour, acknowlodf«f, thai,
from thb eaoM, the aoeldont ocearrad In hit oirn praetioa.

400

of every allowable resistance ; and, in some of these cases, it
is possible, for the perineum to be torn.

It is not sufficient, that the practitioner support the
perinaeum, until the head is going to be expelled ; he must
continue to do so, whilst it is passing out, for there is then a
great strain on the part, as the forehead is passing over the
perinaeum ; e?en the face or chin, moving along it, may pro-
duce injury. He ought, not only, steadily, to support the
perinaeum, with the whole hand, but have that, so placed,
that the thumb, forefinger, and their junction, shall form
an arch, embracing the margin, of the perinaeum and dis-
tended labia, and sustaining the head, as it projects. The
perinaeum, whilst the head is actually passing out, is to be, as
it were, guided, and at the same time supported, backward,
over the head and face, that it do not lacerate. For this
purpose, we particularly press against the thin margin of
the perinaeum, or posterior part of the vagina, as these glide
backward, and sometimes even grasp, laterally, with the finger
and thumb, the distended perinaeum to aid the support.* After
the head is delivered, it is still necessary to place the hand
under the chin, and on the perinaeum, for the arm of the child
CQmes, next, to press against this part, and may either tear it
by pressure, or by coining out with a jerk. Farther, to pre-
vent injury, and avoid pain, the body of the child, should be
allowed to pass out, in a direction, corresponding to the
outlet of the pelvis, that is to say, moving a little forward.
But there is no occasion, that the child should be pressed
forward, betwixt the thighs, for, in a natural labour, the
back of the child comes out, directed to the thighs ; he can
easily bend, and will, naturally, so incline himself, in the
delivery, ad to take the proper direction, provided the thighs
be not too close together. The last advice to be given,
respecting this stage of labour, is, that as we retard, rather
than encourage the expulsion of the head, so, we are not to
accelerate the delivery of the body. Women in a state of
pain, call for relief, and expect that the midwife, is to assist
the delivery of the child ; but no entreaties ought to make us
hasten the expulsion of the head, and after that event, there

* This advice, which I consider as very important, has been objected to bf Dr.
Hamilton. With all deference to the opinion of my jusfly celebrated friend, I
would say, that when the parU are prepared for the evolution of the head, that
can only take place safely, as 1 have alri*ady explained, by the perinapum gliding
backward. To continue the pressure forward, can only, In so far as it is emclent.
interfere with the change which the perinaeum naturallv undergoes, and endanger
either its Ueeration or perforation. The sole question is, whether it be safer to
allow it to glido backward without support, or to afford support in that process.

401

is little inducement to accelerate the labour. SometimeSy in
a few seconds, the child is expelled, but there may be a
cessation of pain for a minute or two. In the first case, we
take care that the body, be not propelled rapidly, and with a
jerk ; in the second, we attend to the head, ascertaining that
the membranes do not cover the mouth, but that the child be
enabled to breathe, should the circulation in the cord be
obstructed. There is no danger in delay, whilst, rashly
pulling away the child, is apt to produce flooding, and other
dangerous accidents. Should there, however, be a consider-
able interval betwixt the expulsion of the head, and the
accession of new pains, we may rub gently on the belly, or
pull the child slightly, so as to excite the uterus to contract.
Or, should the woman have several pains, without expelling
the body of the child, it may be allowable gently to insinuate
the finger, and bring down the shoulder; but even this
assistance is rarely required, and on no account, ought we to
attempt the delivery, by ptdling the head. Sometimes, a
delay is produced, by the cord being twisted round the neck,
and in tms case, all we have to do, is to slip it off over the head.

The child being bom, a ligature is to be applied on the
cord, very near the navel, and another, about two inches
nearer the placenta. It is then to be divided betwixt them,
and the child removed. The hand is, next, to be placed on
the belly, to ascertain that there be not a second child, and
the finger may, for the same purpose, be slid gently along
the cord, to tne os uteri. The hand of an assistant, should
be applied on the abdomen, and gently pressed on the uterus,
which may excite it to action, and prevent torpor. If the
placenta be not expelled soon, the uterine region may be
rubbed with the haikU to excite the contraction of the womb.
Immediately after the expulsion of the child, there is often
a copious evacuation of water, which is sometimes mistaken,
by the patient, for a discharge of blood. But haemorrhage
never takes place so instantaneously, in such quantity. It is
generally a minute or two, sometimes much longer, before
flooding come on ; against the occurrence of this, we are to
be on our guard.

The woman, after the delivery of the child, feels qtdte
well, and expresses in the strongest language, the transition
from suffering to tranquillitv. But, in a short time, generally
within half an hour, (Dr. Clark supposed twenty-five minutes
to be the average,) one or two trifling pains are felt, and the
placenta is expelled, which completes the last stage of partus

402

rition ; and when the prociess goes on regularly, hothmg is
required in this stage, except watchfulness, lest haemorrhage
occur.

The full, and universal, contraction of the uterus, after the
child is expelled, must, by diminishing its surface, detach the
placenta, whilst the membranes, being thinner and more
pliant, may wrinkle, and continue their adhesion, and some-
times do so, till they be peeled off, as the placenta protrudes.
Heemorrhage is prevented, even when the placenta is detached,
by the contraction of the uterine fibres on the vessels, and by
the adhesion of the membranes, still to the uterus, which, for
a time at least, will prevent blood from flowing, unless the
extravasation be considerable. But to these causes, we must
also add the condition of the uterine vessels themselves,
which, immediately after delive^, have, if the state be
natural, their circulation much anected, by the alteration, in
the action of the nerves, of the uterus itself.

But it sometimes happens, that the placenta does not come
away, so early, or so readily, as we expect. It may be
retamed for many hours, nay, even for some days. This,
retention can be caused, by preternatural adhesion of the
placenta, or, by the uterus contracting, spasmodically, round
the placenta, forming a kind of cyst, in which it is contained;
or, the uterus may not contract on the placenta, so strongly,
as to expel it. Some, from a confidence in the powers of
nature, have inculcated, as a rule of conduct, that, unless
flooding take place, the placenta ought not to be extracted.
Others have, with equal zeal, advised it to be brought away,
immediately after the birth of the child. The safest practice,
seems to lie, betwixt the two extremes. To leave the expul-
sion of the placenta, altogether, to nature, is a step attended
with great danger ; for, so long as it is retained, we may be
sure, that the uterus has not contracted, strongly, and regu-
larly. If, then, in these circumstances, the placenta should
be partially, or completely, detached, haemorrhage is very
likely to occur. If it still adhere to the uterus, the risk of
hiemorrhage certainly is diminished, for those vessels, alone,
which opened on the decidua, can be exposed ; but we have
no security, that this adhesion, shall remain universal, for
any given time. As long, then, as the placenta is retained,
the patient is never free from the risk of flooding. In many
cases, she has died from this cause, before the placenta was
expelled ; or, if, after a long delay, the placenta have come
away, its exclusion has, sometimes, been followed by fata\

403

haemorrhage.* But this, although a dreadful accident, is not
the only one, arising from retention of the whole, or part of
the placenta. For, great debility, constant retching, and
fever, are often produced by this cause, and may, ultimately,
carry off the patient. It is, therefore, not without great
reason, that women are anxious for the expulsion of the pla*
centa ; and this prejudice may have a good effect, in operating
against the conceits of speculative men, who suppose that
nature is, in every instance, adequate to the accomplishment
of her own purposes.

On the other hand, daily experience must convince every
one, that there is no occasion, for extracting the placenta,
immediately, after the birth of the child, for it is usually
expelled, with perfect safety, within forty minutes, after the
child is delivered. Nay, we find that the speedy extraction
of the placenta is directly hurtful, both as it is painful, and
also, as it is, sometimes, followed by uterine haemorrhage, or
if rashly performed, accompanied by inversion, or, productive
of inflammation of the womb. The practice then, I think,
may be comprised in two directions : — First, that we ought
never to leave the bedroom, until the placenta be expelled ;
and, second, that if it be not excluded, within an hour after
delivery} we ought cautiously to extract it. This point being
adjusted, it is next to be inquired, how the retention is to be
prevented, and if not prevented, how the placenta is to be
extracted. With regard to the first question, it may be
answered, that the placenta will be less apt to be retained,
if the expulsion of the child, be conducted slowly, and the
uterus made to contract, fully, upon it. The action, if not
likely soon to take place, may be sometimes excited, by
pressing on the uterine region, and rubbing the abdominal
covering, over the uterus, or gently grasping the womb,
through the relaxed parietes. As to the mode of extracting
the placenta, we can be at no loss, if we recollect, that the
expulsion is accomplished, by the contraction of the uterus.
Our object, then^ is to excite this, when the placenta is
retained, in consequence of the womb, not acting strongly.
The hand is to be slid slowly, and cautiously, into the uterus,
which is often sufficient to make it contract ; but, if it do not,
the hand is to be moved a little, or pressed, gently, on the

^ Mr. Whyt« has, in his TreatlM on tbe Manaffcment of Prfgnant sikI
Lying-in Women, p. 607, related aeverml eaaet where the practice of leaviof tbo
placenta to be expelled by nature alone, was productive of fatal hemorrhage i and,
in one initance, thit event took plaoe, although the placenta wm at last expelled,

404

placenta, at the same time that we pull, very slightly, by the
cord, or lay hold of the detached placenta, with our hand,
and, with caution, extract it slowly. This requires no exer-
tion, for the uterus is pressing it down, and if any force be
used, we do harm. Attempts to bring away the placenta, by
pulling strongly at the cord, whether the hand be introduced
into the uterus or not, are always improper. If persisted in,
they are likely to end, either in the laceration of the cord, or
the inversion of the uterus.

There are two circumstances, however, under which the
placenta may be retained, which require some modification of
the practice.

The first is, when the placenta is retained by spasm. In
this case, when the hand is conducted along the cord, through
the OS uteri, the placenta is not perceived, but it is led, by the
cord, to a stricture, like a second, but contracted os uteri,
beyond which the placenta is lodged. This contraction,
usually seated in the upper part of the cervix, or lower part
of the body, must be overcome, before the placenta can be
brought away, which may be accomplished, by gradual
attempts, to introduce one, two, and ultimately all the fingers
through it, and these, if cautiously made, are perfectly safe*
It will, however, be observed, that the uterus, at short inter-
vals, contracts, which is accompanied with pain; but this
contraction, is confined to the stricture alone, the cavity of
the womb not being lessened by it, and, during this state, all
attempts to dilate the aperture are hurtful. We must be
satisfied, with keeping the fingers in their place, to preserve
the ground we have gained. It is also of advantage to press
externally on the fundus, so as to prevent the uterus being
raised or stretched by the eflPort to introduce the fingers into
the upper division. It is not necessary to pass the whole
hand so as to grasp or include the placenta. That may be
laid hold of between two fingers, or by two on each side, and
drawn down, aiding the descent by cautiously pulling the
cord, if that be not frail. If any part of the placenta adhere,
that may be cautiously separated by the finger. We must if
possible, bring the membranes with the placenta, for if torn,
and part be left adhering to the uterus, afterpains, foetid
discharge, or fever, may be caused thereby. Opiates have
been proposed, to remove this spasm, and render the intro-
duction of the hand unnecessary; they seldom, however,
succeed alone; given in a fiill dose, they may make the
manual attempt more easy, but should there be haemorrhage.

405

it is evident, we cannot delay, till they take effect. Some^
times, the sudden application of a cloth, dipped in cold water,
to the belly, has the effect of relaxing the spasm, perhaps, by
exciting, rapidly, the more universal contraction, of the
uterus. A retention of the placenta, from spasm, is rarely a
simple consideration, for, in the majority of instances, it is
attended with haemorrhage, and will fall to be noticed, again,
in another chapter. Here, I must add, that even, with very
little discharge, there is a great feeling of sinking, and often
of sickness, a feeling almost invariably attending this spasm,
and which is only relieved, by introducing the hand, so as to
dilate the stricture, at the same time, that we excite the uterus,
to more general and uniform contraction. Opiates are also
proper, and if the symptoms be urgent, wine must be given,
for some patients may die, if this state continue long, although
there have been little haemorrhage.

The second circumstance to which I alluded is, adhesion
of the placenta, which usually is only partial. This may
occur, with, or without, a change of structure; but in
general, the structure is more or less altered, the adhering
part, being denser than usual, and sometimes almost like car-
tilage. The separation of the adhering portion, should not
be attempted hastily, nor by insinuating the fingers between
it, and the uterine surface. It is better to press on the surface
of the placenta, so, as thus, to excite the uterine fibres,
to contract, more briskly, at the spot ; or, by gently rubbing,
or, as it were, pinching up the placenta, between the fingers
and thumb, it may be separated. If, however, the adhesion
of the part of the placenta, be very intimate, we must not, in
order to destroy it, scrape and irritate the surface of the
uterus, but ought, rather, to remove all that does not adhere
intimately, leaving the rest to be separated by nature.* But,
in taking this step, we are not to proceed with impatience,
nor to attempt to bring away the non-adhering portion, until
a considerable time have elaps^, and cautious efforts have
been made, to remove the entire placenta, thus satisfying
ourselves of the existence of an obstinate and intimate union.
Cases, where this conduct is necessary, are very rare, and
when they do occur, there is, usually, an induration of the

« Dr. Smellie relates two cases of this kind. In the first, hte brought away
tlie indurated portion, but the woman died from bflemorrhage. In the second,
he left the adhering portion, and the woman recovered. Col. 2S. e. 1. and 2.
See also Gifford^s Cases, c. 119 and 1S7; and l4i Motte« o. 368 and S62. In
these, although the adhesion was very intimate, he brought away the placenta
in pieces.

406

adhering part. It is generally thrown off, in a putrid state,
in forty-eight hours. Sometimes, the placenta adheres,
when it is unusually tender and soft, and then we must, with
peculiar care, avoid hasty efforts, by which the placenta
should be lacerated, and part left behind, which should be
hurtftd afterwards; whereas, by a little more patience, and
gentle pressure, on the surface of the placenta, the uterus
might have been excited, to throw the whole off.

In every case, the utmost caution and gentleness, must be
employed, in removing or extracting the placenta, lest
disorder, or inflammation of the uterus, to a greater or less
degree, be excited.*

CHAP. III.

Of Premature Labour.

When a woman bears a child, in the seventh or eighth month
of pregnancy, she is said to have a premature labour; a
medium between abortion, and natural labour.

In some cases, the uterus is fully developed, before the
usual term of gestation, and then contraction commences;
but, in a great majority of instances, premature labour pro-
ceeds from accidental causes, exciting the expulsive action
of the uterus, before the cervix and os uteri, have gone
through their regular changes. The cervix must, therefore,
relax, and be expanded, before the os uteri can be properly
dilated. It is not unusual to find from the first, or even
before pain be felt, the os uteri so open as easily to admit the
fingers, but it is not extended, its lips hanging still down,
thick and protuberant. This preparatory stage, is generally
marked, by irregular pains, and, not unfrequently, by a
feverish state, preceded by shivering. A feeling of slackness
about the belly, with different anomalous sensations, often
accompany this stage of premature labour. When the cervix
is expanded, then the os uteri begins to dilate, and its lips
gradually to be effaced, and this part of the process is often

• Dr. Colliua thinks it useful in all cases where the patient suffers much in the
extraction, to give small doses of calomel and ipecacuanha, and if the abdomen be
tender, to put the patient for an hour in the warm bath. Both of these advices,
particularly the last, must be acted on with caution. From his tables it appears,
that in (K) cases of retentiun, S8 ^ere in fit at pn^nancies, and the greatest num>
ber occurred when the patient had bern onljr from 8 to 4 hours in labour.
J3ut tins 1 nhnuld say, in not the genrriil rule.

407

more tedious, than the same period of natural labour, and
generally as painful. It is, also, frequently attended with a
bearing-Hlown sensation. The second stage of labour, is
usually expeditious, owing to the small size of the child.
The decidua being thicker than at the full time, the protru-
sion of the membranes is often attended, with more sanguin-
eous discharge, and if the woman move much, or exert herself,
considerable hsemorrhage may take place. The third stage
is likewise slow, for the placenta is not soon thrown off.
In the last place, spasmodic contraction of the uterus, is
more apt to take place, in all the stages of premature, than
of natural labour.

A variety of causes, may excite the action of the uterus,
prematurely, such as distention from too much water ; or, the
death of the child, which is indicated by shivering, subsidence
of the breasts, cessation of motion, and of the symptoms of
pregnancy ; or, the artificial evacuation of the liquor amnii ;
or, violent muscular exertion ; or, drugs acting strongly on
the stomach and bowels ; or, passions of the mind ; or, acute
diseases ; or, affections of the uterine fibres, often dependent
on or produced by the state of the nerves, which go to the
uterus, and which may be induced directly, or sympathetically.
<>ertain general conditions of the system, render the operar
tion of these causes more easy, such as plethora, debility, but
especially morbid irritability, or sensitiveness. Colic, in
some instances, and diarrhoea in others, seems to be a cause,
and, in such cases, anodyne clysters are useful. Premature
labour is often preceded, by severe shivering, during, or im-
mediately before which, the child dies, and in some time
thereafter pains come on. It is worthy of notice, that a
much larger proportion of premature labours are preternatural,
than of labours at the full time.

A tendency to premature labour, is to be prevented, by
the means pointed out, when treating of abortion. I have
only to add, that when the abdomen is tense and hard, cr
painful, indicating a sensibility of the uterine fibres, or of
the abdominal muscles, tepid fomentations, gentle laxatives,
repeated small bleedings, and anodyne clysters, are useful.

When a woman is threatened, with premature labour, we
ought, unless there be very decided, marks, of the death of
the child, to endeavour to check the process, which is done
by exhibiting an opiate, keeping the patient cool and tranquil,
and removing any irritation which may exist. If she be
plethoric, or the pulse be throbbing, blood is to be detracted.

408

When labour is established, it is to be conducted much
in the same way, with parturition at the full time ; but the
following observations should be attended to. The patient
must avoid much motion, lest haemorrhage be excited.
Frequent examination, and every irritation, are hurtful, by
retarding the process, and tending to produce spasmodic
contraction. if this contraction take place, marked by
paroxysms of pain referred to the belly or pubis, often
attended with feeling of sinking, whilst little or no effect, is
produced on the os uteri, a fuB dose of tincture of opium
should be given, after the administration of a clyster.
Severe pains, with premature efforts to bear down, and a
rigid state of the os uteri, require venesection, to a moderate
extent, and afterwards an opiate. The delivery of the child
is to be retarded, rather than accelerated, in the last stage,
that the uterus may contract on the placenta. This is
farther assisted, by rubbing, and gently pressing on the
uterine region, after delivery. K the placenta be long
retained, or haemorrhage come on, the hand is to be gently
introduced into the uterus, and pressed on the placenta, to
excite the fibres to throw it off, whilst we also stimulate the
uterus to act, by rubbing externally. We should not rashly
attempt to remove it, for we are apt to tear it ; neither are
we to pull the cord, for it is easily broken. In those cases,
where premature labour, is connected with redundance of
liquor amnii, I think it useful, to introduce the hand, imme-
diately on the delivery of the child, for I have observed, that
the placenta is apt to be retained, by irregular contraction.
We do not instantly extract the placenta, but it is desirable
to get the hand in contact with it, before the circular fibres
contract. Great attention is to be paid to the patient, for
some days after delivery, as she is liable to a febrile affection,
which may be either of the inflammatory type, or of the
nature of weed, to be afterwards noticed.

Whilst we must not confound the effects of premature
labour, with those of the causes which give rise to it ; and
particularly, the antecedent condition of the nervous system,
or some of the viscera, we are not practically to overlook, or
neglect them.

JPremature labour, is sometimes intentionally excited, on
account of deformity in the pelvis, or more rarely, as a mean
of getting rid of some of the diseases of pregnancy, when
these go to an alarming de^ee.

409

CHAP. IV.

Of PretemaiurcU Labour,

Various signs have been enumerated, by which it was
supposed, that malposition of the child might be discovered,
previous to labour. An unusual shape of the abdomen ; some
peculiar feeling, of which the mother is conscious, and which
she has not felt in any former pregnancy ; greater pain oir
numbness in one leg, than in tne other ; a sensation, of the
child rising, suddenly, towards the stomach; have all been
mentioned as indicating this, but are aU, even when taken
collectively, uncertain tokens. We cannot, positively deter-*
mine the presentation, until labour have begun. This is
much more frequently premature than when the child presents
aright. In a great majority of instances, the head, during
the end of gestation, may be felt resting on the cervix uteri ;
but, in repeated instances, I have not been able to distinguish
it, in a pregnancy, which ended in natural labour. Sometimes,
in consequence of a fall, or other causes, the head seems to
recede, but afterwards returns to its proper position. When
labour begins, we may generally distinguish the head by its
proper characters ; but, if it lie high, and, especially, if the
pelvis be deformed, we may not find it always easy, to ascer*
tain the presentation, at a very early period. In such cases,
it is of great consequence, to preserve the membranes entire*
When the head does not present, the presentation is generally
more distant, and longer of being distinctly ascertained,* the
lower part of the uterus is more conical, and the tumour
formed by the cranium, cannot be felt, through the mem-*
branes, or cervix uteri : when the finger touches the part,
through the membranes, it very easily recedes, or seems to
rise up. K the child lie, more or less, across the uterus, the
08 uteri is generally long of being fully dilated, the membranes
protrude like a gut, and sometimes, during the pains, the
woman complains of a remarkable pushing against the sides.
The pains are severe, but in cross presentations she is
sensible, that they are not advancing the labour.

* When the prewntation is long of being felt, we have been adTised to examine
the woman in a kneeling posture, or even to introduce the hand into the vagina,
and rapture the membranes. This last advioe is sometimes useful, as it enables
us» if the presentation require It, to turn the child at a time when it can be easily
done. But this is not to be hastily practised, nor adopted tlU the os uteri be well
dilated, or at least quite dilatable.

410

It is a fact well ascertained, that, although the head have
been felt, distinctly, in the commencement of labour, yet
when the membranes break, it may be exchanged for the
shoulder,* or some other part. On this account, as well as
for other reasons, it is always proper to examine, immediately,
after the membranes have given way.

Dr. Collins calculates that the presentation is preternatural,
in one out of forty cases. The most frequent is that of the
breech.

ORDER FIRST.

The breech is distinguished by its fleshy feel, by the
tuberosities of the ischia, the shape of the ilium, the sulcus
between the thighs, the parts of generation, and by the
discharge of meconium, which very often takes place in the
progress of labour,t or is found on the finger after an examina-
tion. Sometimes the scrotum is pressed down, and elongated
into a firm elastic bag. After the breech has descended, some
way into the pelvis, the integuments may become tense or
swelled, so as to make it resemble the head or face. If the
breech present more obliquely than usual, the ribs approach
the ilium more, and it is sometimes difficult, till the band be
introduced, to say whether it be the shoulder or ischium*
Before the membranes burst, the presentation is usually
very mobile, and bounds up readily from the finger, so that it
IS not always easy, at this stage, to determine the nature of
the case. In some instances, however, it is, from the first,
firmly pressed down in the pelvis, and felt, through the uterus,
very much resembling the head. Dr. Collins says the child's
heart is distinctly heard beating near the umbilicus of the
mother.

Breech presentations are more hazardous to the child, than
when the head presents, naturally, for the cord is apt to be
compressed, when the head is entering the cavity of the
pelvis* They are also, generally, more tedious, for the pre-
sentation is not so well adapted to the shape of the pelvis, and
does not pass so readily, although the size be really less, than
that of the cranium. The lateral diameter, whether taken
from one trochanter, or one crest of the ilium, to the other, is
3^ inches. From the back of the pelvis, to the back of the

* I haTe b««n {nformed of s c«m, where the tboulder xrnn exchnnf ed for the
head, and Joerg sceme to have met trith the lame circumstance. Hist. Partus,
p. 90.

t A discharge of liquor amnii, apparently coloured with meconium, is no proof
that the lireerh presents, still lesM is it a sign that the child is dead.

411

thighs, when they are laid upon the belly, is barely 3 inches*
It has actually occurred,- that the breech has been expelled by
nature, when the perforator was required, before the head
could be brought down. The chest is larger than the breech,
for, if the foetus be injected, the lateral diameter, at the under
end of the thorax, is 3^, the antero-posterior, 3^ inches. In
the Dublin hospital out of 242 cases, 73 children were still*
bom, and of these 42 were putrid.

The breech, and consequently the body, of the child, may
vary in its position with regard to the mother ; but there are
chiefly two situations requiring our attention, because the rest
are ultimately reduced to these. First, where the thighs of
the child are directed to the sacro-iliac junction of the pelvis ;
and, secondly, where they are directed to the acetabulum.
These are ascertained by the relation of the thighs, the ilium,
and the sacrum, to the pelvis of the mother. In either of
these cases, delivery goes on with equal ease, until the head
come to pass. Then, if the thighs have been directed to the
forepart of the pelvis, the face sometimes continues turned
toward the pubis, and cannot clear its arch so easily as the
vertex. In by far the greatest number of cases, the thighs are
directed to the right sacro-iliac symphysis ; next to that, to the
left ; in some to the pubis ; in a ^w to the sacrum.

When the thighs, are directed to the back part of the pel-
vis, we find that the process of delivery is as follows : The
breech which lay with its longest diameter, corresponding to
the diagonal diameter of the pelvis, generally descends
obliquely, one tuberosity, the foremost, or that nearest the
pubis, being lower than the other. This follows the same
turns, as the presenting part of the parietal bone does, in
natural labour, and observes the same relation, to the axis of
the brim, and outlet of the pelvis. Coming to the outlet, one
ischium, is placed at the arch of the pubis, and the other,
on the perinseum. The first, protrudes a little, at the pubis,
but the second, is generally cleared sooner, the distended
perinaeum slipping back, over it, as it does over the head, and,
almost at the same moment, the other hip comes out, forward
from the pubis. Whilst the breech is protruding, it gradually
turns round a little, so that the belly of the child, is directed
to the back of the inside of the mother's thigh, and the shoul-
ders come to pass the brim diagonally. The breech being
delivered, a continuance of the pains pushes it gradually
away, in the direction of the axis of the outlet, until the legs
come so low as to clear the vagina. W^hen this takes place.

412

the head is generally passing the brim obliquely, the face
being turned toward the sacro-iliac junction ; and most fre-
quently the arms pass along with it, being laid over the ears.
They then slip down into the vagina, by the action of the
uterus, are bom at the same time, with the chest, and the
head alone, occupies the cavity of the pelvis. The face turns
into the hollow of the sacrum, and the chin tends toward the
breast of the child. Then, it clears the perinseum, which
slips over the face, and the vertex comes, last of all, from
under the pubis.

Many have advised, that when the breech presented, the
feet should be brought down first; but the established
practice now is, when the pelvis is well formed, and other
circumstances do not require speedy delivery, to allow the
breech to be expelled, without any interference, until it have
passed the external parts.

The management of this labour is very simple. Whilst
the breech is coming forth, the perinasum is to be supported,
and nothing more is to be done till the knee be so low, as
to be on a line, with the fourchette. If they do not naturally
bend, and the feet slip out, the finger of one hand is to be
employed to bend the leg gently, and bring down the foot ;
the knee, in this process, pressing obliquely on the abdomen
of the child. But' w'hether the legs be expelled naturally, or
be brought down, we must carefully protect the perinseum,
lest it should be torn, by a sudden stroke of the leg in passing.
Next, the cord is to be pulled gently down a little, to make
the circulation more free. Thirdly, we attend to the arms ;
if these do not descend by the natural efforts, along with the
breast, but be turned up by the sides of the head, occupying
the brim of the pelvis, together with it, we bring down first
one, and then the other, using no force, lest the bone should
break. We pass the finger along the breast and neck of the
child, over the shoulder, to the forepart of the humerus, and
gently press it downward, and backward, with relation to the
child, so as to make it sweep down by its side. The perinsum
is, in doing this, to be guarded, to prevent a slap of the arm
from injuring it. Fourthly, if the head do not directly turn
down, the finger is to be carried up, and placed upon the chin
or in the mouth, in order gently to depress it toward the
breast, and this is generally sufiicient. To guard the peri-
naeum, the hand must be applied on it, and the body of the
child moved near the thighs of the mother, that the vertex
may more readily rise behind the pubis, whilst the face i»

413

passing. If the body be, on the contrary, removed farther
from the mother, and nearer the operator, the head can
neither go easily pass into the pelvis, nor out from the vagina.
In a natm^ labour, aflter the head is expelled, the whole
body, should be allowed to be slowly bom, by the efforts of
tiie womb alone. But, in breech cases, should the process,
after the breech is expelled, be slow, the delivery of tne body
and head must, by the means I have related, be accelerated,
lest the umbilical cord, suffer fatal compression. For the head,
on entering the pelvis, is apt to jam the cord, between itself
and the brim, and it is well known that the uterus does not
act so efficiently on the head as on a larger body. The first
symptom of danger, is a convulsive jerk of the body, and if
the bead be not brought speedily down, the child wiU be lost.
Should delay inevitably arise, we must try to bring the cord
to the widest part of the pelvis. But even, although all pres-
sure could be removed, the child might be lost, if it be not
soon delivered, as the placenta, is sometimes speedily detached
from the womb and its function destroyed. At the same
time, we must not interfere, by drawing the child down, if
we can help it, as this separates the chin from the breast, and
makes the nead enter unfavourably into the pelvis, and we are,
also, more apt to have the arms turned up, and laid along the
head, instead of coming down before it, with the chest.
Pulling the child by the shoulders is dangerous, if more than
very sUght force be employed, for the spinal cord, in the neck,
is apt to suffer.

When the thighs in breech cases, are directed to the aceta-
bulum, or pubis, the face, as in the former case, b generally
bom first* It might be expected, that it should always con-
tinue, directed to the pubis, from under the arch of which, it
would come with some difficulty. But, whatever may happen
in some instances, we usually find, that the trunk does, in its
expulsion, so turn round, that the face is directed, at birth, to
the perineum, and we may, if there be any doubt of this
taking place, aid it, remembering, that if the left hip be fore-^
most, as it most frequently is, the turn is made to the left of
the mother and vice vena. Should we be disappointed, and
find the face, when the body is born, directed forward, we do
not turn the body, which might twist and injure the neck, but
introduce two fingers, and press with them on the head itself,
endeavouring thus to turn the chin from the acetabulum, to the
sacro-iliao junction of the same side. If the position be not
thus rectified, then, we assist the descent, by depressing the

414

chin, and gently bringing it under the pubis ; and this may
be facilitated, by pressing the vertex upward and backward,
and making it turn up, on the curve of the sacrum, to favour
the descent of the face. We must be careful of the
perinaeum.

When the pelvis is contracted or deformed, it will be
prudent at an early stage of the labour, to bring down
the feet. The danger, in such cases, is great to the child,
but this is not diminished, by leaving the case to nature. For,
granting the breech to have been at last expelled, there has
not only been protracted suffering to the mother, but the
time and effort required, may render the uterus, less able to
assist the decent of the head, which can in no way be facili-
tated, in the case of a contracted pelvis, by the previous pas-
sage of the breech. But if this measure have not been
adopted, at the proper stage, it will be necessary to have re-
course to artificial means, to be afterwards explained. When
the resistance is slight, the insinuation of the fingers over the
groin may, sometimes, enable us to use such extracting force,
as at least excites the uterus more briskly to expel. Should
the head not easily follow the body, we must not attempt to
extract it, by pulling forcibly at the shoulders, as we may thus
tear the neck, and leave the head in utero.* The cord is,
first of all, to be freed, as much as possible, from compression ;
then, we gently depress the shoulders, in the direction of the
axis of the brim, at the same time that we, with a finger, act
upon the chin. Should this not succeed, we must apply the
lever over the head, and depress in the proper direction. If
this fail, the only resource is to open the cranium above or
behind the ear, and fix a hook in the aperture; but this is not
to be done until we have fully tried other means, and by that
time the child will be dead.

When the breech presents, and parturition is tedious, the
parts of generation, are often swelled and livid. When the
parts are merely turgid a little, and purple from congestion
of venous blood, nothing is necessary to be done. But when
inflammation takes place, it is more troublesome, for, being of
the low kind, it is apt to end in gangrene. Fomentations are
useful, but often mitd spirituous applications succeed best.

* La Mottfl, CbApman, Smellie, and Perfect, glre examples of the bead being
left in utero, without the body, and the bod v without the head. There are ehieflf
two mureee of danger : the first and most immediate ie uterine hsmorrhRf e ; the
■eeond proceeds from putrefaction, which produces sickness, oaiisra, fever, and

Ereat debilitr. The bead may be extracted, by fixing a finger in the mouth, or
y the crotchet, with or without perforation.

415

ORDER SECOND.

Presentation of the feet is known, by there being no
rounded tumour formed, by the lower part of the uterus. The
membranes also protrude, in a more elongated form, than
when the head or breech presents. The presenting part,
when touched during the remission of the pain, is. felt to be
small, and affords no resistance to the finger. When the
membranes break, we may discover the shape of the heel and
toes, and the articulation at the ankle. The heel has been
mistaken for the elbow, and vice versa. The toes from
being long, may be taken for the fingers, till the heel and
ankle be felt.

In presentation of the feet, the position differs less, from
that, in which the breech presents, than some suppose, for
a little more or less obliquity of the child, determines which
shall come down. The greater the obliquity, the lower are
the feet, and the higher the breech ; and, in a kind of medium
degree, both the breech, and the feet, may be said to present,
and enter at the same time, into the pelvis. In footling
cases, the legs are laid along the back of the thighs, and the
feet are either turned up, along the front of the tibiae, so that
the heels are felt first, as the lowest parts, or the feet cross each
other, somewhat, so as rather to present the sole, or side of
the foot ; or the toes may be first felt. The feet naturally
go down before the breech, which is directed obliquely up-
ward; one or both feet, may pass into the pelvis. Generally^
if they do not enter at the same time, the one soon follows
the other, but one may come down, whilst the other turns up
along the belly, as both legs do, in a common breech case*

Two circumstances are supposed to contribute to an easy
delivery : first, that the toes be turned toward the sacro-iliac
junction of the mother ; and, secondly, t^at both feet come
down together, but, as we have seen in breech cases, it
seldom makes much difference in the evolution of the head,
whether the toes be backward, or forward. The best prac-
tice is, to avoid rupturing the membranes, till the os uteri be
sufficiently dilated ; then we grasp both feet, and bring them
into the vagina ; or, if both present, together, at the os uteri,
we may allow them to come down unassisted. In either case,
we do not acelerate the deliverv, till the cord be in a situa-
tion to suffer from pressure, that is, till the knees be fully
protruded, and the thick part of the thighs, near the breech^
can be felt ; then, if the face be toward the belly of the
mother, and do not seem to move toward the back, we grasp

416

the thighs, and gently turn the body round. The manage-
ment, is the same as in breech cases. There is little danger,
of the feet of two different children, being brought down
together, as twins are included in separate membranes. But
as the case is possible, it is proper to ascertain, that the feet
be right and left, which we do by attending to the relation
of the great toes.

Sometimes a knee and foot, or the knees alone, present,
and, as they form a larger tumour than the feet, they may,
at first, be taken for the shoulder, or even the breech or
the head. Generally, only one knee presents, and it lies
obliquely, with its side on the os uteri. It is known by its
shape, and the flexure of the joint. Some advise that the
case should be left altogether to nature, but it is better to
bring down the knee or both feet, as may be most easily
accomplished.

ORDER THIRD.

When the shoulder or arm presents, the case has the
general character of preternatural representations. The
round tumour, formed by the head in natural labour, < is
absent, whilst we can ascertain the shape, and connexion,
of the arm and shoulder. A shoulder presentation, can
only be confounded, with that of the breech. But, in the
former case, the shape of the scapula, the ribs, the sharpness
of the shoulder joint, and the direction of the humerus,
together with our often feeling, in our examination, either
the hand or neck, will be distinguishing marks. In the
latter, the round shape, and greater firmness of the ischium,
the size of the thigh, its direction upwards, and its lying in
contact with the soft belly, the spine of the ilium, the parts
of generation, the ^ize of the tuberosity of the ischium, and
the general shape of the back parts of the pelvis, contribute,
with certainty, to ascertain the nature of the case.

The hand and arm may present under different circum-
stances. The original presentation, may have been that of
the shoulder, but the arm may have, in the course of the
labour, been expelled; or the hand may rest upon the oa
uteri, before the membranes have broken ; or the fore arm
may, for a length of time, lie across the os uteri, the hand
not being protruded for some hours. Sometimes, both hands
are felt at the os uteri, and even both arms may be expelled
into the ragina; but, in most cases, this does not happen,
unless an improper conduct be pursued. In some rare

417

Instaiices, the hands of twins hare been found presenting
together, both sets of membranes having given wav ; it is
more common to find both the hands and feet of the same
child presenting ; and this, next to the presentation of the
feet alone, is the easiest case to manage** It is not uncom*
mon, in this case, to find the cord presenting at the same
time, and then, by delay the child may be lost.

In most cases where the superior extremities present, the
feet of the child are found in the forepart of the uterus,
toward the navel of the mother. But their situation may be
known by examining the presentation. If we feel the shoulder,
we know, that if the scapula be felt toward the sacrum, the
feet will be found toward the belly. If the arm be protruded
into the vagina, the palm of the nand is found, in supination,
directed toward the side where the feet lie. It is easv to
know which hand presents. If we examine with the right
hand, we shall find, that if the palm of the child's hand, be
laid upon our palm, the thumb of the right hand, or the little
finger of the left hand, will correspond to our thumb.

In these preternatural presentations, the ancients were
ftcqusdnted with the practice of turning, and delivering the
bhUd by the feet.t But their remarks on this subject formed
no general rule of conduct; on the contraryi practitioners
were almost invariably in the habit of endeavouring to remove
the presentation, and to bring the head to the os uteri.
Par£ was among the firsts who advised turning as a general
practice; but even his pupil Guillimeau disregarded the
rule, and left it to Mauriceau to enforce it both by reasoning
and practice^ Franco dso was an advocate n>r turning*
There may, however, be cases, where it would not only be
safe, but also more proper, to resort to the old practice,

• If tbe uterug be firmly oontrafited, the liqaor amnii harinr liaen all evaea*
ated, it may ■ometimes be neceittary to carry the hand up to the knees, before we
can change the sitnation.

t ^^^7 *'» ^^^> ^y ehanging the posture of the patient to alter the poeitioa
of the child. Mr. Buchanan of Hull, ioformi me, that he succeeded, in one
instanoe ktel^, where « the left side of the breast of the fatus lay diagonally over
the pelvis, with the head forward," in bringing the head right, by making tht
patient kneel and raise the breech, whilst tbe shoulders were brought as low as
possible. The water had not been discharged, llie situation of the head, when
• ^?* down, was made more fayourable by the finger. The child was alive. It

r^!!t P'^P^*'^ ^ <^^t^ t^« position by external manipulation.

t Mauriceau Justly obsenree, that although, after much fatigue^ (the water
naving run off,) the head can be brought to the os uteri, the woman may not
have strength to finish the delivery.— In a case mentioned by Dr. Smeliie, the
patient died of flooding— Joerg still admits tbe propriety of bringing the hcad«
when it is nearer than the feet, to tbe os uteri, or the foetus is so placed, that the
feet cannot, without difficulty and danger, be brought down.

416

altfaeugh asT a general rale it ought to be abandoned. For

lastance, if the patioit be ksowB uauallj to ba^e a short

[. labour, if the pains be lurisk, the os i^ri dilatol, or ia a

relaxed and easily dilatable state, the liqucM* attmii retained^
and the child moveaUe, then, the head may, without mmf
difficulty, or suu^ imtatioii, be -placed in the prop^f positk%
with a fair aud reasonable chance of success. This I hmn
h^ to be a maxim in practice, and see so reason to alter it.
The labour, no doidit, is slower than if we had brou|^
down the feei;» but the child is in much less dagger, wai
this I hold to be the great induoemeat to retam, m fayoiir«
aUe eases, to an €»Id practice. On the other hand, if the
$quor anmii ha¥e been evacuated, or any irritation attaid the
rectification of the presentation, it is bel^^ at once to brinf
down the feet, aad ensure a ddiveiy, safe at least to the
mother. Were the head in such a caee made to presem^
the irritation produced, might throw the uterus into spasmodic
action, or it might not act with any ^ciency, and a tedioM
labour, of the worst and most dangerous kind, might be thQ
censequeaee of this injadicions jpraetice, whereby both
parent and child might be lost. Dr. Hunt^ proposed ta
posh up the shoulder, and make the breech present, but fhia
pr<H>06al has never been adopted.

We should be eyeful, in all cases, not to rapture tbt
membranes prematurely; and, more e&etually to preserve
them entire, we must prerent exertion, or mn<^ motion, oft
the part of the mother. As soon as the os uteri is soft, and
easily dilatable, the haad dhonld be introduced slowly into
the vagina, the os uteri gently dilated, and the membranes
ruptur^.* The hand is then to be immediately carried into
the uterus, and, if we have decided on turning, upwards until
t^e feet be found. Both feet are to be grasped betwixt our
fingers, and brought down into the vagina, taking care that
the toes be turned to the back of the mother. The remaini^
Steps have been already described. This operation is not
very painful to the mother ; it is easily accomplished by the
accoucheur, and it is not more hazardous to the child, than aa
original presentation of the feet. But it is necessary, in order
to render these assertions correct, that the operation be under-
taken, before the liquor anmii be evacuated; and it is of

* Dr. Hamiltoa mji, h» Lai mnBC%tAed in tarning the ehild, widiMt opwina
ilMiaembnoe% by paihlss Uek part^ ■iiccetilTely> wUh tht hind ■€>>»! thvMigli

them.

41»

importanee to fix upon a proper time. We are not to attempt
die introduction of the haiid, whilst the os uteri is hard and
nndilated; this is an axiom in practice; on the other hand
we are not to delay until the os uteri be dilated so much, as
to be apparently sufficient for the passage of a bulky body*
b the cases now under consideration, the os uteri does not
dilate so regularly, and to so great a degree, before the
membranes break, as when the head presents. If we wait in
fids expectation, the membranes may give way before we be
aware. If the os uteri be dilated to the size of half a crown,
thin and lax, the delivery ought not to be delayed, for every
pain endangers the rupture of the membranes. If they do
give way, we are immediately to introduce the hand, and
shall still find the operation easy, for the whole of the water
is not discharged at once, nor does the uterus immediately
embrace the child closely. If the liquor amnii have been
discharged in considerable quantity, previous to labour, or, if
* the membranes have burst, at the commencement of it, when
the OS uteri is firm and small, we must, by a recumbent
posture, try still to presage aportion of the waters, liH the
orifice win permit delivery. The introduction of the hand
into the vagina and os uteri may be rendered easier, and leas
painful, by previously dipping it in oil or linseed tea, or any
other lubricating substance* Oil may also be injected into
&e vagina.

But if the water have been long evacuated, then the fibres
of the uterus, contract strongly on the child, the presenta-
tion is forced firmly down, and the whole body is compressed
80 much, that the arculation in the cord frequently is impeded,
amd, if the labour be protracted, the child may be killed.
This is a very troublesome case, and requires great caution.
If the pains be frequent, and the contraction strong, then all
attempts to introduce the hand, and turn the child, must not
only produce great agony, but if obstinately persisted in, may
tear the uterus from the vagina, or lacerate its cervix or
body. No intelligent man, &erefore, would think of turn-
ing, mider these circumstances. After a delay of some hours,
however, the uterus may be less violent, in its action, but, as
laceration or other evils may, in the meantime, occur, it is
wrong to wait, or trust to thisv Copious blood-letting,
certainly, has a power in many cases of rendering turning
easy, but it impairs the strength, and often retards the re-
covery. If the patient be restless and feverish, it may, to a
certain extent, be necessary and proper ; but if not, we shall

420

generally succeed, by giving a powerful dose of tincture of
opium, not less than sixty or eighty drops.* Previous to this,
if necessary, a clyster is to be given, and if the urine be not
voided, the catheter is to be introduced, lest the bladder
should he injured during the operation* The patient is then
to be left, if possible, to rest. Sometimes in naif an hour,
but almost always within two hours after the anodyne has
been taken, the pains become so far suspended, as to render
the operation sate, and perhaps easy. But it must not be
forgotten, that the effect of the opiate is merely to suspend
the forcing pains, not to prevent the action of the uterus, if
it be excited. We must, therefore, speedily and steadily,
but not hurriedly, take advantage or the uterus having
ceased to press down strongly the presentation, and endeav-
our to slip the hand beyond it^ before strong action be
again excited. Our first object being to get the hand into
the uterus, we must raise up the shoulder a little, working
the fingers past it, by cautious and steady efforts, quicker or
slower, according to the degree of contraction and resistance.
The cervix often contracts spasmodically round the presen-
tation, and is the chief obstacle to the delivery, but the
opiate generally allays this;t and we are not to be in too
great a hurry, nor use violence to overcome this. I believe
'tixst slow efforts, after the use of opium, shall always prove
successful. These efforts generally renew the pains, which,
^though they mav not prevent the operation, yet make it
more painful, and cramp and benumb the hand. Having
passed the hand beyond the cervix, we carry it on, betwixt
the body of the child, and the surface of the uterus, which
is felt hard and smooth, from the tonic or permanent action
of the fibres, until we reach the feet, both of which, if near
each other, we seize ; but if we cannot easily bring both,
one is to be brought down into the vagina, and retained
there. The child will be bom, with the other folded up on
the belly. We may even, sometimes, find it necessary to be
satisfied by bringing down one knee. Indeed, it has been
proposed by Velpeau and others, uniformly to prefer the
knee to the feet. It is, generally, if not always, easier, when
the uterus is contracted, to bring down one knee or foot,
than both at once; it is less painful to the mother, and

* Dr. Collins advises tartar emetic 1 htTS fortiiDately no experience of its
effects in sucli cases.

t The spasm may yield rather suddenly to the band, as if rupture of the fibres
had talccn place. 1 was informed of one case of this kind, but the womb ims
entire, and no bad symptoms appeared.

421

presses less *on the uterus. In bringing down the feet, ad
veil as in carrying up the hand, we must not act during a
pain, but should keep the hand flat on the child, for ^
contrary practice may lacerate the uterus. It is sometimes
very difficult, even adfter the feet are found, to bring down
the breech. This is the case when there is strong spas-
modic contraction. Before introducing the hand, we must
ascertain, by examining the presentation, which way the feet
lie, that we may proceed durectly to the proper place. If
tiie child be placed with its bacK to the mother's front, we
have been advised to use the ri^ht hand, and very properly
to carry it to the posterior part of the uterus. The position
is known bv examining the scapula or clavicle, or, if the arm
protrude, the back of the hand in supination corresponds to
the feet of the child. K the palm of the hand be directed
to the front, we are to expect the feet, in the forepart of the
uterus, and have been desired to use the left hand; but
much must depend on the dexterity of the operator, and the
position of the patient. The position of the patient is usually
the same as in natural labour. But sometimes we may find it
useful to make her lie forward on the side of the bed, with
her feet on the ground, and to place ourselves behind her^
If we should in any case, from spasm or other causes, find it
Very difficult to turn the child, we must consider how far it is
practicable to make the head present and use the forceps, if
spasm still prevent delivery.

When the hand and arm have been protruded, and the
shoulder forced down in the vagina, it has been the practice
with many, before attempting to turn, 'to return the arm
again within the uterus ; and when this was impracticable, it
has been torn or cut off, especially, if the child were supposed
to be dead, but children have been bom alive, in this mutil-
ated state. Others advise, that we should not attempt ta
reduce the arm; nay, even say, that in difficult cases we
shall facilitate the operation, by bringing down the other
arm, in order to change, to a certain degree, the position of
the child. So far from it being necessary to replace the.
arm, we may sometimes find advantage from taking hold of
it with one nand, whilst we introduce the other along it ; aa
the parts are thus a littie stretched, and it serves as a direc-
tor along which we slip into the uterus.

By the means pointed out, and by a steady, patient
conduct, we may, in almost every instance, succeed in deliv-
ering the child. But it must be acknowledged, that, in

422

some caaes, firom iie«)eci^or misnaaigeHieBty tiie ^obma if
brought into great dsnger, or may evoa be allowed to £b
unddiyered« This calastarophe proceeds aonietiines firom
mere exbaustiony or from mflammatiop, but c^ner, I
apprehend, from rupture of Ae uterus; in^, in a negleeied
case, so much irritation may be given to the system^ as well
as to the parts concerned in parturition, that, although the
d^very be easily accomj^hed^ the woman does not reoo?v»
but dies, either from puuiomc or abdominal inflammation, oc
fever, or flooding. Moreover, such tedious cases, genenJly,
wd un£BtvouraUy for the child*

When turning has not been practicable, if the child were
supposed to be alive, the os uteri has been cut, or the Cesa«
rean operation has been proposed and practised.* If dead«
it has been extracted, by pulling down the breech with a
«*otdiet;t iuul sometimes, in order to aasbt delivery, the
body has been mutilated 4 or the head opened with the

Cforator. This ought always to be done, when, on the eoe
id, the presentation cannot be raised to admit of tttmiqg;
and en the other, there is no appearance of the process
immediately to be described, under the name of spontaneous
evohition, taking place.

When the child has been small or premature, it has hap*
pened that the arm and shoulder have been forced out of
the vagina, and then, by pulling die arm, the delivery has
been accomplished.§ In other cases, the child has beeai
expelled double. There have been many instances, where a
spontaneous evolutioni or doubling of ute child has taken
place, and the breech has been expelled first. The action of
the uterus is exerted in the direction of its long axis, and
therefore tends to push its contents through the os utcrL
The child forms an ellipse ; and either in natural labour, or
presentation of the breech, the long axis of the ellqtse corre-
sponds to the long axis of the uterus. But, in a shoulder
presentation, the axis of the ellipse lies obliquely with regard

* Vide Memoir by M. Bauddocqnc^ in ReeoeU Period. Toid. ▼• takk k eaiM
6 and 12.

t IVn, in Olio tu» wkere both amw were protruded, applied a SBel over Hkm

breech to bring it down. Pratlqne, p. 412 Smellle, in 1722, broagbt dowm

the lireeok witJi the crotchet. Co). 86. case d.— Giflard did the eame In 172&
Case S»

t Vide Perfect, Vol. i. p. S51.-.Dr. J. Ha»Uton*s caaee, p. IM. He fomd
it necesaary to separate three of the Tertebr«. — Dr. Clarice twisted off the arm*
and pcrforntcd the thorax flreely. At the end of S6 hours, the fertut was ezpeUed
double. AJed. and Phys. Jour. Vol. viii. p. S9i.

S Glffard, case 21 1 ; and Bandelocque L^i\rt, § I5S0, in a note.~In Mr. Gar-
•^liicr'i €M% the bend foUowvd the ihouldcra Med. CoaDmem. Tom. t. p. ;

telbi ef «ke vtaRB, « to the daeclkM aT Aft fvM;
iherefbm te cpalhwiei adMn «f flra nterat tomj tatd^ l)v
iyiriiting 0ft Urn ndb of tke cUqpae, to dmEcai tke upper end^
aad Smrsb it gradMdlj intp the peMk This eireot can ontjr
W hoped Sir» wheft the AmMar is fvced knr, lad pressed
fmrmrnrA i^ieiiist tbe pehris, es a fixed cr rcsisliiig pointy
SBewid lAitk, to a iniiked eitesk^ it rerolTW^ tlw tmak
^Mfviiig^ nore and more^ the lalero-posterior part of the
tlKwaa eonm^ into ylew» tiilk, at last, de nteraa force the
1n«ech dowB on Ae perinsBun. The uteras mist contnel
eficientty, not qpaamodieallj.

This «fQlatio% was first of all notioed» I betieve, 1^'
fidbflBsheidK ;* hiit Dc Deamanf was the first who, hi Ais
coantffjy eaUed the attenticm of {nractiiioiiers to it« He eok
beted no less than thirty cases, bat, in tliese^ only one child
pas horn aliye. The last stage is generally n^id. In Dr^
DesflMat's third case, be vagndy s^s, ^^the exertions of Urn
aK>ther were wondarfnlly strong. I sat down, whilst she
had two puns, I^ the latter of whieh the duld was doubled,
aai tiie hnd expelled.'* When tbe hreech gets into the
WTity of the pdvis, expnlaion is speedily ceaij^ebed. It does
not appear that the chihi hting large^ is an insuperdbita
ebstade to the deliTery4

A diprersit^ of epinion has prenuled, as to ifhe mode in
which expdnon taxes place. Dr. Deaman s^f^sed, that
the lower extreanties descended daring a pain, and made
reom for die npper, which ascended as Ae others camte down,
tSl, the body tsrnti^ rosnd on its axis, the breech was ex?
MUed, ^*^ in ma original presentation of that part.'* Dr«
&eUy agrees with Dr. Denniaa, as to the existence of an
adtual reyohztion, or taming of the child, but differs from him,
in maintaining tliat the original presentation can ozdy recede^
«ot during the action of the nt^us, but during its relaxation.
The breech, or iroper end of the ellipse, he supposes, is
pressed down by tne action of the nterns, and then, by the
olaBticity of ihe diild, tiie shoulder, or presentmg part, goes
fqp tfie moment the uterus relaxes.

This explanatioQ was dispated by Dr. Douglas, who main*
iaiaed diat it was impoanble, for the vrftper extremities to

; • Acta Hmm. T««i. SL art

f J^J^- Med. Jour. VoL v. p. 64.— See alio case by Mr. Ontwalt, la Kaw
IxHid. Med. Joar. Vrf. ii. p. ITS — Mr. Simmom, Med. FacU and Otia. Vol. I.
». 76.— Pcrleet** caaca. ii. 967.— Med. wid Phya. Jown. Val. Si p. S.— Mcdioo-
Chirurgical Review, Vol. I. 2d. seriea. ^ «c«w.

\ t Mr, Hay'a otm, la Lm^. Med. Jour. Vol. v. p. 805,

424

inount tip, into the contractiiig uterus ; that therefore no part
of the cmld, which once protruded, ever receded ; and, con«
sequently, the process is not that of spontaneous turning, but
that of expelling the child double. According to him, the
shoulder is forced lower by strong pains ; the clayicle lies
under the arch of the pubis ; the ribs press out the perinasuniy
and then appear at the orifice of the vagina. As the expul-
sion goes on, the clavicle is found on the pubis, and the
acromion rises to the top of the vulva. Presently, the arm,
shoulder, and one side of the chest are protruded, and the
breech has got into the hollow of the sacrum. By farther
efforts, the breech and extremities are expelled, but neither
the arm nor the shoulder ever retire.^ Dr. Gooch gives the
same account, in the 6th Vol. of the Medical Transactions.

I offer in addition the following remarks* When the
shoulder is forced so low, as to protrude at the arch of the
pubis, the head is laid on the iluic fossa, and the breech is
over, but yet not so low, as to rest on, the opposite fossa, at
the sacro-uiac junction, and the trunk, at the end of the thorax,
is at the brim. A continuance of the expulsive force, makes
the side present, at the orifice of the vagina, and the breech, at
this time, is entering the brim of the pelvis. The head still
remains in its former position. The breech then descends
lower, by the sacro-sciatic notch, and sweeping down from
a side, it distends greatly, the perinaeum. It then turns for-
ward, and is bom as in a common breech presentation, only,
the arm and side are, at the same time, protruding at the
pubis. In this process, the child must be very much curved,
but if the action of the uterus be strong, and laceration do
not take place, this bending may be accomplished to a suffi-
cient degree. A line drawn from the side of the neck, to the
end of the thorax, which is at the brim of the pelvis, when
the shoulder is at Ihe orifice of the vagina, is 4| inches. The
difficulty is to get down the body, from this point to the breech.
The line from the upper and lateral part of the neck, to the
breech, or upper part of the sacrum, is 5^ inches. This is the
greatest length ot the substance which is to pass. Sometimes
the distance is barely 5 inches, and I doubt not that contin-
ued force may make it less. From the arch of the pubis to
the brim, at the sacro-iliac junction, is 5 inches, and from the
same part, diagonally, to the sacro-sciatic ligament, at the
sacrum is fully 5. It appears, then, that although, at first, we
are not prepared to admit, the accommodation of the child, to
the passage, yet, in reality, there is no physical impossibility of

425

H child, at the full time, passing, in this way, through the pelvis,,
and that, if no interruption be, artificially given to the process,
it may be effected, if the uterine action' be strong and contin-
ued, the breech once brought within the sphere of action, so
as to be pressed down, and the uterus stand out, without lace-
ration.. At an earlier period of gestation the difficulty is less»
In the seventh month, the distance from the shoulder to the
breech, if the child be stiff, is little more than 3^. K the
back be very pliant, it is barely so much.

A knowledge of this fact does not in the slightest degree
exonerate us from making attempts to turn, when this can be
aafely done, the uterus not acting powerfully, in resisting our
efforts; for, although a considerable number of cases are
recorded, where it has taken place, yet these are few, in pro*
portion to the number of presentations of the shoulder. In
ihi^T city, estimated to contain about 244,000 inhabitants, I
cannot learn that more than three cases of spontaneous evolu-
tion have taken place, though some women have either died
imdelivered, or have not been delivered, until it was too late
to save them.*

By opening the thorax at the back or latero-posterior part,
and then dividing the spine, we can bend the body muchmore^
and bring down the breech more readily. The abdomen, if
necessary, can be opened, and the contents, both of it and the
thorax sufficiently removed, to make the body more pliable.
Some decapitate the child, by an instrument which cuts
through the neck, and then with the crotchet bring down the
trunk, leaving the head to be afterwards brought away by a
book inserted into the mouth or foramen magnum; but the
opening I have described is easily made, and allows the crotchet
to be introduced, and fixed on the pelvis, so as to bring it
down* Should however we be in any case unable to effect
this, then we must adopt the other plan. Dr. Hamilton takes
the strong* ground, from his own extensive experience, that
lieither operation can be required if opiates be given.

Sometimes the arm presents along with the head, and this
can only render delivery tedious or difficult, by encroaching
on the dimensions of the pelvis. This case does not require
turning; but we should return the arm beyond the head, and

' * In the report of Midwifery CMea in the kingdom of Wurtemberg, it it nien-
tloDcd that ten caaee of tpontancoua evolution occurred. Moot frequently the
breech or feet came out first. In two caeet after the arm bad inued it retired
and the breech came down. In two othere the feet came. In one the presenta-
tion of the head was changed for a transverse position which made it necessary to
cztrafit by the feeU

49M>

eren retain it Aere till a pahi eamt on, anSL tme ike iMni
down, 80 «a to prevent tlie hmd fiom ngain a]ipeanw« i^
from the d^ree to wUch llie kead liad defleenoed, before im
were called, we find it impractieable to pash up the arm;
we may racceed, in bringing it to a place, wbere it will not
interfere, mnch, with the passage of ibe head» In a eaas^
most probably, at tiie first, of thiBde9Griplion,tliearmhadpro^
tnided, as in an ordinary presentation of the upper extremity,
and the shoulder had descended as low, as the os eztemou
Mr. Wansborrow, carrjring his finger from the presentation^
along by the carve of the sacrum, felt the dnn of Ae diSd^
Ae £bu» presenting within the pelvis, and Ae ooriput re*
fleeted agiunst the Tertebrs of Ae child. Very strong pains
kad no dfeet in propelling tiie child; but ddivery was ended
by means of die long forceps.*

Sometimes tibe head is placed pretty high, being retained
by a spasmodic contraction, of a band of fibres round it, and
the arm is the only presentation, which can be fdit, untfl the
band be introduced. Opiates, in this ease, may be of serfiee^
We must never attempt by force alone, to destroy the strie-
tnre, in order eithor to return tiie arm, or bring down the
bead*

Occasionally, both a hand and the feet, have been feund
presenting with the head, or tiie feet and head present. In
such cases, we can, if necessary, bring down the feet alto-
gether, but whea it can be done, it is safer for the child, to
ynsh the foot beyond tiie head, and make it eater the pdvis
alone, as in natund labour.

Besides these presentations, we may meet widi the badk
part of tiie neck, and the upper part ot the shoulder; or tiM
nape of the neck alone ; or the throat. Tliese, winch are veiy
rare, require turning. They are recognised, by their rdlation
to the head and shoulders.

All preternatural are more dangerous than natural pre^
sentations, both to mother and child. But Dr. Cdlins svra^
that in shoulder cases none of tiie children died from tne
efl^Kts of ddiv^. Twenty children, out of tiiirty-titfe^
turned, were bom alive. Four, out of forty mothers died.

ORDER FOURTH.

The hips, back, belly, breast, or sides, may, tiiougfa veiy
rarely, present, the child lying more or less transvendy.

• Med. Repotitory, VoU xlU. p. 8.

body

427

ThftUf^ is MOMtioieB taken fur the keftdi»* often perbaps £or
Aeekonbier^biitieto bediatiiigiiishedyby theabapeMidreu^cHtt
«f tbe ilnua* In ell the othor ceeee, tibe presentetion remeine
lai^ Ugli, iHit when the finger can reaeb it, the preciae part
be nseertamed^ by one who is accwetomed to fed &t
\y dTa child. If liie child lie txanaversely, it may remain
long in the name poidtion, and the woman may die, if it be
not tttmed. But ii^ as is more frequently the case, it be
placed more or less obliquely, then, if the pains ccmtinne
effeotiTe and regular, eitfaer the breech or the shoulder, .will be
brought ta the ^s uteri, aceording as the original positioi^
Cftvoured the descent of one, or other end of the ellipae, formed
by the child. In these presentations, the hand shonld be
introdnoedt to find the feet, by which the child is to be
delivered. But this rule is not absolute, with regard to tbe
preaentatioa of the hip^ which only renders labour

OBDER FIFTH.

The cbild may present the head, and yet it may be i
properly situated, and give rise to painful and tedious labour.
The uterus, even when a slight obstacle is opposed^ as in some
stages of these presentations, frequently does not, as it were^

St forth its strength, but the pains ranttn trifling, and are
t by the patient to be inefficient. K the presentation be
lectifittd, the puns ohm, become speedily effectiTe ; if it be
mot, thqr are at last excited, but imn not till after the. h^ae
of several hours.

The vertex ought, naturally , to be directed at first to the left
aoptabiilum, or foramen thyroidenm, but it may also be turn-
ed to the right. This, it may be thought, can make little or
BO difference, yet, in general, the labour is more tedious. The
great gat, turns down, at the left sacro-iliac articulation, and
may so influence the forehead, as to make the head enter less
isLvourably. I am so sat»^ed of this, that if tbe head be easily
moyedy and H could, without trouble be done, I think it jus-
tifiable to press it to the opposite direction, at least if the
patient be known to have, in general, a slow labour. If we
do not interfere, it is {Hroper that she be placed on the right,
mstead of the left side.

Among the more marked deviations I notice, 1. The f(M*e-
head, instead of the vertex, may be turned to tbe left ace*
tabuhun. This presentation, it has been calculated, occurs

« La Motto was of opinion tbat no part rewmbkd the head more than the
lip^ ¥idtOW.S8SaiHr^Si.

428

more frequently than the last noticed, and in proportion
to the natural position, as 1 to 2^, but this I do not think
correct. We should naturally expect^ that, in this position, the
occiput should turn into the hollow of the sacrum. This un-
doubtedly does sometimes take place, but I am satisfied with
Naegele, that the reyerse — which Baudelocque, §. 701, says,
is a rare occurrence — is really the most frequent, and I find it
more difficult, for a large head to turn with the occiput into
the hollow of the sacrum, than forward like a natural presen*
tation. The head is found, at first, with the forehead mrected
to the left acetabulum. After some time, the vertex descends
a little lower, so that the heibd comes down a little more
obliquely, than it was placed at first, and we feel more easily
the posteridr fontanelle. But the part which we touch, most
readily, at an early stage, as the presentation, is the upper and
posterior part of the left frontal, or the upper and forepart
of the left parietal bone, accordmg as the head has turned
more or less round. Then, as the labour adrances, the parietal
protuberance comes more round, and is better felt, and ulti-
mately it, or the vertex, turns out from the vagina, as in a
natural laboiur, but the face of the child, is laid by the side of
the left thigh. On examining the steps of this revolution, we
find, that, by the uterine efforts, the vertex is acted on, by the
inclined plane of the right ischium, behind the acetabulum,
and thus, the left parietu protuberance is brought nearer the
pubis. A continuation of the force, makes the posterior part
of the left parietal bone glide forward, first along the inchned
plane of the right ischium, then on the obturator intemus,
then, it and the occiput, move along the rijriit ramus of the
pubis. The posterior and lateral parts of the left frontal
bone glide, at the same time, obliquely backward, across the
plane of the left ischium, toward the spine of that bone, so
that the head is ultimately turned into the direction assumed,
when the vertex is placed to the right, instead of the leffc
side. If, however, the reverse of all this should take place,
the vertex turning to the sacrumi it must glide backward on
the sacro*8ciatic ligament.

As this presentation, whichever way the head turn, is gen*
erally productive of a labour, more tedious than the natural
one, we should co-operate, in the acceleration of the process
of turning the head. K it be discovered early, it is certainly
proper to rupture the membranes, and turn the vertex round,
which is easily accomplished. If this opportunitjr be lost,
we may still giye efficient assistance, by mtroducing either

429

one or two fingers, between the left side of the head, near the
coronal suture, or the temple, and the symphysis of the pubis,
and pressing steadily, during a pain, agamst the frontal, or
parietal bone. SmeUie knew the benefit of this, and the late
Dr. Clark says, that in thirteen, out of fourteen of these pre-
sentations, he was successful in this practice. Even in those
cases, where the head seems rather to be turning, with the
vertex toward the sacrum, I have, although it had descended
so low as to have the nose on a line with the arch of the pubis,
succeeded in turning the face round to the hollow of the
sacrum, with great promptitude, and with so much facility,
that the patient did not know that I was doing more, than
making an ordinary examination. We should keep up the
forehead during a pain, by means of two fingers introduced
into the vagina, or press it up gently, during the absence of
pain, to make the vertex descend. It has been advised that
we should, with the finger, depress the occiput, but this is
more difficult to be done*

2d, The fontonelle, or crown of the head, may also present,
although the face be turned to the sacro-iliac junction. In
this case it is felt early, and, by tracing the coronal suture,
we may ascertain whether the frontal bones lie before or
behind. The labour is necessarily slower, than in a natural
presentation, but, by degrees, the head becomes more oblique,
the vertex descenmng. This should be promoted by sup-
porting the forehead during a pain, or pressing it uj[ during
the remission, and preserving the ground we have gained, by
steady support wiUi the finger, when the uterus acts. It
may even, in some instances, be necessary to introduce the
hand, and alter the position. The rectification, however
effected, usually renders the pains efficient, although before*
they had been teasing the patient, rather than making any
impression. Should any untoward accident, require the de-
livery to be accelerated, we have been advised to turn the
child, and in doing so, to use the left hand, if the occiput lie
on the left acetabulum, and vice versa. But this operation
can seldom be requisite.

• 3d, The crown of the head may also present, with the face
toward the pubis or the sacrum. It has been admitted by
Baudelocque, and other authorities, that the long diameter
of the head, may correspond to the conjugate one of the pel*
vis, but this has with good reason been denied. On examina-
tion, it will be found, that such supposed cases, which are rare,
are merely less diagonal, the vertex, for example, being to

430

the flkle of tfae symphysis pufaiB. In time, the head w3I
generally become mare diagonal, and descend ofafi^i^y but
we ought not to trust to diis. We should rectify tfae portion,
fisr it is by no means difficult to moTC the head, wtth €ke
&iger, if we attempt it earij. We can even carry tiie foi^*
head, from tfae pubw, to die sacro-iliac junctton. The proccaa
is still more simple, when the occiput is turned to the pnfais^
if we perform it cauiy. I^ however, we neglect it, we ftod
that, in a few instances, the head enters the pelris, in the
original unfaTOurable direction, where it soon stops, reqioring
the use of instruments. For, a moderate xesistance ofteo
curbs the action of the uterus, which every one must have
ae^i become suddenly brisk, when that was removed.

4th, The side of the head may present, but this is ao rare
that it has been deemed impossiUe. In this case^ the
presentation is long of being fUt, but it is recogmsed by die
ear. If, however, it have beat long pressed in the petvis, it in
extremely difficult to determine the case. In some instances^
the chBd has been turned, but it is better to rectify the
position of the head, by introducing the hand.

5di, The occiput may present, the triangular part of the
bone being felt at die as uteri. It is known by its shapes hy
the hmbdoidal suture, and its vicinity to the neck. Tee
forehead rests on the margin of one of the peoie muadea,.
and, from this oblique position of the head, the kdmur ia
tedkras. * It has been proposed, to turn ; but here also, it is
better to rectify the position of the head with the haadl, faj
raising the occiput a little* Nature is, however, adequate to
the delivery, even if not assisted. Some advise^ that the
woman should, by a change of position, endeavour to remedj
the obfiquity, making the child indine, so as to affeet the
situation of the head, but this has not much power in altering'
the position of tfae presentation, at least after the water has
been evacuated.

6th, When the fisice presents, the chin is generally turned
to one of the acetabula, more frequently to the right, than toi
the left ; and the forehead, which is usually a litde knrer ibmt
the chin, is directed toward die opposite sacro-iliac articula-
tion. At the very commencement of labour, we <^ten feel first
the forehead ; hence La Motte tells us, that although at first
be thought the presentation to be natural, yet, when the
membranes broke, the face came down. Soon, tfae upp<nr pari
of the right cheek, somewhere between the zygoma and aide
of the nose, presents at the os uteri. By a continuatioo of

431

die uterine forte, tiie head descends, with the forehead still
leweaL The cliin gradually turns forward, whilst the cranium
IB the same proportkm, moyes into the hollow of the sacrum^
•nd the presenting part is a lower portion of the cheek. The
chin finalljr turns quite round to the pubis, and passes out,
nader the arch, which then embraces the throat, whilst the
perinaenm ^ides bads over the skull. When the chin 19
emniiig out, from under the arch, the sagittal suture, is in
the hollow of the sacrum, its anterior extremity near the
frontal bone, beiog on the last bone of the sacrom, or the
first o{ the eooeyx. From the diin to the top of the forehead,
where the hair hepnt^ measures from 3| to 3^ inches ; from
^ diin to the mUldle of si^ttal suture 4^ ; to the end 4| t
ia large heeds, to the extremity of the yertex 5* From the
foot of the neck, near the sternum, to the vertex, when the
head is bent hade, is full 4|* Comparing these dinieBsionay
viiii the capacity oi the pelvis, we see ikat there is space fat
the head to pass, though not so eamly, as when it presenta
naturally. But the finmess of the bones of the foce, which
do not really yield, the shape of the presenting part, the
unfavoiirable way in which the head passes through the
pelvis, the width of the skull between the parietal protuberan*
ees, which is sometimes near four inches, and is sot so easily
or quickly forced down, after the tedious descent of the face,
all conspire to prolong labour. At the same time it is tme,
that thore are mstances, where the process is not unusaajly

The £M)e is recognised by the features, particularly the

se and mouth, but, by a continuance of the bibour, the parts

become swollen, and more indistinct, so that it has oeeo
taken, either for a natural presentation, or the breech.
: By rude examination, die features may be injured, or evasi
Ae skin may be torn ; aad, even under the best management,
the frieef when bmn, is very unseemly, and sometimes quite
Uadc and doagated, so that it has been known to measur€i
nearty seven ioclies* TMs is especially the case, when the
dun turns to the sacrum. Some children die from obstructed
eireulation, owiufir to the continnal pressure on the jugular

Face presentations, have been attributed, sometimes U»
cenvuhdve vomiting, cough, or frequent examination, but
gtMniMy no evident cause can be assigned.

In face presentations, some have advised that the child
flhould be tuned, and this is prraer, if, the membranes being

432

dtill entire^'any circumstance on the part of the mother, reil*
der it desirable, that the labour should be soon completed, at
the same time, that the pelvis is ample, and we expect an easy
delivery of the head, to follow that of the body. But if there
be no urgency, from weakness, or any other state of the
mother, or of the pains, it will be better, merely, to rectify the
position of the head itself, by raising the forehead, turning
the vertex obliquely down, and directing it to the left aceta*
bulum* If the labour have been farther advanced, so that the
head hav^ entered more into the pelvis, and the water have
been evacuated, we shall find it (ufficult to accomplish the
change completely, and may be satisfied by endeavouring to
depress the vertex with the finger, at the same time that we^
sometimes, take the assistance of the thumb in pressing up the
forehead* Some, improperly I think, use a lever, for depress*
ing the vertex. Others consider all interference in the early
9\XLge to be injudicious. If the face be more jammed in the
pelvis, we must let it alone, till the chin turn forward to the
pubis ; then, by pressing it more forward, we aid the turn,
and when thb is accomplbhed, by depressing it we make it
more readily clear the arch. But if the head have descended,
and from tne size of the pelvis, or smallness of the child, or
power of the uterine action, the process be going on with
tolerable ease, we need not make any attempt to aid the
passage. As the perinseum in these cases, is much distended,
we must support it, and not hurry the issue of the head.

The face may also present, with the chin toward one of the
sacro-iliac articulations, and, in this case, it is supposed, that
the chin will, in the end of labour, turn to the sacrum, and
come out at the perineum. But it will often be found, that
the forehead moves obliquely backward, on the inclined plane
ef the ischium, and sacro-sciatic ligament, whilst the chin
comes forward, so that it, at last, comes out, as in the former
case, from under the arch of the pubis. But if it should move
backward, toward the coccyx, the case is ^Ufficult. It is
easier for the forehead to turn down, at the arch, than for the
chin to descend behind, and we find that it may move up
more, along the hollow of the sacrum, and in the same pro*

Sortion, the forehead revolves backward, and the vertex comes
own, and passes out under the arch. This will explain, how
face, have sometimes, ultimately, been converted into natural,
presentations. We shall also understand the treatment,
namely, when the -chin is disposed to turn forward to the
pubis, either to assbt it, or let it altogether alone, whilst if it

433

turn to the sacrum, and the labour be protracted, we press it
up, and endeavour to bring the vertex down.

There are other two varieties, of face presentations,
enumerated, namely, when the chin is directed, either to the
pubis or the sacrum, the long diameter of the face, corre*
sponding to the conjugate diameter of the pelvis. These
rarely exist at first, or otherwise than as the concluding
stage, of the two former presentations. If such a position be
found at an earlier period, it ought to be rectified, by con-
verting it, if possible, into a natural presentation ; if not, by
turning the forehead more to a side.*

ORDER SIXTH.

Sometimes the cord descends before, or along with, the
presenting part of the child. This has no influence on the
process of delivery, but it may have a fatal effect on the
child ; for, if the cord be strongly compressed, or compressed
for a length of time, the child shall die, as certainly as if
respiration were interrupted after birth. If the cord be
discovered presenting, before the membranes burst, or, if the
OS uteri be properly dilated when they burst, and the pelvis
be well formed, the safest practice, in so far as the child is
concerned, is to turn. But as this is more dangerous than
natural labour to the mother, it has been reprobated by many
excellent practitioners. I would decide, in my own practice^
in anv particular case, much by the facility with which I ex*
pected to accomplish turning, for it is not the mere pressure of
the hand on the uterus, nor its pressure on the os uteri, which
causes the danger, so much as efforts made, especially partial
efforts on particular spots, against the contraction or resis*
4ance of the uterus. By carrying up the cord beyond the
head, and endeavouring to have it so placed, as neither to be
compressed between the uterus and the child, nor to fall
down again, it has been thought that there was more safety
than by turning. But even U the hand be retained, till a
pain come on, and force the head a little lower, the cord may
partially descend. It has indeed been proposed, to push the
<5ord bevond the presenting part, or hook it upon one of the
limbs; but, if the hand is to be introduced so far, it is better
at once to turn the child.f If turning appear to be difficulty

* Dr. Rsmsbottoin, p. 8S0, givet a cue of thii k!Dd, whiob reqaired perfbm-
t!on. The forehead was to the pabis, bat the greater part of the head, waa abore
the brim.

t It hat been propoied to path back the cord, and then retain it with a tpoogoy

48i

from the eyaoQadon of tlie water and the hrigknags of tin
pais, we ought clBarlj to be satisfied witfa piulnBg up flie cord
beyoBd the presentation, or tliat part of the child which
would press on it in the peliris, or endeavour to place it in
ench a relation as diall, as far aa we can, prevent pressures
if the head have advanced so far as to enable us to use the
forceps, we should do so, unless the progress be rapid* If th«
OS uteri be not suffieiendy relaxed, we nmst not use fbroe t^
expand it, and little can be done, except by rest, to prevent
as much as possible, the evacuation of the water. If the

5 pulsation in the cord be stopped, and the foetal heart be
bund, by the stethoscope to have ceased to act, then labotur
may be allowed to go on, without paying any attention to the
eord. When the presentation is pretomatural, these dhrec--
tions are likewise to be attended to, and the practice is aim
to be regulated, by the general rules applicable to sudh
labours.

In Dr« Clark's praotioe in the Dublin Hospital, out of
66 cases, 17 children were bom alive. In Dr. Collins' caaest
out of 97, there were 24 bom alive. In several of die fatal
eases, die presentation was preternatural, or die child putrid*

OBDEB SEVENTH.

Various signs have been mentioned, whereby the presenoe
of a plurality of cUldrai in utero, might be discovered^
prei/ious to their delivery. These are, an unusual siae, or
an unequal distention of the abdomen, an uncommon modes
within the uterus, a very slow labour, or a second dischai^
of liquor amnii during parturition* The labour is often
more protracted, and the pains, if not more severe, at least
more teaainff than usual. These signs, however, are M
completely mUacious, that no reliance can be placed upott
tliem, nor can we generally determine the existence of twuut
until the first child be bom.* Then, by plaoing the hand on
die abdomen, the uterus is felt large,t ^ ^^ contain another
ehild ; and, by an examination per vaginami the second set of

tod tlie iiMtroiiMnl.B0ii9«n hxw In^raoied and dqUflM tantriwmainm for ttdi

purpoM. Some have even advised that tbe cord ihould be tied ! .Oaiasder, not

certalnlv a thcoristi proposes to lodge the cord in the midst of a sponge, and

replaeeit.

' * Tbe stethoscope has been need, to ascertain whether the soond of the heart be

heard in two places, or only In one.

f In a eaae related by Mr. Aitken, the ntcros waa felt, after delivery, lam
and hard, aa if it eontiOned another child, but none was discovered. In tfia
course of a fortnight the tumour gradually disappeared. Med. Commtpt* VoL
ii.p.S0a

436

meaaHnran&ikf or some part of Hie child, is found to priDsent*
This mode of inauiry is proper after every delivery**

Soon, goierally within a quarter of an hour^f after the
£rst child k bazn, pains come on, like those vhich throw
nff the placenta, hot more severe; and they have not the
dSect of expeUing it, for it is generally retained, till after the
delivery of the seoond child. No inthnation of the existence
icf another child, is to be given to the mother, but the practL*
tioner is quietly to make his ezammation, and ascertain the
presentation. If it be suek as require no alteration, and the
labQur of the first child, have not been tedious or severe, he
is to allow the labour to proceed, aocerding to the rules of
art, and usually the expulsioii is speedily aeoomplished. The
nost that is allowable, or necessary, in such a case^ is te
suptnre the membranes. Should, bowever, the birth of the
first child, have been protracted, and the uterus fifttigued, it
will be better at once, even in a natural presentation, to turn
the child, but by no means to hurry the delivery, but let it be
slow, and accomplished Inr the action of tiie uterus, till the
cord be in danger. If the ftrst child present the head, the
second generally presents the breech or feet, and vice versa;
but sometimes the first presents the arm, and, in that case,
when we turn, we must be careful dial; the feet of the same
child be iHrought down. This one being delivered, the hand
is to be again introduced, to seardi for the feet of the second
child, which are to be brought into the vagina, but the deUv-^
ery is not to be hurried.

It sometimes happens, that after the first child is bom, the
pains become suspended, and the seoond is not bom for
several hours, or evea days, nay, there have been instances,
authenticated, of weeks intervening. Now, this is aa uu*
pleasant state, both tor the patient and practitioner* She
must discover, that there is something unusual about her ; he
must be conscious, that haemorrhage, or some other dangerous
spnptom may supervene* The fi^t rule to be observed is,
iDBt the accoucheur is upon no account to leave his patient,
till she be delivered* The second, regards the time for
delivering. Some have advised that the case be entirely
left to the efforts of nature,^ whilst others recommend a

* In the Dublin HMpital, fnlly one half of the children were males.
' j* In the Dahlin Hospital, a greater number were delivered of the second
child, at the end of a quarter of an hour, than either before or after that, next to
that in Sto minutes, then half an hour, then ten minutes, then twent)% Four
women ont of 240, were ten hours.

i A case is mentioned in the bulletin de la Faculty for 1816^ p. a, ^rhere »

436

.speedy delivery. The safest practice, if the head present,
lies between the two opinions. If effectire pains do not
come on in a quarter of an hour, the uterine contraction
should be excited, by gently rubbing the abdominal tumour,
with the hand. If this do not efficiently excite the pains,
within an hour, and no circumstance forbid interference, the
second set of membranes should be ruptured, and the child
-delivered by turning, unless we feel the head descending in
the act of introducing the hand, or some other indication of
brisk action commencing. The forceps can seldom be
required, for, if the head have come so low as to admit of
their application, the delivery most likely shall be accom-
plished without assistance. If the second child present in
such a way, as that the feet are near the os uteri, as for
instance, the breech, or any part of the lower extremities,
then the feet are cautiously, but without delay, to be brought
down into the vagina, and the expulsion afterwards left, if
nothing forbid it, to nature.

If, however, the position of the second child be such as to
require turning, we are to lose no time, but introduce the
hand for that purpose, before the liquor amnii be evacuated,
or the uterus begin to act strongly on the child. Turning,
in such circumstances, is generally easy.

In the event of heemorrhage, convulsions, or other danger-
ous Sjrmptoms, supervening between the birth of the first and
second child, the delivery must be accelerated, whatever be
the presentation, and managed upon general principles.

when there are more children than two, the woman seldom
goes to the full time, and the children survive only a short
time. There is nothing peculiar in the management of such
labours.

It still remains to be observed, that we ought to be pecu-
*liarly careful, in conducting the expulsion of tne placentae of
twins. Owing to the distention of the uterus, and its con-
tinued action in expelling two children, there is a greater
than usual risk of uterine haemorrhage taking place. The
patient must be kept very quiet and cool, moderate pressure
should be made with the hand externally on the womb, or
gentle friction may be employed, and no forcible attempts
are to be permitted, for the extraction of the placentae, by
pulling the cords. If haemorrhage come on, then the hand is

•second child was born by nid of tbe foroem after the intenral of more than a day.
Wrre the forceps neeestary <n tbe fint oelirerjr ? On what priociple ean we
jttitifjr tttch a delay ?

437

to be introduced to excite the uterine action, and the two
placentae are to be extracted together* The application of
the bandage, and other subsequent arrangements, must be
conducted with caution, lest hsemorrhage be excited*

The phcentae are often connected, and therefore they are
naturally expelled together, but this adds nothing to the
difficulty of the process* Sometimes they are separate, and
the one is thrown off before the other ; or it may even happen,
that the placenta of the first child is expelled before the second
child be Dom, but this is very rare, and is not desirable*

Women, lyho have bom a plurality of children, are more
disposed than others to puerperal diseases, and must there-
fore be carefully watched* it rarely happens, that they are
able to nurse both children without injury*

It has happened that when the first child presented the
feet, and was so far delivered, the head of the second child
got down, into the pelvis, before that of the first, which
renuuned above it, and could not be extracted without great
difficulty* There can be little hope of the child being bom
alive, in this case, and as we are not able to push up the head
of the second child, it has been proposed to sever the bod^
of the protruded child, which woula permit the delivery^
either by nature, or the use of the forceps, of the second,
child, after which the head which had been severed could be
extracted* Mr* Allan, who has proposed the plan just
advised, has published a case, where botn heads were expelled
at once by a powerful pain.* . It has been said that both
heads have been found in the pelvis at once, and been ex*
pelled seriatim. In great difficulty, the perforator may be
used.

It is possible for two children to adhere, or for one child to
have some additional organ belonging to a second, as, for
example, an arm or a hecid* Such cases of monstrosity may
produce considerable difficulty in the delivery; and the
general principle of conduct must be, that, when the impedi-
ment is very great, and does not yield to such force as can
be safely exerted, by pulling that part which is protruded, a
separation must be made, generally of that part which is pro-
truded, and the child afterwards turned, if necessary .f Unless

* Vide Med. and Chir. Trant. Vol. xll. p. SS6, a ease by Dr. Cloogh in tb«
Med. and Phyi. Jour, and by Mr. Fryer, in Dabiin Med* Trane. E 148^ ili«
licad of the second child was bom first.

f In the aeventh Tolome of the Nout. Joumalt p» 164^ !• • ease where two
children were born at the fall time, united by the Inferior part of the belly, from
the centre of which came the cord* The rer tebral columiw ahuMt toacb«o »t th«

Ae' pelvis be greatly dbe&mHsd, ft vilL be praetiinble Iv
deliver, evea a double dnid, by anass ef perraralBOiL «f tbe
eavities, or such separaiioii as nay be. eaqpedient, and the «n
of the hand, fbroeps, or crofechei» aeooidiiig to drcuBosteiiQaB.
A great degree of defonnity may reader tiie CwwaTOan
operation necessary*

With respect to children wba are nonstroiis from deficit
ency of parts, I may take Ae present apportimity of observing^
that no difficulty can arise during t^ ddiveryy except in
ascertaining the presentation, if the malformation be to great
extent, as, for instance, in anephalons

CHAP. V.
OfTeOkmlahcfmr.

OKDER FIRST.

If the expulsive force of tlte utems be diminished, or the
resistance to the passage of the child be increased, the Ubomr
must be protracted beyond the usual time, or a more thaa
ordinary degree of pain must be endured*

Tedious labour, may occur under Aree different cinnmt*
stances:

Virst^ The pains may be from the beginning, weak or few,
and the labour may be long of becomii^ brisk.

Second^ The pains, during the^first stage, may be sharp md
frequent, but not effective, in consequence of which, tfa«
power of the uterus is worn out, before the head of the child,
nave fiilly entered into the pelvb, or oome into a situation t»
be expelled.

Thirds The pains, during the whole course, may be stroiig

lower part. The two children, who were of different iezes,llTed, we are told^
twelve days, but nothinpr la laid of the labour. In the Bulletins for 1818, p. %
two childran, who were joined by the baek at the ■aenun, are etntad to hvre beiB
bom, and lived till the ninth day. The first child presented the head, bat the
midwife could not weU tell how the second got out. Therr Is another case aft
page 3S, of a woman who, afker many days' labonr, bam a monaler do«bla in iIm
upper parts. The spinal column was united from the sacrum to the top of tha
dorsal vertebrai there the cervical vertebm divided to form two neoka. Th»
Ibidwlfe, finding the head to present along with the cord and a hand, tried to
turn, but could diseowr nothing but superior extremities. She therefore let her
alone. The head was afterwards expelled, but neither nature nor art oonid
deliver the body. M. Ratel, ihiding the head and two arms already alnMat
•eparated from the body, cut these parte off, then Introducing Ids hand, ne foond
«DOther head, tamed tho obUd, and brooght away the whole

4a»

and bviiky but from Bome mwchaninal obitacla, Hhe de&veiy
iBBy bo long prerentedy and it may eiren be aeceasary^ to haTs
tBcaarae to artificial fisrce.

It IB farther neeeesary for me to prenuBe, that the aame
patient, in different htboorB, ahall be deUrered with .varying
aelerity and ease, alttough the size of ihe children be the
aame* The protraction, therefore, cannot dq»end on purely
mechanical aauses, but ia rather to be attributed, to resistance
afforded by the soft parts, as Q.yin^ orgaxm, and the state of
JKStion of the uterine fibres. The dehvery of the c^d, depends
en contraction of the utems, and relaxation of its orifice, and
that of the vagina, and musdes connected with the perinseumi
and these two processes, are not only influenced by, but are
oIbo, generally, proportionate to, each other. Easy and speecb
leiaxation, is productive of rapid and great contraction, whicn
10 not to be meaaured, or determined, by tiie degree of pain or
amisatimi^ but by its efficiency. Powerful contraction of the
Hteras, is attended with proportionally rapid relaxation, of
the opporing soft ports, or at least of the os uteri ; and if the
latter state do not take place, the former cannot easily exist.
When mechanical assistance, seems to stimulate to more
freqoent and violent action, it is often more in appearance than
leoHty, at leoBt, so £ar as the uterus is concerned. The
sensation may be greater, but the actual effort made by the
uterus, is not always so great as the sensation would imply*
The abdominal muscles act more powerfully, and doubttesa
Ae nterus itself, is at last roused, or excited, to strong
action, when the resistance is continued, as, for instance, by
m contacted pelvis, or bad position of the child. The patient
says, she feels as if she would burst; and in some cases the
vterus is actually ruptured, but in many more, inflammation,
ia excited by the effi>rts. Neverthdess, even in this kind of
vesistance, which does not depend on the qb uteri, it is usual
for the action of the uterus at first to be impeded ; the primary
stage o£ labour is slow, and the pains inefficient. But this is
more remarkably the case, when the resistance is situated is
ilte OS uteri, for then, although the pains may be frequent,
tiiey are long of becoming powerful. Then, the abdominal
muscles co-operate strongly, and press down the uterus,
along with the head, into the pelvis. This is particularly
i&ustrated, by cases of morbid contraction, or obhteration, of
the OS uteri.

Various causes may protract labour, and, although, I have
ftought it right to divide tedious labour into two orders, yet.

440

m point of fact, the causes sometimes operate in sudi a way,
as to make the case a mixed one, reierrible partly to both
divisions. They may be arranged under the following heads :
First, feeble or sluggish and languid action of the uterus.
Second, partial or spasmodic action of the uterus* Third,
restrained action, the energy of the uterus being prevented
from being put forth by some other cause. Fourth, an
unusual obstacle to the issue of the child. These stated or
causes, may be excited, by circumstances, in many respects^
differing from one another, and which, at first view, we
would not suppose to act on one principle. The most
important of these, we must presently consider separately.

\Vhen, again, we come to view the means^which we possess,
of counteracting these causes, and accelerating lalK>ur, in
order that we may choose the one best adapted to the case,
we find that they may be referred to the following : Firet,
diminishing reustance, or promoting relaxation, wluch in*
creases contraction. Under this head may be included blood-
letting, gently dilating the os uteri, rupturmg the membranes,
improving the position of the presentation. Second, exciting
the action of tne uterus, by stimulating its fibres, directly or
by sympathy. Under this head may be included, the effect
01 cordials prudently given, heat, gentle exercise, clysters,
spontaneous vomiting. Friction has also often a good effect,
in exciting the action of the uterus, after its mouth is dilated,
or nearly so* Third, suspending weak and useless, or wear-
ing out, action, bv a smtable anodyne, in order that the
energy of the womb, and of the system, may recruit by rest.
Fourtn, removing partial, or spasmodic action, by a fuU dose
of opium. Fifth, diminishing nigh excitement, of the nervous
and vascular system, marked by heat of skin, frequency and
throbbing* of the pulse, confusion of the head or deliriuiD,
by the timely use of .the lancet, cool air, and tranauillity.
bixth, allaying general irritation of the system, which is in*
terfering with the individual action of the uterus, by a small
or moderate dose of laudanum, and thus concentrating the
action in the uterus, premising venesection, if the state of
the vascular system indicate this. Laudanum, in this case
seems to have the effect of a stimulant, on the uterine fibres,
BO also has erffot. Seventh, removing undue action front
other parts, which are acting in place of the uterus, and
checking or subduing its action, on the principle of the
sympathy of equilibrium, which I have alluded to in page
303, and more fully explained in another work. EighUi, if

441

none of these are applicable, or effectual, then, it only
remains to employ artificial or instrumental aid.

Haying made these general remarks, I now proceed to
consider particular states.

The first to be noticed, is that dependent on a weak
or inefficient action of the uterine fibres. This may be
occasioned by a general debility or inactivity, but more fre-
quently it proceeds from the state of the uterus itself. It
is marked oy feeble pains, which dilate the os uteri slowly,
and are long of forcing down the head. But although the
pains be feeble, they may produce as great sensation as usual,
for this is proportioned rather to the sensibility, than to the
vigour of the part. It is, howeyer, usual, when labour is
protracted from this cause, for the pdbis to be less seyere, than
m natural labour. They may come much seldomer, or, if
frequent, they may last much shorter, and be less acute. The
whole process of labour is sometimes equally tedious, but, in
most cases, the delay principally takes place in one of the
stages, generally in the first, if toe cause exist chiefly in the
nterus. If, howeyer, it proceed from general debility, we
often find, that if the first stage be tedious, the powers are
thereby so exhausted, that the second can with oifficulty be
accomplished. Hence, although consumptiye patients often
haye a rapid deliyery, yet, if the first stage be slow, the head
frequently cannot be expelled without assistance. It is not
always easy to say, what the cause of this slow action of the
uterus is. Sometimes it proceeds from contraction commencing
rather prematurely ; or from the membranes breaking yery
early, and the water oozing slowly away; or from some other
organ becoming too active ; or from the uterus being greatly
distended by Uquor amnii, or a plurality of children; or
from fear or other passions of the mind operating on the
uterus; or from torpor of the uterine fibres, frequently
combined with a dull leucophlegmatic habit, or with a consti-
ttttion disposed to obesity ; or from general weakness of the
system.

In a state of suffering and anxiety, the mind is apt to
exaggerate every evil, to foresee imaginary dangers, to become
peevish or desponding, and to press, with injudicious impa-
tience, for assistance, which cannot safely be granted. Great
forbearance, care, and judgment, then, are required on the
part of the practitioner, who, whikt he treats his patient with
that gentleness and compassionate encouragement, which
humanity and refinement of manners will dictate, is steadily

443

to do his duty,' being" neither swayed by her feafs nd
entreaties, nor by asel&h regard to the tamng of his own tioie*

Some women seem constitutionally, to have a lingering
labour, being always slow. In such cases, unless tiie prooess
be considerably protracted, or attended with circumstaxices
requiring our interference, it is neither useful nor proper, tts
do more than encourage the patient, and preserve her strength*

A variety of means were at one time employed for cicitiug
the action of the uterus, sudii as forcible dihUation of the oa
uteri, and the iise of emetics, purgatives, or stimulants* A
very different practice now happily obtains; the patient ia
kept cool, tranquil, and permitted to repose ; only the mildest
diet is allowed, such as, ponado, dry toast with tea, gruel, a
little weak soup, &c.; all fatiguing efforts are nrohibit«i;
and die is encouraged by tiie ment^ stimuli of cneerfulnese
and hope, rather than by wine and cordials, which are geneiw
aUy injurious, and indeed, tiie suffering and anxiety of labour
are best borne by those, who take least during it« mt, whilst
in cases where labour is only a little protracted, and tiie cause
sot venr well marked, we trust entirely to this treatment, widi
tiie addition of a. saline clyster,* which is of much service, and
aught seldom to be omitted, yet, where it is longer ddayed,
some other means are allowable, and may be necessaiy.

The ; psins in tedious labour, connected with deflective
uterine action, may be continuing regular, but weak, not from
exhaustion, but rather from the uterus not exerting the power
it has, or tiiere may be a tendency to remit, the pains connng
on seldom. It is quite a mistake to suppose, that defective,
and what may be eiUled restrained action, necessarily depends
on debility of the uterus. A veir small impediment, as IshaU
presentiy notice, can bridle, if I may so speak, the efforts of
the uterus. If there be heat of the skin, fiill pulse, with
tiiirst and restlessness, perhaps starting, and especially if the
es uteri be not relaxed, and the parts tight or rigid, veneseo*
tion will be of great benefit, by. making tiie uterus act witii
more freedom, and its mouth yield with great readiness*
Long ago, Mauriceau advised bleeding, and Baudelocque,
with most practical writers, has confirmed ito utility* The
late Dr. Rush informed me, that in America it was resorted
to with great advantage, and Dr. Dewees published a short
treatise on the subject. In some instances, fifiy ounces were
taken, before the parts relaxed, but I hold it to be dangerous

^' 7^5*"* ?»™"*on I find objects to the uie of dTsters, on the auppoaltion that they
twmg eBUMMt tnui do good*

443

to bleed to tins estoaL We know that in most dses nf
etarine fasmoniiagey tire ob uteris even when there is no
efiBBtbe iBbonr, and Boaseely anj pain, is not merely dilA*
taUe, bat is partieitjr dilated* In diis instaacey however,
Ike benefit of evaeoaiaan camet be derived, for the discharge
i^JBres and hnnains Hm mhole power of tiie utenis, and in
pnqportioa aa tile oa uteri is extended, the qnantity of the
blood which flows ia increaaed; besidea, the evacuation usually
begins before labour commences, and pains do not come
ea laU the loss of blood excite them* We learn, however,
toasEL this example, the influence of hsBmorrhage in relaxing
Irihe OS uteri, and if we can do this, without impairing tM
ra^ of die womb, we hare certainly a powerful, mean of
aoeelerating labour; venesection does this in certam cases.
in cases where the parts, Ibraugh whidi die child must pass,
aae rigid or dry, or hot and tender, or where Ihe pains sore
great, but irregular, and inefficieKt, or the membranes have
given way prematurely, tiie pains sharp, but abortive, and
the OS uteri thick or hard, or the patient is feverish, blood-
letting is safe, and may be expected to do good. That it is
safie, we know from Ae experience of former ages, and other
countries, as well aa frum the result in cases oif convulsions^
where a great quantity of Uood, is taken away, with present
advantage and future impumty* It is, however, a remedy,
iriuch, is imprudently employed, may do much mischief. In
driiilitated women, and cases d exhaustion, for instance, it
must be dangerous; or where the resistance is afforded, by a
Contracted pelvis, all other circumstances being right; and, in
every constitution, and under every circumstance, in which it
would, independent of labour, be improper to evacuate, it is
evident that it will be hurtful, unless we can thereby save the

Cktient prolonged exertion, and exhaustion. In natural
hour, it is neither necessaiy nor proper ; in labour not
greatly protracted, nor unusuaUy severe and slow in its steps,
it is not to be resorted to. It is better to trust, in these cases,
te the use of clysters, to gentle motion and change of posture,
er to riei^, if it offsr naturally, and the patient require to be
veoruited.

The effect of venesection, in shortening the process of
labour^ and in rendering the pains in many cases brisker, is
to be explained, by its power in relaxing the parts, and di-
minishing the resistence afforded. It is a fact, not sufficiently
attended to, that, in many cases, a very moderate resistance,
which we should think the uterus might easily overcome, does
letard the expulsive process, and render the pains irregular

444

or inefficient. Thus, I know from experience, that the
membranes may be so tough as not readu^ to give winr, and
in this case the pains do become less effectiye> and the Jabonr
is protracted till they be opened. Whenever the reastanoe
is removed, the pains become brisk and forcing. In the same
way, relaxing the os uteri, by blood-letting, excites the nterme
fibres to brisker action. This is the direct effect of veneaeo*
tion, but it also ensures safety, and subseauently aocderatea
delivery, when it removes an existing febrile state, or one of
general excitement, which is interfermg with the due perfoiw
mance of uterine action. Further, it cannot be diluted,
that the uterus must be influenced, by the state of its nerves;
and I beg it to be remembered, that there may be a conditiQii
of these nerves, removable by venesection, which, akfaongfa
referrible to excitement, does retard, instead of prodociiigv
muscular contraction. The nerves, or divisicm of nerves,
destined for sensation, are more affected, than those, on wUck
the proper function, of uterine contraction depends.

Solution of tartar emetic has been employed by some for
whom I have a high respect. But I have no great partiality
for this medicine, especially in parturition. Infusion of ipeca-
cuanha has been proposed as a glyster.

When the pains come at long intervals, and are trifling' in
effect, wearying the patient, we must consider the state of tiie
OS uteri and soft parts. If it be thick, and little ^Uli^tAtflj
and the vagina rigid, we must either sooth and temporise^ ov^
if the patient be not delicate, or weak, take some blood* If
this fail, or have not been proper, and the pains be still
troublesome, but useless, we must act according to the state
of the OS uteri. If that be little dilated, and the bowds
regular, we may endeavour to suspend the inefficient pains, by
giving forty drops of laudanum, or a clyster, containing m
small tea-spoonful of laudanum mixed with thin starcb, or a
suppository of three grains of soft opium. Should tbe
bowels be costive, a mine clyster ought to be ]irc
If the patient become drowsy, die .must be Irft to
and during all her labour, we avoid ^»yrH^ti^¥f> Ibm^
cool, and allow only a little toast-water, tea, or food ht jtfss
%kte8t kind. Sotnetim^ iiistead of these doees of Jaad
m^pendiqg the pain, they render it btiaker, and tbe
yield. This is also desirable.

If the 08 uteri be dihitod, but the pains be weak, seldoB,
and inefficient, we rarely find it proper to bleed, certainly iiot»

n/^ ^^^ ^ *'K^^ ®^ ^'y* ^^ ^^ pati«ttt robust
^^mer means are more useful, such as a saline clyster, wbidi

445

often excites the labour. A gentle purge has been advised,
but it is slower, and more uncertain, in its effect. A moderate
dose of laudanum is often useful, and, unless it disagree with
the patient is always safe. Twenty drops may be given, and
other ten, if no good be done, in two hours. In this small
dose, laudanum acts, if it act at all, as a stimulus to the
uterus, through the medium of its nerves, and also, by
aympaihy with those of the stomach. In less than a quarter
of an hour, there is often an effect produced. Thirty or forty
dram may also be given as a clyster, if that be preferred.

When the os uteri is well dilated, its lips thin, and the
presentation natural, we may also derive advantage, from
the use of friction, during a pain. In general, it is efficient, in
proportion, to the progress tne labour has made. It is best em-
ployed, by placing the flat hand, on the region of the uterus,
particularly the upper part, and making the abdominal parietes
move^ backward and forward, over it. The hand is not moved,
80 as to rub the skin but is kept steadily on the same part, so
as to carry the skin along with it, in its motions. This is only
to be done during the existence of a pain, when the uterus is
felt to become hard ; and different parts of it, particularly those
which feel softest, may be successively acted upon. It has
often a decided effect in rendering the pains more uniform
and efficient ; but, as it also increases the sensation of pain,
it is apt to be objected to. If it be to prove beneficial, it
does so soon.

When every thing is well disposed for the birth of the
child, the lips of the os uteri thin, and soft, and the aperture
consideraUe, letting out the water, has often a good effect,
espedally, if the uterus have been unusually distended. I
shall immediately notice the inconveniences, which often
result, from premature discharge of the water, but under the
circumstances at present enumerated, the rupture of the
membranes is beneficial. Taking away, at a favourable time,
the resistance afforded, tends to excite, efficiently, the action
of the uterus, and promotes labour. If the os uteri be lax,
and especially if its edges be thin and soft, and the orifice
considerably dilated, the same effects may be produced on it
by this practice, that would follow, in cases of greater rigidity,
from Tenesection; for both excite labour, by diminishing
resistance. The more that the os uteri is dUated beyond the
mze of half-aiH^rown, the more beneficial, cderis partbusj will
the practice be : on the other hand, when the os uteri is firm
and little dilated, and the other soft parts rigid, this practice.

go &r firam being iiflefiil» is hnrtfiil aad daogeraus. The
craciiatioii of the water is floccaBded by nunre powerfiul adieiip
a ctrcmnataoce, which, while it poiiitB wA the adia&tage cf
the practice, in the case under cannMiwtioB, foEbids iti
employment in natural labmn-, wiure^the pH>oe86 is gomg q%
with a zegidarity and eaneditiout conoateDt with the views of
nature, and the safety of the wMwa.

An erect posture is another mean which epcEstea, in nar^
on the same principle, for it calls in the aid of gnraty, adUdng
the pressure of the child to the action of the uterus^ Ths
water is allowed to run freely out, and tiie continned appUca^
iion of the presentation, to me dilating os uteri, excites actimb
The child must be more easily propdkd, sordy, if it be ia
anch a situation as to allow it to fm eattf by its own weighty
were it not prevented by tiie soft parfa, thau if it rested ona
borisontal sur&ce, and required to be moved aloug that, bf
muscular effort, as is the case in a reenmbent postare. Tfaa
difference of fscility, then, becomes txyaij a stimulus* Beside^
the muscular motioo, or walking, winoh is employed, in an
erect position, does good, either 1^ Cfyriting the womb directly^
er by remoring sympathetic pasos in the muscles.

If the water have been,.for sometime, discharged, natnrallf
or artificialljr, and the os uteri be not effiused, but be las, or
soft, and thm, so that ifc is applied dbsely on die head, and
is yery yielding, it is both safe and adnantageons, to dilate it
gentiy, with the fingers during a pain. K this be done
cautiously, it gives no additional uueaaiacss, whilst the
stimulus, seems to direct the actinn of the uterine fibrea^
more efficienUy towards the ob uteri, which sometimes tima
clears the head of the child very quiddy, and the pains which
formerly were severe, but, in tiie hngwage of tiie patient,
unnatural and doing no coed, beeonm eiective, md less
severe, though more useful. This adrioey however, is not
meant to sanction, rash and unnecenary attempts to dilate
the OS uteri, which sometimes render labour more tedious, by
interrupting the natural process, aad also lay the foundation
of inflammatory affections afterwards. On no account are we
either to use force, or even to eontinne, for a length of tirne^
such more gentle endeavours, as fiball irritate or tease the os
uteri. Afterwards, if the pains be irregidar, and succeeded
by continued aching of the back, if the state of the os uteri
do not indicate venesection, forty drops of laudanum may be
given with advantage.

In the case I have just considered, I have iq>oken of the

447

leAedft ei dilaiing^tbe 00 uteri, but I do not mean to flsy, that
the practice is useful in such a one alone ; for, in most cases
of tedious labour, it is beneficial, and, as the sudbject is impoxw
tant, I shall explain my sentiments on it fiiUj. Forcible, and
irritating dilatation, ii the os uteri, eren when it is not
productive of dangerous consequences, is apt to occasion
insgular, or spasmodic, aictian <rf the uterus. Tvo exnaao-
staaees are necessary to render it safe : the os uteri ought to
be steady very considerably opened, its edges must be lax^
dilatable, and generalk speakmg, thin; and the cBlatation
jsust be gradua%, and gently, effected, during the continur
anee of a natural pain* If attempted in tiie absence of pain,
and e^ecially if attempted so as to give pain, it is apt t»
Bscite partial or q^aamodic action, and, under any eircum^
rtance^ violent or forcible dilatatitm, besides injoring the
uterine actioe, may lay the foundation of future disease. It
is done best, by pressing on the anterior edge of the os uteris
fchiring a pain, with two fingers, with such moderate force, as
flball not give additional pain, and shall appear, as much, to
eam^ the natural dilatation, as to produce mechanical
opening. By doing this, for several pams in succession, or
oootfionally during a pain, at intervals, according to the efiisct
prodnaed wad the disposition to yield, we shall soon have the
OB uteri completely effaced. This is an old principle, but it
was rashly practised, and too universally adopted, which
joade it meet wi& just reprobation ; and some knowing tliis,
may be surprised at meeting with such an advice in modem
times. I«et not the principle suffisr from its abuse,'else, where
is the plan which could stand its ground? It is perfectly
dear, that when the process is going on well, interference jb
improper ; but it is no less evident, that if a long time is to
be spent, in accomplishing the first stage of labour, or dllata*
tion of the os uten, the vigour of the uterus and strength of
fte patient, may be impaired so much, as to render the sub-
sequent stage, dangerously tedious, or to prevent its comple*
Idon, at least consistently with safety. The first stage of
Ubour, ought always to be accomplished within a certain time,
varjring, somewhat, according to the constitution of the
patient, and the degree of pain. It is an undeniable proposi-
tion, that there is, in every case, a period beyond which, it
cannot be protracted without exhaustion; and it is no less
certain, that if we wish to avoid this exhaustion, which may
be followed by pernicious effects, we have only the choice, of
either suspendmg tixe action idtogether for a time, or, of

448

endeayouriDg to render it more efficient, and of effecting the
desired object within a safe period. The first is sometimes
adopted, but is not always practicable, nor is it always pru-
dent to counteract uterine action, by strong opiates. The
second is safer, and one of the means of doing so, is that
under consideration. If the pains be continuing without sus*
pension, or an interval of some hours, and the labour be going
on all the time, but slowly, it is a ^ood general rule, to effect
the dilatation of the os uteri, within ten or twdre hours, at
the farthest, from the commencement of regular labour. This
is done, if the os uteri be flat and applied to the head, by the
method above described. If it be somewhat projecting, it is
«uded by introducing two fingers, and extending them laterally
with gentleness, during a pain. The dilatation is easily and
safely effected, if the case be proper for it ; if not, bleeding or
an opiate, if the former be not indicated, wUl soon bring
about a favourable state. Of the benefit, and perfect safety,
of this practice, I can speak positively, and am happy to
strengthen my position, by the authority of Dr. Hamilton,
who makes it a rule, to have the first stage of labour finished
within a given time. I need scarcely however, add, that, in
enforcing this rule of conduct, it should be recollected that,
to render it proper, the pains must be continuing so often,
and so decidedly, that the patient can be said to be in actual
labour all the time.

Another mean of accelerating labour when tedious, is the
exhibition of ergot. This, which was known to produce very
deleterious effects, when mixed with food, was recommended
half a century ago, for promoting the birth of the child, and
lately its use has been revived by Dr. Dewees, in cases of
tedious labour, arising from deficient pains. It is given in
the dose of a scruple of the powder, every quarter of an hour,
and he says, that it is seldom necessary, to give more than
three doses. Sometimes, half a drachm is given at once, or,
two drachms may be infused, in a breakfast cupful of boiling
water, for at least ten minutes. The infusion, which is of a
red or pink colour, and has a strong peculiar smell, is to be
drunk by the patient, and may be repeated, if necessary, in
half an hour. In some instances, no effect whatever ispi'^
duced, but, in others a very rapid change takes place. There
is a peculiarity in the uterine action, caused by ergot, namely,
that when it is strong, it is seldom completely intermittent,
like natural pains, but is almost constant. There is not only
an increase of pain, but also very strong pressing down.

449

while both, generally, go off, as soon as the uterus is emptied.
From the strength and constancy of the action, when it is
excited at all, it is evident, that ergot ought not to be admin-
istered, if there be any obstacle, to the delivery of the child,
which it cannot remove. Hence, it ought not to be given if
the pelvis be contracted, or the presentation unfavourable,
unless under circumstances to be mentioned, when treating of
instrumental labour. It ought not to be given, unless the os
uteri be dilated, and generally unless the membranes have
burst. No doubt, if the os uteri be very thin and dilatable,
though not quite effaced, ergot might accelerate the process,
but it is rarely in such circumstances, that we can have occa-
sion for the medicine, and may always delay till the os uteri
be dilated. In a thick and unyielding state of the orifice,
ergot will either have no effect at all, or a bad one, and in a
deformed pelvis, even rupture of the uterus may take place.
The case, proper for the exhibition of ergot, is that, in which
every thing is prepared for delivery, the os uteri open, the
parts lax, the pelvis well formed, and the presentation natural;
nothing is wanting to complete the delivery, but efficient
action of the uterus. In such a case, we would say of the

I)atient, one or two good forcing pains, would finish the
abour. That ergot shall, infallibly, produce this, 1 am very
far from asserting, but that it does so, in many instances, is
fully established. In some cases, it merely excites the pains,
in others, and these the most frequent, it produces a feeling
of increased heat, but the pulse becomes rather slower than
quicker. If the dose be too large, sickness and vomiting are
produced.* It has been observed, that children bom after
the exhibition of ergot, very often are dead, and, in that case,
are blanched and bloodless. This has been attributed to the
strong action of the uterus, but we find this action equally
strong, in other cases, without the production of this effect.
It has also been supposed to proceed, from the separation of
the placenta, before the birth of the child ; but this evidently
must be' conjectural. I would rather attribute it, to the
specific effect produced on the uterus itself, which has an
influence on the ovum ; but fortunately this effect on the child
is by no means invariable, though I must acknowledge it is
frequent, especially if the uterine action, do not expel the

* Dfflcraiiges reinarlu that it often causes vomiting, and this aids farther the
labour ; bat he does not attribute Its effect to this. It Is actlre, In proportion, to
the mlontenesa of the powder and its recency. It fatigues those of a delicate and
nervous constitution, but produces no effect on labour, if given before the os uteri
be dilated four or five lines. Nouv. Journ. Turn. i. p. 54.

2 G ^^^-

450

child, soon after it is excited by the ergot This would make
us more or less willing to use it, according as we expected
the expulsion, to be more or less speedily accomplished. It
has also been supposed that the powerful contraction of the
uterus, might make it surround the placenta and retain it, but
we do not find this retention more frequent, when ergot is
given, than when it is not, neither is it usual, for the pains
and strong action induced, to continue after the uterus has
been emptied. When they do, opium is advised to check the
action, but I have never seen this required. We do not yet
know on what the property of ergot depends.

Though premature, but spontaneous breaking of the mem-
branes, and discharge of part of the liquor amnii, often have
no effect in retarding labour, yet, in some cases it does so, by
occasioning spasmodic action of the uterus, or irregular and
inefficient pains ; in others, a little water passes between the
head of the child and the os uteri, during every pun, and the
effect is rather to press out gradually the water, than to open
the 08 uteri, which may not be effectually acted on, till the
whole, or almost the whole, water have been evacuated, so as
to allow the head to be pressed on the orifice, and the uterine
fibres to act, on that orifice, over the presenting part. In a
natural state, the bag remains entire, until the os uteri have
been considerably opened, and every pain gently dilates it,
both by the uterus acting on the orifice, and also by the
membranes when pushed out, doing naturally, what may be
effected, in some cases, artificially, by the finger, that is,
mechanically dilating the mouth. The pressure of the
membranes also excites active pains. When the presentation
is preternatural, the os uteri is longer of opening than when
the head presents; the membranes do not protrude so broadly,
nor does the presentation act so well on the os uteri, or excite
it so effectually. Whilst rupture of the membranes, as we
have seen, may, in some cases, prove a useful stimulus, in
others, when it is, without judgment or necessity, resorted to,
it must be prejudicial. If the water be discharged very early
in labour, or before the pains come on, the process is often
lingering, but is not always so. The os uteri is, when we
first examine, projecting, then it becomes flat, but the lips
thick; then, thev become thinner and more dilated, and

Eresently very thin ; and the lower part of the uterus is per-
aps applied so closely to the head, that, at first, it might be
taken rbr the head itself. In favourable cases these changes
may take place quickly, but they may also be very slow, and

451

the labour tedious, the pains sharp and ineiFective, and tlie
water discharged in small quantity with each pain. The pains
are scTere, but produce very little effect, and often when they
go off, are succeeded by a most distressing uneasiness in the
back, lasting for nearly a minute after the pain, indicating in
general the existence of spasmodic action. A^saltne clyster
IS of much benefit in this Kind of labour ; and it is useful to
press up the head, especially during the pains, to favour the
evacuation of the water, for, whenever this is accomplished,
naturally or artificially, the action becomes much stronger.
It is also useful to detract blood, if the os uteri be rigid, the
parts not disposed to yield, and the pains very severe. It is
peculiarly proper when the woman has rigors. When the
organs are firm, and the pains lingering, it causes relaxation
and quickens the pains. Opiates are also useful, either in a
full or small dose, according to our intention, founded on the
view already presented, respecting their operation, and the
different states of the uterus, or of the pains. I refer also to
what I have already said, as to the circumstances, under
which, the os uteri, may be artificially, but gently dilated.

There are many cases where pains, at first regular, have
gone off for many hours, or where they have come occasion*
ally, in a dull slight way, for a couple of days, but they have
given little inconvenience, have scarcely interrupted sleep,
and had little effect on the os uteri. They are more of the
nature of false pains : the patient can hardly be said to be in
labour, and is in no respect fatigued, if interference be
proper in such cases, it is by other means, by opiates, by
enemata, or remedies and applications, evidently pointed out
by the nature of the pains, which have formerly been
considered.

Sometimes after the first stage has advanced, and the os
uteri is nearly dilated, the second does not commence for
«ome hours ; but the first kind of pains continue, in different
degrees of severity, without producing any perceptible effect*
if no particular cause require our interference, it is best to
trust to time ; but, if there be^no change soon, labour may
be accelerated by rupturing the membranes, or, if they have
already broken, we may place two fingers on the margin of
the OS uteri, which is next the pubis, and gently assist it,
during the pains, to slip over the bead.

When a woman is greatly reduced in strength, previous to
labour, that process is looKed forward to with apprehension.
It is, however, often very easy. But if it should be pro-

452

tracted, the patient is to be kept from every exertion. The

Jreneral plan of treatment, pointed out for such cases, is to be
ollowed, and, if the strength fail, the child must be delivered.
We must be particularly careful, that haemorrhage do not
take place after delivery, or that it be promptly stopped.

There is another state, in which the pains are weak, or re-
miss, or are ineffective from absolute exhaustion or debility ;
and we distinguish this case, by the weak pulse, languor, and
previous fatigue, and, in part, by the constitution of the
woman. This is the only case in which cordials are proper,
and they must even here be given prudently, lest they pro-
duce a febrile state. It is also useful to suspend, for a time,
the uterine action, and procure rest by an anodyne clyster.
We must take care, that we do not delay delivery too long,
or trust too much to nature.

If the head rest long on the perinsum in tedious labour,
the pains having little effect in protruding it, especially if
the first stage have been lingering, it comes to be a question,
whether we shall deliver the woman. This case is different
from that, where the difficulty proceeds from a contracted
pelvis, for the head is low down, the bones are not squeezed
nor misshapen, there is only a swelling of the scalp, the finger
can be passed round the head, and two or three strong pains
might expel it. The propriety of employing the forceps, in
such cases, will soon be considered.

An inefficient state of uterine action, may be produced, by
some other part acting too much, or being in a state of irrita-
tion; and so long as that continues, the womb cannot be
expected to contract briskly. Such a state is often produced,
by changes in the action or condition of the origins of the
nerves supplying the uterus, caused by the particular action
of their extremities, and thus nerves arising near the same
place, or otherwise connected with them, though going to
very different organs, or distributed more universally, come to
be affected, and the remote actions thereby excited, may have
a powerful and injurious effect on the uterine action. Do we
not sometimes even find convulsions produced, by the accession
of a labour pain, and these again, carrying off the pain, almost
as soon as it begins ? We ascertain the state, by examining
the sensations and state of the patient. If the stomach be
irritated, she is sick and oppressed, and probably desponding,
and sometimes, almost at every pain, has an mclination to
vomit. This is often the effect of the connexion between the
nerves of the os uteri and stomach, and in that case is always

453

increased by an examination, or the slightest irritation of the
OS uteri. The treatment must depend somewhat on a know-
ledge of the habitudes of the patient with regard to certain
medicines. If opium agree with her, a moderate dose alone,
or with some aromatic, is useful ; a little spirit of layender,
or a glassful of hot water, or a little hartsnom, may be em-
ployed, or the epigastric region rubbed with some stimidant
embrocation, but in general it is best to do very little, and
trust to time. Vomiting, without distressing sickness, and
not dependent on exhaustion, but occurring early in labour,
often excites, rather than retards the action. In other cases,
the bowels suffer, and, in these, twenty drops of laudanum
generally give relief. A distended bladder also is a cause of
protracted labour. In other cases, the muscles of the back
or belly become painfully affected, producing what Daventer
called *^ wild and wandering pains," or that state in which the
pains no sooner cease to come on, than they ^^ are changed
into a colic or a cramp, and an impotency of labour." In
such cases he forbade forcing medicines, and advised anodynes.
This advice is a good one ; and, in aU these cases, twenty-five
drops of laudanum will be useful, at the same time that the
pained part be rubbed with the hand, or an embrocation. In
cases of muscular pain, walking or change of posture often
gives relief. When there is no particular organ or part
affected, but only a general irritation, attended with teazmg,
inefficient pains, the same remedy is often of service, and the
energy is directed presently to the uterus. In all these kinds
of cases, it is also useful, in general, to endeavour to excite
the uterus itself, by a warm saiine enema, or by some of the
other means already, or still to be, mentioned, or by rubbing
the uterine region itself, in the manner I have described*
Mr. Power, who has insisted more than any other writer on
metastasis of action, and on the utility of friction in exciting
uterine action, effects it, by drawing the fingers and thumb
rapidly together, over the uterus, so as to make a brisk
friction on the part ; but this is more uncomfortable, and less
efficient, than the plan I have proposed of moving the abdo-
minal parietes over the uterus. That general agitation of
the muscular system, known under the name of rigor, which
often attends the first stage of labour, if carried too far, or
continued too long, may also retard delivery, but in general,
it goes off spontaneously, and the action concentrates more
powerfully in the uterus. Hence, it is a practical remark,
that these rigors often are followed by a brisk labour. This

454

effect, and consequently the propriety (^ interfering, must
depend on their prolongation, and on their influence in carry-
ing off the uterine pain. When we require to interpose, the
practice consists in blood-letting, the use of opiates, or ad-
ministration of a clyster, according as the yascular or nerTOUS
system, or bowels, seem to be principally concerned. Some-
times friction on the uterus, during a pain, seems to concen-
trate the action.

In tedious labour, it is not necessary to confine the woman
to bed, or to one posture ; she may be allowed to sit, lie, or
walk, as she feels inclined, and we are not to urge her to
stand long, or use exertion by way of promoting labour. She
has, generally, not much inclination for food, and, like most
traTellers, gets best on, by taking little, and that only of the
lightest kind ; but if the process be protracted, it is useful to
give some weak soup, and even a little wine, if she desire it,
or feel exhausted. If the urine be not regularly passed in
tedious labour, the catheter ought to be introduced. It is
not necessary that the practitioner remain constantly with the
patient. It will have a better effect upon her, if he see her
at proper intervals, whilst he is thus prevented himself, from
being so fatigued, as he otherwise would be, and is therefore
better able to discharge his duty, with firmness and judgment.

The second generid cause of tedious labour, and one much
more frequent in its operation than many suppose, is irregular
action of the uterine fibres. After the child b bom, the
uterus sometimes contracts like a sand-glass, and retains the
placenta. The same spasmodic action may occur, before the
child be expelled, and it usually affects the circular fibre
of the cervix. Many causes, and some of them obscure,
may excite spasm ; it is apt to take place when the membranes
have given way prematurely, and before the os uteri be in a
relaxed state, or have begun to dilate. Improper irritation
of the OS uteri, often excites it, especially attempts to dilate
it, in absence of a pain, or hurriedly during one. Letting out
the water, when the uterus is not contracting, and when
there is no pain at the time, may also cause it, probably by
allowing the lower part of the uterus, to collapse suddenly
around the head or presentation. Preternatural distention
of the womb may also produce it, even previous to the
discharge of the water. Irritation of the bowels, and mental
anxiety may also be causes of spasmodic action. It is marked
by pain coming, or increasing at intervals, like proper pains,
but it has little effect on the os uteri, or in forcing down

455

the child, nay, the os uteri sometimes seems even to contract
during a pain. If there be any bearing-down, the pressure
is only momentary. The pain does not go entirely ofip, as in
natural labour ; but the patient complains of constant uneasi-
ness in the back, or some part of the belly, but usually in the
former. The paroxysm of pain, is generally described by
the patient, as affecting some part of the belly, particularly
the lower part, corresponding to the cervix uteri. The con-
traction does not go off with the pain, it only lessens ; hence
the band of fibres still compresses the child, or ovum, and, if
the membranes have not broken, they are often kept so tense,
as at first to resemble a part of the child, and may mislead the
practitioner with respect to the presentation. There is often
a frequent desire to void urine — the spirits are generally
depressed, and very often there is a feeling of sinking or
sickness, and oppression of stomach, from the nervous sym-
pathy between the nerves of the stomach and those of the
cervix uteri. If this spasmodic affection be slight, it may
soon go off; but, if strong, it sometimes continues for many
hours. "A smart clyster is often of great service. Blood-
letting sometimes, though rarely, does good, and I prefer
opening the membranes if the presentation be good, and the
08 uteri lax ; this I have found very successful. If, on the
contrary, the os uteri be rigid or undilated, and especially if
the presentation be not determined, they must be kept entire,
until the os uteri will permit of turning, should the position
of the child require it. In such cases, and even when the
state of the os uteri has warranted the rupture of the mem-
branes, but the expected benefit has not accrued, we may
derive advantage from giving a large dose of laudanum ; for
in this spasm, like tetanus, it may be taken in great doses.
Even ten grains of opium have been given, but in general
sixty drops of laudanum are sufficient, and when this remains
on the stomach, it is, from its more speedy effect, preferable
to solid opium ; or an anodyne clyster may be employed.
After the child is bom, the hand should be introduced into
the uterus, not to extract the placenta quickly, but to come
easily in contact with it, and excite the uterus to regular
action ; for, generally, the spasm returns, and the placenta
may be long retained, or haemorrhage produced.

A frequent cause of tedious labour, is a state of over-action,
or unproductive action in the first stage, by which the powers
of the uterus are exhausted, and the subsequent process is
rendered very slow. This exhaustion may also Ho produced.

456

by the continuance of feeble and useless pains. In the first
case, the pains are sharp and frequent, but do not dilate the
OS uteri properly, nor advance the process in general. It
may be produced by irregular action of the fibres, or by
rupture of the membranes, before the cervical fibres be di»*
posed to relax. In the second case, the pains are lingering,
short, and usually weak. I have alr^tdy considered the
remedies for these states ; blood-letting, clysters, gentle
dilatation of the os uteri, &c., and have here only to olmerve,
that the exhaustion of the uterus, and consequently an addi-
tional prolongation of the labour is to be prevented, either by
suspending the pains for a time, or by rendering them more
efiective; and, upon this subject, I refer to what I have
already said, in the beginning of this chapter. Unproductive
action, ought never to be allowed to continue so long, as
materially to impair the action of the womb. If we cannot
safely render the action more efficient, we must endeavour to
suspend it, by which the womb recruits, and the retarding
cause may, m the meantime, be removed, or cease to
exist.

Another cause of tedious labour, is the accession of fever,
with or without local inflammation. Fever is recognised by
its usual symptoms, and may be produced by the injudicious
use of stimulants, heated rooms, irritation of the parts, &c.
It is to be allayed, by opening the bowels, keeping tne patient
cool in bed, and giving some saline julap, at the same time
that the mind is to be tranquillized. If these means do not
immediately abate the heat, frequency of pulse, &c., and
render the pains more efiective, it will genar^Jly be proper to
detract blood, especially if the head or chest be pained.
When local inflammation accompanies fever, it is commonly
of the pleura^ or peritonseum, or vagina. The first is dis-
covered by pain in the thorax, cough, dyspnoea ; the second
by pain in the belly, gradually increasing and becoming
constant; pressure increases it, and, in some time, the patient
cannot lie down, but breathes with difficulty, or is greatly
oppressed and vomits. The labour pains are sometimes
suspended ; on other occasions, they do ultimately expel the
foetus, but the woman dies in a few hours. On the first
appearance of these symptoms, blood should be fredy
detracted, the bowels opened, and a gentle perspiration
excited. In all these cases of inflammation, if immediate
relief be not obtained, the child must be delivered by the
forceps. If the vagina be hot and dry, we are also to

457

deliver immediately, as these symptoms indicate danger from
inflammation.

Labour may also be rendered tedious, by the different
stages not going on regularly, but efforts being prematurely
made to bear down. In consequence of these, the uterus
descends, in the pelvis, before the os uteri be dilated, and the
process is often both painful and protracted. These prema-
ture bearing-down pains, may often be mitigated, by a recum-
bent posture, and the use of a mild clyster to empty the
rectum. In some cases, the womb prolapses, so that its
mouth appears at the orifice of the vagina. This prolapsus
may take place during pregnancy, or after parturition begins.
It is often met with, in a slight degree, whilst the os uteri is
not greatly dilated, and uniformly injures the labour. We
are to prevent it from increasing, by supporting the head, or
the uterus, with two fingers, during the continuance of a pain,
at the same time that the woman avoids, as much as possible,
every bearing-doMm effort, and remains in a recumbent
posture. If the os uteri be slow of dilating, some blood
should be taken away, and an opiate administered, or the os
uteri gently but completely dilated, during successive pains.
It has happened, that by neglecting these precautions, the
uterus has protruded beyond the external parts. In this case,
no time is to be lost in attempting the reduction, which will
be rendered easier by cautiously pulling back the perinaeum.*
If this cannot be done, the os uteri, if lax and yielding, must
be gently farther dilated, the membranes ruptured, the child
turned, and the uterus replaced.f The os uteri has been
eut,t but this can never be necessary if the structure of that
part be natural.§ When the womb does not actually pro-
trude, the vagina may be inverted like a prolapsus ani. A
soft cloth, dipped in oil, should be placed on the part, and
pressure made with the hand. Giesman cut the inverted
vagina on a probe, but this operation can never be required.

• Vide Mem. of Med. Soc. Vol. I. p. 8ia

t Vide Portal** 10th Obe ; and Decreax't case, in Mf m. de ]' Acad, de Cbir.
Tom. iii. p. 368. See also a case by Snxtorph. There is a case by Faaola,
where the uterus, with the child, appears toiiave been protruded for thirty hours.
The child was expelled by a rent, and the placenU beinf extracted, the mother
recoTered.

t Vide a case by Dr. Archer, New York Med. Rep. Vol. i. p. .188.

§ In Dr. Heiisehers case, the difficulty of deliTer^, from the protruded cervix,
was so great, that the forceps were employed The cervix was torn, but the
patient recovered. There had previously been torae black spots. Lond. Med.
and Pbys. Joum. Ixvi. 461. Jn Mr- Coulsou*s case, the womb was prolapsed
before impregnation, and at last could not be replaced, it was as large as a cocoa
nnt, but by rest, fomentation, fto., It gradually went up to a considerable degree,
but premature labour took place in the fifih month. Med. Gazette, vi. 4('4.

458

If the womb prolapse before labour, as happened to RoedererV
patient, we must manage the case as a simple prolapsus.
She had severe pains, although she was not in labour.

The anterior lip of the os uteri has become prolonged, and
extended, during labour, for some inches into the vagina, or
has even protruded at its orifice with great pain. It ought to
be supported with the finger, and very gradually pushed above,
or over, the head. It has been mistaken for the placenta.

ORDER SECOND.

There exists, naturally, such a proportion between the size
of the head, and the capacity of the pelvis, that the one can
pass easily through the other. But this proportion may be
destroyed, either by the head being larger, or more completely
ossified, or the pelvis smaller than usual. In such cases,
which are to be discovered by careful examination, it is
evident that the labour must be more tedious, and more
painful, than it otherwise would be. The first stage of the
process is generally, but not always slow; the second ia
uniformly so. The head is long of descending into the pelvis,
it rests long on the perinseum, the pains are frequent, severe,
but often not very forcing, and the woman says Uiey are
doing no good, riow this state requires both patience and
discretion. The bowels should be opened with a clyster ; the
urine regularly expelled or drawn off; the strength preserved
by quietness, avoiding unnecessary exertion, indulging any
disposition to sleep which may exist, and taking a little light
nourishment occasionally ; the mind is to be soothed, and the
hopes supported. The rule formerly laid down, with regard
to effecting the dilatation of the os uteri, or accomplishing
the first stage of labour, within a certain period, is, if^ practi-
cable, to be attended to, by which the energy of the uterus is
saved, and it is enabled, to go through the second sta^e, more
readily and safely. If the pains begin to slacken, whilst the
strength remains good, an opiate may be given to procure
some rest. How long the case may be trusted to nature,
must depend on the strength of the patient, and the degree of
suffering ; but assuredly, we are not at liberty to carry the
trial to a great extent. The consideration of this question,
however, must be reserved for the next chapter.

Malposition of the head may likewise retard the labour ;
but this has already been considered. Much suffering may
be avoided by attending to this cause, as the position is often
rectified, by pressure with the finger alone. Dr. Montgora-

459

^ry )¥ell remarks, that sometimes, although the head be at
first properly placed, yet, as labour advances, the occiput
turns tovard the spine of the ischium. The head assumes a
transverse position, and the chin recedes from the chest.
The forehead, in absence of a pain, is to be pressed up, and
also backward toward the sacrum. The pains then soon
effect delivery.

Another cause of tedious labour, is rigidity of the soft parts,
which may be dependent on advancement in life, or some local
peculiarity ; and these causes generally act more powerfully,
in a first than a subsequent labour. This rigidity may exist
in the os uteri, in the external parts, or in both ; and if,
along with this, there be premature rupture of the membranes,
the difficulty is usually increased. When it exists in the os
uteri, that part is very long of dilating ; the effect of the pains,
for a long time, is rather to soften than to dilate ; and, after
the woman has been many hours in labour, it is found, when
the pain goes off, to be collapsed, and projecting like the os
uteri in the eighth month of pregnancy. In this case, the
first stage is very slow, lasting, if we do not interfere, some-
times two or three days ; and the second is likewise tedious.
The whole process takes up, perhaps, three days or more.
When the rigidity exists chiefly, or partly, in the external
parts, they are found to be at first dry, tight, and firm.
By degrees, they become moister and more relaxed, but they
may still be so unyielding, as to keep the head for many
hours resting on the perinaeum. Some methods have been
proposed for abating the rigidity ; such as baths and fomen-
tations ; or digitalis and sickening medicines given internally ;
but these have no good effects, and some of them do harm.
Oil has been injected into the vagina, when it was dry or
rigid, or a ball of soft tallow, has been pushed up, in order to
melt slowly. They are at least harmless. It has also been
a practice to rub the back, and sides, and belly, with warm
oil, every night for some weeks previous to labour. Blood-
letting is the best remedy in such cases, and its effects are
often almost immediate. It is so beneficial and so much to
be depended on, that it is never to be omitted, in any case
of labour, protracted from rigiditv, unless the patient be
much debilitated.* Indeed we ought not, in cases of decided
rigidity, to wait till the labour have been tedious, but should
bleed to prevent that. It is even useful, if resorted to before

* Dr. Dewers bleed:} even delicHte women, and thoai* \Tho are disposed to i'aiiii
nn bring bled, but takes a smaller ((uantity from thrm.

460

labour. In delicate women, we must consider whether the
loss of blood, with a comparative easy delivery, or more pro-
tracted suffering, without loss of blood, may exhaust most,
or be most dangerous afterwards. It is 'especially proper, if
any degree of fever attend the labour, an^ in whatever part
the rigidity exists. If, however, the state of the patient
forbid this, then an opiate clyster is the appropriate remedy.
It has been proposed by Chaussier, to apply extract of bella-
dona, diluted with oil to the consistence of cream, to the os
uteri, by means of a small syringe. He says it generally acts
within lorty minutes. It has never come into general use,
and cannot be relied on.

The direction already given, respecting the completion of
the first stage of labour, within a reasonable time, must be
attended to, and is always practicable, when the means of
relaxation have been employed. When the head descends to
the perinseum, it is of service to keep the patient, for some
time, in an erect or kneeling posture. We must not allow
either the general, or the uterine, vigour, to be too much
diminished, but must finish the labour by the forceps, before
any considerable exhaustion takes place.

In some cases, the os uteri or external parts, instead of
heins rigid, are tumid, and apparently cedematous. In these,
the labour is often protracted for several hours, especially
when the os uteri is affected. In tedious labour, the os uten,
and even the cervix, sometimes become swelled, as if blood
were effused into the substance. This requires venesection,
and then a smart clyster.

The OS uteri may be naturally very small. In some instances
it has, with difficulty admitted a sewing needle ; and in two
cases, during labour, I found it almost impervious, hard,
circular, and with difficulty discovered,* but it gradually
dilated. Venesection is, in this state, of service. Sometimes
it is hard and schirrous, so that it has been deemed necessary,
to make an incision into the os uteri, to make it dilate.f it

* In a caie probablf of this kind, from Guy*s Hospital Reports, no os utori
ooald be felt An incision was made into the tumour formed bv the utcros in
the vagina, and the contractions seem to have lacerated this rarther. Grsal
exhaustion followed the laceration and birth of the child, with rapid pulse, but
the patient recovered. Lancet, June, 1S87, p. 892.

f A case of this kind occurred to Dr. Simeon of St Andrew's, and another t»
a practitioner in Amnrica. Dubosc mentions a woman 40 vears of age, who had
convulsions for two davs, during labour, from this cause. The face was pale and
the extremities cold. The orifice was very rigid, and little dilated. He cut it,
and she was delivered of a dead child. Gautier mentions a case where, after
labour had continued 16 hours, no os uteri could be found. The uterus bad
deaeanded oonaiderably in the pelvis, and there was no reason to suppose the oa

461

is also possible for the os uteri to be closed, in consequence
of inflammationy so that it has been necessary to make an
artificial opening.*

Contraction and cicatricesf in the vagina, likewise retard
labour, and cause very great pain, until they either relax or
be torn, but it is seldom necessary to perform any operation.
If it should, they must be cut. From the great contraction
of the orifice of the vagina, it has been found necessary, to
make an incision backward, through a considerable part of
the distended perinaeum. A firm hymen, may also afford so
much resistance, as to require division. It has been main-
tained, that, in all such cases, the hymen was not entire, or
quite shut, but cribriform, otherwise impregnation could not
have taken place. I need not, here, discuss that point.

Excrescences proceeding from the os uteri, an enlarged
ovarium remaining in the pelvis, or tumours attached to the
ligaments, or a stone in the bladder, may all obviously retard
the labour, some of them so much, as to require instruments.
A stone in the bladder ought, if possible, to be pushed up
beyond the head, if not, it must be extracted .{

A hernia of the bladder, by one side of the vagina, or a
descent of the bladder in fi'ont, has the effect of rendering
labour tedious. The urine should be drawn off, and the
bladder supported cautiously during a pain. I refer to page
95, for fartner remarks on this subject, and for the mode of
distinguishing, between the descending bladder, and the mem-
branes of the ovum.

A small vagina may require a long time to be dilated.

A great degree of obliquity of the uterus protracts labour.
The OS uteri may be turned very much to one side, but

uteri was high from obliauity ; an incision was made, and the child extracted by
the forceps. In six weeks the patient menstruated, and when examined after
that, the uterus was found in iin adherent state of antiversion. Other cases ara
to be found in the Diet, des Sciences Medic. Art. Hystertomie.

* Vide Case by Campardon in Reeueil Period. Tom. xli. p. 227. Moscatl
fires a case, where, in consequence of injury bv the forceps, the os uteri was so
small that it would not admit a probe. A number of incisions were made round
it, after which It dilated. In the next pregnancy slighter incisions safficed, and
in the last none were required. Aubertin performed, in a case of the kind, the
Cesarean operation. In a subsequent pregnancy. In the 7th month, the cicatrix
was ruptured, and by very little enlargement, a child was successfully extracted.
In a case given by Gautier, the os uteri was obliterated after a labour in which
the shoulder presented. The menses were retained and required a perforation
for their evacuation.

. t Kroon, In the case of a woman whose vagina was much contracted by cica*
triees, and when the head, which had advanced, took a direction to the anus, cut
the perinseum, and delivered by the vagina, being afraid thati the recto- vaginal
septum would give way. Archives, xvil. p. 614.

I A case is related in the £din. Med. Journ. for January, 1829. where a
tumour existed in the fore part of the pelvic, which could not be pushed up, and
so large as to require the use of the crotchrt. After death it was discovered to
be a stone in the bladder.

462

oftener it is directed backwards and upwards, and may be
out of the reach of the finger. Time rectifies this, but much
time and pain may be spared, by gently drawing the os
uteri forward with the finger. The patient may also be
placed for some time on her back, widi the hips somewhat
raised with a pillow. The fundus uteri may also be elerated,
or supported, by the hand placed on the abdomen. Dayenter,
who was both a candid and an experienced man, has, perhaps,
made the modems too inattentive, to obliquity of the womb,
by going to the opposite extreme.

RetroTersion of the uterus may likewise prove a cause of
tedious labour, and can only be remedied, by cautiously
attempting to press down the os uteri, from above the pubis.

Malformation of the organs of generation, may afford great
obstacles to the passage of the child, so that even an incision
may be required, as happened in the case, related by Mr«
Bonnet, in the thirty*tnird volume of the Philosophical
Transactions.

By shortness of the umbilical cord, or still more frequently,
by the cord being twisted round the neck, the labour may be
retarded, particularly the latter end of the second stage.
The cord may be on the stretch, but it never happens that it
is torn, and very seldom that the placenta is detached. We
have no certain sign of the existence of this situation ; but
there is presumptive evidence of it, when the head is drawn
up again, upon the recession of each pain. It often remains
long in a position, which we should expect to be capable of
very quick delivery. By patience, the labour shall be safely
terminated, but it may often be accelerated, by keeping the
person, for some time, in an erect posture, on her knees.
After the head is bom, it is usual to oring the cord over the
child's head, so as to set it at liberty ; and this is very proper
when it can easily be done, as it prevents the neck from
beinff compressed with the cord in the delivery of the child,
by which the respiration, if it had begun, would be checked,
or the circulation in the cord be obstructed.*

Pretematural strength of the membranes, may also, to a
certainty, prove a cause of tedious labour. This is at once
obviated, by tearing them, which is done by laying hold of
them when slack, during the remission of the pains, or, by
pressing a probe, or goose quill, against them when tense. It
sometimes requires a considerable effort to rupture them.

* Or fhiiriJiill ( Dub. Journ. Marrh, I897> <Iom not ronnidrr thin nUtc of
tn<* ronl, fu of Importiiiirr.

463

CHAP. VI.
Of Instrumenial Labour.

ORDER FIRST.

Various causes may render it necessary to accelerate deliv*
ery, -such as spitting of blood, convulsions, uterine haemor-
rhage, emphysema, the existence of aneurism, &c. These
are, however, to be considered as iti some respects adventi-
tious ; and, at present, I mean to confine myself to an account
of those, which are more immediately connected with the
power of expulsion.

It must be very evident, that if the head of the child be
unusually large, or the capacity of the pelvis be diminished, a
mechanical obstacle must arise, to the delivery of the child.
Of these two states, the last b by far the most frequeiit, and
constitutes one prominent cause of instrumental labour. I
have already explained the effect of resistance, in checking
the free and brisk action of the uterus, until, at last, the
muscular power be more roused, and strong efforts made.
These circumstances require to be maturely considered, for,
in such cases, th^ first stage of labour is very frequently,
although not invariably slow, and, if not accelerated by proper
management, the action of the uterus is apt to become
exhausted, and its vigour prove inadequate, to the safe accom-
plishment of the second stage. Different effects must be pro-
duced by the resistance, according to its degree, the constitu-
tion of the patient, and concomitant circumstances. A slight
opposition may operate, chiefly by impeding, or rendenng
irregular or inefficient, the action of the uterus, and the
consequences may vary much in different labours, and
under different treatment. A greater degree of resistance,
must invariably produce, from the obstacle afforded, a pro-
tracted and severe- labour, and, in particular, we apprehend
the occurrence of two different conditions, which are very
often conjoined. First, the head, by the gradual and severe
efforts of the uterus, and abdominal muscles, is pressed more
or less into the pelvis, and becomes impacted there, so that it
cannot, by the power of nature, be forced lower, and may
even, in many cases, require considerable pressure, to raise it
in any degree upward, by the accoucheur. This is known,
technically, under the name of the locked head, or case of

464

impaction. It is evident, that in this state, natural delivery
is next to hopeless, for all farther efforts are generally un-
availing. Secondly, the continued pressure of the head, on
the soft parts, is productive of farther diminution of the
capacity of the pelvis, for inflammation is excited, and, at
the same time, the return of blood by the veins is obstructed,
and of serum by the lymphatics. This impairs the power of
the soft parts, and renders the inflammation of the low kind,
so that, even when delivery is accomplished, sloughing suc-
ceeds, whereby very dreadful or loathsome effects are pro-
duced, if these, indeed, be not prevented by the death of the
patient, in consequence of a similar low inflammation, being
communicated to the uterus or peritonaeum. This swelling
of the parts contained within the pelvis, may take place,
although the head be not impacted, but the head cannot be
long impacted, without producing that. Here, then, is one
effect of a most formidable and alarming nature, which we
apprehend in the case under consideration. But this is not
the whole of the evil ; for the upper part of the vagina, or
the cervix uteri, may be lacerated in consequence of this
debilitated state, or any part of the uterus may be ruptured
by strong or spasmodic action; or uterine or peritoneal
inflammation may be excited previous to delivery, proving
fatal, in a few hours, after labour is terminated ; or haemor-
rhage may occur, to a fatal degree, from want of energy in
the uterus, after delivery ; or general irritation and exhaus-
tion are produced, the pulse becomes frequent and at last
feeble, the mouth parched, the skin hot, the mind confused,
and the strength sunk ; or the powers of life may be worn
out, so that the patient shall die, without any decided inflam-
mation, or disease referable to a common nosological system.
Such may, and must, in general, be the result, if assistance
be long withheld, or, if the patient, from unusual strength,
or some fortunate yielding of the cranial bones, be able, at
last, to bring forth her child. When we turn from the
mother to the foetus, we find that this continued pressure,
alters the shape of the head, and affects the action of the
brain, or the important function of circulation: first, the
scalp tumefies, and we think the head is descending, when in
reality it is stationary, and the integument is only becoming
raised ; then, the bones are squeezed closer together, and the
presenting part of the cranium, forms an angle more or less
acute, which has been compared to a sow's back. In some
instances, the two parietal protuberances are not more than

465

two inches and a half, distant from one another, but the head
is not always lengthened in the same proportion; on the
contrary, in a few cases, it is even shortened, from one bone
sliding under another. Children have been brought to me,
where the bones have been separated, and the one parietal
bone, forced completely beneath the other. Farther, we are
not to estimate the possibility of propulsion, by the approxi-
mation of the parietal, or more compressible bones ; for, not
only the greatest breadth, but the greatest resistance is near
the ear, &om the one zygoma to the other, and if the whole
of the upper part of the cranium were totally wanting, still
delivery should not be facilitated. The very yielding of the
parietal bones, allows the margin of the less compressible
portion, to become more distinct, and to be more readily
caught by the brim of the pelvis, and also to make, by its
ridge, more injurious pressure on the bladder and other soft
parts. Last of all, partly from pressure on the brain, but
independently of that, from continued pressure on the cord,
or organs of circulation, the child perishes, and whether
bom by the natural efforts, or delivered by art, is dead. Such,
then, are the effects, to parent and child, of a locked head,
effects which can only be avoided, by accelerating the pro-
gress of labour, and taking the aid of extraneous force.

When we talk of a case of impaction, which is not a very
happy term, we must not, however, suppose, that the head
is literally, and entirely, immoveable. That it is, in the strict
sense of the word, sometimes impacted, and cannot be moved,
is no doubt true, but this is not a case in which we can safely
use the forceps ; more frequently, the hand can make it
recede a little, although the uterus cannot make it advance
any more. Levret, took the word in its strictest meaning,
and imagined that the head was jammed between two points
of the pelvis. Roederer went farther, and maintained that
every part of the head was so fixed and pressed on, that not
even a needle could be passed, any where, between it and the

Eelvis. If so, how can the forceps be applied ? If the head
e jammed at every point, even making allowance for the
elasticity of its bones, we could not introduce the finger
between it and the pelvb, or reach the ear. This case of
'universal impaction rarely exists, and when it does, it requires
the head to be opened. The impacted head, admitting of the
use of the forceps, is stopt by the promontory of the sacrum
on the one hand, and part of the pubis on the other. The
resisting point generally is the projection of the sacrum ; but,

466

even in this case, the term impaction is not strictly proper,
for, if the forceps can be used, the head can be a little raised,
and the blades must be capable of being introduced. We
can be at no loss to ascertain the existence of this state.
The slow progress of the labour, the seyerity of the pains,
the tardy descent, or stationary condition of the head, its
gradual impaction, or increasing immobility, its alteration of
shape, the deformity or diminished capacity of the pelvis, the
progressive tumefaction of the vagina, all point it out, too
clearly to be mistaken ; and many of these symptoms, together
with those of general irritation and exhaustion, increase with
the period, to which labour is allowed to extend. This state
may be anticipated, when the pelvis is ascertained to be
deiormed. We know that if the head measure, in its
diameter, only three inches and a half, from one parietal pro-
tuberance to another, and in large males measures fully four,
even that part, must be compressed more or less in order to
pass.* But the distance from one zygoma to the other, mark-
ing the transverse diameter of the firm and resisting base of
the skull, when the protuberances are not large, is occasion-
ally the greatest diameter, perhaps nearly four inches, and even
if only 3|, this portion is so firm and unyielding, that a small
diminution of the pelvic space, especially if the protuberances
have been wide, requires a great and protracted force to push
it through. The more that the brim is reduced below its
natural dimensions, the longer and more piunful must the
labour be, until we come to such a deffree of contraction, as
will either render expulsion altogether impossible, or delay it
until great danger have been induced.

It is difficult to draw the line of distinction, betwixt that
degree of contraction, which will render it impossible, for
delivery to take place naturally, and that which will only
render it extremely difficult. It has been proposed to ascertain
this, by a rule founded on the dimensions of the pelvis. But
this method cannot be brought to a sufficient degree of
perfection, for the result of cases is much influenced by the
size of the child, the pliability of its head, the vigour of the
uterus, and other causes. Besides it is difficult, if not
impossible, to determine, with minute precision, the dimen-
sions of the pelvis, in the living subject, and they are apt to

* The head can be«r much more pressure before the child is born, than after it
has breathed. Respiration is more under the influence of the brain, than the
aetion of the heart is ; and the action of the latter, after birtb, ceatea when th«
brain is injured or compressed, not so much because it is directly affected, aa
because respiration, with which it is associated, ceases.

467

vary, according as the soft parts, within the pelvis, are more
or less swelled.

There is another case of protracted labour, requiring
instrumental aid, where the head is not impacted ; the pelvis
may even be of ample size. It is much more frequent m its
occurrence, and is known under the name of the case of
arrest, or, by the French writers, la tete arretie au passage^
The head is not fixed or jammed, the finger can more readily
be passed round it, the scalp may be swelled, but it is to a
less degree and firmer. The bones are nearer the perinseum,
and are never so squeezed or misplaced, and the retardation
appears to arise, rather from the nature of the pains, or the
unyielding state of the soft parts, at the outlet of the pelvis,
than from any great obstruction, ofiPered by the pelvis, to the
delivery; but I have already noticed, that a very small
obstacle, often decidedly impairs the actual force of the
uterus, though perhaps not tne degree of pain. Further,
the head descends lower than in a case of impaction. The
ear is more easily felt, not only from there being more room
for the finger, but also from being farther down. It can
be felt by introducing two fingers, whereas, in greater con-
traction, the hand sometimes must be introduced into the
vagina, to feel the ear fully. It is a mere case of tedious
labour, but a case protracted to the utmost limits of prudence,
in spite of the employment of those means, which have been
pointed out in the last chapter. It may arise from some
slight disproportion between the size of the head, and the
capacity of the pelvis, or, more frequently from variations and
irregularities of the uterine action, which have already been
fully considered. The case of impaction is clearly marked,
by the symptoms formerly detailed ; that of arrest, is ascer-
tained, by tne simple condition, of the head being station-
ary, but not jammed in the pelvis. There are many cases,
then, of arrest which are si^ely terminated by nature, and
which are placed under the class of tedious labour; but there
are many others, where it becomes prudent to accelerate de-
livery, by artificial force, and the question for deliberation
is, at what period we shall thus interfere, or, when further
delay is hazardous ?

I nave fully, and I hope, practically, detailed and considered,
the causes which render labour tedious, and have pointed out
the impropriety, of permitting the first stage to be protracted,
for, thereby, the uterus becomes enfeebled, and less able to
accomplish the second. But, when this advice has not been

46a

acted on, or when the treatment proper for the particular cases^
already described, has not heen successful in effecting delivery ,
what is the consequence, ukimately, of delay ? The uterus, by
continued, but inefficient action, or unarailing contraction,
becomes gradually debilitated, and, when, at last, delivery is
effected, it cannot contract with vigour and regularity, whereby
haemorrhage is occasioned, or, the same event is produced, by
spasmodic action of the uterus. Here, then, is one very
serious evil which may be anticipated. Next, there is a strong
disposition given to puerperal disease^ not merely to those
troublesome, though less dangerous complaints, known under
the name of weeds, or irregular febrile paroxysms, but also
to more formidable affections, of an inflammatory nature,
especially of the womb or peritonseum. Accordingly, we find
that a much larger proportion of women die, after protracted,
than after natural labour. Here, then, is another class of
evils to be apprehended. Again, although the same local
mischief, that we meet with in locked head, is not so apt to
take place, yet, the patient is not exempted from risk even
of that ; by a continuation of labour, the soft parts at last
inflame and swell, which adds not only to* the difficulty of
delivery, but also greatly to the danger of the case. If it be
necessary to enumerate other hazards, I may set down the
consequence of protracted irritation and exertion, marked by
the induction of a state of fever, and at last of great exhaustion,
insomuch, that the patient may actually die undelivered, but
this event, as well as rupture of the uterus, is less apt to occur
than in locked head. Besides all these hazards to tne mother,
the child is in danger of perishing, not, alone, from compression
of the brain, but from the continued pressure of the uterus,
after the evacuation of the water, intenering with the regular
performance of the function of circulation. These are surely
no trivial evils resulting from protracted labour; and the
utmost that I feel at liberty to concede, in favour of delay, is
that it may be permitted longer in cases of arrest, than of
impaction. Many eminent men, have placed an undue
confidence, in the power of nature, and have been hostile to
the use of instruments. For a long time I was influenced, by
the high authority and plausible arguments, as well as bold
assertions of these practitioners, but experience has compelled
me to adopt the opinion, I am now, with a firm and solemn
belief of its correctness and importance, to maintain in this
chapter. From the strength of the recommendations of Uie
partizans of nature, we ^ould suppose, that whenever the

469

child could actually be born without aid, no hazard occurred,
and, on the other hand, that instruments must of necessity,
prove not only very painful in their application, but dangerous
in their effects. Now, the first supposition is notoriously
wrong, for innumerable instances are met with, where the
mother does bear her child, without artificial aid, and much
doubtless, to the temporary exultation of the practitioner,
but, nevertheless, death takes place, or, at the best, a tedious
and bad recovery is the consequence. Or, granting the re-
covery to be excellent, is it no consideration, that the patient
has been subjected to twelve, perhaps twenty-four hours of
suffering of body, and anxiety of mind, which might have
been spared ? The second supposition, is just as positively
untrue; for, in the majority of cases, if the practitioner be
humane and gentle, the introduction of the instrument, gives
little or no pain, in so much so, that in many books, we meet
with strong and just reprehension, of the clandestine and un-
necessary use of instruments, which could never possibly take
place, if their application were attended, in such cases, with
much pain. Then, as to the pain occasioned by extraction,
that may be greater than the patient was just before suffering,
and yet not be greater than is often experienced in a natural
labour; or, even granting it to be uniformly greater, a con-
cession I make for the sake of argument, it is but for a short
time and on the whole, the suffering of the patient is less,
than if nature had been allowed, at length, to expel the child.
These positions, are perfectly correct in all cases of arrest,
when the practitioner is well instructed and cautious. Next,
as to the danger to be apprehended, I cannot, in cases of ar-
rest, see any source whence it can arise. The mere introduc-
tion of the forceps, if gently accomplished, can scarcely be
more hazardous, than the introduction of the finger, for no
force is, or ought to be, exerted. If there be hazard, it must
be in the process of extraction, and this, it is evident, can
arise, only, either from pressure of the instrument on the soft
parts, or from the head and instrument lacerating the peri-
naeum. The last event must, in general, be the consequence
of want of caution, and the first, can never be carried to any
dangerous degree, in a case of arrest, if the operator know
how to direct his efforts.

In such cases, then, we may experience much evil, from
trusting too long to nature, but add little to the suffering^
of the patient, and nothing to her hazard, by instrumental

470

aid.* When, however, we turn our attention, to the cases of
impaction the matter is different. There is greater difficulty
in introducing, and fixing accurately the instrument, and
doubtless more pain, even in this stage, is given than in cases
of arrest. When again we come to act with it, the suffering
or pain must be increased, even in the hands of a gentle
operator, in proportion to the resistance to be overcome.
The soft parts have already been pressed on, during labour
by the head ; they must still be pressed to a greater degree,
and even if the maxim, that time is equivalent to force, were
acted on, to a certain extent, it would be vain to deny, that
there must be both greater suffering, and greater danger, than
in natural labour, or than in cases oi arrest* These sufferings,
and this danger, must be in a certain degree, proportioned to
the tenderness, which has already taken place in the soft parts,
and therefore may be greatly lessened, but cannot be increased,
by an early application. Their production depends on the
ODstacle afforded. When the head has arrived at a station,
rendering the application of the short forceps practicable, no
good can arise from delay ; we only add, unprofitably, to the
suffering in the meantime, or lay the foundation of a state,
which is to render the later application of the instrument,
more painful and more hazardous. When mischief arises
from the application of the forceps, it always is owing, either
to harsh and unskilful conduct, or to the state induced, by
delaying their use too long. If it require strong efforts to
extract the child, could that child have been, safely bom, by
the power of nature, or could the uterus and abdominal
muscles, after long action, retain vigour sufficient,* to exert a
force equal to that, which is often required, to extract an
impacted head? hideed, our best writers, however fond
they may have been of delay, in cases of arrest, are disposed
to deliver, whenever the head has been locked. Nothing
can be expected from delay, except sloughing, and the alter-
native of speedy death, or a miserable existence ; and in all
oases of decided impaction, the question, I apprehend, is not
whether we shall immediately deliver, but whether we may
succeed with the forceps, or shall be obliged to use the
crotchet.

* Dr. Bttttjr sUtcs that out of 11 1 oiMt in wfaieh he used tha forotfM or l«Ter»
not one of the motbera died, nor did **any unpleaaent reeult foUow.** None oJF
the children, suppoeed to be alire wh«n the inetrument wiie need, periehed} and
not one reoelTcd any blemieh. Dnbliii Med. Trent. Vol. i. p. 61.

471

Holding the opinion I hame been laying down, it was not
without astonishment and regret, that I found Dr. Osborn
stating, that in a case requiring the use of the forceps '' all
the powers of life are exhausted, all capacity for farther
exertion is at an end, and the mind as much depressed as the
body, they would at length sink together, under the influence
of such continued but unavailing struggles, unless rescued
from it by means of art." If such a state be allowed to take
place, even in a case of arrest, but more especially of
impaction, it is much to be dreaded, that the interference of
art, shall prove as unavailing as the struggles of nature.
Were this tne opinion only of Dr. Osborn, I should pass it in
silence ; but unfortunately it is the prevailing doctrine of the
day, and the modern disciples of the school of patience, men
of talent and observation, carry their fears of the mischief,
resulting from the use of the forceps, to an extravagant
length, and place a mbtaken confidence in the efficacy, and
safety of a continued action of the expulsive powers. I have
much pleasure, however, in strengthening my opinion, with the
authority of Dr. Hamilton, the present excellent Professor of
Midwifery in Edinburgh, who has long seen the hurtful efiect
of the temporizing system, and of Dr. Osiander, in Gottingen.*

To place the argument in a yet stronger light, I shall
examine the result of delay, as deduced from the tables,
published by Dr. Breen, of the cases occurring in the Dublin
Hospital, because these appear to have been published, with-
out reference to any particular opinion.

In the course of 57 years, 78,001 women were delivered,
of whom, one out of every 92 died, and one child, out of every
18 was stillborn. If, however, we were to exclude cases of
tedious labour, and attend to the rest of cases of natural
labour, or the consequences of a correct and healthy process
of parturition, we would find the proportion of deaths to be

* In Dr. Smellie's time, be calculated that the forceps were required once in
120 c&M» Af labour ; since tben there hat been ratlier a deterioration in practice
ao.far at delay it conceroedi for the more modern calculations are I in from 158
to 168, or even I in 853. One gentleman, for whom 1 have grent respect, statea,
that the forcepa were not necetsary in the hospital practice, above once in 728
catet, and in private practice, above once in 1000.

Dr. Merrlman't practice comes nearer the line of safety, for it exhibits 1 in
90. Dr. Naegele hat employed them once in about 63 cates, which corresponds
very much with my own list ; bat 1 must qualify this, by saving, that 1 include,
with the result of my general practice, those caset where I have been called in
contaltation, which, I admit, increases beyond the due proportion the number
of instrumental deliveries. In former editions of this work, I cxpretted an
opinion, which I still adhere to, that of two evils it is infinitely safer, for the
mother, to interfere too soop, than to procrastinate.

472

altogether trifling; I am willing, however to adopt this
average. Let us now see the result of tedious labour.

In women, who were in labour of their first child, from
between 30 to 40 hours, one in 34 died, and one child in 5
was stillborn. Here then is a prodigious difference, between
even the average result of all labour, good and bad, and a
protracted labour. During the same period of labour, amongst
women, who had previously born children, and, therefore, if
requiring instruments, might be supposed to have a more
permanent obstacle, or contracted pelvis, though this is not
stated, about one in every eleven died, and one child in every
six was stillborn.

When labour was protracted between 40 and 50 hours, in
women who had not previously bom children, one in 13 died,
and the proportion of stillborn children was as one in 3].

If labour were protracted other ten hours, that is between
50 and 60, one-eleventh of the women died, and when we
proceed to the period of between 60 and 70 hours, one-eig^hth
died, and nearly one-half of the children. It is observable,
however, that only one-twelfth died in the next ten hours, but
this variation must arise from accidental circumstances.

It is impossible to give any comparison of these results,
with those afforded in the same hospital, by the use of instru-
ments ; for artificial aid, it is evident, was always long delayed,
unless in cases, where dangerous symptoms, not essential to
labour, occurred. Instruments were used, on account of
tedious labour, in 44 cases, and of these 18 died. Compare
this, with Dr. Beatty's report, already noticed.

Now, taking the proportion of deaths in the parturient state
to be, including all disasters whatever, as 1 in 92, it is most
important, to observe the progressive fatality arising from
delay. Suffering above 30 hours destroys 1 in 34 ; in other
10 hours the danger more than doubles, for 1 in 13 die; then
1 in 11, and next 1 in 8, to say nothing of the children.

Dr. Collins' tables exhibit a different result; out of 16»414
cases, 164 proved fatal, but in these the duration of labour
seems to have had no influence. Classified by time, the
greatest proportion were only 3 hours, in labour.

To deliver a system of rules, precisely applicable to every
case, is quite impossible, for much must be left to the judgment
of the practitioner, who is to be guided by general principles ;
I can therefore only offer for his consideration, the following
observations.

Firsty It is important in every case of parturition, where we

473

have reason to anticipate a tedious labour, to prevent the first
stage from being protracted. Whenever the uterus is in a
state of unsuspended action, that is to say, the pains decidedly
parturient, and continuing without long intervals, but pro-
ducing a slow effect on the os uteri, the means whether medi-
cal or mechanical, formerly pointed out, for effecting its dila-
tation, within a limited time, generally twelve hours, ought to
be resorted to.

Second^ The forceps cannot be applied, till the os uteri be
completely dilated.

Third, It has been stated by Dr. Osbom, that a living child,
cannot pass, if the conjugate diameter of the pelvis, be only
2|. Dr. Clarke is more correct, when he says, that the head
cannot pass entire, if the diameter be under 3|, and even this,
will generally require the perforator. A case, indeed, is related,
by Eaudelocque, where the distance between the parietal
bones was diminished to 2^, and the length, from the chin to
the vertex, increased to 7|. The child was alive, and by
next day, the head had recovered its shape. As the more
unyielding part of the skull, measures from 3 to 4 inches,
according to the size of the head, it is evident, that in this
case, the pelvis, must either have been larger, than was sup-
posed, from the compression of the parietal bones, or the base
of the cranium, must have descended very obliquely. But no

£roof can be drawn, from any individual case, where an entire
ead, has passed through a very small pelvis, by the power of
nature, of the possibility of always bringing an unopened
head, or the squeezed head of a dead child, to say nothing of
a living one, through such a pelvis. The effect of pressure
by instruments, and by the propulsive efforts of the uterus, on
the head, in the pelvis, is quite different. In this last case,
whilst the lateral bones are brought nearer to each other, to
as great a degree as the connecting membrane will allow, by
the edge of one, slipping a little under that of the other, the
bones before, but particularly behind, are separated, according
to the long diameter of the head, as far from each other, as
the stretching of the membrane will allow, and thus the head
is lengthened, and the shape of the brain altered. On the
other hand, when pressure is made by instruments, the effect
is chiefly to bring the lateral bones nearer, but the length is
not much increased. The degree to which the bones can be
made to approach, will depend chiefly on the breadth, 'and
partly on tne extensibility, of the connecting membranes.
The temporal, arc connected to the parietal bones, by a very

474

narrow intenaediate nemhrawe, whiek niniits of litde phy •
Tlie Biembrane at the ia^ttal aiitiire, L» generally ako
narrow, and in canes wii^e it k greatest, it ia not above half
an ineh broad. It ia here that we ahoold expect the most
change, and it ia evident that if the parietal bones were
strongly pressed, the one might be pushed nnder the other to
the extent of the breadth of the membrane, that is, half an
inch. But in the nugority of crania, there is no such breadth
of membrane, and, including the effect of stretching it here,
and at the narrower connexion at the squamous ai^ure, the
forceps as I have ascertained by experiments on recent
foetuses cannot diminish the lateral diameter, above a quarter
or at the most | of an inch, without altering the shape of the
bone itsdf, that is firactoring it. The occipital booe shdveSt
a very little, nnder the parietab^ and cannot be much pressed
back. L4iteral pressure, therefore, with the fcyrceps, does not
elongate the head, and the shape is little altered, whidi is the
reverse of what happens, in slow, bat continued pressure, by
tbe ntems* Now, taking the maximum of the effect of the
forceps, to be a diminution of half an inch, and this is allow-
ing more than can nsnaUy be calculated on, without pressing
in, or breaking the bones, it is evident, that their power, of
altering the head, is very limited.* But, granting the parietal
bones, to be brought as near, by artificial pressure, as they
sometimes are, by the uterine efforts, so as to form the ridge,
called the sow's back, still, we have the resisting base, which
cannot be taken at less than 3^, often, as we have seen, con-
siderably more. Strong forceps certainly might crush, or
squeeze this part, into smaller size, as they might readily press
in the more limber bones, but the question is not, to what
degree we could, without perforating the skin, diminish the
size of the cranium, by fracturing or bending the bones, or
lacerating their membranous connexion. It simply is, what is
the smallest pelvis, through which, we can bring an entire
head, by instruments ? and this being answered, we next ask,
if the head can be brought through this minimum pelvis,

* Baudelocque took a head which measured fourS»10tht in iu diameter, aiid
tried to compress it with tiie forceps. Tbe instrument beut io reducing it
tifo-tenths.

if the parietal proCubenineea be rtry prominent, one, or lioth, perhaps, ma^ be
depresseOf so as to diminish the diameter at that part. Dr, Campbell mentions
a case, wliere, from exostosis within the pelvis, the left frontal hone, was so
sreatly sunk in, as to malce the eye protrude. The child was alire, and th«
deformity disappeared. It is a point of some importance to know, that even in
premature labour, the parietal bones may be fractured in delivery, >% here the
pelvis is contracted.

475

with safety to the mother, and without death to the child ?
We must dismias from consideration, those cases, where, the
head being pliable, and the pains strong and continued, the
shape has been progressively altered, and the diameter
steadily diminished, till the whole could pass, and also, those,
where the head is small, and the joinings of the bones lax,
and the forceps capable of readily lessening the size. In
ordinary cases, it is evident, that we cannot expect to bring
the head, and the forceps, through a pelvis, whose conjugate
diameter is only 3^, and often it is impossible, though it
measures 3^. Cases of decided impaction, oftener call for
the crotchet, than admit of the use of the forceps, and a head
may be expelled by the natural efforts, through a pelvis which
is too small to permit of delivery by the forceps, for we not
only get rid of the thickness of the blades, but the head
moulds itself better, and passes in a line, more correctly
corresponding, to the axis of the pelvis, than it often does,
when the forceps are employed. But then, on the other
hand, we may either have deficient pains, or before the end
could be accomplished, the power of the womb, and of the
system, might be worn out.

Fourth^ It is possible to apply the forceps, and yet not be
able to act with them, that is to say, we might have them
securely fixed on the head, and yet require to use such force, '
and for such a length of time, as must destroy both mother
and child. The truth is, that this instrument is not proper,
when much resistance is to be overcome, or when the pelvis
is barely sufficient to allow, with great exertion, the head to
be brought through. We may at last succeed, but the child
is killed, and the soft parts of the mother inflame and slough,
or she is exhausted and dies. We cannot easily, sometimes
at all, apply the forceps, in cases of considerable contraction,
but, even when we can, we are not to persevere in the em*
ployment of great force. It has been said, that time is equi-
valent to force, and in many cases it is, but there is a limit to
both, and that limit is more easily recognised by experience,
than fixed by written rules. Do not let me be misunderstood,
when I say, that cases of arrest, are those which are peculiarly
adapted for the forceps, and that their utility is hmited, in
cases of impaction. Neither let me be assailed, with the
charge, of wishing to substitute the crotchet for the forceps.
I distinctly say, that in all cases, where the latter instrument,
long or short, can be introduced, and securely applied to the
head, we ought to attempt to deliver with them, but we are

476

•

neither to make pertinacious and abortive, far less, harsh
endeavours, to apply the instrument, nor having applied it,
are we, violently or doggedly, to persevere in attempts to
br&ig down an immoveable nead, in which, we must either
totally fail, or, if we succeed, must do so, at too great an
expense.

FifAj The lower that the head has descended, the more
easy, and the safer, is the use of the instrument. In almost
every case, where the forceps are beneficial, the head has so
far entered the pelvis, as to have the ear, corresponding to the
inner surface, of the upper part of the pubis, and the cranial
bones touching the perineeum. Until this descent have taken
place, the common or short forceps cannot be employed ; and
it is to this instrument that I confine my remarks, leaving the
use of the long forceps, to be speciaUy considered. When
the finger, without the introduction of the hand into the
vagina, can easily touch the ear, and when the cranium is in
contact with, although not protruding, the perinaeum, the
forceps are applicable.

Sixthy It has been laid down as a rule, that the head should
have rested on the perinaeum, for six hours, previous to the
use of the forceps : but this is quite unsatisfactory, for it may,
in many cases, be allowed to rest there longer, and, in others,
especially when the head is impacted, it would be both
unnecessary, and dangerous, to permit it to remain so long.
It is confessedly, in every instance, allowing the labour,
whether with or without propriety, to be continued, for six
hours, after delivery has become practicable.

Seventh^ Whenever the pelvis, is ascertained to be conr
tracted, we are to take care that the vigour of the uterus, be
not allowed to be exhausted, or the soft parts too long pressed
on. As soon as the head, has come within reach, of the ordi-
nary or short forceps, unless it be descending farther, and the
labour going on briskly, we ought to deliver, and whenever
the head becomes impacted, we are warranted, and impera-
tively called on, to interfere. In cases, then, where the pelvis
is disproportionate to the head, we do not wait any definite
time, and pay no regard to duration, farther than becoming,
every hour that labour is prolonged, more solicitous that the
head, may come within reach of the short, and save the neces-
sity of trying the long forceps, or resorting to the perforator.

Eighth^ Neither are we, in cases of arrest, to proceed
strictly on a rule, founded altogether on time, unless we vary
that, according to the strength of the constitution, and the

477

actual efforts made by the uterus. We cannot, with reference
to the present question, consider a patient to have been,
decidedly, 30 or 40 hours in labour, who has had slight pains
at first ; then a suspension of these, for a number of hours, and
again, perhaps, a return of trifling pains, at long intervals,
scarcely affecting the os uteri. These, can scarcely be called
the pains of labour ; and whether they should be checked or
let alone, must depend on considerations formerly brought
forward. We date our time, from the commencement of
evident and progressive effects, on the os uteri, and are also,
in part, regulated, by the state of the pains, in the second
stage. The patient may have the os uteri fully dilated, and
yet, the next stage, may be suspended, for some hours ; there
may be a pause in the uterine action, occupied in sleep, or
passed in ease. It is quite different when there has, from
the first, been continued uterine action, which has brought
the head into the pelvis; but, whether from weak, or restrained,
or irregular action, has not been sufficient for its expulsion.
In this case, presuming that the rule has been acted on, of
having the first stage accomplished, within a certain number
of hours of actual labour, that pains, producing little or no
effect on the uterus, or its mouth, have been either stopped or
rendered efficient, I am inclined to lay it down as a prmciple,
that the second stage, should be accomplished within a little
longer period of time, than was allowed for the first. But, to
prevent all mistake, in a rule which is connected with time,
I must again expressly state to the reader, that, as I formerly
spoke of the first stage, being accomplished within a certain
period of actual labour, and dated from the commencement,
not of mere pain, which may not even have been truly uterine,
but of pain affecting the os uteri ; so, the second stage, is to be
considered, also, as a state of uterine pain, and is not to have
included in its duration, those hours oi suspension, which may
have been passed in sleep or tranquillity. When I come to
lay down a rule, as to the time of interference, I would say,
and that from reflection and experience, that few cases ought
to be trusted to nature, beyond 36 hours of actual labour, and
in general it is safe to interfere within 30. There may be
cases, especially of impaction, where particular symptoms shall
justify, and call for, aid, within 24 hours ; but, in an ordinary
state of health and strength, a mere case of arrest, may be
safely trusted till between 24 and 36 hours, and the point of
inteiference, in this range of twelve hounr, must be regulated
by the efforts which have been made, the uninterrupted con-

478

tinuance of labour, the obstinacy of irreffular action, the
situation of the head, or length of tune it nas remained in a
situation, rendering the forceps applicable, and, last of all,
the general vigour of the patient. Finally, the longer that
the first stage has been protracted, and the more painful or
severe that it has been, the shorter should we wait in the
second, and vice versa : this remark, however, is only appli-
cable to cases of arrest, and not of impaction.

Ninths In cases where we anticipate the necessity of using
the forceps, and find considerable fever, or excitement of the
vascular system, with or without local tumefaction, we should
have recourse to the lancet before delivery. This renders
delivery safer, or may, in certain cases, happily supersede the
necessity of instruments. We must not, however, mistake
mere frequency of pulse, from long continued eflbrts and
excitement, for synochal fever ; a state tending to exhaustion,
for one requiring depletion.

The doctrine I have now been supporting, rests on this
principle, that it is safer to extract the child with the forceps,
than to allow the uterus to remain long in a state of action,
whether that be regular or spasmodic, and whether it lead
directly to exhaustion, or ultimately to disease arising from
irritation. If I have been tedious in my argument, or been
betrayed into repetition, I plead, that the great importance of
the question to society, has led me to trespass.

Some patients, urge the adoption of any means, which can
abridge their suffering, and are inclined to submit to delivery,
in cases where the practitioner, can, by no means, give his
consent. But in general, an opposite state of mind prevails,
and it is not, until after much distress, that the patient is
reconciled to the use of instruments. The result of a labour
is often uncertain : on this account, as well as from motives
of humanity, no hint ought, in the early part of the process,
to be given, of the probability of instruments being required.
But, as their necessity becomes more apparent, and the time
of their application draws nearer, it will be proper to prepare
the mind of the relations, for what may be necessary, if the
delivery be not naturally accomplished. With regard to the

Jatient herself, we must proceed according to her disposition,
f she be, from what we have already learned, strongly
prepossessed against interference, it will be necessary to give
such prudent hints, and such explanations of the practice, as
relating to others, though not to herself, as will prepare her
for her consent. But if we can perceive, that she is disposed

479

to agree readily, to whatever may be necessary, nothing ought
to be said till very near the time, as the anticipation of evil,
is often as distressing as the enduring of it. When we are
to deliver, it is useful to explain shortly, and delicately, what
we mean to do, which has a great eflTect in calming the mind.

When the child could not be bom by the efforts of nature,
it was, anciently, the practice, to apply strong forceps, which
destroyed the child, or to open the head, and pull it out with
a hook. To give the child a chance of living, it was next
proposed, and soon became a general practice, to turn the
child, and deliver by the feet, as thereby much force could be
exerted. If the resistance were great, however, death was
invariably the consequence ; nay, in many instances, the body
was pulled away from the head, which was left in utero. This
gave rise to many inventions, for the extraction of the head,
under this circumstance. Fillets, or bands of cloth, were also
applied over the head, to enable the practitioner to pull it
out.* These were preferred by Daventer, who informs us,
at the same time, that single or double hooks might also be
employed, and these sometimes even brought out a living
child. I have been in possession of these instruments, which
consist of two blades, like the forceps, and lock like them.
The blades are narrow, and end in a hook, which was fixed
at the ear. The danger of this instrument, arises from its
hook, which, in all cases of contracted pelvis, must have sunk
through the cranium. In cases of arrest, it might sometimes
only go through the integuments, and these are the cases
where living children were bom.

It is surprising that it did not, at once, occur to practi-
tioners, that, by taking away the hook, this danger might be
avoided, and still the head remain fixed between the blades.
It only illustrates, what I have often shown in my lectures on
surgery, that men come, frequently, within a single step of
a great improvement, without taking that step, and often
rest satisfied with imperfect knowledge, and hazardous, if
not almost fatitl practice, rather than exert the faculties of
reflection and investigation. That it is owing to this cause,
and not to any superior degree of the inventive faculty, in the
man who actually does make the discovery, is evident from
this, that no sooner is the fact published, that an improvement
has been made, than skilful men discover it in spite of every
endeavour to conceal it. Dr. Chamberlain, in 1672, pub-

* Dr. Merriman, p. 289, relates a case, where the fillet actually cut through
the neck, thus deeapltating the child.

480

lislied ci translation of the treatise of Mauriceau, in the
preface to which he mentions, that his father, himself, and
his brother, possessed a secret, by which they could deliver
women, without destroying the child, although the pelvis
were small. Previous -to this publication, however, he had
gone over to Paris, in hopes of selling his nostrum; but
rashly boasting, that he could thereby deliver a woman, whom
Mauriceau had declared could not be delivered, otherwise,
than by the Caesarean operation, and failing to effect what
he promised, he was obliged to return, with empty pockets,
and little reputation. Next, he went to Holland, where he
sold at least part of his secret, to Roger Roonhuysen, from
whom it passed to the celebrated Ruisch, as thorough a
nostrum-monger as any of them ; nor was it made public, till
1753, when De Vischer and Van de Pole purchased the
information, and divulged it. The instrument so revealed,
is known under the name of the lever, but it is now ascertained,
that Chamberlain also employed the forceps. Whether he
only sold one-half of his secret to Roonhuysen, or whether
the latter preferred the lever, or only made others acquainted
with it, preserving the forceps to himself, may, like the
lithotomy of Raw, be important in the history of quackery,
but is of little consequence to us. Of late, the originsd
instruments of Chamberlain, have been discovered, which, it
is supposed, he had manufactured himself; one of them is
a lever, the other two are forceps, of which one, is a little
more improved than the other.* Soon after this, other prac-
titioners in Britain, seem to have devised similar instruments,
which they also kept secret, and, perhaps, the first public
description, is to be found by Mr. Butler, in the Edin.
Medical Essays, for 1733. In the same volume. Chapman
is severely reprimanded, for concealing the instrument, which
he gives intimation of, in his treatise. This fault he made
reparation for, in his next edition. Dr. Smellie, in 1752,
published his system, containing, amongst other useful in-
structions, a full account of the mode of using the forceps,
the construction of which he improved ; and nearly about the
same time, Levret, in Paris, performed a similar service to
his countrymen.

I do not conceive it necessary, to detail the various
alterations which have been made on the forceps, but shall
only offer a few remarks on their construction. They may
be divided into the short and long ; into the straight, that

* Vide paper by Mr. CAnsardine, in Med. Cliir. Trans, ix. 161.

481

is, those with a single curve, and those with a double or late-
ral curve ; and those, where both rims, of the corresponding
blades are equidistant, or the one a little nearer than the
other. The endless variety shows, that much depends on the
dexterity or whim of the practitioner, and also, that there is
either no single shape the best, or that this has not been ad-
mitted to be as yet discovered. As the size of the head, and
capacity of the pelvis, and state of the presentation vary, it is
not wonderful, that sometimes one shape, should be found
more useful, than another ; it would rather be astonishing, if
any one instrument, fitted equally well in every case. We
should expect, that the most perfect instrument might be ob-
tained, by taking a mould of the head, of the breadth of the
blades, along that part, on which they are usually applied.
I have done so, and obtained very different results ; for, the
mould of one head, will by no means fit another. We may,
therefore, at once say, that no instrument can be made, which
.shall perfectly fit, and embrace, every head, even if it could
always be applied, on the same lines. We shall also find,
that although in some directions, the two margins, anterior
and posterior, of the opposite sides of the mould, be equidis-
tant, yet, in general, one shall be nearer, sometimes, by a
quarter of an inch, than the other, and whether it be the
anterior or posterior margin, which is nearest, does not always
depend on the part, but also on the shape^ of the individual
head. Now, if this principle were adopted, as it has been,
in some forceps, we should find, that, generally speaking,
such an instrument would be more apt to slip, and more
likely to injure the scalp, by pressing chiefly with one rim,
than forceps of a simpler construction would be.* The origi-
nal forceps were straight, and Levret first added the lateral,
or what was called the new curve. This was supposed to
give great advantage, by corresponding, better, with the
shape of the pelvis, and curve of the vagina. It is evident,
that little good can be gained in these views, for the instru-
ment is applied closely on the head, and ought not to depart
from it, in any way, which could make it, at a single point,
pass beyond it, and encroach on the pelvis. It is the head
that we look to, and the instrument passes with it as an
appendage, not at all affecting the shape of the moving body.t

* In heads of moderate size, ire find •n applying the straight foroepa in the
uenal line, that if the lock admit of any play, laterally, the corresponding rims,
4if the blades behind, are ^ nearer each other, than those before.

f In proof of this, I may mention, that I have known the curved forceps,

482

If any effect be produced, it must be by the portion, between
the lock and the head, but it has never been proposed, to
confine the curve to that portion. The comparative merit,
then, of the straight and the curved forceps, is to be decided,
by the answer to the question, which takes the best hold of
the head, and applies best to it ? This is only to be deter-
mined by experiment, and I believe, that although either
may be safe and eflScient, the straight blades will be least apt
to go wrong. Next, as to the length ; we find the length of
the line, from the presenting part of the head, to the side of
the chin, to be 5 or 5^ inches. The bUdes must, therefore,
*be at least that length ; but, as it would not be convenietit,
to have the lock, exactly, in contact with the head, a little
more must be added. Dr. Orme's' forceps which are straight,
and fit well, are 5| inches.* Dr. Lowder retained the sarte
form, but added another inch. Some, still meant to be
called short forceps, measure, but without advantage, longer,
and I believe. Dr. Burton's on the olher hand, measure less
than 4 inches. ^ As it is not to be expected, that the head
can be safely * brought through a pelvis, whose conjugate
diameter is only 3;^, it may appear linnecessary, to have the
blades capable of approaching nearer to each other, exter-
nally than that : but it does no harm, and may be desirable.
Some have been so wide as 3^, at the most distant part,
others so low as If. The generdity are not above 2|,
which affords every advantage. The distance of the extrem-
ities, from each other, when closed, varies, but it is never
expected, nor intended, that when applifeld, they should
approximate to their utmost degree. If they did, the head
would suffer, and if the extremities grasped the jaw, it might
be much injured. It is necessary, not only to have both
long and short forceps, but also it will be useful, to have a

* applied the vrron|f way, by mistake, aiid yet the' operator ' dellrertd the AM
without difficulty, and only discovered his mistake, after the birth of the bead.

• The best form of forceps, is a modification of Dr. Orme*s. ITiese apply well
to a head of moderate size, but if it be large, we Ifind that the bindes for an extent
of 84 inches from their extreniitles, toward the lock, are not quite in contact witn
the surface, which they ought to embrace, of the lower, and anterior pari oi tbe
parietal bone, the temporal bone, and the cheek; whilst their points nip the Jttr.
This defect is best seen, by applyinf^ them on an aiicurate cast of th^ bead, wbifn
does not yield, for^ on the head itself, it is often less visible, from the soft skin
rising up to the surface ; perhaps, also,' by our befng able to comprtws, somewnwi
the bones, so as to make the instrument fit better. There is, without ^f*^l
Tantage, added to, the diameter, of the passing head and instrument, ffom t tot
Inch. In some cAses, I have found the extreme width, taken from **"• **H
surface of the blades, to be 4^. Tlie defect is remedied, by making the bl«a^
for 3^ from their end, a very little straighter, and the higher part nearer iw
lock, to curve in a trifle more ; but the first alteration is the most imp4»r(ant.

483

air, more curved toward the extreipties, than at the middle,
ike ,the blades of the lever.* This will be found to ansiy^r
better, in face presentations, than the conmion forceps. The
lock may be so disposed, as to make one blade of these, fit
.one of the common straight fprceps, for it is not necessary,
that the two blades should be exactly the same : on the con-
trary, there are ca^es, where bla4es of different curvature,
can be most easiW introduced, apd most efficiently acted
with. I believe Dr. D. Davis was the iSrst, who went,
methodically, on this principle, but perhaps carried it too far.

If the forceps with the double curve be employed, the
blades must be so introduced, that their convex edge, shall be
•next the face. It is, therefore necessary, to determine, which
blade, shall be placed next the pubis, before we begin, and
this we do, by ascertaining to which side the face lies, by ex-
amining the position of the ear, as well as the general shape
of the presentation. The blade to be first used, is to be
placed, nearest us, to prevent mistake. If we use the forceps
with a. single curve, it is a matter of indifference, which blade
is first inserted, .and my directions apply to this instrument.

The blades are to be gently heated, bv pl^^cing them in
tepid water. The bladder being emptied, and the patient
laid on her left side, in the usual posture, but with, the pelves
near the. edge pf the bed, a female assistant, is to go to, the
opposite eiide, to allow her to hold by b^, if she wish it ;
another, may be required, to support and hold i^p , t^e, kncje
and thigh, when, the second blade is introducing.

All things being prepared, and the head bei^g supposed
to be placed, in the same position as in natural labour, th.e
operator, gently introducing two fingers, between the head
and the pubis, feels for the ear ;t that he may know the. part
• of the head, on which he has hia fingers ; then, taking up the
blade, he carries the extremity of it, along the hollow oi the
band, cautiously i^nd gently, into the , vagina, sliding it on,
between, the two fingers and the head. In this introduction,
but more especially, in its passage over that part of t^e
head, which it first touches, it is, owing to the curve of
the .blade, necessary to ht^ve the handle directed backwards.

The lock t^j ^Iflo be brought a lUUe nearer the fenettra, lo th^t the curje
may be rather more abropt. There it no occation for | of an Inch, Intervening
between the lock and the scalp.

* The curre may be the tame as in the lever, till S inches from the extremltv-
Then, in place of being so straight as the lever, let the blades bend In, towatd the
lock, like the forceps.
. t This Dr. Hamilton does pot think necespry.

4h4

and almost parallel with the perinanim ; but, as the blade
a^lvances, the handle will come more forward. The point of
the hlmle, in gently to be insinuated, between the bead and
the pelviM, with a diirht wri^rglin^ motion: and when the
fm^efH are no Ioniser tiseful, in guiding the point, they are to
be, no far, witlidrawn, as not to occupy room. When the
extremity gets opposite to the ear, it in general slips very
easily onward, and the complete introduction, is sometimes
succeeded, by a gush of water, which may be foetid, and
tinned with meconium, although the child be alive. When
the blade is fully inserted, the handle is in a line, nearly par-
allel, with the inner surface of the symphysis pubis, but not
always perfectly corresponding, to the axis of the brim of the

f»elvis, for it is often, as we shall soon observe, carried on a
ittlc too far. In a natural presentation, the blade does not
traverse a line, from the vertex to the chin, but rather from
the pari(;tal protuberance, obliquely forward on the head, with
the vertex considerably beyond the rim. The anterior rim,
or that toward the face, traverses the parietal, perhaps a little
of the frontal, the squamous portion of the temporal bone,
and the zygoma, but the precise spots of the different bones,
which the rim may rest on, need not be detailed, nor are they
always exactly the same. In general, the fenestra includes
the protuberance, so also does it the ear, but sometimes the
posterior rim, merely skirts the ear, perhaps rests on it. The
central part of the points, is generally on the angle of the
jaw ; the anterior, rounded, part of the extremity of the rim,
18 on the jaw blade ; the posterior on the side of the neck,
below the car. If the head be small, and the forceps a little
more advanced, the angle of the jaw, is in the end of the
fenestra. The distance of the points, of the two blades, will
vary from IJ to 2 J. The distance of the lock from the
scalp from | to one inch.

In this introduction and application of the blade, however,
we do not nicely manoBuvre, in order to describe any given
line ; but are sure, if we introduce it directly behmd the
pubis, and fairly over the ear, onwards, till it rest, and the
handle bo brought forward, that it has gone, almost sua spcnte
in a right direction. If we carry, too niuch, to either side of
the pelvis, we have an insecure and bad hold of the head,
and the instrument is almost certain to slip.

If the blades be not introduced, far enough beyond the ear,
to get their extremities over the base of the skull, so as to
embrace fully the head, in their grasp,' it is impossible to act

485

with them. The extremities going only as far as the ears, or
a little beyond them, may indeed catch the head between
their points, but can do no more, and they slip the moment
we begin to pull.

The first blade being applied, it seldom requires to be
supported, but remains sufficiently fixed, between the head
and the pubis, and the operator proceeds to introduce, the
second, exactly in a reyersed manner. When the first was
inserted into the vagina, its handle was placed almost directly
backwards ; when the second is inserted, its handle is directed
forward ; and, therefore, at this time, the thigh of the patient
must be raised from the other, by an assistant. Two fingers
are to be introduced into the vagina, and along these, the
extremity of the blade is to be gently slid, either by the side,
or behind, into the passage, and guided past the root of the
first blade. In whatever way it is inserted, it is to be cau-
tiously brought to lie, on the inside of the perinaeum, or
posterior part of the vagina. Then, by moving the handle
backward, and carrying, in the same degree, the extremity
of the blade up along the sacrum, it traverses the head, in a
line corresponding to the blade, on]^the opposite side. It
glides easily between the head and vagina, along the curve
of the sacrum; and in doing so, comes, sometimes very readily,
and at once, to meet the lock of the other blade, and join
correctly. But, more frequently, it requires a little address
to lock the instrument, so, that it may be necessary, to with-
draw the one, or the other, a little, generally the first, which
has been pushed too far on, in order to make them meet.
If this be not sufficient, it will probably be found, that the
difficulty arises, from the blades not being correctly placed,
on parallel lines, on the opposite sides of the head, but the
one a little nearer the face, or occiput, than the other, or
obliquely, so that when we attempt to join them, they do not
lock, but the handles cross, or pass each other. This is
rectified, by moving the one, which seems wrong placed,
gently to a correct position ; or, if this cannot be done, it
must be withdrawn, and re-introduced. To attempt, by
force, to thrust the handles together, to make them unite,
would give pain, and, most likely, the instrument should
dip, when we begin to act ; and, if a young practitioner, who
tried- the forceps for the first time, were foolishly to attempt
to pull with the blades, without locking them, he would only
pull them out, without bringing away the head. In joining
the instrument, care must be taken, that neither the nyrapha.

486

nor any other part of the mother, be included in the lock.
The finger is therefore passed round the poiAt of junction,
before the handles be pressed tbgether, or correctly locked.
As the blades are fixed along the sides of the heatf, which ia
Tyin^ in the axis of the brim of the pelvic, it is evident fliat
when they are jolrfed, the handles will be situated in the same
line or axis, aiid therefore will be directed downwaJrd, and
backward, the lock resting on the margin of the perinaeum.

I have described the first blade $s being introduced in
front, between the head atid the pubis, but this is by no
meatus necesisalry. On the contrary, we sometimes find it
icLvicYi easier, to introduce the posterior blade first, and, in that
6ase, should do so.

In this process, we must be deliberate and cautious. We
fnust never Restrict ourselves in point of time, nor promise
that it shall be very speedily accofnplished. If we act other-
wise, we shall be very apt to do mischief, or, if we find diffii-
6ulty, to abandon the attempt. When^ the pelvis is so
con'traicted, as to make it judt practicable, to ititroduce the
forceps, that part of the head, which is above the pubis
sometimes projects a little over it, so that we cannbt pass the
blaide until we press backward a little with the finger, on that
part ^hich we can reach, or when the head is impacted, we
taay find it necessary, before we can insinuate the forceps, to
Endeavour to raiise it a little, so as to facilitate the introduc-^
tion of the blade. AH attempts to overcome the resistance
by force, every trial which gives much pain, must be repro-
bated. But, on the other hand, so long as his conduct is
gentle arid prudent, the young practitioner must not be
deterred, because the patient complains, for the uterine pains
Are often excited by his attempt; or, some women, from
timidity, complain, when no unusual irritation is given to the
parts. Slow, persevering, careful trials, must be made ; and
i beg, as he values the Ufe of a human being, and his own

{leace of mind, that he do not desist, and have recourse to
he crotchet in cases at all ddubtful, until it have been well
Hscertaitied, that a safer instrument cannot be appUed.

The blades being joined, we pull the instrument downward,
arid move it, a little, to ascertain that it is well applied. We
then begin to extract^ taking advantage of the first pain. If
the pains still continue, we pull downi^ard, and backward, in
the direction of the axis of the brim. Then we move the
handle a little forward, toward the pubis; and next, after
halting a second, move it slowly back agftin, still pullin«r

487

down. We mudt not Cftrry tjhe forc^p^^ rapidly or strongly,
forward or backward, against the pubis oj; perinaeum, for the
direction, of our force should be downward, in tlie linp of
the axis of the brim. The motion of the pendulum kind, is
intend^ed to facilitate this, but, if performed >vlth a free, and
forcible swing, the soft parts must be bruised^ and great
pajn occasioned. The operatipii of extracting, is not to be
carried oji rs^pidly, or without intermission : on the contrary,
we mu3t be circumspect, and imitate the steps of n,ature.
We must act, and cease to act, alternately, and examine, as
we go op, the progress we are makingy and also ascertain
that the instrument be still properly adapted to the head;
for it someliraes slips, or shifts, and this is particularly the
case, if it have not been., at first, very correctly applied, tt
is sure to slip, if the blades have not been introduced, far
enough, to embrace fully the head, or If they be too pear the
face or the occiput> ox be npt q^uite parallel to ea^cb other,
and however cprrectly they may at first have beep applied,'
the efforts for extipaction may make them shift a little. In
this event, we must stop and rectify the error ; and, in every
instance, must ascertain that the head be descending along
with the instrument, otherwise the forceps may come suddenly
away. The head being made to descend, the face begins to
turn into the hoUpw of thp sac^un^, and, in the same degree,
the handles niust movp round on their a?.is ; and when thg
face is thrown fully into the hollow, the handles must be
turned more forward and upwarfl, being placed in the axis of
the outlet. The peQdi|lum kind of motion, must now be very
little, ai)d is to be dir^ctpd from one ischium toward another.
As tlie head p^ses oi^t, the handles turn up, over the sym-
physis pubis. In this stage, we must proceed circvimspectly,
otherwise the perinaeum may be torn. Thi? U more apt to
happen, if we be not attentivie to the correct position of the
forceps on the head. The blades are apt to slip a little, and
not embrace the head properly, but when it has descended,
and is just about to turn, the blades pTess much pn the peri-
nsuip, and when the head does turn, their e4gc is apt to act
90 much on the perineum, as readily to tear it.

The power require4 fo be exerted, in bringing down the
head, musti evidently, be proportioned to the resistance, and
i^ npn^etimes very considerable. But much paii^ to the
mother, and fatigue to the operator, are sometimes produced,
by npt pulling or acting iu the proper direction.

If we cannot, in the usual way, apply the blades efficiently,

488

or act with them, we sometimes, readily succeed, by intro-
ducing them at the rides of the pelvis, over the face and
Tcrtex, and almost immediately make an impresrion on the
head. The blades often shift gradually, so as to get on the
sides of the head, as it descends. I have not seen the fea^
tures injured in this way.

If the forceps be injudiciously introduced, the bladder or
uterus may be perforated ; or if the head be allowed to re-
main too long jammed in the pelris, some of the soft parts
may slough. The under and posterior part of the bladder
is apt to slot^ off, leaving the woman incapable of retaining
her urine. This is best prevented, by being extremely at-
tentive in every case, especially in those, where the soft parts
have suffered much or long from pressure, to evacuate the
urine regularly twice ar^lay, employing, if necessary, the
catheter. The parts ought also to be kept very clean, and
may be frequently bathed, with decoction of camomile flowers.

If the fontaneile, or crown of the head, present, the blades
of the forceps are placed directly over the ears, which are in-
cluded in the fenestras. The posterior rim, will pass very
near the parietal protuberance, either on it, or just before or
behind its projection, according to the size of the head, and
its obliquity of position. The points, are at the side of the
neck, or sometimes directed toward the back. The anterior
rim, skirts, or perhaps even presses on, the very angle of the
jaw. We endeavour, as the bead advances, to make the
vertex, rather than the face, descend, raising as much as

Eossible the forehead. If the change in the position of the
ead, be such, as to make it useful to withdraw the blades,
and apply them in a better direction, we do so. Indeed, if
any favourable change can be effected, before the forceps be
applied, it will be so much the better.

1 have formerly noticed those circumstances, which, usually,
render a face presentation tedious ; and if the pelvis be m
any degree contracted, or the head above the average size,
the difficulty is increased, and the forceps may be required.
The ordinary instrument, does not apply well to the head,
but its extremities pass off from the occiput. It is, therefore,
proper to have forceps more curved at their ends, as I have,
a little before, described. The blades are applied, as in
natural presentation, on the sides of the head. The lock, is
nearly opposite the lower part of the forehead, or root of the
nose, and the extremities, embrace the back part of the tem-
poral, and side of the occipital bone, near the neck. The

489

forehead is generally lowest, and we have seen, that usually
it turns backward, so as ultimately to rest on the perinseum,
whilst the chin passes out from under the arch of the pubis.
We act with the forceps, in the direction of the axis of the
brim, till the forehead distend the perinseum, and then we
either may desist, or continue to act, but more in the direc-
tion of the outlet. It is seldom necessary to alter the course
of the blades.

In face cases. Dr. Davis proposes, to bring down the occi-
put, by fixing on it a vectis, having sharp projections on its
concavity, to fix it on the scalp. But this advice, I believe,
has not been adopted.

The pelvis is sometimes sufiSciently large ak the brim, to
allow the head to enter, more or less easily, into the cavity,
but the outlet is more contracted, or altered in the shape, so
that the head is stopped there, and the forceps are required.
This is rare, but when it does occur, the blades ought to be
applied on the sides of the head, if possible, in the usual way.
Mere rigidity of the perinaeum and soft parts, can scarcely
ever of itself, require instrumental aid. Timely bleeding,
&c., may prevent this necessity.

When the breech presents, and artificial aid is required,
it is customary, to apply the blunt hook, on one of the groins,
as the thigh is folded up on the belly. This requires care,
lest the end of it, injure some of the skin of the child, or the
external parts of generation. We ought to introduce the
finger, and feel for the point of the hook, after that is passed
over the thigh, and keep on it as a guide and defence till it
be fairly drawn down and fixed. I have known the extremity
forced into the thigh. If much force be employed, the
bone may be fractured, for, it is more easily broken, than
dislocated. If the breech be within reach of the short
forceps, we should apply the blades, over the sides of the
child's pelvis, which will be diagonal with regard to that of
the mother.

Having offered these practical directions, for the use of the
forceps, in cases where the head has descended, considerably,
in the pelvis, I am next to state, that sometimes it remains
long very high, or is absolutely prevented, by the contraction
of the brim, from making any great progress. When it is
altogether above the brim, or only a small part, after many
pains has entered, the forceps cannot be used, and no remarks
that I make, are to be construed as applicable to such a case.
But, if no such deformity exist, we may contemplate the ap-

490

plicaldon of Icmg forceps^ in a high aituatioa of tbe head.
There are two eauses, which may keep the head high. The
first ifi, such a degree of contraction of the brim, as barely-
renders it difficult, for the uterus tp force the head so low> a^
io ordinary forceps cases, and dangerous^ to wait until time
ascertain, experimentally, the impossibility of accomplishing
this. The more yielding parts oi the cranium have entered,
the scalp probably, is swollen, but the more solid and resisting
part of the head, is still aboye the brim, yet, tbe contraction
of the pelvis, is not so decided, as to make us sure of the
necessity of using the instrument. The finger must be car-
ried high, to feel the ear, and ascertain the position, and the
common forceps are too short, as the lock, if not part of their
handles, would be buried perhaps in the vagina. The
second cause is, spasmodic action of the uterus, complicated
with some degree of contraction in the brim, but not so much
as to prevent regular and efficient action, from forcing down
the head ; for I have known this state occur, in those, who
have formerly bom living children, without aid. When
spasm, in such instances, takes place, and is not speedily re-
moved, this very formidable state may be met with ; and so
far from the head being forced lower, by the pains, it is some-
times, rather, raised a little, during the pain. Long delay,
in this state, is dangerous, and whatever practice is to be
adopted, must be resorted to promptly. Inflam^iation is a
frequent consequence, and may begin previous to delivery.

It long ago was, and still with some is, the practice, in thb
state, to turn the child ; but tbe force required, to pull the
head through a contracted pelvis, can scarcely fail to be fatal
to the chUd, to say nothing of the difficulty, and danger of
turning, in a uterus much contracted. Lessening the head
implies, to a certainty, the death of the child, which is barely
possible to be avoided, by the other practice ; but it does not
necessarily endanger the mother. A third practice, and that
which comes before us, now, for consideration, is the appli*
cation of long forceps.* Smellie, first used the long forceps,
in this high situation, and advises the blades to be applied,
over the ears, in the same way as the short ones. It is vain
to attempt this mode of application, when the bead is of the
ordinary size and firmness, if the pelvis, including its soft
lining, do not measure fully 3^ inches. The lateral diameter
of the head, cannot be calc\dated at less than 3^, and it may

• * Baadtlooqae prefers turning, when that St pradicablc. Snxtorphan^ Pleok
positively forbid the forcepH. Hamilton and Oviander um them.

491

be mof^. To this, we mat, in l^e dise^s I am confiidering^,
add the tbicknessT of tfhe* blades af the forcepsy oi^ i, for
although it be said, that the fenestra allows the' prtituberame
to entei*, aiid consequently, the blades to sink, to a level
with their surface, yet this cannot be always depended on.
It is difficult fo e'ompress the skulT beyond ^ of an inch by
instruments, and therefore' the applicability of thei foreeps,
either krag eft short, must be very limited in cases of con-
tritcted pelvis. I have? carefully made trials, in ai pelvis
metouring 3^, and found that the head could not be grasped,
miless it Were ^ee above the brim. In this case, the lock,
although the bl&des from that to their extremity, measure 7
inches, viust be within the vagina, and no part of the head
eati be made to entei^ the pehris ; erven if it could, we should
fiAd it very difficult, to act with the instrumfeni, or draw the
head down, in the proper direction, for, in order to do so, the
handles must pres&r the perinaeum, as far back as the coccyx,
tod if this boile, and the sacrum, curve much forward, even
this positioTil, of the handle, would not be far enough back, to
give us any advantage. Granting that, in every case, the
forceps could be applied^ over the ears of the child, when the
head is aboVe the brim, (yt when oi<Iy a small part has entered,
how far could we bring down the head and forceps, in a pelvis
meaefuring 3^. This may be determined, by marking the
distance from the lock, to that part of the blades, which
recedes exactly to this extent. It is 2J inches, and only
about half an inch of the head, shall have entered the brim.
If we increase the diameter of the pelvis to 3|, the distance
irom the lock to that part of the blades, where the instrument
would stop, Would be 3}, and about 1^ of the head shall
have entered. ' Next, supposing that by the pressure of the
blades, we can squeeze the head smaller, even to the extent
bf half an inch^ which is more than can be depended on, we
should find, that the minimum diameter, of a pelvis, through
Whi($h we call bring a head, in the most favourable circum-
stances) cannot be under 3^ ; and even then, if practicable, it
Will be both difficult and dangerous, to use the forceps,
applied in this way, when the head is above the brim.
From the best consideration I can give to the subject, I must
say, that we really cannot expect to act, in this mode, with
the long forceps, in a pelvis so contracted, as not, if the pains
be strong, to admit, ultimately, of the use of the short forceps.
But an important question, will be, the dimensions being the
same, can we or ouprht wo to use the lonjr forceps, rather

492

than wait, till the head have come, within reach of the short ?
for I am satisfied, that we cannot safely use the former, in a
pelvis, necessarily, preventing the employment of the latter.
We can easily conceive cases, where the head has descended,
not quite low enough to use the latter, and yet not far from
it, and in which, if the pains were brisker, and a little more
could be pushed down, we could apply them. But the strength
is wearing out, and the pains are defective, and we dare not
wait longer. Here we are decided, not by the greater con-
traction of the pelvis, requiring us to do with one instrument,
what we never could have done with another, but by circum-
stances, of a different nature, of expediency. But it may
well be said, that this argument applies only to the applica-
tion of the forceps in an unfavourable way, for, that if we
placed the blades differently, namely, at the sides of the
pelvis, and consequently on the occiput and face of the child,
we should save something, at least, the thickness of the
blades, besides applying them more easily. The objection is
fair, and I am quite satisfied, that we may thus bring down a
head, which barely could not have come within reach of the
short forceps, and never could have been delivered by the
long ones, applied on the sides of the head. Still, the power
of this instrument, is limited to a very narrow line, which I
shall, at the conclusion of this consideration, define. Baude-
locque, first distinctly mentions the plan, and argues against
it, not only from the insecurity of the hold, but from its in-
creasinfiT) by pressure, the lateral diameter of the head,
although his o^ experiments prove, that this sometimes does
not take place at all, and, in any case, only to a very limited
degree. He mentions it as the proposal of De Leurye,* but
it is evident, that he only applied them diagonally. If we
place one blade, toward the sacro-iliac articulation, and the
other, behind the body of the opposite pubis, its inner margin
being at the symphysis, we can make the top of the head,
just project into the brim, but no more. If we introduce the
blades at the sides of the pelvis, and apply one on the occi-
put, and the other on the face, as is now most frequently
done, when the long forceps are used, we find, that the ex-
tremity of the one, on the face, rests on, or embraces the

* <* Le forreps ne s*Rpp1iqae jamais lateralement, une branche est preaque
toi^ours sous le oorp du pubis, et c*est la plus difficile a placer : I'autre se place
pres la tuberosity de I'ischion, et je peux certifier que, matgr^ toutea les pre-
cautions, on n'embrasse jamaifl la tcte cotnpletrment, surtout avec la branclie qui
est la plus pres de la face." Traits dcs accouchemens, § 796.

493

chin.* The extreme width, between the blades varies, of
course, with the size of the head, from 4| to 5 inches, and
the distance from the lock to the scalp, from 1| to 2|. In
this way, we not only introduce, and apply the forceps, more
easily than in the other, but we have a good hold, and save ^
on tne thickness of the blades. We also find, that we can
better acti in the proper direction of the axis of the brim.
We must, however, have a lateral diameter of at least 5 inches,
if the head be large. In order to save the face. Dr. Davis
proposes to have the inside of the blade, which is placed on
the face, stuffed ; but, whilst this, must add to the diameter
of the passing body, it will afford little additional security to
the face. When we have got the blades fixed, we must
endeavour to extract, during the existence of a pain, but
never can succeed, if we do not pull sufficiently backward ;
for if we pull directly .down, we only press the head, more
firmly, against the upper part of the pubis. Although the
upper margin of the sacrum, be sometimes level with the linea
ilio-pectinea, yet, often it is half an inch higher, and projects
nearly as much, over the surface of the first bone. In such
cases, the head can enter easier, if directed obliquely back-
ward, which is another reason for doing so, and also for
placing the blades at the sides. If we succeed, in bringing
down the head, into the cavity of the pelvis, we may then
exchange the long for the short forceps, and apply them in
the usual way, over the sides of the head. On the whole, I
would give it as my opinion, that a well instructed practitioner,
who has had, already, some experience in the use of the short
forceps, is warranted to make a cautious, steady, but gentle
attempt, to apply, and act with the long forceps, in a case
where he is not quite decided, that the perforator is indis-
pensable, and where the head is higher than permits the ap-
Elication of the short forceps. But where the head is very
igh, the success will bear but a small proportion, indeed, to
the failure, and I do strongly urge the operator, never to
make reiterated trials and em)rts, which can only end, in the
production of fatal inflammation.

As a general rule, it is to be remembered, that the employ-
ment of the forceps is dangerous, in proportion to the diffi-
culty of applying them, and the force required in acting with
them. We therefore, when the child is dead, invariably
prefer lessening the head.

* If the forceps have a lateral cunre, the conyex margin of the blade most ba
Introduced toward the tacrum.

494

I doubt not, that. many young praotitioners, when examin-
.ing the poeUion of the head, in a case of tedious labour, or
.of arrest, have imagined, that by using the finger, as a hook,
over the bulging .part of the skull, tthey might accomplish
delivery. But were the fingers strong .enough, they are too
thick, and occupy too much room, and even if they did not,
.they have not sufficient strength. But, what the fingers can-
not do, may often be done with the lever, which is unfortun-
ately named, for it ought not to be employed to wrench, but
'to hook, or draw down, the head, and its proper application,
would be less apt to be mistaken, were it called the tractor.
In using this, our first object, is to h^ve it placed on some
rounded or projecting, and, likewise, firm part of the hea49
which can afford a secure fixture, to > the extremity of the
instrument, and which, at the same time, may not be injured
by it. It has a good hold, on the side of the jaw and chin,
but the bone. may be injured or broken: another, equally good,
and safer, as being a stronger part, is the back of the head)
comprising the lower and back part of the parietal bone, the
very lower and back part of the temporal, where the n^astoid
process is afterward to be developed, and the lower and lateral
part of the occipital bone, as near the vertebra, as the neck
will allow. Here the extremity of the lever ought to rest*
When the head is so oblique, as to have the face much directed
upward, the end has been placed on the forehead. Some
advise, that we should let it remain on the. first place, where
we find it fit, and obtain a hold, without regard to what that
may be. The instrument, may be introduced under the pubis,
but the extremitv being curved, it is often easier, to introduce
it, at; the side of the pelvis, or even at the back, along the
-side of the sacrum, working it gently round, toward the front,
and till it rest on a good place, generally, the one I have de-
scribed. We wait, then, till a pain come on, during which,
'we draw or press down the head, in the direction of the axis,
of the brim, that is, toward the coccyx,, keeping the blade
steady, by pressing it on the head) with the fingers of the left
hand, in the vagina, and if we do, in any degree» employ it
-as a lever, by bringing slightly forward the handle, we make
these fingers, and not the pubis or soft parts, the fulcrum.
Sometimes :we may press, with the thumb, on the stalk of the
blade, and with the fingers, on the opposite part of the head,
in the hollow of the sacrum. But we never wrench down (he
head, nor allow the blade, to squeeze the lining of the pelvis,
making it a fulcrum. There must, indeed, be more or less

495

pressure made, by the head itself, a^inst the back of the

Stelvis, as it moves down along it. When we act with the
orceps, the one blade is an antagonist to the other, and no
pressure is made, necessarily on the soft parts, beyond that
proceeding from the mere bulk of the passing body. But it
is otherwise with the lever, for, although we use it, as much as
possible, as a hook or tractor, yet, it cannot act exclusively
on the head, as the Crotchet might do, but must, by its
pressulre on the one side of the head, make the other, rub or
press on the opposite part of the pelvis, and, therefore, with
all our care, and even if we used two fingers as antagonists,
the soft parts must be more pressed on, than by the forceps.
We shall always find the lever, more or less effectual, in
propoHion to the assistance afforded by the uterus itself, and
it ought not to be employed, when we have no reason to
expect the active co-operation of the pains. It should be
' considered more in the light of an aid to the pains, than the
forceps, and more dependent on: them for success, consequent-
ly, more limited in its utility. In this view it is a subordinate
instrument, in so far as it is used in milder cases of arrest,
which perhaps might, ultimately, have been' terminated by the
natural efforts, but to which, it might not have been prudent,
longer to have trusted. The pains may not be strong, bat
still they assist the instrument, and are generally excited by
it to greater efficiency, otherwise we do less good.* But, in
another view, it is to be considered as superior, in so far, as it
may be proposed,' in oases, midway, between those admitting
' the nse of the short, and demanding that of the long forceps.
Some will sayj that it can be used, whenever the long forceps
can be employed. When the head is brought into the cavity
of the pelvis, the difficulty is overcome, and we may either
remove the instrument, expecting the head to pass oat,
speedily ,"by the natural efforts, or we change the direction of
• the leVer, and act with it, in that of the axis of the outlet.
Some employ the forceps, but if we have gone thus far' with
the lever we may safely make it finish its own work.

When the crown of the head presents, the fixture of the
blade, is generallv near the situation of the mastoid wocess,
or toward the occiput. The last, has the advantage, of sooner
rendering the position of the head, properly oblique.

* If there be scarcely anj pain, and the circomitanees be, otherwise, siicfa as to
make us believe, that with the aid of uterine action, the delivery mlvht be soon
pffected, by the instrnmenf, we mav, after applying it, g\ye ergot, before we Met
with It. This may also be proper in some forceps casra.

496

In face cases, the lever passes in a line, from the forehead
or root of the nose, its extremity resting on the side of the
occiput, between the vertex and neck, but scarcely so far back
as the vertex.

I have long been of opinion, that although practice may
enable a man, to use either the lever or the forceps with dex-
terity, yet, a young practitioner shall be less apt to injure his
I)atient, and less likely to* be foiled in his attempts, with the
atter than with the former, and therefore I give a decided
preference to the forceps. At the same time, I think I have
done justice to the lever.

ORDER SECOND.

It unfortunately happens, that sometimes the pelvis is so
greatly deformed, as not to permit the head to pass, until it
have been lessened by being opened.

It is universally agreed, that a living child, at the full time,
cannot pass through a pelvis, whose conjugate diameter, is
only two inches and a half. It has been stated by high
authority, that if the dimensions were '^ certainly under tliree
inches, a living child could not be born." . This opinion is
decidedly true, and the few exceptions which may, perchance,
occur, depend on the original size, and peculiar constitution
of the child, together with the pliability of the cranium, or
the peculiar shape of the pelvis, and the force and activity of
the uterus, as well as the general strength of the woman. The
resisting part of the base of the skull, often measures above
three inches and a half, sometimes near four inches ; and, in
this case, with all the efforts made by the forceps, even sup-
posing that they could be applied, it must be, in every
instance, laborious, and, in many, next to impossible, with
safety to the mother, leaving the child altogether out of the
question, to bring down the head. There have indeed, been
instances, where, even by the efforts of nature, living children
have been expelled, through a pelvis, supposed to measure only
three inches ; and there are similar examples of the delivery
being under the same conformation, accomplished by instru-
mental aid.* But we have no ground to expect, from what
has already been said, that the head can be brought unopened,

* M. Baadelocque relates a most .interesting case, where there were decided
marks of the foetus being dead in utero, and yet these were delusire ; for, by the
forcm, the woman was delivered of a livinc child, although the pelvis was sup-
po8«Ki to measure, only about three inches. L* Art des Accouch. last edition, sect.
J9 1 7.— Cases in point may also be seen in Dr. Alexander Hamilton's Letters, pp.
94> 102, 18.^Simi]ar instances have come within my own liiiowltrdge.

497

by the forceps through a pelvis whose conjugate diameter is
not fully 3^9 inclusive of the soft parts. Every one knows,
that even at the full time, the child is sometimes very small ;
or the head, when not very diminutive, may be either small at
the base, or more than usually pliant. But in making up our
judgment, in a case of deformity, we are not justified in calcu*
lating on the happy coincidence of such a state ; but ought,
unless the finger can inform us to the contrary, to reason on
the ordinary size and firmness of the cranium. We are not
warranted, however, instantly to open the head, merely be-
cause we estimate that the pelvis does not, in its conjugate
diameter, measure fully three inches ; but because we have
ascertained, by a sufficient, but not a dangerous trial, that the
uterine action cannot force down the head, so that the forceps
or vectis may be applied, or .acted with, effectively. If no
part of the head have entered the brim of a contracted pelvis,
the case decidedly is not, at this time, one for the long forceps,
or lever. If onlv a little of it have entered, or perhiups rather
the swollen scalp, we have not a better opinion. But when
more has been pressed in, and in all cases where the dimen-
sions, and circumstances of the case, are barely such, as to
warrant a belief that the head must be opened, an attempt
ought previously to be made, not in a careless or hasty, far
less in a dangerous manner, but deliberately and attentively,
to introduce, and act with, the vectis or forceps. To ascertain
the dimensions of the pelvis, the hand, in general, will require
to be introduced into the vagina*

We may, however, if the dimensions be under three inches
and a quarter, be assured, that delivery at the full time, can-
not be accomplished by instruments, without the destruction
of the child. But, as it is a matter of great nicety to deter-
mine, within a fraction of an inch, the capacity of the pelvis,
a practice, founded altogether on arithmetical directions, must
be unsafe. In every case, therefore, we ought to allow some
time, for the pains to produce an effect; and this time, should
be longer or shorter, according as, in our estimation, the
dimensions diminish below three inches and a half. When
this is the case, we have no reason to expect, that the head
can pass, unless it be unusually pliable or small, or burst,* or
be artificially opened; and if only three inches, inclusive of the

* So far M I can Jodge, the ratnret yield sooner than the scalp, and Che brain
is effused, or pushed out like a bag. When the integuments open nrst, it is owing,
I apprehend, to sloughing from pressure and injurr. A Ter^ distinct case of
spontaneous bursting of the cranium may be found in Dr. Hamilton's Cases,
p. 17.

498

soft parts, the head should, for the advantage of the mother,
be perforated, as soon as the os uteri is properly dilated, which
ought always to be effected, in the time formerly spedfied.
Until the os uteri be fully opened, no attempt to introduce
the perforator can be sanctioned. One circumstance, how-
ever, must be attended to, in our consideration, namely, that
the promontory of the sacrum may be directed somewhat
obliquely, in which case, although the conjugate diameter,
measured from that to the front, do not extend beyond three
inches, yet, toward the side, the diameter may be greater.
The thickest part of the head, may find its way down there,
whilst a narrower, or more compressible portion, may pass at
the smaller part. In cases at all doubtful, it is imperative to
wait for some time, to ascertain what can be effected; not that
delay is less injurious in crotchet, than in forceps, cases, but,
because interference in the latter, may be productive of much
benefit, without purchasing that, at the certainty of mischief;
whilst in the former, the greater safetv, or abridged suffering
of the mother, arising from the perroration, necessarily im-
plies the destruction of the child. Some eminent men on
the continent, seem to think that the long forceps may, in
most cases, supersede the necessity of the crotcnet : but I
must dissent from this opinion, and wjiilst I endeavour to pre-
vent the unnecessary loss of the child, I cannot place out of
consideration, the danger, if not die destruction, of the
mother, which may follow from improper delay, and the inju-
dicious employment of the forceps.

But although it be thus laid down as a general rule, that
the pelvis, which measures fully three inches and a quarter
in its conjugate diameter, may, possibly, admit a living child
to pass, either by the application of the vectis or forceps, or
still more rarely by the efforts of the womb, yet, it is never-
theless true, that sometimes the child must be destroyed,
even when the space is greater. This may become necessary,
owing to the great size of the child, and firmness of the
cranium, or a hvdrocephalic state of the head ;* or the soft
parts in the pelvis may swell so much, as to diminish in an
increasing ratio, the size of the pelvis and effectually to obstruct
delivery ;T or spasmodic action of the uterus, may so retard

* I hare teen a craniiim so enlarged with water, that when it wai inflatedt
after delirery, lo as to reenme its former slxe, it measured twenty-two inches in
circumference.

f Bandelocque TArt des Acoouch. sect 1706. — See also a case in point, in Dr.
A. Hamilton • Letters, p. 8S.— £Tery attentive practitioner musti from his
own experience admit the fact.

499

the descent of the head, as to prevent it from coming within
reach of the forceps, within a time, safe for the mother, or of
avail to the child. The parts may also be so tender, as to
render even a common examination painful, and to prevent
the application of the forceps, or their effective action, in a
case merely equivocal. I have seen in a first labour, from
the tardiness of the process, and slow descent of the head,
the long forceps fail in the hands of a very judicious operator,
now dead, although the conjugate diameter of the pelvis
measured fully three inches and a half, and, in that case,
even the use of the crotchet required exertion. I know some
will be ready to say, the operator failed, when he ought to
have succeeded ; but I was most attentive to the steps, and

Suite satisfied of the correctness of the opinion I give, of
16 impracticability of delivering with the forceps, in this
particular case. Alarming convulsions, may likewise induce
us to perforate the head, in a case of deformity, where it is
perhaps possible, that the vectis or long forceps might
succeed, after a greater delay, or length of time, than is com-
patible with the safety of the mother ; but this combination
of evils must be rare. No practitioner, I believe, in this city,
has met with such a case. At one period, however, the
crotchet was employed in cases of convulsions, where the
vectis or forceps would now be used.

By the rash and unwarrantable use of the crotchet, living
children, have been drawn through the pelvis, with the skuU
opened, and have survived, in this shocking state, for a day
or two.*

To prevent all risk, of bringing a living mutilated child, to
the world, and to avoid, at the same time, killing or giving
pain to the child,t even in those cases which clearly demanded
the use of the perforator, some have delayed operating, until
the child appeared to have been destroyed, by the expulsive
efforts, or otner causes, and have therefore been anxious to
ascertain the signs, by which the death of the child might be
known.t It was still more desirable to know these, at a time

* VId« Mauriceau, oba. 564.— La Motta, caae czc~Hamilton*i Letters, p. IfiS.
Pea La Phitlqoe, p. 346— Crantzde Re Instrument., &c, sect. 88.— Mr. Haxn-
moDd relates a case where the child lired 46 hours. Jt was able to cry, and was
supposed to die more immediately from loss of blood than injury of the brain.
The cerebellum was not hurt ISIed. and Chir. Trans. Vol. xii. part 2d.

fit has been disputed, whether the child in utero was capable of sensation ;
but both facts and reasoning are in farour of its sensibility.

t The sirns of a dead child have been described to be a feeling of weight, or
sensation of rolling in the uterus, want of motion of the child, pallid countenance
and sunk eye, coldness of the abdomen, with diminution of size, flaccid breasts
which contain no milk, foetor of the discharge from the Tagina, liquor amoii

500

when the forceps were undiscovered. But the signs enu-
merated, are in general extremely equivocal. Of late, the
stethoscope has been employed to decide the case, by the
presence or absence of the sound of the foetal heart. Much
and unnecessary suffering, it is asserted, may thus be saved.
When the heart is distinctly heard, there can be no doubt,
but the converse of this is not so satisfactory ; one man is
more acute than another in hearing, and something must be
conceded to the effect of practice. It is certainly desirable,
that students should take every^ opportunity of becoming
expert in this matter.

The steps of the operation are very simple : the rectum,
out especially the bladder, being properly emptied, we place
the forefinger of one hand, on the head of the child, and with
the other hand, convey the perforator, to the spot on which
the finger rests. The instrument, being carried cautiously
along the finger as a director, can neither injure the vagina
nor OS uteri, and, in general, no difficulty is met with in this
part of the operation. Sometimes, however, in very great
deformity, the os uteri is placed so obliquely, that it must,
previously, be gently brought into the most favourable, that
IS, the widest part of the pelvis; and afterwards, the perfo-
rator, being placed on the head, must have its handle m the
axis of the brim, which may require the perinseum to be
stretched back. These points being attended to, the scalp
is then to be pierced, and the point of the instrument rests
on the bone, through which it directly, or after a momentary
pause is to be pushed, either by a steady thrust, or a boring
motion. It is to be carried on, till checked by the stops.
The blades are then to be opened, so as to tear up the
cranium, and in order to enlarge the opening, they may be
closed, and turned at right angles to their former position,
and again opened, so as to make a crucial aperture. If the
liquor amnii have been well evacuated, and a portion of the
cranium have entered the pelvis, the perforation can be made
without any assistance, but if the whole of the head be above
the brim, it may be necessary to keep it steady, by pressure

eoloared afiparently wltb meooniam, altboaf h the hnd prMentt, puffy feeling «f
the hf ad, want of firm tumour formed by the scalp when the hcao is pressed lo a
narrow peWis, no pulsation in the cord, «c Vide Manriceau, Obs. SSI. When
a woman bears a child which has been for some time dead, we mast wBtch, lest
her recovery prove bad.

I may notice here, that in order to get rid of the crotchet, small forceps have
been applied over the collapsed head, or a kind of crutch, or tirs tite, baa been
Inserted within the cranium. Some have employed a trephine, In place of a
perforator.

501

above the pubis. It is proper to add, that if the face present,
we must perforate the forehead, just above the nose.

If we have turned the child, and wished to open the head,
the instrument must be introduced behind the ear, and the
bones freely opened, both laterally and upward. The crotchet
is then introduced, and obtains a good fixture, on the base of
the occipital bone and foramen magnum.

It is scarcely necessary to break the brain down, by turning
the perforator round within the head. If part of the cranium
have entered the pelvis, some of the brain, may come out,
with a squirt, whenever the bones are opened; and at all
times we have more or less hemorrhage, from the vessels of
the brain. Sometimes the blood flows very copiously. We
have been advised always to delay, a considerable time, after
opening the head, before we apply the crotchet, and doubt-
less, if the perforation have been made early, we may leave
the case, for a little, to the operation of the uterine efforts,
which, although they cannot effect delivery, yet, may force
the yielding head down, and render the action of the crotchet
less severe. But when the labour has been already long
protracted, the propriety of this direction, is to be strongly
disputed, on grounds I have formerly explained, relating to
instrumental aid. If there be reason to believe, that the
crotchet can at once be easily used, what advantage is there
in delay? In greater deformity, there may sometimes be
advantage, in delaying for some time* Dr. Osbom, in his
£8says, advises that the head should be opened early, and
that we should then delay to extract for thirty hours. In
cases of deformity, decidedly requiring the use of the crotchet,
the first direction is important ; but the delay of the specific
number of thirty hours is, in most cases, if not in every in-
stance, much too long ; it is not sufficient to produce, in
any case where the child was alive when the skull was perfo-
rated, such a degree of putrefaction as materially to facilitate
the operation. The chief benefit of delay, is to bring as
much of the cranium as possible into the pelvis. But, in
obtaining this, we must consider whether we do not exhaust
the mother more, by the continuance of the pains. There
may be cases, where it would be useful, after perforation, to
procure a little sleep, and when this can be done, delay is
proper.

If the deformity have been no more, than just sufficient, to
require the use of the perforator, then, if the pains become
strong, it is possible for the head to be expelled without

502

further assistance. But this is not a general occurrence, for
the base of the skull does not readily yield, and it is better at
once to use the crotchet. But in all cases, if the deformity
be greater, or the pains weak, only the pliable part of the
cranium can descend, and the face, and basis of the skull,
remain above the brim of the pelvis, until artificial force be
used. When this aid is required, which is generally the case,
the crotchet is to be introduced through the aperture of the
cranium, and fixed upon the petrous bone, or such projection
of the sphenoid bone, or occiput, as seems to afford a firm
fixture, or on the outside of the base of the skull, at the pubis.
This will be, generally, near the mastoid process, and is often
found to be a good situation. We then pull gently, to try
the hold of the instrument, and this being found secure, we
proceed to extract in the direction of the axis of the brim, by
steady, cautious, and repeated efforts, exerting, however, as
much strength, as may be necessary, to overcome the difiicidty.
In doing this, we must always keep a hand, or some of the
fingers, in the vagina and on the cranium, to save the soft
parts, should the instrument slip. If the force be steadily and
cautiously exerted, we may always feel the instrument slipping
or tearing the bone, and have warning, before it come away.
We should, in extracting, co-operate as much as possible with
the pains. Should we not succeed in this way, the instru-
ment may be withdrawn, and fixed on the outside of the head,
sinking it in, near the base of the skull. Sometimes an ex-
tractor, in the form of pincers, is used in place of the crotchet,
or different tire tetes have been proposed. The craniotomy
forceps, at present used, are considered safer than these,
and preferable to the crotchet: one blade, goes within the
bone and the scalp, and the other, without. A kind of double
crotchet, one blade going within, and another, with prongs,

going without, has been proposed by Dr. Davis. In cautious
ands, however, I think the crotchet may be safely trusted.
It is quite a mistake to suppose, that because the head is
opened, therefore, the delivery must be easy. The force
requisite to bring down the base of the skull, even when the

5>elvis is barely so small, as to prevent the application of the
brceps, is often much greater tnan is generally used in forceps
cases. The reason is, that part of the force is spent unprofit-
able. It is not very easy to fix the crotchet, so as to make its
action on the head be direct, without inclining it in any degree
obliquely, with regard to the axis of the pelvis, or making it
press unprofitably, or even hurtfully, on some part. It is

503

indeed often impossible, to bring down the opened bead,
without drawing it so, as to make its base enter obliquely, and
offer a smaller diameter. We find, after delivery, that the
diameter of the unyielding part of the skull, is above a quarter,
perhaps near half, an inch broader than the diameter of the
pelvis, as ascertained after death. It could, in this case,
only pass obliquely. Small forceps, whose blades could come
considerably within three inches of each other, may, in a
particular aegree of contraction, act better and require less
exertion.

When an arm protrudes along with presentation of the head,
its bulk increases the difficulty, and if it cannot be returned,
it is sometimes necessanr to remove it at the shoulder joint,
before or after perforating the head. This has been done
successfully by my son.

It may happen, that the pelvis is so small, as to require
the head to be broken down, and nothing left but the face and
base of the skull. This is an operation, which will be facili-
tated, by the softening o{ the head, which takes place some
time after death, rather by pressure than putrefaction. If the
child be recently dead, the bones adhere pretty firmly ; and,
in a contracted space, it will require some management to bring
them away. But if the parts have become somewhat putrid,
or been much squeezed, or the child have been dead, before
labour began, the parietal and squamous bones come easily
away, and the frontal bones separate from the face, bringing
their orbitary process with them. We have then only the
face, and basis of the skull left, and if the pelvis will allow
these remains to pass, then the crotchet can be used. I have
carefully measured these parts, placed in different ways, and
entirely agree with Dn Hull, a practitioner of great judg-
ment and ability, that the smallest diameter offered, is that
which extends firom the root of the nose to the chin. For,
in my experiments, after the frontal bones were completely
removed, and the lower jaw pressed back, or its s^physis
divided, so as to let its sides be pushed away, this did not, in
general, exceed an inch and a half. It is therefore of great
advantage, to convert the case into a face presentation, with
the root of the nose directed to the pubis. The size of
the crotchet, which ought to be passed over the root of the
nose, and fixed on the sphenoid bone, must, however, be added
to this measurement. I never have yet been so unfortunate,
as to meet with what may be considered, as the smallest pelvis,

504

admitting of deMverjper vias naiurales;* but I would conclude,
that whenever the pelvis, with the soft parts, measures fully
an inch and three quarter8,t or, if the head be unusually
small, the child not being at the full time, an inch and a half,
the crotchet may be employed, provided the lateral diameter,
of the aperture in the pelvis, be three inches, or within a
fraction of that, perhaps two inches and three quarters, if the
head be small or very soft ; and the operation will be easy, as
we extend the diameter of the pelvis beyond what may be
considered as the minimum. It is scarcely necessary to add,
that if the outlet be much contracted, it will make the case
more unfavourable ; and where we have any hesitation, owing
to the shape and dimensions of the brim, it will determine us
against this operation* The hand, if necessary, must be
introduced into the vagina, and a careful examination made.
The general impression, from the shape, &c^, made by this, of
the possibility or impossibility of delivery, and the calculation
or deduction, drawn from the supposed dimension, are correc*
tive of each other. It ought not to be forgotten, that it is one
thing to extract, aird another to extract safely, in extreme
deformity* It is possible, after much exertion, to bring away
the child; but every one, must have seen the mother lost, in
cases where the capacity of the pelvis, was far from being
reduced to the minimum. Sometimes the uterus is ruptured,
sometimes the soft parts slough ; but oftener the patient dies
either of peritonitis, or the belly swells without pain, and
she sinks. We ought to be satisfied, not only that we can
bring through the child, but that we can do so, without so
much violence, as must,* in all probability, kill the mother.
I question much, if extreme cases, be not as dangerous to the
patient, as the Caesarean operation ; certainly they are more
painful.

In this manner of operating, the face is drawn down first,
and the back part of the occipital bone, is thrown flat upon the
neck, like a tippet. It we reverse this procedure, and bring
the occiput first, and the face last, fixing the instrument in
the foramen magnum, then, as we have the chin thrown down

* I cannot learn that any caae of extreme deformity in a pregnant woman, anch
aa to render it barely poeaible to doliTer with the crotehet, or neoeeeary to bara
reoourae to the Cesarean operation, has oocurred in thia dty, ainoe the year
1*115, when Mr. Whyte performed the latter operation.

f M. fiaudeloeque conelden tlie crotchet aa inadmieeible, when the pelria
meaaurea onlv an inch and two-thirda. Dr. Daria laya, that by meana of bona
nippera, or what he calli an oatcotomisti he hai io broken the cranium, aa to bring
it through a machine, witbao aperture, of only one loch diameter.

505

on the throat, we must have both the neck and face, passing
at once, or a body equal to two inches and three quarters. I^
on the other hand, we fix the instrument in the petrous bone,
which is certainly preferable to the foramen magnum, and
bring the head sideways, we must have both that bone and
the vertebraB passing at once, or a substance equal to two
inches and a half in diameter; and if the head pass more
obliquely, then it is evident that the size must be a little more.
Although, therefore, Dr. Osbom be correct, in saying, that
the base of the cranium, turned sideways, does not measure
more than an inch and. a half, yet, we must not forget, that
when the opposite side comes to pass, the neck passes with it,
which increases the size.

The head being brought down and delivered, we then fix
a cloth about it, and pull the body through ; or, if this cannot
be done, we open the thorax, and fix the crotchet on it,
endeavouring to bring down first a shoulder, and then the
arm.

In operating with the crotchet, we must always bring the
head, through the widest part of the pelvis ; but where the
deformity is considerable, no small force is requisite. This
is productive of pain during the operation, and of danger of
inflammation afterwards, which may end in the destruction of
some of the soft parts ; or, affecting the peritonaeum, it may
prove fatal to the patient, From injury done to the bladder,
retention of urine may be produced, which, if neglected, is
attended with great risk. Incontinence of urine, is less to be
dreaded, as it is sometimes cured by time. Severe pain in
die loins, and about the hips, with lameness, is another trouble*
some consequence. If the patient be not affected with mala-
costeon, the warm, and at a more advanced period, the cold
bath, friction, and time, generally prove successful. Much
advantage is also derived, in this kind of pain, from applying
a compress on the sacro-sciatic notch, and binding it on, with
a roller, wound firmly round the pelvis, and aU the upper part
of the thigh.

In considering the necessity of using the crotchet, I have
not, more than in the observations on the forceps, made any
special remarks on those instances, where the capacity of the
pelvis is diminished by an enlarged ovarium, or other tumours,
as the practice is the same, or, when a different course is
proper, that has been pointed out, in the commencement of
this work.

To avoid the destruction of the child, and the severity of

506

the" operation of extracting it, the induction of premature
labour has been proposed :* and the practice is defensible, on
the principle of utility, as well as of safety. We know that
the head of a child, in the beginning of the seventh month,
does not measure more than two inches and a half in its
lateral diameter ; two and three quarters in the end of that
month ; and fully three in the end of the eighth month. We
know, further, tnat there is no reason to expect, that a full
grown foBtus, can be expelled alive, and very seldom, even
after a severe labour, dead, through a pelvis whose dimensions
are only three inches; and, lastly, we have a great many
instances, where children, bom in the seventh month, have
lived to old age. Whenever, then, we have, by former expe-
rience, ascertained beyond a doubl^ that the head, at the full
time, must be perforated, it is no longer a matter of choice,
whether, in succeeding pregnancies, premature labour ought
to be induced. It is certainly easier for the mother, than the
application of the crotchet, and no man can say that it is
worse for the child.f All the principles of morality, as well
as of science, justify the operation ; they do more, they
demand the operation. Two methods have been proposed
for exciting expulsive action : First, by insinuating a finger
within the os uteri, and gently dilating it, and detaching
a part of the membranes, from the portion of the cervix in its
immediate vicinity. This may also be done, by conducting
within the os uteri a pair of ball forceps, by slightly opening
which, we gently and slowly dilate it, so as freely to admit
the finger. This is better than the finger alone, and gives
less unprofitable irritation. It ought to give no pain re^rri-
ble to the os uteri, but is productive of sensation, not amount-
ing to pain, in the back. If we have not thought it prudent,
to dilate at once the os uteri, so as to admit the finger, freely,

* Thia practice wm fint adopted aboat the middle of the laat eentoiy* bj Dr.
Macaulay, In London, and fraa afterfrards folloired by others. About tvrentj
yeara after ihla. It was proposed on the Continent, bv M. Roussel de Vanaeeme ;
and lately, Mr. Barlow, in the eighth Vol. of Med. Facts, ftc ; has glTen several
cases of its success. — See also Med. and Pbys. Journal, Vols. xix. zx. and xxl.
It may not be improper for me to mention as a caution, that I have been called
to consider the expediency of eTacuatinc the liquor amnii, where there was no
deformity of the pelvis, but merely a collection of indurated faces In the rectum*
Dr. Merriman has a very sensible paper on this subject, in Med. Chir. Trans.
Vol. Hi. p. ISS, where he sutes that, out of 47 cases of premature labour, Indoead
on account of distorted pelvis, 19 children have been bom alive, and capable of
sucking. He very properly advises that, before puncturing the membranes, it
should be ascertained that the presentation is naturaL ff it be not, it may
become so in a day or two.

f It has been proposed, by low diet, to restrain the growth of (he chllH ; but
this Is a very uncertain and prrcariou!« practice. It is romantic.

507

to touch the membranes, we may repeat the dilatation gently
at the end of twelve hours, and then detach the membranes
cautiously from the cervix uteri, by the finger. But, for this
purpose, it will be necessary, to have the hand introduced into
the vagina. If this be not followed by indications of labour
within three or four days, we must have recourse to the
second proposal, namely, evacuating the liquor amnii, by
piercing the membranes, with a long, narrow, pointed probe,
conducted by the finger, or a canula, with a concealed stylet,
the point of which is, after the canula is guided by the finger
within the os uteri, to be barely pushed so far on, as to pierce
the membranes. Could the nrst always be depended on, it
would be preferable to the second, as evacuation of the
water, is sometimes succeeded by spasmodic or partial con-
traction of the uterine fibres, and it also appears that the
circulation is more apt to suffer. It ought therefore always
to be first tried.

In the beginning of the seventh month, the distance from
the margin of the lip of the os uteri, to the membranes, is
nearly an inch and a half. The canal, from the os uteri, along
the cervix, is fiUed with a substance Uke unclarified jelly- It
is flattened, and, at both extremities, about half an inch oroad.
From this account it is evident, that there must^ he consider-
able dilatation of the cervix produced, before the finger can
touch the membranes, and it must also be introduced far, if
we expect to detach them.

There may be cases where the uterus is excited to labour,
with so much difficulty, that even after puncturing the mem-
branes, it may be necessary to resort to gentle dilatation of
the 08 uteri. But these are exceedingly rare. The period
at which the labour should be excited, must depend upon the
degree of deformity ; and where that is very great, it must
be at a period so early, as to afford no prospect of the child
surviving. It must be done in this case to save the mother.
There are many cases, where the bones gradually yield, and
become so distorted, as at last to prevent even the crotchet
from being used. Now, granting a succession of preg-
nancies to take place in this situation, it follows, as a rule of
conduct, that if the deformity be progressive, we should regu-
larly shorten the term of gestation, exciting abortion, even in
the third month, if necessity require it, and treating the case
as a case of abortion, enjoming strict rest, and plugging the
vagina to save blood. Some may say, Shall we thus by ex-
ci^jng abortion, destroy many children, to save one woman ?

508

This objection is more specious than solid. Those who
make it, would not in all probability, scruple to employ the
crotchet frequently, and where is the difference to the child,
whether it be destroyed in the third, or in the ninth month ?
How far it is proper for women, in these circumstances, to
have children, is not a point for our consideration, nor in
which we shall be consulted. I would say, that it is not
proper ; but it is no less evident that when they are preg-
nant, we must relieve them. Sometimes it may be requisite
to use the lever, even when labour has been prematurely
brought on.

The interval which elapses, between the use of the means
for promoting labour, and its accession, varies from two, to
five or six days ; the fourth day is not an unusual time. If
shivering come on before pain, an opiate is the best remedy.

CHAP.. VII.

Of ImpracticcHUe Labour.

It may be urged against the reasoning, in the conclusion of
the last chapter, that the Csesarean operation ought to be per-
formed ; and, doubtless in cases of extreme deformity, if the
nroper time for inducing labour be neglected, it must be per-
formed. But the danger is so very great to the mother, that
this never can be a matter of choice, but of necessity. In
balancing the Cesarean operation, against the use of the
crotchet, or the induction of abortion, we must form a com-
parative estimate, of the value of the life of the mother and
ner child. By most men, the life of the mother has been
considered as of the greatest importance, and therefore, as
the Caesarean operation is full of danger to her, no British
practitioner will perform it, when delivery can, by the destruc-
tion of the child, be procured per mas naiurales. As, in many
instances, the woman labours under a disease, found to be
hitherto incurable, it may be supposed, that the estimate
should rather be formed in favour of the child. But, in the
first place, we cannot always be certidn that the child is alive,
and that the operation id to be successful with respect to it ;
and, in the second place, it ought to be considered how far
it is allowable, in order to make an attempt to save the child,
to perform an operation, which, in the circumstances we are

509

now talking of, must, according to our experience, doom the
mother to a fate, for which, perhaps, she is very ill prepared.
There are, I think, histories of twenty-four cases, where
this operation has been performed in Britain ; out of these
only two women have been saved,* but twelve children have
been preserved. On the Continent, however, where the
operation is performed more frequently, and often in more
favourable circiimstances, the number of fatal cases is much
less.t If we confine our view to the success of the operation
in this island, we must consider it as almost uniformly fatal to
the mother. This mortality is owing, not only to the injury
done to the cavity of the abdomen, and the consequent risk
of inflammation, even under the most favourable circumstances,
and with the best management, but also to the morbid con-
dition of the system, at the time when the operation was per-
formed, many of the women being affected w^th malacosteon,
which would in no very long time have of itself proved fatal.
These dangers have, probably, sometimes been increased, by

* Vide acaM by Mr. Barlow, in Med. Records and Researches, p. 154; and
another by Mr. Knowles of Birmingham, in 4th vol. of Trans, of Frov. Asso-
eiatioQ.

f According to Dr. Hull, vre had, when he published, at home and abroad,
records of 831 eases of this operation, 199 of which proved successful.— Vida
Translation of M. Baudelocque's Memoir, p. 23S. A mater number now
exist. See also Sprengel, Hist, de Med. — In a case fatal to both mother and
child, the operation was, on the third dav of labour performed at Pavia, by Dr.
Omboni. The pelvis measured three inches and a line, but the os uteri could
not be dilated by the finger. The occiput lay to the pubis. She was bled with-
out advantage. The practice in such a case, I apprehend ought to be, after free
▼eneseetioDy to introduce the hand into the vagina, and gradually dilate the oe
nteri, and then use the perforator. If the os uteri from disease could not be
diUted, it should be cut. In a case related by Vanderfuhr, the woman was only
8 feet 8 inches high, and the saero-pabic diameter under two inches. The opera-
tion was performed in the linea alba, and the mother was able to nurse her child.
In Dr. Muller*s case, the patient recovered. Edin. Jooni. zzxi. p. 443. A
fiital case by Mr. Crichton, zxx. p. 5S ; also, a fatal case by De Haber, where
the operation was performed on account of a large exostosis in the pelvis. Journ.
Compl. xl. p. 248. Dr. M'Kibbin performed the operation In Belfast, on account
of an exostosis in the hollow of the sacrum, which reached to one inch and an eighth
of the symphysis. The brim itself was pretty natural. Dr. Montgomerie of
Dublin, showed me a cast of this pelvis in his museum. The patient died in
17 boars. In the same museum, 1 saw a preDaration of a very large fibrous
tumour growing from the uterus, a portion of which entered the pelvis, and filled
It up. The operation was performed by Mr. Porter. The woman survived «1
bonrsk Dublin Journal, Vol. vi. p. 418, and Exposition, &e.p. 184. In the case by
Tassinari, the child was loat, but the mother recovered. She could have been
delivered by the crotchet, for the conjugate diameter of the pelvis, although aaid
to be scarcely three fingers* breadth, yet, Iqd admitted the head so far, as to
make it neoesaary, after «>pening the uterus, to introduce the hand into the vuina,
and push up the head. Repertoire, vi. p. 56. The operation was lately perform-
ed at Arras by M. Duchateau, with success both as to the mother and child. La
Presae Medicale, No. 7, 1887. It has been performed three times on the same
woman by Dr. Michaelis. It was performed ailso successfully by a bull. Archives,
Jnlllet, 1888.

510

delaying the operation, until much irritation had been excite<L
From this unfavourable view, it may perhaps arise as a ques-
tion, whether nature, if not interfered with, might not, as in
extra-uterine pregnancy, remove by abscess the child from
the uterus ? It has been said, that this event has taken place ;
but I do not recollect one satisfactory case upon record.
Whenever this has happened, the uterus has either been
ruptured, and the child expelled into the cavity of the abdo-
men ; or, in a very great majority of the instances, the child
has, evidently from the first, been extra-uterine. We are,
therefore, led to conclude, that the mother, who cannot be
delivered by the crotchet, must submit to the Csesarean
operation, or must iilevitably perish, together with the fruit
of her womb.

It has been asserted by Dr. Osbom, that this operation
can seldom, if ever, be necessary ; never where there is the
space of an inch and a half from pubis to sacrum, or on
either side : and that he himself has, in a case where the
widest side of the pelvis, was only an inch and three-quarters
broad, and not more than two inches long, delivered the
woman, by breaking down the cranium, and turning the basis
of the skull sideways. As the patient recovered, and after-
wards, I think, died in the country, where she could not be
examined, we cannot say, to a certainty, what the dimensions
of the pelvis were. Dr. Osbom must only speak ac^cording to
the best of his judgment. I have the highest respect for his
character and for his works, and nothing but irresistible argu-
ments could make me doubt his accuracy. But, from the
statement which I have already given, of the dimensions of the
head, when broken down at the full time, as well as from the
experiments of Dr. Hull, and the arguments of Dr. Alexander
Hamilton, and Dr. Johnson, I am convinced that there must
be some mbtake in Sherwood's case. Had the child been
brought by the face, there might have been room for it to

Eass, so far as the short diameter of the passage is concerned;
ut the lateral diameter was too small, for the head, if of the
usual size, to pass, in that, which I consider as the most
favourable position. In the cases related by Dr. Clarke,* who

* V{de Dr. Osbom't Estavs, p. 808,«nd I.ond. Med. Journal, Vol. viL p.40.

Lee*i pelrlt, m stated by Dr. Hull, was semfcireular, and the greatcat diameter
when cleared vras I ten-sixteenths. Redman's was trianffular, and at each sid«»
the enttre particular diameter was only 1 one-slzteenth. There hare been peWlses
with still smaller diameters. In De Saeher's patient, the ossa pubis were quite
overhung by the sacrum. This woman was twice operated on. Jn a second pr^-
nancy, the uterus ruptured and the child was extracted by operation. A woman
was also twice operated on by M. Scbenk of Siegen. She had prerlonsly bom

511

was a practitioner of the highest authority, we are informed,
that the short diameter of the passage, did not exceed an inch
and a half, but we are not informed of the lateral extent. As
the women both recovered, the precise dimensions and con-
struction of the pelvis cannot be determined. It is likewise
much to be regretted, that the diameter of the cranium, or
cranium and neck, in the state in which they may have been
supposed to come through the passage, was not taken after
delivery. Where, and only where, it can be ascertained, that
the head placed in the position in which it was drawn through
the pelvis, does not form in any part, a substance measuring
more than an inch and a half, by two or three inches, it is
allowable to infer, that the cavity through which it passed,
may have been so small as that.

Finally, this is a question, on which, although we may lay
down a general rule, we must admit of some exceptions ; for
a premature, or a very small child, may be brought through
a pelvis, which will not permit, by any means, an ordinary
sized foetus to pass. But it behoves us, in our reasoning, to
judge every child to be at the full time, unless we know the
contrary, and to make an estimate on the average magnitude;
and until the contrary be proved, by dissection of the mother,
or careful and rigid measurement of the child, after delivery,
I must hold to the position formerly laid down, that the
crotchet cannot be used, when the child is of the full size,
unless we have a passage through the pelvis, and its linings,
measuring fuUy an inch and three-quarters, in the short dia-
meter, and three inches in length ; or, if the child be prema^*
ture and soft, an inch and a half broad, and two inches and
three-quarters long.f It is, in this extreme deformity, very

six ehlldrcD, bat in tb« Mrentb the pelvis from 'malaooeteon had become ao much
deformed that the iachia were not alMve two fioirers breadth distant. Archires
z. 591.

t I bellere few will dlspate. that the precise deformity requiring the Cnsarean
operation, moat, to a certain extent, be modified by the dexterity of the operator.
I shall suppose that a surgeon in a remote part of the councrv, far from assistance,
is called to a patient, whoee child is cTidently alive, and whoee pelvis measures
just as much as would render it barely possible to use the crotchet, were he
dexterous ; but he has not a belief that he could accomplish the delivery with that
instrument. Would that man be wrong in performing the Casarean operation ?
In each a case I would say, upon the principle that a man is to do the most good
in his power, that if no operator more experienced can be had, within such time
as can be safely granted, the surgeon ought, after toking the best advice he can
procure, to perform the Csesarean operation, by which be will save one life at
least. By the opposite conduct, there is ground to fear that both would be loet.
Jn a case related in the Jour, de Med. for 1780, a woman in the village of Son,
had the child turned, and even the limbs separated without delivery being accom-
plished ; four days afterwards, the Cesarean operation was performed, and the
woman died.

512

questionable, whether extraction be not as dangerous, as the
Caesarean operation and we always ought to consider well,
before we give the preference to mutilation, in such cases.

The operation itself, though dangerous in its consequences,
and formidable in its appearance, is by no means difficult to
perform. Some, advise the incision to be made perpendir
cularly, in the linea alba, others transversely, in the direction
of the fibres of the^ transversalis muscle, others, obliquely, in
the direction of the fibres of the external oblique muscles.
By cutting along the inner margin, of the rectus muscle, we
avoid, as is observed by Dr. Campbell, the epigastric artery,
but the precise situation and direction of the wound, must be
regulated by the circumstances of the case, the shape of the
abdomen, and projection of the uterus.* The length of the
incision, through the skin and muscles, does not require to be
above five or six inches. If a vessel bleed, so as to require
the ligature, it will be proper to take it up, before proceeding
further, but there may be so little haemorrhage, as not to
make this necessary. The uterus, is next to be opened, by a
corresponding incision ; and as the fundus, owing to the pen-
dulous shape of the abdomen, is the most prominent part, the
incision will in general be made there, unless the external
wound be made lower than usual. The child is next to be
extracted, and immediately afterward the placenta. If the
placenta adhere to the divided part of the uterus, it is better
to detach it, and rupture the membranes, at the margin, than
to cut through it. One assistant is to take the management
of the child, whilst another, takes care to prevent the protru-
sion of the bowels. In this part of the operation, although the
arteries be numerous and the venous sinuses large, yet, the
haemorrhage is seldom great : it has, however, proved fatal .f
The external wound is now to be cleaned, its sides brought
together, and kept in contact, by a sufficient number of
stitches, passed tnrough the skin alone, or the skin and
muscles, avoiding the peritonaeum. Adhesive plasters are to
be placed carefully in the intervals; and a bandage with a soft
compress being applied, the patient is to be laid to rest. An
anodyne should be given, to diminish the shock to the system;

* The epigaitrle arter j reaches the rectus masele and ascends hetween Its Inner
surface and its sheath. One large branch goes up the middle of the mnsde,
whilst the trunk runs up by, or near, the outer margin and sends ramifications
outward. The linea alba, when circumstances permit it, would therefore be the
best place, and there, we arc also less likely to be troubled with the intestine.

t In an operation (which ended fatally) lately performed at Dresden, twenty
minutes were required to excite the contraction of the uterus.

513

and our future practice must, upon the general principles of
surgery, be directed to the prevention, or removal, of abdomi-
nal irritation or inflammation. The patient may die, although
there be very little inflammation of the peritonaeum. It has
been proposed by Dr. Hull, to operate as soon as the os uteri
is dilated, and before the membranes burst, in order that the
wound of the uterus may contract into a smaller size. It is of
great consequence to operate early, before the patient be much
excited, far less eidiausted.

Graefe advises the operation to be performed just after the
rupture of the membrane and the commenoement of the expuk
sive pains. The place chosen, to be that where the motion of
the child is best felt, and the uterus closest to the abdominal
parietal. He applies large warm sponges along the line, where
the incision is to be made, in order to keep in the intestines.
His external incision is five inches long, that in the uterus,
about half an inch less; the sutures are of soft silk, a line and
a half thick.

When the mother dies in the end of pregnancy, and there
is reason to think that the child is alive, there is an impera-
tive call to perform the operation. The uterus may live
longer than the body, and after the mother has been quite
dead, the child still continue its functions. An instance is
lately related, by Dr. Ebel, where the uterus expelled a child,
after the interment of the mother, and the fact was discovered,
by raising the body for examination, owing to a suspicion of
murder.

A woman died of dysentery of two months' duration, in the
end of pregnancy, and by the operation, performed about
twelve mmutes after death, a living child was extracted. Dr.
Jackson restored to animation, a child, extracted half an hour
after the mother's death.

Vaginal hysterotomie, as it has been called, does not come
to be considered here, as it relates to extra-uterine pregnancy,
obliteration of the os uteri, &c.*

In order to supersede the Caesarean operation, and even to
avoid the use of the crotchet, it was many years ago proposed
to divide the symphysis pubis, in expectation of thus increas-
ing the capacity of the pelvis. This proposal was founded on
an opinion, that the bones of the pelvis, either always or fre-
quently did spontaneously separate, or their joinings relax,

* See a eaee by Flamant, J oar. Compl. T. xlil. p. 268. Aleo a soceessful case
by Dr. C»ffe when the operation was performed on account of obliteration of the
ecnrix. £dln. J oar. xzzv.

514

during gestation and parturition, in order to make the delivery
more easy. In deformity of the pelvis, the symphysis was
first divided hy a knife, during labour, by M. Sigault, in
1777, assisted by the ingenious M. Alphonse Le Roy. The
operation was afterwards repeated on the Continent, with
various effects, according to the degree of deformity, and
extent of the separation. It has only once* been adopted in
this country, because it is not only dangerous in itself to the
mother, but also of limited benefit to the child. We have
already seen, that there is a certain degree of deformity of
the pelvis, which must prevent a child at the full time and of
the average size, from passing alive, or with the head entire.
In a case, where it is barely impracticable, to use the lever or
forceps, and where it just becomes necessary to open the
head, the division may perhaps save the child, and with no
more danger to the motlier, than would result from the
Caesarean operation, which is the only other chance of saving
the infant. If we increase the contraction of the pelvis
beyond this degree, then, the chance of saving the child is
greatly diminished ; and the extent to which the bones must
be separated to accomplish delivery, would in all probability
be attended with fatal effects. In such a case, the crotchet
can be employed with safety to the mother, and continues to
be eligible, until we find the space so small as to require the
Csesarean operation ; and, in this case, the division can do no
good. It cannot even make the crotchet eligible, owing to
the shape of the pelvis in malacosteon, and the great mischief
which would be done to the parts after the division, by the
necessary steps of the instrumental delivery. There is only
one degree of disproportion, then, betwixt the head and the
pelvis, which will admit of the division; but the smallest
deviation from this destroys the advantage of the operation.
Now, as this disproportion is so nice, we cannot, in practice,
ascertain it ; for although we could determine, within a hun-
dredth part of an inch, the capacity of the pelvis, yet we can-
not determine the precise dimensions of the head, and thus
establish the relation of the two. On this account the division
of the symphysis pubis cannot be adopted, with advantage^
either to the mother or child. I know well, from my experi-
ments on the dead subject, that in the puerperal state, the
articulations are soft, and we may, after dividing the symphy-
sis, separate the bones, to the extent of three fingers' breads,

• Vide case hj Mr. Welehman, in London Med. Jonrn. I«r 1790, p. 46.

515

imd leas than this could do no good. This is invariably
attended, with separation of the sacro-iliac articulation, so,
that, altogether the operation, even if it could be of any service
in ddivery, must be as dangerous as the Csssarean section*

CHAP. VIIL
Of Complicaied Lalxmr^

ORDER FIRST.

During labour, there is always a slight discharge of bloodv
slime, when the membranes begin to protrude, for the small
vessels of the decidua, near the cervix uteri, are opened. In
some cases, a venr considerable quantity of watery fluid,
tinged with blood, flows from the womb, but this is attended
with no inconvenience. It may happen, however, that pure
blood is discharged, and that in no small quantity. If this
take place in the commencement of labour, it diflPers in
nothing, from those hasmorrhages, which I have formerlv con-
sidered. But, occasionally, the flooding does not begin, till
the first stage of labour be nearly or altogether completed. If
the membranes be still entire, it proceeds certainly from the
detachment of part of the placenta or decidua, and often is
connected with unusual distention of the uterus, from ex-
cessive quantity of liquor amnii, or with ossification of the
placenta. K the membranes have broken, dien we may
consider the possibility of its proceeding from rupture of the
uterus, and must inquire into the attending symptoms.
Sometimes it will be found to proceed from tedious and
exhaustinff labour, from improper exertion, or rude attempts
to dilate the os uteri, or alter tne presentation ; or it may be
caused by rupture of the umbilical cord. Now, in this order
of labours, the practice is very simple, and admits, of little
diflPerence of opinion. For every experienced practitioner
must admit, that when the hssmorrhage is considerable, and
is increasing, or continiung, the only safety consists in
emptying the uterus. If the pains be smart, frequent, and
efiective, the labour advancing regularly, and there be reason
to suppose, that it shall be finished, before the hemorrhage
have continued so long, as to produce injurious effects, we
may safely trust to nature. We must keep the patient very

' 516

cool, and in a state of perfect rest. But if the pains be
weak, ineffective, and rather declining than increasing, whilst
the haemorrhage is rather increasing than diminishing, we
must deliver the woman, either by turning the child, or
applying instruments, according to the circumstances of the
case, and the situation of the head. Opiates are useful.

ORDER SECOND.

When haemorrhage takes places from the lungs, or stomach,
during parturition, we ought to have recourse, in the first
place, to blood-letting, or such other means, as we would
employ, were the patient not in labour. If the haemorrhage
continue violent, or be increased by the pains of parturition,
we must consider whether artificial delivery, or a continuance
of the natural process, shall be attended with least exertion
and irritation, and, consequently, with least danger, and we
must act accordingly. In general, these cases can seldom be
trusted to nature, and prompt delivery is requisite, whenever
it can be accomplished without much excitation. It is
scarcely necessary to add, that a complication of labour, with
other diseases than haemorrhage, but which may be increased
by it, to a dangerous or fatal degree, will equally justify
interference. Of this complication, pleurisy affords an exam-
ple. I may also observe, that if this disease occur in the
course of pregnancy, and require bleeding, &c., to a great
degree, the patient usually has premature labour.

ORDER THIRD.

Syncope may proceed from various causes, such as haemor-
rhage, or rupture of the uterus ; but these cases have been
already, or will be considered. It may proceed from a delicate
nervous constitution, from long continued labour, from parti-
cular states of the heart or stomach, from passions of the
mind, and from an unhealthy state of the spinal cord, in
which case, it is generally preceded, for some time, by a dis-
tressing feeling of sinking. Syncope probably from this
cause, has proved fatal, without any explanation being given
on dissection. A simple paroxysm of fainting, unless it pro-
ceed from causes, which would otherwise incline us to deliver,
such as tedious labour, flooding, &c., is not to be considered
as a reason for delivering the woman. We are to employ
the usual remedies, and particularly keep the person in a
recumbent posture. Ammoniated tincture of valerian, or
tincture of opium, are useful. But if the paroxysms be

517

repeated, whatever their cause may be, we ought to deliver
the woman, if the state of the os uteri will permit. We must
be very careful to prevent haemorrhage, after the expulsion of
the child.

ORDER FOURTH.

Convulsions may occur, either during pregnancy or labour,
and are of different kinds, requiring opposite treatment. One
species is the consequence of great exhaustion, from excessive
fatigue, tedious labour, or profuse haemorrhage. This makes
its attack without much warning, and generally alternates
with deliquium, or great feeling of depression and debility ;
the muscles about the face and chest are chiefly affected, and
the pulse is small^ compressible, and frequent, the face pale,
the eye sunk, the extremities cold. The fits succeed each
other pretty quickly, and very soon terminate in a fatal
syncope. This species naturally requires, that we should,
first of all, check the farther operation of the exciting cause,
by restraining haemorrhage, or preventing every kind of
exertion, and then husband the strength which remains, or
recruit it by cordials. Opiates are of great service. Delivery
is usually necessary.

Hysterical convulsions, are more common during pregnancy
than labour, and have already been noticed. I have only to
say here, that the muscles of the trunk and extremities are
affected to a greater degree, than those of the face ; there is
an appearance of globus, often considerable palpitation, and
occasionally a kind of crowing, or screaming, during the fit.
At the termination of it, there is usually wind discharged
from the stomach, and, often as the strugghng is about to end,
the bowels seem to be much inflated, and suddenly subside.
Part of this, however, is a deception, for the spine is in such
cases, frequently bent back, so as to render the abdomen ap-
parently more prominent. In the interval, there is a tendency
to laucrh or cry, or sometimes a childish appearance. This
kind of convulsion, is rare in the parturient state. If the face
be flushed, or there be headach, and sufi^sion of the eyes,
venesection should be premised ; and if this be not sufficient,
then, we give antispasmodics. If, on the other hand, there
be no undue vascuw action, or determination to the head, we
may at once give antispasmodics, such as tincture of valerian,
or asafoetida; a smart clyster is also of great service. If these
means fail, and the labour be far advanced, it will be proper

518

to employ the forceps, but in general, artificial delivery is not
required.

The most frequent species of puerperal convulsions, how*
ever, is of the nature of eclampsia, or of tetanus, which occurs
a hundred times, for once, that the others appear. Convul-
sions may affect the patient suddenly and severely. She
rises to go to stool, and fails down convulsed ; or, sitting in
her chair, conversing with her attendants, her countenance
suddenly alters, and she is seized with a fit ; or, she has been
lying in a sleep, and the nurse is all at once alarmed, by the
shaking of the bed, and the strong agitation of her patient.
Immediately, aU is confusion and dismay, and the screams of
the females, announce, that something very terrible has hap-

Sened. Presently, the convulsion ends in a short stupor,
*om which the woman awakes, unconscious of having been
ill ; and thus for a time, the apprehensions, of the attendants,
are calmed. But, in a short time, the same scene is generally
repeated ; or, perhaps, although the convulsion have gone off,
the stupor remains ; and it is always more unfavourable, when
the patient continues insensible, in the interval of the fits. It
Is, however, not unusual (Dr. Hamilton says it is invariably
the case), for the fit to be preceded by some symptoms,
which, to an attentive observer, indicate its approach. These
may even exist to a degree, which cannot be neglected. They
are, headach, which is sometimes dreadful; ringing in the
ears ; dazzling of the eyes, or appearance of substances
floating before them, either opaque, or, more frequently, of a
fiery brightness. Or, there may be more fixed and constant
pain, felt in some part of the spine, and always confined to
that, without any pain in the head. In other cases, the first
indication, is violent pain in the stomach, with insupportable
sickness, for sometimes the stomach is the first part which
suffers from irritation of the origin of the nerves, and the
patient may die before convulsions take place. The pulse
usually is slow ; the patient sometimes sighs deeply, or has
violent rigors, which, in the second stage of labour, are
always hazardous. There is great drowsiness during the
pains. It is neithw uncommon, nor dangerous, for the woman
to be drowsy between the pains ; but, here, even during them,
she falb into a deep sleep. When the attack comes on, which
very often, is soon after these preludes appear, the muscles
are most violently convulsed ; the whole frame shakes strong*
ly; the head is jerked quickly and strongly backward, or

519

obliquely to one side, by the extensor muflcles, and the face is
dreadfully distorted,* and often swollen. The tongue is
much agitated, and is very apt to be greatly injured by the
teeth; foam issues from the mouth, and conyulsiye inspiration,
often draws this in, with a ^' hissing noise ;" or she snores
deeply, and cannot be roused during the fit. The skin
usually becomes, during the conyulsion, liyid or purple. The
pulse, during the whole of the disease, is often slow, but
sometimes it does, at last, become frequent, small, and
irregular. This attack may end at once in fatal apoplexy,
but generally the patient recoyers, and is quite insensible of
having been ill. There may be only one fit, and without
any interference, I have known the disease go ofi^, and no re-
turn take place. But in general, the attacks are repeated,
and if they do not prove soon fatal, or be not averted by art,
they recur with the regularity of labour pains, becoming more
and more frequent as they continue ; and if the patient have
been sensible, in the interval of the first two or three convul-
sions, she soon becomes quite insensible, lying in a state of
stupor like apoplexy, agitated, at intervals, with convulsions
increasing in violence ; she appears to have no labour pains,
yet the os uteri is afiected, and sometimes the child is expell-
ed during a fit ; or, if the patient become sensible in the in-
tervals, and feel a pain coming on, it appears to be speedily
carried ofi^, by a supervening convulsion. The fit may last
only a few seconds, or may continue, with very little remission,
for half an hour. In some instances the patient lies for hours
insensible, after the child is born, and is afterwards long of
recollecting her delivery.

Children even when delivered naturally, are often Btill-^boro,
but the exact proportion of dead and living, setting aside
cases of perforation, and even of turning, is not determined.
Some make the living predominate over the dead, but all
agree that the hazard to the child is great. I am inclined to
think, that it is in proportion to the severity and duration of
the convulsions.

Convulsions may occur in any period of labour, or before it
have begun, or aner the delivery of the child ; and in this
last case, are sometimes preceded by great sickness or op-
pression at the stomach. Dr. LeaL relates the case of a
patient, who had ten or eleven of these fits ; the abdomen was

* Mr. Fvnocy fives a oMe» where the lower jaw was lazated dorinff oodtuI-
siona, whioh came on in the birth of a second cnlldy or twio. Med. Comment.
Vol. ix. p. 880.

520

swelled and tense, and she vomited phlegm mixed with blood,
which probably came from the toi^e. She recoTered by
means of blood-letting and clysters.

Puerperal convulsions, are quite different from epilepsy, for
they recur at no future time, except perhaps in a subsequent
pregnancy. They take place in greater number, in a giveo
time, than epilepsy does in general, and belong to the genus
Eclampsia of Sauvagcs, ^^artuum vel musculorum plurimorum,
spasmus clonicus acutus, cum sensuum obscuratione." This
differs from his definition of epilepsy, by the absence of the
character *^ periodicus ;" and on the same principle Vogel
simply defines it ^'epilepsia acuta.*' The principal difference,
and one of a highly important nature in practice, is, that
whilst the symptoms are the same in both diseases, they arise,
in epilepsy, from some organic affection of the brain, or direct
irritation of that organ ; whilst, in eclampsia, they rather de-
pend on some sympathetic and temporary cause — very often
the uterine irritation, acting on the spinal cord, and thence
on the brcun. Sometimes the effect on the cord is the most
prominent, and the patient may truly be said to have tetanus.
Hence, eclampsia may be produced by worms, by costiveness,
indigestion, &c.; and occasionally, not only by the parturient
condition of the' uterus, but, also, by other sections of the
same organ, in the virgin state. I have seen distinct cases of
eclampsia, where the fits were very severe, and repeated, and
accompanied, in the interval, with coma, or delirium, caused
altogether by menstrual irritation, attended with severe pain
in the hypogastrium, and bearing-down sensation. In such
cases, venesection and purgatives give relief, and a blister on
the head, perfects the cure. Fomentations, or the hot bath,
are also useful, but opiates are not to be given, at least at
first. To return from this digression, puerperal convulsions
often recur, exactly, like labour pains, or are frequently
accompanied or preceded by them ; though, when the convul-
sion comes on, the feeling of pain is suspended, and often,
but not always, the uterine contraction is stopped or dimin-
ished. The same observation applies to excessive rigors,
which are indeed a species of convulsions, but are not at-
tended with distortion of the face, nor insensibility. If the
patient be in a state of stupor, she frequently has the coun-
tenance distorted at intervals, accompanied with some uterine
action. They are never preceded by aura, and the patient
usually recovers sensibility much sooner, and more com-
pletely during the intervals, than in epilepsy ; at the same

521

time, there have been instances, of the patient remaining
in a state of stupor for two days. The organs of sense,
particuhirly the ear, are often pretematm*ally sensible.

Convulsions, of the kind I am considering, evidently are
connected with gestation or parturition; they occur at no
other time, and are more frequent in a first labour. Some
suppose that thev are much more apt to attend a natural, than
a preternatural, labour ; but taking into account the frequency
of the one kind of labour compared to that of the other, it is
very doubtful if the opinion be correct. They arise parti-
cularly from uterine irritation, but also seem, frequently, to
be connected with a neglected state of the bowels, a fact to
which I wish to call the attention of practitioners. It is a
general opinion, that pregnancy produces plethora,, and I do
not mean here to dispute the fact, but diistinctly to assert,
that we often confound the effects of excitement, with those of
fulness; for, in many instances, a powerful stimulus, will
produce the same consequences, in a spare and bloodless,
that a smaller one, would have done in a plethoric, habit. Is
apoplexy confined entirely to the latter? There are, per-
haps, few subjects more deserving of inquiry, than the eTOcts
of irritation, of the extremities of the nerves, supplying the
abdominal viscera, on the basis of the encephalon and the
spinal marrow.

There is nothing either more difficult, or more mysterious,
in the etiology of puerperal convulsions, than of chorea, or
stupor, or apoplexy, or insupportable feeling of fulness in the
bead, from stomachic or intestinal irritation, connected with
costiveness, worms, bile, or unhealthy action of the alimentary
canal. If practical observers know, that these causes, do pro-
duce often such effects, where is the ground of surprise, that
uterine excitation, especially, when associated with irritation
of the bowels, arising from long neglect, should produce
tetanic, spasmodic, or even apoplectic affections, during labour ?
The sympathetic irritation, is almost invariably accompanied,
by an affection of the vascular system, productive of great
determination to the head, either directly, or indirectly through
the medium of the spinal nerves, which aggravates the evil,
and becomes, indeed, the chief source of danger. I am in-
clined to think, that, in a majority of instances, the spinal
cord is first affected, by the state of the uterine nerves, and
immediately afterwards, the head suffers, as described in a
future chapter, on spinal and cerebral disease. A strong pre-
disposition, is given to this condition of the nervous system*

522

by a bad state of the bowels, and, labour seems to bring die
matter to a serious crisis.

It has been observed by most practitioners, that by far the
greatest number of cases, occur in women in labour of their
first child.

On inspection after death, we sometimes find turgescence of
the vessels of the brain, or slight eflusion of serum, but very often
no mark of disease is to be discovered any where. Inflammation
of the bowels seems to be an accidental complication.*

The first object, in practice, is to prevent the patient from
injuring the tongue, by inserting a piece of cork or wood into
the mouth; this occupies no time. Next, we bleed the
patient, and must not spare the lancet. All our best practi-
tioners are agreed in this, whatever their sentiments may be,
with regard to the nature of the disease, or to other circum-
stances. We must bleed once and again, whether the con-
vulsions occur during gestation or pregnancy .t There is
more danger from taking too little blood, than from copious
evacuation. Often, in a short time, several pounds of blood
have been taken away with ultimate advantage. Blood-letting
also tends to relax the os uteri. The quantity to be taken
away, must depend on the severity, and obstinacy, of the
symptoms. We never ought to take away more than is
required for relief; nor, on the other hand, are we to stop
prematurely. It is desirable to procure the discharge as
speedily, and in as full a stream as possible ; but it is not
essential, that it be taken from the jugular vein, nor is that
often safe or practicable. I have, when treating of the dis*
eases of pregnancy, observed, that, in many cases, affections,
arising evidently, by sympathy, from a state of irritation of
some of the abdommal viscera, might require venesection for
their removal ; or, if this were neglected, and the disease treated
merely by purgatives, protracted illness, or immediate danger,
might result. Nothing can illustrate this principle, better, than
the present disease, which requires instant, and generally a co-
pious loss of blood ; the mere removal of the irritation, which
excited the iordinate action of the nervous and sanguiferous

• Dr. CoUios thinks that there if so stronf a teodency to the iaflamiiiatioii,
that he urges great attention to the least degree of pain, and oses tartar emetic,
opium, leeches, calomel, ftc., on the first appearance.

f La Motte mentions a case, 622, where a woman, in the last Ayo months of
pregnancy, was bled eighty-six times. Sometimes 2 oz. would relieTe her.— By
modern practitioners, from 40 to 80 ox. have been taken with advantago, in m oaaa
of puerperal couTulsions. Puzos insists on the necessity of copious Uood-lettinf
and speedy delivery. This practice is adopted by the most Judicious of the present
day.

523 '

syBtems, not being sufficient for the cure. Next, we admin-
ister a smart clyster, which, if given eariy in the precursory
stage, is, of itself, sometimes sufficient, to arrest the progress
of the disease. A smart dose of calomel, or solution of salts,
may also be given with advantage, when the person can
swallow, especially if the convulsions have occurred during
pregnancy, with little tendency to labour. We roust also
attend to the bladder, that it be emptied, for its distention
alone, has sometimes brought on convulsions.* When bleeding
fails or cannot be carried further, nauseating doses of tartar
emetic have been proposed, but the free use of this medicine
being often attended with bad consequences, I have not tried
it in this disease. I cannot speak of the benefits from personal
experience. ,

One part of practice, then, and a most important and
essential one, too, consists in depletion, by which the risk of
&tal oppression of the brain, or extravasation of blood, within
the skuU, is diminished, and the convulsions mitigated. But
this is not all ; for the patient is suffering from a disease,
connected with the state of the uterus, and this state is got
rid of, by terminating the labour. Even, when convulsions
take place, very early in labour, the os uteri is generally
opened to a certain degree, and the detraction of blood, which
has been resorted to, on the first attack of the disease, renders
the OS uteri usually lax and dilatable. In this case, although
we have no very regular labour pains, yet, we must introduce
the hand, and slowly dilate it, if that can be done easily, and
without either using force, or producing excitation, marked
by an aggravation of the disease, and deliver the child. Whilst
I entirely agree with those, who are against forcibly opening
the OS uteri,T when it is firm, and perhaps but little dilated, I also
cordially concur with those, who advise the woman to be deliver-
ed, as soon as we possibly can do it, without violence.^ There is,

* La Motto, 82S» 824 Leak relatei a case where it prodaoed ntbtuUus lea-

dimum, and ezcessive pain at the pubis. Vol. ii. p. S44.

t Dr. Bland is rather against dellTery, and. for tmstlng to nature. Dr.
Gartshore, Jour. Vol. Tlii., says, more women have recovered of this, who
were not delivered, than of those who were vioIenUy delivered— Dr. Denman
oonelndes, that women, in the beginning of labour, ought not to be delivered,
ii. 881, and admits of it only when it can be done easily.— Baadelooque says,
tliat we ought not to be in haste to deliver, and never to do it wjien nature seems
to be dlspoaed to do it herself. Dr. HuU, Obs. &c, p. 246, says, that we should
trust to the usual remedies, till the os uteri be easUy dilatable, or be dilated, and
then deliver* He informs me, that in every case which proved fatal, there was
no dilatation of the os uteri. Gardien is disposed to limit the propriety of deli-
very, to those cases, where there is great sensibility of the os uteri, with pain at
the external parts. Trait^, Tom. Ii. p. 484.

t Dr. Osborn, p. MS says, that no remedy can be used with any reasonable

524

I am convinced, no rule of pacdce more plain or benefit
cial,* when evacoationsfiiiltochecktlieconvnlsions. Itnot only
remoYCS an original canse, but also tends to put a stop, to
that renewed aggravation of symptoms, which attends on
every pain or ^ort, whether it be called parturient or
convulsive. Delivery does not, indeed, always save the
patient, or even prevent the recurrence of the fits, but it does
not thence follow, that it ought not to be adopted. I look
npon it as indispensable, if the convulsions be not checked by
venesection. In no case, however, ought we to deliver, till
we have freely detracted blood, as we otherwise might add to
the excitement of the brain or spinal nerves. When the os
uteri is rigid, the hip-bath and emollient vaginal injections
have been recommended, but they are useless, as well as
troublesome. The application of extract of belladonna, has
been proposed for removing rigidity, but of this I have no
experience, and believe that if venesection do not produce
relaxation, nothing else can. Chaussier applies it to the os uteri
by diluting the extract, and putting it, when of a soft con*
sistence, into a small syringe, which is to be guided to the os
uteri, and a little forced out there. In obstinate rigidity, the
OS uteri has been cut with advantage; but this is an example
not to be rashly followed, and I must say, no case requiring
it, has ever come within my notice. The mode of delivery
must depend on circumstances.' If the head be high, and the
waters not discharged, I should have no hesitation in deliv-
ering by turning. If, on the other hand, the head be low,
and within reach of the forceps, there can be still less doubt,
as to the practice. Indeed, those who condemn turning, and
consider it as greatly increasing the danger, do in general
advocate delivery by the forceps, whenever that instrument is
applicable.

The case where there is most room for demur, is that, in
which the water is discharged, and the uterus contracted
round the child, whose head is not yet within reach of the
forceps, long or short. In such a case, we must palliate as
long as we can, but if the disease continue, cautious turning

ezMctation of benefit, tiU ddivery i« completed; and that therefora it is onr
inditpenaable duty to effect it in the quickest poeeible manner — Dr. J. Hamilton,
Ann^a, t. 8I& et seq. says, that when oonTulsiom occur during labour, dellTcry

*•»• accomplished as soon as possible Dr. Leak, that when they seem to

PT**^/"*? r 1? "*«'^»P««*y delivery is useful; but when from "any cause
independent of the state of pregnancy/* deliTery would be hurtful, ii. S48.

vl«L c^yir**?***"' *""• "'»'**'' •»»" *»". M. Baudelooque admits, been of ser-
IhUd sneidllir w-"*"* ??f' **"• *»• «*«f * ^" hard and callous, It wwm divided, the
cbild speedily bom. and the woman immediately became calm, 1 1«0.

525

will be the least of two evils. In certain degrees of contrac-
tion of the pelvis, we can conceive, that it may be necessary
to use the perforator, when we should, had there been no con-
vulsions, have given a longer trial to nature. But to justify
this, the head must be high, the symptoms obstinate, and in-
creasing, and the pelvis more or less contracted, and the effect
of the pains, little, on the presentation ; or, the child must,
by the careful use of the stethoscope, be ascertained to be
dead.

Internal remedies have been advised, such as opium, and
musk, and camphor ; but experience does not establish the
utility of the last two, and the first is highly dangerous. It
seldom suspends the fits, till it convert the disease, into fatal
apoplexy. If in any case it be admissible, copious venesec-
tion must precede it, and the bowels must have been opened.
In general it is to be strictly avoided, as the most fatal agent
which can be employed, and is only admissible, when there is
acute and obstinate pain, in the head or stomach which has
resisted the lancet, and the application of a sinapism to the
part. Ergot has been tried, with the effect, we are told, of
aggravating the disease. Blisters to the head can never be
trusted to, for they are long of operating, and even the pre-
paratory step of snaving the head is troublesome. If stupor
remain after delivery, the head ought to be shaved, and a si-
napism applied to it, which often contributes greatly to reco-
very. If it do not, then, a blister should be applied. Cutting
the hair off, and bathing the head with cold water has been
proposed, but is seldom of decided utility.

The practice, then, which may be deduced from the view
I entertain, of the nature and causes of puerperal convulsions,
and which, independently of all theory, comes recommended
by experience, is, first, to detract blood ; second, to remove
intestinal irritation by clysters, and afterwards by purgatives,
which, although they may not immediately, yet wUl ultimately,
produce beneficial effects ; third, to get rid of the uterine ac-
tion, by accomplishing delivery, when that can be done, without
much irritation ; fourth, to avoid every thing which can excite
the nervous and vascular systems, sucn as cordials and opium.

If the fits have been only apprehended, but have not taken

Elace, then, we may use remedies as preventives. The most
eneficial treatment is, to empty the vessels and the bowels.
When there are evident symptoms of disordered stomach, a
gentle emetic has been advised, but I have never seen it ad-
ministered myself, and am, from its effects on the head, not

526

partial to its exhibition. When a Yiolent pain in the stomach
takes place, we should bleed, and, if it i^all continue after
that, give an opiate. I wish it to be carefully remembered,
that when we have headach, or any other symptoms indicating
a tendency to conyulsions, the lancet is necessary. Blood-
letting can seldom do harm, and it may do much good; it may
be the only means of preserving life, and if this book serve,
merely to impress that fact, on the mind of a single reader, I
will not regret having written it. When one spot of the spine
is very painful, and pressing on it produces spasms, it is de*
sirable, if possible, to take blood from it by cupping, if vene*
section have not relieved it.

When symptoms of nervous irritation exist, without any
determination to the head, or fulness of vessels, then, after
bleeding, opiates may be of advantage,* but I have very great
hesitation in employing them, I ought rather to say in sanc^
tioning them, for I have seldom, iS ever, used them myself,
and, in the ordinary puerperal convulsions, should expect no*
thing but mischief from them. Camphor has been strongly
recommended by Dr. Hamilton, as the most powerful internal
remedy which can be prescribed ; but I cannot, from my own
observation say much respecting its virtue during labour.

When convulsions have continued after delivery, or when
the recovery was not complete, I have found cam|Mbor of ser*
vice, and recommended it to be always tried, but would not
trust to it alone. The head, as I have alreadv said, ought to
be shaved, and have a einapism or blister ipplied. l^orty
drops of laudanum may be given in a clyster. Opiates at this
time are much safer than before delivery, and are oflten of use
if depletion have been free previously, or during labour. We
must keep up the strength, by sedulous endeavours to get the
patient to swallow nourishment.

If convulsions take place, after the delivery of the child, for
the first time, then, the placenta, if it have not come away, is
immediately to be extracted, or coagula are to be removed.
If the countenance and pulse justify it, a vein is to be opened,
and afterwards, the bowels purged. The case is very rare.
We must not confound with it the convulsions which accom*
pany or follow great uterine hsemorrhage.

• Optates have been ttronaly recommended by aome practitloncn, partlcnlarly
Dr. Blaad. Jonm. Vol. iT. p. d28> 8bc— Dr. Hamilton aa atron^ prohlblta
them. Aooala of Med. Vol. y. .-Petit aayf they kill both the mother and the
child. Dr. Collins utet them along with tartar emetic if the fit continue after
delivery.

627

If the practice be prompt and vigorous, the generality of
patients recover from puerperal convulsions.

Those who have had convulsions during labour, ought, in
a succeeding pregnancy, to pay the utmost attention to the
bowels, avoid a regimen which induces plethora, and lose
blood once or twice. When labour commences, a clyster
should be given, and the patient bled, on the slightest feeling
of uneasiness in the head.

Apoplexy, may take place, at the commenment of labour,
or during gestation, without convulsions. In the latter term,
the OB uteri is rarely affected ; still, in a few instances, if death
did not take place immediately, it has been found to dilate a
little. The practice, in either case, is much the same, and
differs in nothing from that to be followed at other times. The
chief resource is the lancet, and delivery can do no good to
the mother, as it does in the case of convulsions. The child
claims our attention in this disease. If it occur during labour,
and death be evidently approaching, the delivery ought to be
promoted, as soon as possible, by turning, or the forceps, in
order to preserve the cnUd. If it occur in the end of preg-
nancy, the CsBsarean operation should be performed, imme*-
diately after death, or, with a better chance, just before it,
when the mother cannot suffer, being unconscious or insensi-
ble.

ORDER FIFTH.

The uterus may be lacerated during labour, under different
circumstances, and from various causes. Any part of it may
be torn, but generally the rupture takes place in the cervix,
and the wound is transverse. It is more frequently in the
posterior than the anterior part, but either may be torn. It
is rare that it is confined to the side. Perpendicular rents
are not common, and when they do occur, the hsBmorrhage is
generally not so great as in the transverse. The rent is usually
oomplete, but in a few cases.it has been confined to the peri-
toneal surface, whilst in others the peritoneum has remained en-
tire, the tissue of the uterus alone being torn.* In either case,
the sinking has been as great and rapid as in perfect lacera-
tion. Sometimes the uterus remains entire, and the vagina
alone is torn, or the laceration is so near the vagina, that the
child is delivered, through the rent, per vaginam.t

* In 9 out of 34 cases related by Dr. Collins, the peritoneal coat remained en-
tire, yet these sank as speedily as the others.

f i>r. Kennedy showed me in the Museum of the Lying-in Hospital at Dublin,
a Yery fine preparation of this species of laceration.

528

Laceration may happen during any stage of labour, and
even before the membranes burst,* but this is uncommon. It
may take place when the head has fully entered the pelvis, or
in the moment when the child is delirered^f It does not ap-
pear that the age of the patient has any material influence,
and, although a greater number of ruptures take place in a
first labour, yet, the risk is not very much less in a second, or
a subsequent confinement.

The uterus may be ruptured, by attempts rashly made to
turn the child ;t or, after the water has been long evacuated,
some projecting part of the child, may so a£Fect a portion of
the uterus, as to make it tear. A certain set of fibres, may
also be suddenly, and spasmodically, contracted, and laceration
may thus take place. In these cases, there is often venr little
warning, and the accident may happen, when we are just in
expectation, of a happy termination of the labour. In a case
detailed by Mr. Douglas (p. 50), the head of the child was
resting on the perinseum, when the lady, who had been subject
to cramp, uttered a violent cry, and the head receded. The
child was delivered, but the patient died. Mr. Goldson's

Eatient complained of cramp in the leg, in the intervals of the
Lbour pains ; and in the instant when the rupture happened,
she exclaimed, " the cramp I" Dr. Munro's patient (Works,
p. 677) was sitting in a chair, when she suddenly screamed,
and the uterus was lacerated ; she was not delivered, but lived
from Tuesday till Friday. If the os uteri be obliterated by
previous disease, the cervix is apt to be torn. Morbid rigidity,
of the OS uteri, may also be a cause of laceration.§ It dilates
very slowly, requires great exertion of the uterine fibres, and
the patient suffers much pain. The uterus may at last be
torn, even, although, the nead have, partlv, descended into
the pelvis, and the pelvis be large. In this case, the liquor
amnii has been discharged, before the rupture takes place.
But a verv frequent cause of this accident, is a disproportion
between the size of the head, and the capacity of the pelvis,
by which, a portion of the cervix uteri, is pinched between the

• Vide Mem. of Med. Soc. Vol. ii. p. 118.

t In a case which I saw, the placenta was retained by a spasmodic strictnre
thongh the child was expelled ; every allowable attempt was made to extract it,
but in Tain. The uterus acted from the os uteri towards the rent, which was
at the fundus, 'llie woman died. The placenta was found still in utero. The
intestines were inflamed. See also Cntntz, de Utero Rupto, p. 22 ; and Dr.
Cathral's case in Med. Facts, Vol. viii. p. 146.

\ A fatal case of this kind Is'related by Mr. Deasc^One more fortunate in the
issue, is inserted in Mem. of Med. Soc. Vol. Iv. p. 25S.

§ Perfect*s Cases, Vol. ii. p. 4S9.— Hamilton's Cases, p. 188.

529

head and the pelvis, and fixed, so, that the action of the
uterus, is directed against this spot, rather than the os uteri.*
The woman feels very severe pain, either in the back or at
the pubis, which, dunng the action of the uterus, augments
to an extraordinary degree, and then the part is torn. An-
other way, in which the cervix may be lacerated, is by the
linea ilio-pectinea being so sharp,t that when the uterus is
pressed against it, the parts are either cut through, or so much
acted on, that they are in a manner killed4 Even without
pressure, some part of the uterus, may be softened by disease,
and rupture take place. Preternatural presentations, from the
obstacle afforded to delivery, become aliBO causes of rupture.§
There is a preparation in the Hunterian Museum, of a uterus,
where there is a laceration of the cervix, and an implantation
of the side of the placenta over the os uteri. There is no his-
tory of this singular case, but it is merely said, that there was
reason to believe, that there had been considerable haemor-
rhage.

Now, from this view we learn, that those women, are most
liable to rupture of the uterus, who are very irritable, and
subject to cramp ; or who have the pelvis contracted, or its
brim very sharp ; or who have the os uteri very rigid, or any
part of the womb indurated. Scholzius relates a case, where
it was produced by scirrhus of the fundus ; and Friedius, one,
where it was owing to a cameo-cartilaginous state of the os
uteri. Sometimes the uterus seems to be predisposed to this
accident, by a fall or bruise. Reidlinus relates one instance
of this. Behling, Steidle, and Perfect, furnish us each with
another. Salmuthus considers a thinness of the uterus as a
predisposing cause of rupture ; and Dr. RossB relates a case
where it seemed to have this effect, the womb not being above
the eighth part of an inch thick, and tearing like paper.

The bladder, being connected to the cervix, is apt to be

* It bai been oUeabited, that in tbree-foortht of tbe eaaet of rupture, tbe ebild
has been a male. Tbe bead of tbe male it a little larger than that of the female
feMoa.

f In a caee of tbia kind, tbe line was on one tide, aa sharp as a fruit knife, and
a eartilaf inous knob projected from the symphysis. Tbe bladder was torn.

I Mr. Scott of Norwich has sent me a case which be published in the 11th
Vol. of the Med. Chir. Trans, where the lower part of the uterus, including ito
mouth, came away. The patient was, after the laceration, deliTcred with the
lerer, and rccoTereid.

§ In a case related by Dr. Collins, the arm was protruded, and the child fixed,
but there were aU the symptoms of rupture. Tbe thorax was opened, and the
breech easily brought down with tbe crotchet. The laceration was in the cerTix.
Tbe patient recoTcred. Dub. Med. Trans. Vol. L p. 1.

I Annals of Med. Vol. Ui. p. 277.

2 M

530

laeeratedy* if the front, of the lower part, of the ateruB, be
ruptured. It is attached to the uterus, at the full time, for
nearly an inch and a half above the upper part of the lips of
the 08 uteri. It descends on the vagina nearly two inches
below that part. The rectum can only be torn, when the
rent ext^ids down the vagina behind. The cervix, is of a
different structure, from the rest of the uterus. The vessels,
particularly the veins, are very numerous above it, but not
in it.

We are led to anticipate laceration, when the patient is
restless, and complains of very severe local pain, subject to
great exacerbation, and attended with a very acute or tearing
sensation. The pains are violent and frequent, and usual^
do not produce a great effect on the os uteri, which is often
very rigid. These symptoms are still more alarming, if the
liauor amnii have been fully evacuated. The treatment to be
fbllowed must depend on the apparent cause ; rigidity is to be
overcome by venesection ; spasmodic action, by an opiate dya*
ter ; change of structure of the os uteri may demand con-
sideration how far incision may be proper ; malposition of the
child must be rectified ; and, finally, when the pelvis is con-
tracted, and there is any symptom, indicating the risk of la-
ceration taking place, the forceps are instantly to be employed ;
or, when such symptoms exist, in any case, where the forceps
are applicable, it would be criminal to delay. In more urgent
cases, the use of the perforator is justifiable.

When this accident does happen, the woman feels some-
thing give way within her, and usually suffers, at that time,
an increase of the pain, and sometimes becomes very sick or
faintish. The presentation disappears more or less speedily,
unless the head have fully entered the pelvis, or the uterus
contract spasmodically on part of the cluld, as happened in
Behling's patient.f For the uterus, can force the cMld, more
easily, through the rent, than through the pelvis. The action
of the uterus continues, more or less, till the child get out of
it, and if the presentation have been fixed, and we deliver with
instruments, the uterus is felt to assist, probably, as much as
usual, in the expulsion. The labour pains go off as soon as

* M. Oliver relates the hiitory of a wofnao» whO) in a fifth prefnancy, had tbt
aterue rtrv oblique* and in labour suffered muoh. She was delivered by the for-
ceps, and died or peritoneal inflammation. On inspection, the uterus was found
to be bilobed. The dtvl&ion which had oontained the child, was, together with
the bladder, lacerated. The other, which was suMHMed to have contained tha
former children, was three inches long aod two broaif. £ack had an orifice optninf
into a common neck, and each had an ovarium*

t Ual]er*s Dlsput. Tom. ill. p. 477.

531

the child passes through the rent into the abdomen ; or, if the
presentation be *fized in the pelyis, they become irregular, and
then cease. The passage of the child, into the abdominal
cavity, is, as soon as the body is expelled, through the rent,
into the belly, attended with a sensation of strong motion in
the belly, or, has eyen been, sometimes, productiye of conyuU
sions. The motion is not long felt, for the child dies speedily.
The shape of the child, can be felt, pretty distinctly, through
the abdominal coverings.

The patient, after this accident, soon begins to vomit a
dark coloured fluid, the countenance becomes ghastly, the pulse
small and feeble, the breathing is oppressed, and frequently
the patient cannot lie down. Sometimes, the intestine pro*
trudes, through the wound in the uterus, and has even been
strangulated in it. These symptoms do not all appear, in
every case, nor come on, always, with the same rapidrty. In
Dr. Ross's patient, although the child escaped, through a rent
in the vaeina, into the cavity of the abdomen, and, though the
nature oi the case was ascertained^ yet no haemorrhage^
fainting, nor bad symptoms took place ; and the child being
delivered, the woman recovered.

When the presentation does not recede, the nature of the
case is still well ascertained by the symptoms ; and the great
depression, &c., fully warrant immediate delivery, whatever
opmion may be formed as to their cause.*

If the patient be not speedily relieved, she becomes very
restless, tosses in the bed, and vomits frequently ; complains
of a pain in the belly, which becomes swelled, the pulse is
rapid, the extremities become cold, and the strength sinks.
In every case that I have seen, the intestines were chiefly
afiected> being much inflamed. The interval which elapses,
between the accident and death, is various ; but whether the
patient be delivered or not, she, notwithstanding the many re-
corded instances of recovery, generally dies within twenty-four
hours, often in a much shorter time. Steidle, however, relates
a case where the patient lived till the twelfth day ; Dr. Gart-
shore's patient lived till the twenty-sixth day ; and in the Coll.
Soc. Havn. Vol. ii. p. 326, there is the case of a Voman,
who, after being delivered, lingered for three months. In a
patient of Dr. J. Wilson's, recovery seemed to be going on
for five or six days, when, after a fit of passion, she sunk in

♦ Rupture was not suspected, till diseorered on dissection, in a case where the
child had been turned on account of deformed pelvis. Archives, ii. 77.

532

consequence of internal haemorrhage. In protracted cases,
abscesses have formed about the peiyis.

Different opinions have been held respecting the best mode
of treatment. Some, have advised the performance of the
Csesarean operation, some, delivering per vias luUurales^ and
others, leaving the case to nature. We have instances of all
these methods being successful ; but the delivery, by turning
the child, or otherwise, has advantages over the other modes,
and certainly ought, with scarcely any exception, to be resorted
to.* When the os uteri is dilated, before the accident take
place, as is usually the case, and the hand can, without much
difficulty, be introduced, it is to be passed through the os uteri,
and the rent in the uterus, into the abdominal cavity^ in search
of the child's feet, which are to be brought down, and the case,
managed in the same way, as in presentation of the feet.
Then, we extract the placenta, after which, we are to intro-
duce the hand again, to ascertain that no part of the intestines,
have protruded, through the wound. This process is usually
easy, when the rent is in the cervix uteri or the vagina. But,
sometimes, the delivery is succeeded, by feeling of sinking, or
by considerable haemorrhage, under which, the patient must
be supported.! When the rent its Higher, there is sometimes
great difficulty, owing to the contraction of the uterus, which
may be affected spasmodically, or may have universally con-
tracted, and the rent become very small. When attempts are,
in such a case, made, to carry the hand along the cavity of
the uterus, to the rent, the fibres may contract over the hand,
and the contraction is felt sweeping toward the rent, so as to
carry, as it were, the uterus off the hand. It would be both
cruel and useless, to attempt delivery, in such a case.

If the head have entered the pelvis, and be within reach of
the forceps, we must cautiously introduce the blades, taking
great care, not to press up the head so as to make it recede.
From this hazard, and from observing, that the child, in such
cases, is generally dead, it has been advised, by good autho-
rity, to perforate the head. But if we have no other induce-
ment to use the perforator, I should consider, that unless the
head be high, the forceps would be as safe, in this respect.
The child may live for hours, if the placenta be not detached,
or the haemorrhage great. ( The stethoscope may aid our judg-
ment.) If expelled into the abdomen, it invariably dies speedily.

* Raptnra of the utonii during getution, bat already beeo oontidered, and the
remarka here, do not apply to rach caaea.

Thiatook place in Mr. Park! naon*ii patient, vrho reoorered. Med. Gaictte»
▼II. p. 173.

533

When the os uteri is rigid, and very little dilated, before the
accident happens, and cannot be opened, without extreme
irritation, which is, indeed, rather a state which may be
supposed, than actually met with ; or when the uterus is
spasmodically and yiolently contracted, between the rent and
the OS uteri, which I know is apt to happen, if the fundus be
lacerated, I consider forcible attempts to deUver, as adding to
the danger. These cases are only rare, because the rupture
is generally in the cervix, for, when the body or fundus is torn,
the contraction is often strong; and, although there be,
doubtless, instances of delivery being accomplished with facili-
ty, some hours after the rupture, yet, in most cases, such con-
traction soon takes place, as must altogether prevent it, or
render it highly dangerous. It may also happen, that great
deformity of the pelvis, prevents delivery.* In such circum-
stances, we must either perform the Caesarean operation, or
leave the case to nature. If we have been called early, and
before the abdominal viscera have been much irritated by the
presence of the foetus, we ought to extract the child by a small
mcision.f This is assuredly safer, than either leaving the
child, or bringing it down, with or without perforation, through
a contracted pelvis. At the same time, the period within
which the child dies, is so very short, that I do not argue on
the supposition of saving it4 If many hours, however, have
elapsed, then, it may be said that such irritation is often already
produced, as renders it very unlikely that the additional injury
of the operation could be sustained. Still, the operation should
be performed, as giving the best chance. On the other hand,
if little irritation be yet excited, and the woman be tolerably
well, there is room, it may be said, to hope, that a natural
cure may be accomplished, as in extra-uterine pregnancy ; and
therefore, as the child cannot be saved now, it may be argued,
that it is more prudent to trust to nature.§ Even in this case,

* In Mr. Macintyrv's o«M} the o« uteri was contracted, but yielded to the hand.
The child was in the i^eneral cavity of the abdomen. It was turned, but the lever
was need on the head, for two hours before it was extracted, yet, this patient re-
covered. Med. Gazette, vii. p. 9.

t Vide successful case by Thibault, in Jour, de Med. for Maj, 176B.^M.
Bandelocque relates a case where the operation was twice performed on the same
patient for the same cause. In Essays Phys. and Lit., Vol. iL p. 870, is a case
most incredible, where both the uterus and abdominal integ umente were torn
daring labour. The chUd escaped, and the woman recovered. A case is related
lately in one of the French Journals, where the Caesarean operation was performed
twelve hours after the rupture, with success.

I There is, however, a case, related by Frank, where pstrotomie was'performed,
and a living child extracted, by Ceoconi, twelve hours, after the rupture had teken
place. Archives, vii. 69a

$ Astnic liv. V. chap. iv. quotes a cam where the child remained in the

534

I am inclined to extract by a small incision, which I conceive
to be less dangerous, than leaving the child. Lastly, when
the pelvis is well formed, but there has been much time lost,
it may be asked, shall we extract the 6hWd by the rent, or re-
move it by an incision ? The practice must depend on the
state of the uterus. If it be contracted, and very tender, the
forcible introduction of the hand and extraction of the child,
should be more hazardous than the incision. I believe, how-
ever, that in most cases of ruptured uterus, delivery will be
found to be practicable.

Another risk arises from the extravasation of blood into the
abdomen, early exciting inflammation ; and it haa been pro-
posed by M. Deneux and others to evacuate the blood by an
aperture.

The cases which admit most easily of delivery, are those,
where the rent is situated in the cervix uteri or vagina ; and
laceration of the vagina is less dangerous than rupture of the
nterus,* provided the bladder be not injured. I do not think

ftbdomen for S6 jtan. In another eate, the midwife felt the child^ hmif but
after a serere pain it dlsapjpearedi and the woman complained onljr of a weight
in the bellf. It was expelled bv abscefls. Hist, de laaoolet^ de Med. Tom. I.
p. 888. In Dr. Bayle'e oate, the child was retained 20 years. PhiL Trans.
xio. 139$ p. 997. In Mr. Birbeck's case, the child was discharged by the navel.
Phil. Trans. Vol. xxil. p. 1000. Bromfield's patient did not get rid of the child,
bat she lived for many years, and after her death the rent was Tldble. PhiL
Trans. Vol. xli. p. 096. In Or. Sym's patient, the process for expelling the
child by abscess was in a faTourable train, when, by imprudent exertion, fktal in-
flammation wva excited. Med. Facts, Vol. Tlil. p. lAO. Bartholin also glYta
cases. Le Dran relates an Instance where the uterus was ruptui^ed on the Slid of
April. On the 13th of May the placenta was expelled; on the 16th, a tumour
appeared at the linea alba, %Thich was opened, and a child extracted ; the woman
recovered. Obs. Tom. ii. oh. 99.

* In a case communicated to Dr. Hunter, the forceps were pushed through the
eervix uteri, and the Intervening portion between the laceration and the oe vteri
was afterwards cut, The laliour was finished naturally, and the woman reeov-
ered. Med. Jour. Vol. vlii. p. 368. Dr. Douglas relates the successful case of
Mn. Manning, in his Observations, p. 6. Dr. A. Hamilton gives a fortanato
case, where ddlvery saved the mother. Outlines, p. S8i ; and Dr. J. Hamilton

relates one in his Cases, p. 138, where the rent had contracted so much, as to give
some difficulty to the delivery. The case is instructive. In the case of £. Dwyer,
related by Dr. Labat ( Dub. Trans.), recovery took place, but, in the nextpreg-
nancy, the same accident occurred and proved fatal. In the 8d vol. of the Irans.
of the Coll. of Phys. in Dublin, p. 16, Dr. Friael, gives the ease of Bridget
Fagan who had the uterus ruptured in consequence of the child presenting the
arm. M Itb great difficulty, and aided by the crotchet fixed on the foot of the
ehild, he succeeded in turning and delivering It, when he found the ntema exten>
aively ruptured at its cervix, and the intestines protruding. He renlaoed the
bowds) and thinks he prevented a reprotuslon by making one edM or the rent
overlap the other. She recovered. In the Sd vol. of the iVans. of the Assoela*
tlon, &&, Is a case by Dr. M'Keever, which Jie sent me, of a ruptured vagina, aooom*
panied with protrusion of a yard and a half of intestine. It could not be reduced,
and sloughed off. The patient recovered. The stools were Tolded by the
▼agina, but after a time they came by the anus. In the 19th vol. of the Med.
Chir. Trans, is a case by Mr. Powel, where the cervix was lacerated, and,
nlthangh during the extraction of the child, which was effected by taming and

535

it neceasarj, to make any further remarks, on the laceration
of the ragina, as distinct from that of the womb, except to
say, that deliyery may be practised, after a greater lapse of
time, than when the uterus is torn ; for the vagina does not
contract.

Afiter delivery, the great risk proceeds from peritoneal in-
flammation, complicated with exhaustion, sometimes the symp*
toms of the one, sometimes of the other, predominating.
Venesection is only admissible in a few cases, and, in general,
we shall find the application of numerous leeches to the belly
to be better. Fomentations, or warm poultices, if their weight
can be borne, give much relief. The bowels are to be freely
opened, which sometimes at first is very difficult to do ; after
this opiates are useful. The strength should be supported, by
mild nourishment, and the patient kept very dean, and in
every respect as comfortable as possible.

When, from precursory symptoms, we expect that laceration
is about to take place, we must accelerate labour, generally
by the use of instruments. This is more necessary if the
patient have formerly had the uterus torn. Turning must
be dangerous, in such circumstances, after the water has been

then perfbntlDg tlM bead, tb« patient required to be supported by brindj,
vet the recovered. M. Haime gWee a fatal caae in the Journ. Gen. for De&
1829. I>r. Hendrie*8 case of rapture of the right side of the neck of the uterus
and part of the vagina, took place in consequence of an exostosis from the sacrum.
The fondos was strongly oontractedi but the body and neck relaxed. The child
was extracted by the feet, and the patient recovered. Rev. Med. iv. 288. In
Solera's patient, the os uteri was obliterated, and an incision required to be made in
the vagina and aterus. After the head descended, the forceps were required.
This is not, indeed, a case of rupture, but of wound. The patient recovered.
Archives, xviii. 107. In Mr. Guitskiirs case, there was no dilatation of the os
«terL When the surgeon was absent, the child was expelled by a rent in the
rectum, the os uteri remaining hard. Med. Rep. for March, 182S. In the ISth
vol. of Med. Chlr. Trans., Dr. Smith relates a case of rupture of the vagina, in a
premature labour, in the seventh month. He cut part of the indurated neck and
extracted the child, which required to have the head opened. The mother re-
covered. Dr. Birch has in the same vol. two cases ; one recovered, the other died
ml the end of six weeks. There is a fatal case by Moreno In Archives, xix. 801.
He considered it as extra*uterine.

M. Coffiners gives a memoir on this suMect, in the Recueil Period. Tom. vi.
in which he remarks, that laceration near the vulva is easilv cured ; at the upper
lateral part of the vagina it is dangerous ; and at the anterior and posterior part,
near the bladder and rectum, it is generally mortal ; but in one case the woman
recovered, although the hand could be introduced into the bladder. The woman
had incontinence of urine afterwards. In his eighth case, the child lay trans-
versely, and the vagina was torn and filled with clots ; but the peritonaeum was
still entire, and therefore the wound did not enter the abdomen. The aterus was
supported with a napkin until the child was turned. Dangerous symptoms
supervened, but the woman recovered. He gives fifteen eases, and of these six
recovered. Several were produced by attempts to reduce the arm of the child.
See also a memoire in Arcnives, xv. SIS. Dr. Birch takes a different view, and
thinks that laceration at the sides and front, even interesting the bladder, is less
dangerous than behind. Med. Chlr. Trans, xiil.

536

evacuated, and before that, there can be seldom any indication
of danger. It has been calculated that rupture takes place
once in 940 cases.

ORDER SIXTH.

Suppression of urine may take place during labour, in con*
sequence of the head of the child, being locked in the pelvis ;
or, from a kind of paralytic state of the bladder, produced by
long retention of the urine ; or, by a small stone, or quantity
of lymph, obstructing the urethra. It produces tenderness,
and great pain, in the hypogastric region, which is also
swelled. The pain is constant, but is increased during every
effort, of the abdominal muscles, to bear down, because, tiien,
the bladder is pressed. It is injurious, in so far as it tends to
impair the uterine action, and it is dangerous, on account of
the risk, of the distended bladder being ruptured,* by the
contraction of the abdominal muscles, or its giving way by a
gangrenous rent. The bad symptoms consequent to this
event, do not always come on instantaneously, and sometimes
the bladder stiU retains a little urine. In a case related by
Mr. Hey, in the fourth volume of Medical Observations and
Inquiries, they did not take place till the second day. The
patient was thirsty, vomited, had a frequent de»re to void the
urine, which she ddd very suddenly, but not more than a tea-
cupfid at once. The pulse was quick, the belly swelled, and
pressure gave her pain. She died about the eighth day, and
the bladder was found to be ruptured at its upper part.

When the urine cannot be passed, by the voluntary efforts
of the woman, aided sometimes by pressing up the head of
the child, the catheter must be introduced. The perforations
of the instrument, however, ought to be large, as a slimy
touffh mucus in the urethra, sometimes fills, completely, those
of the ordinary size. If the head should be so jammed in the
pelvis, as to prevent the introduction of the catheter, which is
rare, the woman must be delivered. I have never koow such
a case.

In some cases, although no water be made for a long time,
yet no inconvenience is felt ; and when the catheter is intro*
duced very littie urine is evacuated. This depends upon a
diminished secretion, and although, of itself, it cannot aeter-
mine us to accelerate delivery, yet, should it be attended with

* A ease it rdated bj Mr. Bedingfiddt where the bleddfr leeme to have barrt,
dnriBf ft vtnr eesy labour of on! j two boon* duration. The petient died after
ptritoneal inilaaBiatlon. Laneet» June, 1887, p. 871.

537

other bad symptoms, in tedious labour, it may form an addi-
tional argument fpr interfering, as then the functions are be-
coming impaired, and effusion may take place into some of the
cavities.

There are some other complications, which might perhaps
be made the subject of distinct orders ; such as the existence
of aneurism, hernia, &c., &c., but these may more properly be
referred to the head of cases requiring the use of instru-
mental aid. It ought to be a general rule, and it is a very
clear one, that whenever a disease exists, which mav be
much, or dangerously aggravated, by a continuance ot the
efforts of labour, that process ought to be shortened, as much
as possible.

BOOK III.

OF THE PUERPERAL STATE,

CHAP. L

Of the Treatment after Delivery.

Immediately after the placenta is expelled, the finger ought
to be introduced into the vagina, to ascertain that the
perinaeum or recto-vaginal septum be not torn, and that the
uterus be not inverted.

Then, if the patient be not much fatigued, she is to turn
slowly on her back, and a broad bandage is to be slipped
under her, which is to be spread evenly, and pinned so
tightly round the abdomen,* as to give a feeling of agreeable
support. This bandage is made of linen or cotton cloth; and
it is usual to place a compress over the uterus, to assist con-
traction. In some, if not in many cases, this might be dis-
pensed with, as we see in a state of nature ; but, in civilized
life, it is useful, if not absolutely necessarv. For, the
abdominal muscles do not contract, so as to afford a support
to the parts within, and syncope, breathlessness, or other
unpleasant effects, may be tne consequence. The wet sheet
is also to be pulled from below her, and an open flannel petti-
coat is to be put on ; it has a broad topband, which is pinned
like a second bandage over the first. A warm napkin is then
to be applied to the vulva, and the patient laid in an easy pos-
ture, having just so many bedclothes as make her comfortable.
If she desire it, she may now have a little panado or any other
light nourishment, after which, we leave her to rest. But
before retiring, it is proper to ascertain that the bandage be

* The abdomen from the time of the birth of the child, tiU this be Applied,
ehonld be euppcMted, or pressed on, especially oyer the aterusi by the expanded
hand.

539

felt agreeably tight, that there be no considerable hemorrhage,
and that the afterpains be not coming on seyerely. It is aiLso
proper to mark the state of the pulse, and to leave strict
directions with the nurse, that every exertion, and all stimu-
lants be avoided.

Having thus simply stated what appears to be necessary, I
must next say what ought to be avoided. It is customary
with many nurses, to shift the patient completely, and, for
this purpose, to raise her to an erect posture. Now this
practice may not always be followed by bad consequences, but
it is very reprehensible, for the patient is thus much fatigued,
and if she sit up, even for a short time, haemorrhage or syn-
cope may be produced. The pretext for this is to make the
patient comfortable ; and, indeed, if the clothes be wet with
perspiration or discharge, there may be some inducement to
shift them. But this ought to be done slowly, without raising
her, and if she have been fatigued, not untu she have rested
for a little. Another bad practice, is the administration of
stimulants. I do not deny, that these, in certain cases of
exhaustion, are salutary; but I decidedly maintain, that,
generally, they are both unnecessary and hurtful, tending to
prevent sleep, to promote hemorrhage, and excite fever and
mflammation. A third practice, also injurious, is keeping the
room warm with a fire, drawing the bedcurtains close,
increasing the bedclothes, and giving every thing hot, to pro-
mote perspiration. This is apt to produce debility, and
many hysterical afiSections, as well as a troublesome species of
fever, which it is often difficult to remove. It also renders
the patients venr susceptible of cold, and a shivering fit is
very readily excited. On the other hand, exposure to cold,
or the application of cold, in any way, is to be avoided, being
very apt to produce local inflammation. I have known too
many cases, where fatal disease was produced, by the patient
being allowed to feel cold during the night. Lastly,
gossipping and noise of every kind, is hurtful, by preventing
rest, occasioning headach or palpitation, as well as other bad
symptoms.

At our next visit, which ought to be within twelve hours
after deliveiT» we should inquire whether the patient have
slept, the afterpains have been severe, or the discharge
copious, and ascertain that the pulse be not fi*equent, for, it
is, always, a suspicious circumstance, when the pulse con-
tinues quick. We should also particularly inquire if she have
made water ; and if she have not, but have a desire to do so.

540

without the power, a cloth dipped in warm water, and wrung
pretty dry, snould be applied to the pubis. If this ful, the
urine may often be voided, if the uterus be gently raised a
little, with the finger, or, the catheter may be introduced.
There are two states, in which we are very solicitous, that
the urine be avoided ; the first is, when the patient has much
pain in the lower belly, with a desire to void urine; the
second is, after severe or instrumental labour.

A stool should be procured, within twenty-four or tlurty-
six hours after delivery, either by means of a clyster or a
gentle laxative. If the patient usually have the milk-fever,
smartlV) or the breasts be disposed to be punful and tense, a
mild dose of some saline laxative, is better than a clyster.
But if she be delicate, and have formerly had little nulk, a
clyster is to be preferred. If she be not to suckle the child,
then, the laxative should be rather brisker, and may be
repeated at the interval of two days.

After delivery, there is a discharge of sanguineous fluid
from the uterus for some days, which then becomes greenish,
and lastly pale, and decreases in quantity, disappearing
altogether within a month, and often in a shorter time.
This is called the lochial discharge. During this time, it is
necessary that the vaginal orifice, and external parts, be daily
washed with tepid milk and water.

During the latter end of gestation, milk is generally secreted
in a small quantity in the breasts, and sometimes it even runs
from the nipples. After delivery, the secretion increases, and
about the third day, the breasts will be found considerably
distended. Many women, indeed, complain at this time, of
much tension and uneasiness, and there is usually some
acceleration of the pulse. A pretty smart fever may even be
induced, which is called the milk-fever. The best way to
prevent these symptoms, from becoming troublesome, b to
Keep the bowels open, and apply the child to the breasts,
before they have become distended. This may generally be
done, twelve hours after delivery.

The diet of women in the puerperal state, ought to be
light; and if they be not to give suck, liquids should be
avoided, the food must be, as much as possible, of the dry
kind, and thirst should be quenched, ratner with ripe fruit,
than with drink. If they be to nurse, the diet, for the first
two days, should consist of tea, and cold toasted bread, for
breakfast, arrow-root or weak chicken soup, for dinner,
and panado for supper ; toast water, or barley water, may be

541

given for drink, but malt liquor should be avoided. Unless
the patient be feeble, and at the same time have no fever,
wine should not be allowed for some davs ; a little may then
be added to the panado or sago, which is taken for supper ;
and a small glass diluted with water, may be taken after
dinner. A bit of chicken may then be given for dinner, and
in proportion as recovery goes on, the usual diet is to be
returned to.

The time at which the patient should be allowed to rise,
to have the bed made, must be regulated by her strength,
and other circumstances. It ought never to be earlier Uian
the third day, and^ in a day or two longer, she may be
allowed to be partly dressed, and lie for an hour or two on a
sofa; but even in the best recovery, and during summer,
she ought not to leave her room, within ten or twelve days.
She ought not to go out for an airing, in general, till the
month be out. In cold weather, and when the patient is
delicate, she must be longer confined. By rising too soon,
and maldng exertion, a prolapsus uteri may be occasioned,
and, stiU more frequently, the lochia are rendered profuse,
and the strength impaired. If there be, or have formerly
been, the smallest tendency to prolapsus, it is absolutely
necessary to keep the patient, very much, for some time,
in a recumbent posture, on a sofa, avoiding, however, that
degree of heat wnich relaxes the system. It is also necessary,
in this case, to stimulate the uterine lymphatics to absorption,
by a mild purgative, once in the three or four days, to bathe
the external parts with rosewater, having a third part of
spirits added to it, and at the end of a fortnight begin a tonic,
mixed with a mild diuretic.

CHAP. II.

Of Uterine Hamarrhage.

In natural labour, after the expulsion of the child, the
uterus contracts so much, as to loosen the attachment of the
placenta and membranes to its surface, and afterwards to
expel them.* This process is always accompanied by the

* When the ateriu eontraeta properly after the delWery of the child, it will be
felt, if the hand be applied on the abdomen, like a hard and aolid maai ; but when
torpid, it ic not so distinctly felt, for it is softer, being destitute of tonic contrac-
tion.

542

discharge of blood, but the quantity ia general is amall.
If the uterine fibres, should not duly contract, after the
delivery of the child, so as to diminish the diameter of the
vessels, and at the same time accommodate the size of the
womb, to the substance which still remains within it, then,
provided ihe placenta and membranes be wholly, or in part,
separated, the vessels which passed from the uterus, but
particularly the venous apertures, shall be open and un-
supported, and will pour out blood, with an impetuosity,
proportioned to their size, and the force of the circulation*
This flow, which is chiefly, if not entirely, venous, will
continue, until syncope check it, a state, too often, only the
prelude to death. So long as the placenta and membranes
adhere, we have no haemorrhage, although the uterus be
relaxed. But as soon as partial detachment takes place, the
blood flows, and many of our worst cases, occur after the
placenta is expelled. Contraction of the uterus, is a primary
cause of the prevention of hsmorrhage, after the placenta
is detached. We also find, that part of the deciduous portion
of the arteries and veins, and of the decidua itself, is left for
some time, attached to the parietes of the uterus, and is
blended with coagulated blood. This forms a brown coatings
or lining, which at first greatly assists in moderating the
discharge.

The contraction of the uterus by acting on the vessels, tends
to prevent haemorrhage. But, whilst we assign the due value to
this contraction, and hold its absence as a cause of haemorrhage,
still, we must attribute somewhat, to the state of the vessels
themselves, as affected by the nerves of the uterus. If any
circumstance, shall keep up an excitement, of the nerves of
the uterus, the whole vascular system is also kept active, and
should this be conjoined, with relaxation of great part of the
fibres, as happens, particularly, when part is thrown into spas-
modic action, the effect in producing haemorrhage must be
decided. In almost every, if not, absolutely, in every instance
of flooding, either before or after the expulsion of the placenta,
we find spasmodic contraction of the fibres of the cervix uteri,
which seems suflicient to excite the vessels, perhaps also retard
the return through certain veins. This spasm, if not the eause^
is, at least, generally the concomitant, of a relaxed state of
the rest of the fibres, and these two opposite states, are both
apt to be produced, if the labour have been tedious, or the
cnild expelled suddenly, by a strong, but perhaps only
momentary contraction. Even independent, however, of the

543

state of muscular contraction, lunnorrhage may take pbtoe
from that of the vessels, and sometimes has been preventedy
in those liable to it from this cause, by detracting blood dur-
ing labour, or in the end of pregnancy. But this seems use-
ful, not so much as Dr. Gooch supposes, by lessening general
plethora, or unusual arterial action, as by its local influence
on the origin of the uterine nerves.

The inertness of the uterus, is sometimes so universal, that
when the hand is introduced, it passes almost up to the
stomach. But, generaUv, a circular band of fibres, contracts,
spasmodically, about tne upper part of the cervix uteri,
enclosing the placenta above it, whilst the rest of the fibres
become relaxed, or, the contraction may be higher, and
merely the upper part of the placenta grasped by it, for there
is no one part of the uterus exclusively anected. This has
been called^ though not very aptly, the hourglass uterus;
and if I did not know the hazard of establishing a general
rule, I would say, that in almost every instance, this con^
traction takes place. I have, rarely, introduced the hand into
the uterus, in a case of flooding, without meeting with it,
whether the placenta had, or had not, been expelled. When
it is not present in any degree, I suspect, that its absence
b often owing to an almost moribund state of the womb.

This spasm of the uterus,* is accompanied with pain in the
back, sometimes severe, great depression of strength, and a
very feeble pulse, sickness, and paleness, as well as by uterine
haemorrhage, which is not the sole cause of the sinking and
debility, for these often precede, even, internal haemorrhage,
though they are speedily increased by it, to an alarming de-
gree. They depend greatly on the spasm, and, as I shal!
hereafter notice, sometimes arise, directly, from affection of the
spinal nerves. If a patient feel sick or weak, or the pulse
sink, or she become pale, soon after delivery, whether there
be, or be not, haemorrnage, we may be sure that this spasm has
taken place, or that she has had formerly an affection of the
spinal cord, which is now operating in a dangerous way, and
that in either case, nothing but prompt measures can preserve
life. This effect of spasm, in causing debility, independently

* Soma IwTe denied Uiat the pImcenU wm retained by tpasm, but imtglned that
tbe cyst, in which it lay, was produced by tlie torpor of the part, whiut all the
reit contracted ; or from the uterus contracting round the placenta. Dr. Douglaa
coneeiTes that the spasm is always produced by mismanagement, particularly,
irritating the vagina or pulling at the cord. For the peace of mind, of many
attantlva and camul practitioners, I am happy in differing from the opinion of
the respectable writer. See Med. Chir. Trans. Vol. tI.

544

of the actual quantity of blood lost, or altogether dispropor-
tionate to it, is analogous to the effect of spasm of the stomach.

Uterine haemorrhage usually appears very soon after de-
livery, and very often before the placenta liare come away ;
but it may not occur till some time after the placenta hare
been expelled. It is, however, rarely met witn beyond half
an hour after the expulsion ; when it does occur, it is gene-
rally rapid and profuse, producing the usual effects of haemor-
rhage on the system ; and these effects, are greater and more
speedy, than those, which follow from haemorrhage before de-
hvery, for the loss is instant and extensive, and the consequences,
often, aggravated by the combination of spasm. If there be
little spasm, or no great effect produced by it, the first gush
may not produce great debility, because it consists chiefly of
blood, which formerly circulated in the uterus, and is not
taken directly from the general system ; and the separation of
the secundines not being wholly effected at once, tne loss at
first is more slow. But, speedily, even when the separation
is partial, the effect appears in all its danger ; and it is not
unusual for the woman, if not assisted, to die within ten minutes
after the birth of the child.*

When the placenta is rashly extracted, immediately after
the delivery of the child, we often find that the uterus does
not contract properly, and the vessels pour out blood plenti-
fully. This in part escapes by the vagina, but much of it
remains in the cavity of tne uterus, where it coagulates, and
hinders the free discharge of the fluid by the vagina. But

* The pfttient naj die ipeedlly after the birth of the child, in oooMquenoe of
other caueet, lome of which it may not be improper to notice. Sodden death
may proceed from an organic affection of the neart, such aa oaiflcation of tho
Talvee or artericc, dilatation of the caritiet of the heart, or anearitm of the aorta.
The effect of any ladden change in the tyetem, in these cases, most be known to
every prMtltioner. Whenerer we suspect such disease, the moat perfect rest most
be obaerred after dellTcry. Should there be anv ineooality in the size of the two
ventricles, the rif ht belnc larger, for instance, tnan the left, then any cause cap^
ble of horryinc tne circulation, may make boUi sides contract to their utmost, the
consequence of which is, that all the blood in the right side is thrown out, bat it
cannot be received into the left : rapture of the pulmonary vessels must take place»
and 1 have known many instances where the patient was immediately suffocated.
Speedy death may also arise from the brain becoming affected in a way similar to
that which takes place in puerperal convulsion. In this case, the first symptona
often is pain of tho stomach, and the patient may die before any farther effect is
produced, if a sliaht hsmorrhage accompany this state, the sinking effect Is grsat,
and from the combined causes, the patient may die, altbouch there be little loos of
blood. Great difficulty of breathing, and most alarming. If not fatal syncope may
take place, from the mere emptying of the uterus. If an adequate support have no!
been given, as we also sometimes see after tapping for dropsy. In this case, even
when due attention was paid to the application ot a bandage, I have seen gasping
and alarming weakness produced. Tne best remedy Is an opiate, with a uttw
warm wine or brandy. It Is possible for air to enter the uterine slnnse% and
produce speedy death.

545

blood may, in this, and in other cases, be still poured out into
the cavity of the womb, which becomes distended, and that,
often, to a great size. Thus it appears, that after delivery
the haemorrhage may be sometimes apparent, sometimes con-
cealed. When it flows from the vagina, it is always dis-
covered by the patient ; but when it is confined in the uterusi
it is known only by its effects ; the pulse sinks, the counte-
nance becomes pale, the strength departs, and a fainting fit
precedes the fatal catastrophe.

Even when the placenta has not been rapidly extracted,
fasemorrhage may be occasioned by rash exertion, or much
motion.

The continued application of a great degree of heat, men-
tal agitation, and the use of stimidants, may also contribute
to the production of haemorrhage.

A partial or complete inversion of the uterus, is another
cause of haemorrhage, and which can only be discovered by
examination.

If flooding occur after delivenr, the woman says there is
surely an unusual discharge ; and, on examining, it is found to
be really so ; but, at first, the pube is pretty good, and the
countenance is not much altered. In a minute, perhaps, the
pulse sinks, the face becomes pale, the hands cold, the respi-
ration is performed with a sigh, or, after lying quiet for a lit-
tle, a long sigh is fetched, and the patient seems as if trying
to awake from a slumber. She exclaims she is sick, and im-
mediately vomits; she throws out her arms, turns off the bed-
clothes, and seems anxious for breath; she complains of cold,
or perhaps is listless, and begs not to be disturbed; or lies in
a state approaching to syncope, or gazes wildly around her,
and is extremely restless, breathes with difficulty, and quickly
expires. The danger of flooding is universally known, and
the consternation excited by it is in many cases great. One
exclaims the patient is dead, another she is dying, one is
wrin^ng her hands, another running for cordials, and it
requires no small steadiness and composure, in the practi-
tioner to prevent mischievous interference, or procure neces-
sary aid.

From the view I have given, it is evident, that flooding is
to be prevented, by preserving the muscular action of the
uterus, and avoiding whatever can increase the force of the
circulation. A powerful mean, of keeping up the action of
the womb, consists in preventing it from emptying itself very

546

Buddenlv. It frequently happens, when the child is instaa*
taneously expelled, by a single contraction, being in a man*
ner projected from the uterus, or when the body is speedily
pulled out, whenever the head is bom, that haemorrhage takes
place* DeliveiT, therefore, is not to be hurried, the steps ot
expulsion should be gradual ; instead of pnlling out the body
of the child, we should rather retard the expulsion, when it
is likely to take place rapidly. Those who estimate the dex-
terity and skill of an accoucheur, by the Telocity with which
he delivers the infant, ground their good opinion, npon a most
dangerous and reprehensible conduct, and he who adopts this
practice, must meet with many untoward accidents, and pro-
duce many calamities. On the other hand, severe and pro-
tracted labour, is no less apt to be followed by irregular con-
traction of the uterus, and haemorrhage*

Another mean, of preserving and exciting the uterine ac-
tion, is by suppcnrting the abdomen, and maSung gentle mres-
sure on it with the hand, immediately after delivery. I do
not say that this practice is, in every instance, necessary, but
it is so generally usefiil, that it never ought to be omitted.
Indeed, Dr. Clarke judiciously advises, that in the act of ^l-
pulsion of the child, the hand should be placed on the fundus
uteri, so as to follow it with a support, during, and after the
contraction* The circulation is also to be moderated, by the
free admission of cool air, by lessening the quantity of bed-
clothes, by a state of perfect rest, and by avoiding the exhi-
bition of stimulants. If these directions, which are few and
simple, be attended to, we shall seldom meet with haemorrhage,
after the delivery of the child. Some women, no doubt, are

Cculiarly subject to this accident. They are generally of a
a fibre, easily fatigued and fluttered^ and subject to hysteri-
cal affections.* When a woman is known to be subject to
haemorrhage, we should give her a full dose of laudanum, im-
mediately after delivery, excite the action of the uterus by ex-
ternal pressure or friction; and, on the first appearance of
discharge, perhaps, in most of such cases, whenever the child
is bom, we ought to introduce the hand into the uterus. We
are not to meddle with the placenta, or endeavour to extract

* Daring prnnanoTV there it lometliiiM a ioor1mti« or linuorrliagio diftthesis
Induced, marked by vibices, tpoocy guma, bleedlog from theee or from the dom*
or from a smaU wound, or after the extraction of a tootli. If this be not correct-
<«d by atrengtliening diet, the free use of ftmit and yefeCablee, and attention to
the bowels, uterine hamorrba^e of an obstinate doaeriptioo may talce ptoea after
delivery. Dry diet andjaxativea have been proposed. Tor those who were liable
to b»morrhage ; bat the most effectual prsyentlTO, is daa regulation of Hbt labour,
and exciting the uterine contraction after deUrery.

547

it; our object is, by the preaettce and geatle pretmire of the
hand, to excite the contractioD of the womb, and make it in
due time expel the secmidines. This gives little pain^ and
may be attended with most important consequences, to the
future health or comfort of our patient. We are ako enabled,
at once, if we feel the uterus c<mtracting spasmodically, to
carry the iSngers beyond that part, and gently dilate it. I
need scarcely, I think, add, that in every case, more especial*-
ly in those^ where the labour has been tedious, or the woman
has been subject to haemorrhage, we ought not to leave the
bedside, but should examine frequently, to ascertain that there
be no unusual discharge.

The instant a woman is seized with hamorrhage after de*-
livery, we ought to take steps, for exciting the contraction of
the uterus, upon which alone, we place our hopea of safety,
for, it is a fatal error, to wait till dangerous symptoms appear.
Some powerful means are, at all times, within our reach; the
introduction of the hand into the cavity of the uteruB, exter*
nal pressure, or friction, and the application, in extreme
cases, of cold to the beUv. These are aided, by the instant
exhibition, of forly or finy drops of laudanum.

The retention of the placenta, is not in general the cause
of the hasmorrhage, but a jwit effect, together with it, of the
state (A the uterus. Our primary object, therefore, in intro*
dttcing the hand, is not so much, to extract the placenta, as
to excite the uterus to brisker action. How improper and
dangerous, then, must it be, to thrust the hand into the
uterus, grasp the placenta, and brine it instantly away ; or to
endeavour to deliver the plaeeirta, by palling rorcibly at the
umbilical cord. By the first practice, we are apt to injure
the uterus, and certainly cannot rely upon it, for cneoking the
hemorrhage. By the second, we either tear the cord, or in-
vert the uterus. Yet, although tins be correot, I must not
carry the rule too far. The placenta is retained, because the
uterus does not act vigorously; but, in oonsiderable torpor, I
am inclined to think, that it may soeoetimeB act injuriously,
by preventing the uterus from omlapsing, whilst it does not,
on the other hand, make aay stimnhiting pressure against its
surface, as can be done by the hand. The mere removal of
the plac^ta,. after the womb has been, for a short time, ex-
cited by the introduction of the hand, allows the sides, of the
now empty cavity, to &11 together, and this of itself stimulates
to contraction, as the discharge of the water does, during la
hour; at all events, we find the removal, attended, by at least.

548

a temporal^ siispension of the hemorrhage. But, in most in-
stances, it IS prudent, to reintroduce the hand, and retain it
for a short time. Hence also, the manual abstraction of
coagula, if hemorrhage take place after the expulsion of the
placenta, is of signal benefit, often of more advantage, than
retaining the hand longer in the uterus.

When we introduce the hand, if the placenta be not yet
expelled, we use the cord as a director, but do not pull it.
It leads us to the stricture, which we find embracing it, whilst
under that, we have a loose cavity, formed by the vagina, and
under part of the uterus, often filled with coagula, amidst
which, we find the flabby lips of the os uteri, which the prac-
titioner must not mistake, for either clot, or placenta. The
stricture is often such, as with difficulty to admit the finger.
We cautiously pass it along the cord, within the contraction,
and then a second finger, and perhaps a third, and gently
-dilate the stricture. We have two objects in doing this, the
•one, is to get at the placenta, which is above it, which we
slowly detach and bring down. We use no force in separat-
ing the placenta, but rather press it toward the opening;
often a great part of the placenta, is in the under division, and,
the stricture does not grasp the cord, but a portion of the
placenta, in which case, the removal is more easily efiected,
than in the former case. The other object, is to excite, by
this dilatation, the general contraction of the uterus, whicn
we aid, by gently moving the hand, in the under and free part
of the womb. The placenta being freed, is to be brought
away immediately, along with the coagula, and then, we rein-
troduce the hand, and aid the contraction by external pres-
sure, &c. We do not dilate again the stricture, which we
shall find still to exist, unless the rest of the uterus be very
flaccid, and then we do so as an excitation. We cannot ex-
pect the stricture to go ofi^, all at once, but if the haemorrhage
'cease, we find that it gradually goes off, particularly by the
use of laudanum. We never can permanently remove it, by
ilistention, and ought not to try it.

But I shall suppose, that the placenta has been already ex-
celled, before the haemorrhage comes on, and some of the
most appalling cases are of this description, occurring even
after the patient is bound up, and laid to rest. The same
practice is to be followed, the hand is to be introduced, and
pressure made externally, the lower part of the uterus
emptied of clots, and the stricture somewhat dilated; the
hand is then either to be retained, or reintroduced if it had

549

been withdrawn, and moved gently in the slack part of the womb,
to' excite it if there be haemorrhage still, or, any new clot is to
be remoYcd. It is a mistake to suppose, that the presence of
coagula, will either close the mouth of the vessels, or stimulate
the uterus to contract. This is best effected, by the removal
of them, and by the pressure of the hand within and without.
No remedy can be at all depended on, without the use of the
hand, and the removal of coagula. I now proceed to con-
sider what farther assistance may be given. I have already
advised, immediately on the attack, and as soon as possible
after introducing the hand, for we lose no time in this respect,
to give forty or fifty drops of laudanum. We then press
firmly over the uterine region with the other hand, or the
hand of an assistant, and move the abdominal parietes some-
what briskly, but not rudely, over the womb, and occasionally
grasping that viscus gently. Friction, is intended to excite
to contraction, whilst pressure is calculated also, though, I
fear, not effectually, to impede distention.

The contraction of the uterus, is sometimes powerfully as-
sisted, by the application of cold. The quantity of clothes^
should be lessened, so far, as to prevent the surface being
heated, and the circulation excited ; but our principal expec-
tation, is from cold as a topical application, which should be
made, if the other means fail, but only in that case. Cloths
dipped in cold water, should be laid, suddenly, upon the belly.
In obstinate cases, it has been found useful, to project it, for-
cibly on, with a syringe. It has been proposed to dip a sponge,
or a piece of cloth, in cold water, and carry it, in the hollow
of the hand, into the uterus. Nay, ice itself has been intro-
. duced into the womb,* but we must not forget the possibility
of inducing inflammation, by these measures, which can there-
fore only be justifiable in extreme cases. In general, when
cold can be useful, its external application, by means of cloths,
will be sufficient to save the patient. I feel confident in ad- ^_
vising it, when requisite, and have never known any bad con-/ v,

sequence result from it. \

* Saxtorph nacs Iniectlont of yinegar and cold water. Past! has the hardihood
to use alcohol and acids, to cauterize, as it were, the mouth of the uterine vessels,
yrhich cannot fail to cause inflammation. Others introduce a sponge dipped in
cold water, or a 80w*s bladder, which they afterwards blow up with air, to press
on the uterine surface, or fill it with cold water, at the same time that they apply
external pressure. Others use the cold bath itself. Le Roy rubs the abdomen
'vrith spirits, and Lapira praises the external application of a strong solution of
carbonate of ammonin. 0*ardien supposes it jn-xs sometimes be so active as to
require the lancet. Others plug the os uteri, and compress the abdomen. 1 do
not think it necessary to comment on these proposals.

550

Ergot has been adTised, and, in Boone cases, is aaid to hare
done good, but nothing equals the cautions nae of the hand*

K &e placenta be found detaohed, and loose, in die uterus,
we move the hand gently, to excite the womb, and also use
the other means already noticed, vis*, pressure, friction, opiates,
&c. Then, after a short effort made to excite the uterus,
we withdraw the placenta and dots. We should lose little
time, however, in this attempt with the hand, to stimulate the
uterus, for, if it do not very quickly produce the effect, it is
best, at once, to remove &e placenta, and, the mere emptying
of the uterus, will be found to have a good effect. 'Hie hand
mav thra be redntrodueed, and probably the uterine cavitv
wiu be found greatly diminished. Even in this case, which
is ccmsidered as an instance of general flaccidity of the uterus^
we may in general, by attention, discern a spasmodic contrac-
tion, wove the cavity which receives the lumd.

When it happens, that part of the placenta, adheres pretty
firmly to the uterus, we are not to be rude in our attempts to
separate it.* It is too much the practice, with some mid-
wives, to trust more to their fingers, than to the contraction
of the uterine fibres, the consequence of which is, that they
tear the placenta and irritate the womb. Yet, it is certain,
on the other hand, that gentie attempts to separate it, are
sometimes neoesssry ; but these should be so cautiously and
deliberately made, as not to lacerato the placenta. The
fingers should be very dowly and gently insinuated, betwixt
the uterus and the placenta, so as to overcome the adhesion,
which is seldom extensive. I have known the placenta retained,
for four days, by an adhesion not larg^ than a shilling. This
ease proved fatal by loss of blood, which continued to take
place, I understand, in variable quantity, during the whole
time. No attempts were made to relieve the woman, until she
was dying.

We can, in general, save the patient in flooding, if we be
on the spot when it happens; but if much blood have been
lost before we arrive, the strength may be irreparably sunk.
In those cases where great weakness has been produced, we
must not only endeavour to excite the uterine contraction, in
order to prevent further injury, but we must also husband
well the power which remains. As every exertion is danger-
ous, motion must be avoided, and upon no accoimt is the

• One of the moel perfect cam of UenUfieation, of Uio Qterine ud nlMDtaiy
eorfooes, b preMnred in the Muoom of the Lyipg^n-Hoipilia at DolAiii.

551

patient to be shifted or disturbed for some time^ By impni^
dent attempts to raise the patient, or, ^* to make her more
comfortable," she has sometimes suddenly expired. But it
is of consequence to have the whole belly, firmly supported
with a bandage, if this can be applied without moying the
patient much.

The state of the stomach is to be watched, preventing, as
far as we can, that feeling of sinking, which is apt to take place
in all floodings. Cordials, as for instance, undiluted wine,
or brandy, diluted or pure, should be given freely, for some
time, to support the strength ; but after recovery begins to
take place, and the puke steadily to be felt, they should be
omitted or decreased, for, if persisted in, to the same extent^
fever or inflammation may be excited. Opiates, are of great
service, in all cases of uterine hemorrhage, after delivery.
They are among the safest, and best cordiids, we can emplovt
and must, in every instance, be exhibited. The dose ought
to be proportioned to the urgency, varying from fifty to
sixty drops. In some instanees, when the debility was ffreat,
a hundred drops of the tincture, or when the stomach wa«
very irritable, nve grains of soft opium have been given at
once, and afterwards three grains every three hours, till the
patient was out of danger. But I do not consider such large
doses of laudanum to be necessary, and as for the solid opium»
it ought to be given in doses, only of a grain, to allay the
irritability of the stcmiach, after the pressing danger is past»
for, in no dose, can it act instantly, or be depended on in
uigency. Moderate doses of laudanum by the stomach, or in
clysters, never prevent the contraction of the uterus, or pro*
duce afterwards any bad efiect. Opiates snpply, in so far, the
place of wine, and are infinitely safer, at the same time, we
must not neglect wine or brandy, as the one assists the other»
and these last stimuli are more immediate in their effects, a
property which is of essential importance. Aromatics have
been given, such as tincture of canella, with good effect.
Iced water has also been recommended, but of this I have no
experience. When the patient has recruited a little, it will
be proper to give small quantities of soup, properly seasoned^
or such other nourishment as she can take.

We must be careful neither to give cordials nor nourish*
ment, so frequently, as to load the stomach, which produces
sickness and anxiety, until vomiting remedy our error. This
last symptom, when moderate, is not always unfavourable^
for it sometimes excites more powerfully the contraction of

552

the womb. The rising of the pulse, and relief of the patient
after it, are to be ascribed, not so much to any direct power,
which this operation has, of invigorating the system, as to the
consequent removal of sickness and oppression. If these
effects do not follow from vomiting, the case is veiy bad.
Soft opium is the most effectual remedy against repeated
vomiting. It must be given in the dose of urom one to two
grains.

When the haemorrhage has produced complete syncope,
the state of the patient is very alarming. Yet the danger is
not the same in every case, for some women faint from slighter
causes than others. La Motte, relates one case, where the
patient fainted no less than twenty times, in the course of the
night. In a faint, she is to be kept in a state of the most
perfect rest, the face is to be smartly sprinkled with cold
water, and, when she can swallow, a little wine or brandy, or
spiritus ammonias aromaticus diluted with water, and having
laudanum added to it, given to rouse the system. After-
wards, warm spiced wine may be given, in small quantity,
and warm cloths applied to the feet. Friction on the region
of the stomach, with some stimulating embrocation, as harts-
horn and spirits, or the application of a sinapism, may be
useful. I need not add, that the patient must, in these awful
circumstances, be carefully watched ; and that, if the expres-
sion be allowed, we must obstinately fight against death. It
may appear to some, that stimulants, and other means to re-
move syncope, must renew the haemorrhage, and that syncope,
itself, is useful, by checking the circidation. But no man of
observation, can suppose syncope to be safe, in haemorrhage
after delivery, or hesitate, by opium or brandy, or wine, to
recall his patient to auimatiouj or to prevent a renewal of the
fainting fits.

The transfusion of blood, has been proposed, in this des-
perate case. But, partly from the diflSculty of getting an
apparatus when required, and partly from the little success
attending the practice, it has seldom been resorted to, and is,
already, noticed merely as a speculation. Injecting tepid
water, into a vein, with due precaution, might, by refilling
the vessels be, I suppose, as useful as transfusion. We must
not forget, in considering the proposal, the risk of inflamma-
tion of the vein, should the patient survive.

It was, at one time, the practice, to prevent the patient from
sleeping, or indulging that propensity to drowsiness, which
often follows hemorrhage. But we can surely, at short inter-

553

yals, give wbateyer may be necessary to the patient, without
absolutely preventing sleep, or rather slumber, for the patient
never sleeps profoundly. We are to attend so far to the ad-
vice, as not to allow the slumber to interfere, with the admin-
istration of such cordials or nourishment, as may be requisite*

Sometimes a partial or irregular contraction of the uterine
fibres takes place, and the person is tormented by grinding
pains, accompanied by repeated haemorrhage.*

The retention of a small portion of the placenta, which has
firmly adhered to the uterus, is also a cause of haemorrhage,
and the discharge may be renewed for many days, until the
portion be expelled.

It may also happen, that, from some agitation of mind, or
morbid state of body, the uterus may not go regularly on, in
its process of contraction, or restorationf to tne unimpreg-
nated state. In this case, the cavity may be filled with blood,
which forms a coagulum, and is expelled with fluid discharge.
The womb may remain, thus stationary, for a considerable
time, and the coagula be successively expelled, with slight
pains, and no small decree of haemorrhage. These symptoms,
very much resemble those, produced by the retention of part
of the placenta, and cannot easily be, with certainty, dis-
tinguished firom them. We have, however, less of the foetid
smell, and we never observe any shreds or portion of the
placenta to be expelled, whilst the coagulum, if entire, has
exactly the shape of the uterine cavity.

Lastly, we find, that if exertion have been used, before the
uterus have been perfectly restored, there may be excited a
draining of blood, which does not come, in general, very
rapidly ; but, from its constant continuance, amounts ulti-
mately to a considerable quantity, and impairs the health and
vigour of the woman. This has been called menorrhagia
locbialis.

When the haemorrhage proceeds from irregular action of
the uterus, and is attended with grinding pain, a full dose of.
tincture of opium is of advantage, and seldom fails in reliev-
ing the patient. Laxatives are also proper.

* When the ahdomen hM been bandaged too tightly, the parts within are
injured. The patient it reetleas and uneasy ; the pulse is frequent ; she com-
plains of pain about the uterus, and numbness in the thighs. Sometimes the
lochia are obstructed ; sometimes, on the contrary, pretty copious hiemorrhage is
produced. Relief is obtained by slackening the bandage ; by giving an anodyne ;
and, if there be no hemorrhage, by fomentmg the belly.

t This, at first, is owing to muscular contraction ; afterwards, absorption
forma part of the process. But if these operations shall be interrupted, or
injured, then the yessels, which are^still large, not being duly supported, will be
Ttry apt to pour out blood.

S54

If the placenta ham been toni, and a portion of It raonhi'
attached to the uterus, the hamorrhage is often very obstinate.
Both dotted and fluid blood, will be discharged repeatedlj.
The clot has the shape of the uterus, and is expdled with
fluid blood like an abortion. An offensive ameU, proceeds
from the uterus, and» at last, the portion of placenta is expelled
in a putrid state, after the lapse of many days, or even weeks ;
and this expulsion, is often attended with severe attacks of
haemorrhage. By examination, the os uteri irill be found
soft, openfaad ir^akr.

If, by the introduetion of the finger, we can feel any thing
within the uterus, it should be cautiously extracted ; but we
are not to use force or much irritation, either in our examina-
tions or attempts to extract, lest we in^ame the womb. It is
more advisable to plug the vagina, and even the os uteri, so
as to confine the blocNd, and excite tiie uterine contraction.
We may also inject some astringent fluid, for the same pur*
pose, or throw a stream of water, moderately cold, into the
uterus, from a large syringe, by way of washing out the por-
tion of placenta, if it have become nearly detached, or, if the
smell be very offensive, we may use a weak solutbn of chlo-
ride of lime. A gentle emetic sometimes promotes the ex-
pulsion. The bowels are to be kept open, and the strength
supported by mild and nourishing diet; but we must tt^e
care, on the other hand, not to fill the vessels too fast. If
febrile symptoms arise, the case is still more dangerous, as I
will presently notice.

mien the haBmorrhage proceeds from an intermption of
the process of restoration, our principal resource, consists in
exciting the contraction of the womb, by the use of clysters —
by friction on the abdomen — ^by injecting cold and astrinffent
fluids into the womb — ^by the exhibition of a gentie emetic —
and by clapping, if other means fail, a cloth, or sponge, wet
with cold water, suddenly, upon the abdomen, when the womb
is expelling the coagulum. We also check the haemorrhage,
and save blood, by the prompt application of the pl^9 and
diminish the action of the vessels themselves, by aUaying or
removing every irritation, and avoiding the frequent use of
stimulants, or attempts to fill the vessels too qmckly. The
feeling of sinking, sickness, tendency to syncope, &C., are to
be obviated by the means abeady pointed out.

Lastiy : — The monorrhagia lochialis, is to be cured by rest,
cool air, the use of tincture of kino, sulphuric acid, or other
tonics, bathing the pubis or back with cold water, and inject-

555

vog aa astringent flokU tbeee or four times a-dby, into Ae
Yagina. Somotbaea ^wlienever tha diachame atopa, the patient
comphana mttch of atomachio afiBection. This is to be allajed
by bzatiyes and aramatiics^ or rabefisbcients a;]nplied to the
epigastrium. When it alternates with diarrhosa, confectio
catechu is useful^ along mth some bitter tincture. V the
pulse be frequent, .tiie exhibition of digitalis, for a short time,
may be of adjantage. Pain in the bade, generally attends diis
disease, and is sometimes so sei^ere, as even to affeet the breath**
ing. In tiiis case, a warm plaster applied to the back is often
of service ; and, if the pulse be soft, an anodyne should be
administered. In slight caaes, the application of cloths dipped
in cdd yinegar, to the back, does good.

The distressing paljutations, beating in the head, and head-
aeb, with anomalous nervous, affections, which often follow
haemorrhage, are best relieved by the regular and steady use
of laxatives, which may be conjoined with asafostida, or tonics,
such as iron or quinine, according toTcircumstances. In a
former part of this work, the student will find remarks on the
effects of great haemorrhage.

CHAP. ni.

0/ Inversion and Retroflexion qfthe Uterus*

Ikvbbsion of the uterus, implies, that the inside is turned
out, and down into the vagina. It may take place in differ*
ent degrees, and has, accordingly, been divided into the
simple depression ; the incomplete mversion, when the fundus
is merely engaged in the orifice ; and the complete, when it
protruded out of the vagina, and exactly resembled the uterus
after delivery, only, the cervix turned upward. The vagina
is, in this case, sometimes partially drawn down, or also partly
reversed or inverted, so that the tumour is of considerable
length. We cannot, however, say, that the inversion is strictly
complete, for, in most oases, the lips of the os uteri hang down,
and the inversion terminates at tne lower part of the cervix.
The term, complete inversion, is therefore not quite correct.*
When^it is more partial, the tumour is retained altogether, or
chiefly, within the vagina, and the fundus only protrudes, to a
certain degree, through the os uteri, forming a firm substance,

* Some mainUin Uiat it Is pomiUe for tlie lipt to be tvmod fiiite up*

556

soi&etbiog like a cluld's head.* When the uterus is inTerted,
the patient feels great pun, generally accompanied with a
beanng-down effort, bywhich a partial inversion, is sometimes
rendered complete. The padn is obstinate and seyere, she
feels very weak, the countenance is pale, the pulse feeble, per-
haps nearly imperceptible, a hiemorrhage, yeiy generally, at-
tends the accident, and often is most profiise. But it is worthy
of notice, that frequently complete inyersion, is not accompa-
nied with h£Bmorrha£e,f whilst, a yery partial inversion, may
be attended with a mtal discharge. Although there be little
hemorrhage, the feice is pale, and the pulse weak and rapid ;
a sensation of dragging at the stomach, or a feelmg, as if the
bowels were pulled out of the belly, may accompany inversion.
Planting and convulsions, are not unn'equent attendants, al-
though the haemorrhage have been trifling. Inversion may be
suspected to exist, from the symptoms mentioned, and on ex-
amination, the womb shall be felt, more or less protruded, like
a mass of flesh, whilst no hard uterus can be discovered in
the hypogastrium.

Inversion, in a great majority 'of instances, depends upon
the midwifej: endeavouring to extract the placenta, by pulling
the cord. Sometimes the uterus is directly pulled down, and
the placenta still adheres ; in other cases, it is separated. It
may also happen, if the child be allowed to be rapidly expelled,
for, if the cord be short, or entangled about the child, the
fundus may receive a sudden jerk, and become inverted.
From the same cause, or sometimes, perhaps, from sudden
pressure of part of the intestines, on the fundus uteri, occa-
sioned by a 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 ; but if the cord be pulled, or if there be any ten-

' • The late Dr.;White of Paisley deaeribes it very well, as resembling a printer's
ball. Med. Com. Vol. zz. p. 147* Sometimes It does not pass through the os
uteri. Denman, toL li. p. S51.

Mangetusi lib. iy. p. 1019, relates a fatal ease, where the tamonr was taken for
the head of a second child. It was at first partially, and then completely, invert-
ed with excruciating pain.

Mr. Smith relates a ease of inTersion, where the accident was followed by syn-
cope, subsultua, &c. The subsultus and frequent pulse continued for some days,
witli smart fever, and inability to move. Med.fand Fhys. Jour. Vol. vi. p. 60S.
In the same volume, Mr. Primrose gives an Instance where a great part of the
uterus sloughed off, and the woman recovered.

t This was the case, in the instance related by Dr. Hamilton. IMed. Com.
Vol. xvi. p. 31d.»In the case by Mr. Brown, the haemorrhage was considerable.
Annaln or Med. Vol> ii. p. 277. I have seldom seen much naemorrbage attend
complete inversion.

t Cliapman relates a case of inversion, where the midwife pulled forcibly at the
uterus, and excited convulsions, fainting, aud death. Case 29, p. 123.

557

dency in the uterine action, to go toward the fundus, as hap-
pens when that part is lacerated, and may in like manner oc-
cur in the present case, the depression is speedily converted
into perfect inversion, which may thus take place, spontan-
eously, and without any fault of the attendant. Dr. Merri-
man (Synopsis, p. 149), mentions an instance, where it took
place, when the nand of the operator, was introduced for the
purpose, of effecting the separation of the placenta. It is in
this way, that we are to account for those cases, which haye»
apparently, occurred many days after delivery, and where,
either with or without haemorrhage, the uterus has suddenly
come down. It would appear, however, that this depression
of the fundus, ending at last in complete inversion, may take
place some time after delivery. There is one case, of this
Kind, recorded, where, on account of haemorrhage, the hand
had been introduced, and the uterus was not found unusual
in its figure. On the 12th day, inversion took place. Even
in this instance, however, it is oy no means certain, that there
was no depression early; for the practitioner, might not
have attended, minutely, to this circumstance, not expecting
it. An incomplete inversion, may remain for life, and occa-
sion incurable fluor albus and haemorrhage. Some, however,
speculate on a cure being effected by pregnancy, which doubt-
less would be the case, if that could take place.

It has been supposed possible, that inversion might take
place in the virgin state, if the womb had been distended, by
blood or other fluid.

Inversion may terminate in different ways. It may prove
rapidly fatal by haemorrhage ; or it may excite fatal syncope^
or convulsions ; or it may operate more slowly, by inducing
inflammation, or distention of the bladder ; or, after severe
puns and expulsive efforts, the patient may get the better of
the immediate injury, the uterus may dimini^ to its natural
size, by slow degrees, and give little inconvenience ;* or it may
discharge foetid matter, and give rise to frequent debilitating
haemorrhage, with copious mucous discharge in the intervals ;
or hectic comes on, and the patient sinks in a miserable man-
ner. It has also been said, that after a lapse of many years,

* La Motte, S8S, mentioni a woman who had inyenion for aboTO thirty yean.
The late Dr. Cleghorn, Med. Comman. ii. 226, relates a caee where the nterus
slowly returned to ita natural size. Thla woman still menstruated and enjoyed
tolerable health, after It had been of twenty years' standing. The womb was smooth,
moist, and gave little pain. Menstroation also contioued in Dr. Hamilton's oase*
Com. xvL p. 816.

558

the inyersioa might be spoataBeoualy oured^ whioh DsOUeE
ezplauiS) by supponng that the tubes pull up the myerted part.
Tnere are two examples of this tennijiation reeorded, and one
of them (Mad. Bourchalatte) on the authority of the justly
celebrated Baudelocque.* In this case the restoration took
plaoei after a lapse of eight years. From examination of pr&>
parationsi there appears to be nothing physically impossible, in
forcing up the inyerted portion, but whether it could be done
with safety, is another question. Spontaneous reduction, nmst,
at least, be exceedingly rare. The contraction of the oe uteri,
of itself, would be an obstacle to the return of the body and
fundus.

If inyersion be disooyered early, the uterus may be replaced.
If it haye protruded out of the yagina, it is first of all to be
returned within it ; if it haye not, we proeeed directly to en*
deayour to return it within the os uteri, by eaotiously grasp*
ing the tumour in the hand, and pushhag it upwards, within
the OS uteri. This may be facilitated, by pressing up the most
prominent part of the nmdus, in the direetkm of ibe axis of
the uterus, so as gradually to undo the inyersion, or VMnyert
the protruded wwib» A piece of wood, with a round head,
has, by some, been used in this way, but the fingers are safer.
If we push, cUrectly, without compresshig the tumour, we some-
times bring on yiolent bearing-down pama* These are, occsr
sionally, attended with increase, or renewal, [of flooding, and
in all cases, on pressing the uterus, small yessels spout, kke ar-
teries in an operation. K we succeed, we should carry the hand
within the uterus, and keep it there for some time, to excite
its contraction. If the placenta still adhere, we should not
remoye it, until we haye reduced the uterus ; after which, we
excite the contraction of the womb, to make it tlurow it off.t

It is sometimes lonff brfore the pdae come steadily to be
felt.t Occasionally, after the reduction, when the patient is
seeming to do well, she is seised with a fit and dies^ Or, she
may remain ]oag weak, and haye swelled fieet.j|

If inyersion naye not been discoyered early, it is more

* Gardlen IMU, Tom. iii. p. S86.

t In a oMe rdated io Memoin of Med. Soc Vol. y. p. 202, the placenta was
allowed to remain five days after reduction, but this is a hazurdous piaetice..— Per-
fect, case 71, brought it away after four hours. Dr. Merriman, In one instance,
followed the adTice of Pu2os> to remora the placenta before ndue^n* but altbongh
he did it without detriment^ yet, he acknowledgea ha ironld boI fiiUaw tha
ourse in future.

i Case Dr. Duffield, in Trans, of CoU. at FUL 176.

1 £^ Jsr ^* Albers. Annals, of Med. VoL t. 990.

I Mr. White's Case, Med. Comment. VoL xx. 247.

559

difficult) najs sometimes impossible to reduoe it^ owing chiefly
to contractioii of the os uteri. Dr. Denman says, that he has
found it impossible to reduce it, even four hours after it took
place, and m a chronic inversion, he never once succeeded.
Li such cases, it is not prudent, to make yenr violent efforts,
to reduce the uterus, as these may excite inflammation, con-
vulsions, &c. Soon after becoming inverted, the uterus is apt
to swell and inflame. If this have happened, no attempt
should be made to reduce, till, by bleedmg, and rest, and
mild fomentations^ this state have been allayed* We must,
in every instance, alleviate urgent symptoms, such as syncope,
rotation of urine, or inflammation, by suitable means. I
may further observe, that when a patient, after delivery, com-
plams of obstinate pain, or bearing-down, or suppression of
urine^ or is very weak, we should always examine per vaginam.
If the uterus be inverted, we may feel the tumour, and we
may find the hard womb, to be absent in the belly, or lower
down than it should be. If this examinatbn be neglected,
the patient may be lost. I have known the first intimation
given to the practitioner, to be his finding no uterus in the
belly, when it was op«Bied after death. Examination is of the
utmost consequence.

When the uterus cannot be replaced, we should, at least,
return it into the vagina. We must palUate symptoms, apply
gentle astringent lotions, keep the patient easy and quie^
attend to the state of bladder, support the strength, allay
irritation by anodynes, and the troublesome bearing-down by
a proper pessary ; the bad effects of neglecting, or removing
this, are to be seen in La Motto's 385th case. A spring ban-
dage is also useful. If inflammation come on, as is usually
the case, we prescribe blood-letting, laxatives, &c. By these
means, the uterus may contract to its natural sice, and the
woman menstruate as usual, but generally tibe health is deli-
cate. Sometimes, the uterus becomes scurrhous, or gangreah
ous sloughs take place.*

If the uterus discharge foetid matter, and bsemiNrrhage
take place, the strength is apt to sink, and the patient dies
hectic. Astringent applications, with attention to cleanliness,
good diet, and the occasional use of opiates, may give relief;
but if they do not, we are warranted, to prefer the trial of
the ^Ltirpatioii of the utems, to certain death. This opera-

* Schnmolcir'b Svfical ISmty," Art, xrU.— A can ii glren, Mad. Jonrti. ^i.
967, wli«e affMniim of jniiffme» from tintfig«kittoD, took pltoti The woittb
WMfearifltd,aa4tkttwttiiiif qolekly dlMppemd. The ptuent xvecmnd.

560

tion has been repeatedly succeasfiily* and is performed by
applying a ligature high up, and cutting off the tumour below,
or allowing it to drop off, like a polypus. But it must also be
remembered, that in some cases, where the inyerted uterus,
has been either intentionally extiq>ated, or mistaken for a
polypus,t death has followed. If much pain, follow the

* The ioTcrted nteru hu been torn off with the ereCdicC, hdof mistaken for
the child** head. Jour, de Med. Tom. zlL p. 40l A case of suooeasfdl ex-
tirpatioD, i* inaerted In the same work for Anrust, 17B&. Wriabcrf relates a
case, where It was cat off by the midwife, who had inTerted It. A snocessfiil
case is gircn hj Dr. Clarke, in Edin. Med. and Sorr. Joor. VoL IL pi. 419.
Anotiier case, n mentioned In the ReeneU des Aeles de la Society de Lyon.
Another, by Mr. Baxter, Med. Phys. Joom. VoU aczr. and by Mr. CheTaUcTy
related in Dr. Merriman*s Synopsis, p. 286. Petit, of Dgon, says, a surgeon by
mittakfi applied the ligature and cured the woman. The surgeon's son deniea
that the cure was wrought by mistake. Osiander, rdatea a ease where the
midwife puUed down the uterus and placenta, and cut them both awar. The
patient recovered, and afterwards was exhibited during every coarse of lectures.
The late Mr. Hunter of Dumbarton gives a saceessful case. In Annala of Med.
Vol. Iv. p. 966. I particularly eacammed this woman, several years after the
operation. She was delivered without anv riolcnoe, after having been twenty-
four hours in labour. In about an hour the placenta came away. She had con-
siderable flooding and great weakness. She could not void her urine, which ia
two days was drawn off with the catheter, and this was frequently repeated. A
fortnight after delivery, the womb» inverted, piMmded firom tiie vagina, with
pains. It was replaced, but came down again. A fbtid discharge to«kk places
and the woman was reduced to a state of great weakness. A ligature was applied*
which, she says, gave her a good deal of pain, and the tomoor waa cut oiL Her
account differs in some respects from Mr. Hunter's, probably owing to her speak-
ing from memory alone, some years after the event ; and she does not notice the
Jirevious extraction of any lumps from the uterus, which Mr. Hunter meBtieaa»
or most likdy she did not know of that. About two years ago, she had for a
length of time, a discharge of thick white matter. At present (l^^)* ^> vagina
Is of the usual length ; and at the top, a travene aperture Is fel^ the poatcrlor Un^
or edge of which, is longer and more tendinous to the feel, than the anterior. It
admits the tip of the finger, and feels softer than the oo uteri. In a natural state.
There is no cervix uterL The mamma are firm, and of good sise, and she has
not lost the sexual desire. She is subject to dyspepsia. From the preparatiout
in the possession of Dr. Jeffray, there can be no aoubty that part or the uterua
was extirpated.

Mr. Newnham, In [his Treatise on Inversion, p. 31, relates the case of Mrs.
Glasscock who had a ligature applied to the inverted uterus, but on account of
pain, it was removed; in some nours. As she was evidentiy losing ground. It
was re-applied on the' ISth of April. It produced much pain, which came at in-
tervals, like that of labour. This was allayed bv opiates, and the ligature gradu-
ally tightened. She was very irritable, and suffered much from spasmodic pain ;
but, on the 6th of May, the tumour dropped off, and she got quite well. As the
finger could l>e passed within the os uteri, and around the tumour, the Inversion
was probabiv incomplete. The inverted uterus, when touched with the finger,
appeared to be nearly Insensible, and bad never caused pain. The uterus has also
been successfolly extirpated, partiy by the ligature, partiy by the scissors, by Mr.
Windsors. Med. Chir. Trans. Vol. x. p. S68.

fiartbolln relates a, case, where the inverted womb was torn away, and found
under the bed of the dead patient.— Blasius, a case, where the uterus was hard
and scirrhous ; it was tied, but on the third day the patient died. In the cavity
of the portion were found the ovaria and ligaments.— Goulard's patient died on
the 18ih day. Mem. of Acad, de Sciences, 1782.

,.tIru?».?fiJ^*^ *" Recueil des Actes de hi Society de San(« de Lyon, the
co^er^ u ™ f« • **,P^yP?^ *"* *""• ligature applied. The mistake hiiog dla-
covered, it was instanUy wflhdrairn, but the wom^ died In a few dayfc *

5C1

application of the ligature, not yielding to opiates,* the
ligature ought to be removed, and means, if necessary,
t^en to allajr inflammation.f We must farther recollect,
that, in what is called, a total inversion of the uterus, part of
the bladder may possibly be drawn down within it, unless
its attachment to the cervix give way. We ought, therefore,
if the ligature is to be applied high, and soon after the pro-
duction of the inversion, to ascertain the relation of the blad-
der to the tumour. I do not know of any instance, where
the intestine descended into the inverted bag.

Inversion, when it has been of long duration, may be con-
founded with prolapsus, or polypus : From the first, it is dis-
tinguished by the shape, and by the absence of the os uteri ;
from the second, by attending to the history, and by careful
examination. We must recollect that in every instance, the
inversion is encircled by the os uterij like the polypus, but the
lips cling to the tumour, or form a part of it, and nothing can
be passed beyond them. In polypus we can generally carry
a probe up within the uterus ; at the same time it is to be ob-
served, that the polypus may adhere to the cervix.§ A poly-
pus, is more moveable than the inverted portion of the uterus,
especially, more capable of being rolled. It is quite insensi-
ble; scratching or irritating it, does not give pain. The
uterus is also, at least in some instances, when long protruded,
insensible. Dr. Montgomery showed me a preparation of
inverted uterus, which had, during life, been quite insensible
to the application of the needle.

• Dr. Gooch applied the ligature, on a uterus vrhich had been invf rted fur be-
tween two and three years. The patient had much pain, but that wns allnycd by
opiates. The ligature came away on the 14th day, and the patient did well. Ati
Accounti &c., p. 263.

f Dr. Symonds appUed the ligature, and subdued pain by opium. The uterus
rame away on the fifteenth day, but the patient died of inflammation, on tlichixth
day after that; there was pus in the abdomen. Med. Gazette, Vol. xii. p. 242.

f In the Hunterian Museum there is a preparation of inverted uterus, which
might, during life, have been mistaken for polypus, if the relation of parts nlono
liad been attended to. The vagina and uterus are both opened. The uterus is in-
verted from ^he cervix, but the lower part of that, and lips of the os uteri nre in
their natural position. Before being slit, then, the inverted portion mu.Nt have
been surrounded, or embraced, by the os uteri, like a polypus. The uterus, tliough
altered in shape, is Qot larger than usual, and the inverted portion mny be about
an inch and a half long. The tubes and ligaments are seen turning down into
the inverted cavity, which is openecl to show their tprmination as usual, nt the
fundus. No part of the bladder is turned over, or drawn iuto the sac. Whether
any part ever had, is doubtful, but at this stage we cannot expect the blad<ler to
descend in any degree, both because the inversion takes place, not in the Vrtgina,
the lips of the os uteri being directed upward, but at the cervix uteri, the lips
being directed downward, and also, because the repeated distention of the bladder
must have raised it, had it ever, in a small degree, been drawn in. There is no
history of the case.

§ In one cnse the os nteri adhr: i»d to the neck nf the potypiw, and gave rise to
appearance of inverted uterus. 3Iem. of Med. Sac. Vol. v. p. 14.

2 o

562

Retroflexioo» or bending back of the fundus and body of
the uterus, may take place aft«r delivery, especially, if the
bladder have been much distended, and still continues to be ao«
I believe that the di^laocmrat is more likely to happen if the
placenta be still retained, than if it have been expdfed* The
OS uteri will be pressed forward and somewhat elemfted, whilst
a tumour is felt behind the vagina. Uterine hemorrhage
may be a consequence, but if not, the attention may be first
directed to the case, by retention of urine, and bearing
down pains. The hand is to be introduced into the utema,
and the poatien rectified.*

CHAP. IV.
Of Jfterpains*

Few women, proceed through the early part of the puer.*
peral state^ without feeling attacks -of pain in the belly, which
^n called aftarpains. These, are genenlly least sevo^
after a first labour. They proceed from the contractuNi of
the uterus, in an irregular manner, excited by the presence of
coaguia, or other causes, and each severe pain, is generally
followed by the exudbbnof a clot. They come on, usually,
very soon after delivery, and last for a day or two. Hiey are
often increased, when the woman first apjuies the child to the
breast* They are distinguished from inflammation, of the
nterus or peritonseum^ by remitting or going off. Tbe belly
is not painM to tbe touch, the uterine discnarge is not ob-
structeid, the patient has no shivering nor vomiting, the milk
is secreted, and the pulse is seldom frequent. When the
pulse is frequent, then we must always be on our guard; for,
if this be the case, before the accession of the milk-fever, the
patient is not out of danger, and if any other bad symptom
appear, we must be prompt in our practice. Afterpains may
also be caused, by flatulence and costiveness, which we know
by the usual symptoms; but a combination of this state, with
uterine afterpains, is often attended with a frequency of the

* Velpeau says he hue met witb 15 cases, one of which proved fmta1« from oos*
vtipation. Mad. Boi via mentions a case following great distentioo of the biadder.
daring labour. It was so large as to give.rise to the suspicion that another obUd
was In the uterus. The catheter was used, and a large quantity of nrisa drawn
off. Tbe hand was then Introduced into the uterus, and tbe fundus raised.
Omtractlon toolc place, and both Uie placenta and the hand wer« excluded.

563

pfuke, and ma;f gire rise to a fear, that inflieiimiiation is about
to come on, but other symptoms are absent. Uterine after-
pains, are relieyed by opiates, firiction, and fomentations, and
these are the usual remedies; but if protracted, orrery severe,
the spasmodic action which causes them, is more readily and
effectively r^noved, by a purgative, than by opium. If the
pulse be frequent, this is indispensable. A severe, constant
pain, in the hypogastric region, is sometimes produced, by an
affection of the heart, and proves fatal, yet the uterus is found
healthy.

Upon this subject, it may not be improper to mention, that
a young practitioner may mistake spasmodic affections, or
coUc pains, for puerperal inflammation; for, in such cases,
there is often retcfamg, and sensibility of the mntseles, which
render pressure paio^. But there is less heat of die sldn,
the tongue is moist, the pulse, though it may be freqoent, is
ao^ the feet are often cold, the pain has great remisaons, if
it do not go off completely, there is little fabess of the beUy,
and the patient is troubled with flatulence. It ret^ires
laxatives, anti-epasmodics, anodyne clysters, and friction with
camphorated spirits* The appiioation, of a warm linseefd meal
poultice, is very useful. If this faU, we may apply a cloth,
wet with oil of turpentine, on tibe pained part. It is prndent
to take some blood early^ Blood drawn in this disease, after
it has continued for some hoisrs, even when the wxmian is not
in childbed, is sizy; and it is always so^ in the puerperal, as
well as the pregnant state, although the woman be well.

It is necessary to attend, carefully, to the duration, and
situation, of pain after delivery, and to the symptoms connected
with it. For it may proceed firom inflammation of the viscera ;
or, in some cases, it is felt near the groin, and may be the
forerunner of swelled leg, or, about the hip, ending m a kind
of rheumatic lameness; or in consequence of the application
of cold, pain may be felt in some part of the recti or oblique
muscles, which, if not removed by fomentations and leeches,
may end in abscess, whtdi frequently is long of bursting, and
excites hectic fever. It ought to be opened with a lancet.

Rheumatism, affecting the muscles of the abdomen and
pelvis, is accompanied with less fever, than puerperal inflam-
mation, and wants the other symptoms. The pain is shifting,
and aching, or gnawing, though sometimes it is pretty sharp,
like a stitch. It is relieved by friction, with laudanum, by
mnapisms, and by mild diaphoretics, bark, and the usual
treatment. When speaking of rheumatic pain, it may not be

564

improper to mention, that chronic rheumatism, especially of
the extremities, is very troublesome when it occurs after par-
turition. It requires the usual remedies. Cod-liver oil, in
doses of half an ounce, three times a^day, has been much
recommended. I have formerly noticed those pains in the
limbs, which mav succeed the use of the crotchet.

CHAP. V.
Of Hysteralgia.

By hysteralgia, I understand uterine pain, proceeding from
spasm, and not from inflammation. This may occur soon
after delivery, and is marked by severe pain, in the back and
lower belly, frequent feeble pulse, sickness, and faintness*
This is sometimes accompanied with discharge, or succeeded
by expulsion of a coagulum. In other cases, although attend-
ed with severe bearing-down, we have no expulsion of
ooagulum, no retention of iu*ine, no inversion of the uterus.
It is mere pain and irritation, perhaps from some bad position
of the uterus. The late Dr. Baird of this city, supposed that
it might always be relieved, by pressing the uterus from its
situation, generally one of the sides of the belly. Hysteralgia
requires a purgative clyster immediately, and afterwards an
opiate ; or, if it occur very early after delivery, we may reverse
this practice, and give instantly an anodyne clyster, to be fol-
lowed by a purgative medicine, if the stomach will bear it.
Another modification of this, comes on later, but always with-
in three or four days after delivery, and a'ttacks in general
very suddenly. Perhaps the patient has risen to have the bed
made, becomes sick, or vomits, and is seized with violent pain
in the lower part of the belly, or between the navel and pubis.
There is no shivering, at least it is not a common attendant,
and the pulse becomes very rapid, being sometimes above a
hundred and twenty, the skin is hot, the lochia usually ob-
structed, and the uterine region is somewhat painful on pres-
sure. After some hours, the severity abates, and presently,
by proper means, the health is restored.

As tnc lochial discharge is usually obstructed, this obstruc-
tion, has been considered, as the cause of the pain and other
symptoms; but it is merely an effect, and sometimes does not
exi.<«t. The cause, appears to consist, in a deranged state of

565

action in the uterus, which is productive of spasm of the
uterine fibres, and sometimes of the intestines. This is more
apt to occur, after a severe or tedious, than after an easy
labour, but it may occur in any case, especially if exposed to
cold. The symptoms will vary a little, in severity and in
appearance, according as the uterus alone is affected, or as
spasm of the bowels, is combined with the uterine pain. It is
distinguished from inflammation, by the sudden nature of the
attack, the absence of shivering in general, the pain becoming
speedily more severe, than it does at the same period of in-
flammation ; and, frequently, it greatly remits, or goes almost
entirely away, for a short time. This state, especially if it
be neglected, may readily excite inflammation, which is
marked by constant pain, more or less severe, according to
the part affected, and an obstinate continuance of the fever.

The first thing to be done, is to administer a smart purga-
tive clyster, to open the bowels. Then, the belly is to be fo-
mented, and a warm poultice applied. If speedy relief be not
obtained, we must take blood, and give an anodyne injection.
We then give the saline julap freely, with the addition of a
little antimonial wine, in order to excite a free perspiration.^
Purgatives are useful, and a cloth, soaked in oil of turpentine,
must be applied to the pained part of the belly, if the poultice
do not relieve. A combination of the soothing and depletory
plans, often answers much better, than either of them
singly.

CHAP. VI.
0/ Retention of part of the Placenta,

If either the whole, or a considerable portion of the pla-
centa, be left in utero for some time, the patient is exposed to
great danger. Haemorrhage is not the only risk, for, in many
cases, severe headach, hysterical affections, sickness, nausea,
prostration of strength, and fever, have taken place, and con-
tinued, until the placenta have been expelled, after which, the
patient has begun to recover. On tne other hand, it has,
though more rarely, occurred, that the placenta, having been
retained for a length of time, has been expelled, before these
symptoms have become urgent; but they have afterwards

566

gradnallj increased, and carried off. ike paltflBt.* SmutimM
t\kd. symptoms rua so high, or the portions of. the jdaeeata sore
so obstioatdy retained, tfaftt the yttimt sinks ux^er the dis-
ease,, as in ordinary cases of hectic, with freqaent small pnlse,
burning heat of the hands and feet, profuse penppirations, and
imif«n^ emaciation ; and dies with symptoms aunilar to those
of putrid fever ; or is oarried off suddenly by a convulsion, or
by an attack of h«monhage.

These fljn^>kaia have a very indefinito dnration, for the
patient may die in a very few days ; in other instances, they
are protracted for two or three weeks.f Sometimes no haemcHr-
rhage takes place, during the whole course of the disease,
but occasLonaliy, repeated Iwmorriiages do occur, adding
greatly to the dd>ility of the patient. In several cases, inflam-
mation has come on, asad spread to the intestines. In some
of these, the placenta has be^i afterwards expelled, in others
extracted, but very few, in either case, have recovered. On
inspecting the nterus, it has either been found black, as if it
Iftad been gangrenous, or in a state of high inflammation, or of
suppuration, whilst the parts in the vicinity were in various
stipes and degrees of inflammation. It has be«[i supposed,
that the chief source of danger, arose from inflammation of
the veins.

Now, when these symptoms have taken place, our object
ought to be, to remove the cause, and support the patient,
under the disease. I am aware, that some have attributed
these symptoms, not to the placenta, but to concomitant cir-
cumstances, such as injury done with the hand, in endeavour-
ing to take it away. But we find, that thev take place when
the whole of the placenta has been left, without any attempt
having been made to remove it. They are produced when
any substance is left to corrupt in utero.t They continue as
long as it remains, and they usually eease when it is expelled.
At the same time, it must not be denied, that the forcible
extraction of the placenta, by the injury done, renders the
effect, of retention of part of the membranes, or a bit of the

* In a case related by Mr. Wbyte, the secnndkiesy after a dyater, came awav
In a putrid etate, on the fifth day. On the anth. the patient was mttch oppMeed,
hiid iketid breath, ftc. ; on the tiralftb an eruptian appeared, and aha died on the
twenty- second.

f Dr. Perfect relates a ease, tn which the seeandiaea were retained tlU the eiglUh
day, when the patient died. Her stomach reieeled all food and medicine, she had
weals, quielL pulse, hiccup* and §ubtultvt ttnainum. Vol. ii. p. 990.— In another
case the pUceata was retained tUl the thirteenth day, and the woman diad on the
twentieth^ p. 881*

\ Similar symptoms hare been produced by the head of the child being left in
ntero. Perfect, Vol. ii,. p. 80.

567

placenta left, much more severe, aad is apt to produce a de*
gree of local inflammation, marked by more or less pain, or
tenderness on pressure.

It may be proper to examine, wifth the finger introduced
into the os uteri, whether any portion of the placenta can ba
fish and removed : but generally this cannot be freely dane»
for the uterus itself, as well as its mouth, is hard and can-
tvaeled, and do violent, or painful attonpt, with the hand or
fioger, ottght to be made. But, when we can easily feel, and
aot upon a portion, we ought, slowly and gently, to endeavour
to bring it out ; and, if thie whole of the placenta have beea
left, which is indeed rare, sach attempts are still more neoefr>>
sary, and likely to succeed. The os uteri affords oonsideraUe
resistance, to the introduction of the hand, in cases where the
retention has subsisted for some days, but, by very slow and
gentle efforts, such as are scarcely felt by the patient, it may
be dilated ; sometimes it yields very easily, or is not at all
contracted. If, however, it be rigid and unyielding, a condi-
tion rarely conjoined with retention of the entire placenta, wo
must not use violence.

When a portion of the placenta is retained, and cannot,
with facility, be removed, we may derive advantage, from in-
jecting, frequently, warm water, or warm infusion of camo-
mile flowers, or weak solution of chloride of lime. A strong
decoction of oak bark has been proposed, to tan the retained
2»ubstanee. These injections may be made, by fixing a female
catheter, to an elastic gum-bottle ; or, a syringe, with a long
pipe, may be employed.

Sometimes natural, or artificial vomiting, assists the expul-
sion.

The patient, should be allowed the free use of fruit, and
vegetable acids, and light mild diet should be given, in small
quantity at a time. The bowels ought to be kept open, and
opiates should, occasionally, be given, to allay irritation.
Vomiting and nausea, may be checked or mitigated, when
urgent, by effervescing draughts. Quinine has been given,
but I cannot place much confidence in it. When there is
fulness about the abdomen, and a te ndency to inflammation,
])urgatives are of service. If the nervous system be much
disturbed, the camphorated mixture may be given, in its usual
dose.

568

CHAP. VII.

Of Strangury.

After severe labour, the neck of the bladder and urethra,
are sometimes extremely sensible ; and the whole of the vulra
is tender, and of a deep red colour. This is productiye of
very distressing strangury, which is occasionally accompanied
with a considerable degree of fever. It is long of being re-
moved, but yields, at last, to a course of gentle laxatives,
opiates, and fomentations. Anodyne clysters are of service.
An inability to void the urine, requires the regular, and speedy,
use of the catheter.

CHAP. VIII.
O/Pneumonia,

It is unnecessary to detail the symptoms, of inflammation
of the lungs or pleura. It is sufficient to say, that this disease
is not uncommon in the puerperal state ; and if there be such
a state of the lungs during pregnancy, as tends towards
phthisis, that disease is exceedingly apt, to be rapidly induced,
after delivery.

Pleurisy requires, on the first attack, copious blood-letting,
laxatives, and blisters, which are never to be omitted. If the
early stage have passed over, the use of the lancet is doubtfiil,
and it is better to trust to the application of blisters. Laxa^
tives are also not to be neglected.

CHAP. IX.

0/ Spasmodic and Nervous Diseases.

Palpitation, is not an uncommon disease after delivery. It
usually attacks the patient suddenly, and often after a slight
alarm. She feels a violent beating in the breast, and some-
times has a sense of suffocation; she has also a knocking

569

within the head, with giddiness, and a feeling of heat in the
face.

The puke is extremely rapid during the fit, and the patient
is impressed with a belief, that she is going to die. After the
paroxysm, the mind is left timid, and the body languid.
Sometimes, it is succeeded by a profuse perspiration ; and,
should the fits be frequently repeated, the temperature is
variable, during the intervals, and the stomach is filled with
gas. This is often a very obstinate, but it is not a dangerous
disease, unless it proceed from uterine disease, marked by
pain and swelling of the belly. It is to be relieved by giving,
during the paroxysm, a liberal dose of ether and laudanum ;
and, during the intervals, antispasmodics, laxatives, and
tonics, are to be employed. As soon as possible, the patient
should remove to the country.

Hysteric fits, hiccup, syncope, and dyspnoea, are to be treat-
ed upon general principles, by full doses of opium, and other
antispasmodics, and clearing out the bowels with purgatives.
When a patient is known to be subject to syncope, it will be
proper to give her, the instant the child is born, a draught
containing spiritus ammoniae aromaticus, and laudanum, and
to have the abdomen firmly supported by a bandage.

There is a species of dyspnoea, that depends upon exertion
of the muscles of respiration, during labour, or distension of
the abdominal muscles. When the abdominal muscles are
affected, the person often feels the difficulty of breathing,
chiefly during expiration. It is relieved, by tightening a little
the compress round the belly, and giving thirty drops of
laudanum. When the diaphragm is affected, the uneasiness
is usually greatest during inspiration ; and there is often a
pain in the side, or in the back, or about the pit of the
stomach, which may be very severe. It is attended, sometimes
with a sense of stuffing in the breast, in other cases, with an
acute feeling of suffocation, or very sharp pain across the
lower part of the thorax, with deadly paleness, and the pulse
is extremely rapid. A large dose of laudanum, with ether or
ammoniated tincture of valerian, removes the spasm ; if not,
a sinapism must be applied. These affections come on, within
a few hours after delivery. The spasm of the diaphragm, is
to be distinguished from pleurisy, by its coming on suddenly,
and being very acute ; whereas, inflammation comes on more
slowly, and is often preceded by a shiverinff fit; there is
more cough, and the pulse at first is not so frequent, but is
sharp.

570

too tight.

C<iUc,.]ii«]r occmr wklim a few dajs after delivery. It
attaeks suddmly, and genenallj in the evtaaiag. It is not
pieeeded by shiverHig, but is aometiines acconipamed wxdi
sickness. The pabe laay, at first, be citfaer sbw, or of the
natural frequency, but soon becomes finequent. The pain is
sdbject to exao^rbalion aad remissiffn, but somcdmes, does
not entirely go oS^ for several hours. The cUef risk of this
disease, is the induction of inflammation, if the exotement be
not soon removed. We ought, instantly, to give a smart
purgatiye dyster, and, at the same time, a &11 dose of laud*
anum with some cavminatiTe. This does not prerent the
operation of the clyster and eonfirms &e rdief it proeures.
If the laudanum be vomited, an anodyne clyster may after*
wards be given, and if the patient have been costive^ we should
early give a purgative. Warm fomentations are beneficial.
If the symptoms do not go entirely off, the saline juhq> with
laiidaoiwi is of service. K there be mmdi flatnlenee^ tincture
of asi^tida eaA hyoacyamns are proper.

Cramp in the stomach, is very dangerous, when it occmrs
within three weeks after delivery. It reqaires the immediate
exhibition ot at least sixty, or eighty drops of hradanum, with
a drachm of sulphuric ether, or twO'draidims of spiritus am*
monisB aromatious, in a suitable quantity of water ; a sinapism
is also to be applied to the region of ibe stomach.

Pain in the region of the kidney, sometimes proves very
troublesome, for two or three days after ddiy^rr. It comes
in paroxysms, which are rdieved by sinapisms, fomentations,
clysters, purges, and opiates. If the poke be a&cted, blood
should be taken.

Those females, who have suffered, fi-om that formidable
disease of the sfMUal cord, described in the Mh drnfiter of the
next book, are in great hazard after delivery. They often,
within half an hour, after the plaeenta has been expired, <ur
after a longer interval, feel great debility and mv^mg^ with or
without sickness, and, although, the discharge have not been
more than usual, yet, they insist they are flooding, or going to
faint, from loss of blood. The pulse is sometimes fe^e, but
often it is much stronger, than the feelings of the patient,
would lead one to expect. The hand placed on the abdomen,
ascertains that the uterus is not dist^ided with coagula, and
that there is no concealed heemorrhage. The cloths are not
wetter than usual ; there is no pain, indicating spasm of the

671

uterus ; and, even if the hand be introduced, no spasmodic
stricture of the uterus is disocnrered. The practice I have
found best, is to give thirty drops of laudanum, and after*
wards, amidl doaes of wme or bi andy, or atcmatic spirit of
hartshorn, or ammoniated tincture of valerian, till the deadly
feeling of sinking be .abated. But ve sbonld Qftver earry the

stimulant plan &r,.for we are mt to have too much excite*
ment afterwords. On the other hand,, if we: gire nothing,, the
patient may speediiy die, and this I believe to be a cause of
sudden death, after delivery, which can, in no other w^r, be
accounted for. The previous disease, is often obscure, u tiie
patient do not recover, completely, from this state, we find,
that, next day, or within three days at farthest, Ae complains
of heodach, and great nmse in her head, as if hail were rat-
tling on a cupola ; her eyes are red, the skin, hot, the pulse
lErequent, and she is extremely restless. These symptoms may
abate, or may usher in, puerperal mania, but, if negleeted^
they are more likely to end in the patient cnmtiiwiing to oom-
plam of her head and neck, weight over the eyes, great pain
m the arms and legs, then painful sense of sleeping or numb-
ness, then complete paralysis; the pulse becomes slow, the
breathing diffionlt, as if from the preesnre of a weight on the
chest, and the patient, within a few days at farthest, expires,
apparently, from tiie mere fsilure, of tiSie functians of respira-
tion and circulation. The mind remains clear till the very
last. In some cases, she merely complains of giddiness, or
confusion of the head, with very rapid palae, then, tiie abdo*
men becomes tumid without pain, an^ lastly, fatal stupor
takes place.

The only useful practice, is to Ueed freely, from the arm,
the moment that the state of excitement appears, marked by
heat of skin, and frequency of pulse, and beating in the head.
Leeches opjdied to the head, may also be usefid, after vene-
section, but cannot be trusted to, alone. The bawds are to be
freely opened ; and, if these means do not chedc or cure the
disease, a blister should be applied to the nape of the neck,
if the arms or breathing be much affected, or, to the back of
the head, if the eyes, or fifth pair of nerves be more affected.

Sudden death, may also take place, from strong emotions
of the mind, but tnstsnees of this are oompaiativdy rare.

CHAP. X.

0/ Ephemeral Fever or Weid^ and Semittait Fever.

The increased BensibUity of the system, as well as the deli-
cacy of particular organs, after delivery, render voToeD, at
that time, peculiarly liable to febrile affections. Some of
these, seem to arise from the general susceptibility, of the
vhole nervous system, others, from local luFection of the
breasts, the bowels, or the uterus. The first of these symp-
tomatic fevers, is, generally, pretty easily recognised, by the
sensibility of the breast ; the others, pu^icularly, that con-
nected with the state of the womb, are often more ambiguous,
the local symptoms being, in many cases, insidious.

The ej)bemera, or weid, as it has been called, is a fever
usually of short duration, the paroxysm being completed,
generally, within twenty-four hours, and always within forty-
eight hours, for, if it continue longer, it becomes a fever of a
diS'erent description. It proceeds from great susceptibility of
the nervous system, by which, slight exposure to cold, mental
agitation, or some local cause, excite a universal disorder of
the frame. It consists of a cold, a hot, and a sweating stage ;
but if care be not taken, the paroxysm is apt to return, and
we have, cither, a distinct intermitting fever established, or,
sometimes, irom the co-operation of additional causes, a con-
tinued, and very troublesome fever, is produced.

Disease may take place in two ways ; by the application of

causes, directly, to the part affected, and which act on the

extremities of its nerves, or, by causes acting, immediately, on

the origin of its nerves, and tlius on their extremities.

Hence, local Inflammation may be produced in two ways; by

direct application of causes to the part, or by the state of the

origin of its nerves. An afiection of the extremities of the

nerves, may either excite, or render more inactive, their ori-

a; and cither state, is a{tt to

During portions of the briun,

nvolve the origins of nerves,

and to distant organs, which

d an extensive cl^n of evil,

ffection of the extremities of

influence, those going to the

wao, and slight disease in one

il disease in the others. The

573

affection of the origin, of a particular nerve, in consequence
of irritation, or excitement of its extremity, may also react on
that extremity, and increase the disease there. Further, as
it is probable, that different portions, of the same trunks of
nerves, and, assuredly, different individual nerves, have distinct
destinations in an or:i:an, as, for instance, producing sensa**
tion, secretion, muscular contraction, changes of the circula-
tion, &c., we may have various modifications of disease pro-
duced, according to the nervous fibrillae, principally affected.
Another effect, of the excitement of the extremities, on their
origins, is not the induction of marked disease, in any one
distinct organ, but of general disorder of the system, in the
form of fever. Applying this view, to the puerperal state, I
would go on to say, that one of the simplest effects, is the
ephemeral fever, arising, evidently, from excitement of those
nerves, which influence the heart, and the secretion of heat.
It may, doubtless, be produced by some causes, acting directly
on the origin of those nerves, and which may, or may not,
depend on the state of the uterus. But, in many instances,
it is caused, by the condition of the extremities of the uterine
nerves, in the same way as temporary fever, is caused, in
children, by irritation of the stomachic or intestinal nerves.
The wonder is not, tliat the uterus after delivery should have
this effect, but, rather, that it should not always produce it.
One single attack may be produced, or, when the effect on
the spinal cord, or sympathetic nerve has been greater, the
consequence is, a prolonged fever of the remittent kind, which
may last, without any prominent local symptom being induced,
though, doubtless, very apt to end, in more marked disease,
of some important part. But, sometimes, from causes we can-
not always explain, whether from a difference in the original
irritation, of the nervous extremities of the uterine system,
for instance, or, from different integral parts of the nerves,
being affected at their origins, we have superinduced, various
and formidable local affections, inflammation of the abdominal
cavity, as in peritonitis, or of the extremity, as in swelled leg,
&c.

The production of a sudden sensation of cold, in any part
of the system, is very apt to induce ephemera, and if the sen-
sation nave been long continued, the effect is likely to con-
tinue long. This disease, generally makes its attack, within
a week after delivery, but, it may come on at any time, during
lactation, or a complaint, essentially the same, may occur in
any female. It may be occasioned, by irregularities of diet,

574

Gt imtatioB of the vkooral nerves, ariakiff, either from the
^ate ef the bowelsy or some conation of the uiems or its
appendages, not acute eoough to produce pain, or my per*
laaaeBt local syn^tom, or, by causes acting, directly, on the
haae of the brain, or medulla spinalis. No cause is more .fre-
quent, than the application of cold to the surface^ so as to
produce sensation. Some, when nursing, cannot toaeh any
thing cold, without having an attack. Fktigne, exhaastian,
passiQBs of the mind, or want of rest, if not e&chjag canaes,
give a strong prediepeBitioB.

The attack^ is sometimes directly ushered in, by a fit of
palpitation, or is preoeded by a fri^tful dream, mm wfaieh,
the patient awakes in a shivering fit, with a rapid pulse ; or
the chill comes on, acoompanied with pain in the back and
head, after some slight akrm^ or igfadidoos exposal to
cold. When the cold stage, Ims cnntiwHed for some time,
the hot one conuBenoes^ and this ends in & profhse per^
spiration, which either carries ctf the fever completely, or
procures a great remission of tiie symptoms, llie hesii is
usually pained, often intenasly, especially over the eyes, ia
the first two stages. The pidae is exticmely rapid, mtil
the third stage hare continiied for some time ; it is aba
subject to very great irregularities, and is very changeabkin
its. degree of frequeaey. The thirst is conaiderd^ the
tongue furred, the stomach generally filled witii flatus, and
the belly bound. The mini often is weakened, and the
patient is mudi afraid of dying. In some instances, she is
slightiy delirious, in others, ^ has shifting pains in the
abdomen. If the paroxysm be repeated, the secretKoa of
milk is diminished.

The paroxysm oontimies for some hours, and then may
completely go ofi*, not to retnm again. But in other cases,
it recurs daUy, tor a length of time^ being always preoeded by
a cold fit, and often with a pain in the back ; and sometimes
the fit bcqgins, regulariy, one or two hours sooner, every sno-
ceeding day. It is more fiivourable, when the fit postpones.
Id other cases, after one or two distinct paroxysms, the (erer
aasmnes a more eontinoed form, or the exacerbations art not
preceded by distinct chills. When this disease is not com-
bined with any local injury, it is lesa dangerous than moat
fevers, occuiring in childbed; but, if it recur very freqnenti^,
and be attended with mnch detnlity, the danger increases, m
proportion to the continuance of this disease.

J^elioate women, and those wbo have suffered modi, in

575

parturition, are chiefly affiscted with this' dkease, but aU,
are mere or less liable to it, especially, if the bowels be
neglected.

It is distinguished from symptomatic feyer, arising from
looal inflammation, by the absence of the particular paiB)
and other specific symptoms, which attend these ferers^
whilst, in them, the pulse is usually, at first, not so rapid, as
in the eph^o^al fever*

In the cold stage, we give small quanties of warm fluid,
askd apply a bladder, or flat case, filled with warm wovfcer, to
the stomachy or, on the commenoemeBt of the Ghihiess,'a
warm flannel to the back* Hayii^ hai^iened on the hot
stage, we lessen, very esuttously, the number efiiie bedclothes,
and gire saline julap with diluents, to brins on the sweatifBg
stage. When this is done, we are carefiu not to enoonrage
perspiration too much, which increases the werimess, or brings
out a miliary eruption, iind renders the disease more obstinate.
On the other hand, if the per0pira:tion be too soon cheeked,
the fever continues, or recurs more severely ; a g«ntile ffweat
may be kept up for five or six honrs by tepid fluids* Then
we refrain from th^n; and when the pnooess is over, the
patient is to be oavtbusly shifted^ the cloths being previously
warmed. Alter the fit, if the patient be ezhsusted, a little
wine may be given. In the whole paroxysm^ we must watdi
against the aiidden applicatum of oold^ widoh, in the last
two stages, renews the shivering. If there be any local pain^
or whare the pulse is very frequent and full, and iHaete is no
contra-indicatioD, a tittle blood should be taken away. In
the first case, it is neeessary, in the second, it is, if the patient
be strong, always safe, and ofben usefal in preventing a
repetition of the attack, especially, if the bo\wls be immedi-
ately opened. In all cases, it is neeessary to give a purgatm,
as soon as tlie stomach will bear it, for it is essential that the
bowels be freely opened. If the tongue be foul, and Ae
patient very siol^ or inclined to vomit, we may, with advantage,
even during the cold stage, give seme warm chamomile tea,
or five grains of ipecfteuanha, to excite gende vomiting.
This, uaaider these cireumstanoes, if the diilliness contiauie,
induces heat, if it have gone o^ it causes persjnratimi. In
the act of vomiting, the patient most not be reposed to eold,
and should take such apositicai, as shall not cause any muscle
to be strained^ in the effort.

When the fits recur^ and no local caase can be detected,
we may sometiaieB dieck Item, by giving an opiate, with

576

ether, just before the expected accession, and applying heat
to the back and stomach, the moment the chilness is felt, or,
we rub the whole back well, daily, with a stimulating embro-
cation, such as camphor dLssolved in the oil of rosemary. It
is of great consequence, to keep the bowels open, by such
medicine, as agrees best with the patient, for, the paroxysms
often are repeated, or continued fever produced, from intesti-
nal irritation alone. For a time no particular appearance may
be observed, but soon, hard and offensive stools are obtained,
and from that day, improvement begins. Tonic medicines,
such as infusion of bark, sulphuric acid, or sulphate of quinine
are afterwards useful ; and, in some cases, valerian may be
joined to these, with advantage. Sleep is to be procured by
opiates, if they do not produce confusion of mind. During
the whole time, the strength must be supported by suitable
diet, with a little wine ; and as soon as possible, the patient
should be carried to the country. If the fits return often, it
is generally necessary, to give up nursing. In very protracted
cases, the disease has been mitigated, by sponging with cold
water and vinegar, after the cold stage had gone quite off,
and that, without regard to the presence, or absence, of per-
spiration. Any temporary chill, thus produced, is removed
by a little warm wine and water. This is more especially
useful, in the hectic form of the disease.

This fever, whether consisting only of one paroxysm, or of
many, or becoming continued, is always dependent on a local
cause, sometimes, the mere production of the sensation of
cold, at a particular part, or, a deranged state of the bowels,
&c. But, in many other cases, more troublesome, if not more
serious, local disease, may be the cause. At first, this may be
so very obscure, as to escape detection, but if the fever be
prolonged, it becomes more manifest. Very often, the breast
becomes inflamed, and nurses say, that the fever has gone to
the breast, whereas, the affection of the breast, though for a
time obscure, was the original cause of the fever. Wo ought
also, carefully, to attend to the uterine region, for, often, this
fever proceeds from slight inflammation of the ovarium, or
round ligament, or of the uterus itself, or of its veins, or of
the lining of the pelvis, or from retention of a bit of placenta.
In prolonged cases, sometimes, the coxal nerves become very
painful, or even paralysis of the extremities may take place.
Very protracted cases will always, I believe, be found to be
of the nature of hectic, and dependent on a local disease, at-
tended with suppuration, especially of the veins of the uterine

577

system. Other cases, of shorter duration, are marked by
pervigilium, and a tendency to puerperal delirium, or to sen-
ous affections of the brain, or may be considered, as the intes-
tinal fever, soon to be noticed. A fatal termination, in acute
cases, is usually preceded by coma, or vomiting of dark-
coloured matter, which is most apt to take place, if the origin
of the nerves have been affected.

Occasionally, suppuration takes place within the pelvis,
particularly, after the application oi cold, or from allowing
the fire in the apartment to go out. This is not always
preceded by much pain, and often, in its coiurse, is attended
with little or none, tall the progress have advanced far
beyond any control. Even when the uterus has been im-
plicated, so as to form adhesions to the sides of the pubis, as
appears after death, there may be no pain felt, on pressing
it, from the vagina. The fever, in this case, is long continued,
and of the hectic kind, and the disease, of the nature of
lumbar abscess. The matter points, at last, about the groin
or buttock, and must be let out. The treatment, in such
fevers must be varied, according to the nature of the local
cause.

CHAP. XL

Of the Milk Fever.

The secretion of the milk is usually ushered in, with a
slight degree of fever, or, at least, a frequency of the pulse.
But, sometimes, it is attended with a smart febrile fit,
preceded by shivering, and going off with a perspiration.
This attack, if properly managed, seldom continues for
twenty-four hours ; and, during this time, the breasts are full,
hard, and painful, which distinguishes this, from more dan-
gerous fevers. Sometimes, during the hot fit, there is a
slight delirium. A smart purge, generally cures this disease,
and is often used, in plethoric habits, on the third day after
delivery, to prevent it. Mild diaphoretics, during the hot
stage are also proper. Applying the child, early, to the
breast, is a mean of prevention.

2 V

578

CHAP. XII.
Of MiHary Fever.

Ths miliary fever begins with chilness, sickness, languor,
sometimes amounting to syncope, and frequency of pulse,
with heat of the skin. There is, also, a sense of pricking or
itching on the surface; and sometimes the extremities are
numbed. The febrile symptoms, usually continue for some
time, before the eruption appears, often, for four or six days*
Previous to the eruption, the patient feels very much op-
pressed, and has a great weight about the chest ; the spirits
are low, and a sour-smelled perspiration takes place, in a
profuse degree. The eyes are occasionally dull and watery,
or inflamed, and the patient has ringing in the ears. The
tongue is foul, and its edge red, as in scarlatina. Aphthse,
sometimes appear in the throat. The lochial discharge, it
diminished or suppressed. Before the eruption is seen^
the skin feels rough, like the cutis anserina. Presentiv, a
number of small red pustules appear, like millet seeds, which
are felt, with the finger, to be prominent. In a few hours,
small vesicles form on their tops, containing a fluid, first straw-
coloured, and then white or yellow. In two or three days,
small scabs form, which fiedl off like scales. The pustules are
generally distinct, but sometimes they form clusters. They
appear, first, about the forehead, neck, and breast, and then
spread to the trunk and extremities, but very rarely affect the
face. Different crops of pustules, may come out, in the same
fever. Burserius, and others, diride the pustules into several
varieties ; but most writers, are satisfied with two, taken from
the general appearance, the red and the white, and the first,
is attended witn a milder disease, than the second.

This disease is peculiarly apt to attack those, who are
weakened by fatigue, evacuations, or other causes; and
hence, we can easUy explain, why women in childbed, diould
be subject to it.

Some, have considered the eruption, as altogether depen-
dent on the perspiration. Others, consider it as, in many
oases, idiopathic ; and both, perhaps, at times are right. We
can only consider the disease as idiopathic, when the eruption
mitigates the symptoms, when the fever goes off, as the
pustules arrive at maturity, and there is no other puerperal
disease present, acting as an exciting cause. It does not

579

appear to be contagious, unless connected with a fever which
is so of itself, such as typhus.

Miliary eruption, also occurs, durmg childbed, as a
symptom connected with other puerperal diseases. It often
accompanies the milk-fever, or the protracted weid, when
the perspiration is injudiciously encouraged, and this is by
far the most frequent form, under which the febris miliaris
appears. It never alleviates the symptoms. It may also
accompany fevers, connected with a morbid state of the
peritonaeum or brain, which generally prove fatal, death
being preceded by vomiting of dark-coloured fluid. Women,
much reduced, have also partial miliary ei'uptions, generally
of the white kind, without fever, which require no particular
treatment.

Whether the miliary fever be idiopathic, or symptomatic,
the treatment is the same. We endeavour at first, to check
or remove the fever, by means which I have pointed out in a
former chapter.

When profuse perspiration, with or without eruption, takes
place, we must cautiously abate it, by prudently lessening the
quantity of bedclothes, or making the bed-room cooler. The
rest of the treatment, consists, chiefly, in removing irritation
from the intestines, by the use of Isoatives, and supporting,
the strength by light nourishing diet, whilst we use tonics,
such as sulphuric acid or bark. These tend, also, to abate
the perspiration, which is scarcely ever to be encouraged.
The linen should be frequently changed. When the eruption
suddenly recedes, we have been advised to renew the perspi*-
ration, apply blisters, and give musk and cordials, especially
when convulsions are threatened. This dangerous retroce»*
sion, however, I have not met with, and apprehend that it
very rarely occurs.

CHAP. XIII.

Of IntesHnal Fever.

Wb shall, presently, have an opportunity of observing, that
the state of the bowels, frequentlv produces, in children, a very
troublesome species of fever, which, though proceeding from
a cause, which has been some time in existence, may make ita
appearance suddenly. The same holds true, with regard to

580

women in childbed, who, either from previous costivenesd,
during the end of gestation, or some error in diet, after
delivery, are seized, within eight or nine days, generaUy
earlier, with fever, which passes for weid ; and most cases of
what is called protracted weid, without any appearance of
local disease, will be found to be fevers of this description.

After an attack of shivering and chilliness, the patient be-
comes sick, oppressed at the stomach, and loathes food. The
pulse is frequent, and the skin, except at the feet, feels, from
the very first, hot to the touch of another person, though the
woman, herself, complain of being cold. Afterwards, she feels
very hot, especially in the hands and feet; — she has no
appetite — is thirsty — has a white slimy tongue — is sick —
and occasionally vomits phlegm or bile, and is troubled with
flatulence. The pulse is quick ; she does not sleep, but rather
slumbers, and is tormented with dreams and visions, and talks
during her slumbers. Generally, she complains of throbbing,
often of confusion, but seldom of continued pain in the head,
though, for a short time, headach may be severe. She has
no fixed pain, nor any tumour in the belly, but complains
rather of stitches or griping. The bowels may either be
costive or loose, but, in either case, the stools are foetid and
dark coloured, and, frequently, laxatives operate both early
and powerfully. The lochial discharge is not necessarily
obstructed, nor does the secretion of milk, in many instances,
sufier for several days. The eye and the countenance are
nearly natural. The belly, sometimes, in the course of the
disease, becomes full and soft, as if the bowels were inflated,
and this size, occasionally, continues during life. These symp-
toms may be complicated with others, proceeding from nervous
irritation, such as palpitation, starting, &c., or, in the course
of the disease, new ones, arising from injury of the function
of the womb, may supervene, and are marked, first, by pain,
and, afterwards, by tumefaction of the lower part of the belly,
and pain in making water, or in passing the fueces. The
duration of this fever, varies from a few days to a fortnight.*

* Since the publication of thi« work, the feyer I have called inteatinal, baa
been described by Dr. Granrille, in bis Report, p. 160. He notices that it la
sometimes, when there is much inflation of the bowels, mistaken for puerperal
fever ; but the tumefaction, in the intestinal fever, precedes pain in the bowels,
and the symptoms are decidedly relieved by purgatives.

More recently still. Dr. M. Hall appears to have described this fever, under
the name of '* a serious puerperal affection,** and enumerates the various com-
plications which may take place, but which do not seem essential to the disorder,
sach as, vertigo, palpitation, feeling of sinking, &o., and divides the disease
itself into two varieties ; that which takes place acutely, and that which comca
on more slowly ; the former being preceded by more distinct shivering, and

581

On the first appearance of this fever, a very gentle emetic,
of ipecacuanha, should be administered, and afterwards, when
the operation is over, we determine to the surface, by giving
the saline julap, with f epid drink. Then, in a few hours, we
administer a dose of rhubarb and magnesia, to remove offen-
sive matter from the bowels ; or, if necessary, we give a suit-
able dose of castor oil, or calomel. After this, if there be
considerable griping, or a tendency to much purging, we give
an opiate clyster, and repeat this, every night, till the bowels
are less irritable, taking care, if they become costive, or the
«tools foetid, to intef pose, occasionally, gentle laxatives. The
great principle, indeed, on which we proceed, is the early, and

5>rompt evacuation, of the offensive matter, whether bilious, or
eculent, from the bowels, and the prevention of re-accumula-
tito, and this must be done by such doses as are required.
The diet is to be very light, such as beef tea, calves' feet jelly,
arrowroot, &c., and if there be no diarrhoea, ripe fruit may
be given. Ginger wine and water, form an excellent drink,
and, in a few days, such a quantity of Madeira wine may be
given, as is found to impart a comfortable feeling, without
inducing heat or restlessness. When the tongue becomes
clean, small doses of columba, or other bitters, will be useful.
If there be much nervous irritation or palpitation, or ten-
dency to delirium, the camphorated julap is proper.

CHAP. XIV.

General remarks, on Abdominal Inflammation, in the

Puerperal State.

Inflammation, within the abdominal cavity, has been
divided, into that, resident in the serous membrane or perito-
neum, and, that, affecting the substance of the viscera covered
by that membrane. The first, has been subdivided, according to
ite seat, or the part covered or lined ; hence, we have hysteritis,
nephritis, enteritis, &c. Now, it is, no doubt, true, that we
may have inflammation, confined to a small portion of the
peritoneum, but it rarely goes to a great degree, without
spreading from its original seat, and therefore, it is not usual,
to find inflammation of the peritoneal surface of the uterus,

Htteiidrd with more severe uffectiuiie of the brain or Rbdomiiial viscera, tliaii the
latter.

582

prove fatalf witbout an eztenuon of disease, to more or less
of the rest of the membrane. Although, then, we give a
particular name to the complaint, according to the spot
where it seems to begin, we yet must be prepared soon to
find inflammatioD extend. Still, this distinction is important,
as inflammation, is not only more apt to spread, fit>m one
part or organ, than from another, but it is also, more imme*
diately dangerous, when it originates in one tiscus, than in
another. We must also recollect, that inflammation, be-
ginning in one part^ or texture of an organ, may soon be
communicated to others, or to the whote, that of the peri*
toneal coat, for instance, to the proper substance, or some of
its constituents, and vice versa. In practice, then, we must
expect complications beyond, what we meet with in nosology.
When inflammation begins in the deeper texture of a part,
it is more likely to be longer confined, or limited, than when
it begins in the serous coyering, but when the latter comes
to participate, it npreads faster. It also is apt to spread
sooner, when it affects the veins or lymphatics, than when it
is more resident in the proper tissue.

Pain, is not a criterion of the degree of inflammation,
for the parts, in similar degrees, may differ much in their
sensibility, and, no doubt, if the nerves be peculiarly involved,
the sensation must be greater. It woiud further appear,
that the nerves, under the peritoneum, whether covering the
intestines, or lining the abdomen, may be rendered very sensi-
tive, in consequence of inflammation in one part, although
that be extremely limited. The patient may die before such
inflammation have been so extensively produced, as to leave all
the marks, after death. In other words, there may be a state,
which, although it might ultimately, perhaps, have ended in
inflammation, or even gangrene, had time been allowed, yet
is not, correctly, to be considered as inflammation. The
mere absence of redness, or injection of the capillaries, after
death, is not a proof that inflammation had not existed during
life, but, if, at the same time, there be no opadtr of the
membrane, no degree of infiltration, nor change of organic*
zation, or softening, I would not think it correct to say, that
the part had been inflamed, although the intestines were
distended. In most of such cases, however, we find, that, in
various parts, there is some change of texture or appearance,
although not an increase of redness, indicating, that morbidly
increased action, had existed, by whatever name it is called.
We also shaU find that some particular spot, more or less

583

extensive, does exhibit the ordinary marks of inflammation.
That this condition, is of the nature of inflammation, is further
confirmed, by the fact, that we usually find more or less serous
effusion in me belly, with flakes of lymph, and this effusion
is often too great, to come from the smdl spot, evidently
inflamed, or that is so situated, as not to be able to yield it*
This exhausts as quickly as, or more so than, true inflamma-
tion.

There is, also, as a general attendant, on inflammation of
the abdominal viscera, an inflation of the intestines, or tym-
panitic condition. This may depend on actual inflammation,
of the coats of the intestines, but it may also arise, from mere
loss of tone or contractility, of the muscular fibre. It is
therefore an attendant on diseases, and, in abdominal inflam-
mation, we find it often great, when the various marks of in-
flammation found after death are very limited. It may or
may not, be attended with sensibility or pain, but in the acute
disease, I am considering, it always is conjoined with frequent
pulse, and very often with disturbance of the stomach. If
the fever be moderate, and the swelling slow in its progress,
it may be connected with inflammation, confined to a small
part, for instance, the. ovarium, and the patient recovers,
though, perhaps, afterwards, ovarian disease manifests itself.
But if it occur early, and increase with frequent pulse,
even although there be little pain, the patient generally dies.
There is {dways some pain produced, by pressing on the
lower part of the belly, and, before death, there is much dis-
tress, from the swelling and difficulty of breathing. This is
particularly apt to take place, if the patient have been much
exhausted during labour, and, perhaps, at last, delivered by
the crotchet. We may have very little, or very limited,
local inflammation, but most extensive inflation. In gunshot
wounds, and other injuries, we may also have sinking, before
inflammation can be fully established. Of a nature, some-
what, allied to this, is the state of a patient, who is subjected
to the influence, of a deleterious atmospheric condition, or of
contagion. The abdominal contents, are more predisposed
to disease, after delivery, than at other times, and a cause wiU
act then, which would not have acted formerly. If, in such
circumstances, disease be produced, it may rapidly become
very extensive, or, if the actual inflammation be very limited,
the other effects may be rapidly produced, and the patient
exhausted.

Effusion of serum, and of albumen, or exudation of fibrine,

584

always attend, extensive peritoneal inflammation, but the ex-
tent of the one, is not always proportioned, to the degree of
the other.

Distant parts, may be affected in conjunction, so as even
to lead off the attention for a time, from the abdomen ; for
instance, the disease, may, at first, put on more the appear-
ance of puerperal delirium.*

CHAP. XV.

0/ Inflammation of the Uterus^

Inflammation of the womb may appear under two forms^
the slight and circumscribed, and the extensive or severe. This
is a distinction which those, who are not much conversant in

1)ractice, may not be disposed to admit ; but it will, neverthe^
ess, be useful to describe them separately.

The first, begins within the ninth day, very like the
ephemeral fever, and is considered by the nurse, as a weid*
The patient shivers, feels cold, is sick, and perhaps vomits.
The pulse is frequent, but not hard nor sharp, the skin becomes
warm, and between the cold, and the establishment of the
hot, stage, the patient complains of a dull pain, in the lower
part of the bellv. It is not constant, and is apt to pass for
afterpains. The lochial discharge continues, and the secre-
tion of milk is not checked. The pain, at first, and usually

' « M. Tonoelle, in hU memoir on tlie puerperal ferer, m it appeared in La
Matemit6 in 1829, particularly In the month of January, eutea, that in 293 cases,
which were inspected, inflammation of the peritonaeum, combined with that of
the uterus, occurred in )65; inflammation of the peritonsum, 28; of the uterus*
89. The substance and covering of the uterus, in 190 cases, exhibited simple
metritis, 79; superflcial softening, 29 ; deep softening, 20 ; Inflammation of th«
ovarium, fi6 ; do., with alMcess, i. Suppuration of the veins, occurred 90 times»
viz., accompanied with suppuration of the uterus, S2 times ; with sofkening, or
putridity, 1 1 ; with metritis and softening combined, 5 ; with peritiMiitia, ind^
pendent of all othsr change, 84 ; alone, or without any other anection, 8. Sup-
puration of the lymphatics, occurred 44 times, of which, :29, were complicated
with that, of the veins ; IS, with that, of the uterus ; ft, with softening ; 8, with
simple peritonitis ; 8, without any other change. The ovarla were inflamed.
In 83 cases, with various complications, but the greatest number, with simple
peritonitis.

in 222 inspections, there were found, combined with peritonitis, which might be
considered the primary disease, various other affections* for instance, circumscribed
pleurisy, 29 ; effusion of blood, or serum, into the chest, 14 ; softening of the sto*
mach, 8; enteritis, 4; abscess of the liver, 3 ; abscess in muscles, 14; abscess in
the articulations, 10 ; in the cellular substance of the pelvis, 8. Archives Gene-
rales, T. xzii. p. 482.

585

during the whole coarse of the disease, is slight, it is generally
felt, near the pubis, but it may also extend a little to one
side, or toward the groin. Sometimes, there is pain in the
back, but frequently there is none, unless when the patient
sits up. The pain in the belly very soon is not perceived
when she lies still, but is felt when she turns, or when
pretty considerable pressure is made with the hand, or
occasionally one or two sharp pains dart through the
uterine region. There is no hardness to be felt, and the
belly is not tender, but becomes a little full; the lochial
discharge gradually diminishes, but does not of necessity
stop, and the milk sometimes continues plentiful. There is
considerable thirst, no appetite, and the sleep is disturbed.
The pulse, which at first is very frequent, falls in a day or
two to 100, or varies from 98 to 108. The head is confused
rather than painful, slight wandering pains may be felt in
the belly or sides. The bowels are generally affected, being
at first rather bound, afterwards loose or irregular, and the
fseces, dark, slimy, or foetid. Sometimes there is a degree of
strangury. In the course of a fortnight, the pulse becomes
slower, the appetite^ gradually returns, and these circum-
stances are preceded or accompanied with a slight discharge
of blood from the womb, or of purulent matter by l£e
rectum, or from the vagina. Sometimes, the disease is much
shorter in its course, being little more protracted than an
ephemera, the symptoms yielding, completely, to the treat-
ment ; or, they may be removed, in so far, as that all fever
and pain go off; but when the patient comes to rise, she
feels a pressure, like prolapsus uteri, which continues for
many days, or even weeks, so that she cannot stand, but has
an instinctive desire to run to a seat. It is not easy to dis-
tinguish this state from prolapsus, except by examination.
The uterus is felt in its proper altitude, but often the os
uteri is turned a little to one side, and sometimes is tender
to the touch, and the vagina is not lax, but may be rather
rigid: pessaries give little or no relief. The complaint
continues obstinate, preventing the patient from walking,
though she be in tolerable health, until a little purulent
matter, or still more frequently, a little blood, like the
menses be discharged, and then she is almost instantly
cured.

The treatment of this species of uterine inflammation con-
sists in immediately taking away a moderate quantity of
blood, exciting early a free and pretty copious perspiration.

586

fomenting the belly, and opening the bowels fully with a
purge, which operates mildly without griping. If the pain
be more permanent, leeches may be necessary, and a poultice
should be applied over the pained part, or a small blister,
may be placed there.

The more serious, and extensive, inflammation of the uterus,
may be excited, in consequence of rude management, or other
causes. The disease, usually, begins between the second and
third day, after delivery, but it may take place at a later
period, and sometimes even earlier. It is pointed out, by
pun in the lower part of the belly, which gradually increases
m violence, and continues without intermission, though it be
subject to occasional aggravations, like very severe after-pains.
These aggravations, at first, seem to proceed from contrac-
tions, or spasms, of the inflamed fibres. The uterine region,
is very painful, when it is pressed, and it is a little swelled.
There is, however, little general swelling of the abdomen
with tension, unless, the peritonaeum have become affected.
But the parietes, are rather slack, and we can feel distinctly
the uterus, through them, to be harder than usual, and it is
very sensible, whilst pressure can be borne on other parts of
the belly, if applied so as not to affect the uterus. There is
also pain felt in the back, which shoots to one or both groins,
accompanied with sensation of weight ; and there is, usuaUy,
a difficulty in voiding the urine, or a complete suppression,
or distressing degree of strangury. The situation of the pain,
will vary, according to the part of the uterus, first, and prin-
cipally, affected.' The internal parts, also, become, frequently,
of a deep red colour, and. the vagina and uterus, have their
temperature increased. The red lochial discharge is very
early suppressed; if renewed, it is sero-purulent, and the
secretion of milk, diminished or destroyed. Nearly, about
the same time, that the local symptoms appear, the system
becomes affected. The patient shivers, is sick, vomits bilious
fluid, and often has headach. The pulse, very early, becomes
frequent, and somewhat hard, and the skin is felt to be hot.
The ton^e is first white and dry, and then red and fiery, the
urine high coloured and turbid, and, if the bladder be affected,
it mav be retained. The vomiting, in some cases, continues,
and the bowels are at first bounc^ but afterwards the stools
are passed more frequently. If the peritonaeum come to par-
take extensively of the disease, then we have early swelhng,
and tenderness of the abdomen, and the danger is greatly
increased. Sometimes the internal or mucous membrane is

687

chiefly affected, and, succeeding to pain, fever, and suppres-
sion of the lochia, we have a puriform discharge.

If the inflammation do not extend along the peritonaeum,
this disease, is more easily cured, than other visceral inflam«
nations, in the puerperal state. It may terminate, favourably,
by a free perspiration, a diarrhoea, or a uterine bloody dis-
charge, which last, is the most frequent and complete crisis.
If the pain abate, the pulse come down, and the lochia and
secretion of milk return, we consider the patient, as having the
prospect, of a speedy cure. But, in many other cases, the dis-
ease is more obstinate, the fever continues, the pulse becomes
more frequent, but is full for a day or two, after which, it
becomes small, the tongue is redder, but dry, the pain does
not abate, and, in some days, shiverings take place, and the
pain becomes of the throbbing kind. The face is pale, unless
when the cheeks have a hectic flush ; the urine which was
formerly high coloured, now, deposits a pink-coloured sedi-
ment, in great abundance. The nights, are spent without
sleep, and the patient is wet with perspiration. After some
time, matter is discharged from the vagina, or by the bladder
or rectum, but oftenest from the rectum. The hectic symp-
toms continue for many weeks, and may at last prove fatal.
Sometimes, the disease early proves fatal, the pulse increasing
in frequency, the tongue becoming very red, and the strength
sinking; but, even in this case, it will generally be found, that
suppuration has taken place. No reliance is to be placed, on
the abatement of pain, and the apparent improvement of the
pulse, if the patient continue to vomit, and the tongue remain
dry and fiery, or aphth® appear.

On inspection, we sometimes find the peritoneal coat also
inflamed, or, the inflammation is most marked, in the internal
lining. This is often supposed to be mortified, when it is only
covered with a dark coating, made up of blood and the remains
of the decidua. In this disease, the coating is often foetid, or
mixed with pus. The substance of the uterus, is generally
thickened, when it is inflamed, and the whole organ, is larger
and less contracted, than it ought to be. The tissue is
softened, and has more of a fibrinous appearance. The vas-
cularity is more or less increased, and the colour deeper in pro-
portion as the substance has been more or less universally in-
named. The ovaria when inflamed, are much redder and fleshy
looking in their tissue, and their peritoneal coat more vascular.*

• Dr. Campbell mentions two cnscs, in which the peritoneal nerves, and one,
in which thew, and the uterine nerves, were ffreatly auhu^yed.

588

There is a peculiar kind of softening which has been par-
tially described by Boer, Luroth, and Albert Danyau, under
two forms ; first, the superficial, which is almost always con-
nected with some other form of inflammation, and Tonnell^
observes, that its existence, has no sensible influence, over
the train of symptoms. It is recognised by irregular, super-
ficial, patches, of a reddish brown, or buff colour, and bad
smell. The deep ramoUissement, on the other hand, is a
more distinct complaint, giving a malignant character to the
disease, which runs its course very rapidly. It extends some-
times through the whole thickness of the parietes, and the
tissue is red and almost gelatinous, or a brown, or even black,
unorganized pulp. The inside of the womb is covered with
foetid brown coloured or black tenesmus stuff, or the putres-
ence may be confined to this surface, the rest of the substance
being healthy, or it may altogether be confined to the cervix
and OS uteri. It has been considered as a peculiar state, in-
dependent of gangrene, and little under the control of medi-
cine. It may commence before labour or appear almost im-
mediately after delivery, or not for some days. It is chiefly
to be distinguished from common inflammation by the early
and rapid sinking. The spiculum has been prepared to as-
certain the state of the os uteri. Evacuations can only be
admitted in the very earliest stage. Quinine and due nourish-
ment are more generally indicated, and pledgets of lint, wet
with camphorated or spirituous liquids, have been applied to
the uterus within the vagina.

Inflammation of the uterus, may arise, without any veiy
perceptible predisposing, or exciting cause, but frequently it
IS distinctly attributable, to previous exertion during tedious
labour,* or to rash manual interference, or hurried extraction
of the placenta, or the application of cold in any way. It, as
well as peritonaeal inflammation, is also, peculiarly apt, to
affect those, who have suffered from uterine haemorrhage.

This disease, calls for the early, and free, use of the lancet,
which is the principal remedy ; and the number of times, that
we repeat the evacuation, must depend on the constitution of
the patient, the effects produced, and the period of the di&-
ease.t If three or four days have passed over, the pulse may

.i.li"*?!l' .^*;«>'«*« «?»«•* o*' tJ** pnu:tlc« of midwifery. In Wurtemberg, it !•
wom-^^f^i*" "»'^?P« «»^» dependent on contracted pelTis, and rlirldity, OM
S,«~o;tlml' rUlIr**"^?"****"^ '" «*•** «»^ turning, under all circumataiion,
tfSL uiid "Ifh^" «i:!^t being at an .Tera^e, one. In ten. When the crotciS
•hould & SlcuUtS on. ° * ^""^ ^^^' ^ **"^"^ '**• mortality gr«iter. than
- French «*iter« erroneoutly donot contiderthe Ij^ncttaarequlidie, mil«.

589

be full and frequent ; but this is an indication^ that suppura-
tion is going on, which will be ascertained by throbbing pain,
&c. In this case, the lancet is hurtful. Leeches applied
above the pubis, are useful immediately after yenesection, and
a warm poultice not only encourages the flow of blood, but re-
lieves the pain. If it be not employed fomentations should be
used. Mild laxatives are also highly proper. A blister ap-
plied to the hypogastrium, is often highly beneficial, more
especially, when the disease seems to be, in, what may be
called, a hesitating state. Diaphoretics ought to be adminis-
tered, such as the saline julap, with the addition of antimonial
wine and laudanum. Calomel, combined with opium, has
been given to such an extent as to affect the system. I ex-
pect most good from the latter, for whatever soothes and
allays pain tends to lessen inflammation. Emollient clysters,
or, sometimes, anodyne clysters, give relief. In the suppura-
tive stage, we must keep the bowels open, give light nourish-
ment, apply fomentations, and allay pain, with anodynes.
When the matter is discharged, a removal to the country, will
be useful, and tonic medicines, should be given.

Sometimes, the round ligament suffers chiefly, and the pa-
tient complains of pain, and tenderness, at the groin, increased
by pressure. The lower part of the belly, is, after a little,
swelled and uneasy, or a diffiised hard and fixed tumour is
felt above Poupart's ligament. Fever attends this disease,
and, sometimes, the stomach becomes irritable. It is often
caused, by hasty extraction of the placenta. It reauires the
early use of laxatives ; and, if the symptoms be violent, it is
proper to take blood from the arm, and apply leeches to the
grom, which should seldom be omitted. Afterwards, we em-
ploy fomentations and blisters. If neglected, the disease may
ena in suppuration, or in a painful swelling, at the ring of the
oblique muscle, which lasts a long time. This is sometimes
removed by issues, if not, it must be treated like lumbar ab-
scess. Anodynes should be given, to allay irritation, and the
strength must be supported, under the fever, which resembles
hectic.

In some cases, the internal membrane of the uterus, is
chiefly affected. The pain is not constant, but the uterus is
always tender when pressed, and the patient complains of
paroxysms, like severe after-pains, witn wandering pains,
about the abdomen and thorax. The discharge is faetid,

the symptom! be very acute, but trust rather to leeches, applied to the rulva.
Gardi^n, Tom. iii. p. 447.

590

and sero-purulent. The skin is hot, and sometimes moist,
the pulse is of moderate frequency, the sleep is disturbed, and
the bead pained. Sometimes, the bowels become inflated, and
the breathing more or less oppressed.

The treatment consists, in taking, at first a little blood, if
the local symptoms, or fever, be considerable, opening the
bowels, and applying warm fomentations, to the belly ; after^
wards, opiates are useful, alternated with laxatives. Great
attention, must be paid, to remove the foetid discharge.

Uterine phlebetis has been known to occur, within six hours
after delivery, but the most frequent time, is about the fourth
day. More cases commence earlier, than later. The symp-
toms, as may be expected, are much the same, at first, with
those of hysteritis, with more or less of which it is combined.
Almost always, the disease begins with chills, sometimes with
great coldness, rigors, and chattering of the jaws. The pulse
is frequent, and, headach, is a very usual attendant, particu-
larly, pain in the forehead. Dehrium early takes place, in
many instances, and it is very rare, for the disease to run its
course, without the occurrence of this symptom, at one stage
or other ; sometimes, it is the earliest, and most prominent
affection, the pain in the belly being, in such cases, dull. In
general, however, the pain, there, is acute, and when it is
not, there is tenderness on pressure, or on examination by the
vagina, which is hotter than usual. The uterus is felt, exter-
nally, to be hard, and larger than it ought to be, at the period,
or at least, more distinct ; and during the whole progress of
the disease, it continues large. The belly is more or less
swelled, either tense, or slack. Nausea, or even vomiting,
are early symptoms, but sometimes, there is no disturbance
whatever of the stomach. The skhi soon becomes hot, the
face flushed, and the eye troubled or reddish ; the pulse con*
tinues frequent, but becomes throbbing, though compressible.
The tongiie is parched, and furred, there is much thirst,
little or no sleep, the lochia generally, but not necessarily, or
invariably suppressed, the breasts are flaccid, and often the
bowels loose.

After these symptoms have continued, for about four days,
more or less, it is not unusual, for the patient, to seem to be
getting better, but, in a few hours, or even after some days,
the aspect changes, or, without any apparent amendment, the
second stage commences. The face is pale, and the counte-
nance collapsed, the eye sunk, sometimes red and rolling, or
the conjunctiva shining, the tongue becomes dry, or, together

591

with the throat, aphthous, the puke frequent, and small, and
feeble, the skin sallow, or even jaundiced : chills, or shiver^
ings, reappear, sometimes regularly, like an intermittent fever.
There is increased delirium, or a listlessness to sensation, a
discharge of foetid, purulent matter, from the vagina, with
great, and increasing, prostration of strength. During one
period, or other, of this stage, if not in the first, there is often
pain felt in the chest, with more or less cough, or, abscesses
form in some of the extremities, under the skin, or in the sub-
stance of the muscles, or around the joints, particularly of the
wrist and knee, or in the articulations of the pelvis. These,
are sometimes formed, with little pain ; in other cases, the
pain is acute. I have known the arm more complained of,
than the uterus. Erysipelas, on different parts of the body,
sometimes appears, without inflammation of the subjacent veins.
The pulse becomes irregular and very feeble, the stools are
passed involuntarily, and, it is not uncommon, for the patient
to be much distressed, with vomiting of green, or dark stuff.
The diagnosis between this, and simple metritis, is not always
easy. It is chiefly made, by the pain or abscesses, in the
course of other parts, of the venous system, or around the
joints, and, partly, by the rapid prostration, in the second
stage, when pus is supposed to mix with the blood. When
there is little abdominal pain, the disease has been taken for
puerperal delirium, or prolonged intermittent fever.

This disease is variable in its duration. It has proved fatal,
within twenty-four hours, and been protracted, for three
weeks or more, but a very usual period, is, from six to eleven
days ; a few, have died so early, as the third day, after its
invasion.

On inspection, the veins in the uterus, are found to be in-
flamed, and thickened to a greater or less extent, sometimes
universally, sometimes only on one side, or, about die former
site of the placenta, affecting only the ovarian veins, or, the
inflammation, does not involve the uterine veins, but the hy-

Jogastric, &c. On making a section of the uterus, the veins,
lied with pus, often resemble small abscesses. But, especially
in protracted cases, the inflammation of the veins is less
marked than that of the uterus itself. The uterus itself, is
generally larger, than it ought to be, at the period ; its peri-
tonseal coat sometimes quite healthy, at other times inflamed*
The substance is thickened and softened, so, that, in some
cases, the finger can easily be put into it, and it is generally
darker in the colour. Some portion, especially, at or near

592

the OS uteri, may be almost in state of black putrilage, and the
mucous coat there more or less destroyed. Very often, dis-
tant parts are affected, abscesses are found on the extremities,
or pus in the liver, or spleen, which may be enlarged and very
soft, or substance of the lungs, which may be hepatized, or in
the joints. Although, there have been violent delirium, we
often find no traces of disease, in the brain, or, only some tur-
gescence, in the vessels of the pia mater. The intestines are
generally inflated, sometimes inflamed, and, then, we have
both adhesion and effusion. We may also have more or less
extensive inflammation, or suppuration, in the linings of the
pelvis, or within the pubic articulation.

The treatment, as in hysteritis, consists in the early
use of the lancet, fomentations, or poultices, applied to
the region of the uterus, mild purgatives, and diapnoretics.
Leeches ought to be employed, when there is circumscribed
pain, after the lancet has been properly, and early used. In
the second stage, we can do nothing but support the strength,
by light nourishment, cordials, and, if it agree with the
Stomach, quinine: opiates are useful. The discharge from
the vagina, should be removed, by washing or syringing, with
tepid water.*

Inflammation of the lymphatics, is rarely met with, by
itself. The symptoms are nearly the same with those of
phlebitis, and the treatment similar.

CHAP. XVI.
Of Peritoneal Inflammation.

The peritonseal lining of the abdomen, or the covering of
the intestines, may be inflamed alone, or, this disease, may be
combined, with inflammation of the uterus.

Peritonaeal inflammation, may be caused by violence, during
delivery, or the application of cold, or the injudicious use of
stimulants. Those who have suffered from uterine haemor-
rhage, after delivery, are most liable to this disease, as well as
to inflammation of the uterus. It may not come on, for three
weeks after delivery, but it usually appears on the second

* For the general history, and puticalar easM, sea the memoir by M. Danee»
in the 18th and 19th rols. of ArchWes Generales, the memoir of M. Tonnell^, in
Arcliives, xxli. 864. Dr. Lee, in Med. Chir. Trans. Vol. xrl. p. 2. Duptay In
Journ. Comp. zlii. 3, and 290.

593

day ; and it may often be observed, that the pulse continues
frequent, from the time of delivery. It is preceded, or attend-
ed, by, shivering and sickness, or vomiting, and is marked by
pain in the belly, which sometimes is very universal, though, in
other cases, it is, at first, confined to one spot. The abdomen,
very soon, becomes swelled and tense, and the tension rapidly
increases. The pulse is frequent, small, and sharp, the skin
hot, the tongue either clean, or white and dry, the patient
thirsty ; she vomits frequently, and the milk and lochia, usu-
ally, are obstructed. These symptoms, often come on, very
acutely, but it ought to be deeply impressed, on the mind of
the student, that they may also approach insidiously. Wan-
dering pain is felt in the belly, neither acute, nor altogether
constant. It passes for afterpains, but it is attended with
frequency of pulse, and some fulness of the belly, and a little
sickness. But, whether the early symptoms, come on rapid-
ly or slowly, they soon increase, the belly becomes as large,
as before delivery, and is often so tender, that the weight of
the bedclothes, can scarcely be endured; the patient also
feels much pain, when she turns. The respiration becomes
difficult, and, sometimes, a cough comes on, which aggravates
the distress; or, it appears from the first, attended with pain
in the side, as a prominent symptom. Sometimes, the pa-
tient has a great inclination to belch, which always gives pain.
The bowels are either costive, or the patient purges bilious or
dark coloured faeces. These symptoms are more or less
acute, according to the extent, to which the peritonseum is
affected. They are, at first, milder, and more protracted, in
those cases, where the inflammation begins in the uterus;
and, in such, the pain is often not very great, nor very ex-
tensive, for some time. If the disease be to prove fatal, the
swelling and tension of the belly increase, so, that the abdo-
men becomes round and prominent, the vomiting continues,
the pulse becomes very frequent and irregular, the fauces arc
aphthous, death is marked in the countenance, the extremi-
ties cold, and the pain usually ceases rather suddenly. The
patient has unrefreshing slumber, and sometimes delirium mite,
but she may also remain sensible till the last. The disease
usually proves fatal, within five days, but may be protracted,
for eight or ten days, or even longer. If the patient be to
recover, the swelling does not proceed to a great degree, the

Siain gradually abates, the vomiting ceases, the pulse becomes
uUer and slower, the breathing easier, so, that the patient
can He better down in bed, and she can turn more easily.

594:

times, this disease ends in Buj^ratioii, and tbe abscess
piniits, and bursts, externally. Dr. Gordon, in bis treatise on
puerperal fever, relates three cases of this kmd. In one of
these, the matter was discharged firom the nmbificus, a month
after the attaok;. in another, six weeks after deliyerj; and in
the third, after two months, it came from the urethra* Simi-
lar cases have come under my own observation.

Upon dissection, the peritonaeum is found in a state of high
kiflammation, but it is rare to find it mortified. The omen-
tma is often inflamed. A considerable efluston of serow fluid>
Buxed with curdy substance, is found in the belly.

The patient is only to be saved, by vigorous means, and
great attention. If tlie pulse continue aoove a hundred in
tAte minute, for twenty-four hours alter delivery, there is
veason to apprehend, that some serious mischief, is about to
happen ; and, therefore, unless the frequency depend, decid-
edly» on debility, produced by great hemorrhage, &c., we
ought to open the bowels freely, and give a diaphoretic.
We must carefully cKamine the belly, and, if it be full, or
painful on pressure, or, if the patient be inclined to vomit,^
we ought instantly to open a vein, and use purgatives. One
copious bleeding, on the very invasion of the disease, is more
Mseful, than ten afterwards ; and the delay of two hours, may
be the loss of the patient, whose danger, even, under the
most active practice, is extreme. I know, that many are
miwilling to bleed women, in the puerperal state ; and the con-
dition of the puke, may seem, to young practitioners, to forbid
it. But, in cases of peritonseal inflammation, I must strongly
urge the necessity of Uood-letting, at a very early period ;
and the evacuation is to be repeated or not, according to its
^ects, and the constitution of the patient. If she have borne
it ill, and not been relieved, when it was used first, I appre-
hend that the case, has not been simple peritonseal inflamma-
tion, but malignant puerperal fever. If she bear it well, and
ihe pulse become slower and fuller, and the pain abate, we
are encouraged to repeat it. I wish to impress on the mind
of the student, in the most earnest manner, the fatal conse-
quence of neglecting blood-letting, in this disease. How
many women, fall a sacrifice, to the timidity or inatten-
tion of their attendant! The lancet is the anohor of
hope : it majr indeed be poshed too far ; it may be used by
yMuig practitioners, in cases of sfnsm, mistaken for peri-
tonitis ; but the error is safer than the contrary extreme, for,

^o evilS) debility, is move easily remof ed^ uian inflamma^

595

tioD. Wben I say Ibis, however, I do not mean to urge the
senseless, and extravagant, use of the lancet. A prudent
practitioner will bleed early and freely, so long as be is, there-
by, abating inflammation ; but he will stop in time, and ob-
serve whether he be, really gaining advantage, by evacuation,
or, (m the contrary, sinking the patient, and destroying that
vigour, which is necessary for an effort to recover. He will
never bleed late in the disease, unless it be, to subdue an ex-
acerbation, and when the effect of former depletion, leads him
to hope for renewed benefit. Whilst some have been dila^
tory, and too timid, others, I fear, have sunk their patients^
as effectually, by inordinate evacuation, as if they had left the
inflammation quite uncontrolled. After the lancet has been
early used, if pain continue, many leeches, or the soarifica^
tor, should be applied to the most painfid part. The ab-
domen, should then be covered, by a warm poultice. A large
dose of opium, that is, three grains, is to be administered
after the bleeding, and repeated, according to circumstances,
in smaller doses. The bowels are, at the very first, to be
opened freely with calomel, or some other purgative, which
we require to give in a large dose, particularly calomel, for
ordinary doses do no good. Dr. Armstrong, who is also a
powerful advocate, for the use of opium, gives half a dram of
calomel, and, afterwards, a purgative draught of senna and
salts, to work it off, and I thmk the principle safe, provided,
we regulate the dose of the medicine, by the constitution and
habits of the patient. In an advanced state of the disease,
after effusion has taken place, we must employ purges,
alone, rather than blood-letting. Sinapisms and blisters have
been advised, but are chiefly useful, when the pain is circum-
scribed. Fomentations, or warm poultices, if the weight do
not give pain, are more generally useful. Digitalis has been
given, either to abate inflammation, or promote absorption,
after effusion has taken place ; but I have never, in one single
instance, found it useful. After effusion has begun, and de-
bility is produced, cordials, of which wine is the best, should
be given, and anodyne clysters are to be administered. There
are one or two cases recorded, where the fluid had been,
either, spontaneously, discharged by an opening, taking place
in the intestine, or, artificial^, by paracentesis, and with a
good effect.

A modification of &is disease, is not unfrequent, in which,
the inflammatorj affection, in so far as traces are left after
Jl«atb, is apparently Hmited, to a very small extent, as well as

596

in degree. The pain seems to arise, more from high sensi-
bility of the nerves, than, from actual inflammation of the
parts, and it often shoots, in the direction, of some particular
abdominal nerve, for instance, the ilio-pubal. There is, at first,
cither, circumscribed pain, or, wandering pain like gripes. The
pulse is frequent, but not sharp. The skin hot. The bellj^,
little swelled, and the pain telt, chiefly, on pressure, or m
turning, or breathing deeply. The discharge, usually, con-
tinues. This disease, generally comes on, about the second
or third day, and, if not checked, the pain increases greatly,
the belly swells, and becomes tense, and the patient dies, with
the usual symptoms of peritonitis. But, on inspection, the
peritonaeum is not found to be inflamed ; often it is pale, or
at most, rather more injected than usual. The bowels are in-
flated, and there is some serum in the abdomen. The uterus
is contracted, and apparently healthy, but more minute ex-
amination, usually, discovers, some slight, or limited mark of
inflammation, in the veins, or cervix, or appendages. The
state of the abdominal nerves, has not been particularly
attended to. The diagnosis is difficult. There is seldom
t^hivering or coldness, the pulse is soft, the pain, is soon, more
acute, than usually happens, in peritonitis; but, the chief prac-
tical mark, is, that venesection, although, it may give momen-
tary mitigation, aflbrds no permanent relief, and, if repeated,
15 as little beneficial. It is, however, always proper to take
away some blood, at first, and it is found to be sizy. Then,
we give an opiate, either by the stomach, or in form of clyster,
and apply a large linseed meal poultice, to the abdomen ; after
tills, if necessary, a saline clyster, or mild laxative is to be
iriven. In some cases, I have found most benefit, from opiates,
in others from poultices.* The feverishness lasts for some days.
If there be continued local pain, leeches should be applied
to the part.

Peritonseal inflammation, may take place, during preg-
nancy, and not prove fatal. After delivery, the pulse con-
tinues quick, the face is flushed, the belly is swelled, and
fluctuation is perceived. The patient dies of rapid hectic,
and, on inspection, the intestines are found inflamed, and
pushed aside, with much pus. If the disease be not checked,
by bleeding, in the commencement, I believe nothing can do

* Dr. Gooch has detailed sereral ca«e« of this disi^ase, which, in some instancea,
seemed to proceed from the griping ooeration of a brisk purgative, in others, from
Kcvere afterimins, more especially when the patient in her ordinary state was
^ehrnto and nervous. He is against bleeding, and advises Dover's powder, and

697

good, in the hectic stage. Paracentesis may be proposed,
but its effects are not to be depended on.

Chronic, or slow inflammation of the peritonaeum, is not
veiy unfrequent, and may last for some weeks. It is attended
witn constant pain, in some part of the abdomen, but it is not
unbearable ; the belly is tender, the pulse frequent, the thirst
urgent, and, often, the mind is affected as in hysteria, or, a
train of hysterical symptoms supervenes, which may lead off
the attention, from the seat of the disease. It requires, at first,
blood-letting, and, then, the frequent use of laxatives, with
repeated blisters.

When upon this subject, it may not be improper to men-
tion, that a young practitioner, may mistake spasmodic affec-
tions, or colic pains, for puerperal inflammation; for, in such
cases, there is often retching, and sensibility of the muscles,
which renders pressure painM. But, there is less heat of the
skin, the tongue is moist, the pulse, though it may be fre-
quent, is soft, the feet are often cold, the pain has great
remissions, if it do not go off completely, there is little fulness
of the belly, and the patient is troubled with flatulence. It
requires laxatives, antispasmodics, anodyne clysters, and fric-
tion with camphorated spirits. If these means, do not give
speedy relief, then, we use the lancet. Blood, drawn in this
disease, after it has continued for some hours, even when the
woman is not in childbed, is sizy, and it is always so, in the
puerperal, as well as the pregnant state, although the woman
be well.

Inflammation of the mucous coat of the intestines, is not
an uncommon disease, during pregnancy, and is marked by
dysenteric symptoms, and great emaciation, if it be pro-
tracted. After delivery, the purging generally increases, the
stools are liquid, and often slimy, and usually without pain,
at least, except, at the moment of discharge, which is perhaps
very rapid. There is seldom pain on pressure, or, if there
be, it seems rather at the epigastrium, from vomiting, than
from any other cause. The pulse is frequent, the appetite
lost, considerable thirst, occasional vomiting of bilious fluid,
extreme emaciation, and oedematous extremities. In many
cases, the inflammation seems to be concentrated, into spots,
here and there, and the vicinity, is only in a state of irritation
or excitement. In the early stage of the disease, bleeding
may be necessary. Mild laxatives should be ^iven, to remove
acrid, or indurated, faeces, and the diet should be light.
Afterwards, opiates must be exhibited, to allay the irritation.

598

and the best form, is tiiiat of pills* In tfae more advanced
stage, clysters, with laudanum, or suppositories of three or
four grains of opium, must be given, and, in extreme cases,
brandy is useful, in supporting the strencrth. I have not
known astringents do good, neither, have I derived so much
advantage, from external irritation, as I expected, or as should
induce me to subject the patient to it.

CHAP. XVIL
Of Malignant Puerperal Fever.

There can be no doubt, that, in, particular seasons, a con-
tagion has prevailed,* inducing fev^ , in the puerperal state,
attended with the symptoms, of the preceding inflammatory
diseases, varying, however, according as one or other of these,
predominated, in the individual cases. In some instances,
proving fatal, rather, from mere exhaustion, than from inflam-
mation. In others, leaving marks of great inflammation, or
of suppuration. It is not, therefore, to be expected, that,
either, the post mortem examination, or the individual symp-
toms, during life, should be very different, from peritonitis,
&c., the chief distinction, being, in the complication with a
malignant influence, and, in the patient, being neither bene-
fited by, nor bearing depletion, so copiously, as should have
been, both warranted and useful, in the simple affection.

The description, therefore, in many of the essential points,
must be much the same, as that of hysteritis, &c.

Malignant puerperal fever, sometimes, begins in an insidi-
ous manner, without that shivering, which, usually, gives inti-
mation, of the approach of a serious maladv. But, generally,
shivering is perceived, and varies considerably in degree, being
either slight or pretty severe. The first symptoms, indepen-
dent of the shivering, are, frequency of piuse, oppression,
nausea, or retching, pain in the head, particularly over the
eye-brows. The niglit is passed with little sleep, much con-
fusion, and, occasionally, some delirium. It must not, how-
ever, be unnoticed, that, in many instances, there is no headach,

* It was very preyalent in Parit, in 1746; in Dablin, 1767; in Ediobofth,
1773 ; in London, 1787-68 ; In Olugow, in 1819 ; again in Edinburgh, In 188l.» ;

1" '- r fl"/*'* >^^* '^^^ ^t t^« it v^M epidemic. In Glavow, wm ia the aum-
mer of 1835. ^^

599

in aay stage of the dueaae, nor any sickness^ or v:aimfln^, ih
the beginning. In some, tbe temper isi from the firs^ on-
commonly irritable; in othera, there is much timidity^ or
UsthttsnesBt or apathy. Hysterical symptoms, not unfreqaently
supervene ; or, particular nerves become more sensible ; or,
organs of sense are affected, thus^ some imagine they hear
the performance of a piece of mu^. From the beginning of
the attack, or very soon afterwards^ pain is felt in the belly,
at first alight, but it presently increases ; and, in some instaa-
cfts, the abdomen become so tender, that, even, the weight of
the beddothes, is productive of distress. A general fulness of
the belly, precedes this, or, at least, accompanies it, from the
first, and this usually increases, pretty rapidly, and may pro-
ceed so far, as to make the patient, nearly, as large, as she was
before delivery, and in such cases, tbe breathing becomes
very much oppressed ; indeed, in every instance, the respirar
tion is more or less affected, the free action of the abdominal
muscles, which exQ concerned in that function, being produc-
tive of pain. The degree of pain, its seat, and period of
accession, vary in different cases. In some, it evidently be-
gins in the uterus, never going entirely off, yet, being subject
to severe exacerbation, accompanied with sense of bearing-
down. The uterine region is painful, particularly, toward
.one side. The os uteri, if examined, is not much more
sensible, than usual. There is, generally, pain in the back.
In other cases, it is first felt, about the lower ribs, on one
side, and is accompanied by cough, the belly is tumid, and
tender when pressed, but, excepting then, or when the patient
turns, she complains little of it. Sometimes, severe pain, like
spasm, attacks the iliac region, and extends down the thigh,
and toward the bladder and pubis. The face, is sometimes
flushed, at first, or the cheeks are suffused, but the counte-
nance, in general, is pale and ghastly, the eyes are without
animation, and the lips, and angles of the eyes, arc white.
When the face is flushed, the cheeks are generally covered,
with a broad patch, of deep red, whilst the brow, and other
parts, are caiUiverous, or covered with perspiration. The
whole features, indicate anxiety, if not terror, and great debi-
lity. Vomiting, frequently, occurs at the very commence-
ment, and, in that case, it is bilious. In the course of the
disease, it sometimes becomes so frequent, that nothing will
stay in the stomach; and towards the conclusion of the fever,
the fluid thrown up, is dark coloured, and frequently fcstid.
This is a symptom, which, so far as I have observed, always,

GOO

if it do not proceed from a morbid structure, indicates, in
whatever disease it occurs, an entire loss of tone, of the
stomach. But to proceed with the history. There is a
great dejection of mind, languor, with general debility of the
muscular fibres, and the patient lies chiefly on her back; or,
there is so much listlessness, that she sometimes makes little
complaint. The skin is not very hot, but is rather clammy
and relaxed. The tongue is pale, or white, at first, but, pre-
sently, becomes brown, and, uniformly, aphth® appear, in the
throat, and extend down the oesophagus, and over all the in-
side of the mouth. From the irritability of the stomach and
bowels, it is probable, that these organs, participate in the
tender state; and, from the cough which is excited, the upper
part of the larynx, seems also to be afiected. It has already
been mentioned, that, from the first, the pulse is very fre-
quent, and is at that period, fuller than in simple peritonaeal
inflammation, but it soon becomes feeble. The thirst is not
always great, at least, the patient often is careless about
drink. The bowels are often, at first, bound, but, afterwards,
especially about the third day, they usually become loose, and
the stools are dark, foetid, and often frothy. This evacuation
seems to give relief. It is, indeed, peculiarly deserving of
remark, that often in this disease, either from spontaneous or
artificial evacuation, or, sometimes, without any perceptible
cause, there is a delusive calm, and the patient is supposed to
be better ; but in such cases, I cannot say, I ever remember
to have found a corresponding improvement, in the pulse,
and, therefore, T placed no reliance on the apparent relief.
The urine is dark coloured, has a brown sediment, and is
passed frequently, and with pain. The lochial discharge is
diminished, and has a bad smell, or is changed in appearance,
or gradually ceases ; and it is observable, Uiat the reappear^
ance of the lochia, if they had been entirely suppressed, which
is not common, is not critical. The secretion of milk stops,
and the patient inquires very seldom about the child. In some
cases, I have met with pleuritic symptoms. As the disease
advances, the pulse becomes more frequent, and weaker, or
tremulous. In bad cases, the swelling of the belly increases
Tapidly ; but the pain does not always keep pace with the
swelling, being sometimes least, when the sweUing is greatest,
and in the end, it generally goes entirely off. The breathing
becomes laborious, in proportion as the belly enlarges. The
strength sinks ; the pulse, always frequent, becomes weak and
tremulous; the throat and mouth become sloughy; perhaps^

601

the stools are passed involuntarily ; hiccup sometimes takes
place ; and the patient usually dies before the fifth day of the
disease, but in some cases not until the fourteenth ; in others
so early as the second day. In some instances, death is pre-
ceded, by low delirium, or stupor. In others, the mind con-
tinues unimpaired, till within a few minutes of dissolution,
and the patient is carried ofi^, after a fit of a convulsive kind.

This fever, attacks, generally, on the second, or, sometimes,
on the third day, after delivery, but it has also occurred, so
late, as after a week. The earlier it attacks, the greater is
the danger, and few women recover, who have the belly much
swelled.

On dissection, there is found in the abdomen, a consider-
able quantity of fluid, similar to that met with in peritonitis.
The omentum and peritonaeum, are inflamed, in a^ variable
degree ; sometimes considerably, sometimes very slightly, and
gangrene is unusual. The swelling, is neither proportioned
to the inflammation nor effusion, nor, in every mstance de«
pendent on these, but on the inflation of the bowels which
results from that relaxation of the muscular fibres of the
bowels, which is so common, in the puerperal state, particu-
larly, in puerperal disease. The uterus, although sometimes
the first seat of the pain, and occasionally found considerably
inflamed, yet, in general, is not more affected than the intes-
tines. In some cases, the thoracic viscera are inflamed, and
as well as the intestines, or they may be almost exclusively
affected. In either case, sero-purulent effusion is found in
the chest.

It is most frequent, and most fatal, in hospitals. In private
practice, it is less malignant, though still very dangerous. It
IS sometimes epidemic, but I do not know tnat it has, above
twice, been a very prevailing epidemic, in this city. In some
instances, it was easy to trace the contagion, from one woman
to another. In hospitals, it has conspicuously appeared as a
contagious disease. There has been much dispute, whether
the contagion were one, ^i generis^ or that of typhus, or erysi-
pelas, or hospital gangrene; or if the disease depended on
• some noxious state of the atmosphere, conjoined with the
absorption of putrid matter.* The disease appears to depend^

• When this fever U preTalent, women, after abortion, are liable to it ai well, as
thoie who have reached the full time. Unmarried women who attended the
sick, have also died with many of its symptoms. Patients who miscarry daring
typhus fever, are in great danger of dying, and when they do so, there is almost
invariably pain in the belly with tympanitic swellingi and in most easei inflam-
mation and sappuration are found on inspection.

602

<ni inflammtttiMi of die peritoamiiD» eov^iAaoi wiiii theiqpeia*
tion, of some debilitating poison, more or less- contagions. It
is not oonnectedi with the state of the labour, exo^ in so finr,
as» that haemorrfaage seems to predispose to it ; but when epi-
, demic, it occurs amor a rapid and easy, as well aa after a m<me
painfid labour. It is also, I think, established, that not only
different individuals may hare, more or less violently, symp-
toms of inflammation, but, also, that particular epdemics,
have the perttonitie state, more or less pronunent and acute,
and in some, there is much swelling, with little pain* I hai«
formerly stated, that inflammation, and other local discaae
may take place, as well by causes acting on the origin of the
nerves, as by those applied to tibe part itself. In this disease,
I am inclined to attribute the eroet, to flie first mode, bat
have not, as yet, satisfied mysdf of the existence of increased
vascularity, &c*, of the ^nal sheath.

We attfionpt the diagnosis, rather, perhaps, by our know-
ledge of the ^stence of an epidemic, than, at first, by any
special symptom. We also find, that, very soon, the symp-
toms of depression, are greater than should be expected, at
tiie period, in simple inflammation, and venesection doea less
good, even, for a few minutes.

This disease is dangerous, in proportion to the malignancy
of the cause, and the situation of the patient* All writers
agree, that in hospitals, it is peculiarly fatel, and that few
recover from it. In private practice, the disease is milder,
out still, it is most formidable.

With regard to the best mode of treatment, there has
been a great difference of opmion,* whidi partly depends,

« Dr. DenmaDi Vol. ii. p. 49dr coniidtrfl pi&erperal fever ae contngioas. He
strongly adTiaee nr}y bleeding, giving an emetie or aniimonlal, eo as to vomit,
parg e, or cause perspiratloa ; aim if this do good, he repeats the dose, and usee
clvsters, fomentations, leeches, and blisters. He gives an opiate, at night ami
a laxative in the morning ; or, if there be great diarrhoBa, he employs emollieat
clysters. The strength is to be supported, by spt. ether nit. or other cosdials^

Dr. Leake, VoL li. trusts much to blood-letting ; if the patient be sick, be
gives a gentle vomit; if not, lazativee, and then antimonials; applies bllsteiv,
and in the end, restrains purging with opiates, and prescribss bark.

Dr. Gordon, p. 77, et seq., depends on early and copious blood*lelting, taking
at i^rst, from 20 to 84 ounces, and purges, with calomel and J^ap. He is regu*
lated rather by the period of the diasaae, than the state of the puke— bleedkig*
though it be feeble.

Dr. Butter, pttr^eoand bleeds, only, where there is well m«>ked inflammatioa*
and is satisfied, otten, with taking only three ounces of blood, at a time, when
there is an exacerbation.

Dr. Manning very rarely bleeds, but trusts to emetics and purges, and emplojra

Dr. Denman's antimonial, which is taro grains of tartar emetic, mixed with ^U.

of crabs* eyes, and the doss is from three to ten grains.

Dr. Walsh forbids venesection, and advises emetics, followed by opuOts, ami
cordials.

603

on giving the name of puerperal fever, to diierent dtsordiBra.
I am sorry that I find it much easier to soj, what remedieB
have failed, than what have done good. I have stated, th«t
in peritonseal inflammation, blood-letting and laxatives are the

* Dr. Hulm trusU to dysters, purges, aiul dUpkoretici» |iad does not Ueed un-
less there be pain in the hypogastriam, accompanied with Yl<^nt stitehesy and a
resisting poise. Even tlien ne bleeds sparingly.

M. Doulcet advises repeated emetics, followed by oQy polioBS, and bark, eov-
bined with camphor.

Mr. Wbyte is against blood-letting. He dves, at fint, a gentfe emctle» fol-
lowed by a laxative and diaphoretics. Then, he gives baric, with vitriolic acid,
and supports the strength.

Dr. Joseph Clark trusts chiefly to saline purges, and fdmentations.
^ Dr. John Clarke, in his excellent £«ay8, forbids venesection, and advises baifc
as freely as the stomach will bear it. Opium is idso to be givea, together wkh
a moderate quantity of wine along with sago. If there be much porging, tiie
bark is to be omitted, till some niabarb be given, or a vomit, if there be iftHe
pain in the belly.

Dr. Kirkland bleeds only if the patient have had little uterine discharge, and
and the pulse indicate it. He employs laxatives, and, in the end, bark and
camphor. . , , .

Dr. Hull considers this disease as simple peritomeal inflammation, which may
affect three dasses, the robust, the feeble, and tliose who are in an intermediate
state. In the first he bleeds and purges, in the second he begins with emetios
and ends with bark, and in the third he bleeds with great caution.

Dr. Hamilton advises puerperal to be treated ss putrid fever.

Guiaot, Allan, and others, recommend carbonate of potash, in doses of ten or

fifteen grains. _ _,

M. Vigarous, joins with those, who consider this as not a fever tia $«Mrf#,
but one varying according to circumstances. It frequently begins, ho save,
before delivery, but becomes formed, about the third day after it. He has nve
different species. 1st, The gastrobiiious, proceeding from accumulation of biU
during pregnancy. The essential symptom of this species is iirtense pain in the
hyiMwastrium. He advises, first, ipecacuanha, which he trosts to, chiefly, and
then, clysters, laxatives, and saline julap. 2d, The putrid bilious. Xbis is
occasioned by bleeding, or neglecting evacuants in the former species ; or even
without improper treatment, the fever may, from the first, be so violent, that
bilious matter is absorbed. It is marked by great debUity, small or intermitting
pulse, tumour of the hypogastrium, with sharp pain and putrid symptoma,
aphthn, vomiting, fatid stools, &c. He advises vomits, laxatives, and barkm
great doses, with mineral acids, and clysters containing camphor. 8d, The
nituitous fever, attended with vomiting ot pitnita. The surface Is pale, the pulse
has not the force, nor frequency, it has in the former spedes, the heat in general
not Increased, anxiety, weight, and vertigo, rather than pain of head, often miliary
spots, and the usual symptoms of pain In the belly, and subsidence of pain in the
' breasts. He gives vomits, and afterwards three or four grains of lpecaenanlM»
every three hours, if he use purgatives, he conjoins them with tonics. 4tfa.
With phlogistic affection, or inflammation of the womb, attended with great
weight about the pelvis, swelling, pain, and hardness in the lower belly, supprea-
olon of evacuations, sharp, frequent, pulse, acute fever, and the countenance not
so sunk as in the putrid disease. He advises venesection, leeches, and low diet.
The same remedies, with blisters, are to be used, if pleuritic symptoms occur.
6th, Sporadic fever, proceeding from cold, passions of the mind, ftc. l^uerperal
fever, he considers as apt to terminate, in milky deposits in the brain, chest, legs,

Dr. Armstrong considers this fever as decidedly inflammatory, and trusts to
the early use of the lancet, followed by a large dose of calomel, from one aornMe
to half a dram, with the subsequent assistance of Infusion of senna w»*h eaWJ.
Later, he seemed, from meeting with other constitutions, to tmat more to bleafl-
' Ing. followed by the use of full doses of opium. - . , j , *.i

Dr. Brenan baa published a pamphlet, recommending, in pl^e of blood-tetting,
the free use of oil of. turpentine, internally, and the external appUcattoa to the
belly of a cloth soaked in it.

604

principal remedies'; but in this disease, blood-letting must be
employed with greater caution. It must be resorted to, very
early, and ought not to be pushed far, but the exact extent
to which we may prudently go, must depend on the nature

/ Mr. Hty is decided is to the inflammatory natnre of the disease, and traats
entirely to the early and free uee of the lancet* and the administration of jalap
and calomel, vrith other cathartics, so as to maintain a purging, for tiro or three
days, or longer, if necessary.

llttfeland applies cold poultices to the abdomen.

Gardien admits six species. 1st, Puerperal fever, complicated with la fieATe
angloteniqne, or synocha, marked by the ardent symptoms of that fever. It is
more strictly Inflammatonr, but is the least frequent species. It is to l>e treated
by strict antiphlogistic regimen. Venesection is only allowable in tbe most robust
and plethoric. A dozen of leeches applied to the vulva or anus, are safer. Lac-
tation is the 1>est remedy, and the surest preventive. 2d, With la fievre adeno-
mening^e, or mucous fever. This is met with often, and is more slow and Insi-
dious : the mouth is slimy, and the abdominal pain is obtuse. It ia{to be treated
with bitters and tonics. Sd, With la fievre menlngo-gastrlque, or bilious states
marked by yellow tinge, epigastric pain, nausea, bad taste, &c In this case, tbe
violent abdominal pain is not always from inflammation. It is to be treated by
emetics or purgatives, according as the stomach or bowels seem most affected.
4th, With la fievre adynamique, or putrid fever. This is the most fatal, but most
rare species, and is marked bv great weakness, small pulse, dry mouth, paleness,
and foetid diarrhoBa. The pain Is less acute, and the swelling is from gas. We
should neither use the lancet, nor active tonics, such as bark, but rather a kind of
negative plan, giving lemonade and cream of tartar, or perhaps camphor. 6tby
With la nevre atazique, or nervous symptoms, as hiccup, convulsions, && 6tbt
With other local phleffmasia, as of the brain, lungs, &c

Dr. Campbell and Dr. Macintosh, have both published on pnerperal fever, and
look on it as inflammatory, non-contagious, and to be cured only by active deple-
tion. Their treatment consists in bleeding freely from the arm, fomenting the
abdomen, and applying to it, and the puaendum, from 60 to 100 leeches, con-
joining also, the use of purges, such as calomel, with antimony and clysters.

Dr. Douglas, in the 8tb vol. of Dublin Hospital Report, divides the disease
Into three species, the synochal, gastrobllious, and epidemical or contagious. In
the flrst he advises venesection freely, purges, &c. In the second, venesection
more moderately, and calomel in the dose of ten ffralns, with castor oil. In tbo
third, the same dose of calomel, with opium ancT a clyster. Then, from two to
four doxen of leeehes to tbe abdomen, and pure oil of turpentine to be exhibited
in the dose of three drams.

In the Edinburgh Journal for July, 1824^ is an account of the report made on
the disease, as it appeared at Vienna, and an abstract of tbe^opinions of Boer.
There appeared marks of vascularity or turgescence in all the cavities, and, in
most instances, peritonaal inflammation existed. The nterus was little con-
tracted, its substance flabby and tender, and iu internal surface gangrenous—
a condition, in every case, most strongly prevalent at the os uteri. It was con-
sidered not to be contagions. The treatment consisted, chieflv, in venesection,
the application of loeohet, clysters, blisters, and then diff^usible stunull, but seldom
with good effiect.

The disease was, In the year 1819, epidemic in this city and more especially In
the suburbs, particularlv toward the east. 1 made particular Inquiry into tbo
treatment, and fear it nas not been so snocessful as the attendants could have
wished, although the utmost care and promptitude were exercised. In a few in*
stances, the lancet was neglected, and the tonio plan used, but without c0ect»
The universal opinion, 1 found, to be In favour or tbe lancet, at the same time^
that its too general failure was fullv admitted. Dr. J. Watson Informed mc^
that in most of the cases he met witn, the disease seemed to begin as hystcritis*
and spread to the peritoneum. Copious bleeding, blistering, and large doses of
opium, were tbe remedies used by himi and only in one case did be think turpcn-
tfne of service.

Mr. S. Clark expresslv says. In a statement he gave me, that all the cases ha
law coredj and his practice was very extensive in Uic disrasei were by mcaBs of

605

of the epidemic, and the constitution of the patient, as well
as the special symptoms, of her particular case. I am quite
convinced that, in simple peritonitis, the lancet is the anchor
of hope, if hope may be indulged ; but in contagious or puer-
peral fever, it must be used with more circumspection, and is
still less to be depended on. I am fully aware, from experi-
ence, of the good effects which often follow from bleeding,
early, in typhus or contagious fever ; and, therefore, I have
no prejudice against that remedy, in this contagious disease.
I have, on the contrary, used it freely myself, and have known
it done so by others ; and to this free trial I have been led,
by the respectable testimony to its advantage, as well, as the
fatal issue of the disease, under other treatment. I am, how-
ever, from observation, convinced, that if this remedy be use-
ful, it is in the very early stage, and that it cannot be too
soon employed. If the disease have gained any progress, I
never have found it useful. Like other remedies, particularly
purging, it has been followed by an apparent relief, but the
pulse did not come down, nor was the patient cured. My
conviction, therefore, is, and, if an opinion given in an ele-
mentary work, is to influence the conduct of those who read
it, I cannot state it, without a feeling of awful responsibility,
that the lancet is only admissible, in the very commencement
of the disease, and if decided benefit be not derived then, we

very copious depletion, both by yenesection and purgatives. " After copious
bleeding, large doses of calomel were useful in -the epidemic which prevailed lately
at Kilsyth, but none recovered there, nor in the country around, without bleed-
ing.** He at first tried the tonic plan, but with universal failure, whereas he says
a third part recovered, by the other, if used early and boldy in constitutions pre-
viously sound.

Dr. Cusac has three specios. one which bears bleeding, another, which does not
bear even leeches, a third which does, but will not bear the lancet.

M. Dance considers it as phlebitis, and treaU it accordingly. M. Tonnell^
looks on it either as the suppurating, or what he calls typhoid stage, of phlebitis,
or as a peculiar " forme atazique,** in which, appearances on dissection, are in no
degree proportioned, to the severity of the symptoms. He employs leeches,
ipecacuanha, mercurial friction, and poultices of linseed, injections into the
uterus, and quinine.

M. Nonat, admits also the inflammation of the viscus. M. Velpeau seems to
think that lesion of the symphyisis pubis precedes phlebitis.

Dr. Lee considers it as decidedly inflammatory ; but when the deep tissue of
the uterus, the veins or absorbents are affected, be says leeches are, in general,
better than the lancet.

M. Dubois, when 1 visited La Maternity, Informed me, that whilst he adapted
his practice to the condition of the individual ease, be^ In general, preferred leeches
to venesection.

Dr. Collins has seen the disease commence even before delivery ; but the
largest proportion began on the firat, and next to that, on the second day. The
greatest number died from the second to the fourth, but especially on the third
day. He advises the application of three or four dozen or leeches, the warm
bath, and four grains of calomel, with at much Ipecacuanha, every 2d, Sd, or 4th
hour. Three or four hundred grains have been given. Opium he also often
conjoins* He seldom employs venesection.

606

ought not to repeat the eracuatioii. It is my duty to say, and
I do it, considering the opposite sentiments of good judges,
with a sense of deference, that I have never known any patient
jeoover, who had been largely and repeatedly bled, and that
my successful cases, have been amongst those, who either
were not bled at all, or bled ear|y, not above once, and that
not id>andantly. At the same time, I am willing to admit,
that much must depend, on the constitution of the patient, aa
well as the peculiarity of the epidemic, and particular circum*
stances. If bleeding be indicated, let us bleed early, and be
guided by its effects.

The applieation of n&merous leeches, to the abdomen, and
the subsequent application, of a warm poultice, is more use-
ful, than a repetition of venesection, and, in many cases, is
safer, and more to be depended on, even £rom the first.

On the appearance of the disease, it will be proper, at the
same time that we bleed, or apply leeches, immediately, to
give a dose of some purgative medicine, such as diall fredy
evacuate the bowels without irritating ; as, for instance, a fiiD
dose of calomel, or a moderate quantity of castor oil, infusion
of senna, or solution of sulphate of magnesia. As soon as
the operation is effected, an opiate diould be given, either
alone or combined with calomd. Opiates, after purgatives,
hme the effect of abating hrritation axMi pain, and of restrain-
ing immoderate diarrhoea, should that come on. Diarrhoea
should not be allowed to continue long, and is always to be
restrained, unless, it evidently give relief, and the fisBces be
very foetid. In this case, calomel and diluents should be em-
ployed. If there be tenesmus, anodyne clysters should be
given, after the use of the calomel. In all cases, we are to
attend much to the bowels, using gentle purgatives and clys-
ters, where there is no diarrhoea; milder doses, alternated
with opiate clysters, where there is. Vomiting is to be re-
strwied, by solid opium, and by an opium plaster applied to
the region of the stomach ; soasetimes saline draughts are of
service. Nausea has been supposed to indicate the necessity
of an emetic ; but if no r^ef be obtained from natural vomit>-
ing, which most practitioners admit, I do not see, that artifi-
cifld vomiting can be useful, nor does experience support the
practice. Anodyne, or rubefacient embrocations, sometimes
abate the pain in the abdomen, but if the weight of a warm
poultice can be borne, it is in general more useful. The re-
Mated application of bUattrs, has been extoUed by some, bat
I am quite indined to concur with Dr. Clarke, m thinking

607

Aal Ihtj vner csdte sb injuioiB iiiiuiiua. Ciolia»

vitk oil of tarf^ensmt^ applied to die bciiT« pndace
atitntkBd knutiooy and are at katt aac&eraaL if
ao, in rdaewwm the imrma] pain. Thestroisth shoad
aappOTted, bjr liglxt noansfament, and, iiliiaiii iy, br a
tale praportioo of wine, or other eordials, akn^ with q^"i— -
Digitalis and other dinreticB hare been given, to canr off dbe
dhicd flnid, bat th^ hare no effsct. Sohw, have diavn off
the fluid oy piuwiiHaia. rMrtirw aod latDDanah, I «■
afrud, do tatmt hant in ^enenl than goad. M4

IWIIBJlll 111 IIWI llll kl llllllIM if

CHAP. XVIIL

Thb swdhng^ of the mfienor eiiicuutr^ in puerperal
k nBuaPy preceded, bj marls of oterine initatioD, and a
der stale, of the parts within the pehris, not anftequently, by
symptans of iiitaaimatitin, higher in the afadondnal csTity,
and even in the diaphragm. In many cases, tUs sfcrlion,
seems to be seeondary, that is, foUows some decided disrase,
within the pdric, pnaaihly of weeks' doration. In others, it
appeals without pfcvioas complaint* About a fortnight after
delivery, sometiBies so eariy as the sixth day, or even so lafte
as the sixth week, the patient eomplaiim of pain in the lower
beDy, increased hj pressnre, and oocaflonallv has pain and
difficulty in making water. The uterine region is somewhat
swelled, the pdse b fr^eqnent, the skin hat, the thirst in-*
creased, and these symptoms are often preceded by shivering*
Stiffioess and pain are now felt, in one of the groins, near Ike
passage of the round ligament, or tlic exit of the tendon of
the psoas smsde, or, m some csset, abont the ctiuin of the
sartorios and rectos imisckM* I'be pstn in attended witk
swelling, both of wlwh auiy pror^ifd frrsdaalhr down the
limb ; but, more freau^tly^ psin U Mi, nuAiUtttUf m the in-
side of the calf of the k^, or si thi* knse, mw ttie tostrtion
of the sartmns mnscle, and is m*n4, Mn$fm in the eoorse of
that mnscle ; it also dart« il/;wri Ui Oi«< h^t^h ^ •I'MHr ^^ ^^
tribotuB of dm nervws sapbetitis« m tbn l«c« T\^9 » g«M-
isfly, a thicheiting and harilifi'^fi of (bf roabi of tk# f«M ss*
and aiqmsite tendoTMis m pr9«miiy ^^m$. 000^

606

m^Iit not to repeat the eTacuation. It is my duty to say, and
I do it, considering tbe opposite senlimoits of good judges,
with a sense of deference, toat I have never known any patient
recover, who had heen largely and repeatedly bled, and that
my successful cases, have been amongst those, who either
were not bled at all, or bled ear^y, not above onc^ and that
not i^ondantly. At the same time, I am willing to admit,
that much must depend, on the constitution of the patient, as
well as the peculiarity of the epidemic, and particular drcum-
stances. If bleeding be indici^ed, let us bleed early, and be
guided by its effects*

The application of nmnerous leeches, to the abdomen, and
the subsequent apnlication, of a warm poultice, is more use*
£il, than a repetition of venesection, and, in many cases, is
safer^ and more to be depended on, even from the mt.

On the appearance of the disease, it will be proper, at the
same time that we bleed, or apply leeches, immediately, to
give a dose of some purgative medicine, such as flfaall freely
evacuate the bowels without irritating ; as, for instance, a fuH
doM of calomel, or a moderate quantity of castor oil, infouon
of senna, or solution of sulphate of magnesia. As soon as
the operation is effected, an opiate should be given, either
alone or comluned with calomel. Opiates, after purgatives,
have the effect of abating irritation and pain,, and of restrain-
ing immoderate diarrhoea, should that come on. Diarrhoea
should not be allowed to continue long, and is always to be
restrained, unless, it evidently give rehef, and the fSesces be
very foetid. In this case, calomel and diluents should be em-
ployed. If there be tenesmus, anodyne clysters should be
given, after the use of the calomel* In all cases, we are to
attend much to the bowels, using gentle purgatives and clys-
ters, where there is no diarrhoea; milder doses, alternated
with opiate clysters, where there is* Vomiting is to be re-
strained, by solid opium, and by an opium plaster applied to
ike r^on of the stomach ; sometimes saline draughts are of
service. Nausea has been supposed to indicate the necessity
of an emetic ; but if no rdiief be obtained from natural vomit-
ing, which most practitioners admit, I do not see, that artifi-
cisi vomiting can be useful, nor does experience support the
practice. Anodyne, or rubefacient embrocations, sometimes
abate the pain in the abdomen, but if the weight of a wann
poultice can be borne, it is in general more useful. The re-
vaated application of bUsters, Imis been estolled by some, but
I am quite inclined to concur with Dr. Clarke, in thinking

S07

tkat tkey ratfier excite an injarious irrttatioii. QoAgy wet
with oil of turpentine, applied to the bellj, produce leas con*
atitutional irritation, and are at least as effectual, if not more
ao, in reUering the internal peb. The strength should he
supported, l^ light nourishmeut, and, ultimately, by a mode-
rate proportion of wine, or other cordials, along with quinine*
Digitalis and other diuretics have been given, to carry off the
effused fluid, hut they have no effect. Some^ have dbrawn off
the fluid hj paracentesis. Emetics and atntimonials, I am
airadd, do more harm in general tban good. Mercury has
been eonnnended by some, but is adidom i£ ever useful.

CHAP. XVIIL

Thb swelUng of the inferior extremity, in puerperal women,
is usually preceded, by marks of uterine imtation, and a ten-
der stale, of the parts witlnn the pelvis, not unfrequently, by
symptoms of inflBmmation, higfa^ in l^e abdominal cavity,
and even in the diaphragm. In many coses, this affectioBy
seems to be secondary, tint is, follows some decided disease,
within the pelvis, possibly of weeks' duration. In others, it
appears without previous complaint. About a fortnight after
delivery, sometimes so early as the six& day, or even so late
as the sixth week, the patient complains of pain in the lower
belly, increased by pressure, and occasionally has paim and
difficulty in making water. The uterine region is somewhat
swelled, the pulse is frequent, the skin hot, the thirst in-
creased, and these symptoms are often preceded by shivering*
Stiffaess and pain are now felt, in one of the groins, near iSt
passage of the round ligament, or the exit of the tendon et
the psoas nniscle, or, in some cases, about ihe origin of the
sartorius and rectus muscles. The pain is attended irbk
swelling, both of which may proceed gradually down the
limb ; but, more frequently, pain is felt, suddenly, in Ae in-
side of the calf of t£e leg, or at the knee, near vie insertion
of the sartorius muade, and is mest aeute in the course of
that muscle ; it also darts down to the heel, or along the dis-
tribntioa of Ihe nervus saphenus, on the leg. There is gene-
idly, a thiAkming and hardness of the eoato of the vena sa^
yiwirin^. and eaquisite tenderneae on pressiiig these. Some"

610

getting better^ daily shivering, with yomiting, piun in other
parts, and rapid pulse, with delirium, precede death. On
dissection, the limo is found to be infiltrated with thin fibrine,
sometimes, there are many small abscesses, between the mus-
cles, or a large abscess in the thigh. The veins, either the
femoral or saphena, are inflam^ and contain pus, which
is also met witn, perhaps, in the absorbents. Within the pel-
vis,, we sometimes find an abscess, or the glands, there, and
at the groin, are swelled, or the articulations are inflamed and
loosened, or there are marks of peritonitis, or often inflamma^
lion of the veins, particularly of the uterus, but frequently
that viscus is, itself, quite healthy. Inflammation also is, in
many cases, found to have existed in the thorax.

The production of this disease, does not seem to depend on
the circumstances of the labour, for it appears both after easy
and diflicult deliveries. Those who give suck, and those who
do not, the strong and the weak, are affected by it. But if it
be late of occurring, it is generally in those, who have suffer-
ed from mammary abscess. It has succeeded an abortion, or
suppression of urme, or cancer of the uterus, and a slight de*
gree of it, has followed abdominal pain, attendant on menstru-
ation, and been repeated for one or two periods. It is not
peculiar to the female.

We cannot always detect any apparent exciting cause, but,
when we can, it is generally cold, standing, for instance, on
a cold or damp floor. I am inclined to consider the cause, to
be an irritated, or inflamed state of the parts, within the pelvis,
which sometimes produces, merely, stiffness and swelhng at
the passage of the round ligament, sometimes, an irritation
of the nerves which pass to the leg. The same effect, is also
very apt to follow, from inflammation of the diaphragm, par-
ticularly, when it extends along its crura and downwiurds.
Puzos and Levret, consider this disease as proceeding from a
depot of milk: Dr. Hunter denied this, but gave no particu-
lar opinion, as to the nature of the complaint. Mr. Wbyte
considered it, as dependent on obstruction, and rupture, of
the lymphatics, Mr. Trye, on swelling of the glands, and in-
flammation of the absorbents, and Dr. Hull, on an inflammar
tory affection, producing, suddenly, a considerable effiision of
lymph, into the cellular substance. Others look on it, as, what
they call, diffuse subcutaneous inflammation. Dr. Davis is of
opinion, that the chief cause, is inflammation of one or more
of the large veins, within the pelvis, which obstructs the re-
turn of blood. Dr. Caspar, on the other hand, found the

611

yeins healthy, but the orifice of the uterus, and the yagina, in
an inflamed state. M. Velpeau, and Dr. Lee, consider it as
dependent on inflammation, of the veins of the limb, con-
nected with uterine phlebitis. The former refers it also to
inflanunation of the pelyic articulations. That the Teins are
more or less inflamed, seems to be established, but it does not
follow, that this is the only cause. The hypogastric yeins
haye been inflamed, without any swelling of tne Umb. Swel-
ling, from infliammation of veins, is generally redder than that,
of phlegmatia dolens, and, both in uterine phlebitis, and other
varieties of the disease, distant abscesses are ant to form. I
consider that the nerves are implicated, as mucn as the veins,
and, that whilst both may contribute, we shall find in different
cases, one or other predominate.

If any part of the skin, of the leg for instance, be nricked
with a rough substance, so as to irritate considerably tne ner-
vous fibrillA, we often find, that the whole leg swells, becomes
tense and painful* It is glossy, firm, and elastic, as if a fluid
were contained below the fascia, although none exist there.
At first, the swelling is so firm, that it receives, with difficulty,
the impression of the finger, but, presently,' it pits more readily,
and, finally, the efiused fluid is absorbed, and the limb returns,
though perhaps very slowly, to a state of health. This is a
peculiar momfication of inflammation, probably connected
with, if not dependent on, injury of a n^vous filament, and
it is extended over a great portion, of subcutaneous substance.
It rarely suppurates. This must be familiar to surgeons, and,
accoucheurs may, at once, recognise, a strong resemblance to
phlegmatia dolens, which seems to be a similar kind of inflamr
mation, dependent, however, more firequently, on irritation of
the trunk, or orieins of the nerves, than of their extremities.
It will be difficult to prove, that cases of this disease, in the
puerperal state, ever arise without prerious inflammation, or,
at least, much irritation of some part within, or about, the
abdomen ; and this, on the principle alluded to, in the chapter
on ephemeral and remitt^it fever, may cause general fever,
and remote local effects, varying according to circumstances.
The local disease produced, is undoubtedly inflammatory, but
so modified, as, more rarely, to terminate in suppuration,
than, speedily, to produce a secretion, into the cells of coagu*
lable lymph. The state of the nerves also produces, earl^, a
powerless condition of the limb, independent of the inability
to move it from pain.

612

The treatmeat natunlly divides itsdf, into tlutt of the
limby and that of the constitation.

Our first object, is to check the disease, within the pelvis.
For this purpose, leeches ought to be applied, in greater or
less numbers, to the groin, and we should immediately open
the bowels with a purgative. A small blister should then be
applied to the groin, and afterwards cloths, wet with tepid
solution of acetate of lead, or with warm wat^, to the limb.
These means may prevent the swelling, or render it milder.
If the disease have, already, taken place in the limb, leeches
should be applied to the most painful spots, and afterwards
tepid fomentations, or gentle friction, with warm oil, anodyne
balsam, or camphorated oiL The bowels should still be kept
regular, but the patient is not to be purged. Opiates are
useful, to allay irritation. When the acute symptoms are
over, we endeavour to remove the swelling, and restore the
tone of the part, by friction with camphorated spirits, and the
use of the flesh brush, and a roller ap|died round the limb.
•The liberal use of solution of cream of tartar, is also, in many
cases, of service. If the disease threaten to be lingering, small
blisters may be applied to the groin, and difierent parts of the
limb. If much weakness of the limb remain, the cold bath is
proper, or a bath of warm sea-water, if the former disagree.

Besides these means, we must also employ remedies, for
abating the fever, and constitutional affection. We never de-
rive advantage, from venesection, in this disease, when it has
been established, although we may have occasion to use it,
freely, for that, which sometimes precedes it. In the disease
itself, it not only is useless, but even detrimental, sinking the
strength, and retarding the recovery. At first, we may use
saline draughts, but these are not to be often repeated, and
must not be given, so as to procure much perspiration. In a
short time, they should be exchanged for bark, sulphuric acid,
and opiates, which tend to diminish the irritability. In the
last stage, we give a moderate quantity of wine. When the
pain sbiifts, like rheumatism, bark, and small doses of calomel
are useful. In every stage, the bowels should be kept regular.
If the uterine discbarge be foetid, it is proper to inject tepid
water, or infusion of camomile flowers, into the vagina. I
cannot agree with those, who, in the very outset of the dis-
ease, give wine liberally, as there certainly does, at that time,
exist an inflammatory tendency. The diet should be, from
the first, light, and in the progress, both light and nutritious.

613

Exposure to cold, during the first stage of recovery, may catise
a relapse.

CHAP. XIX.
0/ Paralysis.

SoMB women, after delivery, lose, for a time, the power of
the inferior extremities, although they may have had a very
easy labour. This paralysis, may exist in different degrees,
and in some cases, the muscles are painful. Sometimes, it is
attended with retention of urine. It is not accompanied with
any cephalic symptoms. In general, the disease wears off in
a few weeks. Friction, the shower-bath, tonics, and gentle
exercise on crutches, are the means of cure. The bowels are
also to be kept open.

After a severe or instrumental delivery, the woman may
complain of excessive pain, about the loins and back, attended
with lameness, or even palsy. This is sometimes a very tedi*
ous complaint, but usually it is at last removed. A roller
firmly applied, and anodyne embrocations, relieve the pain ;
at a more advanced period, sea-bathing is proper.

Hemiplegia, may attack women in the puerperal state, as
well as at other times. It proceeds from the same cause, and
requires the same treatment as usual. If death take pUce»
blood is found extravasated in the brain.

CHAP. XX.
()f Puerperal Mania and Phrenitis.

Thb diseases to be noticed in this'chapter, may be divided^
1st, Into that, which is the most distinct form, of puerperal
insanity. The* mental aberration is the prominent symptom,
and the bodily affection, is secondary, in degree. It is rarely
fatal, and though it may continue for months, yet, it almost
never becomes permanent. I have known it go off, in twenty-
four hours. Depression of spirits, or melancholy, is a mom-
fication of this.

2d, The mind, is much less affected, than' the body. There
is, at least, congestion of the vessels in the head.

614

Sd^ The chief seat of the disease, is in the spinal cord, of
its vessels.

4th9 The brain, or its coTerings, are distinctly inflamed.

5th, The state of the mind, is connected with an affection
of the uterus, particularly, inflammation of the veins.

All the last four, are dangerous, and usually fatal, if not
arrested at the commencement.

All women, in the puerperal state, are more irritable, and
more easily affected, both in body and mind, than at other
times, and some, even, become delirious. The period, at which
this mental disease appears, is various, but is seldom, if ever,
sooner than the third day, often, not for a fortnight, and, in
some cases, not for several weeks after delivery. It usually
appears rather suddenly, the patient awakening, perhaps,
terrified from a slumber ; or, it seems to be excited by some
(casual alarm. She is sometimes extremely voluble, talking
incessantiy, and generally about one object, suppo&ng, for
example, that her child is killed, or stolen; or, although
liaturally of a religious disposition, she may utter volleys of
oathS) with great rapidity. In other cases, she is less talkative
but is anxious to rise and go abroad* It is not, indeed^
possible to describe, the different varieties of incoherence, but
there is oftener a tendency to raving, than melancholy. She
always recognises surrounding objects, and either answers any
question put to her, or becomes more exasperated by it. She
can, by dint of perseverance, or by proper management, be,
for a time, interrupted in her madness, or rendered obedient.
In some instances, she reasons, for a little, pretty correctiy
on her insane idea. The eye has a troubled appearance, the
pulse, when there is much nervous irritation, or bodily exer-
tion, is frequent, but it is not, in general, permanentiy so,
though it is liable to accelerations ; the skin is frequently, at
first, hot, the tongue white ; the secretion of milk is often,
but not always, diminished; and the bowels are costive,
unless the patient have previously been affected with diarrhoea.
The face is rather pale, and the expression is that of tropin
dation, combined with imbecility. There is seldom perma->
nent headach, often, neither pain nor giddiness ; but these
symptoms are sometimes produced, pretty severely, by attempts
to go to stool, if accompanied by tenesmus, or by efforts to
void urine in strangury.

^ In the form, I have just described, the mental affection is
either almost coeval with the bodily disorder, or, perhaps,
may be the first circumstance, whicn calls the attention, to

615

the state of the patient, and there is no permanent or distinct
fever.

In this form, we open the bowels with a purgatire, and pre-
serve them, afterwards, right, by suitable Lucatires. We keep
the surface gently moist, by means of saline julap, and, pre-
sently, allay irritation, with liberal doses of camphor. Blood-
letting is generally condemned, and is hurtful, rather, than
useful. It is now admitted, that haemorrhage, not un-
frequently, is an exciting cause of this disease. Blisters,
have by some, for whose opinion I have much regard, been
considered as useless, or detrimental ; but I am confident I
have seen them do good, after they had discharged freely.
When they do good, they induce sleep. Opium, is a very
doubtful remedy ; it oftener makes the patient restless, thaa
procures sleep, but in the wane of the disease, it does, in some
cases, agree with the patient, and is productive of great
benefit. A good, although I will not say the only good, form,
is Battley's liquor opii. Dover's powder, is also a useful pre-
paration, if there be not much perspiration. Solution of
tartar emetic is used, in the early stage, in the Dublin Hospi-
tal. When there is much debility, quinine, and cordials in
small quantity are useful. It is a good sign, when these
(£minish the. frequency of the pulse. There is sometimes
considerable difficulty in keeping the patient in bed, and
making her take either food or medicine. It is, therefore, in
such instances, of great advantage, to have early recourse, to
the mufi'', which not only commands the patient, but tends
to make her exercise self-control. The strength is to be
supported, by mild nourishment, and, if necessary, even
by cordials. In the whole course of the disease, the greatest
attention must be paid to procure, and preserve, proper alvine
evacuation. This is of essential importance. ^ Often, the
patient voids both urine and feces, without telling, not from
being unable to retain them, but from inattention, or perver-
sity. The mind is not, at first, the subject of management,
but in the progress of the complaint, it may, by prudent
efforts, be aided in convalescence, by cheerful conversation,
light reading, music, and, afterwards, by daily walking and
change of scene.

Some, are peculiarly liable to this disease after delivery,*

* Gardien deniei that this ditease depends on the puerperal state, but says it is
to be attributed to moral causes, as Jealousy, fright, &c He advises a blister to
be applied to the neck ; or, if the lochia be obstructed, leeches to be applied to the
yuItiu a scruple of colocynth mixed with some blaud substance, as lard, has been

616

in consequence of the irritable state of the nervous system, at
that time. In such cases, the patient, if plethoric, ought to
be bled, during pregnancy, particularly, towards its conclu-
sion ; unremitting attention should, especially, be paid, to the
state of the alvine discharge, which I am disposed to consider
as of the utmost importance. She must be carefully watched
after parturition. Every irritation must be removed, every
source of alarm or agitation obviated, and the camphorated
julap, with laxatives, will be proper remedies, these being the
most powerful means, of diminishing the excessive irritability
of the nervous system. It is impossible to be too vigilant, of
the state of the bowels, either m a prophylactic or curative
view. The diet is also to be regulated. K the patient do
not sleep well, hyoscyamus, or a hop pillow, should be used.
It is often of service, to get the patient up, as soon as can be
done with safety, and have the mind occupied, with such
amusements and pursuits, as keep it equally exercised, without
risking irritation.

Melancholy, usually, comes on later than furious delirium*
The disease, differs nothing, in appearance and symptoms, from
melancholy madness, occurring at other times. It \b obstinate,
but generally goes off, aft;er the child is weaned, and the
strength returns. It is, therefore, proper to remove the child,
and send the patient to the country, as soon as possible. In
some instances, both kinds of madness, seem to be dependent
on a morbid irritation, such as inflammation of the mamma^
&c. Here, our attention must be directed to the cause.

In the second form,'the mind is less affected, from the first
than the body. There is fever, but the pulse is rather small.
It is easily quickened, whilst, altogether, the patient has more
nervous excitation, than appearance of inflammatory action,
and often the state resembles hysteria. It is not unusual, to
find the pulse vary, more than twenty beats in the minute,
in a very short time. The skin is hot, the tongue clean.
There is no pain in the head, nor indeed any where. The
milk is diminished, but the lochia continue. The bowels
are oftener loose than costive. The eye is either inexpressive,
or rather wild, but not suflused, the pupil dilated. There is,
particularly towards evening, or during the night, a fixed
or inattentive state of the eye, and, indeed, the whole
features are quiet, and immoveable, the eye open, and the

reeommended, to be robbed on the abdonieii three timet A-d«7, to Httle pnrpOM I
fear. Dr. Burrow siiys, thtt ope-btlf of the patients, had an hereditary tendcnej'
to inianfty.

617

body remains as still, as if in a faint. Then, this state alter*
nates with more or less motion of the extremities, or even
bending back of . the spine. In two or three hours, this
excitation, during which the pulse is accelerated, goes off,
and the patient returns to the quieter condition. She is al-
ways, unless when in that state, which approaches to catalepsy,
able to recognise those who are beside her, and to remember
whom she has seen : the delirium is of a mild kind, often very
slight, and partaking more of the nature of whim, or fanciful
apprehensions, than decided insanity. It, like the bodily dis-
ease, is subject to remissions and exacerbations.
- This form of the disease, seems to be dependent on, or con-
nected with, a state of congestion, of the vessels of the pia
mater of the brain, followed by more or less effusion, of serous
fluid, under the dura mater, and, perhaps, in the sheath of the
cord. The danger is, ceteris paribus^ to be estimated, by the
degree of fever, and its obstinacy.

From the appearances after death, it is evident, that vene-
section should be resorted to, at the first,* but it is seldom
necessary, and often injurious, to repeat it. If the patient,
have been already reduced, by uterine haemorrhage, or by
other causes, the lancet is not to be employed. Leeches,
applied to the temples, are more universally safe, and, in doubt-
ful cases, should be preferred to general bleeding. The head
should be shaved, and bathed frequently with cold water, and
a blister, ought to be applied, either to the nape of the neck,
or back of the head. The rest of the treatment, is to be con-
ducted, on the general principles, applicable to the first form.

There is a third variety of this disease, in which we find the
patient, very soon after delivery, complain of restlessness, or
rather inability to sleep. The head is slightly pained, there
is a feeling of unusual muscular weakness, the pulse very little
quicker than it ought to be. Then, rather rapidly, the symp-

* M. Eiquirol Mys, puerperal manin is generally attended by suppresaion of
the lochia and milk. He thinks Tenesection should be employed, only with
ffreat caution, and that leeches applied to the thigh, and pudenda are more useful,
ainapisms he also usca, laid on the nape of the neck, or legs and thighs. Blistera
he has not found serviceable at first, but thinks they are so in the sequel. Clystera
are to be given.

M. Georget proposes clvsters of milk and water, the use of the tepid bath, and
in congestion, local bleeding, adding that venesection has been much abused.
Dr. Gooch^ in the 6th vol. of Med. Trans, of Coll., says that venesection is sel-
dom safe, but if the pulse be full and strong, and not brought right, by purginf,
and applying cold to the head, blood may be taken from the scalp, or neck, by
cupping or leeches. AVhen the pulse is only frequent, without evidence or deter-
mination to the head, be forhids even topical bleeding. The best aoporlAo, be
says, is the tepid bath, with camphor and extract of hyoecyamos, each in th«
dose of t«n grains.

618

toma become more marked, the pulse becomes very frequent,
the skin hot, the face flushed, the hearing acute, the eyes suf-
fused, and sensible to light, the eyelids heary. There is a sense
of tightness in the throat, or suffocation ; the feeling of mus-
cular weakness, is converted into a degree of paralytic debility ;
the head is acknowledged to be pained, but sometimes only a
Tery indistinct, and varying account, can be got of the eenaa^
tion. There is thirst, the bowels are costive, and the secre-
tion of milk goes on. There is often no apparent mental
dwangement, only, the patient is generally dull or still, though
sometimes irritable, but in some cases, decided insanity takes
place. If the disease be not attacked vigorously, the paraly-
tic symptoms increase ; the pulse becomes very slow, and, in
many instances, even death might follow. I look on this dis-
ease, as dependent, on that particular state of excitement, in
some part of the spinal cord, which I have described, in dif*
ferent parts of this work. By instant venesection, to a con-
siderable extent, all the febrile symptoms subside, the skin
becomes cooler, the flushing goes on, the pulse falls from
perhaps 130, to 80 or lower, and the patient says that she can
now open her eyes freely, and feels relieved from weight in
her head, which she remembers to have had, although, before
bleeding, she perhaps would not admit its existence. In a
few cases, by free purging, and blistering the head, she is
restored at once to health. But more frequently, the recovery
is partial. She complains still of muscular weakness, some*
times of her head, and often of extreme acuteness of hearing,
or sensibility to light, and the mind is affected, in so far, that
she doubts the identity of her child, or becomes suspicious of
her friends, or impressed with the idea of approactiing evil,
or indifferent about every thing. The appetite b generally
keen. This state, by attention to the bowels, regulation of
the mind, change of scene, or inducement to moderate, but
renewed exertion, goes off, although sometimes not for many
months.

Fourth, Inflammation of the brain is a rare occurrence, for
the spinal affection, which I have just described, is often mis-
taken for it. It may be caused, by determination of blood to
the head or preternatural irritabiuty of the sensorium, or, it
may occur, in consequence of a constitutional tendency to
mania. It generally appears, within the third day, after par-
turition, but it may also take place later. The pidse usually
continues frequent, from the time of delivery. The patient
does not sleep soundly, and indeed is watchful. In many

6id

cases, she early complaiiis of pain, or throbbinff within thd
head, or in the throat, or ears; then, of connision, hears
acutely, dislikes the light, and speaks in a hurried manner^
and often is unusually interested about some trifle. There is
at first little delirium, but only a kind of confusion of thought,
and when delirium is decided, it differs from that, in the first
species, in not being connected chiefly with one object, but
varying much. She is also often able to describe her feelings,
and, in some instances, there is little pain in the head* The
bodily sensations, here, are the first symptoms, whereas in ma*
nia, the mind is more apt to be affected before, or, at least, as
early as, the corporeal feelings are noticed. It is more difficult
to distinguish phrenitis, from the sympathetic effects, produced
on the brain, by inflammation, or high excitement of the spi-
nal cord, or its coverings. But this is the less to be regretted,
as, at first, the practice, in both, is the same, namely, early
and free venesection. Afterwards, the state of particular
nerves, or the sensibility of one, or more, portions of the
spine, to pressure, may assist the diagnosis, and direct where
to apply blisters or issues. If the disease be not speedily ar-
rested, we find, that soon, all at once, furious delirium comes
on ; she talks rapidly, and vociferously, the eyes move rapidly,
are wild, and sparkling, and very sensible to the light. This
state may continue, with little interruption, till symptoms of
compression appear, or there may be a short interval of rea^
son, but, presently, the furor returns, and alternates perhaps
with sullenness. The case is, in these respects, modified
according to the inflammation ; for, sometimes it comes ^on
rapidly, and to a great extent, at other times, it proceeds
more slowly. The lochia are not suppressed, nor are .the
bowels bound, but the secretion of milk ceases. In three or
four days, she becomes paralytic in one side, and then sinks
into a low, comatose state ; the extremities become cold, the
breathing laborious, and sometimes convulsions precede death*
This disease, requires the prompt, and early use of the anti-
phlogistic treatment, general and local blood-letting, the use
of purgatives, and the application of a blister to the scalp.
The inflammatory symptoms being subdued, the delirium
abates, or goes off, by the use of remedies formerly pointed
out.

Fifth, In some instances, the delirium is connected with the
state of the uterus, particularly of its veins, which are in-
flamed. There is fever, accompanied with delirium, which is
the prominent symptom, so, that the primary cause is over-

622

the axilla. There, between the two layers, 84 well as deeper,
we find lymphatic glands. From the skin or corium, there
descend numerous septa, of dense cellular substance, to be
lost in, or identified with, the fascia covering the gland.
These, form cells or chambers, of various sixes, filled with fat.
Some of these, are quite shut up, and may be as large as a
walnut, others, open into the neighbouring cells or compart-
ments. These anatomical facts are of importance, in explain-
ing the propogation of disease from the breast.

The gland, itself, varies at different ages, and under dif-
ferent circumstances. If we examine a breast after delivery,
we find it to be a circular cake, sometimes, more than an inch
thick at the centre, but becoming thinner as we approach the
circumference. On cutting it, we distinctly observe the sec-
tion, to exhibit an appearance, of grains, imbedded, in sub-
stance very dense, though of a pulpy look, having interspersed,
numerous canals or small tubes, many of them cut across.
Here and there, in the substance of the ^land, we sometimes,
but not uniformly, find small packets of fat, which have no
communication with those above, between the fascia and the
akin. They, when present, are oftenest met with, toward the
circumference.

If we inject the gland, from the nipple, we find that the
grains, or acini, are filled, and from each little grain, arises a
small tube, which joins with others, coming from neighbour-
ing acini, and these, at last, unite in forming one large duct,
opening on the nipple, and often dilating, before it rise in the
nipple, so as to form, what has been called a sinus. Each
large duct, when injected, can only fiU, with wax, a certain
number of acini, all the way from the nipple to the circum-
ference. The number of large ducts is variable, twelve, fif-
teen, &c., and if we fill these, with injections of different
colours, we find the gland, to be a party-coloured cake.
But without this, we cannot discover any boundary or dis-
tinction, between the portions, which give rise, to the larger
lactiferous ducts, and which have been called lobes. If, on
the other hand, we trace the duct from the nipple, we find it
subdividing^ into very numerous canals, each ending in an
acinus, and the various acini, are connected by dense, smooth-
looking substance.

K we do not inject the ducts, then, the gland, when cut,
resembles an agglomerated package, like millet seeds, some-
times of a redmsh, often of a whittish colour, connected by

6S3

dense substance. The acini resemble, rather, little curls, or
dilated portions of tbe duct, than grains.

If the female be not giving suck, or pregnant, we find the
gland, to have an homogeneous appearance, not granulated,
but smooth, apparently, made up, of white firm substance, in
which, when cut, we see small ducts, beat observed, when
they are divided. In every state, arteries, veins, and lym*
phatics, are seen, with small branches of nerves, especiiuly)
in the cellular substance.

In old women, the appearance is variable. Sometimes, tbe
ffland is homogeneous, flat, and thin, with small portions of
mi interspersed, and pervious ducts visible. In other breasts,
the gland is still more absorbed, and only a very thin portion,
may be left, between the two layers of fascia, or, it may be so
much more effaced, as to make the whole, including the
fasciae, resemUe a sheet of fascia, in which, we find striae
running, like radii, from the nipple, or, sometimes, lines more
reticulated. They are the ducts.

In a child of ten years of we, the gland has tbe same
homogeneous appearance, as in tne adult, but it is very thin,
not much larger than a sixpence, and adheres to the firm
pectoral fascia.

Inflammation of the mamma, may be divided into three
species, according to its seat — the subcutaneous cellular sub-
stance, the fascia, and the ghoxdular substance. It may take
place, at any period of nursing, but is most readily excited*
within a month after delivery. It may be caused, by the
direct application of cold, engorgement from milk, the irri-
tation of excoriated nipples, mental agitation, &c. Some^
have the breasts prodigiously distended, when the milk firs^
comes, and the hardness extends, even to the axillae. If, in
these cases, the nipple be flat, or the milk do not run freely, the
fascia, particularly, m some habits, rapidly inflames. Others,
are more prone, to have the dense substance, in which the
acini and ducts are embedded, or the acini themselves, in*
flamed.

The subcutaneous inflammation, if circamscribed, differs in
nothing, from a common phlegmon, and requires the same
treatment. It is not easv to resolve it, but a tepid poultice
will do thiq, if it can be done; if not, it brings it rorward*
When it bursts, the poultice should be exehaoged^ in a day
or two, for mild dressings.

The inflammation of the fascia, if slight, is marked by some
little tension of tbe breast, with erythema of the skin, over the

624

affected portion. There is considerable fever, but not much
pain, and the disease is likely to yield, to tepid fomentations,
and a purgative, if the milk can be drawn off freely. If the
fascia be more extensively, or severely, inflamed, the breast
swells quickly, and this distention, adds to the disease, which,
indeed, is often caused, at first, by distention of the fascia.
The pain is great, and the fever considerable. The inflam-
mation never is confined to the fascia, but is communicated,
either, to the subcutaneous cellular substance above it, or to
the parts below it, usually to the former, and often, at the
same time, to the latter.

When the deeper parts are affected, the inflammation may
be more or less prominent, in the lactiferous ducts, or a cluster
of acini, or, often, in that dense peculiar kind of substance,
which is their medium of union, or, in those fatty packets,
which are sometimes met with in the gland. Often, it seems
to commence, in one of the sinuses near the nipple, and
spreading, involves the surrounding cellular substance. In
this case, it soon becomes prominent, and seems as if quite
superficial. Milk is not secreted, by those acini, which have
suffered. Matter presently forms, and spreads under the
fascia with much destruction ; and when, at last, after long
suffering, the abscess gives way, much pus is discharged, with
pieces of slough, chiefly, consisting of portions of fascia.
Usually, there is a considerable degree of fever, attending the
complaint, and the pain is often severe, especially, when the
breast is extensively affected.

It is a very difficult thing, to prevent this inflammation, from
ending in suppuration. It is to be attempted, however, by
purgatives, and the application of a tepid poultice, of bread
and milk, or cloths moistened with tepid water. Cold solu-
tion of acetate of lead, alone, or preceded by leeches, has been
recommended, but I have long been obliged to abandon this
practice, from the little success which attended it. If it be
ever useful, it is only in slight cases, where it is adopted early,
and the disease is, chiefly, in the cellular substance, near the
surface. If there be only a little diffused fulness, with some
degree of pain, gentle friction with warm oil is useful. If
the breast be distended with milk, it will be proper to have a
little taken away, occasionally, provided this can be done
easily, and without increasing the pain. Our object in doing
so, is to diminish the tension, and prevent farther irritation,
from accumulation in the vessels. The breast is also to be
carefully supported, and, indeed, the patient will be easiest in

625

bed. The internal exhibition of tartar emetic has been recom-
mended; but I cannot, from experience, speak of its utility.

When the pain becomes throbbing, a warm bread and
milk poultice, is proper, to assist the suppurating process.
After the induration has abated, and matter is formed, it ought
to be freely let out, by an opening of sufficient size, provided,
there be no appearance, of the abscess bursting soon, of its own
accord. This, is never the case, where the fascia is strong, and
if we delay long, we not only protract the suffering of the
patient, but add greatly to the destruction of the breast. If
the puncture be followed, by a troublesome oozing of blood,
from the wound, dry lint and compression must be used. In
one instance, I knew the haemorrhage prove fatal. After the
abscess bursts, or is opened, there is, for some time, a dis-
charge of purulent matter, which frequently is mixed with
milk ;* then, the surrounding hardness gradually abates. The
poultice may be continued for several days, as it promotes the
absorption of the indurated substance ; but if it fret the surface,
and encourage a kind of phagedenic erosion, it is to be ex-
changed, for mild dressings. A little fine lint, is to be applied
on the aperture, but not so firmly as to confine the matter,
and over this, a cloth spread with spermaceti ointment : great
attention is to be paid to the evacuation of the matter, and
the prevention of sinuses. Fungus, at the orifice of the sin-
uses, requires escharotics.

In some instances, the milk soon returns, and the patient
can nurse, with the breast which was affected, but more fre-
quently it does not, and the child is brought up, on one breast.
It may even be requisite, if the fever and pain be great, and
the secretion of milk much injured, to give up nursing alto-
gether.

It sometimes happens, if the constitution be scrofulous,
the mind much harassed, or the treatment not at first vigilant,
that a very protracted, and even fatal disease, may result.
The patient has repeated, and almost daily shivering fits,
followed by', heat and perspiration, and accompanied with
induration, or sinuses, in the breast. She loses her appetite,
or is constantly sick. Suppuration slowly forms, and per-
haps the abscess bursts, after which, the symptoms abate, but
are soon renewed, and resist all internal and general remedies.
On inspecting the breast, at some point distant from the
original opening, a degree of oedema may be discovered, a

^ * A durt hnn been dUtentlrd, and the milk'nrcumulatcd, so as to form a con-
«idvrabU* collectioiii nithiii the brcnst, Jike an abscess.

G2^

'Bever-failing sign, of the existence of decp^catedmcatter there,
and, by pressure, fluctuation may be ascertained. This may
become distinct, very rapidly, and therefore the breast should
be examined, carefully, at least once a-day. Poultices brin^^
forward the abscess, but too slowly to save the strength, and,
therefore, the new abscess, and every sinus, which may have
already formed, or existed, must be, at one and the same time,
freely and completely laid open ; and, so soon, as a new part
suppurates, the same operation is to be performed. If this
he neglected, numerous sinuses form, slowly discharging fcetid
matter, and both breasts are often thus affected. There are
■daily shiverings, sick fits, and vomiting of bile, or absolute
loathing at food, diarrhoea, and either perspiration, or a dry,
scaly, or leprous state of the skin, and, sometimes, the inter-
nal glands, seem to participate in the disease, as those of the
mesentery, or the uterus is affected, and matter is discharged
from the vagina. The pulse is frequent, and becomes gra-
•dually feebler, till, after a protracted suffering of some
months, the patient sinks. It is observable, that often in those
cases, which seem to depend on a constitutional cause, and
•when there is great debility, the sinuses heal rapidly, after
being laid open, but a new part, instantly, begins to sup-
purate. Internal remedies cannot be depended on here, for
they cannot be retained. If they can be taken, they ari»
those of a tonic nature that we would employ, with opiates to
abate diarrhoea, and procure sleep.

The diet must be as nourishing as possible, and a Iiber<:1
■allowance of that kind of wine, whicn agrees best with tl.*
stomach, must be given. Our prognosis, indeed, will b ^
more or less favourable, according to the nourishment whicli
can be taken. The main security, however, of the patient,
rests on an early stop being, if possible, put to the disea.-i. ,
by opening the abscesses or sinuses freely, and before the con-
stitution have been injured, or undermined, by repeated paro::-
ysms of fever. If, however, the sinuses be deep or numerouF,
it will, in the first instance, be proper to try the effect ui'
enlarging the most dependent aperture. It ought to be im-
pressed on the mind of every practitioner, and every patieiU,
that unremitting attention should be paid, early, to the state
of the breast, and no deep-seated collection of matter, ever
be allowed to remain unopened ; for we do not know where*
the mischief, if permitted to continue, may end. This jb
urgently necessary, in proportion to the severity of the con-
stitutional symptoms.

627

•There are indolent cases, where sinuses form, and give little
or no trouble, except by the dressing or attention they require.
Timid patients will not submit to have these opened ; but the
cure is Jiastened, if that be agreed to. In the former state, it
was, from the affection of the general health, and the state of
the patient, imperative. In this indolent state, where the
patient is in pretty good health, and walking about, it is
proper, but nevertheless, more optional. Superficial sinuses
should be laid open. Those which are very deep, should
eithei* have a counter opening made, or a seton introduced,
but this is seldom necessary. Induration, with sinuses, yields
to laying the sinuses open, and then employing gentle friction.
This even holds true, often, with regard to simple induration,
occurring after an operation for cancer. In the case under
consideration, I have never known bad effects, but quite Uic
contrary, follow from free incisions, even into the substance
of the breast.

Sometimes, although the abscess heal readily, and have
been small, an induration remains, which either may continue
long indolent, and cause apprehension respecting the- con-
sequences, or it may occasion a relapse. It is to be removed,
by gentle friction, with camphorated spirits, three times a day,
and the application, in the intervals, of cloths wet with cam-
phorated spirits of wine, with the addition of a tenth part of
acetum lytbargyri, or a bread and milk, or cicuta, poultice,
may be applied. In more obstinate cases, mercurial friction,
or a gentle course of mercury, may be tried, but I cannot
speak with any confidence of the effect. The bowels should
always be kept open.

After an abscess heals, it is not uncommon, for the breast
to swell a little, at night, from weakness, and the same cause
renders a relapse easy. It is therefore proper, to invigorate
the 'system, and defend the breast, for some weeks, more care-
fully than usual, from cold. When a relapse takes place,
especially if the patient be not nursing, the tumour is some-
times pretty deep or indolent, is for a long time hard to the
feel, and graduallv extends more through the breast, forming
a pretty large substance, not unlike a scirrhous or scrofulous
gland. But, during this time, suppuration is slowly going on,
though there may be little pain. At last, a more active change
takes place, the pain increases, becomes throbbing, the skhi
grows red, and, finally, the abscess bursts. This state, requires
the application of warm poultices, and hot fomentations.

Excoriation of the nipple, is a very frequent affection, and

628

T)ften excites that disease, we have just been considering. The
sore may be extensive, but superficial, or, it may be more
circumscribed, but so deep as almost to divide the nipple.
When the child sucks, the pain is severe, and sometimes a
considerable quantity of blood flows from the part. In some
instances, an aphthous state of the child's mouth excites this
affection, in others, excoriation of the nipple affects the child.
A variety of remedies have been employed. Spirituous, saline,
and astringent lotions, have been used, previous to delivery,
with a view of rendering the* parts more insensible : they
have not always that effect, but they ought to be tried.
When excoriation takes place, six grains of sulphate of zinc,
dissolved in four ounces of rose water, form a very useful
wash, which should be applied frequently. Solutions of sul-
phate of alumine, acetate of lead, sulphate of copper, nitrate
of silver, &c., in such strength, as just to smart a little, arc
also occasionally of service; and it is observable, that no
application continues long to do good. Frequent changes,
therefore, are necessary. The nipple should always be bathed,
with milk and water, or solution of borax, before applying
the child. When chops take place, dressing the part with
lint, spread with spermaceti ointment, is sometimes of use.
A combination of white wax, with fresh bntter or melted
marrow, with, or without vegetable additions, orms popular
applications. Stimulating ointments, such as ung. hyd. nit.
diluted with axunge, are sometimes of service ; or the parts
may be touched with burned alum, or nitrate of silver, or
dusted with some mild, dry, powder.

It is often useful, to apply a tin case over the nipple, to
defend it, or broad rings of lead or ivory. It is also proper, to
make the child suck through a cow's teat, or an artificial nip-
ple, that the irritation of its tongue or mouth may be avoided.
This often is of great service, although, it do not always suc-
ceed ; and some children cannot suck through it, but this
sometimes happens, from it not being so applied, as to pre-
vent the child drawing in air. The artificial nipple, is pre-
ferable to the cow's teat. The assistance of a nurse, to
suckle the child, through the night, is useful. But although
the nipples ought to be saved as much as possible, yet, if we
keep the child too long off, or permit the breast to become
much distended, inflammation is apt to take place. When
all these means fail, it is necessary to take off the child, as a
perseverance in nursing, exhausts the strength, and may ex-
cite fever. The part then heals rapidly.

C29

Venereal ulcerations of the nipple or areola, accompanied
with swelled glands in the axilla, and a diseased state of the
child's mouth, require a course of mercury.

It may be proper, before concluding this chapter, to add
some remarks, on causes, disqualifying a woman from nursing.
If the nipple be very flat, and cannot, by suction, be drawn out,
so that the child can get hold of it, the woman cannot nurse.
A glass pipe, however, frequently used, sometimes remedies
this defect, or the artificial nipple can be used. A deficiency
of retentive power, so that the milk runs constantly out, is
another disqualification, and it is not easy to find a remedy.
When the milk disagrees with the child, having some bad
quality, we are also under the necessity of employing another
nurse. If the mother be very delicate, or be consumptive,
or affected with obstinate melancholy, or have her eyes much
inflamed, or the sight injured by nursing, or if the secretion
be very sparing, she must give up nursing. Some delicate
women, suffer so much from nursing, that chlorotic or phthi-
sical symptoms are induced. In this case, we must take off
the child. Opiates are useful, at bedtime, to procure sleep,
and the bowels are to be kept open. Many women, after
delivery, are subject to disorders of the alimentary canal,
especially diarrhoea, and worms. These impair the health,
and diminish the secretion of milk. They are to be treated
with the usual remedies. Anasarca, jaundice, erysipelas, &C.,.
may also occur in the puerperal state, and prevent nursing.
The ordinary methods of cure are to be employed.

When a woman weans a child, or, from the first, does not
suckle it, it is usual to give one or two doses, of some purga-
tive salt, by way of lessening the secretion of milk. The
secretion is also checked, by keeping off the child ; but if the
breast be very much distended, so much must be taken away,
occasionally, by suction, or milking the breast, or applying a
warm glass bell, as relieves the feeling of tension or pain. If
this be neglected, inflammation may be excited.

Some women feel, after lying in, a considerable weakness,
or sensation of want about the belly, which is frequently
increased by nursing. It is often produced, by taking off the
bandage, too soon, from the abdomen, which should not be
done for a month at least, and is relieved, by the application
of a broad firm band, round the belly. When there is con-
stant aching in the back, and failure of the appetite, nursing
must be abandoned.

Pain in the side, or in the abdomen, which is sometimei?

630

produced by narsing, is often relieved by friction, wanfr plaa-
ters, and an inyigorating plan. General weakness requires
tonics, which must be yaried.

CHAP. XXIV.
Of Tympaniiee.

Ik consequence of affection of the menstrual actbn, or aAsp
confinement, especially, if the patient be exposed to oMd, the
bowels become inflated, and the belly is slowly distended^
without pain. This may also happen during nursing, or
towards the cessation of the menses, giving rise, in either
case, to an idea that the woman is pregnant. This compfaunt
is not productive of bad health, but, occasionally, is accom-
panied oy acidity and dyspeptic symptoms, and it is moreover
very unseemly. The enlargement is always increased, about
the menstrual period, if menstruation continue. It arises from
a relaxation, of the muscular fibres of the intestines, and may,
not only, appear as a peculiar disease itself, but, also, accom-
pany many puerperal affections, particularly of the febrile
kind, although, there be no well marked inflammation of the
bowels. Nevertheless, it is, in many cases, connected with
some degree of inflammation, which also lays the foundation-
of future ovarian disease.

It is best prevented, by keeping the bowels in a regular and
active state, paying attention to the application of an abdomi-
nal binder, cofter confinement, and avoiding exposure to cold,
and other exciting causes of disease^

After it has taken place, it is exceedingly difficult to accom-
plish a cure. Brisk purgatives, the regular use of aperients,
so as to excite a uniform but not powerful action, carminatives,
squills, turpentine, mercury, Harrowgate water, stimulatin<r
embrocations, regular compression, tonics, and sea bathing,
have all been tried, but upon none of them, can I place any
great reliance. This disease is very apt to be succeeded by
ovarian dropsy, or, rather, to be attendant on the early stage
of that disease.

Acute tympanites, accompanied with fever, is a more for-
midable disease, and has been already noticed, when treatin
of inflammatory affection.

631

CHAP. XXV.
0/the signs that a Woman has been recently deHveretL

Ws discover that a woman haA been recently deHrered^ by
finding that the external parts are relaxed, and redder, or of
a darker colour than uaual. There is a sanguineous or lochlal
discharge. The uterus is enlarged, and has neither the shape
of the gravid nor unimpregnated uterus; the cervix is indi&*
tinct, and the os uteri is nearly circular, and will admit two
or more jSngers. The abdomen is prominent, and the intego^
nients relaxed, wrinkled, and covered with light-coloured
broken streaks. The breasts are enlarged, have the areola
very distinct, and contain milk. It is possible for this secre*
tion to take place, independently of pregnancy, but not with
the appearances just described. ^

By examination per vaginam, within a fortnight or three
weeks after delivery, the uterus may still be felt larger than
usual, its lips- softer, and capable of admitting the point of the
finger without much difficulty. The milk, at this period, will
not have left the breasts, which are firm, and have a dark
areola round the nipple. A question here occurs. May not
all these appearances take place, merely, from hydatids ? I
reply, that although hydatids may produce, to a certain degree^
the same effects with gestation, because they generally spring
from conception, yet, it is very rare, for the belly to be en-
larged, so much, as in the end of pregnancy, and wben the
mass is expelled, as it is soft, the perinaeum cannot be injured.
If then it can, in a criminal case, be proved, that the womaft
had the belly greatly enlarged, and if afterwards, she be found
with the breasts containing milk, the uterus large, and its
mouth soft and open, and part of the perinaeum or the four-
chette torn, there can be no doubt that slie has bom a cliild.
Other circumstances nmy also concur, in confirming the opinion
oi the practitioner; as, for instance, if the patient give an
."bsurd account, of the way in which her bulk suddenly left
]i:;r, ascribing to it a perspiration, which never in a single
night can carry off the great size of the abdomen, in the end
of a supposed pregnancy.

Very contradictory accounts, have been given by anatomists,
of the appearance and size of the uterus, wlien inspected at
different periods, after delivery. If the woman die of haamop-
rhage, or from any cause, destroying her, soon aft^jr delivery.

632

the uterus is found like a large flattened pouch, from nine, to
twelve inches long, about seven broad, and three thick. The
cavity contains coagula, or a bloody fluid, and its surface is
covered, with remains of the decidua. Often, the marks of
the attachment of the placenta, are very visible. This part is
of a dark colour, so that the uterus is thought, by those who
are not aware of the circumstance, to be gangrenous. The
surface being cleaned, by scraping it, the paler substance of
the womb is seen. Every where, it is lined with a tenacious,
dark-coloured coat, formed by the remains of the deciduous
vessels, mixed with coagulated blood. This, at first, aids in
checking haBmorrhage. If water be injected into the veins,
it runs out, freely, by large orifices, on this surface. The
vessels are both large and numerous. The Fallopian tubes,
round ligaments, and surface of the ovaria, are so vascular,
that they have a purple colour. The spot where the ovum
escaped, is more vascular, than the rest of the ovarian surface.
This state of the uterine appendages, continues, until the
womb have returned, to its unimpregnated state.

Three days after delivery the fundus uteri is nearly a hands-
breadth above the pubis. The parietes are about an inch
thick, their substance whitish, and internal surface covered
with adherent clot. The uterus is fully seven inches long,
about five broad, and two thick. Its mouth, or opening, is
above one long.

A week after delivery, the womb is about six inches long,
and sunk into the pelvis, so, that its fundus, is scarcely higher
than the brim. In a day or two more, it has lost an inch.
The inner surface, is covered with a thick coat, of black
bloody substance, which may be scraped ofl^, when we find a
thin layer of lymph in immediate contact with the uterus.
The muscularity is distinct, and the orbicular direction, of the
fibres round the orifice of the tubes, very evident. The
peritoneal surface is pale pink, the substance whitish and fib-
rous, and the thickness variable, being sometimes not more,
than, in the unimpregnated state; in other cases, nearly
double. The cervix is generally darker than the body,
and its rugse are distinct. The intestines have generally,
though not always, assumed the same order as usual, for, tne
distended colon is sometimes more prominent than the rest.

At the end of a fortnight, the uterus is hid in the pelvis, is
from four, to five, inches long, and about three and a quarter
broad. The peritoneal coat is pale.

It is three weeks, at least, before the uterus be felt, per

633

taginaiD, to resemble its unimpregnated size, but the os uteri
rarely, if ever, closes to the same degree, as in the virgin
state. It is later before it have, in all respects, returned to
the former state ; seldom in less than two months. At six
weeks the length is about three inches, the cavity longer than
natural, and the inner surface has partly a fibrinous, partly a
bloody appearance. The Fallopian tube preserves its greater
vascularity, for a very considerable time, I cannot say how
long, after delivery ; and passions of the mind, or other
causes, may produce a rupture of the tube, and fatal haemor-
rhage, although no new impregnation have taken place. Such
rupture during lactation, is not always referrible to an extras
uterine conception.

A corpus luteum is invariably found in one of the ovaria,
and can at once be detected by its prominence, colour, vascu-
larity, and slight scar. It is, however, best seen, by making
a section, when it appears very distinct from the rest of the
ovarium, and cannot be mistaken for any thing else. It is less
than at an earlier period of gestation, but still it is about half
an inch long, but not so broad, nor so deep in the substance
of the ovarium. Its appearance is described, p. 191. ; After
delivery it diminishes more rapidly, and at last disappears,
but the scar remains longer. Dr. Montgomery says he never
found the corpus existing beyond five months after delivery,
and maintains that the cicatrix also disappears.

We know that a woman has had a recent miscarriage, by
the state of the breasts, the sanguineous disqjiarge from the
vagina, the size of the uterus, and the softness and dilatation
of its mouth. If she die, the womb is found enlarged, its
inner surface covered, either, with the decidua and coagulated
blood, or the maternal portion of the placenta. The vessels
are enlarged, the tubes and ligaments very vascular; the
ovarium contains a distinct and large corpus luteum. The
peritoneal coat over that is very vascular, or blood is effused
there, or even into the calyx.

The appearances during life, or after death, which occur
from a miscarriage, may also arise from the expulsion of
hydatids, which, usually, are produced by the destruction of
an ovum.

BOOK IV.

OF THE MANAGEMENT AND/DISEASED OT

CHILDREN.

CHAP. I;

0/4he ManagemeMt of ChUdren.

SECTION FIRST.

Whbn a child is born, tbe first thing to be done, is to
tain if it breathe, or be alive« If it cry, or breathe Tigoronelj,
then, it may be safely separated from the mother.* This is
done, by tying the navel-string about half aa inch from the
navel ; another ligature is applied two inches nearer the pla^
centa, and the cord is divided between these, with a pair of
scissars. In some countries, the division is made with a sharp
flint ; in others, by means of fire. The necessity of applying
a ligature, has been denied by different speculators ; but it
has sometimes been found, that when the ligature had become
slack, a considerable quantity of blood was lost, .and even fatal
haemorrhage has taken place.

When a child does not breathe, soon after it is bom, it is
not always easy to say whether it be alive, for we have, at this
time, no criterion of death, except putrefaction ; and, there^
fore, it behoves us always, unless this mark be present, to use
means for preserving the child, by which some have been
saved, after being laid past as dead. Children may be bom,
apparently dead, in consequence of the head having remained

* Dr. Denman, from observing that some children, after thev had began to
breathe, had respiration checked, and died after the cord was tied, adrises, that
the ligature should never be applied till the pulttation cease. But when the child
is vigorous and cries lustily, there is no occasion for delaying so long ; nor ba%*e
I ever known any bad effect result from this practice. It has been supposed,
that as long as pulsation continued, the function of respiration was imperfect ;
but it is not so : the pulsation depends more on the continuance of the vitality
or action of the placenta, than on the state of the lungs.

635

iMg in the pelvia, or having been sqoeesed^ in a defianDeil
pelvis ; or owing to the- cord having been •oompveaiedy etti»r^
during the process of toming and deiiveringa cbiid, or, from',
its having descended before the presenting part of the child,
or, being so situated daring labour, as to.l:M» compressed by-
the uterus, especially during tedious labour. Seme childrcuv
diC) owing to the head being bom^ oe^iered with the meni»-
branes, some time b^bre the body. This is the consequence^
of inattention, for, if the membranes be removed from the face,
there is no risk of the child* In whatever mode children aret
stHlbom, the eSect is referrible, either, to compression oq th^
cord, first suspending and then destroying animation, or, tm
pressure on the brain, or, to a state of insensibility andfeeble»>
nes^ preventing the action of respiration-, from taking place
after birth.

Pulsation may continue, for some time, without apparent
respiration, and when it stops, may, for a time, be renewed by
inflating the lungs. The child all the time may be in a state
of mere vegetation, never exhibiting any movement, or mark
of vitality, beyond that of pulsation, and soon dies. Children*
bom rapidly, are bom sometimes in this state, and, in this
case, are seldom- made to breathe.

In determining on our treatment^ of stillborn children, our
first object ought to bo, to ascertain if the circulation, be stilt
going on in the cord.

If the pulsation have stopped, no good can accrue, from
allowing the child, to remain connected to the mother. The
cord is directly to be divided, and means used, as shall imme«
diately be mentioned, for the production of respiration.

If pulsation continue regular and steadily, the child is not
in danger from want of respiration, for the festal mode of
living is continuing. The canse of stillness, then, is most
likely, a kind of syncope, or torpor^ which prevents the action
of respiration, from being established ; or it may be from com*
pressed brain. In both cases, the skin is purple, from the
blood not having been arterialized, and we have no mark of
distinction till respiration begin. It is very common, in the
first case, for the child to be still for a minute or more ; then
it makes a slight seb, and breathes low, with a sound of fluid,
{liquor aranii?) in the trachea; and then, of a sudden, re*
spiration becomes perfect. In the second case, respiration^
after it begins, continues long oppressed, and may perhaps
stop, the child dying in a short time.

When the cord pnlsates, at the time of birdt, we are newr

636

to be rash in' dividing it. . It is of importance' to keep up the
foetal circulation, till tbe new mode of acting, can be estab-
lished, and we ought not completely to divide the cord, in such
cases, till pulsation stop ; because, if respiration should flag,
we have the placenta as an auxiliary, if the connexion still
exist, and, the pulmonary action being suspended, the foetal
mode will continue, and support life, till respiration become
vigorous ; for the two modes, of changing the blood, are not
incompatible. Pulsation will, no doubt, at length stop, either
from the heart of the child stopping, or the placenta being
detached from the uterus, and its function being lost ; but as
long as pulsation continues, and the child does not breathe
perfectly and regularly, no ligature should be applied. If,
however, respiration do not begin, we are to open, with a
lancet or scissars, one of the umbilical arteries, from which
blood spouts in a small stream ; and, in a short time thereafter,
breathing commences. If it should not, some method must
be adopted for exciting animation, such as wrapping the child
in warm flannel, whilst it is still in bed ; friction, especially
over the thorax, with the hand, or strong spirits ; applying
spirits to the nostrils with a feather ; or giving a gentle con-
cussion to the body, as for instance, by slapping the back.

But the most effectual remedy, is inflating the lungs, by ap-
plying the mouth, directly, to the child's mouth, at the same
time that the nostrils are held, and the cartilages of the
larynx, pressed gently back, to obstruct the oesophagus. If
the head be slightly bent back, we can also readily introduce
into the glottis, from the mouth, a tube which is somewhat
curved, like the old catheters. It can be inserted, without
much difficulty, although a quarter of an inch in diameter, but
it is better to be less, and it ought to be obtuse at the point.
It may be six inches long. The distance from the gum, of
the lower jaw, to the front of the cervical vertebrae, is 1 J inch ;
the epiglottis, is not a quarter high, above the tongue, and
the rima, is a quarter below the margin, of the arytenoid
cartilage. We ought, in either case, to blow, with great gen-
tleness, at the same time, that we press up, a little, the mar-
gin of the thorax. It is, however, chiefly, by the descent of
the diaphragm, that we can get the lung expanded, but this
is only partial. Such force as could raise the rib, must, as-
suredly, rupture the bronchii or lungs. I cannot, too strongly,
enforce the necessity of gentleness. The attempt at inflation,
is to be alternated, with pressure on the thorax and abdomen,
to force the air out again. If, by this time, the pulsation

637

have stopped in the cord, and the child do not recover, the
cord is to be divided, for connexion with the placenta is use-
less, after the circulation stops. The cord is not to be tied,
but only a loose ligature put round it ; then, it is to be divi-
ded, and the child removed to the fire, or its body immersed
in warm water, and the artificial respiration sedulously con-
tinued. An injection is also to be administered. Could a
stream of electricity be employed, there is ground for think-
ing, that it might be beneficial. Should the child, by these
means, or after a longer time, begin to breathe, a little blood
will most probably issue from the cord, and the quantity will
increase. If this seem to assist the breathing, and make the
child more active, it is to be permitted to proceed, to the ex-
tent of two or three tear-spoonfuls; but if it do not, manifestly,
produce a good effect soon, it is to be stopped with a ligature,
that it may not throw the child back, into a state of inaction.
Even when it is of service, it must be kept within bounds,
otherwise dangerous debility will be the consequence.* It
will be chiefly useful, when the breathing does commence
freely, but is slow and oppressed, with stupor, indicating af-
fection of the brain. By perseverance, we sometimes find
that the heart beats, and the child breathes once or twice, but
does not continue to do so. In these cases, it is probable
that the spinal cord has been stretched or injured, or that the
brain is affected.

If the shape of the head be much altered, it has been pro-
posed, whilst other means are employing, to attempt slowly
and gently, to press it into a more natural shape, but of the
good effect of this I have great doubt. In footling cases, it
has been supposed, that extension of the spine was a cause
of death, and this may be correct, if force be employed to ex-
tract the head.

It often is desirable to know, whether a child have been
alive, and destroyed afterwards ; but the signs are not with-
out ambiguity. If the lungs be auite solid, and sink in water,
the child certainly has not breatned ; and although respira-
tion, may, from the first, be prevented by the midwife, it can-
not by the mother. There are, doubtless, instances, where
the child has breathed, and lived some hours, and yet the
lungs have sunk. But, in this case, they are not uniformly
solid. Some portion has received air, whilst the rest has the

* It is occasionally of serrice, In weaUy performed rMpiretion> to give lome
geotlo cordials or stimulants.

«38

lanie-natal appearance.* If the head be much mis-shapen,
there is additional ground for believing the child to have been
stiUbom, and if clothes have been made for the infant, it is to
be presumed, that the mother intended to have preserved it.
When, on the other hand, the child has a healthy look, when
the lungs swim in water, and the air-cells contain some air,
giving, when an incision is made, a frothy appearance, to the
mucus, squeezed out of them, there is no doubt that the child
has breathed. But we cannot from these circumstances say,
that it has been intentionally deprived of life. Some corro-
borating facts must be necessary to fix this point, such as the
birth having been concealed, and no preparation made for
preserving the infant ; the cord being untied, by which it has
been allowed to bleed to Ueath, which, I believe, must always
happen if a ligature be not applied ; or its being cut longer or
shorter than would have been done by a midwife, marks of
violence on the child, with the total want of all exculpatory
evidence. On this subject, however, I must observe, that it
is clearly established, that one or more of the bones of the
csamum, may be crushed or fraotured, during natural labour,
and also, that even the longitudinal sinus may be lacerated.

If the child have not breathed, the lungs, though soft, oon-
tain no aii\ When cut into, they have rather a solid appear-
ance, no air can be squeezed from the cut surface, which is
like soft liver or spleen, and, externally, of a liver-^rown colour,
rather darker within. The right lung, is pretty thick, anti
comes forward, to the side of the pericardium. The lefl, is
smaller and thinner, particularly at its margin, which is laid
flat on the pericardium, fully an inch and a quarter of which,
is exposed. If respiration have been established, they are
paler in colour, redder, and when cut, air can be squeezed
irom the surface, which has, also, a somewhat acinated aspect.
They cause the diaphragm to descend lower, and cover, in a
greater degree, the heart. Respiration expands the lungs
gradually, and it has been maintained, that not only one
portion of lung, becomes filled with air, before the rest, but
the right lung, expands or fills with air, before the left, and
that the right bronchus, is a fourth larger, than the left. The

* Dr. Joerg thinks that too ruid, as well u diiScalt dellrery, affecCs the ro.
«piration of the child. If not Btill-bom, the interrals b^tvreen the Inspirmtioit^
•re Kmf, the child is bine, and when he eries, the irofee is week. If death tak^
place early, perhaps only one- tenth of the lung may be found to hare receivt-il
air. If, on the other hand, the child live for some weeks, the lungs are foaii«l
hepatixed, or Inflamed, with small collections of pas. The foramen oyale is open,
and the vessels of the brain gorged. Dublin Jouro. t. S6.

639

tine required, fer the complete expansion of the air ceDs, is
various, and differs in individuals. Palletta says, it is at least
a week, before all the air cells, of both lungs, be filled. Dr.
Brent thinks we may determine the question by this, that the
foramen ovale, if the child have not breathed, is exactly at
the fossa ovalis, but it is turned to the right as soon as it has
respired.* This is rather a doubtful test. Some say that
the liver becomes less in weight, immediately after birth.

If the child, have the cord soft and spongy, and the stomach
contain, only, a little nmcus, or bloody fluid, and a great
part of the colon, contain meconiimi : if the body have lost
its firmnees, and the cuticle peel off, leaving the skin below,
purple or bladdsh, and the head be flat and flaccid, whilst
the cellular texture, is infiltrated with red serum, and the
viscera have a deep red colour, there is evidence, that the child
has died in utero. We also often find, effusion of bloody
sevuro, in the thorax, which is not met with, if the child have
been bom alive, at least, not till putrefaction have begun.
When the cord is shrivelled, and its attachment, surrounded
with a circle, bearing marks of inflammation, the child must
have been bom alive, and lived, for some time, before this
inflammation could take place. We must, however, be care-
ful, not to confound redness of the skin, exhibited after the
cuticle has peeled off, for inflammation. When the child has
fived for some time, the great gut is nearly free from meco-
nium, and if he have not been starved, there may be remains
of aliment, found in the stomach. If he have a full eye, be
stiff, and the skin of natural colour, he has died very recently.
Wo cannot depend on the conclusion, drawn from the skm
being free, from the white spermaceti coating, it usually is
covered with, at birth, for, some children have little or none
of it. The umbilical arteries, the veins, the ductus arteriosus,
and foramen ovale, are closed, in the order enumerated, and,
generally, within ten days. On examining a child, after the
cord has fallen off, and the umbilicus has healed, we find that
the umbilical arteries and veins are closed or obliterated, just
at the navel. The foramen ovale and ductus arteriosus are
still pervious. The latter seems to close by the formation of

* lie rays, that the doct immediately becomes contracted at the aorta, so that,
instead of beings cylindrical, it is conical. Then, from being uoireraaUy con-
tracted, it becomes again cylindrical, and at the end of a Treek is not larger than
a crow quill. The foramen OTsle is sometimes closed the first day, but frequently
not for several days. Its position on the vaWe is changed, at first it is in the
centre, but as soon as respiration commences, it is on the right side, and prooeeds
from below upward toward the left side, reroWing as it were round the .right
edge of the TalTe.

640

a septum, and coagulation on both sides of that. This is
pretty distinct on the fourth day.*

Physicians are much divided in opinion, as to the impor-
tance to be attached, to the circumstance, of the lungs, with
the heart connected, swimming or sinking in cold water. —
Dr. Hunter, amongst other objections, states, that the child
may, when the head alone has been born, breathe, but may
die before the body be delivered. M. Marc, on the other
hand, contends that the thorax, being compressed within' the
pelvis, cannot expand, and the air can only enter the trachea,
without inflating the lungs. In this, I think him so far wrong,
for air may, partially, enter the lungs, but I do not believe
that they can be so filled as to resemble lungs, where respira-
tion has been established. Again, it has been stated, that
although the child were bom dead, yet, artificial attempts
having been made, to inflate the lungs, they will swim, even,
if the child have never breathed. But, in reply to this, it is
urged, that, although, air may be forced into the lungs, yet,
it is more partially, than in respiration, and the blood-vessels
w^ill be found empty, or with very little blood, compared to
the rest of the sanguiferous system. The lung cannot be so
fully inflated, by artificial, as by natural respiration, for we
have not the aid of the elevation of the ribs, and descent of

' * Devergie, Tom. i. p. 520, gives the following resume of his examinations :«-

1st Day. The cord begins to shrivel, but is intimately connected to the umbUI-
cnl rinff by its membranes— foramen ovale and all the vessels open.

Sd iJay. Complete shrivelling of the cord. Foramen ovale open, except 4 times
out of 22 ; partly shut in S cases. Ductus arteriosus beginning to close. Umbi-
lical arteries obliterated to a greater or less extent. UmbUical vein and ductus
venosus free.

Sd Day. Cord dry. Foramen ovale sometimes shot Ductus arteriosus
Sometimes obliterated ; 2 in 22 cases. Umbilical arteries very often obliterated.
V>in and ductus Tenosus open.

4th Day. Cord beginning to separate. Foramen ovale open in 17 out of 82.
Ductus arteriosus partly obliterated in 7, perfectly in Q. Umbilical arteries
sometimes still pervious near the illacs. Vein and ductus venosus considerably
contracted.

5th Day. Cord generally separated. Foramen orale open in IS out of 29.
Ductus arteriosus open in one half. Umbilical arteries, vein, and ductus venosus,
obliterated. - Vein, however, sometimes open.

6th Day. Cord always separated, and cicatrization begun. Foramen open
5 times in 20. Ductus arteriosus completely obliterated in one half. The other
ressels closed.

From ninth to eleyenth day, cicatrization often complete, but frequently there
is a mucous exudation till the complete obliteration of the vessels. It continues
till the twenty-iifth day, so that the cuUiieous cicatrix does not form till later.
Kpldermis coming off the trunk, and to the fold of the articulations.

20th to 26th Day. Detachment of all the epidermis.

dOth to &5th Day. Complete throwing off of the epidermis, except of Che hands
, and feet, which does not take place till the 40th day.

« At^^^ *^^^ volume conuins a circumstantial account of the state of the f«tus at
different periods of intn-uterine life, which may be useful in questions of Juris-
1*1 uoence.

641

the diaphragm to amplify the thorax. If the diaphragm be
pushed down, by the expansion of the lung, it is very proba-
ble, that so much force has been employed, as to rupture some
of the cells in the lungs, which is easily done. Putrefaction,
it is also argued, will make the lungs swim, although the
child have never breathed. But Camper, Marc, and other
excellent observers, agree that the lungs putrefy, later, in the
stillborn child, than most other parts of the body, and main-
tain, that this process does not, even in summer, take place
within the thorax, in less than six days, and in winter, in less
than as many weeks. It is also a mistake to suppose, that a
putrid lung, must, necessarily, be emphysematous. I have
Kept the lung till putrid, and found it still to sink, and no air
disengaged in its substance. It is more likely to be extri-
cated under the pleura. On the whole, I am inclined to place
very considerable reliance on this test, and am happy to find
that my opinion is confirmed by M. Foderc, who observes,
** La supemation du coeur, avec les poumons, est une preuve,
que la respiration a et^ tres prononcee." If the lungs have
been fully inflated, by respiration, they require, when the
heart has been detached, to have a weight, equal to from two
to four ounces, affixed to them, to cause their fully sinking.

The sinking of the lungs, and heart, and thymus gland,
taken in conjunction, with the appearance of the lung, of the
stillborn child, just described, will decide that the child has
not breathed. If we inflate the lungs of such a child, they
instantly assume a beautiful vermilion colour, and when
emptied as much as possible of air, by pressure, they still are
different in colour ; but the circumstance at present to be
noticed is, that even if only the left lung, be allowed to re-
main, it will make both the heart, and thymus gland swim.

Ploucquet, from considering that the lungs, in the fcctu?,
contain much less blood, than after respiration, concludes,
that it will be possible to determine, whether the child have
respired, by comparing the weight of the lungs, with that of
the rest of the body, by means of an accurate balance. The
blood flowing into the lungs, by respiration, doubles their for-
mer weight. Thus, before respiration, the weight of the
lungs, to that of the body, is found to be as one to seventy,
whilst after respiration, it is, as two to seventy. Others, as
Haartmaun, give a different proportion, making it as one to
fifty-nine, beforS, and one to iorty-eight, after respiration.
Lecieux, again, states, from a multitude of experiments, that
there is no constant relation. The lungs of a full grown footus,

2 T

642

bc^forc respiration, arc found to weigh, nearly, eight hundved
grains. The absolute, as well as Uie relative weight of the
hinge, may, with propriety, be attended to. By calling in the
mi of all these tests, we can seldom be at a loss to decide,
and our opinion will be confirmed, if we observe signs of :in^
jury.* We may also take the assistance of chemical tests, to
ascertain the nature of the gases collected, by tearing, or
pressing the lungs, under mercury.

SECTION SECOND.

'Afiter the child is separated from the placenta, it is to .be
wrapped up, in a piece of soft flannel, called a receiver, and
given to the nurse. Next, the soft white substance, which
generally covers the skin, is to be gently and delicately re-
moved, by ablution with tepid water, and tne use of a sponge,
and sometimes of a little soap. It is not necessary to remove
every part of this, nor make such attempts as will fret the
skin : but, in every instance, and especially if there be reason
to suspect, that the mother has had gonorrhoea, or chancre,
ibe surface should be washed. It is also customary, witli
Kany nurses, to bathe the body, or at least the heaid, wiUi
spirits, a practice which can serve no useful purpose, but may
be attended with mischief. The child being dried, it is usual
to wrap a bit of soft rag, round the remains of the naval string,
and retain this, by means of a bandage, brought round the
kelly. It is alleged, that this is necessary, to prevent nmbilical
bemia ; but hernia does not take place, because the child is
not bandaged, but because the umbilicus is unusually wide :
and in those countries where no compress is used, hernia is
not a frequent complaint. A tight bandage produces paiu,
difliculty of breathing, and other deleterious effects. The
cmly purpose, to be served by a bandage, is to retain the mg,
which is, for the sake of cleanliness, applied roimd the cord.

It was at one time, the practice to wrap the child, very
tightly, round the whole body, and to stretch both the arms
Mid legs, whilst the head was secured by tapes, passing from
the cap to the body. A more easy method is now adopted,
and it seems to be agreed upon, that tbe more simple and
loose the dress is, the more comfortable will the child be.
Nurses arc peculiarly afraid of the head being cold, and

^ There are some very good ]Miper9 on infanticide by IMTr. Hittdieton, In Utc
Sff#d. and Phys. Jeurii. No. fifti. et im. See alto La Medleine l^fftle at*
Ci|nir«>n, and a very useful view of the subject In the £dln. Med. Jimm. Vol.

jlfx. P-'liP, and the Le^onn of M Orfila. One of the foUeat Moanoto la to be

fiftxHi kn Med.. legale par Dcverfle, Tom. i. p. iSi, et aaq.

64B

;tiierefore are apt to keep it too wann. In summer, one oot-
*ton cap, I believe k sufficient to preserve the heat, but in
winter, an under cap may be added, but neither of thtae,
ought to be secured by pins. Soft tapes are preferable, for
this, and every other part, of a child's dress. The rest of ibe
I clothing, consists of .a short shift, and a wrapper of fine flan-
nel, which is better for a week or two, than the separate
pieces of dress, employed by many, and which add to the time
and trouble of shifting the child. All children cry when
shifted and dressed ; therefore the shorter and simpler that
.the process can be made, the better. Last of all, a cloth is
to be applied, to receive the faeces or urine, and this is to. be
•removed the moment it is soiled. By attention, a child may
^ery early be taught, to give indication when he wiahes to
void urine or fasces, and can then be held over a pot or basin.
Jt is proper to encourage the child, to use these at regu-
lar intervals. Children, should have their bottom and thighs,
washed and wiped dry, alwayaafter soiling tliemselves. The
whole body ought likewise to be regularly washed, morning
and evening, with a aponge and water, at first rather tepid,
but soon brought to be cold, at least of the temperature, that
cold water has in summer. But although this be a general
practice, yet, some children do not agree with it, being lan-
guid, cold, and pale, after being washed, and these ought to
Ea^e the water wanned a little. Plunging the child into cold
water is, in this country, for some weeks too violent a shock,
but about the third month, it will be proper to do so daily.

The temperature- in which children are kept, should be suoh)
as neither to increase nor diminish, the natural heat of the sur-
face. The child in utero, is placed in a temperature of abo«t
96 or 98 decrees : but its power of generating: heat, is pro-
bably much less tlian after birth. The heat of the room, and
the quantity of bedclothes, should be nearly such, as would be
agreeable to a healthy adult. Depressing heat, is to 'be
avoided, on the one hand, and exposure to cold, on the other.
The apartment should be well ventilated, but the infant ougbt
not to be exposed to the open air, for nearly a month in win-
ter, as it is apt to produce convulsions, or catarrh, with fewr,
or bowel complaints.

SECTION THIRD.

It is customary to give some food, before the child be.ap-
j)lied to the breast, and very frequently medicine also, such as
salt) magnesia, or manna, to purge off the meconium* The

644

absolute necessity^ of either of these practices, may perhaps
be questioned, especially, if the mother be able to suckle at
the usual time. A little milk and water is at all events suffi-
cient ; and with respect to laxatives, I believe that they are
seldom necessary. If, however, the meconium do not come
freely away, and the child have no stool, in twelve or sixteen
hours, or seems to be oppressed, or troubled with pain, a little
manna may be given, with much advantage ; but generally the
milk which is first secreted, called colostrum, is sufficiently
powerful. When the bowels begin to act, and the bile is plen-
tifully secreted, it is usual for the child, in consequence of
.absorption of bile, or perhaps of meconium, to have a yellow
tinge, on the skin, which is called the gum. This is somc-
4imes attended with a drowsy state. If it require any mcdi*
cine at all, it is a gentle laxative.

All children are intended to be brought up on the breast,
and they ought to be applied early, generally betwixt twelve
and twenty-Four hours after birth. Some mothers, however,
cannot, and others will not, suckle* their children, but employ
another nurse,! or bring the child up on the spoon. If the
.latter mode is to be adopted, it is necessary to determine the
.proper diet, and the best mode of giving it.

It is evident that the diet, which will be most suitable, for

"* Van Helinot, and after hScn, Browzet, and others, haveadvispd, that children
should not be brought up on the breast, but fed on ossea* and goats* milki or a
panado, made of bread, boiled In small beer, and sweetened with honey.

f In choosing a nurse, it is necessary to be satisfied that she enjoys good health,
and has an adequate supply of milk. Certain rules have been laid down, to
enable us to ascertain the quality of the milk, by its appearance; bat it is suffi-
cient that it be not too thick, and have a good taste. Witli regard to the quantity,
we cannot Judge at first, for the milk may be kept up, so as to distend the breast,
and give it a full appearance. A woman who is above the age of S5 yearn, or
who has small flaccid breasts, or excoriated nipples, or who menstruates during
lactation, or who is of a passionate disposition, should not be employed'as a nurse.
The milk, during menstruation, is apt to disagree with the child, and produce
vomiting or purging, but this is not uniformly the case. Violent nassions of the
:mind, affect the milk still more ; it often becomes thin, and yellowish, and causes
colic or even fits. Those who labour under hereditarv disease, should, at Icust
for prudential motives, be rejected. The woman's child, if alive, should be in-
spected, to ascertain how it has thriven, and both it, and the nipple, should b«>
examined, lest the nurse may have syphilis. A woman who has, already, uur»ed
several months, is not to be chosen, as the milk is apt to go away in some time,
4»r become bad ; the Quantity of curd increases. It is farther of great advantage,
to attend to the moral conduct of the nurse, for those who get drunk, or are dissi-
pated, may do the child much mischief.

With regard to the diet of a nurse, It is improper to pamper her, or make
much difference, in the quality of the food, from wnat she has been accustomed to.
It is also proper, that she be employed, in some little duty, in the family, other-
wise, she becomes indolent and overgrown. When a nurse becomes pregnant, the
milk often diminishes in quantity, but does not become hurtful ; on the contrary,
the quantity of phosphate of lime it contains, appean in the course of gestation,
"to increase.

645

an infant, is that, which most nearly resembles the mother's
milk. It is not sufficient, that we merely give it milk, it must
be milk similar to that of the human female. It is certain,
that the lacteal secretion, of each species, is best fitted for the
young, of that species ; and we know that there is a great
diversity, both in the flavour, and proportion, of the component
parts, of different milk. Yet, in many cases, the milk of one
animal, will agree with the young, of a very different species.
Thus, a leveret has been suckled by a cat. Milk consists of
cream, curd, and whey ; and the whey, the greatest portion
of which is water, is the only part that becomes sour. .The
quantity of cream, is greatest in ewe's milk, next, in that of
woman, the goat, the cow ; and then, the ass and the mare.
The proportion of whey, is greater in the milk of mares, and
women, than of the cow, or the sheep. With regard to the
caseous part, it is greatest in the milk of sheep, the goat, the
cow, the ass, the mare, in the order in which they stand, and
it is little, in that of women. Sugar, again, is most abundant,
in the milk of the mare and woman, and less so, in that of the-
goat, the sheep, and the cow. Woman's milk, contains more
cream, than cow's milk, yet, no butter can be made from it.
It contains much whey, and yet it scarcely ever becomes sour,
by exposure to air, and does not pass either to the vinous or
putrefactive fermentations. Acids do not coagulate human
milk.

Prom these remarks it follows, that if a child be not suckled,
the best food will be milk, resembling that of women, and the
nearest is asses' ; but as this cannot always be procured, we
must change that of cows, so as to diminish the proportion
of curd, and increase that of sugar and cream, wnich is
done by adding an equal quantity of water, a sixth part of
fresh cream, or less, if it be rich, and a little sugar. Some,
dilute . the milk with water gruel, barley water, or very thin
arrowroot ; or a little water may be mixed with it, and so
small a quantity of salt, as shall not give it a taste. It may
then be sweetened with a little sugar. This is to be mixed,
just as it is required, for, by standing, it acquires bad proper-
ties. It is not to be given with the spoon, but the child is
to suck it, of a proper heat, out of a pot, which is made for
the purpose, and which has a piece of soft cloth, tied over the
perforated mouth, or artificial nipple. Panado, made with
crumbs of bread, is not proper ; and meat, made with unbak-
ed flour, is still worse* In the third month, we may, besides
the milk-mixture, give, occasionally, a little weak beef-tea, or

648

a sniftil quantity of spoon-meat, such as pana<ib, madls wiAi
the crust of fine bread) care being taken to break down the
lumps completely, and a little salt, which is bettor than sugar;
"FKis is to be mixed with milk. Arrowroot, calves'-feet'
jelly, &c., are also very proper; and as the* child advances ia
life« eggs, in the form of light custard, &c;, are allowable*
9oni^ have proposed a panado, made with the flour of wheal
matt. By attention, a child may be taught to eat, at pretty^
regular hours,* especially, after he is a few months old; and
grent oare should be taken, that he do not eat too much at a'
timii. If the child be not suckled, we ascertain' that thtf
arttftcial diet is agreeing with him, if he be lively; and the"
bowels be correct. But when it does not suit, as is too often'
the case, be is either dull and heavy, or cries much, and«
often the bowels are either bound, or too loose ; and in both'
states, the stools are foetid, and have a bad appearance. If
this condition of the bowels, cannot be corrected by medicines,
the child, in all probability, shall be lost, if a nurse be not
pi'Ocnred ; convulsions, or diarrhoea, may carry him off.

When a child is brought up on the breast, there is no
occasion, if the supply be abundant, to give him any other'
nourishment, for three or four months. After this time, how-
over, it will be proper to give a little' food, of the kinds men-
tioned above, and the proportion ought to be gradually
increased, as we proceed to the time of weaning, by which, the
organs of digestion, are enabled, to accommodate themselves,
better to the change of diet, which then takes jJace. With
regard to the age, at which a child should be weaned, it is not
possible to give any absolute rule. In general, the longer it
is deUyed, if we do not go beyond a year, the better does the
diild thrive, provided the milk be good. When a child is
nnrsed beyond a year, and receives little other food, or, when
the milk becomes earlier altered, he is apt to be injured. At
all times, delicate, should be nursed longer, than robust chil-
dren; and, if possible, weaning should not be made to interfere,
with the development of teeth, nor be attempted, in the pros-
pect of, or soon after, the cure of, any debilitating disease.
If the mother's health permit, children may be suckled from
nine to twelve months. After the child is weaned, the diet
must be carefully attended to, and should consist of plain
soup, bread and milk, light pudding, arrowroot, &c. As*^

* It it alio of mlTantage. that wben « chfld ii broafbt up on th« breiift. be Mm
not applied at all hourt, iaditcriminately ; and no child aboiild be eUewed to
ftuck, vrhilst ibe iiurae Is aslMp, m be ie apt to attrfeit himadf.

647

soon: as teeth, sufficient to maaticate, appear, a Utile auiouil
ftKxd, may be given, once a-day.

The dress of children, as they grow up, must be regulate^
in some respect, by the custom of the country, and the seasott
4^f die year* It ought always to be easy and warm* Bir;
ILoake advises, that a child should wear thin shoes, and get!
wet feet, that he may become hardy ; but experience provesy
that the children of the poor, who are exposed to many
privations and hardships, are not improved thereby. Clean-*
liaesB is essential to health, and the whole surface should b«
washed once a-day at least, and the hair daily combed, and
brushed, which may prevent scald-head. The exercise should
be proportioned to the age. Infants sleep much, and can
take no exercise, if we except that given by their nurses ; but
wben they are about two months old, they may be placed on
tie carpet, and encouraged to creep. When they are able to
walk, they should be allowed to run about freely ; and it will
be of great advantage, where circumstances permit, that tfaer
iinst years of life, be spent in the country.

It is very difficult from the imperfection of tables, to aacer«^
tain the comparative mortality at different ages. In this city
in 1830, there were 6397 Uving children bom ; viz. 3284
males, and 3116 females. There were 877 burials of children
under one year, and 623 under two. In both cases, the males
preponderated*

Last year, (1836,) there were 3225 children registered^
yiz*f 1795 males, 1530 females. There were 1618 children
under one year buried, the females preponderating. There
were 1216 from, one to two years; 1055 from two to five;
and 484 from five to ten. There were 188 under one mouthy
of these the males greatly preponderated ; afterwards, till at
least a year, it was the reverse. The greatest number of
«leaths, occurred in children from a year, to fifteen months old*
next ta that, the mortality was greatest between tlu*ee moatbsi
£ind a year.

CHAP. II.
0/ Congenite and Surgical diseases.

SECTION FIRST.

.When a child is born, it is necessary to ascertain, that il
have no congenite imperfection, or have met with no accident

G4S

during birth. I can here only make a few short remarks, on
some of the most frequent^ and important imperfections. The
first 1 shall notice, is the hare-lip, which may exist in different
degrees, and be accompanied with a vacancy in the palate.
Sometimes an operation has been performed, soon after birth,
but it generally fails, and, occasionally, the child dies. It is
better to delay it, for ten or twelve months, or even longer.
In the meantime, the child must be brought up on the spoon,
imless the defect be so trifling, as to permit him to suck a
large nipple, from which the milk flows freely ; otherwise, he
can only suck a mouthful or two at a time, by pressing the
nostrils on the breast.

SECTION SECOND.

Imperforated anus, may exist in diflercnt degrees. There
may be an appearance of anus, but an obliteration a little
higher up. This is discovered, by introducing a bit of oiled
paper rolled up, which ought always to be done, when the
child is long of voiding the meconium. If the paper be
soiled with feeces, we may be sure that the rectum is pervious.
A blunt probe, cautiously introduced, will also ascertain the
state of the gut, or even the little finger previously oiled, can
without much efibrt, be introduced, to ascertain the state of
the gut above. A probe, if directed a little forward, will
reach the promontory of the sacrum, when it has been intro-
duced, fully an inch and a half. Sometimes, the anus is cov-
ered with a thin membrane only. In other cases, a great part
of the rectum is wanting, or it terminates in the bladder of
the male, or vagina of the female, which last is not a fatal
deviation. It is proper always to make an incision at the
anus, or at the spot where it ought to open, if there be no
mark of it ; and this is to be carried about half an inch or an
inch deep. If no intestine be found, a trocar or lancet may
be passed a little deeper in the proper course of the rectum.
If, by any of these means, the bowel be opened, a tent should
be employed to keep the aperture from closing.* But if it
be not thus found, we are not to prosecute the dissection
farther, but must form an artificial anus,t by opening the
colon. This gut, is, in some respects, irregular in its course,

' * In a CAM operated on by M. Cenrenon, where the Incision was ohllfrd to be
rarried an inch bifb. It waa necenary to um a boogie for a year. The child was
enabled to retain the faces, but the anus appeared as If it were annk an Inch
deeper than usual. Recuell Period. Tom. i. p. 96.

f Vide Obserrations on this subject, by Dumas and AUan, In the Recuell
Period. Tom. Hi. p. 46 and 189^ and a case in point by Duret, In Ton. Ir. pb 45b

649

on both sides, but it is uniform in its relation, at one part, on
the left side, where alone it ought to be opened. It comes
down, by the crest of the ilium, and runs forward, close
by Poupart's ligament, for a considerable way, in some
foetuses, even directly across the pubis, to the other side, before
it turn. We begin our incision, at the spine of the ilium,
and continue it parallel to Poupart's ligament, and, just so
far, above both, as to avoid the circumflexa ilii. We do not
carry it more than an inch forward, in order to avoid, both
the epigastric, and hypogastric, or umbilical arteries. The
colon Ls generally filled with meconium here, but sometimes
it is empty at this spot, and we must therefore attend to the
size, and not go, almost any distance, above the ligament, in
laying hold of the gut, lest, we draw down, a fold of the small
intestines, instead of the colon. The bowel is then to be
opened, and, if there be much tendency to protrusion, which is
more to be apprehended, than retrocession, one stitch may be
introduced, in the female, the tube and ovarium, lie under
the colon. We must not pull them down. In some cases, the
colon is close by the parietes, in others, a very little back from
them. It is not possible, owing to the curves of the colon, to
pass, with safety, any flexible instrument, from the opening,
to the rectum ; otherwise, we might, by introducing the little
finger into the anus, or into the incision, supposed previously
to be made, in that region, feel the end of the bougie, and cut
the part. Death does not always follow, from refraining from
an operation. In the Revue Med. for Dec, 1823, there is
an account of a man, then alive, and aged 70, who had both
the anus and urethra imperforate. He voided the excrement
by vomiting.

Imperforated urethra is rare, for generally the canal opens,
in supposed cases of imperforation, about midway, between the
scrotum and glans penis. There is no occasion to do any
thing instantly, and even at a more advanced age, the opera-
tion of perforating the glans seldom succeed. It is only pos-
sible that it can do so if the urethra open near the extremity.
Retention of urine, not dependent on malformation, is readily
removed, by introducing a probe into the bladder. Devia-
tions in the structure of the vagina, and hymen, have already
been considered.

Imperforated meatus auditorius is very rare, andean seldom
be remedied, except there be, merely, a membrane stretched
across the canal. Adhesion of the eyelid, is often complicated

650

with a defect in the eyeball itself; but when ibis is not* tbe
ease, an operation will be advisable.

I lately saw a child, where the nasal' duct, surrounded by
eommon integuments, hung down on the cheek, and slowly
discharged tears from its extremity.

Children, but especially abortions, sometimes have an es*
tremity wantino;^ or amputated. This is well described by
Dr. Simpson and Dr. Montgomery, the latter of whom has
some fine specimens preserved. He attributes the removal to
Mie formation of a band of fibrine acting like a ligature round
the limb.

aECTIOlf THIRD.

Sometimes, the umbilicus is pecidiariy liirge, and hernia,
covered by polished integument, takes pliEtce soon after birtfa^
but still more frequently, betwixt the second and fourth months.
Two modes of treatment may be adopted. The first is com^
pression, carefully maintained, which should be always tried.
This, in some instances, produces a radical cure, the umbili*-
eal opening' contracting, which it never does in adults. The
second mode is, reducing the intestine, and tying the sac, with
a single, or double ligature. It has also been proposed, to
open the sac, and close the umbilical aperture by pins or
stitches ; but this has no advantage over the double ligature.

In some cases, a very great portion of the intestines, is
found protruded at birth, into the sheath of the cord; This
may be complicated with an imperfect, or transparent state,
of part of the abdominal parietes ; but whether it be or not,
flie child generally dies within forty-eight hours. The abdo-
men is too small, to receive back the intestine quickly ; and
even although it could be reduced, the child, if we may judge
from experience, has no great probability of existing. In one
case, Mr. Hey found the tumour burst during labour.

Other species of hernia, are to be treated on general prin«
ciples. The bowels are to be kept open, and violent exertion
avoided. The propriety of endeavouring to retain the bowel
with a bandage, must depend on our being able to do it
eflfectuallv ; for, if the bowel protrude, it is pinched by rtie
pad. This produces pain and local inflammation, and not
unfrequently convulsions.

SECTION FOURTH.

Spina bifida, is an imperfection of the vertebral canid, if not

651

«bo* of the spinal miim> w^. The bone is deftcient, Die pesft
ferior part being wanting ; a tumour* is formed, estemaUj^
which contains a fluid, and is covered by skin^. sometimes lilee
the rest of the integuments, but generally thinner, polished,
and of a reddish or purple colour. It is seldom, at birth,
larger than a small chestnut ; but if the child live, it increaaes,
perhaps, to tho size of the fist. It contains flliid, either pd*
lucid or coloured, so that it is soft and fhictualxng, or elastic^
according to the degree of tension. The medulla, may eithen
go on entire, along the sac, or terminate there, and recom^
mence below it ; but even when it seems to terminate, it often
is only expanded, or spread, as a lining over the sac, or dilated
membranes of the cord, which are thicker, and more vascular
than usual. When it does so, filaments are given ofi^, whicb
form the great nerves of theischiatic plexus; for, althou^
the tumour may exist any where, from the neck downwards^
yet, it usually is situated in the lumbar r^on. It is generally
connected with hydrocephalus, always, with water in the spinal
sheath, on which account, it has been called hydrorachis* If
the quantity of fluid be small, it can, by pressure,, be forced;
from the tumour into the spine. The lower extremities may,
or may not, be paralytic, or the urine and fasces retained, or
paased involuntarily; and the difibrence is not^ always, depeiw
dent, on the integrity, or imperfection of the cord. In some
instances, the sac is open, at the time of hirtiu This is a fatal
disease, and death is generally preceded by inflammation, or
sloughing of the sac.

Two modes of treatment have been proposed, the palliative*
and the radical ; but the last, is founded on the idea, that the^
disease is confined to the seat of the tumour, whereas, there uu
a combination with more extensive efiusion. The first, con-
sists in endeavouring, by pressure, to get the fluid to retire
within the vertebral sheath, if it be not so great, as to pro-
duce compression of the parts, and then a compress or trusa*
is applied. Or, if the tumour be larger, than to permit of
this, then, a hollow compress, made from a mould, taken in
plaster of Paris, may be applied, at least in the first in-
stance. This plan is only palliative. The second, exposes-
the patient to great danger, from constitutional irritation. It
consists in repeatedly puncturing the tumour, with a needle,
and drawing off the water. At last, adhesion of the sides of
the sac is produced, and the opening from the spine is closed,
the skin banging shrivelled over it, gp becoming puekered at

k
I

652

the part.* Puncturing the tumour, with a lancet, and tying
a ligature round the empty bag, is almost invariably fatal.
:The palliative plan is the best.

SECTION FIFTH.

Marks and blemishes are very frequent, and may be placed
on any part of the body. They are of two kinds : First,
simple discoloured patches, generally of a red colour, and not
elevated. These are not dangerous, but rarely admit of cure,
for if we destroy them with caustic, the cicatrix is almost as
bad as the original blemish. Second, elevated discoloured
marks, which are of a purple or red colour, and very vascular.
These are apt to increase, and at last bursting, great haemor-
rhages may take place. They may be seated on the face, or
in the lip, eyelid, &c., or on the spine, resembling spina
bifida, but are more solid or spongy, and the bone is not
deficient. These ought to be extirpated as soon as they begin
in the smallest degree to increase, and even if situated on the
gums, or within the mouth, however small they be, they ought
to be removed. When on the palate, and extending to the
velum or tonsils, the case is most hazardous. Nsevi may also,
safelv, and with little trouble, be removed by ligature, a
small needle being previously passed across, fairly below the
base, so as to insure the proper application of the thread.
Small marks have occasionally been removed, by raising the
skin with a blister, and then applying mild escharotics, or
by means of caustic. But in almost every instance, extirpa^
tion is better. The application of cold, or pressure, can
seldom be depended on, neither can we trust to tyiug the
main artery of the part.

SECTION SIXTH.

Children, may especially after tedious labour, be bom with
a circumscribed swelling on the head. This seems to contain
a fluid, and has so well defined hard edges, that one, who,
for the first time saw a case of it, would suppose that the
bone was deficient. It requires no treatment, or, bv apply-
ing cloths dipped in brandy, the efilused fluid is soon aosorbecl.
This, which is called hsematocele, is generallv on the parietal
bone. Encephalocele, as Naigel6 remarks, is oftenest at the
posterior fontanelle or occiput.

• Vid« cMe bj sir A* Coofer, Ja Med. Cbir. Tnst. Vol. U. ^ 9M.

653

SECTION SEVENTH.

Distortions of the feet are not uncommon. They are called
vari, when the foot is turned inwards ; valgi, when outwards.
These, and similar deviations} are to be cured by pressure^
applied with proper bandages adapted to the nature of the
case. They must operate constantly, but gradually, and
ought to be applied as early as possible. It is a bad case,
indeed, which cannot thus be benefited, if not quite cured,
by a good mechanic* Dieffenbach proposes to keep the foot
in a proper position, in a mould of plaster of Pans. At a
more advanced age, the tendo- Achilles has been cut, and the
extending apparatus immediately applied.

Congenital dislocation, particularly of the hip-joint, seems
to depend on malformation of the socket. Dupuytren says,
he has seen twenty cases.

SECTION EIGHTH.

When the frenum linguae is too short, or attached far
forward, the child can neither suck well, nor speak distinctly.
It is very rare in its occurrence. I have not seen two chil-
dren, where it was really necessary, to perform any operation ;
for, in all the rest, the child sucked the finger, or a good nipple,
very readily. The operation consists, in dividing, to a suffi-
cient extent, the frenum, with a pair of blunt-pointed scissars.
If the artery be imprudently cut, the haemorrhage is to be
checked by compression or cautery. The ranular vein is in
more danger.

SECTION NINTH.

Imperfection, or malformation of the heart, is a very fre-
quent occurrence ; or the fcetal structure, may continue long
after birth. If the imperfection be great, the symptoms come
on, almost immediately after birth ; but if slight, or consisting,
merely, in a continuation of the foetal structure, they may not
come on, till the child begin to walk, or get teeth, or even
later. The child is dark-coloured, or the skin has a dirty
appearance, the nails and lips are livid, the breathing is more
or less difficult, and he is subject to attacks of asthma, or a
kind of suffocating cough, like that in peripneumonia, or
hooping-cough ; and whenever this attacks an infant, I augur
very ill. I have no remedy to propose. Comparative ease

* For the anatomy of the olub-foot, ride Scarpa. For other deformations, see
alao Lafond, Reoherchea, ftc

'654

may be obtained, by JEeeping the child as quiet as possible,
ayoiding a loaded stomach, or costive state of the bowels.
For an account of the different kinds of malformation, I
Tefer to my brother's excellent Work on the Diseases of the
Heart.

SECTION TENTH.

Children have sometimes a swelling of the breasts afW
birth. This is chiefly owing to secretion of a milky fluid,
«nd much injury is often done, by attempting to «queese it
i)Ut. Gentle Motion, vrith warm oil, is of service ; but if in-
flammation come t)n, from rude treatment, a tepid poultiee
must be employed.

Hydrocele, generally goes off, by applying compresses dipt
in solution of muriate of ammonia. A puncture is rarely ne-
cessary. Phymosis, requires astringent lotions.

Prolapsus ani, is to be cured, by keeping the bowels easy,
using the cold bath, and returning the gut whenever it pro-
trudies. The child should ako be prevented from remaining
long at stool. If the prolapsus prove obstinate, injecting a
'^little decoction of oak bark may be proper.

Serous discharge from the navel, sometimes takes phioe,
after the separation of the cord ; and, in general, it will be
found to arise from a small fungus, not larger than a cherry-
stone. This is removed by a little powdered- alum, or, if that
fail, by a little red precipitate, or by a ligature.

Excoriation of the navel is different; for thereisnofungnts,
but rather inflammation and superficial festering. It is to be
removed, by opening the bowels, keeping the part very clean,
and bathing it occasionally with Port wine ; after which it is
to be dressed with eerussa ointment. If n^lected, or the
bowels be not attended to, swelling, of the natmre of furun-
cuius, may take place, or the inflammation may become
,erysipelatous,.and end in gangrene. If this be tnreatensd,
gentle laxatives, a good nurse, and mild dressings, poultiees,
or the application of cloths wet with weak solution of
chloride of lime, if there be much smell, constitute the
practice.

Sometimes, a day or two after the cord separates, or at the
time of separation, hiemorrhage takes place from the navel.
This may yield very readily to compression, or astringents ;
but, nevertheless, may also prove obstinate and fatal. The
actual cautery has been proposed, or nitrate of silver, or- cut-
ting at the navel and applying a ligature at the end of the

655

vehi, which k supposed to bleed oftener than >&e arteries. I
know, from experience, that no compress can, at all times, be
depended on, except the point of the finger, and that cannot
well, be steadily applied, for hours or days in succession : yet,
in obstinate cases, I know no safer nor better plan, the as-
mtant being relieved, at proper intervals, for some time, both
night and day. I give this opinion, from finding other means,
apparently more powerful, fail. Strong astringents, orescha-
rotics, caustic applied so as to form an eschar, a .ligature car-
ried by means of a needle, round the umbilical aperture, and
tied tightly, the twisted suture, made by crossing two needles,
and working the whole navel over, tightly, with thread, have
all failed, and appealed, by propagating inflammation to the
peritonceum, to hasten death.

It has been proposed to apply a bit of cloth, wet with solu-
tion of caoutchouc in ether, over the navel, applying the same,
frequently, with a pencil, till a firm coating, or plaster were
made to cover the part. If it should be necessary to. tie the
vessel, the umbilical vein is exposed, by cutting directly up-
ward from the navel, so as to divide the skin and aponeurosis,
taking care not to open the peritonssum. In ascending, it in-
clines a little to the right. If the finffer be placed in the
wound, a rope may be felt, consisting oithe vessel, which is
Tendered tense, and more distinct, by pulling the remains of
the cord, or the navel. It is to be laid hold of, with forceps,
and a ligature cautiously put round it. The margins of both
lobes of the liver, are often so low, as a line drawn across Uie
navel, but the top of the cleft between them is higher, so that
there. is from | of an inch, to an inch of the vein, between the
navel and its entrance into the cleft. The incision may cor-
respond more to the left, than the right margin of the vessel.
The arteries, should they bleed, are exposed, by cutting di-
rectly down from the umbilicus. They go up on each side, of
the ligament of the uraehus. At half an inch below the
navel, they are, if not in contact, not more than a quarter Df
an inch separate. At the brim of the pelvis there is. about f
distance between their internal margins.

Discharges of blood, but much more frequently of mueos,
or muco^purulent matter from the vagina, occur in infisincy,
hut still oftener in childhood, and sometimes are very pro-
tracted; they are not, however, hazardous. The bowels are
to be kept regular, by the administration of rhubarb and mag-
nesia, and sometimes small doses of calomel. Tinetnre of
atcel is also nsefiol in ehildhoad. The cold bath ahouhi be

G56

employed. The discharge is carefully to be remoyed, by fre-
quent ablution ; and, if these means fail, some mild astringent
solution, is to be injected frequently into the vagina.

Incontinence of urine, during the night, often depends on
a bad habit, and is to be treated accordingly. It sometimes
depends, on a sensitive condition, of the neck of the bladder.
Lallemand, recommends aromatic baths, with the addition of
a glass of spirits. When it continues long, the cold bath is
proper, but I have known it, in spite of every thing, remain
even in adult age.

Scalds and burns, arc best cured, by applying, instantly,
cloths wet with cold water or vinegar. This is the proper
practice, whatever part is injured ; but when the face or neck
are scalded or burned, it is of the utmost importance to pre-
vent a mark, and nothing does so, more effectually, than the
instant application, for a short time, of vinegar, alone, or if
it give much pain, diluted. This, if the injury be slight, prc^
vents the part from blistering, or only a slight vesication
takes place. The part, should then be covered, with dry
cotton wool, and, indeed, without the previous use of vinegar,
it is a good application. It is to be allowed to remain on the
part, till it come off as a mask, entire or in part, unless the
discharge be such as to wet It, in which case, it must be daily
renewed, taking away only the wettest portions, and replacing
these with dry wool. In scalds and superficial bums, on other
parts, cotton is also a good application. It sometimes suc-
ceeds well, when the cutis, itself, is considerably disorgan-
ized, but it is not so certain, as in more superficial cases; still
we may use it. The old remedy, of lintseed oil and lime
water, often is useful, or, the parts may be covered with a
cloth dipped in a liniment, composed by adding to melted
lard, as much of a mixture, of equal parts of rose water and
acet. lyth. as it can incorporate with, or, we dress with
cerussa ointment, or anoint the spot with this, and then
make it dry with cerussa or chalk. The part is to be wash-
ed, at least, once a-day, to remove any irritating matter
which might fret it. A weak solution, of chloride of lime,
forms a good wash.

If vesications have formed, they are to be opened with a
very small puncture, to let out the fluid, and then cotton is
to be laid on ; or, if the liniment be used, and it give much
pain, it may be diluted with oil.

In more extensive and severe burns, if the surface be nearly
torrefied, itmay^be wet with oil of turpentine, applied with a

657

soft brush, or dressed with ung. resinosum, mixed with a
fourth part of oil of turpentine ; but in all cases where the
cutis is not disorganized, this would be too severe, and the
best application, is cold water for a time, if it do not produce
shivering or depression, or increase pain. We must be much
guided in our application, by the sensation produced. What-
ever permanently increases pain, or produces coldness or
sickness, is pernicious; and, on the other hand, that treatment,
in which the individual does find most comfort, is the best.
Two patients, apparently in the same circumstances, may,
therefore, by an attentive man, be treated oppositely. Some-
times, tepid water gives most relief. After a short time, the
old formula of equal parts of lime water and linseed oil, is
often useful. Afterwards, simple ointment thickened with
chalk may be used, and in some time longer, the sore may
be covered with powdered chalk, which is to be continued
till it heal. It represses fungus, and forms an artificial scab.
Cotton, applied after suppuration has taken place, sometimes
agrees very well with the sore. In all cases, pain is to be
allayed by opiates, and the bowels are to be kept open.
Stupor is very apt to follow a severe bum, and if it be not
relieved, by a blister to the head, and purgatives or clysters,
it soon proves fatal. Inflammation of internal organs, is also
apt to succeed a bum or scald. Infants are easily sunk by
bums. When boiling water, tea, &c., are swallowed, severe
inflammation of the parts is produced, and the larynx or
trachea may participate. Local applications can scarcely be
made, and the practice is very limited. We must lessen
local inflammation, and support the strength. It has also
been proposed to perform bronchotomy.

Blisters, are sometimes as serious, in infancy, as scalds, and
ought never to be kept long on. If the child be very weak,
or irritable, there is danger of the sore becoming, first, covered
with thick fibrine, then, it assumes a honeycomb appearance,
and much foetid matter is discharged, or, from the first, it
becomes sloughy, and either a bufi^ or a black eschar is formed.
Usually the surrounding skin is erythematic, and the sore is
apt to sjH'ead along this as well as to go deep.

In general, a poultice is the pleasantest application, at first,
then, we dress with simple ointment, thickened with prepared
chalk, or cerussa, and bathe with weak solution of chloride
of lime, to destroy the smell. When there is much discharge,
sometimes dressing with dry cotton, or with dry chalk is of
use. Pain is to be allayed by opiates, the bowels kept regular,

2 u

658

and above all, the strength supported by nourishment. We
also give quinine and cordials.

Earach, is a very frequent, and painful disease of children.
It is discovered, if the child be old enough, by his complainin?
of his ear ; but if he be too young to do this, it may be sus-
pected, by his being seized with a sudden and severe fit of
crying, as if he had colic, and, like it, the pain seems to remit
occasionally. He does not, however, spur with his feet, nor
ia the belly hard, but he is restless with his head, and com-
plains if his ear be touched. In some time he falls asleep, and
next day, perhaps, his cap is stained with matter. Nothin?
gives so much relief as heat. Warm oil, or a warm poultice,
is to be early applied, or the outside of the ear is to be rubbed
with warm laudanum. If a foetid discharge, succeed this dw-
ease, and the child be deaf, the ear is to be daily washed out,
with milk and water, by means of a syringe. Small blistew
may be applied behind the ear, or back of the head, and the
constitution is to be invigorated. The bowels, in particiuaTj
are to be kept regular. Many children have occasional dis-
charges of matter from their ears, upon catching cold, withou
much pain, and at that time they are deaf. But by keeping
the ear warm, and by scrupulous attention to cleanliness, tnc
discharge stops, and the hearing returns. ^

SECTION ELEVENTH.

The mucous secretion of the nostril, is sometimes cxcced-

the child.

ingly foetid, so that it is disagreeable to come near tne cnu •
The mucus dries, and comes away in thin pieces. Astnnge
injections, stimulating liniments, and a variety of local app
cations, as well as internal remedies, such as tonics, mercury

&c., have been tried. These have not always, however, a ff^
effect. At the age of puberty, the foetor sometimes sponU^'
neously ceases. . j

Foetid discharge from the ears, generally, is accoini>^ *
with a destruction of the membrana tympani, and a canes
the small bones. It is usually attended with deafness, ^
very obstinate. Great attention is to be paid to cleanii»
and to the state of the constitution. If there be ^^^a^^
internal inflammation, a leech should be applied behind*
ear, or a small blister to the back of the head. The ^^.^
arises, from propagation of the disease, to the inside ot
head.

659

SECTION TWELFTH.

Infants are subject to inflammation of the eye, which is
of the kind, called purulent ophthalmy. This, begins about
the end of the second, or beginning of the third, day. The
eyelids seem, first, glued together, then, thick pus is dis-
charged. The inside of the eyelids, is found to be very red,
but speedily they swell so much that they cannot be easily
opened. If separated, the lining is found to be highly in-
flamed, and the whole eye, more or less, covered by the pus.
When the child cries, tne eyelids are turned out. Both are
generally aflected. If neglected, the cornea, in about a week,
becomes dim, and in a day or two, pus is formed in its sub-
stance, to a greater or less extent. Then, it bursts, and the
eye, within a month, perhaps earlier, is lost. The cause is
sometimes obscure, but, frequently, it is, evidently, owing to
the application, during birth, of leucorrhceal matter.

The treatment consists, in washing away, perhaps every six
hours, the matter with tepid water, by means either of a soft
sponge, or a small syringe.* Besides this, we put, once, per-
haps twice a-day, into the eye, by a soft brush, a drop, of a
solution of four grains of nitrate of silver, in one ounce of dis-
tilled water. Other metallic solutions have been used, as those
of sulphate of zinc or of copper, muriate of mercury, &c. The
eyelashes are, also, to be anointed, every night, with precipi-
tate ointment, or golden ointment, greatly diluted. We ought
seldom to omit, the application of a small blister, to the back
of the head, and should keep open, by savin ointment, a part
of it, as large as a penny-piece. The bowels are to be care-
fully attended to. If the mflammation be high, a leech has been
applied to the root of the nose ; but it is better to scarify the
inside of the eyelid. It is usual to give small doses, also, of
calomel, if the disease be protracted ; and, in that case, the
vinum opii has also been used with benefit.

SECTION THIRTEENTH.

Children are sometimes aflected, with spongoid disease of
the eye. The pupil is first observed to be dilated and im-
moveable ; whilst, from within, the light is reflected, as if
from a brazen speculum. This symptom, however, it must

• Mr. M'Kenziey (|Mige 908) reoommeods m r lotion, a Mdution of one grain
of muriate of mercury, in eight ounces of water. Dr. Kennedy introduce* Into
the eye a solution of nitrate of silver, varying, in strength, from five grains to half
a dram to the ounce of water. But he seemn to trust atill more to gently removing
the matter, frequently, with a «(ponge wet wUh tepid water.

660

be admitted, may attend non-malignant diseases of the choroid
coat. Presently, this reflecting substance, enlarging, comes
nearer the pupil, and is seen to be yascular. It presses for-
ward the iris, which is changed in its colour. The cornea
and sclerotica inflame. The whole eyeball becomes painful,
fixed, irregular on its surface, and at last some part gives
way. From this a bloody looking fungus protrudes. The
bones become carious. The disease either spreads to the
brain, causing coma, or the patient sinks exhausted. If any
thing can save the patient, it must be a very early operation;
but in every instance that I have seen, even those where the
eye was removed before fungus occurred, there has been a
relapse.

Melanosis begins with dimness of vision, which presently is
lost. The pupil becomes opaque, and the eyeball enlarges,
with circumscribed protrusion of some part of the cornea or
sclerotica, from which, ultimately, issues a solid fungus. This
is invariably fatal, and is generally complicated with a similar
disease in tne abdomen or thorax. When the tumour is cut,
it is found to be, in a great measure, made up of black or dark
brown thick pulp, or in some places of portions like coagulated
blood, or fluid like ink. The optic nerve always, perhaps, at
its medullary part is black, whilst the neurilema is white.

SECTION FOURTEENTH.

Scrofula, is dependent on a peculiarity of constitution, de-
rived at conception. This is often marked, by a very fine
skin, light hair, large blue eyes, with dull sclerotica, and deli*
cate complexion. Others have the skin darker, or of a rough
dirty appearance, the hair is dark, the upper lip tumid, and
the countenance sallow, and sometimes swelled. When the
scrofulous constitution is not strongly marked, the person may
pass through life, without any inconvenience. But when it
exists in force, different parts of the body are apt, without any
evident cause, to have their action deranged ; their structure
is changed, and then inflammation slowly takes place. The
glands are most frequently affected, but the joints or viscera
may also suffer. I do not think it necessary to describe these
changes, especially, as I have, elsewhere, entered pretty fully,
into this subject. I shall merely state, what ought to be done,
as a preventive, or as a cure. In the first view, we advise
whatever can strengthen the system, and preserve the different
parts, vigorous, and in health ; such as the cold, or when that
produces languor or chilness, the warm bath, daily, gentle

661

friction, over the whole surface, for half an hour every evening,
regular exercise in the open air, great attention to cleanliness,
an open state of the bowels, and good nourishing diet, with,
or without, a small proportion of wine, as circumstances may
demand. Animal food is much recommended, more so, per-
haps, than necessaiT* Sea-bathing is useful. When the
glands are swelled, it has been proposed to rub the tumour
with an ointment containing iodine ; but I have seldom seen
it do good. When suppuration is taking place, we ought not
to be rash in applying a poultice, as it does not, materially,
accelerate the process, and is apt to make the skin tender.
The abscess, should be very early opened, by a very small
aperture ; but if the skin be already thin, and universally red,
it is better to let it open itself. In the first case, however,
we are apt to have a depressed regular scar ; in the second,
an irregular, and generally a larger, but often a flatter cica-
trix. When a sore is formed, gentle stimulants are proper.
The constitution is to be treated, in the way, already mention-
ed. Muriate of lime, or of bartyes, cicuta, bark, and a great
variety of medicines, have been advised, but I do not know
that any one can be depended on. Iodine seems to be, in
some cases, really useful, and it also improves the digestion.
Other medicines are chiefly useful, to obviate existing symp-
toms, such as costiveness, &c.

Diseases of the joints and spine, are to be managed chiefly
by issues, and such treatment as improves the health.

SECTION FIFTEENTH.

The disease called rickets, is characterized by flabby muscles,
relaxed skin, sallow or bloated countenance, debility, listless-
ness, and softening of the bones, so, that the long bones be-
come, more or less, curved, and their extremities apparently
enlarged. The ankles and wrists swell first, then the back
changes its shape, and the breast protrudes. The bones of
the pelvis, approach more nearly together, the sacrum coming
forward. The head is increased in size, and the belly becomes
large and hard. The appetite and digestion are impaired, the
bowels are bound, or foetid stools are passed. The pulse is
weak and frequent. The teeth are late of appearing, and are
not good. The mind is often prematurely advanced. This
disease may prove fatal, by ending in water of the head, con-
vulsions, or hectic fever ; but it often is cured, spontaneously,
or with assistance. It usually attacks betwixt the sixth month,
and second year, but it has been known to aflPect even the

662

rcetTis in utera. It is to be treated, by a course of laxatives^
to bring the bowels into a proper state, the cold bath, regular
exercise, nourishing diet, general friction over the body, chaly-
beate medicines, and warm clothing.

CHAP. III.

Of Dentition.

The formation of the teeth, is begun long before the foetus
leave the uterus. It is carried on slowly, and is not com-
pleted till several months after birth. The parts concerned
m this process, are the jaw, the gum, and the soft rudiments
of the tooth itself. The jaw, at first, has only a channel run-
ning along its surface ; but this, afterwards, is divided by trans-
verse septa, into separate cells, which are the origins of the
alveolar processes. In each of these, is lodced a membranous
bag, containing a soft nulp. The bag consists of two laminae,
both of which, especially the outer one, are vascular. These
sacs, adhere firmly to the gum, so that if it be pulled away
from the jaw, the sacs come with it : the pulp is also vascular,
and assumes nearly the size and shape, which the bodv of the
tooth is to have, when ossification has commenced. The tooth
consists of two parts, bony matter, and cortex striatus, or crys-
tallized enamel, covering the bone. The bone is formed on
the pulp, which gradually ossifies ; and in the eighth or ninth
month, of the foetal life, sJl the pulps have begun to ossify, and
at birth, the shell is considerably advanced. Soon after this
process begins, the inner surface of the sac, deposits a soft
earthy substance, which crystallizes and forms enamel. When
ossification is advanced, so far, as to form the shell of the body
of the tooth, the lower part becomes contracted, so as to form
the neck ; and as the shell thickens, the pulp, though dimi-
nished in quantity, protrudes through the neck, forming a
kind of stalk or mould for the fang. If the tooth be to have
two fangs, then a septum is stretched across the cavity of the
neck, and the pulp protrudes in two divisions* As ossification
advances on the root, the body rises in the socket, and the
sac rises with it ; but in proportion as the enamel is crystal*
lized, the sac becomes less vascular and thinner, and at last is
absorbed ; and when the tooth has acquired its proper height,
the whole membrane is destroyed. Thus it appears, that the

663

sac is not stretched, and bursts by distention^ but is absorbed,
and being fixed to the neck of tne tooth, and not to the jaw,
it rises with the tooth.

There are only twenty teeth, evolved in infancy, ten in each
jaw, and these are not permanent. They are shed, to give
place to others, more durable and more numerous, as the jaws
are longer in the adult. The permanent teeth, begin to be
formed, even, before birth. Like the fang of the tooth, they
are set ofi^, from the body of the temporary tooth. A small
process or sac is sent off backwards. This is lodged at the
back part of the socket, where a little niche is first formed,
for its reception, and then a distinct socket. Hence, the tem-
porary, and permanent teeth, are connected together, and this
connection remains for a considerable time. In the fa3tus,
there are, besides the temporary teeth, the rudiments of the
first two permanent grinders, therefore, there are twelve sacs
in each jaw. The sac of the anterior permanent grinder,
sends, when the jaw lengthens, a process backwards, to form
the next grinder ; and it again, in course of time, sends off
the third grinder.

Generally, teeth cut the gum, about the sixth or eighth
month after birth. The two middle incisors, of the lower jaw
first appear, and, in about a month, those of the upper jaw
come through. Then, the two lateral incisors, of the lower
jaw, and next, those of the upper one, appear. About the
twelfth or fourteenth month, the anterior grinders of the
lower, and, soon, those of the upper jaw, cut the gum.
Between the sixteenth and twentieth months, the cuspidati
appear; and from that period, to the thirtieth month, the
posterior grinders come through; so, that the child, when
about two years and a half old, usually, has all the first set of
teeth. These continue till the sixth or seventh year ; and as
the permanent teeth are in progress, all this time, we find,
besides the twenty teeth, which are visible, twenty-eight below
the gums. At this time, the first two permanent grinders,
appear at the back part of the jaw, and the middle incisors of
the lower jaw loosen and drop out ; and, by degrees, all the
milk teeth give place to others, which are larger, stronger,
and better adapted to the increased size of the jaws. In this
curious process, which strongly displays the wisdom of God,
we are early taught the perishable nature of our frame. But
it is also a pleasing reflection, that dissolution is succeeded by
a state of greater perfection.

Many children cut their teeth, with great ease and regu-

664

larity, but some suffer considerably. It is usual for the cliiUI,
to have some irritation of the mouth, during dentition. The
gums are hot and itchy, and somewhat swelled, or full, over
the tooth, and the anterior edge, is not sharp as formerly, but
is rounded, and the investing membrane unfolded. The
secretion of saliva is increased : and the stomach and bowels,
sometimes are rendered irritable. Partly^ from ihis cause
producing gripes, and, partly, from pain darting through the
gum, the child is seized with frequent and sudden fits of cry-
ing. The symptoms seldoip continue urgent, above ten days
at a time. If the child be very irritable, and the tooth ad-
vance fast, or several teeth come forward, at the same time,
very unpleasant effects may be produced, such as severe
bowel complaint, or fever, or spasmodic cough, or convul-
sions ; or the skin is affected, an eruption appearing on dif-
ferent parts, which is a much more trifling effect, th^ any of
the former, or the gums ulcerate, or sometimes the tongue
and mouth become aphthous. The urine is often scanty,
but, on the other hand, it may be too abundant; and this
superabundant discharge, is productive of debility. Costive-
ness adds to the danger of dentition. When tne first grin-
ders, and cuspidati are cutting, and come forward quickly,
there is great irritation, for there are then eight teeth making
pressure on the gums. It is probable, one cause of the dan-
der of dentition, arises from the direct effect produced, on the
third branch of the fifth pair of nerves, which, arising from
the base of the encepbalon, not far from the origin of the
eighth pair, affects that, in a powerful degree. This subject
will be better understood, by the explanation given in Chap.
V. of this part of the work.

In every case of troublesome dentition, we have three indi-
cations to attend to : — First, to allay local irritation ; second,
to alleviate urgent or symptomatic complaints ; third, to sup*
]K>rt the strength.

The first is accomplished, most effectually, by dividing the
gum, with a lancet, completely down to the tooth, if it be
considerably advanced. Even when it is not so far advanced,
as to be near the surface, the division of the gum, gives tem-
porary relief. Gum-sticks act, somewhat, in the same fuga-
cious manner ; by enabling the child to press, or rub the gum
a little, he obt£dns a short relief. All children, instinctively,
thrust their fingers into the mouth, and this may be per-
mitted; nor is there any risk of a bad habit being induced.
This is as ui^eful as the g-um-stiek, and safer ; for a hard

665

gum-stick is apt to be thrust into the eye, or the gum may
be bruised by it. A crust of bread is often used, but part
of it may break off, and choke the child. An ivory ring is
safer.

Second^ We allay general irritation, or fretfulness, by keep-
ing the bowels open, and having the child out, frequently, m
the cool air. The cold bath, every morning, is also useful,
when it does not positively disagree, and, at night, the child,
if hot, may be sponged with cold water. If this do not prove
effectual, we may rub the spine and belly, with a little laud-
anum, which acts as an opiate, without inducing the injurious
effects on the stomach, wnich the internal exhibition too often
causes. Fever, if high, is to be abated, by the use of the
t^pid bath, morning and evening ; the bowels are to be kept
open. If the child be plethoric and drowsy, besides giving a
smart purge, either one or two leeches, ought to be applied to
the forehead ; and, if the determination to the head continue,
the scalp should be shaved, and a small blister laid upon the
occiput. Diarrhoea, if considerable and detrimental, is to be
abated by those means, which will hereafter be pointed out,
and, especially, if it be severe, by mild opiate clysteriB ; at the
same time that we, if the stools be very bad, give small doses
of calomel or blue pill at proper intervals, to bring the bowels
into a better state. The neatest number of children who'
die during dentition, perish m consequence of obstinate or ne-
glected diarrhoea. Sickness, loathing at food, and ill-smelled
breath, require a gentle emetic. Spasmodic and convulsive
affections, require the warm bath and purgatives. It ought
not to be forgotten, that as the irritation of the third branch,
of the fifth pair, causes more or less excitement, of the base of
the encephalon, we should, if the symptoms be acute, detract
blood, and apply a blister to the back of the head, nor are
we to be rash in healing that blister. Opiates are not to be
given, without much circumspection. They are always hurtful,
when there is much vascular excitement, but they are use*
fill, when this is absent, and there is, at the same time, great
irritation of the nervous system, or pain of the bowels. They
ought, in general, to be combined either with oil of anise, or
ascdfoetida, or with both. It is not easy to describe the different
symptoms, which occur during dentition, or may be connected
with it ; but one general rule must be laid down, namely, to
treat them, as we would do in any other circumstance, with
the additional practice of cutting the gum. Delicate and
Blender children, suffer chiefly from bowel complaints, and

666

spasmodic affections ; stout or plethoric children, are more apt
to suffer, from acute fever, with determination to the head.

Thirdy We support the strength, directly, by the breast
milk, arrowroot, beef tea, or, if necessary, by clysters of veal
soup, or calves'-feet jelly ; and indirectly by restraining im-
moderate evacuations. If the child have been recently weaned^
it is often of service to apply him again to the breast.

CHAP. IV.
OfCuianeous Diseases.

Nosological writers, unfortunately, do not agree in giving,
uniformly, the same name to the same disease. I have, how-
ever, endeavoured to detail faithfully, so far as I am able, the
symptoms characterizing the eruptions which I describe, by
whatever name they may be called,* and also to point out the
mode of treatment commonly employed.

* I adopt the termi of Dr. Willan, not that I think hit arrangement free from
many objections, but iMcaiue it is now best Icnown. If any of my readers have
leisure and opportunity to form a more correct division, I would suggest the
practical utility of introducing, as part of their improTement, an arrangement of
thoee mixed diseases, where there is a resemblance in character to two different
genera ; and the]nomencIature, in this case, might be similar to that of the chemist,
exhibiting the composition. For the structure of the skin, I refer to a paper by
Breschet and Rousel de Vauzeme, in the 2d vol. of Annales des Sciences Natu-
rales, 2d serie, p. 167, et seq. They divide the structure into, 1st, The derme,
a dense fibrous vascular layer, forming the frame for all the rest. The blood vea-
lels are found chiefly at its surfaces, especially its internal, forming there a rete or
sort of erectil tissue. 2d, The appareil neurothete or papillse, which are little
mamelons, terminating the nervous system, covered, like a hood, by the epidermin.
8d, The appareU diapnogene, which is found in all the thickness of the dffrme. U
consists of glandular or secretory sacs, surrounded by numerous capillaries, and
ending each in a spiral excretory duct, which passes between the papilbe, and fur-
nishes the sweat. 4th, The appareil d* inhalation, vessels accompanying the former
ducts, in a reversed course. Thev are part of the absorbent system. 6tn, Appareil
hlennogene composed of little reddish vascular glands, situated at the deepest part,
and some in the substance of the derme. Kach sends oiT an excretory duct to opeo
at the surface, where the mucous fluid they secrete, is thrown out to form epider*
mis. 6th, The appareil chromatogene, or a vascular and glandular snbstanee of a
spongv and areolar texture, situated at the external surface of the derme. Fmn
this, ducts go off which pour out a colouring matter, which, mixing with the mu-
cous matter, forms the epidermis or corneous substance. This is made up of im-
bricated scales, formed by the chromatogene, on a fine cellular bed, formed by the
hlennogene. The substance at first fluid, moulds itself, layer by layer, round the
papills, enveloping and protectiiu^ the sudoriferous canals. The colour of the
negro then depends on the scales formed by the chromatogene. It is, in its tran-
sition from the fluid to the solid form, that the secretion has lieen considered as a
particular tissue, for the rete mncosum has no existence as a distinct subsUnce.
The free edge of the scale is coloured black or white. The pedicle and the bed

667

SECTION FIRST.

The first eruption, which I shall mention, is well known,
under the name of red gum, and is described very accurately
by Dr. Willan, as his first variety of strophulus, a papulous
eruption* The strophulus intertrinctus, or red gum, consists
of a number of acuminated elevations of the slan, of a vivid
red colour, n#t, in general, confluent, and sometimes, even,
pretty distant from each other. The papulae are surrounded
with a red base. This redness, is often the most evident part
of the eruption, in very young infants, and the disease then
resembles measles. It covers a great part of the trunk, and
keeps almost entirely off the face. In the centre of the spot,
we may observe, a very minute elevation, or papula, witn a
clear top. There is no fever, nor has the child catarrhal
symptoms. The eruption comes out irregularly, and is either
more durable, more fugacious, or more partial, than the
measles. On the feet, the papulae are still more distinct.
The papulae of strophulus, are often intermixed with small
red specks, not elevated above the surface. They are hard,
and contain no fluid, or only a very small quantity under the
cuticle, at the apex, giving it a glistening appearance ; but they
seldom discharge any fluid, and scarcely ever form pus. This
eruption appears, generally, on the face, and superior extremi-
ties, but sometimes it spreads, universally, over the body. On
the back part of the hand, the papulae occasionally contain a
little yellow serum, but this is presently absorbed, and the
cuticle is thrown off, like a slight scurf. This variety of stro-
phulus, generally appears during the first ten weeks* of life,
and is not productive of any inconvenience. It seems to be
connected with the state of the stomach and bowels : and any
uneasiness the child may suffer, during the continuance of
the eruption, or previous to its appearance, seems referrible
to this source. The particular connexion, existing betwixt the
chylopoetic viscera, and. the surface, I do not pretend here to

Into which it is fixed are mlwayt white. The epidermis then is sn organized
texture, and from its transparency, the parts helow, when filled with hiood, seem
red. In the humid and squamoee dartre there is a more abundant secretion of
oomeons matter, which retains its fluidity and mucous appearance, or, oondensingf,
forms scales or crusu. The sudoriferous canals may, in certain diseases, be en-
larged or eroded, or the glandular organs In the derme much indurated.

Mekel, Tom. i. p. 473, gives a particular description of the skin, though diflTer-
ent from this, especially with regard to the rete. We have also in diflTerent parts
of the iNMly little culs-ae-saos, called sebaceous glands, which yield a peculiar ex-
cretion. These may be diseased.

* Sometimes a few spots of this kind may be observed on the forehead of
children, at the time of birth.

668

explain or investigate. I hold the fact to be established^ and
from no circumstances more decidedly than these, viz., that, in
adults, certain kinds of food do, with individuals, invariably
produce an eruption on the surface; and that, in children,
where all the system is much more irritable, trifling irritation
of the bowels, is followed by cutaneous eruption, whilst the
sudden disappearance of the eruption, on the other hand, is
succeeded generally by sickness and visceral disorder. I am
inclined to attribute, to a cause within the abdomen, all those
eruptions, which are not produced, by the direct application, of
irritations to the surface.* The affection, at present under
consideration, requires no particular remedies. It is sufficient
to avoid the application of cold, which might suddenly repel
the eruption, and filth or other irritation, which might
increase it, or superinduce another affection. Should the
stomach or bowels be affected, or the child be oppressed, a
very gentle laxative, may be occasionally administered ; or,
should the bowels be too open, and the child flabby, a little
tincture of myrrh, or myrrh with lime water, may be given,
and, if necessarv, an opiate. If the eruption be repelled, and
the child thereafter be disordered, the warm bath, with a gentle
laxative, will be proper.

SECTION SECOND.

The next variety, is the strophulus albidus, which is an
eruption consisting of minute whitish specks, hard, and a little
elevated ; sometimes, but not always, surrounded by a very
slight and narrow border of redness. No fluid is contained
in the papute, which appear chiefly on the face, neck, and
breast. This generally is met with, after the period, at which
children are subject to red gum ; it remains rather longer,
but requires no peculiarity of treatment. Sometimes children,
at a more advanced period, have this kind of eruption, on the
neck, which is exposed to the sun, in warm weather. It has
sometimes been mistaken for the itch.

SECTION THIRD.

The strophulus confertus, is a very frequent affection, dur-
ing dentition, but seldom appears before that period, though it
may occur after it. It consists of papulse, often set extremely

* Dr. Underwood is indiDed to think, that when children are euljecC to re.
peated eruptions, the millc does not agree with the etomach, and ought tohe changed.

.•'^.? ^^TY "^*^^ disposed to adopt hie opinion — See aleo Tamer on the Diecaaee
of the Skin, p. 69.

669

close together, forming patches, varying from the size of a
sixpence to a dollar. Such, at least, is the appearance on the
face and arms, to which parts it is often confined, especially
to the former. But it sometimes appears on the trunk, and
there the papulae are larger, flatter, and surrounded with
more inflammation, than those on the face or arms, looking
at a distance like measles. This eruption not only varies a
little, according as it appears on the trunk or extremities, but
also according to the age of the child. For after the seventh
month, we find, especially on the arms, the papulae pretty
large ; and either red, with scarcely any appearance of lympn
at the top, or of a light yellow colour, but the base surrounded
with a halo or inflamed rim. These papulae may, on some
parts, be distinct from each other, whilst elsewhere they form
clusters so close, that the redness surrounding one, communi-
cates with that of another, forming altogether a large inflamed
ground-work. In some cases, the red patch is the prominent
feature ; it may be as large as a dollar, with innumerable little
dots within it, like pin heads, with clear or watery-looking
tops, or larger red hard papulae. This eruption is sometimes
preceded by sickness, and, in certain circumstances, has been
mistaken for measles ; but it is attended with little or no fever,
and has none of the catarrhal symptoms met with in measles.
By not attending to the characters of the two diseases, they
may be confounded ; and not unfrequently, when young chil-
, dren take measles, the strophulus confertus appears on the
arms, previous to the proper eruption, or even auong with it.
Dr. Underwood says, tnis eruption does not dry off like
measles ; but as Dr. Willan remarks, it often does terminate,
with a slight exfoliation of the cuticle. A variety of this
disease, appears like red patches, on different parts of the body,
particularly on the arm, and often coming out in succession.
They are as large as a split pea, and a very little raised toward
the centre. By near exammation, several small papulae may
be discovered, which are something like vesicular points. In
three or four days, the patches become yellowish or brown,
and covered with small scurf. This is denominated by Dr.
Willan, strophulus volaticus, and is said not to be very com-
mon, but I think it is frequently met with. It is seldom
necessary to give any medicine for this complaint. If, however,
it be troublesome, it is usual to prescribe gentle laxatives, and
testaceous powders. Some, advise emetics, and the use of
the bark ; but neither, I believe, are in general necessary.

670

SECTION FOURTH.

Strophulus candidus, consists of papulae, having a smooth,
shining surface, which appears of a paler colour, than the rest
of the skin, and the base is not surrounded by any inflamma-
tion. It is described by Dr. Underwood, as resembling itch,
but is neither red nor itchy. It generally either attends den-
tition, or succeeds some acute disease of children, and is
considered as rather a favourable symptom. It is most fre-
quently met with, on the trunk of the body, the arms, or fore-
head. In a few days the papulae die away. No particular
treatment is necessary.

SECTION FIFTH.

A different eruption, from any of the foregoing, is the lichen,
a term, restricted by Dr. Willan, in his elaborate work, to a
papulous eruption, chiefly affecting adults. It may, however,
appear also in children ; and I have seen it succeed some of
their febrile diseases, as for instance, measles. It consists of
numerous distinct papulae, some of which, are pale at the top,
but very slightly red at the base ; these are generally small
like pin heads. Others, are larger and flatter, and more
inflamed, but have always, at first, a clear apex, and do not
end in ulceration, but die away in slight scurf. Sometimes
on the body, there are small shining or silvery-looking
patches, from exfoliation of the cuticle; or the skin may peel
off more extensively, as if it had been blistered. They
often resemble the papulae in strophulus, but seldom form in
clusters, and have not, in general, any diffused redness con-
necting one papula to another. There is, however, sometimes
about the joints or forearm, a considerable degree of red
efflorescence, covered with scurf. This eruption may be pro-
duced by exposure to heat, and by drinking cold water when
heated, or other less obvious causes. It is frequent in warm
weather, and a species of this, is known under the name of
prickly heat. It is preceded, often by febrile symptoms, and
the eruption itself, may last for more than a fortnight, but in
a few cases it goes off in a day or two. These papulae, at
different stages, bear a resemblance to two very dissimilar
diseases, the itch and the measles; but it is not pustular
like the itch, neither does it ulcerate ; it is not very itchy,
and if scratched, so as to take off the top, it does not yield
matter, but a little bloody scab is formed. It differs from
the measles, in being papulous, and having on the spots.

671

before they form slight scurf, a clear-looking top; it ia
general lasts longer than the measles, and is not attended
with catarrh. Further, it is sometimes accompanied, with a
broad scurfy efflorescence, about the elbow joint, or other
flexures. A suitable dose of calomel is the best remedy, or
should the patient be oppressed, an emetic and saline mix*
ture may be given. When there is no febrile affection, it
will be sufficient to keep the surface clean, by means of the
tepid bath. A variety of this, named lichen urticatus, by
Dr. Bateman, resembles the bites of bugs, and appears in
irregular wheals, which are very itchy. This ends m small
elevated papulse, and the whole body may be successively
covered with these papulae. The itching is intolerable at
night. It seems to be relieved by small doses of sulphur,
and, if the child be weak, by tofucs and chalybeates. No
external application is useful, if we, perhaps, except tepid oil.

SECTION SIXTH.

Intertrigo, is a kind of ery thematic affection, of those parts
of the body where the skin, forms folds or sinuosities, as, for
instance, tne joints of fat children. It also is very common,
about the nates, and inside of the thighs, in consequence of
the urine fretting these parts. The inflamed surface, ought
to be washed, occasionally, with tepid milk and water, and the
child should never be allowed to remain wet, but ought to be
bathed, and gently dried, after making water, when the thighs
are affected. Afterwards, the parts are to be dusted with
some cool powder, such as tutty, white lead, levigated flowers
of zinc, &c. It is not usual for intertrigo to end in gangrene
or suppuration, but sometimes the form of the disease changes,
and the cellular substance inflames ; either of these termma-
tions may then take place, and wUl require the usual
treatment.

SECTION SEVENTH.

During dentition, or in consequence of affections of the
bowels, different anomalous eruptions may appear, which are
not distinctly referrible to any well defined species. Sometimes,
we find upon the arm, one, two, or three inflamed portions
of the skin, something like small-pox, but rather larger, with
a small acuminated speck of lymph, beneath the cuticle at the
apex, or sometimes the top is flattened and shrivelled. Occa-
sionally, a greater number of pustules appear on the body,
pretty large, hard, and inflamed round the base, with a white

672

top. This kind of eruption is not attended with feyer, and
is neither painful nor itchy ; it goes off in a few days without
any medicine.

Infants who are supplied with deficient nourbhment, or
bad milk, are subject to troublesome and successive crops of
ecthymata, or inflamed pustules, which slowly suppurate,
burst, and form brown scabs which presently fall off. They
affect every part of the body, and sometimes are combined
with one or two pustules, so large and hard, that they may
be called boils. The colour is dependent on the constitution,
the exhausted, having the pustules lurid or purple; the
stronger, having them of a more arterial colour. This
eruption, named ecthymata infantile, requires a more nutri-
tive diet, or a new nurse, with all the usual means, for invig-
orating the system, amongst which, I particularly mention,
attention to the bowels, and removal to the country. If ne-
cessary, the pustules may be defended, with a little mild salve.
Young people, after much exertion, or from gross feeding, are
sometimes affected with a similar eruption of the pustules.
Laxatives, with vegetable tonics, cure this. Ripe fruits, par-
ticularly gooseberries, are proper.

Anodier kind of eruption, attacks children above two years
of age, suddenly covering, the greater part of the body. It
consists of red elevated spots, at first sight, something like a
kind of pock. The spots are distinct, and most numerous on
the thighs and le^. They are of a dark red colour, pretty
flat, with a smooth flatted vesicular-looking top, which does
not burst, nor discharge matter, but gradually dries and
desquamates. The eruption is scarcely painful or itchy, and
is not attended with fever. It may continue for four or five
weeks, and is sometimes combined with lichen, or other cuta-
neous diseases. The bowels should be kept open, and some,
advise antimonial wine to be given, with a little tincture of
cantharides.

There is a small and very itchy pustule, which begins with
a black spot on the skin, and contains a sebaceous fluid,
which can be squeezed out, in a worm-like shape ; such pus-
tules are not uncommon in youth, and have been called crin-
ones. They are cured by applying ung. hyd. nit. and wash-
ing with almond emulsion, containing a little muriate of
mercury, or with soap and water.

Boils, have been divided into the furunculus, or acute boil,
and the phyma, which is more tedious. They are hard, usu-
ally flat, with an extended base, and of a purple colour.

673

They are sometimes solitary, and very large, but occasionally
they are scattered, in considerable numbers, over the body.
They generally proceed from a bad state of health, and, in
place of requiring, as some suppose, an abstemious diet, they
demand more nourishment, but it must be easily digested, and
the bowels should be attended to. A bread and miUc poultice^
is to be applied to the boil, until the top open, which it does
by a kind of sloughing. Scarcely any matter comes out, but
a kind of ash-coloured, or yellow core, is gradually thrown
out, after which the part heals. Resinous ointment, is the
best application, during this process. Those large indolent
boils, or small abscesses, which succeed small-pox, or other
debilitating diseases, require hot poultices, and then, when
they burst, or are opened, and the pus they contain evacuated,
stimulating dressings, with moderate pressure, are proper.
Good diet,^and even wine, may be reqmred.

SECTION EIGHTH.

Authors describe some other eruptive diseases, which may
be noticed here with propriety: one of these, called pom-
pholyx, consists of a number of vesications of different sizes,
appearing on the belly, ribs, and thighs, and containing a
sharp lymph ; they may appear during teething, or in bowel
complamts, and continue for several days. These vesications
are not uncommon in very warm weather ; and I think boys
are most subject to them, especially about the ankles, if they
do not wear stockings. Lory, considers this disease, as a kind
of erysipelatous affection, produced by the heat of the sun.
It requires no medicine, but the lymph ought to be let out, by
a small puncture.

A similar appearance, generally attended with fever, and
sometimes with aphthae, is more serious. The vesicles, at
first small, presently, become pretty large and oval, and their
contents turgid. They appear soon after birth, generally in
emaciated infants, affect both the trunk and extremities, are
surrounded with a livid inflamed halo, and, when broken, are
succeeded by spreading ulceration. Notwithstanding bark
and cordials, the fever and irritation generally prove fatal, in
about a week ; and only those children are saved, who are
previously possessed of a tolerable degree of strength. This
may be mistaken for syphilis. Some, have considered it as
pompholyx, under a different modification ; others, as a dis-
tinct disease, under the name of pemphigus.

674

SECTION NINTH.

Scnertufi describes, under tbe name of sudamina, an erup-
tion like millet seed, fretting the skin, and affecting children
about tbe neck, arms, &c. Plenk defines it in the following
terms: Sunt vesieukB, grants milii magnitudine ei similis^
sulntOy absque fthre^ erumpentes. Tbe child should be bathed
occasionally in tepid water. This eruption often takes place
in hot weather. A similar eruption, attended with fever, is
also met with, which I find yeir well described by Dr. Willan,
in his reports on the disease of London, under the name of
acute miliaris. It does not affect infants, but children old
enough to take active amusement. It begins with a febrile
attack, attended with head-ach and pain in the back. The
tongue is of a dark red colour at the edges, with the papillae
prominent, as in scarlatina: the rest of the tongue is covered
with white fur. The pulse is small and frequent. Presently,
the patient complains of heat and pricking at the surface, is
sick at stomach, and perspires freely through the night. At
a period, varying from the third to the sixth day of the fever,
an eruption appears, of small pustules like millet seeds.
These are of a red colour, but contain at the top, a white
lymph, and are either difiused over the body, or collected in
patches on different parts, especially the back and breast;
they may alternately appear and disappear, and though the same
pustule does not continue long, it may be speedily replaced.
They may sometimes be combined with small red efiBorescences,
and generally vesicles appear, on the tongue and fauces, end-
ing in aphthous ulceration. The complaint often terminates
in about ten days, but it may be prolonged even to twenty.
It is frequently the consequence of being overheated, or drink-
ing cold water in that state. It requires, first of all, an eme-
tic, and then a purgative. During the course of the disease,
the patient should be kept moderately cool, and use acidulated
drinks freely.

SECTION TENTH.

Itchy eruptions, are frequently met with on children, but
these are not always the true itch, nor the consequence of in-
fection. The mrurigo mitis, described and dehneated very
accurately by Dr. Willan, is a disease often met with in

C75

spring. It appears without any previous indisposition, and
consists of soft, smooth, elevations of the skin, or papulae, dif^
fering, in colour, very little from the surrounding integuments.
When they do become red, it is in consequence of friction.
If the top be rubbed off, a clear lymph oozes out, which forms
a thin scab, of a dark, or almost black colour. The erup-
tion is itchy, especially on going to bed, and, if scratched,
it may become pustular and contagious, which it is not in its
early stage. At first, it may be removed, by washing fre-
quently with tepid water, and a little soap, or lemon juice;
but, if neglected, it requires the application of sulphur, espe-
cially in the form of bath.

A variety of this disease, consists of minute red acuminated
papulse, with a very small vesicle at the top, terminating not
in suppuration, but yielding, when scratched, only a little clear
serum. Sulphureous preparations give relief, and time, with
attention to cleanliness, confirms the cure. Sometimes, very
little itching attends this eruption, and it disappears by using
the tepid bath.

SECTION ELEVENTH.

The scabies*, or true itch, is contagious, and consists of
small pustules, which have a hard hot base, with a watery-
looking top. They are attended with an intolerable desire
to scratch : in consequence of which, the tops are rubbed off
the pustules, and scabs come to be formed, partly by blood,
and partly by a kind of matter, furnished by the httle ulcers.
But if the pustules be not disturbed, but removed by proper
applications, they end in a slight desquamation of the cuticle,
'* qu4B vtx furfur aliquod aatendat^ The itch first appears
betwixt the fingers, on the wrists and hams, but, if neglected,
it may spread over the whole trunk and extremities, and, in
consequence of the continual irritation, impairs the health,
nay, some children die in consequence of it. In neglected
cases, the inflammation surrounding one pustule, spreads to
another, and the part becomes universally red, with pustules
or scabs, according to circumstances, scattered over it. This
is often the case, on the back of the hand, and forepart of the
feet. Sometimes small boils, and phymata, appear in the
course of the disease, on the thighs or body, or about the face.
The itch has not always the same appearance, being, in some

* Chitdrm, in cooteqaenM of handling mangy dogi or kittens, are ■omMimM
nifcetod with an obftinate itdijr eruption, which it not aeabiai, but may be eured
bj the remedies need for the iteh.

676

cases, more yesicular, or more pustular, than in others. Four
different yarieties have, accordingly, been admitted by Dr.
Willan: — 1st, The scabies papuliformis, where the eruption
looks like papulae, but really consists of small pointed vesicles,
which are very itchy ; when these break, they are succeeded
by scabs. This variety is apt to be confounded with lichen,
or prurigo, when there has been much scratching, but these
are more distinctly papular. 2d, The scabies lymphatica, or
eruption of vesicles of considerable size, without inflamed
base, but extremely itchy. These may heal by scabbing, but
often suppurate, and form small ulcerated blotches, and, in
the same part, we have all the intermediate steps, from vesicle
to small open ulcer. The disease, with which this, is most apt
to be confounded, is eczema. 3d, Scabies purulenta, or erup-
tion of distinct prominent pustules, about the size of a split
pea, filled with yellow matter, and having a slightly inflamed
base. These ulcerate in a day or two, and become then more
painful. They are not unlike small-pox, but are very itchy.
The scabs are thin and hard, of a yeUow colour, or inclining
to brown. They are surrounded by a diffused redness of the
skin, which often has a puckered appearance, as if drawn
towards the scab. These pustules, are most frequently situat-
ed, between the thumb and forefinger, or about the wt\bU
4th, Scabies cachectica, combines the character of the former
varieties, which it exhibits, at the same time, in different por-
tions of the skin. It originates in cachectic children, without
infection.

The cure may generally be accomplished, by freauent
ablution, and rubbing the parts affected with sulphur-vivum
ointment,* which, in obstinate cases, may be rendered more
effectual, by the addition of powdered hellebore, or sulphate
of zinc, or sal-ammoniac. Rosenstein says, that the hands are
very soon cleared, by washing them with a strong decoction
of juniper-berries ; and, that, when the eruption is great, as for
instance, on the feet, he has applied cabbage leaves with
advantage. They cause, at first, a great discharge, but the
parts heal afterwards. Sulphureous baths are also useful.

Sometimes, the friction excites an eruption, different from
itch, and kept up by the remedies intended to cure it. M.
Burdin remarks respecting this, that it consists of small round
pustules, ^'qui se remplissent, quelquefois, de serosit^, et dont

* Dr. JoHeph Clarke conniders it as dangerous to use sulphur ointment fvith
infants, lest ttie eruption be suddi*nly repelled : and advises rather to boil a piece
of stick brimstone in water, in order to make a bath.

677

la cicatrice laisse, le plus souvent, une tache d'un rouge brun,
le prurit qu'elle occasione, est aussi moins fort, que celui
de la gale." In inveterate cases, the use of Harrowgate
water is of great benefit, or a sulphur vapour bath has been
used. In order to avoid the smell of sulphur, other applica-
tions* have been employed, such as sulphuric acid, or nitrous
acid, combined with hog's lard, ointment of nitrated mercury,
camphorated ointment, hellebore, or corrosive sublimate,
mixed with hog's lard, &c. These often fail, and even when
they do remove the eruption, the cure is said frequently not
to be permanent. Ointment containing white precipitate, is
sometimes useful, particularly, in the pustular variety. Itch
may be combined with other diseases, such as herpes, syphilis,
&c., in which cases, it is more obstinate than usual, and may
sometimes require the use of mercury.

SECTION TWELFTH.

Herpes, is a vesicular disease of short duration. It consists
of irregular clusters of small vesicles, which arise in close
approximation to each other, from an inflamed surface, and
the inflammation surrounds also the base of the cluster, to a
small breadth. The vesicles, which appear rapidly, contain
a pellucid fluid, that presently becomes turbid, oozes gently
from the opening or declining vesicle, and forms a yellowish,
or brownish scab on the part. In some instances, however,
the vesicle ends in ulceration, and the discharge is copious
and thin. If the scab be prematurely forced off, the surface
below is found raw and glossy. In slight cases, the sensation
is that of heat or itching, but, when more extensive or severe,
the neighbouring parts are pained, and the eruption itself is
preceded by some degree of fever.

A great number of affections, have been comprehended
under this name, many of them of very opposite characters, and
even our most correct nosologists, who have excluded those
which are not vesicular, have admitted, as species, mere vari-
eties of the complaint. The first species, for example, of
Alibert, is the herpes furfuraceus, or dartre filrfurac^e, which
is a scaly, and not a vesicular disease, and his other species
are also very doubtful in their nature. The subdivisions,
again, of Willan and Bateman, are often founded on mere situ-
ation, or arrangement of vesicles. The herpes phlyctaenodes,

• M. Been advises the following lotion : Take of tobacco leaves two pounds,
saKammonlac one ounce, ammonia two ounces, water three Paris pints. Infuse
for two hours.

678

the fi^t species of WiUan, and the sixth of Alibert, is, perhaps,
the only one to be admitted, all the rest being varieties. This,
when well marked, is preceded by slight febrile irritation, for
about three days* Then, irregular clusters of vesicles appear,
which become opaque in the course of a day. By the fourth
day, the surrounding inflammation becomes less, and the
areola fades, whilst the vesicles themselves begin to scab, and
continue in this state, till the end of the week, or sometimes
a day or two longer, when the scabs fall, and leave the surface
below red. The size of the vesicles varies. When small,
they are called miliary, and, in this case, the clusters often
spread over a considerable part of the body : and, as they do
not appear, all at the same time, the disease may last alto*
gether a fortnight. When the vesicles are larger, their
clusters are not in general numerous, and sometimes are
solitary. Within a day or two, after the appearance of the
vesicles, the slight general indisposition goes off.

A slight degree of this complaint, is common about the lips,
or chin, or side of the nose, and is called by Dr. Willan,
herpes labialis. It is not, in general, attended with indispo-
sition, but popularly, is attributed to cold, which is then said
to strike out. In some cases, however, there is a degree of
fever, and successive crops come out, round the mouth, accom-
panied with swelling, hardness, and sensation of heat in the
lips.* In such cases, the fauces may be affected with a similar
vesication.

Another variety, has vesicles, arranged in the form of a
ring, the central portion being only very slightly inflamed.
As the vesicles break and scab, and the scabs tall off, this
central portion throws off the cuticle, in form of fine exfolia-
tions, like bran. The size of the ring, also often increases,
by the successive formation of concentric circles of vesicles,
ouccessive circles of this kind, appear on different parts,
particularly on the face, and upper extremities, so that the
disorder is prolonged for, perhaps, three weeks* This is most
frequently met with in children, who are also subject to the
last variety, the herpes labialis. It forms one kind of ring-
worm, of which there are different varieties. It is named by
Dr. Willan, herpes circinatus, and is supposed to be infectious;
but I believe that every variety of herpes may be inoculated.
The herpes circinatus of Alibert is a nirfuraceous disease.

* Uodtr this nama Alilwrt dewribM iin eruption, to ivhicb voung girl% near

fiubortv, are •ubject, and which he makce a Taricty of bit piutular berpM. At a
ittie distance it looks lUce measles, but is smaller and pustular.

679

Another variety, also met with in youth^ but not often in
infancy, is popularly named the shingles, or, by Dr. Willan,
herpes zoster, and by Alibert, herpes zonseformis* It is pre-
ceded, for two or three days, by febrile symptoms, accompa-
nied vrith shooting pain about the stomach, or lower part of
the chest, and smarting sensation in the skin* This sensation
is perceived chiefly about the trunk, and is soon attended
with an eruption oi irregular patches, of a red colour, a little
distant from each other, and on which small vesicles soon
arise. These run the usual course of herpes. Successive
clusters appear, so disposed, as ultimately to encircle nearly
the part where they are situated, travelling, for instance, like
a zone round the waist, but seldom completing the circle.
Alibert has selected, as a specimen of this, in his superb
plates, the disease passing round the thigh. I do not con-
sider it as necessary here to describe any other varieties.

With regard to the causes of herpes, we are much in the
dark. It sometimes appears to follow exposure to cold, or
to be consequent to violent exertion ; but, perhaps, it most
frequently is connected, with some particular condition, of the
abdominal viscera.

The treatment of this disease is very simple, consisting in
the administration of gentle purgatives, restricting the patient
from indigestible diet, and from the use of stimulants. No-
thing can, with much advantage, at first be applied to the
vesicles, unless it be with a view to prevent their abrasion* If
any thing more active be employed, it should only be some
weak astringent wash, such as solution of sulphate of zinc in
rose water. When crusts are formed, the application of a
little ung. hyd. nit. appears to accelerate their fall, to heal
sooner the surface below, and to abate heat and itching.
Wlien there is much glutinous discharge, either this, or some
other milder ointment is useful, to prevent the linen from ad-
hering to the part.* The application of nitrate of silver has
been useful, or weak sulphureous baths.

* There are two dioeaset which are apt to affect females, erm when youngs
but which 1 hare never teen in iiifaiicv. They are of tlie mixed character, and
cannot Btrietly be included here. The herpes orbicularis of Alibert appears often
on the cheek, as a very superficial excoriation, etidiiig in broad, thin scabs or scales.
The part is red, and a little itchy, and the scabs are generally thickest at the cir-
cum Terence. It is a very obstinate disease, and lasts for years. The herpes
cnistaceus of Alibert appears lilie a cram of dried honey on an erysipetatous
ground. 1 1 arises front a raw surface, with thickened margins of a purple colour,
'i'liere is often swelling, and induration of the nt'ii;hb4i tiring cellular matter, and
the crust itself is elevated. On the cheek it forms a thick, vellowish crust ; ou the
wing of the nose it Is still thicker, so that this has been calhrd stalactiform herpes.
Thp»e diae<ises are often connected with a scrofulous habit, and after remaining

680

SECTION THIRTEENTH.

Impetigo, is a term differently applied by writers, and,
hence, uncertain in its meaning. Some, confine it to a pus-
tular, and others, extend it to a vesicular, or herpetic erup-
tion. It appears in clusters of small pustules, which are
rather flat, tilled with yellow matter, somewhat irregular in
their shape, and inflamed at their margin. These are set
pretty close to each other, and the whole group, seems a very
little higher, than the surrounding skin. They are itchy, and
pungent, and soon break, discharging much ichor. The
surface has a raw, glossy appearance. Then the part becomes
covered with scabs, of a greenish yellow colour, and after
some weeks, the surface below healing, they fall off, and
discover it to be red and scabrous, and easily fretted, so that
the discharge and scabbing may be again renewed. The
healing process, generally begins in the centre of the patch,
and occajsionally, as it heals, concentric and enlarging circles
of pustules, successively appear as in ring-worm, and this
variety has been called impetiginous ring-worm. The pustules
are oiten mixed with distinct vesicles, filled with transparent
fluid, which presently becomes dark, or even bloody, and then
crusts form, which are rough, of a yellow colour, inclining to
brown. There is a good deal of surrounding redness, and
radiation of the skin. The vesicles are generally, in this
case, the chief portion of the eruption, and are more distant,
or scattered, than the pustules. This variety, is oftenest met
with, on the hand, and about the knuckles and fingers. This
bears a resemblance to the scabies purulenta, but the pustules
are smaller, and more clustered, and it is not infectious : the
discharge is greater, and the skin rougher and redder. This
variety is more frequent with children, whilst they are seldom
affected with the other kinds. It has been divided into the
impetigo figurata, and sparsa ; the former, however, differing
only from the latter, in the pustules being clustered, whereas,
in the sparsa, they are scattered distantly, and especially over
the inferior extremities. Other varieties have been enume-
rated, but do not fall to be noticed here, as they rarely occur
in childhood, such as the erysipelatous, beginning like rose,

lon^statiooarv, somctiiaesend in corroding ulceration, caries, and fatal exbaosUon,
or oectic. Mercury may do no harm, but never does good, except in a fevf caaea*
where very small doses of muriate of mercury have altered the habit. Sarsaparilla,
with arsenic. Is more useful, and aperient waters, containing sulphur, are a)ao
employed. Hemlock has not maintamed its reputation. Only mild local appli-
cations should bf* prescribed.

681

and then in place of blisters forming, an eruption of psydra-
ceous pustules appears ; the scabida, where the whole limb
becomes cased in a crust ; the rodens, which is a malignant
and spreading sore. The best internal remedy is sulphur : if
that fail, mild diaphoretics and sarsaparilla may be given.
Topical stimulants do harm ; mild applications, such as sul-
phur ointment, or cerussa ointment, are better. In very
irritable cases, ablution with tepid water, and smearing the
parts with cream, or fresh oil, is more useful. In the scabby
state, sulphureous waters, as a lotion, and also taken inter-
nally, are useful. When cured, the cold bath prevents a
relapse.

SECTION FOURTEENTH.

Children are sometimes affected with ichthyosis, a disease,
in which, the skin becomes dry, and covered with scales, resem-
bling in their distribution, and sometimes in their appearance,
those of a fish. The disease may come on at any period of
life; it may even be connate, but this is very rare. It is
proper to employ the warm bath, and during its use, to pick
off the scales. Their regeneration, is to be prevented, by
gentle friction, and repeated bathing. Sarsaparilla, and mild
laxatives, are the internal remedies. Sometimes, children have
this disease conjoined with boils.

SECTION FIFTEENTH.

Lepra (from the Greek word signifying rough), is a very
common disease amongst children, and is vulgarly known,
under the name of scurvy spots; others, commonly, call it
ring-worm, herpes farinosus, or dartre furfurac^e. It is dis-
tinguished from other scaly eruptions, by the nearly circular
shape of the patches. There are two species, the vulgaris and
alphoides, which differ from each other, chiefly in the latter
being smaller and more distinctly circidar. Neither become
moist, or form scabs or crusts. The species to which young
people are subject, is the lepra alphoides. This appears, in
the form of small patches, of nearly a circular form, seldom
exceeding half an inch, but more frequently less. The spots,
which generally come out quickly, are first red, but, soon, be-
come covered with small shining scales. The margin, is a
little elevated, and usually somewhat inflamed. These patches,
are generally confined to the extremities, particularly, the in-
ferior, but they may also appear on the trunk. They rarely
become confluent. The causes of this obstinate disease are

682

obscure. The treatment which I hare found most useful, con-
sbts in the use of tonic laxatives, and the administration of
arsenic. A dram of the common solution, may be added to
four ounces of water, and of this mixture, a tea-spoonful
may be given, in a glass of water, three times a-day, to a
child three years old. It should always be given after eating,
and not when the stomach is empty. If it produce sickness or
griping, the quantity is to be diminished, aflber suspending it
altogether for a short time. If it produce no such effect, the
dose may be gradually increased, to double the quantity pre-
scribed, watching, however, the state of the stomach. It re-
quires sometimes to be continued for several weeks, before a
salutary effect be produced. If there be great irritation and
tenderness of the skin, venesection has been useful, and in
children who have been rather too well fed, the regimen must
be strict. As topical applications, diluted citrine ointment, and
ablution morning and evening with soap and water, are pro-
per. The tepid bath is also proper, and presently, with ad-
vantage, we substitute the soda bath, or sometimes the sul-
phureous, as described in speaking of psoriasis.

SECTION SIXTEENTH.

The scaly tetter,* dry itch, or psoriasis of Dr. Willan, con*
sists of red rough spots, which are very soon covered with a
laminated scale, sometimes as thick as paper, but generally
thin, and very like a bit of the dried scale of a herring. They
are irregalar in their shape and size, occasionally, not lai^er
than a coriander seed ; sometimes, as large as the nail of the
little finger, resembling a dried fish scale pasted on the skin ;
and frequently they are interspersed, with shining silvery-
looking portions of the surface, or the patches become conflu-
ent, so that a considerable extent of surface may be covered
without inter-limitation. These scales, are formed by the
exudation of a whitish matter, which is very glutinous, and,
as Sylvius observes, stiffens the linen, when it happens to
exude in sufficient quantity. In adults, some portions of the
surface, yield so much fluid, that the parts are quite moisty
and scales do not form. Different species have been enume-
rated by Dr. Willan, which, however, mav rather be viewed
as varieties. I do not mean to notice aU those here, as it doea
not consist with the object of this work. 1st, Psoriasis gut-
tata, or dartre orbiculaire of Alibert, is not uncommon in chil-

* Tetter has been derived from dHrtrc, but U cornea from the Saxon word> sif ni-
fying acurf or scab.

683

dren, and often spreads rapidly over the whole body, and even
the face. It is occasionally preceded by slight constitutional
disturbance. The eruption consists of small distinct scaly
patches, of an irregular shape, resembling lepra in appear*
ance, but differing from it, in wanting the elevated border, in-
flamed margin, distinct circular or oval shape, and, in the sur-
face below, being more fretted and irritable. It forms a link
between the next species and lepra. 2d, Psoriasis diffusa,
forming large irregular patches, which sometimes become con-
fluent, and possess the general character of the disease. A more
severe variety, is termed inveterata, and others are named from
their situation. Different complications and modifications ap-
pear in children, forming, perhaps, the most frequent cutane-
ous disease we meet with.

The spots on children, generally begin like papulse, of small
size, and are sometimes vesicular at the top. These end,
sometimes, in scurf, oftener, in thin scales, as has been de-
scribed. On the back of the hand, the vesicles, when they do
form, are sometimes pretty large ; whilst in the palm of the
hand, the eruption is rather pustular, and ends in broad thin
rough scabs, of a yellow colour. In the early stage, it is some-
times combined with strophulus. The parts are itchy, but
when they are scratched, matter does not come out, by the
removal of the scales, but a little blood flows. This eruption
often begins on the face or neck, and spreads to the body and
extremities. It is very obstinate, and sometimes destroys the
nails. When it has continued for some time, the skin, espe-
cially about the hands and feet, is found to be universally red,
with dark coloured scales interspersed. The skin looks as if
it had been scalded, and partly covered with thin scabs, or
scales, in different degrees of adhesion ; and, in some cases,
the whole of the extremities, and even the body itself, ot* the
head become red, partially excoriated, and covered partly with
scales and scurf, and partly with scabs, which are yellow, and
pretty thickly set, often loose, and easily detached. Some-
times, on different parts of the body, particularly on the arms
or legs, there are many soft red indolent bumps, more espe-
cially if the child, have been seized with this disease, soon
after the small-pox or chicken-pox. The appearance on the
head, is nearly the same as in pityriasis, but in general it
wants the white scurf. It is rare not to find the head affected
in this disease.

Excoriation, sometimes also takes place about the anus, M-ith
a slijrhtly elevated state of the surface ; in consequence of

684

which, and the disease of the skin taking place soon after
birth, I have been consulted respecting children given out to
nurse, who were apprehended to have syphilis. Dr. Willan
remarks the syphilitic appearance of this disease, but observes,
that all other marks are absent. The syphilitic form of this
disease, is supposed to be marked by hoarseness, the patches
of a livid colour, with a slighter degree of scaliness, and the
margin sometimes higher than the centre. I know, however, that
these marks are not infallible. I have seen syphilitic-looking
excoriations about the lips and mouth, and extensive ulcera-
tion around the anus, and excoriation about the labia, groin,
&c., where no effect was produced on the nurse, and where
there was every moral certainty that neither of the parents had
ever been even exposed to infection. In one case which
proved fatal, mercury was of temporary benefit.

It is not, like the itch, very contagious, nor is it easy to say
what occasions it ; but we know, that inattention to cleanli-
ness is favourable to its production. It is in every plan of
treatment necessary to administer laxatives, if the bowels be
not quite correct ; and if the alimentary secretions be morbid,
these ought to be frequently combined with mercury. A mild
mercurial course of solution of blue pill, so as to give two
grains every night to a child, or from five to twenty drops
(according to the age) of liq. oxymur. hyd. in water, alone,
or with the same quantity or antimonial wine, every night.
Some mild diaphoretic may also be given through the day,
such as acetate of ammonia. If these means fail, solution of
arsenic should be tried, or sulphur may be given internally,
or tincture of iodine. Much may be done by diet. K the
child be not weaned, it may be necessary to change the nurse.
If older, the food should be light, and if the child be robust,
should not be too nourishing. If there be much irritation
and extensive disease, leeches at an early period are useful.
At a more advanced age venesection is proper, and indeed
some cases never yield till this be resorted to. It has been
too much neglected, from being originally proposed on a false
theory.

With regard to local applications, the best, when there is
much tenderness, is the tepid bath, and the frequent use of
butter-milk, or emulsion oi almonds as a lotion. When there
is less tenderness, the worst parts may be anointed with diluted
citrine ointment, or, if not extensive, with a salve made by
rubbing a drachm of calomel, with a drachm and a half of
prussic acid, and two ounces of lard. This does not keep

685

long, and therefore should be prepared in a small quantity at
a time. When the skin is not raw and tender, we ought also
to use every night, or every second night, instead of tepid
water, a bath made by dissolving an ounce of carbonate of
soda in a pailful of tepid water, or proportioning the strength
of the solution, to the state of the skin. Sulphur may next be
used if this fail. Half an ounce of sulphuret of potash may
be dissolved in a quantity of tepid water, sufficient to receive
the child, and to this may be added a drachm of diluted sul-

Ehuric acid. These ingredients can be increased, if the skin
e not tender. Through the day, if salves be not employed,
the parts may be bathed twice or thrice, with a lotion made
by dissolving two grains of corrosive sublimate, or a scruple of
sulphate of zinc, in eight ounces of emulsion of almonds.

SECTION SEVENTEENTH.

The pityriasis, is a disease known, commonly, under the
name of the dandriff. It consists of a dry, scurfy, and scaly
eruption on the head, amongst the hairs. Near the forehead,
the skin is covered with a thick, white scurf, which can be
removed, in a powdery form ; farther back, larger scales are
formed. This is cured, by cutting and shaving the hair, and
brushing the head, daily, with a hard brush, washing it with
soap and water, and applying ung. hyd. nit. If neglected,
ulcers may form, and tne disease be converted into the one
next to be described. Pityriasis is sometimes infectious. A
variety of it appears like small red marks on the scalp. The
circumference extends, and continues red, whilst the centre
becomes pale and scaly. It is accompanied with falling off of
the hair.

This disease is not confined to the head, but affects other
parts. That variety, named pityriasis rubra, by Dr. Willan,
is of frequent occurrence at all ages, although said to be most
apt to appear at advanced age. It begins with a redness, of
variable size, and indefinite shape. It may be small or exten-
sively difiused ; the colour becomes deeper, and the surface
rough ; then, it puts on a mealy appearance, from commenc-
ing exfoliation ot the cuticle. As this advances, the part is,
in a great measure, covered with small branny scales, which,
as they, in different spots, fall off, discover the skin red below.
Repeated exfoliation may then take place, and when the sur-
face is extensive, the patient's bed is often found covered with
smaU scales. The adSected parts are itchy, and sometimes

686

feel stiff. The skin is dry, and no perspiration can be, in
general, naturally, or artificially, produced.

There is a great analogy between all scaly diseases, and
often the same person exhibits, in different parts, different
species. In some the disorder has more the appearance of
psoriasis, and in others, there are distinct patches, of the
nature of lepra. Sometimes, it is not very easy to say, whether
the disorder belongs, most, to one species, or to another. It
is this pityriasis, and its modifications, which are most fre-
quently misnamed herpes farinosus ; an appellation also given
to modifications of psoriasis, and, indeed, to every superficial
scaly disease.

The treatment consists in regulating the bowels, avoiding a
saline or irritating diet, in the frequent use of the tepid bath,
gentle friction with ung. hyd. nit., or ointment, containing
finely powdered cocculus indicus; the exhibition of some
diaphoretics, such as decoction of sarsaparilla, with a little
antimonial wine, arsenic, sulphureous waters, internally and
externally.

SECTION EIGHTEENTH.

Porrigo, or tinea, is a collection of achores, or pustules,
containing a yellowish-coloured fluid, something like honey,
and ending sometimes in the production of a raw and secret-
ing surface, but oftener in the formation of scabs, which are
generally white or yellow, but sometimes darker, from an
aidmixture of blood. The pustules begin on the face or head,
and have their chief seat, sometimes in the one, sometimes in
the other of these parts, or, occasionally, both are pretty
equally affected. The pustules, there, are pretty large, and
have a red margin. They are not in general painful, but are
itchy, especially at night. The matter* discharged is often
abundant, and sometimes so irritating, that the absorbent
glands, about the lower jaw or neck^ swell, and suppurate.
Glands in dbtant parts of the body, t)r in the mesentery, are
sometimes, in unhealthy subjects, enlarged, as a concomitant
symptom. Over the body, there are also many pustules,
which are smaller than those on the head. They have a red
base, and lymphatic top, and are itchy. Presently, the straw-
coloured fluid they contain exudes, and forms flat ragged
crusts, of a bloody, or dirty-brown colour. The proportion

• An AHMlytla of thia has been pabllahed, bat it throws little light on the
tFMtment*

687

is, however^ not always the same, between cuticular redness
and incrustation ; for often, especially, about the back of the
neck, the whole surface is of a dark-red colour, with only
small, loose scabs, scattered pretty thickly over it. In other
instances, it is intermixed, in various parts, with furfuraceous
patches, and with papulous eruption, like prurigo. When the
scabs fall off, the skin below is left red, but no soar remains,
unless in rery bad cases, where deep ulceration has taken
place. Very extensive excoriation, yielding much secretion,
and having an alarming appearance, leaves no permanent
mark, or cicatrix. This disease is infectious, and is general-
ly, if not always, dependent on a scrofulous constitution.

This disease, has been divided into many species, but no
arrangement, that I have seen, is free from objection ; and I
have no wish to add to the number, but will describe what I
have met with, under the names employed by Dr. Willan.

Neither the names, nor the descriptions, of different
writers agree, and many seem to form distinct species of cases,
which, from description, appear to have, no dissimilitude.
Alibert and Gallot say, thai nine-tenths of cases are, tinea
favosa, most of the other tenth, tinea granulata, and that the
remainder consists of rarer species, including the tinea
muciflua, which is a mere variety of Dr. Willan*s porrigo
favosa.

1st. Porrigo larvalis, so named, on account of the crusts
covering the face, like a mask. It is also known under the
name of crusta lactea, or milk blotch, ignis sylvestris, or vola-
ticus. The tinea muciflua, of Alibert, may be considered as
synonymous, both with this, and with the last species of Wil-
lan, the porrigo favosa, which is a mere variety, differing in
nothing, except, in the pustules being a little larger. It usuuedly
begins on the brow and cheeks, by an eruption of clusters of
small achores, from an inflamed or red surface ; or of larger,
and rather sparser, roallicerous-looking pustules, called favia,
and in that case, constkuting the porrigo favosa of Willan.
The pustules spread on the face, and amongst the hair, over
a great part perhaps of the scalp, or they may be more con-
fined round the margin of the scalp, and about the ears*
Numerous pustules, are also often scattered over the body and
extremities, but these are seldom so large, as those on the
head. The pustules, which are itchy, soon break, and the
viscid fluid they contain, hardens into a crust, sometimes thin,
sometimes pretty thick, but generally yellowish, if not tinged
with blood. When the scabs are rubbed off, or drop, the

G88

surface below is red or purple, but not chopped, and many
places, are found covered, still, with little fragments of crust.
In other cases, the discharge is so profuse, that time is not
allowed for scabbing, but the whole surface, except the upper
margin, or one or two small patches of crust, is raw and ex-
coriated, and the discharge falls in large drops. In a few
instances, where there is greater irritation, or the part has
been deeply and hastily scratched, little cup-like ulcers form ;
and, except in such spots, no cicatrix is ever left by this dis-
ease. Even in these cases, the health does not suffer, further,
than from want of rest, and fretting from the itchiness. When
the urine acquires a peculiar smeU, like that of cats, the dis-
ease is supposed to be on the wane. This eruption, if it do
not depend on, is at least very prevalent in, scrofrdous habits.
It has been attributed to the richness of the milk, but it is
just as frequent in those who are sparingly fed. It seems to
be more connected with indigestion, or bad state of the bowels,
and also is often associated with, if not excited by, the irrita^
tion of teething.

In the treatment of the milder varieties, of this complaint,
it is sufficient to give, regularly, some gentle laxative, as rhu-
barb and magnesia, interposing, occasionally, gentle doses of
calomel; or, different preparations of sulphur, may be given for
the same purpose. The diet b to be attended to, and if the
child be plethoric, barley-meal, as being less nourishing than
some other grains, may be given as food ; a decoction of the
viola tricolor, has been advised by Strack and Stoll, but I do
not know that any internal medicine is useful, farther than as
required for the bowels. Soda or potash, in such doses as
keep the bowels open, are useful. As for bark and other
tonics, it is difficult to get them administered, and I have seen
little cause to have confidence in them. The same may be
said of cicuta. Iodine is one of the best internal medicmes.
If the patient be robust, and of sufficient age, venesection is
useful, if there be much inflammation. If younger, leeches
may be applied to the scalp. It has been proposed to open an
issue elsewhere, but thb is not of much use.

Local applications in slight cases are not demanded ; but
when they are, on account of the number of the crusts, and
the itching, preparations of sulphur and mercury are proper.
The sulphur ointment, or sulphur with oil of bays, or charcoal
ointment,* alone, or with the addition of a little soda, or ung.

* Powdered charcoal, mixed with as much lard a« makes it into a MiWe or pasiN
has at least the effect of destroying the bad smell. Some use it, in the prop«rtioii

689

hyd. nit., or cooulus Indicus ointment, may be applied three
times a-day ; and the red portions, which are not defended by
crusts, may be washed with lime-water, or water in which
quickUme and sulphur have been boiled, or a yery weak soIik
tion of muriate ot mercury, or solution of acetate of lead, in
the proportion of three grains to an ounce of water. Lint
wet witn this, and covered with oiled silk, has been found
useful. When there are few scabs, but much excoriation, and,
indeed, whereyer there is an irritable surface, mild applica^
tions must be employed along with laxatives. The salve I
have found most useful in such states, is ung. cerussse, or
lard with washed chalk, whilst the parts may be also bathed
with a weak solution of sulphate of zinc, in emulsion of al-
monds.

2d. Porrigo fiirfurans, is more frequently met with in
women than in children. It is confined to the scalp, and the
pustules are small, contain little fluid, and soon form thin
scales, so that the disease very much resembles ptyriasb, but
differs from it, in its origin, and, also, in the occasional re-
appearance of the pustules, with moisture. The hair becomes
thinner and more brittle. The treatment consists in shaving
the head, and removing the scabs or scales by ablution with a
sponge, and soap and water. Then, if the dcin be tender, or
irritable, cerussa ointment may be applied, or lard mixed with
a fourth part of its weight of coculus Indicus, or of charcoal.
If less tender, some stimulating application may be made, as,
for instance, ung. hyd. nit., or decoction of hellebore, which
has been recommended by Dr. Heberden.

3d. Porrigo lupinosa, or the tinea granulata, and tinea
favosa of Alibert, is a tedious and obstinate form of the dis4
ease. It is chiefly confined to the scalp, but occasionally
small patches appear on the extremities. On the head, many
separate clusters of achores form, and produce crustsjor scabs^
about the size of a sixpence. These are more elevated at the
margin, than the centre, which is depressed and powdery in its

•f only • flftb Mit of cbaroool, rad AliWrl prefers that bwIo of piteool. OtiMro
mix It with •ulphur ; both Capuron and Gardlen Join in tastimony to ita advan-
tage ; but I fear 1 miut say of it aa of other applications, that It eannot bo
certainly depended on. An opposite prescription, namely, a salve made with
roanfanese, instead of charcoal has been advised, but 1 am lees disposed to trust
to it. Rayer applies the following ointment :—]J, CretsB ppt. i i. ; subcarb.
potas. T ij> ; pttlv. earb. « i.; auxunge, q. s. Brett strongly reeommends a mlve
made with from S4 to OS gr. .of iodide of salphnr to an onnee of lard. A lotion it
used by eome, coDslsting of sulphurst of potash, dissolved in water, with the ad-
dition of iodine. Dr. Crampton trusts leso to local applications, than purgativco,
and such reaediea aa Improve the health. Trana. of Irish Cot of Fbys. VoL vl,

690

appearance. The colour is dirty white, unless when tinged
with bloody and the appearance like dried mortar. The smell
has been compared to rancid butter. These patches are not
confluent, but the intervening skin is furfuraceous, or scabby,
and if neglected, almost an entire incrustation may coyer the
head. It is named from a supposed resemblance to the seeds
of lupines.

. It is necessary to have the hair removed, which it has been
proposed to effect, in this, and all the other species of the
disease, by applying a pitch plaster to the scalp, and then
forcibly tearing it off, that it might pull out the hair. This
barbarous practice is now abandoned. Depilatories, as quick-
lime, have also been proposed ; but it is always practicable,
by softening the scabs, and repeated clipping and shaving, to
get the hair removed. Both for this purpose, and also to
expose the diseased surface, it is necessary to apply sapona^
ceous lotions, poultices, and mild ointment, to soften and
loosen the scabs ; afterwards, the surface is to be frequently
anointed, with an ointment consisting of oil of bavs, sulphur
vivum, and camphor, or axunge with hyd. precip. alb., or ung^
hyd. nit., or ointment containing hellebore. Dr. UnderwoMl
recommends the lotio saponacea, or decoction of tobacco, but
this is dangerous, if the skin be abraded. Mr. Barlow advises
the following lotion : — B. Kali sulph. 3iij* ; sap. alb. 5jss. ;
aq. calcis ^vijss. ; spt. vini §ij. M. — An oUed cap has been
advised in porrigo, to retain the applications, and keep the
parts warm, but I question if it be or utilitv.

4th. Porrigo scutulata, or ring-worm of the scalp, seldom
occurs before the age of three or four years ; but when it does
take place, oft«n continues, not only for many months, but in
varying degrees, for years. It begins with distinct clusters, of
very small, itchy, yellow achores, which break and form thin
scabs, covering the original patch, which is somewhat of a
circular shape. The base of each little achore is red. The
clusters are thickest at the margin, and the pustules fewest
towards the centre, where the scabs are thinnest, and drop off
first. When the scabs or scurfs fall off, the skin is found to
be red and shining, and very speedily, red pustules appear,
with a more extended margin, whilst the centre becomes first
a little redder, and then more scurfy. The hair, at the
affected part, becomes lighter in colour, and more woolly,
thinner, and presently, at the central parts, falls quite off*
Many of these rings, form over the scalp, so that we have at
last, at different parts, numerous patches which are bald, or

691

thinly covered with hair, and exhibiting the disease in all its
steps; some bare and shining, sprinkled with scurf; others^
with the exterior circle of yellow achores, and inflamed mar*
gins ; others, in a state of crust or scab, and, so long, as the
surface retains any unnatural appearance, we may be sure
that the disease is still to return. Similar appearances are
observed on other parts of the body, or there may be modifi*
cation of herpes or lepra.

This disease may appear without any evident cause, but,
most frequently, it occurs from infection, by using the same
comb, or towel, or cap, with one who has already the disease*

In this as in the other species, it is necessary to keep the
head shaved ; but this is to be done with as little irritation as
possible. Various applications have been proposed, but when
there is much tenderness, we must begin with the mildest, or
perhaps be satisfied with frequent ablution, or the use of very
weak solution of muriate of mercury in emulsion of almonds,
or with solution of chloride of lime, or cerussa ointment, or
charcoal ointment. When there is little inflammation or
tenderness, and we have the dry scurfy, or scaly state, most
prominent, we must use more stimulating apphcations, and
these are always necessary, sooner or later. They must be
varied, according to their effects, and so must their strength.
The mildest, perhaps, is the manganese ointment, already
noticed in a note. More acrid, are prepared from muriate of
mercury, acetate of copper, cantharides, tobacco, capsicum,
hellebore, arsenic, gunpowder, nitrous acid, alum, &c. Dr.
Hamilton strongly advises the ointment of Banyer,* alone, or
diluted with lard. Some have employed pyroligneous, or
diluted muriatic, or sulphuric acid, or strong solution of com-
mon salt. All of these, or other stimulating applications,
have succeeded; but not unless prudently employed, the
strength never being greater than the part could bear. In
two many other cases, as Capuron observes, when speaking of
irritants, after having more or less, ^^ martyris^e la tete," they
have failed. The disease at last wears itself out.

SECTION NINETEENTH.

The bloody scabs, which are formed on different parts of
the head, especially, in the hollow near the neck, in conse*
quence of vermin, are cured by combing and washing the
hair daily, and rubbing some mercurial preparation on the

* IS* Ceras. IbM. ; llthtrg. aor. J IJ. ; alaBi. vat. z J« ; mer. ftablim. cor*
MM. ^ Jii. • axuiif i» IbU* ; tercMnib. Venct, lb«. M. liat uof . ad •cablem.

C92

scabs ; whilst an ointment, composed of oil of bays and staves-
acre, should be rubbed oyer the scalp, among the hair, or the
powder of stavesacre, may be dusted in, among the hair.

SECTION TWENTIETH.

Children and adults, are occasionally affected with baldness,
without any of the foregoing complaints being eyident* Cd-
sus, terms tnis, area, which consists of two yarieties, the alopecia*
where the baldness occupies irregular portions of the scalp ;
and ophiasis, where it spreads from the occiput, round the
head, m a serpentine direction. Usually, the patches are
nearly circular, and the skin is ouite bare, shining, and smooth,
whilst the neighbourhood has the ordinary appearance of the
scalp, and the hair is healthy. This has been considered as a
species of porrigo, by Dr. Willan, and is called porrigo decal*
yans, but tnere is no proof, that it is ^ther necessarily, or fre*
quently, preceded by the formation of achores* The patches
increase in size and number, and at last, perhaps, the whole
head, with the exception of one or two tufta, is bare. Then,
without any eyident cause, the skin assumes a more natural
look, and hair grows. The treatment consists in haying the
head shayed, once ar*week, and rubbing the surface, twice or
thrice, daily, with some stimulating substance, such as oliye
oil, with as much nitrous or muriatic acid, as makes it gently
pungent, but not acrid. Strong camphorated embrocation, or
spirits and oil of turpentine, may be used, or some other
essential oils, or tincture of cantharides, or blisters^ or solution
of nitrate of silyer so strong as to irritate a little. Dr. Beau^
champ recommends, if the part be red, the application of
leeches. If it be not, he uses as a lotion a solution of tartar
emetic, in the proportion of five grains or more to the ounce.

SECTION TWENTY.PIRST.

Purpura, or petechiie sine febre, is a disease not nncoiB-
mon with children, particularly those who liye in confined
houses, or are fed on poor or improper diet. It consists of
an eruption of small purple spots, which are circular, not at
all eleyated, seldom larger than the diameter of a coriander
seed, more frequently of the size of the head ot a pin. They
are scattered oyer the whole body, and eyen oyer the hairy
scalp. They come out suddenly, without any feyer or
apparent indisposition, and go off slowly. They are not, in
general, attended with foul tongue, spongy gums, or foetid
breath ; and the fseces do not become unnatural^ but they

693

BometimeB are so, before the disease takes place, and the belly
may be very tumid, but these are not essential symptoms.
By good diet, the use of acids, and removal to the country,
together with moderate exercise, in the open air, this disease
is easily removed ; or sometimes it goes off without any par-
ticular change being made, in the mode of treatment. I have
never seen this disease affect children, till after they were
weaned. This eruption, is sometimes intermixed, with hard
papulae, forming a disease described, separately, under the
name of lichen lividns, by Dr. Willan. These continue for
a considerable time, and end by slight exfoliation of the
cuticle, but afterwards may be succeeded by a new crop. No
peculiarity of treatment is required. A worse species of this
disease, affects children as well as adults, and attacks more
dowly. For a considerable time, before the spots appear, the
patient is languid, and feels uneasy at the stomach. Then,
red spots, larger than in the former species, appear on the
extremities, especially the legs, which are painful before the
eruption comes out. The body is next affected, and the spots
very soon become livid; sometimes vibices are also observed
on the skin. This disease, is attended with frequent, and
dail^ haemorrhage, from the nose, mouth, alimentary canal, or
vagina, and sometimes even from the toes. This species
occasionallj proves fatal, but is often cured by the use of
quinine, wine, acids, good diet, and country air. It is, how-
ever, frequentlv, very tedious. In worse cases, and in feeble
children, the disease often begins with livid blotches on the
scalp, which presently have the skin abraded ; and then we may
find some of them moist, and discharging blood or bloody
matter ; others dry, but without any scab or a cuticle ; others
covered with a thin black crust. Gangrenous sores form
behind the ears : and the gums, especially near the symphysis
of the jaws, become foul, and covered with a brown lymph.
An eruption of petechiae then suddenly appears, and the child
generally dies.

SECTION TWENTY-SECOND.

Erysipelas* sometimes affects children, and even infants
very soon after birth.f This disease appears to have been

* ErrsipplM is mttended with fever, and the part affected It red and hot, with
•oftf difftieed swelllnip. The redness disappears when pressure is made with tba
finger, but immediately returns when that is removed. There is a tendency to
the formation of resides, which bursting, form either scabs or troublesome ulcers.

t Dr. Undei'wood says, he onoe saw a child born of healthy parent^ with mb^
livid infiammatorv patches, and ichorous vesications, about the lielly and thifhs;
but by the use of tark, and especially the motber^s milk, it recovered.

694

noticed by Avicenna, under the name of itndimiam, or bumid
erysipelas, and afterwards, at different times, by other writers,
but was first accurately described by Drs. Underwood, Garth-
shore, and Broomfield. Dr, Unaerwood conceives, that it
rarely makes its attack, after the child is two months old,
oftener a few days after birth. Dr. Broomfield, however, saw
it in a child much older, and I have met with the same cir-
cumstance. It makes its attack in general quickly, and the
worst kind, begins about the pubb, and spreads along the belly,
and down the thighs. There is not a great swelling, but
the parts become hard, purple, and often end in mortifica-
tion ; so that the organs of generation drop off. This kind,
very frequently proves fatal, the peritonaeum and intestines
partaking of tne disease. It is a variety, of the erysipelas
gangrenosum, of Dr. Willan. A milder kind, which I have
met with much oftener, begins about the hands and feet, or
not unfrequently the neck or face ; and it is worthy of obser-
vation, that this frequently ends in suppuration ; and on the
neck especially, a very large collection of matter may be
formed.

In the milder kind, the redness is more bright, and the heat
greater, than in that, which tends to gangrene ; but if there
be much tumefaction, or hardness, of the subjacent cellular sub-
stance, it is difficult to prevent the formation of pus. The
treatment consists in giving a purgative, attending afterwards
carefully to the state of the bowels, and keeping the child
cool. The improvement of the constitution, and particularly
of the action of the chylopoetic organs is of more consequence
than the local treatment. The heat of the part, is to be
abated by the application of cool water, which is better and
safer, than any more medicated lotions. The part is not to
be made cold, nor are we to have it constantly moistened with
cold water, which might either produce a dangerous metas-
tasis, or great local debility, ending in mortmcation. All
that I propose is, the moderation of the heat by sponging, or
bathing more or less frequently, according to circumstances.
The usual remedy is flour, which does no good, unless as a
medium for the frequent application of cold. The prejudice
against wetting the skin is quite unfounded. But should the
surface be already tolerably cool, and the action rather tend-
ing to the weakened form, we must refrain from cooling it
farther, and rather apply dry cotton wool. It is only in the
case of robust children, and high inflammation, that we can
venture on making an incision, as in adults. The loss of

695

bloody and consequences of the wound, may be worse than the
disease. If suppuration take place, a breieul and milk pouU
tice, is to be applied, and the matter should be early let out,
and the parts gently supported with a proper roller, applied
over mild dressings, in order to prevent the formation of sin-
uses. If these take place, they must be opened. The
strength is to be preserved by means of a good nurse, and
giving cordials, as, for instance, white wine whey.

In the worst kind^ or that which tends to mortification,
the colour is, from the first, or, at least, very soon becomes,
darker, or purple ; there is less heat, nay, sometimes the skin,
speedily, feels colder than natural ; the subjacent cellular sub-
stance is first pretty hard, and then becomes more flaccid^
without fluctuation, and the most prominent points become
livid or blue. The constitutional debility, and the advance^
ment toward mortification, and spreading of that state, keep
pace with each other. It is evident, that the local treatment,
applicable to the former species, would be hurtful here, unless
in those few cases, where this is preceded by more distinct
symptoms, of increased arterial action, than is usual, such as
heat. In general, the best iapplication, from first to last, is
camphorated spirit of wine, which was long ago recommended,
by the late intelligent Dr. Garthshore. But if this smart or
give pain, it does harm, and, in that case, a mild application
must be substituted, such as a weak solution of sulphate of
^inc, or dry cotton. If sloughs form, and the child still
survive, a bread and milk poultice will be proper, and the
parts may be bathed, with weak solution of chloride of lime,
to destroy the smell, or a poultice made with that and
bread, may be applied, which also tends to detach the slough
sooner. Ammonia, given early, in doses of from four to six
grains, every three hours, has been of service ; but I have
derived more advantage from calomel, in such doses, as to act
on the bowels, than from any other medicine. Green, foetid
stools are generally brought away. Quinine, in doses of half
a grain, twice or three times a-day, has also been given, but
the precise degree of advantage, derived from this medicine,
in infantile diseases, is not yet fully ascertained. Still, when
it can be easily given, and agrees with the stomach and
bowels, or, when it can be administered and retained, as a
clyster, I am disposed to advise it, and would employ it. I
need not add, that the greatest care must be taken, to support
the strength, by suitable nourishment, and cordials prudently
exhibited. The best of these, is wine whey; opiates are only

696

useful, when ihere is much irritation, or a diarrhooa. It is an
error to give them, indiscriminately, as part of the cordial plan,
for they are of no service except in these two yiews. Afineral
acids are rarely, if ever, proper for infants.

Erythema, according to nosologists, differs from erysipelas,
in not being attended with the same diffused swelling, nor
having the same tendency to form vesications ; neither is it
preceded, or accompanied, by any regular fever, though the
system may be occasionally disordered, during its appearance.
in some cases, the inflamed part seems at first to be rough,
as if covered with innumerable papulae, but this appearance
presently goes off. The treatment is nearly the same as in
erysipelas. Sometimes small, irregular, erythematic patches,
accompanied with oedematous sweUing, appear about the
joints, eyelids, or different parts of children,* with fretfolness
or feverishness. They, in general, require only to be kept
clean, by being bathed with tepid milk and water, and dusted
with some cool, absorbent powder, or bathed with vinegar.
Calomel is of service, alone, or with other laxatives, and strict
attention to the diet, &c.

After the cow-pox, erythematic patches sometimes appear,
not only on the arm, where the inoculation was performed,
but even on more distant parts. This is most apt to take
place, after the veside has arrived at the height, or is on the
decline. The inflammation sometimes ends, if not in ran*

grene, at least in a livid state of the parts, with fatal debuity.
pirituous applications are soon necessary* When the part
becomes livid, the strength must be carefully supported, and
the bowels opened. In the commencement of this affection,
saturnine lotions are proper, and often remove the disease.
Calomel is useful. Dr. Willan describes this as a species of
roseola.

There is a species of erythema, erythema nodosum of Dr.
Willan, in which the patches are raised, toward the centre.
This elevation takes place gradually. In a few days, hard
and painful tumours are formed, which threaten to suppurate,
but they presently subside, soften, and end in desquamation.
These are most freauent on the chin, but they may affect any
part of the body. Laxatives are proper.

SECTION TWENTY-THIRD.

Excoriations, frequently take place, behind^the ears, espe-

• The 0ryth«matic pttehei produced by the bitei of bugt, ftc, in tboee whoev
diiii li dellcste, are dietlogitlebed by hvrlng • tmaU mark or epeck in the middle.

697

daily during dentition. The skin, under the lap of the ear,
is covered with small pustules, and the inflammation extends
from one to another. Sometimes, a kind of erytbematic
Inflammation takes place, without pustules, and ends in vesi*^
cations, which discharge thin matter. This complaint is not
generally dangerous, but it is sometimes troublesome, and
causes swelling, of the lymphatic glands, about the jaw and
neck. Occasionally, however, the parts become first livid^
and then gangrenous ; and in such cases the child generally
sinks, even idthough the sloughs begin to separate. In
mild cases of sore ears, it is seldom necessary to do more, than
wash the surface, frequently with milk and water. If the part
be very itchy, it may be bathed with rose water, containing a
littie tmcture of opium, or with weak solution of sulphate of
zinc ; but astringent lotions, or such applications as tend to
heal the surface speedily, if it have been long abraded or
dischar^ng much, are, unless purges be frequently given,
justiy esteemed dangerous, and apt to excite disease within
the cranium, especitJly in those, who are predisposed to con-
vulsions, or hydrocephalus.

If other applications be necessary, the citrine ointment, or
liniments containing acetate of lead, calx of zinc, juice of
Bcrofularia, sulphur, charcoal, cerussa, &c., have been em-
ployed. The last of these, is often the best.

When the parts become livid, or threaten to mortify, cam*
phorated spirit of wine, should be applied with a small brush,
and the part dressed with mild salve ; afterwards, when slough
has formed, the fermenting poultice, or solution of chloride
of lime is to be used. The strength must be carefully sup-
ported. The bowels should be kept regular.

SECTION TWENTY-FOURTH.

The gums, about the time of dentition, or sometimes when
the first set of teeth are shedding, become spongy and ulcer-
ated, discharging a quantity of thin, foetid matter. This, at
first, may generally be stopped, by applying a mixture of
muriatic acid and honey, in such proportions, as to taste
pretty sour ; or the parts may be frequently washed, with equal
parts of lime-water and tincture of myrrh, or with a solution of
sulphate of zinc, or of chloride of lime.

If neglected, the ulceration becomes either fungous, and is
called scorbutic ;* or sometimes of the kind whicn resembles

• In tbi« catp^ Mine bare reoommended •timulanU and Mtrinftnt loCione, othcn
compression. M. Benbe adrises tbe part to be cut off; and Capderille propossa
aotnml eaaterj. Solution of common salt bas alto been recommended.

698

sloughing phagedena, that is, a foul, fcBtid, spreading sore^
destroying the gums, and, in some cases, the jaw-bone and
cheek ; so that, if the child suryive, no teeth are afterwards
formed, in that part of the jaw. Occasionally, from the vary
first, this disease assumes a malignant form, beginning wiUi
some degree of inflammation of the gum, generally where the
incisors should appear. The part is not swelled, but bright,
^nd of a pale, red colour, and this extends along the gums a
considerable way. This soon festers, forming a line along the
gum, marked by a white or brownish slough ; whilst, exterior
to this, the surface is inflamed, and this inflamed part next
festers ; so that inflammation precedes festering, till the mouth
and cheeks be afi^ected, and a large foetid sore formed, which
soon injures the bones. This disease has been called the
canker. It is attended with considerable discharge of saliva,
and the breath is very foetid. Good diet, the use of orange
iuice, and sulphate of quinine, with great attention to clean-
liness, at the same time that we- use solution of chloride of
lime, as an occasional wash to destroy the smell, are the most
likely means of cure.

In some families, many of the children, are subject to a
spongy, and ulcerated state of the gums, which thus expose the
teeth down to the jaw, or these become loose. The gums
bleed, and sometimes haemorrhage takes place from the nose,
and there are livid spots on the skin. This is best remedied
by removal to the country, the free use of ripe fruit, and
vegetable acids, bark, or sulphate of quinine m half-grain
doses, laxatives, and nourishing diet. Solution of borax, is one
of the best local applications.

SECTION TWENTY-FIFTH.

Another corroding disease begins, in the cheek itself, or the
lip. It commences with some degree of swelling, which is
hard, and firm, and shining. It generally be^ns on the cheek,
which becomes larger than the other, and the upper lip
becomes rigid, swollen, and glossy. On some part of the
tumefied skin, generally on the cheek, we observe presently a
livid spot, which ulcerates and spreads, but laterally and
downwards. Being generally seated near the mouth, it soon
reaches the £;ums ; and even the tongue partakes of this disease,
which is of horrible aspect. We often find, a great part of
the upjper or under lip destroyed, perhaps only a flap or por-
tion of the prolabium left, all the rest being eaten away. The
gums are foul, the teeth loose, the tongue thickened, partly

699

destroyed, and lying so close on other diseased parts, that we
cannot say what is tongue or what gum, except by the child
moYing the tongue ; and the mouth, itself, is filled with saliva.
The sore is foul, shows no granulations, but a^ears covered
with a rough, irregular, coat of brown lymph* The surround-*
ing parts are somewhat swelled : near the ulcer, they are hard
and red ; farther out on the cheek, they are paler, and have
more of an oedematous look. These local appearances, are
accompanied with emaciation and fever, and the child is either
restless, or lies moaning in a drowsy state. This disease often
proves fatal ; sometimes, indeed, the parts cicatrize, or the
patient recovers, after an exfoliation oi part of the jaw-bone^
This sore, is best managed^ with stimulants, such as solution
of chloride of lime or of nitrite of silver, camphorated spirit
of wine, tincture of opium, &c., but sometimes it is necessary
to give these up, for a linseed meal, bread and milk, or a
carrot, or a fermenting poultice, for whatever gives pain,

Earticularly prolonged pain, is hurtful. The bowels are to be
ept open, the strength supported by milk, soups, and wine ;
and ripe fruit given, if it do not purge. Before ulceration
takes place, the best application is camphorated spirit of wine,
provided it do not give pain, or, if the part be swollen and
hard but not red, we employ slight friction, with camphorated
liniment. A course of gentle laxatives is useful.

Another disease, destroying the parts, is called noma, which
differs from the former, in destroying rather by gangrene than
ulceration. It attacks chiefly the cneeks, and labia pudendi
of children, and begins with a livid spot, without pain, heat^
or swelling, or with very little; and is not preceded by fever.
It ends in gangrene, which destroys the part, and the patient
often dies in a few days. It is to be treated, at first, with
saturnine applications; afterwards, when sloughing takes place,
the nitric acid may be applied to one spot, with a bit of lint
or small brush, taking care that it do not spread beyond it ;
then, we use solution of chloride of lime, or a fermenting
poultice, whilst opium and wine are given internally, with or
without quinine, according as the stomach will bear. The
bowels must also be excited to action.

Some children, more especially those of a scrofulous habit,
suffer much from a fretting and inflammation, which often, at
the same time, affect the nostrils, upper lip, and labia pudendi.
The mens veneris and labia, are tumefied, red, and very itchy.
They sometimes are covered with minute blisters, or little
scabd, or yield serous discharge. The internal parts furnish

700

muco-punilent matter, and there is pain in voiding the urine.
The cnild is pale, the bowels in bad order, the puke frequent,
the appetite bad, and the sleep disturbed.

I have never found any thing so useful, as the application
of white lead ointment, or simple ointment, mixed with pre-

1>ared chalk, and bathing the parts frequently with weak so»
ution of sulphate of zinc, having a smsdl proportion of vine-
gar added to it. The bowels require also to be carefully
attended to.

A very formidable affection, I have occasionally found to
succeed measles or scarlatina, but it may likewise occur, with*
out any preceding disease, of a formed or specific kind, and is
decidedly infectious. The labia usually are affected, and
sometimes the disease is confined to one side. The exterior
surface becomes slightly erysipelatous, and little vesications
form, which, in the mildest cases, shrink, and end in small
scurf. In worse degrees, the inflammation is greater, and the
vesications end in livid sores or sloughs. The inside of the
labia, are of a deep red colour, one or both nymphae swell,
but the prseputium clitoridis is chiefly affected, and speedihr
swells much. Exudation of yellow, or buff-coloured lymph
takes place, followed almost immediately by death of more or
less of the parts, which form an ash-coloured slough, and
when this comes off, the parts below, are in a suppurating
fiery state, without granulations. If the exterior sumce par-
ticipate, the sloughs are black. The whole of one labium may
be destroyed, or part of both, but the destruction is often
comparatively greater in the nymphse, and particularly the

Iirseputium clitoridis. At first, there is a copious muco-puni*
ent, and then, a sanious or bloody discharge, very foetid.
From the very commencement, there are languor, paleness,
and debility, greater or less, according to the severity of the
disease, in some, the pulse is not very frequent, nor is there
much heat of skin, the tongue is moist, and the appetite is
not lost, nor is the pulse much accelerated. In otners, the
tongue is dry, the skin cold, or of a sharp heat, the pulse fre-
quent, and tne eye heavy, and there is no appetite, but rather
nausea and thirst. As the disease advances, the debility in-
creases, and the child soon dies. It is a v^y fatal disorder.
It is sometimes conjoined, with the affection of the cheek, al-
ready described. It requires the use of mild laxatives, sedo-
lous attention to nourishment, and the judicious exhibition of
wine, and laudanum to allay irritation. We may also give
the sulphate of quinine. The parts must be kept very clean.

701

bathed frequently with weak solution of acetate of lead, and
dressed with salves^ containing oxyde of lead, or of zinc.
When slouehs form, the best wash, is a weak solution of
chloride of Ume, which always for the time destroys the smell.
A bread and milk poultice, is often the most useful appli-
cation, or, if the sloughs he deep and extensive, a poultuse,
made of solution of chloride of lime, and bread, is beneficial.
The actual cautery has been employed on the Continent, but
seldom in this country. A variety of this disease, differing in
no essential symptom, is attended with a fever sui generis.*

SECTION TWENTY-SIXTH.

Aphthie are small white specks, or exudations of coagulated
animal mucus, appearing on the tongue, inside of the cheeks,
and the fauces. This disease appears under two forms. The
mild, in which the eruption on the . mouth is shght, and the
svmptoms comparatively trifling; and the severe. In which
the local disease is extensive, and the constitution greatly
affected. In the first, or milder form, a few scattered spots
appear on the mouth, as if little bits of curd, were sticking to
tne surface of the tongue, or within the lips. These, in a
short time become yellowish, and then £aU off, but may be re-
newed for three or four times. Thev leave the parts below,
of a red or pink colour. The child, in this complaint, is
generally somewhat fretful, the mouth is warmer than usual,
and the bowels rather more open, and sometimes gnped,
which has been attributed to an acid state of the saliva* The
stools are altered in their appearance, being green, or contains
ing undigested milk, or of an offensive smeQ. There is no
fever or .general indisposition, except what may proceed
merely from irritation of the bowels. It is most frequent,
within the first month, but may occur later.

In the severe, or worst form of this disease, a feverf even

* Mr. Wood daicribes a very MTcre Tarioty of this dtMue^ affeetinf the ezter-
■al parts. It it preeeded bj febrile ayinptomt* but, toon, there ie pain in making
water, aii4 the parte are found to be inflamed anddark^eoloiired. In a few hour^
afterwards resioation appears, which ends In ulceration, and the surface beoomco
excessively tender. Tne ferer increases, and along with it the debility. The uU
etration spreads, and becomes deep and foul, but mortlflcatlon rarely occurs. 1|
is a fatal disease, but by the use of bark, cordials, and lazatiTCs, with tepid satur-
nine poultices, and afterwards dressing with mild salTss, sevend recovered after
the end of perhaps three weeks. Purulent dieehaife from the vagina, is apt tu
rsmain for some time, and contributes to keep up the debility. Med. Chir.
Trans. Vol. rii. p. 84 A slmihu* disease U dceeribed by Dr. Hall, in the Edin.
Journal for Oct., ISld. M. Cevoule maintains that it is almoti always the coo-
sequenoe of a solitary ulceration on the inelde of the month, or labia, and is not
preceded by fever, the constitutional symptoms being merely eymptomatic.

t Dr, Underwood Is of opinion, tlmt fever Ttry rarely atlcnda aphtha, an-
pearing aa an original disease. Foreign writers have divided this form of the

702

of a contagious nature, precedes, or attends, the aphths ; and
the child is sometimes drowsy and oppressed for some hours,
or even a day or two, before the spots appear, and occasional-
ly is affected with spasms. The fever and oppression, are
sometimes mitigated, on the appearance of the aphthse. The
eruption is pretty copious in the mouth, and may become
confluent, so that almost the whole surface, is covered with
curdy-looking matter. The stomach and the bowels, are very
much disordered, and the child vomits and purges. The
stools are generally green, sour-smelled, and sometimes acrid,
so that the anus is excoriated. The aphthse may not be con-
fined to the mouth, but may descend along the trachea, pro-
ducing cough, and great difficulty of breathing ; but much
oftener, they go along the oesophagus, to the stomach, which
becomes very sensible, is painful to the touch, and the child
vomits speedily after sucking. The mouth is likewise tender,
so that the child sucks with pain, and with difficulty, if the
crusts become hard, the tongue being rigid. After a short
time, the aphthae change their colour, and begin to fall off ;
but they may be renewed, and the abdominal symptoms may
increase, so that the child is exhausted, and dies.

There are two sources of danger, in bad cases of aphthae :
the first, proceeds from the disorder of the alimentary canal,
which always attends the disease; and the second, arises from
the particular state of the system, connected with the local
disease, as in malignant sore throat, and many other diseases.
It behoves us, then, in forming our judgment, to attend to
the sensibility of the stomach and bowels, and pay attention
to the egesta. Frequent vomiting, repeated thin stools, with
griping, and a tender state of the abdomen, with or without
tumour, are very unfavourable ; drowsiness, oppressed breath-
ing, moaning, spasms, and great languor, with frequent pulse,
are likewise dangerous symptoms. With regard to the local
disease, we find, that if the spots be few and distinct, and be-
come a little yellow, and then in three or four days fall off^
leaving the part below, clean and moist, we may expect that
the eruption will not be renewed, or will become still more
mild. But if the aphthae turn brown or black,* which last

diMSM into four •taget: let. What they caU the incubation or inTiaion of the
aphth«, marked bj ferer, reetlcaaneea, alekneta, baming heat of the epifastriim*
hoanenesa, and hot tender state of the mouth. Sd. The puUulation or eruptioa.
The membrane of the mouth becomes red, the aphthn appear, and spread, with
ooagh, diffieult deflntition, dlarrhoBa, he. 8d. The symptoms incrsose. 44h.
The aphth« ehange Into crusts, and fall off In frajpoenta. Ther deny that the
eruption Is ever attended with mitigation of the constitutional aifiwtlon.

* Sometimes mortification takes place, and CTen the palate hones have bevn
known to suffer.

703

18 not a common colour, the prospect is not so good, and is
worse in proportion to the rapidity with which they change.
The longer that the aphthae adhere, the more apt are they
to become brown ; and the case is worse, than when one crop
succeeds another more speedily. If the succeeding crop be
more sparing than the former, we augur well, and vice versa.
When the aphthae fall off, we expect their renewal, if the
parts below are parched and look foul. If, however, in this
state, the eruption do not take place, and the oppression,
weakness, and drowsiness continue, the danger of the case is
increased ; and, in such circumstances, it has been observed,
if the eruption afterwards appear, the child is relieved. It is
also unfavourable, if a new eruption come out before the
former one be thrown off. When the aphthae fall off, the
mouth becomes very tender, so that the mildest fluids some-
times give pain. Occasionally, a salivation takes place, and
the inside of the cheek bleeds. Dr. Armstrong remarks, that
he has seen the tongue covered with a crust of aphthae, and
the cheeks and gums full of angry pustules, and little fungous
excrescences.

Now, with regard to the cause, we find that this disease is
produced, by derangement of the stomach and bowels, excited
by improper diet, exposure to cold, &c., and sometimes slight
attackis, are occasioned, by giving spoon-meat too warm. The
tongue and mouth, sympathize very much, with the state of
the alimentary canal, in every period of life ; but in early in-
fancy, the cnanges produced, in the membrane lining the
mouth, by derangement of the function of digestion, are great
and sudden. Whenever the diet is deficient, or improper, or
the action of the stomach is deranged, aphthae are produced,
especially during the first month ; afterwards, at least, when the
infant is considerably older, the tongue merely becomes foul
or furred, when the digestion is injured. It is rather with the
stomach, than the bowels, that the mouth at first sympathizes ;
but the bowels also are generally affected, either, from a pro-
pagation of diseased action from the stomach to them, or, nrom
the operation of causes directly on them, as well as on the
stomach. Hence, the stools are generally bad, when the
mouth is aphthous, and hence, a change of diet, or medicines,
which stimulate and invigorate the whole tract of the canal,
remove the affection of the mouth. If a child be brought up
on the spoon, or the milk be bad, one of the most early indi-
cations of injury, is the appearance of aptbae, or white exudar
tions on the tongue. Some particular states of the atmosphere.

704

would seem either to excite this disease, or predbpose to it»
for it is most frequent in damp situations, and in spring and
autumn ; and Van Swieten telk us, that it is peculuurly pre-
Talent in Holland. It would appear also, to be produced by
sucking an excoriated nipple; and, on the other hand, an
aphthous mouth, may infect the nurse. It has been said by
Dr. Moss, that a hedthy child, sucking a breast immediately
after a diseased child, receives the infection; and I belicTe it
to be the case.

In the treatment of aphthsB, the cause is often overlooked,
and local applications are expected to remove the disease.
The first object, however, is to remove the cause, which most
frequently, is resident in the stomach and bowels. For thia
purpose, strict attention ought to be paid to the ingesta, for
many nurses, instead of bringing the cnild up, at first, enUrel^,
or almost entirely, on the breast, give spoon-meat, and that m
too great quantity, and not unfrequently combined with an
anodyne, to keep the child quiet. Emetics have been strongW
recommended by Ameman, and others, in this disease. A
little of the vinum ipecacuanhflB may be employed, which ia

S referable to antimony. This may be given early in the
isease, if it require interference with active medicines, or do
not yield to mild laxatives ; but if relief be not soon obtained,
it should not be repeated, and, on the whole, I am not very
partial to the use of emetics. Gentle laxatives are highly
proper, such as manna, or a little magnesia alone, or with a
small proportion of rfauburb, and an aromatic. Small doae^
of calomel, may also be given with advantage. The remedy
I chiefly recommend is laxatives, such as rhubarb, magnesia,
or calomel, given so as to evacuate all offensive matter, and
excite the action of the whole canal. The operation is to be
gentle, but must perhaps be repeated for some .days. EmiH
Uent clysters, made pretty large, and without stimulating in*
gredients, are likewise useful. Milk or soup may also be in-
jected, to suppcNTt the strength, when the chud does not suck,
or take food by the mouth. If^ however, the child have a
purging, then we must proceed, according to the directions,
which will be nven, respecting diarrhoea.

Local applications have been always employed, and, ia
slight cases, are trusted to by the nurse, without any intcamal
medicine. The most common remedy is borax, in the form
of a saturated solution in water, or mixed with honey or syrup (
or a little of the powder may be put into the mouth, and it
seems to have a better effect, than could be expected, from iia

705

sensible properties. It cannot, however, be expected to re-
mo?e the aphthae, until they be about to separate, when it
ought to be employed, and may prerent a renewal. Until
this period, white of egg, beat up with cold water, should be
used in its place. Van Swieten recommends syrup of turnips.
Applications which force off the aphthae, prematurely, do
harm to the part, and seem to produce a renewal of the
exudation.

In the worst species, we must very early give a gentle laxa^
tive, or a mild emetic, if the child be much oppressed ; and
afterwards, the bowels must be regulated, and medicine given
according to the appearance of the faeces, and the state of
sensibility. Nourishment is to be given carefully, or if the
child cannot suck, clysters must be administered twice a-day.
Where the debility is considerable, the strength must be supi-
ported by cordials, such as white-wine posset. Quinine, in
the dose of half a grain, three times a-day, has been recom-
mended, when the debility is great, and especially when the
mouth has a sloughy gangrenous appearance, or tendency
thereto. If it cannot be taken, or retained, it may be given
in the form of clyster. Small doses of calomel, with opiates,
^ are useful. A weak solution of the sulphate of zinc, or water

acidulated with muriatic acid, have been proposed as lotions,
I and may occasionally be of service; but it is highly improper

. to wash the mouth, roughly, with a cloth dipped in these, or

any other lotions.

J SECTION TWENTY-SEVENTH.

Aphthae sometimes appear on the tonsils of children, and
adults, with or without tever ; and from an apprehension of
the existence of a malignant sore throat, give much alarm.
There is, however, very little inflammation, and no lividity of
} the parts ; the fever is very moderate, the strength not im-

I paired, and the aphthae do not spread, but, becoming brown,

^ presently fall off. This is cured by acid garbles and laxatives.

^ Another kind of sore throat, is attended with the usual symp-

I toms of inflammation, accompanied with an exudation of

^ tough yellow mucus. It yields readily to the same treatment.

SECTION TWENTY.EIGHTH.

f A malignant, and highlv infectious, species of aphthae, is

^ one of the most formi£ible diseases, to which children are

I liable. It constitutes what has been called, by some, the putrid

sore throat. It attacks in different forms, and is always an

> 2 z

706

insidious disease. In some, it begins with heat of the skin,
uid smart fever, and the cheeks, if not flushed, are at least
not pallid. The child complains a little of the throat, which
is found to be of a dark red colour, and patches of lymphatic
exudation appear on the tonsils. At the same time, we find
one or more glands under, or behind, the angle of the jaw,
more or less swelled and painful. The tongue is coTered
with a brown, or yellowish coat. The eye is dull, perhaps
watery ; there is little appetite, not much thirst, seldom much
headach; and, on the whole, the child suffers little. In three
or four days, the fever abates, and the pulse becomes nearly
of natural frequency, but other symptoms increase. The
throat becomes darker in colour, and the sloughs browner,
and when any part separates, some blood is discharged. The
nostrils discharge ichor, and become excoriated, or bleeding
takes place from them, and the inside of the eyelid, or even
the adnata of the eye itself. The cheeks swell and become
glossy, and the skin over the nose tumid, then red, and lastly,
livid. Dark, pitchy stools are voided, either from blood swal-
lowed, or discharged from the intestines themselves. Bilious,
and sometimes feculent vomiting takes place. Petechias
appear, the pulse, without becoming more frequent, becomes
weaker, and at last imperceptible ; but, for some hours, the
power of moving, and perfect consciousness remun.

In other cases, the child becomes first of all, and rather
suddenly, sick, listless, and cold ; his pulse is quick and
feeble; his eye heavy, and his countenance pale. The throat
is seldom complained of, but if inspected, is of a deep red
colour, and ash-coloured exudations, are visible on the tonsils.
Even at this time, the breath has a bad smell. Soon, the
skin becomes hot, and, perhaps, for a short time, the cheeks
are flushed, but they soon become either pale or livid, and
the heat is never ardent. The pulse is extremely frequent,
and yery feeble. The throat is covered with a slough, and
filled with viscid phlegm. The tongue is brown, or dry and
livid. The nostnls discharge acrid ichor. There are in-
creased foetor of the breath, hoarse cough, and striduloos
breathing as in croup.* And few, if any, recover, who are
thus seized, for it runs the same course as croup ; there are
the same hoarse cough, the same sonorous breathing, the same
fits of suffocation. These symptoms increase, the stools are
dark and offensive, the breath putrid, the sloughs spread, the

* It hM been coosldered identica] with croup by Dr. Bretonneiu, who
it diphtberit*. But the true croup begins in the larynxy and not hi the

707

pulse becomes fluttering, and, often, within forty-eight hours,
sometimes in twenty-four, the child dies. Death, however,
rather takes place thus speedily, from the intensity of the
laryngeal affection, than from the mere debility, consequent
to the operation of the infectious virus. A variety of this
complaint, seems to be described by Dr. Hamilton, where the
peculiarity is extreme slowness of breathing. This I have not
met with. Various remedies have been tried. Emetics,

Eurgatives, the early application of leeches to the throat,
listers, and calomel, have all failed. Some of them have
perhaps aggravated, none of them have relieved the symp-
toms, and blisters have only added a painful and foul sore, to
a deadly disease ; nor do I know any plan which can be de*
pended on, with the least confidence, after the croupy symp-
toms have decidedly appeared. If these have not taken place,
or be only slightly threatened, the practice I have found most
useful, consists in the administration of gentle purgatives, and
the instant use of sulphate of quinine by the mouth, with such
nourishment and cordials, as the child can swallow or retain ;
or bark may be given in nutritive clysters : as auxiliaries, w6
may endeavour to have the throat and mouth cleaned, by wash-^
ing with diluted solution of chloride of lime, attend to venti-
lation, and shifting the bed linen, and give ripe fruit. Rub-
bing the part over with nitrate of silver has, in some instances,
seemed to do good, and to the best of my knowledge, was first
prescribed, a number of years ago, by Dr. James Watson, of
this city, at the suggestion of Mr. Macarthur. Dr. Breton-
neau, afterwards, advised muriatic acid, or powdered alum. I
must, however, say, that no great dependence can be placed,
on either application, and most of the recoveries take place,
rather from the arrestment of the disease, in its progress down
within the glottis, by some unknown circumstance, than by
the power of medicme. In the variety described by Dr.
f Hamilton, he says, the superacetate of lead was useful, in the

; dose of half a grain every three hours. In desperate cases,

; would tracheotomy be of any avail ? It has been tried here

with success, in a case, apparently, of this nature, and Dr. Bre-
f ionneau relates a successful instance. But I cannot urge it,

and expect little from it.

SECTION TWENTY-NINTH.

About the time of dentition, the tongue, gums, and inside
of the lips, are sometimes spotted over, with superficial exco-
riations. They are seldom larger than a coriander seed, of

708

an irregular shape, and covered with yellow or brownish
mucus, adhering so firmly, and being so thin, as to resemble
the solid base of the sore itself. They are tender, and gene-
rally accompanied with salivation. They are cured by being
touched with alumen ustum, or lightly with a pencil, dipped
in weak solution of nitrate of silver. Borar also, or tincture
of myrrh, seems to do good. But perhaps these would always
heal, easily, if left to follow their own course.

SECTION THIRTIETH.

Infants may be affected with syphilis in different ways.
They may be diseased in utero, in consequence of the state
of one, or both, of the parents. They may be infected by
passing through the vagina, when the mother has chancres ;
or by sucking a woman who has the nipple affected. Of all
these method^, the first is the most frequent; and it is worthy
of remark, that this mode of infection may take place, when
neither of the parents has, at the time, any venereal swelling
or ulceration, and perhaps many years after a cure has been
apparently effected. I do not pretend to explain, here, the
theory of syphilis, but content myself with relating well es-
tablished facts.

In such cases, it is very common for the mother to miscarry,
or have a premature labour, without any evident cause; and
when this takes place, the child is found to have the epider-
mis wrinkled or peeled off, as if it had been macerated, and
sometimes deeper ulcerations are discovered. The liquor
amnii is turbid and foetid. We are not, however, to suppose,
in every instance, where these appearances are met witn, that
the chud is syphilitic; for any cause, producing the death of
the foBtus, a considerable time antecedent to its expulsion,
will produce nearly the same appearance. The diagnosis,
then, must depend much upon the repetition of the prema-
ture labour, the circumstances attending it, the history of the
parents, and the distinct appearance of ulceration. In such
cases, the parent, originally affected, ought to undergo a met^
curifid course; and if the other parent have any suspicioiis
symptoms, mercury should be administered to both. Some-^
times, the disease seems to wear itself out, without any reme*
dies being employed; and the children bom in future are
healthy. But it often happens, that the child, though it hare
received the venereal disease in utero, and probably possessed
it, as a peculiarity of constitution, from the time of conception,
is bom alive, and has even no apparent disease on the skin.

709

or in the mouth. Frequently, indeed, it is bom before the
time, and perhaps it has been preceded by one or two dead
children. It may be clean and healthy, and continue so, for
even a month or two,- but oftener it is feeble, and rather ema-
ciated ; and sometimes it has at the time of birth, or soon
afterwards acquires, a wrinkled countenance, having the ap-
pearance of old age in miniature, so very remarkably, that no
one who has ever seen such a child, can possibly forget the
look of the petit vieiUard. In such a case, the child has
scarcely any hair upon the head, but may have pretty long
hairs on the body ; it cries in a low murmuring tone, and ap-
pears so weak, that it cannot suck for a minute at a time.
But whether the child be apparently healthy or emaciated, at
the time of birth, other symptoms presently appear ;* and of
these, the most frequent and earliest, is generidly an inflam-
mation of the eyes, accompanied with ulceration of the tarsi,
and purulent discharge. This appears a few days after burth.
The eye presently, if neglected, becomes ulcerated, and the
cornea opaque. Copper-coloured blotches, ending in ulcers^
tion, appear on the surface ; or numerous, livid, flat, suppu-
rating pustules, cover the surface ; or many clusters of livid
papulae appear, which presently have the top depressed, and
then end in ulceration. These papulse, are sometimes atten-
ded by an eruption of pale, shining, pimples on the face,
which enlarge, become red, and often run together. Chil-
dren have sometimes an eruption of leprous or scaly spots,
which I have formerly described, and which resemble syphilis.
The syphilitic blotches are of a darker colour, are more apt
to end in ulceration than in scurf, or to form crusts or scabs,
and seldom disappear, without the use of mercury ; or if they
do, they soon return, and become worse by continuance, and,
presently, are combined with additional symptoms of the
disease.

The genitals and anusf become- ulcerated, and sometimes

* M. Mahon, from hU olMenratlont in THoipiM de VaoKirard, nyi, that the
symptoms appear at follows, the most frequent being put first. Ophthalmy ;

Eurulent spots ; ulcerations ; tumours ; chancres on the mouth ; and aphtha ;
▼id, ulcerating, and scabbing pustules; chancres on the genitals, and about the
anus ; excrescences ; peeling off of the nails of the feet and hands.

f Children may hare ulceration about the anus, genitals, and groins, snoceed-
ing intertrigo, owing to neglect of cleanliness, without any venereal affection.
But the absence of other symptoms, particularly of sore throat, or ulcer of the
mouth, and the amendment experienced by the use of lotions, and keeping the
parts dbr^ and clean, will enable the practitioner to form a diacnosU, and the
aspect of the sores wUl assist him. This fretting of the parts, and eren some de-
gree of excrescence, may attend psoriasis, and the leprous suots of children for-
merly described ; and in this oaae, especiaUy, if the child belong to a poor pvson.

710

excrescences sprout out, from these parts. Foul sores, Wok
retorted edges, and a centre, pale, and like lard, cover thcb-
side of the mouth ; and chancrous ulceration takes pUce k
the lips, especially, about the angle of the mouth. Thes
sores and chops, are often surrounded, pretty extensiTely,Tc:
a whiteness of the skin, as if the part had been scalded, «
recently rubbed with lunar caustic, and, perhaps, from tiik
circumstance, these sores have been called, though impropenj,
aphthae. They may, however, be combined with aphtha, a
some cases, the white and dusky patches, cover the wbok ^
late and inside of the cheeks, whilst the ^ms are ulcentol
or even nearly gangrenous. The ulceration of the gums I*
always a very angry look. The nostrils become stuffied, i^i
discharge purulent matter. On the face and hands, we «?
obstinate sores, covered with pus, others with crusts, wm^
the intervening skin is sallow. The child early beconitf
hoarse, and the glands of the neck, with those below th®]*'*
are often swelled. Children, like adults, have in general the
surface affected, and then the tonsils and mouth, but sooe-
times the one follows the other quickly. They seldom h^^
long enough to have the bones <£[seased. They are al**y*
in great danger, and those who are much diseased never Tf-
cover. Mahon, with great justice, ranks among^ incuraw^
symptoms, the old decrepit visage, great destruction of "»
globe of the eye, chancres on the middle of the lip, spreadjo^
to the fraenum, and extensive ulceration of the mouth. Itm^
be remembered, that syphilis, not only may appear, under ij
own peculiar characters, but may also exist, under the f®^
some of the eruptions, common to children ; such as crosP
lactea, lepra, psoriasis, &c. These are known to be venereaij
by their being of a more livid colour than usual ; they tf^
slowly to ulceration, and when the scab or crust, with w>"^
they are furnished, comes off, a foul honey-comb like ulc^
tion is observed below. But the best diagnostic is, that tbe;
are soon attended with other symptoms, such as hoarscnc9»»
ulceration of the mouth and throat, &c. We must vaske ^P
our judgment slowly, and with deliberation. I have seen
child entirely covered with psoriasis, have excoriation ^
mouth, hoarseness, and pustules on different parts, a^^ J^

the disease is too often decided to be syphilis. There is, however, perhap* ^f^
dividual symptom, which can decidedly characterize syphilis in children ; ^^^
diagnosis most be formed by the combination of symptoms, and often ^f^^
gress of the disease. Many children are rashly put upon a course of niercury>^^
do not re<|uireit ; perhaps, because the practitioner thinlcs It a point of h«"^'
to determine the nature of the disesse, at the first fiance.

711

from the healthy condition both of the parents, and hired
nurse, it was doubtful if the disease were syphilitic ; and in
another case, still more resembling syphilis, it decidedly was
not, unless we can suppose that the disease had skipped oyer
at least one generation. I admit, however, that gonorrhoea
may produce these symptoms in the offspring. Diseases, in-
fectious, are not always to be considered, on that account,
syphilitic, as we see in moUuscum contagiosum. Ecthyma
cachecticum is also sometimes mistaken for syphilis.

When a child is infected during delivery, the disease ap*
pears more promptly on the surface, in the form of ulcers ;
and the usual train of symptoms follow, the mouth and genitals
becoming presently affected. The disease generally appears
within a fortnight after delivery, sometimes so early as on the
fourth day.

If the child receive the infection from the nurse, we discover
ulcers on her nipples, and the disease appears on the child's
mouth, before the surface of the body be affected.

It has been proposed to cure this disease, by giving mer*
cury to the nurse alone, but this mode is now abandoned,
mercury being given directly to the child ; and it ought to be
remembered, that this medicine produces less violent effects
on the bowels in children, than in adults, and scarcely ever
excites a salivation. But if given too long or too liberally, it
may kill the child by its irritation, or may excite convulsions.
Calomel is very onen employed, and with great benefit, a
quarter or half a grain being given three times arday. Others
advise frictions, which are equieJly useful. Fifteen grains of
mercurial ointment, are rubbed on the thighs, alternately,
once in two days, until the mouth be found hot, when it is in-
termitted or continued, according to the state of the system,
and the effect on the disease ; it must be used till the disease
be removed. It has been remarked, that children apparently
cured, when on the breast, have had a relapse after being
weaned. If the child be griped, a gentle purge, and then an
opiate, will give relief. Some have used the ung. acid,
nitros., in place of the mercurial ointment, but it is not to be
depended on. It is, however, useful as an auxiliary, when
applied to the affected part of the surface. . It often happens,
that after all appearances are removed, the disease returns
some weeks or months afterwards. It is, therefore, necessary
to continue the medicine, for some time, after an apparent
cure.

Sometimes, in consequence of the use of mercury, a pecu-

712

liar eruption, called the eczema mercuriale, takes place* ThU
generally begins on the lower extremities, and spreads to the
body. It consists of yery small yesicles, which at first are like
papuke. Each yeside may, with a glass, be seen to be sur-
rounded with redness ; and, if they be not disturbed, they
acquire the size of pins' heads ; then their contents become
opaque. They are attended with heat and itching, and a
general tumefaction of the part affected. Presently, eyen if
not scratched, the yesicles burst, discharging thin acrid fluid,
which stiffens the linen, and sometimes excoriates the part
When the discharge ceases, the cuticle becomes of a pale,
brown colour, and then blacker ; and, separating in pretty
large flakes, leayes the skin below, of a bright red colour.
After this, the skin comes off, in scales or scurfs, perhaps two
or three times. The disease ceases of itself, sometimes with-
in ten days ; often, howeVer, it is protracted longer. Those
parts, which are first affected, are nrst cured. Relief may be
obtained, by applying saturnine lotions, or weak satumioe
ointment.

SECTION THIRTY-FIRST.

The disease termed skin-bound, is not distinctly mentioned
till' 1718, when a case was published by Usembozius; since
then, many accounts haye appeared. It may be diyided into
the acute and chronic, the last being chiefly met with in
priyate practice. The acute species, generally appears soon
after birth, and proyes fatal in the course of a few days. The
earliest good description of this disease, is giyen by I)r. Un-
derwood, and by M. Andry, as it appeared in the hospitals of
London and Paris. In London, the children were seized at
no regular period ; but it was obseryed, that, wheneyer the
disease appeared, seyeral children were attacked, within a
short time, and especially those, in the last stage of bowel
complaints, in which the stools were of a clayey consistence,
and of which the induration of the skin, appeared to be only
a sequel. The skin was of a yellowish white colour, like
wax, and it felt hard and resisting to the touch, but not
oedematous. It was so fixed, to the subjacent flesh, that it
would not slide, nor could it be pinched up. This state waa
found to extend oyer the body, but the skin was peculiarly
rigid, about the face and extremities. The child was always
cold, did not cry, but made a moaning noise, and had con-
stantly the appearance of dyiAg immediately. In the French
hospitals, the disease differed, in being more frequently

713

attended with spasm, or tetanus, and always with erysipelas,
especially about the pubis, which, though purple, was very
cold. Tnese erysipelatous parts, rarely suppurated, but some-
times mortified. The legs were oedematous, and the children
died on the third or fourth day, or at farthest, on the seventh
day from birth. This disease differs, then, principally from
that observed in this country, in being combined with erysi-
pelas and tetanus, which are bv no means essential symptoms ;
and perhaps the erysipelas of children, has sometimes been
mistaken, for the disease called skin-bound.

In private practice, the disease appears under a more
chronic, though not less dangerous form. The children
affected are generally delicate ; and in such cases, as I have
seen, the skin, from birth, was not so pliable as it generally
is, being most rigid about the mouth, which had more of the
orbicular shape than usual. The skin gradually becomes tight,
hard, and shming, and of a colour, a little inclined to yellow.
In some cases, the whole skin is thus affected ; in others, chiefly
that about the jaws, neck, and joints. The scalp is often bald
and shining, and the veins of the head peculiarly large and
distinct. Li some instances, parts of the skin are rough and
slightly leprous. The appetite at first, ia not greatly impaired,
^ and the bowels are sometunes uniformly regular. Presentlv,
* the child becomes duU and listless, and moans, and gradually
sinks, or is carried off by fits. The complaint lasts for several
weeks. In some cases, the disease is less severe, the appear-
ance of the child being healthy, and the thickening and
rigidity of the skin, confined to the joints of the extremities,*
or the disease may be confined nearly to one extremity. I
have met with this circumscribed form, the whole groin, leg,
and thigh, for instance, being swelled and purplish, and the
muscles hard ; the belly also discoloured, or red and mottled,
as if numerous small veins were disposed over it, or as if there
were a kind of ecchymosis, the child being, in other respects,
pretty well. In such a case, the tepid bath and mild laxatives
have been useful. It may be said tnis is merely a modification
of erysipelas. Dissection sometimes throws no light on this
disease, there being found only a deficiency of oil, in the

• Adulto are ■ometimes leised with this diaeaae. A Tcryreiniirkable case of
this kind is recorded io the 48th toI. of the Phil. Traoe.— The eubjcct of it was
* S^rlf H^ 17 years. She had ezeesslre tension and hardness of the slcin, aU
ortr the bodv, so that she could hardly moTe. The skin felt like a dry bide or
piece of wooo, but she had some sensation when pressed with a nail or pin. It
was cold and dry, the pulse was deep and obecore, bat the digestion good. It began
in the neck, then alfected the face and forehead, and at last she oould scarosly open
her mouth.

714

cellular substance, with induration, or infiltration of tbin
albumenous fluid, tinged with bile* Instead of this, Palletta,
occasionally, found fluid blood, in the cellular substance, and
the muscles, giving the skin a livid colour. The veins, along
the cerebellum, pons Varolii, and medulla oblongata, were
gorged with blood. The lungs had black blood in their
substance, or sometimes air. In general, all the veins were
fuller than usual of black blood. The liver was often of a
brown red colour, so as to appear almost entirely composed
of dark blood, at other times, it was swelled, tense, and as if
inflamed, and then the intestines seemed to participate.*
Camper says, there is always, or at least very n*equently, a
little hard tubercle found in the cheek, under the malar bone;
but this can have no connexion with the production of the
disease. Sometimes more children, than one, in the same
family have been affected ; and in such cases, they have been
always of the same sex. A variety of remedies have been
made use of, such as mercury, laxatives, aromatic baths, and
emollient frictions. Gardien advises vinegar, having gum
ammoniac dissolved in it, to be poured on hot bricks, and the
vapour applied to the indurated part. When there is stupor,
or determination to the head or lungs, a blister apphed on
the indurated part has been proposed, but I h&ve no evidence
of its utility ; others, have, as a remedy for the induration,
advised blisters to be applied to distant parts, with a view of

! producing counter-irritation. Palletta, found most benefit,
rom the application of leeches to the extremities, and the use
of the warm bath. A gentle course of calomel has appeared
to do good, when the affection was confined to the extre-
mities. Decoction of sarsaparilla, with the frequent use of
the warm bath, decoction of mezereon, and a variety of
diaphoretics, may be tried ; and in cases where more children
than one, in the same family, have been affected with the
chronic species of this disease, it may be worth while to
try the efiects of mercury, and some other medicines, on the
parents.

SECTION THIBTY-SECOND.

The small-pox, begin with a febrile attack, which com-
mences generally about mid-day. It is marked by chilness,
listlessness, pain in the back and loins, drowsiness, vomiting)
pain in the region of the stomach, which is increased by pres-

♦ Archives, Tom. v. 105.

715

^ure, starting, and coldness of the extremities. As the fever
advances, the pulse becomes more frequent, the skin hotter,
the face flushed, the eyes tender, and the thirst considerable*
The child starts, grinds his teeth, or has one or more eclamptic
fits, or sometimes complains of severe cramp in the legs, or
lies in a kind of comatose state. On the evening of the third,
.or morning of the fourth day, an eruption appears on the face,
and then on the neck, from which it spreads to the body. In
mild cases, the eruption is completed, by the evening of the
fourth, but sometimes not till the fifth day, or even later, if
the pustules be very numerous ; and then the fever declines
or goes off altogether. The eruption consists, at first, of
small, hard, red pustules, of a fiery appearance. On the secoid
day, the top is clear, and a very small vesicle, is observed to
be forming. On the face, we frequently find patches like
measles, but containing many minute vesicles, rfext day, if
the eruption is to be copious, the number of pustules is
farther increased, especially on the face, where we often find
more patches. These patches, and the succeeding confluent
vesicles, seldom appear in the inoculated small-pox, or in the
natural small pox, when very distinct. They are numerous,
in proportion to the tendencv, to the confluent form, of the
disease. The pustules on the body, are more raised and
rounder, though in some places they are flatter, and more
extended* The base is surrounded with an inflamed rim;
and presently, if the eruption be copious, this inflammation
spreads from one pustule to another, so that all the surface
appears to be red. The cuticle of the vesicle, at this time, is
somewhat opaque, but its contents are limpid, like water.
On the fourth day, if there be anv patches on the face, they
are evidentlv covered with flat confluent vesicles ; on the body
and arms, the vesicles are larger, and rounder, than the day
before. The surrounding redness is a little paler, the skin of
the vesicle is whiter, and more of the pearl appearance ; so
that at the first glance, the eruption seems to consist of white
elevations. The vesicles are fnll and smooth. On the fifth
day, they are rather flatter. On the sixth day, the skin of
the vesicles, on the body and extremities, is drier and harder,
and the contents still limpid ; all those on the body are entire,
but about the chin, some have broken, and crusts are formed.
If there have been patches on the face, these are now covered
with flat vesications. On the seventh day, the vesicles on
the body and extremities, are of a dead white colour at the
circumference, but more glossy, like candied sugar at the

716

centre. Their contents are a little turbid ; more crusts are
formed on the face. On the eighth day, the fluid on the
extremities is whitish. On the ninth day, the crusts on the
face, are more numerous, and they begin to be formed about
the bend of the arm, &c. The pustules on the extremities,
are whiter, as if filled with pus, but the fluid is thin and
milky ; the skin of the vesicles is thick. On the tenth day,
the pustules on the face, are covered with scabs, and many
are rormed on the extremities. On the breasts, the vesicles
are prominent, like two-thirds of a sphere, but compressed,
and nave no redness round them. Many vesicles are empty,
and covered with thin, brown skin. Scabs are formed, by the
skin becoming dry, hard, and brown, or sloughing. The
contained fluid is partly absorbed, and partly efiused by exu-
dation, so as to add a crust to the slough of the vesicle.

When the scabs are picked off, about the seventeenth day,
the base of the mark, is, in general, elevated above the rest <^
the skin, but the centre is depressed, a little, below the mar-
gin. The colour is light-red. On the twentieth day, the
blanes on the body and extremities are smooth, flat, or slightly
scurfy, so that they somewhat resemble leprous spots.

The, process is not always regular; for, in very mUd cases,
the suppuration is indistinct, and the scab thin ; the pustule
dries without forming much matter, so that inoculators can
scarcelv get their lancet wet. This is a favourable condition.
Sometimes the matter, though considerable in quantity, does
not exude to form a scab, but is absorbed, and the vesicle
remains for a time entire, forming what has been called
variola siliquosa.

About the seventh or eighth day of the disease, when the
pustules are numerous, the face swells ; but about the tenth,
or eleventh, it subsides, and then the hands and feet swell*
It is also common, about ^the sixth or seventh day, for the
throat to become sore, with sneezing, and some degree of
hoarseness or cough ; and in unfavourable cases, the secretion
about the throat, becomes tough and thick.

When the pustules are numerous, a return of the fever may
be expected about the eleventh day. This is called the
secondary fever ; but, in mild cases, it is very trifling, and does
not last long.

Such is a general history of the distinct small-pox ; but the
disease may also appear in a different form, known under
the name of the confluent small-pox. In this case, the erup-
tive fever is more severe, attended with greater pain m toe

717

loins, and often with coma. It differs also from the former,
which is of the inflammatory kind, in being of the low
type, so that sometimes petechise appear. The eruption
comes out earlier, generally on the morning of the third day,
and is sometimes preceded, by «rythematic inflammation, of
the face or neck. The eruption is copious, and at first, more
like measles than small-pox, so that some practitioners have,
at this stage, mistaken the one disease for the other. The
pustules, which are not so much elevated as the variola dis-
creta, become confluent, especially on the face ; and though
they may be confluent only on the face, yet those on the body,
are not of a good kind. They form matter earlier, do not
retain the circular form, and, instead of having the interstices
of the skin, where they do not coalesce, of a red colour, as in
mild small-pox, these spaces are pale and flaccid. The
coalescence, is most remarkable on the face, which often seems
as if covered with one extensive vesicle. The matter which
these pustules form, is not thick and yellow, like good pus, but
either of a whitish brown, or black colour. Scabs generally
form, about the eleventh day of the disease, but these do not
fall off, for a length of time, and leave deep pits. The swell-
ing of the face, is greater and more permanent, than in the
former s]>ecies, and uie eruptive fever does not go off, when
the eruption is completed ; it only diminishes a little, till the
sixth or seventh day, when it increases, and often proves fatal
on the eleventh.

The treatment of the distinct, is different from that of the
confluent, small-pox. During the eruptive fever, the anti-
phlogistic regimen must be carefully enjoined, the diet must
be light and sparing, the surface kept cool and clean, and the
bowels loose. £metic8, at an earljr^ stage of the fever, have
been serviceable, and it is generally proper to give laxatives.
Eclamptic fits are relieved by opiates and cool air. When
the eruption is coming out, the cool regimen should still be
persisted in, and the boweLs kept open. After the pustules
nave appeared, the fever generaUv abates ; and then, although
heat should be avoided, the cooling and purging plan, n^
not be carried so far as formerly. But if the fever still con-
tinue, these means should be also continued. The diet must
be sparing, and plenty of ripe fruit should be given. If
secondary fever supervene, it is to be removed, chiefly, by
laxatives and cool air : or if there be oppression at the stomach,
a gentle emetic may be given.

In the confluent kind, during the eruptive fever, the cold

718

plan should be diligently employed, and cathartics are of
essential benefit. When the eruption appears, the cooling*
regimen should still be persisted in, and both vegetable and
mineral acids ought to be given freely. Quinine is also proper,
provided that it be not productive of sickness or vomiting.
When the fever is aggravated, at the height of the disease,
emetics have been sometimes given with advantage ; but in
general they are not necessary, and more benefit is derived
nrom laxatives and clysters. Opiates are useful, for abating
irritation; and wine, with nourishing diet, should be pru-
dently given, to support the strength, which is apt to be com-
pletely exhausted, under the constant fever and irritation.
On this account, also, it is necessary to restrain diarrhoea,
when it is frequent, and adds to the weakness. Blisters have
been advised as stimulants, but they are only useful, when
deep-seated inflammation exists. Sometimes the brain seems
to be affected, the head being pained, the eyes impatient of
light, and the patient delirious. In this case, leeches may be
applied to the temples, and a blister put on the head. When
the kuigs are affected, blisters on the sides or breast do good.
When the stomach is very irritable, if saline draughts and
opiates do not give relief, a small blister should be applied
over the stomach. If the swelling of the face subside quickly,
and be not followed by tumefaction of the feet and hands,
blisters have been applied to the wrists, but sinapisms are
better, though it is not decided that either are of great utility.
When the throat is much affected, and filled with viscid
phle^, gargles are of use, and sometimes a very gentle eme-
tic gives relief.

If the eruption suddenly subside, cordials tend to bring
back a salutary inflammation ; or if it altogether recede, the
tepid bath, with ammonia, and other internal stimulants, will
be proper. The boils and inflamed pustules, succeeding
variola, are very troublesome, and sometimes prove fatal.
When large, suppuration should be hastened with a poultice ;
when small, unguentum resinosum may be applied ; or if they
be indolent, gentle friction, with camphorated liniment, and
bathing with laudanum, is of benefit. The strength must be
supported, and, as soon as possible, sea-bathing should be
resorted to.

The violence of the variolus disease is generally lessened by
inoculation,* which was first introduced, into this country, in

• Inoculation, even nfter exposure to infection, ia capnble of prodaclog a mild
4iteMe.

719

the year 1721. The operation itself is very simple, consisting
merely in abrading the skin, on the arm or leg, with the point
of a lancet, and then applying on the small scratch a little of
the variolas matter, which should be taken early, as when it
is delayed until the pustules are collapsing or scabbing, it
sometimes produces a spurious inflammation. By the third
day, we are sure of success, by observing a slight redness on
the arm at the incision. On the third or fourth day, the part
is hard to the touch. The redness gradually increases, for the
two succeeding days, and then a small vesicle may be perceiv-
ed. By the eighth, or at farthest the tenth day, the pustule
has completed the variolus character. It forms a circular
elevation, surrounded with circumscribed redness, and the
vesicle is a little flatted on the top. The constitution at this
time becomes afiected; and the earlier that the eruptive fever
appears, the milder, in general, is the disease. The character
of the succeeding disease may, it is supposed, be foreseen,
even before the eruption take place, or be completed, by ex-
amining the arm ; but this is doubtful.

The safety of the practice of iooculation is greatly increas-
ed, by having the system as free as possible from every dis-
eased state; and, therefore, children are not inoculated during
dentition, at least if they cut their teeth with any trouble.
Very young children are not considered as favourable subjects.
Dr. Fordyce observing that two-thirds of those who died, from
inoculated small-pox, were under nine months. If we have
our choice, the best age is said to be from two to four years,
but it is dangerous to wait so long, lest the child should take
the casual small-pox; and Dr. Adams informs us, that of
three thousand children, inoculated at the hospital, in one year,
two thousand five hundred, were under two years of age, yet,
only two out of that number died. Full plethoric children,
should be frequently purged, and fed sparingly, before the
operation. Some particular modes of preparation, have been
ohen employed, such as giving calomel or antimony, but these
have very little effect. The attention ought cmefly to be
directed, to bring the body into a state of good health, if
previously delicate, or diseased : and, on the other hand^ if
requisite, diminishing plethora, and inflammatory disposition,
by the obvious means. After the inoculation, the bowels
must be kept open, and all stimulants avoided ; and when the
eruptive fever commences, the antiphlogistic regimen' is to be
strictly practised, and often has so good an effect, that few
or no pustules come out ; or if they do, they do not maturate,

720

and we have no secondary fever. In general, the arm heals
kindly ; but when it forms a sore, it should be exposed to the
air, or dusted with chalk : if it threaten gangrene, it should
be bathed with camphorated spirits, or tincture of myrrh.

SECTION THIRTY-THIRD.

As a preventive of the small-pox, the vaccine inoculation
is now universally practised. This is productive, in general,
of a very mild and safe disease, consisting of a single vesicle,
forming on the place where the inoculation was performed.
On the third day, the scratch is slightly red, and, if pressed
with the finger, feels hard. Next day, the red point is a little
increased, and somewhat radiated. On the fifth day, a small
vesicle appears, but it is still more easily seen on the sixth.
This gradually increases, until it acquire the size of a split
pea. The colour of the vesicle is dull white, like a pearl. Its
shape is circular, or slightly oval, when the inoculation has
been made with a lengthened scratch, acquiring about the
tenth day, a diameter equal to about the third, or fourth, part
of an inch. Till the end of the eighth day, the surface is
uneven, being depressed in the centre ; but on the ninth day,
it becomes flat, or sometimes rather higher at the middle than
at the edges. The margins are turgid and rounded, project-
ing a littie over at the base of the vesicle. The vesicle is not
simple, but cellular, and contains a clear, limpid fluid, like the
purest water. On the eighth or ninth day, the vesicle is sur-
rounded with an areola, of an intense red colour, which is
hard and tumid. About this time, an erythematic efflo*
rescence, sometimes, takes place near the areola, and spreads
gradually to a considerable part of the body. It consists of
patches, sUghtiy elevated, and is attended with febrile symp-
toms. On the eleventh or twelfth day, as the areola decreases,
the surface of the vesicle becomes brown at the centre, and is
not so clear at the margin ; the cuticle gives way, and there
is formed a elossy, hard scab, of a reddish-brown colour, which
is not detached, in general, till the twentieth day. When it
falls off, we find a cicatrix, about half an inch in diameter,
and with as many pits as there were cells, in the vesicle.
During the progress of the vesicle, there is often some disor-
der of the constitution ; and occasionallv, a papulous eruption,
like strophulus, appears near the vesicle.
, A« aecority aj^auurt thesmaU-pox, U not procimsd by smi-
nous vaccme vesicles, it becomes necessary to study careniuT,
the character of the genuine disease^ which I have briefly

721

described. A very frequent species of spurious cow-pox, i^
rather a pustule than a vesicle. It increases rapidly, instead
of gradually. From the second, to the fifth or sixth day, it is
raised toward the centre, and is placed on a hard, inflamed
base, surrounded with diffused redness. It contains opaque
fluid, and is usually broken by the end of the sixth day, when
an irregular, yellowish-brown scab is formed. If the vesicle
be regula;r in its progress, and have pretty much of the gene-
ral aspect of the vaccine vesicle, but contains on, or before, the
ninth day, a turbid or purulent matter, it cannot be depended
on ; and the security will be still less, if the scab be soft*
Besides this, Dr. Willan has characterized three spurious
vesicles. First, a single pearl-coloured vesicle, less than the
genuine kind ; the top is flattened, but the margins are not
rounded nor prominent. It is set on a hard, red base, slightly
elevated, witn an areola of a dark rose colour. The second,
is cellular, like the genuine vesicle, but somewhat smaller, and
with a sharp, angulated edge. The areola is sometimes of &
pale red colour, and very extensive. It appears on the seventh
or eighth day after inoculation, and continues more or less
vivid for three days, during which, the scab is completely
formed. This is less regular than the genuine scab, and falls
off sooner. The third, is a vesicle without an areola. These
forms of the disease, do not give security against the small-pox ;
and it would appear that a vesicle, which is even regular at
first, or which runs through the whole course with regularity,
may fail to secure the constitution ; for there are well authen-
ticated cases, where the small-pox has thus succeeded the
cow-pox. Professed writers on this subject have enumerated
three causes of failure. 1 st. From matter having been taken
from a spurious vesicle, or from a genuine vesicle at too late
a period. The best time for taking matter, is about the eighth
day ; and after the twelfth, or when it becomes purulent, it
cannot be depended on : or the same effect will be produced,
by any cause which can disturb the progress of the vesicle*
2d. From the patient being seized, soon after vaccination,
with some contagious fever, such as measles, scarlatina, influ-
enza, or typhus. 3d. From his being affected, at the time of
inoculation, with some chronic cutaneous disease, such as
tinea, lepra, &c. The precise circumstances, under which
these causes, produce their effect, or the degree to which they
must be present, in order to operate, have not yet been deter-
mined with certainty. It has also been supposed, that pun&*

3 a

722

turing the vesicle, in order to take matter from it, may, by
disordering the process, sometimes prevent its efficacy.

Even where none of these causes exist, and when the vesicle
runs its course with distinctness, it does, not unfrequently
happen, that the constitution is not rendered insusceptible of
the variolus action. It were much to be wished, that some
test could be discovered, by which the security could be de«
termined. The constitution is often manifestly disordered,
during some part of the vaccine progress, and such children
have greater security ; but sometimes the disorder is too
slight to be discovered, and, therefore, this sign is not to be
relied on. We are also assured, that even when no constitu-
tional disorder has taken place, the child is secured. Other
means, then, have been resorted to, in order to discover if the
system be affected, so as to have as complete a change induced
by the inoculation, as it can effect. These are two in number:
1st. If a second inoculation be performed, on the fifth or sixth
day, after the first, a vesicle will arise as usual, but it will be
surrounded with an areola, nearly, as early as the first one.
2d. If a second inoculation be performed, any time after the
twelfth day, after the first inoculation, some degree of inflam*
mation will be induced ; but if the system have been affected,
no regular vesicle will be produced. But the most satisfac-
tory method is, to inoculate with small-pox matter, which
produces a smaU pustule, generally unattended with constitu*
tional affection ; but sometimes, even although the constitu-
tion have been changed by the vaccine inoculation, a febrile
affection may be excited, either without pustules, or attended
by an efflorescence on the skin, or an eruption of little papu-
lae, or small pustules, which disappear in about three days.
It unfortunately happens, however, that parents, in general,
do not think it necessary to adopt any of these means ; and
inoculators, perhaps, trust too much to their own power of
discrimination, in determining how far a vesicle is capable of
producing the desired effect. Some test is the more requisite,
as vaccination is often performed in a very careless manner,
and by people ignorant of the character of the disease.

It has been said, that if a child, properly vaccinated, should
afterwards take the small-pox, the eruption is papulous, or
tuberculated, and does not suppurate, but endsin desquamadon.
I have, however, known very distinct cases of suppurating
small-pox, in those, who, some years before, had gone through
the vaccine process, in the most satisfactory manner. Few

723

factSy I believe, are now better ascertained, in our '' ara con-
jecturalis/' than tbat small-pox may take place after vaccina-
tion, yes, even the most perfect vaccination ; and I believe
that the proportion will increase, as we recede from the date
of vaccination, and augment the activity of the infection.*
Many shall escape, who are merely exposed to the, casual,
company of those who have small-pox, who should take the
disease, if inoculated with virus. This much, at least, I know,
that a great majority of those whom I have inoculated, have
taken a mild small-pox. The eruption has been more papu-
lous, than if vaccination had not preceded, and has only vesi-
cated, and dried like chicken-pox. In other cases, the prin-
cipal part of the eruption, has been efflorescent like measles.
But all who were formerly conversant with small-pox, know,
that children inoculated, and properly treated, often, had
scarcely any eruption, and that not coming to suppuration.
Those, again, who take small-pox, from exposure to contar-
gion, have the disease more severelv ; the fever may be hi^h,
and attended with delirium, the body completely covered with
pustules, which maturate, and leave for a time distinct blanes.
The disease may even prove fatal. Variola occurring after
vaccination is contagious, and produces the same disease in
those who are not vaccinated, as any other small-pox would
have done. Some seem to think, that by changing the name
they can change also the disease, and have called this, not
variola, but a varioloid disease. It must either be small-pox,
or it must be something else. If it be not, then, small-pox
virus can produce a new disease. We are told it does so,
and long ago it was maintained, that chicken-pox was merely
a modification of variola ! The substitution of the term
varioloid, is indeed a very good way of getting rid of the fact,
that small-pox may occur after vaccination ; but it is not an
original idea, for Falstaff fell on the same expedient with re-
gard to stealing — ** Call it conveyingy Hal." I do not, from
these remarks, mean to depreciate the cow-pox; on the con*
trary, it is only bv ascertaining the precise power of vaccina^
tion, that its full benefit can be derived to mankind : and,
although, the warmest friends of this discovery must admit,
that it is not always successful, yet, it has hitherto failed in so
small a proportion of cases, that we must consider it as justi-

* I hare known m Tsriolout poitnle produecd on the arm by inocuHitlony lOon
aflcr YMcioation, without miv eonttittttiooal effect, ehowing that the •jrtCem was
thtn secure ; aiid yet, year* afterwards, the same Indlridual has had caaui^ small-
pox, proving that time had diminished the efleaey of Taccination.

726

contain purulent matter ; if they have burst, they are coTered
with slight, gummy scabs. The scabs fall off, in from four to
five days, and often leave durable pits. A fresh crop of
pustules, comes out on the second or third day, and runs the
same course with the first ; so that the eruptive stage in this
species, is six days, and the last formed scabs, are not separated,
till the eleventh or twelfth day. 3d. The swine or bleb-pox.
The vesicles are large and globated, but the base is not exactly
circular. They are surrounded with inflammation, and con-
tain transparent lymph, which, on the second day, resembles
whey. On the third day, they subside and shrivel, and
appear yellowish, the fluid being mixed with a little nas.
Before tne end of the fourth day, they are covered with thin,
blackish scabs, which fall off in four or five days.

* The chicken-pox is a very mild disease, and requires no
other management, than keeping the bowels open, and the
surface moderately cool. The skin may be sponged with cold
water, which dimimshes the heat and lessens the number of
pustules, if done during the eruptive fever; at a later period,
it abates the itching. I have, especially in scrofulous children,
observed, that if the bowels were neglected, by the parents,
and the diet were full and heavy, the pustules became much
inflamed, and ended in sloughs, which left large and perma-
nent cicatrices ; and in some cases, boils and abscesses have
occurred from the same cause.

SECTION THIRTY-FIFTH.

Urticaria, or nettle rash, may appear either as an acute or
chronic disease.* The first is most frequent with infants and
children. It b preceded by languor, sickness, and fever, on
the third day of which, but sometimes earlier, an itchy erup-
tion appears, bearing a very exact resemblance, to that pro-
duced by the stinging of nettles. It consists of irregular
patches, slightly elevated above the surface. These, are of a
dull, white colour at the centre, and red towards the margins,
which are sometimes hard and well defined. The size and
shape of the patches are very various. GreneraUv, they are
about the size of a penny-piece, but sometimes form pretty
lonff stripes. This eruption, is, in some cases, attended by a
slight turgescence of the skin, but especially of the face and
eyelids. The patches do not remain constantly out, but appear
and disappear, Irregularly, during the disease, which lasts for

* Dr. WIIIrii noticM five different epeoiw of this dieeMe ; but for the prceeat
purpose, this tlmple diTition is sufficient

727

seven or eight days, including the period of the eruptive fever.
When the eruption declines, the languor, stomachic symp-
toms, and feverishness, go off. The disease terminates by
slight exfoliation of the skin. In infancy and childhood, it is
often dependent on dentition, or affections of the bowels ; and
from the itching which attends it, great distress is produced.
The febrile urticaria is not infectious, but in certain seasons
it is very prevalent ; and the same holds true, with regard to
the chronic species. Chronic urticaria is more rare in infancy.
It differs from the former, chiefly, in being destitute of fever,
and vexing the patient, at intervals, for a length of time;
sometimes even for years. The patches seldom continue out,
however, for above a few hours at a time. They are, like the
former, reproduced readily by exposure to cold, and are also
particularly troublesome after undressing to go to bed. A
temporary eruption of this kind, without fever, is often con-
sequent to eating particular kinds of fish, or substances which
disagree with the. stomach. An eruption, somewhat, resem*
bling urticaria, is described by Dr. Willan, under the name
of roseola annulata ; it differs in size, and some other circum*
stances, whilst it agrees in others. It consists of circular
patches, about half an inch in diameter, the margins rose*
coloured, the centre, of the usual coloiu: of the skin ; but I
have seen the patches of a purple colour, and with very little
central white. These cover the body, and produce, especially
at night, a sensation of heat and itching. When unattended
with fever, the eruption fades in the morning, and becomes
round and elevated at night. The use of mineral acids, and
sea-bathing, will be of service.

A gentle emetic, followed by one or two purges, gives relief
in acute urticaria. The chud should, ii possible, be kept
from scratching, so as to tear the skin; and this will be the
easier done, if he be preserved in an uniform temperature.
The tepid bath sometimes gives relief. The chronic species
is more obstinate, and in consequence of the abrasion of the
skin, from frequent scratching, it has sometimes been treated
as itch, but of course, without advantage. The bowels are
to be kept open, by small doses of calomel, or rhubarb and
magnesia, and some tonic medicine should be administered.
The tepid bath daily will also be proper, but sometimes, sea-
bathing, continued for some months, succeeds better. Mer-
curials have been tried with very little good effect, except in
so far as they acted on the boweb. Soda is useful.

728

SECTION THIRTY-SIXTH.

Scarlatina,* may appear under two different forms. In the
first, it is accompanied with inflammatory fever, and is gene-
rally mild ; in the second, it is connected with a low fever,
and is very malignant. The first species admits of a further
subdivision, according to the degree of mildness; one variety,
being attended with slough or ulceration of the throat;
another, still milder, with little or no affection of the fauces.
This has, by some, been called scarlatina simplex, to distin^
guish it from the first, or scarlatina anginosa.

The scarlatina simplex, begins with a febrile attack, attended
with considerable debility, chilness, nausea, and pain in the
belly, and about the loins and extremities. It generally
attacks, very suddenly, in the afternoon or evening, the patient
having been, not an hour before, lively, and apparently in
good health. The pulse is extremely rapid, being often 140
in the minute ; the trunk is very warm, and the feet cold ; the
respiration frequent, irregular, and sometimes sonorous ; the
eye dull, and the eyelids turgid and red on the inside*
Sometimes, but not often, convulsions occur early, and are to
be considered as unfavourable. On the next day, if not
earlier, an eruption appears, first on the face and neck, and
very soon, always within twenty-four hours, it is diffused over
the whole body. It consists of numerous minute specks, so
closely set together, that the skin appears altogether of a red
colour, like a boiled lobster, and it feels rough. Broad patches
also appear on those parts which are most exposed to heat or
pressure. Sometimes papulae are intermixed with, or even
precede, the eruption. The inside of the eyelids, nostrils,
cheeks, and fauces, are of a deep red colour, and the tongue
participates in the appearance. The eruption is most virid
at night, and especially on the evening of the third or fourth
day. On the fifth day it declines, and is wholly gone by the
seventh, when desquamation takes place. During the erup-
tive stage, the patient is generally either restless, or very
drowsy, often slightly delirious, and both during this stage,
and the process ot desquamation, complains much of itchiness.
Whilst the fever lasts, the skin is extremely hot. The con*
tagion, in general, operates on the third, or fourth, day after
the person has been exposed to it.

The scarlatina anginosa, is attended with more severe symp-

* Thia, roMoU, and mcatlcs, appear at first to have been confounded vritb one
another.

729

toms. It commences with the usual symptoms of fever ; and
in general, whenever these appear, or even before the fever
commence, the throat will be found, on inspection, to be
affected ; but sometimes the cynanche does not take place till
the eruption come out, which is nearly about the same period
as in the former species. Dr. Sim says, that the first marks
of disease, are paleness and dejection of countenance, and
that, at this time, the fauces will be found to be red. I am
very much inclined to adopt the same opinion. From the
first, there is a sensation of stiffiiess, about the muscles of the
jaw and neck ; and very soon, generallv on the second day,
the throat feels as if straitened, the voice becoming hoarse,
and sometimes a croupy cough takes place. In this case, the
breathing often becomes sonorous, or even so obstructed, that
the child is suffocated, as in cynanche trachealis. In very
many cases, deglutition is performed with difficulty, and some-
times the drink returns by the nose. On examining the
mouth, we find, at the first, that the tongue has a very red
colour, and its papillae are evidently elongated. In the pro-
gress of the disease, it is often covered with a fur. The
tonsils are early observed to be of a deep red colour, and, very
soon, whitish streaks may be discovered. Superficial ulcera-
tion is frequent on the second or third day, and the parts
become covered, with a white, or ash-coloured, substance or
slough, whilst the rest of the tonsil becomes of a dark red
colour. These sloughs are sometimes not removed, for a week
or more, but often are detached on the fifth or sixth day, when
the cuticular eruption declines. The inside of the nostrils
is inflamed, and sometimes ulcerated. The lips, likewise,
become tender and itchy, and, owing to the child picking at
them, they, as well as the gums, are ant to be covered with
black patches, chiefly from efiusion of blood. The eruption,
in this variety, is the same in appearance, and duration, as in
the former. When it is slight, or disappears suddenly, it has
been said that the event is hazardous, but this is not always
the case. The fever is attended, often, with great nausea,
bilious vomiting, restlessness, headach, and delirium. The
heat is excessive, the pulse feeble, and sometimes fluttering,
always very rapid. The languor and inquietude are great,
especially when the sloughs are forming. About a week, or
ten days, after the eruption fades, anasarcous swelling of the
legs may take place, and continue even for two or three weeks.
Sometimes, other parts of the body swell, or the patient has
ascites.

730

Scarlatina is sometimes succeeded by paia in the ear,
followed by temporary deafness, and the duscharge of foetid
serous fluid. This often abates, upon syringing the ear with
decoction of camomile for a few days ; but it may be more
obstinate, and the child remain permanently deaf. The ton-
sils occasionally suppurate, after the external disease abates.
Swelling of tne parotid ^land is not uncommon, and it is
said by yarious authors, when it is late of appearing, to pro*
tract or renew the symptoms, eyen the eruption itself; bat
this I do not belieye. Sometimes the glands of the neck
swell and suppurate, or the bones of the nose, after obstinate
ulceration, become carious. I haye seen some unfortunate
cases, where the lips haye sloughed completely away, and
these ended fatally. Eyen after the patient has, to all ap-
pearance, recoyered from scarlatina, there sometimes, unex-
pectedly, superyene languor, debility, and pain of the bowelsy
frequent pulse, and loss of appetite, which symptoms termi-
nate in dropsy. Bronchitis, or pneumonic affections, may also
be produced. In some cases, the patient becomes languid,
without fever or dropsy, but these generally do welL

In the second species, or scarlatina maligna, the pulse is
rery small and feeole, sometimes indistinct. The debility is
very great, the patient fainting on making the smallest exer-
tion, and very generally he is unable to sit up in bed. In the
scarlatina benigna, the tongue is red, the eyes and eyelids
red, the throat at first red, and the skin like a boiled lobster ;
but in this species, the tongue is livid, tender, and soon
covered, together with the teeth and lips, with a brown or
black crust, the eyes are dull, and the inside of the eyelids
dark-coloured, the cheeks are livid, the throat of a dark red
colour, with brown or blackish sloughs ; there is very foetid
breath, with much acrid discharge from the nostrils. The
inside of the labia pudendi of girls, and of the prepuce of boys,
has, in scarlatina, the same colour with the inside of the cheeks
and lips ; in the scarlatina maligna, the vulva and lips are of
a dark colour, and sometimes mortify. The eruption is som^
times faint, in other cases, very dark and purple-coloured, and
often appears and disappears irregularly. In the progress of
this disease, delirium, great fretfulness, or coma, may come
on. The breathing is rattling, the neck seems to be full, and
of a livid colour, and the head is bent back. This disease
sometimes proves fatal in a few hours. It is not, however, always
alike mortal, for there are several smaller degrees of malignity,
forming a gradation betwixt thisi and the scarlatina anginosa.

731

The first Bpecies, when properly managedy is not very dan-
gerous, but the last is attended with great hazard. The
prognosis must be made, by attending to the symptoms of de-
bility, the progress of the affection of the throat, the tendency
to inflammation of the trachea, and the general character of
the epidemic*

Drs. Withering, Adams, and Willan believe, that the
scarlatina* does not attack the same person twice, though the
throat may be, to a certain degree, repeatedly affected. I am
disposed to adopt the same opinion as a general rule.
Aphthous affections of the throat, and exudation of lymph
from inflammation, are often considered as belonging to scarlet
fever, though the eruption be absent, but the conclusion is
incorrect. Those who are exposed to the contagion of
scarlatina, may have sloughs in the throat, attended with
considerable debility, but a regular repetition of the scarlet
fever, is certainly not a frequent occurrence. Sometimes
other eruptive diseases, such as roseola infantilis, have been
taken for it.

The scarlatina simplex and anginosa, are often so mild
diseases, as to require little medicine, but, still, great atten-
tion is necessary. Emetics, given early, are said to be atten-
ded with advantage, and supposed to render the subsequent
disease milder. But to the truth of this opinion, my experi-
ence does not permit me to bear testimony. Laxatives are
still more useful, and, in mild cases, are the only medicines,
which are required. In some epidemics, the bowels are
moved, with greater difficulty, than in others, and in those
cases, the laxative must be stronger. Even, when there is a
tendency to diarrhoea, if the stools be foetid, and unnatural in
their appearance, purgatives are equallv necessary, as in the
opposite state. The best medicine, to be given at first, and
the earlier the better, is calomel, either alone, in a brisk dose,
or combined with some other laxative, to ensure its operation ;
this often, even at the commencement of the disease, brings
away foetid stools. After the operation of the first dose of
calomel, the bowels must be kept open, or even rather loose,
by the daily use of infusion of senna with an aromatic. This
is better tlian repeated small doses of calomel, which often

* M. Dane« in a paper eontaiiicd in Archive* Geoerales, Tom. zxiii., obMnrea,
that inflammRtion is tlie chief cause of death, and insisU on the intiphlog istic
treatment. This paper is ▼aiuable from the disai'ctions, which showed inflamma-
liont in the mucous membrane of the air passage, digestive canal, or membranra
or subfitance of the brain, which has been found sablee de points rouges, and the
pta mater of a uniform madder red.

732

affect the mouth considerably. But if the stools be very
fcetid, the patient oppressed, and the bell^ fuU, a brisk purga-
tive may be given, oftener than once, m the course of the
disease.

Another remedy of utility, is affusion with cold water*
This, however, is contra-indicated, when there is any internal
inflammation. It is of consequence to use it early, if it is to
^ be done at all, and whenever the patient feels steadily hot,
the shivering having gone off, and the skin feels very warm,
to the hand of another person, it is time to put him into an
empty tub, and pour over him a large ewer-full of cold water.
By this I have known the disease arrested at once, the erup-
tion never becoming vivid, and the strength and appetite in
a few hours returning. Even where it is not arrested, it is
pleasant to observe the change, which often is produced.
The patient, from being dull, languid, and listless, feels brisk,
and (Usposed to talk or laugh ; the skin becomes, for a time,
colder, and refreshing sleep is frequently procured. The
repetition must depend on the degree of heat, and on the
effect of the first. If that have done no good, it is useless to
try it again. One application is sometimes sufficient, but it
may be necessary, the first day, to use it twice, and once the
next day. It is seldom requisite afterwards : for, although the
disease may continue, it is mild, and laxatives complete the
cure. If the fever be mild, and the heat not pungent and
great, we do not employ the affusion. We keep the patient
cool, or have the surface cooled, frequently, with a sponge
dipped in cold water, and indeed this seems now, in most
instances, to have superseded the use of the afiusion. These
two remedies, especially purgatives, do not only mitigate the
disease, but lessen the risk of dropsical swelling taking place
afterwards. When, there is marked determination to any of
the cavities, it is generally safe to take some blood by the
lancet, and cold affusion is improper. When, either in adults
or children, there is severe faeadach, or feeling of weight,
accompanied with much fever, the instant use of the lancet,
has been attended with inmiediate and permanent relief, or,
at a later period, I have found leeches of much advantage*
If there be delirium, preceded by much earach, a blister to
the head may afterwards be applied with good effect. By
neglecting these means, at the proper time, the patient is apt
to be carried off in a fit, or in a comatose state. Gargles are
often useful, when they can be employed. Water, acidulated
pretty sharply with muriatic acid, or mixed with capsicum

733

yinegar, forms a very good gargle. Acid fruits are proper.
The diet should be light and nourishing. If the debility be
considerable, small doses of wine, may, towards the end of the
disease, be administered. Should anasarca take place, laxa^
tives and diuretics, such as digitalis, are proper, but mere
swelling of the face, or one or more of the extremities, is
generally removed, by the free use of supertartrate of potash.
If the urine be dark coloured, as if it contained some of the
colouring matter of the blood, vegetable diet has been thought
safer than animal food. When the glands about the throat or
neck swell, the best application is cloths wet with cold water ;
or if the glands be painful and tender to the touch, one or
more leeches, according to the age and other circumstances,
must be previously applied, and this practice is often of signal
service, not only in checking the disease of the gland, but in
relieving drowsmess or stupor attending this state. If sup-
puration take place, it is to be hastened by a warm poultice.*
The scarlatina maligna is much more dangerous, and
requires the most vigorous practice. Early sponging, with
cold water, is proper, provided it give comfort, and be not
followed by chilness, and often gives a favourable turn to the
future disease. Laxatives are likewise necessary, and so far
from weakening the patient, if prudently administered, seem
to increase his strength. Wine should be given, in such doses
as do not flush the patient, or make him hotter. Ammonia
is sometimes of benefit. Two drachms should be dissolved in
six ounces of water, and the solution sweetened with sugar.
To infants, two tear-spoonfuls, and to elder children, from a
dessert to a table-spoonful of this solution, may be given every
two hours, or oftener, if possible. An infusion of capsicum
in vinegar is also employed with advantage ; so much of it is
to be added to a given quantitv of water, as renders it pungent.
This mixture may be given in the same doses as the solution
of ammonia, and it both acts as a general stimulant and as a
local application to the throat. Bark has certainly, in man^
cases, been of service ; but in general, children do not take it
in such doses as to do much good; or they loathe it, or reject
it by vomiting. Even when taken freely, it is not a medicine
that can be depended on, in the cynanche maligna of children,
but at present I know of nothing better to propose. When

* Dr. Higglitz recommends in scarlatina, first, an emetic of ipecacuanha, and
then so much Epsom ealu as shall procure four stools, in bad cases he gives
four grains of calomel daily, or rubs iu ung. hyd. Whenever the salivary gUmds
become affected, the disease, he says, takes a turn. 1 doubt it muA.

734

it 18 prescribed, it maj be combined with anmumia or capsi-
cum. Bat in general, it is better to give it in cljsters made
of beef tea without salt, or to use the sulphate of quinine.
&fyrrh has also been given, combined with vinegar; but, of the
efiect of this, I cannot speak from mj own observation.
Oxygenated muriatic acid in doses of twelve drops to children,
has been employed ; but I question if it produce better effecta
than water acidulated with sulphuric acid, which, if the
ammonia be not employed, makes a very proper drink. If
the patient, at an advanced period, be restless, and the skin
dry and rough, ablution with tepid wat^ will be useful. As
gargles, capsicum vinegar with water, or muriatic or nitrous
acid with honey and water, may be emploved; but as children
often cannot, or will not use gargles, tneir utility must be
limited. They might be thrown on the tonsils with a syringe,
but are apt to go into the windpipe, if they get so far back as
the fauces. It is also proper to touch the sloughs and tonsils
frequentlv, with a pencil dipped in solution of chloride of lime,
or a weaK solution of this may be used as a gargle. Fumiga-
tions, made bv pouring sulphuric acid on nitre, placed in a
vessel in the bed-room, have sometimes a good elBPect on the
throat. When the sloughs are large, or the child breathes
with difficulty, or has a croupy cough, gentle emetics have
been proposed. On this subject, I must refer to what I have
said already, (sect. 28,) respecting laryngeal disease, occurring
in putrid sore throat. Blisters have also been applied to the
throat, but they never do good, and decidedly add greatly to
the irritation of the child. In bad cases, there is also much
risk of their being followed by mortification of the part.
Sometimes, in the course of this disease, apoplexy succeeded
bv hemiphlegia, and inability to articulate distinctly, takes
place. Blisters should be applied to the head, and if the
patient survive, the paralvtic symptoms go off in a few weeks.

During the course of the disease, the strength must be
supported by nourishment, or, if that cannot be swallowed, by
nutritive clysters.

When a disease of this kind, appears in a family, the chil-
dren who are unaffected ought, if possible, to be sent away,
and should not return for a month. In the meantime, the
clothes should be washed, and the apartment well ventilated,
and fumigated with chlorine. This fumigation may be em-
ployed, even during this disease, for the destruction of the
contagion, and of the smelling matter in the room.

735

SECTION THIRTY.SEVENTH.

Measles* commence with a distinct eruptive fever, on the
first and second days of which, the patient complains of
irregular shiverings, alternating with beat, general debility,
languor, loss of appetite, has white tongue, thirst, pain in the
back and limbs, slight sore throat, hoarseness, with dry congh
and sneezing, weight and pain across the forehead, giddiness,
drowsiness, sometimes convulsions, frequent and irregular

Jmlse, costiveness, and high-coloured urine. On the third or
burth day^ the symptoms become more severe ; the eyes are
tender, watery, and appear as if inflamed, the eyelids are often
swelled, the nostrils discharge thin serum, and the patient
sneezes more frequently. There is now often some degree of
d^spncea, and sometimes pain and tightness in the chest.
These febrile symptoms usually come on distuictly, about
twelve or fourteen days after exposure to infection ;t but I
have known children seized more gradually, being teased with
hard cough, and rendered more irritable and fretful, for many
days before the eruptive fever commenced. The eruption
appears betwixt the third and sixth day of the fever, but most
frequently on the fourth, and it remains for about three days.
It is first visible on the forehead, then on the neck, then on
the face* Next day, it appears on the breast, and by the
evening, it covers the trunk and extremities. The eruption
consists, at first, of small red spots, apparently a little raised,
like papulae, but without vesicular tops. Then, the spots
extend so far as to form oval or irregular figures, slightly
elevated, but flat, resembling flea^-bites. Very soon, large
patches appear, intermixed with the distinct spots. These
are irregular in shape, but tend to the semilunar figure ; they
are made up of clusters of distinct spots* In some cases, the
eruption, though vivid, is not considerable ; and in this case,
it consists, almost equally, of patches and circular and irregular
spots, and the intervening skin is of the natural appearance.
When the eruption is more copious, the patches are most
numerous and extensive. In children under a year old, the
eruption is not so thick and confluent, as in older subjects, and
in many places has a papulous appearance, especially on the

* DerlTtd from tha Saxon. MtMd, is a I«p<r, muaUf or my§el^ Icproiu. The
disesM \% also caUed morbilli, from bavini^ been considered as a lUtle plague.

f It would appear, that during this neriod the constitution is susceptible to
other diseases ; thus, 1 bare seen a child seized with chicken-pox, and before
this had well gone off, measles appeared, and immediately after that hooping-
cough. I hare also seen scarlatina precede measles, only by three or four days.

736

face and hands. In some cases, the eruption, though of tbe
usual configuration, is pale and indistinct ; but in genenL
whether vivid or not, when the finger is passed over the
surface, the skin feels unequal, from the elevation of the spots
and patches. The colour is most vivid after the eruption las
been out for a day. Sometimes the eruption suddenly and
prematurely recedes, or never comes fully out. Both of these
cases are unfavourable, the fever is high, and the oppressoB
great. In the regular course of things, the eruption on tbe
face, fades a little on the sixth day, and next day, that on the
body becomes also paler.* From this to the ninth dar, the
eruption is going off, and then the former sitaation of tbe
rash, is only marked by a slight discoloration. The departure
of the eflBorescence is attended with desquamation, dunnz
which the patient complains much of itchiness. The f*uce?
in this disease, about the fourth day, are covered with stm
red patches, which next day have a scattered or streakw
appearance. The inflammation of the eyes, sneezingf ^
hoarseness, generally decline with the eruption, and towards
the end, epistaxis sometimes takes place. The fever co"**"^
during the eruption, but the sickness and nausea abate, wb^
the eruption comes out, and about the sixth day the heat anfl
restlessness go off. A spontaneous diarrhoea often femun**^
the fever, and then the appetite returns pretty keenly-
Sometimes, especially if the disease have been severe, tfl
measles are followed, either by an eruption of inflames*
pustulesf over the body, which may ulcerate, and pTore
troublesome, but more frequently they fade, or by a vesicuUr
herpetic-looking eruption about the mouth, or sometimes by
gangrenous affections of the lips or vulva, J or by enlargement
of the glands of the neck, or dropsy, or a cough, somcwna
resembling that in hooping-cough, or by hectic fever, contmi^
ing for many weeks.

Sometimes the sickness and oppression are great and f^'
manent. The child never looks up, but breathes heavily.

* Sometimes, instead of this, the eruption heoomes yeiy dark eo1oored» ^f^^
with increase of the languor and fever. Mineral acids in this state arc usetiUi ^
most children recoyer. The daneer is greater when petechia appe*"" •■'*^»
patches, for tliis marlcs great debility. •mitBT

f These are sometimes taken for a kind of small-pox. They are ^^'^^JrJJwfc
succeeded by a scabby disease of the skin. The skin is inflamed and eo^^^^ ^
rough, loose, yellow scabs. ^--.

f The measles, about thirty-five years ago, were more prevalent *"*?j^
practitioner I met with remembered them to have ever been before. T**'? "^j
about the middle of winter, and continued during the summer and ■"^""""1^
had occasion, during that epidemic, to see different instances of the f*"f.[J7(!i
affection I have mentioned. The children all belonged to the poor, and "^
confined houses.

737

and, owing to stuffing of the nostrils, loudly. He coughs
often, has frequent pulse and hot skin. He can scarcely be
roused up, eyen to taJce a drink. This state arises more from
the brain than the lungs.

In measles, the membranes are very apt to be affected.
Generally, the membranes of the wind-pipe, bronchi, fauces,
nostrils, and eyelids, are chiefly affected, but sometimes that
of the stomach or bowels principally suffers, producing sick*
ness, vomiting, or purging. At other times that of the brain,
is affected, producmg coma.

Rubeola, in general, is not a fatal disease, when stimulants
are avoided. When it proves fatal, it is most frequently in
consequence of the pulmonic affection, sometimes of coma, or
fever and oppression, with symptoms of effusion in the brain
connected with recession, or imperfect appearance of the
eruption.

The treatment is extremely simple, and may be briefly
explained. During the eruptive fever, the use of mild
diaphoretics, and the tepid bath will be of advantage. The
bowels should be kept open, but the child should not be much
purged after the first day. If there be a considerable diarrhoea,
from extraneous causes, as dentition, or directly connected
with the fever, it is often found that the eruption is late of
appearing, and a late eruption is generally attended with some
troublesome symptoms, as it indicates a tendency to affection
of some internal membrane. A little rhubarb, given early,
often moderates this.

If the eruption do not come freely out, or recede prema^
turely, and the child be sick, oppressed, and breathe high,
we must attend first of all to the bowels. If diarrhoea exist,
and the child be not plethoric, a little rhubarb should be given,
and then spiritns ammoniae aromaticus with laudanum, and
the child must be put into a warm bath, having a little
mustard diffused in it ; afterwards, a sinapism, followed by a
warm plaster, should be applied over the stomach, and we
determine to the surface, by giving a saline julap. If in this
state the child be costive, a gentle purgative should be given,
for the bowels may be either too torpid or too irritable.

I have not advised the liberal use of purgative medicines,
though these are found beneficial in scarlatina, because we
often find that diarrhoea interferes with the eruption. But
the bowels are, upon a general principle, to be kept regular,
or rather open : and if the stools be foetid or iU-coloured,

738

then, even although diarrhoea exist, small doses of calomel
should be given, and afterwards, if necessary, the purging is
to be moderated by anodyne clysters. So far as I have
observed, the continuance of the diarrhoea, in this case, does
not mitigate the symptoms; and if the child recover, it is
either by the use of medicines bringing the bowels into a
better action, or it is independent of the mere evacuatbo
produced by the diarrhoea.

If the pneumonic symptoms be considerable, marked by
cough, oppressed breathing, flushed cheeks, and pain in the
chest, which in young children, may be discovered by the
effect of coughing, and if a slight motion excite coughmg, a
blister should be applied to the breast, and if the symptoms
be urgent, either tiie lancet must be early used, or leeches
may be a{>plied to the top of the sternum, according to the age
and constitution of the child, and moderate doses of calomel
given to keep the bowels open. If the. cough be frequent,
without inflammatory symptoms, opiates give great relief. If
the symptoms of inflammation be such as to require bleeding)
or to render the propriety of using laudanum doubtful, then,
small doses, of solution of tartarite of antimony, may be given
every two hours, but not to such extent, as to produce sidmess
or vomiting. Diarrhoea should not be checked, unless severef
and it increase debility, or produce hurtful eflTects. Anodyne
clysters are then the best remedies.

Coma or drowsiness very frequently attends the measlesy
and the child may perhaps scarcely look up for some da^fs.
When the nostrils are stuffed with mucus, the breathing* jo
this case, has an alarming appearance of stertor. Most chil-
dren recover from this state ; but as some die evidently from
this cause, and as we have no means of ascertaining the secu*
rity of any individual, I hold it expedient to use means for
the removal of the coma, particularly by ffiving a purge, if
the child have not a looseness, and shaving the head* sod
afterwards applying either a sinapism or a blister. When the
child is plethoric, it may also be proper to apply leeches to
the forehead.

The cough which remains after measles, is generally relieved
by oniates. Hectic fever is often removed, by keeping the
bowels open, giving an anodyne at bedtime, carrying the
child to the country, and adhering to a liffht diet. Other
symptoms are to be treated on general principles.

When the measles are epidemic, it is not uncommon to
find those who had formerly the disease, affected sometimes

739

with catarrh* without any eruption, sometimes with an erup-
tion preceded by little or no fever, and without any catarrn.
This has been very distinctly observed during every season
when the measles were prevalent. Whether l£e eruption be
of the nature of measles, is not easily determined, but cer-
tainly the external resemblance is very great, in so much that
this eruption has been called rubeola sine catarrho. It requires
no particular treatment, and is only noticed because it is
sometimes mistaken for measles, but does not prevent the
patient from a second attack.

SECTION THIRTY-EIOHTH.

Sometimes an eruption, termed, by Dr. Willan, roseola,! is
mistaken for measles4 The first species, roseola aestiva, has
no small resemblance to rubeola. It is often preceded by
chilness, alternating with flushes of heat, languor, faintness,
restlessness, occasionally with severe headacm, delirium, or
convulsions. At some period, betwixt the third and seventh
day, from the commencement of these symptoms, the rash
appears, generally first on the face and neck, and afterwards
in a day or two over all the body. The patches are larger,
and more irregular, than those of the measles,) in which the
eruption consists of spots like flea-bites, and patches, made up
of tnese spots, arranged sometimes in a crescentic form, and of
a colour seldom deeper than bright scarlet, often much paler.
In this disease, however, the eruption is at first red, but in
ffeneral it soon assumes a deep roseate hue, from which Dr.
willan gives its name. The fauces are tinged with the same
colour, and the patient feels a slight roughness in the throat.
The eruption appears first at night, and continues vivid next
dav, with considerable itching. On the third or fourth day,
only slight specks, of a dark red colour, are observable, which
next day disappear, and, together with these, the internal
disorder. In some instances, the skin, on many parts, becomes

* During the epidemic, thirty yean ago, ophthalmia waa extremely preyalent
amoDffst yoong and old.

f Thk be deflnee to be roae-coloared raab, without aealee or papula* Tarloualy
figured, and not oontagiout. By aome former writera, this term Is applied to a
dlteaM reaembling nettle-rash. Vide Lory, 896w — The appearance of roaeola
astlva is extremely well expressed by Dr. Willan in his plate.

i Lichen simplex is also apt to be at first mistaken for measles. From Its
itcniness, and the effects produced by rubbing or scratching the extremities, it haa
also been mistaken for itch.

I Sometimes young infants have an efflorescence of numerous coalescing patches,
of a strong red colour, rounded, and of the size of a sixpence. These terminate
Id desqaamation in lesa than a week.

740

of a dusky colour, with an appearance of slight vesicatioii or
desquamation. The drowsiness, sneezing, watery eyes, and
running at the nose, so common in measles, are wanting in
roseola, and there is no pulmonic complaint, whilst, at the
same time, the patches are larger, and occasionally intermixed,
on the body, with an appearance of nettle rash. Sometimes
the rash is only partial, appearing in patches slightly raisdi
above the surface, with a dark red flush of the cheek. This
form lasts about a week, the rash appearing and disappearing
occasionally ; and usually the disappearing of the rash, is
attended with nausea, faintness, &c. In some cases, no fever
is observable, or the progress and duration of the eruption, is
more irregular than I have described ; and sometimes on the
breast or trunk, the eruption has a resemblajice to urticaria,
whilst on the arms the appearance is like roseola. This disease
decidedly is infectious. For, in particular seasons, I hare
observed it to be unusually frequent, and to afiect all the
children, and manv of the adults in a family. In such cases,
the eruption has lasted from two to four days, but has been
attended with very little fever. The only treatment which is
necessary, consists in giving gentle laxatives, the use of acids,
and light diet. If the eruption be suddenly repelled, the
warm bath is proper. Should there be a marked determina-
tion to the head, brisk purgatives are proper.

Another species, called roseola autumnalis, aflfects children
generally in the harvest, and consists of distinct patches, of
an oval or circular shape, which increase to nearly about the
size of a shiUing ; they are not elevated, but are of a very
dark colour, appearing at a distance, as if a black cherry, or
brambleberry, had been pressed on the skin, so as to leave the
impression. The patches are not attended with fever, are
usually diffused over the arms, and disappear in about a week.
Acids, with mild laxatives, may be taken internally.

The roseola infantilis appears during dentition, or in a dis-
ordered state of the bowels. It consists of a red efflorescence,
usually veiy closely set, so that the surface is almost entirely
of a red colour, as in scarlatina ; but there is more appearance
of patches, that in that disease, and the other symptoms are
wanting. The eruption generally goes off in a day, but it
sometimes appears and disappears for several days, with
symptoms of^ great irritation. No particular treatment is
necessary, except what is required on account of concomitant
circumstances. It is sometimes preceded, or attended, by
vomiting or convulsions, with pale face and languor. In

741

such cases a gentle emetic, the warm bath, and cordials are
proper*

CHAP. V.

Of Cerebral and Spinal Irritation, and Congestion.

Thb action of the brain, and spinal marrow, may be affected
in different ways. Certain parts of the animal system sym*
pathise with each other, in a manner which cannot always be
accounted for, on the principle of communication of nerves.
This sympathy manifests itself variously; but three of the
most important modes are. First, where one part becomes
associated with another in action, the former having its action
increased or altered by the latter. This sympathy of associsp-
tion, may exist between remote parts, which come to act simi-
larly, but not always exactly in tne same degree or proportion.
Second, where action spreads without interruption, from a
part to the neighbourhood, or perhaps, to a great extent.
This I would call communication of action ; and it may be
salutary, or the contrary, according to circumstances. Third,
when one part has its action diminished, in consequence of
another having an increase, and vice versa. This I have called
the sympathy of equilibrium. In all of these ways, the brain
and its appendages may be influenced ; but they are not the
only modes, and some others seem also to assist these. For
instance, the brain considered as the sensorium commune, or
origin of the nervous system, may undergo certain changes
peculiar to it in that view. A sudden failure in its power or
action, by whatever cause or in whatever way it may be pro-
duced, may occasion instant debility, or even death itself.
A slighter degree, gradually produced, is followed by less
striking, but not always less serious changes. A similar de-
gree, suddenly produced, occasions not only debility at the
instant, but important secondary effects afterwards. These,
which have been attributed to re-action, as it has been called,
proceed from the communication of action, already men-
tioned, whereby the part which is weakened, is not allowed
to act, in that degree, which is proportioned to its vigour ; but
has more action excited, than it can properly perform ; and
the same consequence is produced, as if a positive and direct
stimulus, had been applied to it. This is illustrated by bruises.

742

and the effects of cold, inflammation attacking frostbitten
parts, not only from the improper application of heat, but
also from the conmiunication of action from their yicinity.
Hence, one object, in such cases, is to preyent communication
of action, by endeavouring to moderate that of the neighbour-
hood, or even of the system, at the same time, that we avoid
the operation of stimuli, on the part itself. It is also illustrat-
ed by concussion of the brain, wnere, in the stage of re-action,
as it has been called, venesection is required to cure the dis-
ease which is excited. A similar state is produced in those,
who, having been long exposed to hunger and cold, have heat
suddenly applied to the body, and warm soup speedily given,
or cordials administered. Such excitement of the bnun,
thereby is produced, as requires depletion and great care.

Another mode of affecting the action of the brun, is by the
direct operation of stimuli, both mental and corporeal, on it
In the latter case, it is similar to any other viscus. The heat
of the sun, especially if the person be stooping, a current of
cold air blowing on the head, &c., may thus excite disorder.

Injurious effects may also be produced, by irritating the
extremities of important nerves, whereby, not only the origins
of these nerves are affected, but also the parts in the vicinity
of these origins, and the nerves, which come off there, are
irritated, or the whole encephalon may, more or less, and in
varying degrees, be affected. This is exemplified by the
effects of irritation of the nerves of the jaw, in dentition, or of
the intercostal, and par vagum, in abdominal affections. These
are two of the most important nerves of the body, and are
intimately connected with the basis of the brain and spinal
marrow, and also with one another, both anatomically and in
function. The 8th pair of nerves, so important to the stomach
and thoracic viscera, arises at the very base of the skull,
chiefly from the groove, which separates the criis of the cere-
bellum, from the corpus olivare. It communicates with the
intercostal and cervical nerves, and its recurrent, as well as
the laryngeal nerve it gives off above, has a most important
influence on the larynx. Near its origin, we have the 5th, 6th,
7th, and 9th pairs of nerves given off. The intercostal does
not arise, itself, from any particular part of the brain, although
so important as to be called the great sympathetic nerye.
Considering it as a distinct ganglionic system, we say it b^ns
in the carotid canal, or cavernose sinus, by the cavcmose
ganglion, which sends twigs to communicate with the fiAh
and sixth nerves, or, when this ganglion is wanting, these, are

743

sent up from the superior oervical ganglion. Ramuli abo are
giyen off, to form connexions with the 8th, 9th, and spinal
nerves ; and the arteries in the course of the nerve, seem to
have a coating of fibriUae from it. Whilst it is important to
the thoracic viscera, and along with the 8th pair, supplies the
stomach, it also goes on to all the intestines and abdominal
viscera, so, that they cannot be affected, vrithout influencing
this nerve.

The effects produced on the brain, or its appendages, by
these causes, may, perhaps, be referred to the following heads.
1st. A moderate degree of excitement, or irritation, producing
a febrile state, with or without spasmodic affections, or distant
pain, or uneasy sensations. 2d. Pain referred to the head,
or spasms and pain in other parts, without fever : or extreme
sensibility of some organ of sense, with susceptibility of men-
tal emotion. 3d. A higher degree of irritation, inducing in-
flammation. 4th. A diminution, or loss, of power and action
in part of the brain, or its appendages, producing a corre-
sponding injury, in the parts dependent thereon, such as weak-
ness, anaesthesia, palsy, &c. This has too often been attri-
buted to pressure; but pressure only produces this state,
which may exist without it, as we see in simple concussion, or
some diseases to be soon noticed. 5th. Apoplexy. 6th. As
secondanr consequences of some of these states, we may have
suppuration, serous effusion, torpor, or extreme susceptibility,
chanffe of structure, occasioning in its turn, new symptoms.
7th. It is most important to remember, that not only may one

S^art of the brain, be diminished both in its power and per-
brmance of function, whatever that may be, and another, per-
haps in the immediate vicinity, be in a state of excitement,
but, the very same part may be diminished in its power or
capability, and yet irritated or excited in its action, and thus
we may nave in a distant part, the nerves of which are affec-
ted by this portion of brain, a very complex condition pro-
duced.

The visible consequences, of cerebral or spinal irritation,
are so various, that it is not only impossible to class them, but
also difllcult to believe that they arise from the same source.
They vary, not only in kind, but likewise in intensity and
danger. All that I can propose here, then, is only to give a
short sketch, of some of the effects produced, without attempt^
ing methodical arrangement. We are very much in the dark,
with regard to the effect of intestinal action and irritation.
Some suffer nothing, others almost continually from this cause

744

It appears that there is a kind of sympathy of equilibrium,
between the stomach and intestines, the action gradually de*
scending along different portions, so that when t£e duodenum
is active, the stomach is less so. Few, therefore, can eat con-
stantly, unless the nerves be in a particular state, as we see in
some patients, who have certain varieties of insanity, and these
seldom digest the food. In some cases, the different portions
of the canal act irregularly, or inordinately, or become torpid,
in consequence of which, the functions of the stomach and
liver are disordered ; and, on a former occasion, I have said,
that in many Instances, where the stomach was supposed to be
primarily, it is only secondarily, affected* Improper action of
the stomach or bowels, may not only operate on the extremis
ties of the nerves, of the portion in fault, but also, by sympathy,
on other parts of the canal, and their nerves; a very frequent,
though seldom a dangerous effect of this, is headach, which
varies in its seat, sensation, and severity, according to the part
of the bowels affected. Intense thinking, anxietv, or reading
long, gives headach, and in that case the stomach is affected,
the food, if recently taken, becoming acid. Abstinence, for
a longer period than usual, also causes headach ; acid in the
stomach does not uniformly occasion, but always aggravates
it ; so does bile. The most frequent cause of headach, accom*
panied with anorexia, or sickness, is irritation of the intes*
tines, by acid, undigested food, ine£Gicient doses of laxatives,
or whatever can produce partial, or slowly progressive excite*
ment, or irritation of the bowels. An opposite state, or de»
gree of torpor in part of the canal, may do the same. The
upper portions of the small intestines, but especially the duo-
denum, are the most^^important in the present view. They
have more action to perform, than the lower parts, and the
duodenum, in particular, is to be considered as a second
stomach, and not only intimately connected with the first, in
function, but also by nerves, which communicate directly with
the brain, as well as by those, which arise from ganglia. When
affections of the inferior tract produce headach, I believe it is
by sympathetic action on the duodenum and stomach. If tibe
colon be briskly excited by clysters or medicines, it often
happens, that by sympathy, the stomach, or duodenum in its
vicinity, are affected, and the person is sick or vomits, when
he is going to have a stool ; or, in infants, a convulsive fit
often takes place at the time. Severe griping, in the lower
part of the ileum, has the same sympathetic effect, whilst it
produces faintness. A moderate degree of griping generally

745

relieves sickness aad headach. Laxatives rather add to the
evil, till they get low, and produce this effect ; relief is then
obtained, if the irritation have not been too great. Griping
is also salutary, when it is moderate, and affects the colon,

Earticularly at its sigmoid flexure.* It is not always there,
owever, when relief is obtained by the discharge of flatus,
for this may produce a sympathetic effect on the ileum, and
give relief. Griping is quite different from spasmodic pain,
which in children often produces eclampsia, probably through
the medium of the stomach or duodenum. In female adults,
again, spasm of the duodenum often affects the brain, and in
its turn is perhaps renewed by such affection. Severe pain
referred to the stomach, often alternates with insensibility,
intense headach, spasmodic affection of the throat, or
eclampsia. This is peculiarly apt to happen at, or imme-
diately after, the menstrual period. It is relieved by blood-
letting, clysters, . and laxatives, followed by an opiate, com-
bined with assafcetida. If coma or carus occur, a blister to
the back of the head, and leeches to the temples, are to be
superadded.f

The eclampsia of infants might very properly be noticed
here, but I shall refer its consideration for a separate chapter.
The same is the case with spasmodic croup,t and chorea.

Cough is another affection of a spasmodic nature, which
I can merely notice here. In some cases, in young females, I
have known almost incessant cough continue for weeks during
the day, and resist both laxatives, antispasmodics, and opiates.
Occasionally, there are not only incessant paroxysms of cough
through the day, after each of which, the patient falls back
exhausted, but tnere are also many through the night. Some

* Griping is attended with relief, not only aa it arises from excitement of the
bowels, but from the mere sensation. Many are reliered, for a time, from botli
headach and siclcness, hj transient and shining pain in the side, bowels, arms,
&C. When affections of the stomach or duodenum, produce a sensation of stric-
ture or pain across the chest, there may be flatulence, but rarely either headach or
sickness.

f The effect of inflammation of the extremities of the nenres, in produeinc
not only pain at the spot, but convulsive Jactitation, pain in the head, and
delirium, is noticed bv Lobstein, p. 147, in a case of inflammation of the
semilunar ganglion, irritation, or spasm, may also have a similar effect. A
boy, for instance, had some pain in his bowels always after eating, which was
often transferred to the head, particularly at the temples. That pain was also
broaght on by reading or singing. He was cured by sohd diet, and blistering the
epigastric region.

f The disease termed spasmodic asthma is of this nature ; the accumulation
of phlegm, the flatulence, the frequent pulse, and difficult respiration, all coming
on rapidly, and going off as speedily, the respiration remaining unaffected in the
intervals, depend on an affection chlefl v of the eighth pair of nerves ; and what-
ever irritates or disorders the stomach, is sure to bring on an attack.

746

times it appears to succeed an ill-formed hooping-cough.
When there is no other apparent cause, it may be suspected
to arise from some affection, of the cervical portion, of the
spinal marrow. If pressure be made on the different verte-
bree, cough is excited by pressing on one of them. In that
case, leeches, and afiberwards blistering the part, and keeping
up a discharge, cures the disease. At the same time, the
bowels are to be kept open. Etcu if there be no effect pro-
duced, by pressing on the cervical vertebrse, it will be found,
if there be any giddiness, or headach, or flushing of the face,
that leeches applied to the neck or head, will give almost im*
mediate relief. Quinine, opium, hemlock, mercury, &c., have
done no good, after the disease was established, and such as
were cur^ seemed to be so, rather, by time than medicine.
Change of air has often, at least for a short time, a good effect.
If this disease be neglected, especially at, or after, the time of
puberty, the trachea and lungs become affected, and phthisis
takes places, a fact I wish were more attended to.

Palpitation, constant fi*equency of pulse, and marked debi*
lity of the lower extremities, with or without pain of the
intercostal or abdominal muscles, may also arise fi*om spinal
affection, and be cured by blisters kept open, or issues. Ob-
stinate costiveness, on the one hand, and diarrhcsa, on the
other, may arise ft^m the same cause, and may alternate with
cough and other pulmonary symptoms, or with diuresis, the
urine being generally pale, or straw coloured, or there may
be some pain in the rectum, with or without tenesmus. I
wish explicitly to state, as my opinion, that many diseases, sup-
posed to arise from local causes, acting directly on the oigans
affected, do often proceed from disordered states, or preter-
natural excitement, of some portion of the spinal cord. Even
inflammation of these organs, may thus be produced.

The remarks I have made on cerebral, are applicable to
spinal, excitation ; and cough is an example of the effects,
which will be farther seen, in an obstinate disease I am soon
to mention. More irremediable, or even fatal consequences,
may arise, from inflammation of part of the spinal marrow,
or efiusion of blood, or serum. Local pain, with paralyas or
spasmodic affection, or pain of the organs supplied below, are
the symptoms, and death succeeds either a general spasm or
stupor. If any thing can be done, in these cases, it is by free
topical bleeding, and the subsequent application of caustic.
The cases which end best, are those where there has only been
torpor of the part, succeeding possibly to previous excitement.

747

These may be tedious and alaiming, but are curable. When
the disease is seated high in the cord, the internal muscles of
the neck lose their power, the head falls forward, the arms
become paralytic, and the inspiration sonorous. If the head
be not supported, and caustic applied to the neck, the patient
sinks. In elderly people, this state sometimes is produced, by
a particular state of the brain. It is more minutely injected
with blood, and firmer than it ought to be.

Affections of the cervical glands, produced by cold, blows,
or struma, sometimes so involye the nerves, as to produce
contraction of the muscles they supply, and twisting of the
neck, with or without more extensive disease, or affection of
the head itself. Friction, with weak mercurial ointment,
having iodine added to it, and conjoined with fomentations, is
of service.

Some affections of the abdominal nerves, as well as of por-
tions of the spinal cord, produce headach, attended with>much
feeling of fulness. Now, in many cases, this fulness is the
most prominent part of the disease, and is more obstinate than
headach. It may even go the length of apoplexy ; but this
1 cannot consider here, nor is it necessary to do more than
mention it. There is, however, in females, both at an early,
and mature period of life, a very distressing disease, which
must be attended to here. It may succeed to exposure to the
sun in summer, or stooping ; but it may also come on sud-
denly, entirely from visceral affections. The patient, in
slighter degrees of it, merely feels, suddenly, heavmess of the
eyes, weight in the head, some pain at the upper part, but
this is not constant, vertigo, and a sense of fulness in the
throat. If standing, she is obliged to sit down, partly from
giddiness, partly from weakness of the limbs. The latter
symptoms abate, and she feels relieved, but not well, and suf-
fers many aggravations of the complaint. In the more severe
cases, she feels as if the blood were rushing, violently, to the
head, and has so much vertigo, that she cannot stand, hardly
can sit, and requires to have her head held. If no active
means be pursued, the complaint becomes very protracted,
and, for months, she cannot wklk, and even sits with difficulty.
These are merely different degrees of the same complaint.
The best remedy is instant venesection, to an extent propor-
tioned to the violence of the symptoms. Leeches are useful,
but in a very inferior degree. Cupping at the upper part of
the neck, is highly advantageous. The head ought, in severe
cases, to be sfaAved and blistered. In all, the bowels are to

748

be freely opened. In protracted cases, asafetida with aloes
appears to be useful, and an issue in the neck, or on the head^
is requisite. Some prolonged cases have speedily been r&-
moTed, by erysipelas, followed by sloughing and copious sup-
puration, taking place about the issue.

Another modification of this disease, appears under a variety
of symptoms, and too often is considered merely as hysteria,
as was noticed when considering that disease. I do not object
to this, if thereby the proper treatment be not omitted.* I
shall describe some of the varieties, as they appear in females,
generally, but not always, at an early period of life. One
frequent form, is spasmodic croup, or acute difficulty of breath-
ing, accompanied with hoarse cough and wheezing, rapid pulse,
and heat of the skin. This yields speedily to bleeding, but is
apt to return, and therefore requires purgatives, to remove the
primary cause. It often occurs for many nights in succession.
Emetics are dangerous, without the previous use of the lancet ;
and, in severe cases, the patient cannot wait their operation.
A full dose of prussic acid I have found, once or twice, check
the fit ; but it is not to be used if there be much sense of
fulness in the head, marking an excited state of the spinal
cord, for, then, it is invariably productive of tetanic spasm,
relieved only by bleeding. Arsenic and foBtids, in the mter-
vals, are useful ; but purgatives and strict diet are indispen-
sable.

In some cases, the pulse is excessively rapid, the face flushed,
the eye suffused, and the head confused.f The sensibility is
morbidly increased, so that a very little light is offensive, and
the smallest noise, excites either spasmodic croup, or general
muscular agitation , and there is, at an early, but particularly
at a more advanced period, a propensity t^ laugh or cry witlh-
out any evident cause. There is thirst, and no appetite. The
head either is not pained, or the patient does not attend to it,
or at least does not acknowledge it, although she says after
being bled, that her head is now easy. The eyelids are heavy,
and soon cannot be raised. Presently, the fits of spasmodic

* In former editions of this work, I called the attention of the prafcMWm to
this subject, but regret that so little liglit has yet been thrown on it, or on its
treatment. Some valuable cases have lieen published by different writers, both la
this country and on the Continent, and many of them have l)een collected by Dr.
AkMrcrombie, in his lata work on the brain. Two important cases are tharo
related by Dr. Monteith, in both of which I was consulted, aud can say, that tho
description is not too highlv coloured. Dr. Marshall Hall seems also to have
described a modification of this disease, in a work on female diseases.

t The reader will do well to connect this, with remarks made in the 9th chap-
ter of the last book, and with the chapter OMde on puerperal delirium.

749

breathing become leas frequent, but the head cannot be sup*

Eorted, from weakness of its muscles ; and soon, the whole boay
ecomes more or less paralytic. The arms cannot be moved ;
a weight, like a bar of iron, is felt on the chest ; the pulse
becomes slow, and soon beats only perhaps thirty times in a
minute. In other instances, the pulse at the first is preter-
naturally slow, and the face flushed from venous congestion ;
a weight is felt over the eyes, vision is impaired, the face
and its bones feel painful, or seem to the patient herself
as if they were swelled, and sometimes there is a sensation, as
if the face were projecting or elongated. The patient is sick
and vomits. Then, she becomes very hot, thirsty, and restless,
with frequent pulse, and feeling of bursting in the head, and
pressure about the nose, eyes, and cheeks, with pain extend-
ing from the neck over the occiput, in the direction of the
suboccipital and first cervical nerves, and down the neck and
shoulders, along the parts supplied by the spinal accessory
nerve. What the result might be, if relief were not artificially
obtained, I do not know ; but the probability is, that death
would take place. Even active means, if not promptly em-
ployed, do not prevent a very tedious and varying disease.
The treatment I have found most useful, is the instant and
free use of the lancet, detraction of blood topically, full
purging, and shaving and blistering the head. These means
are soon productive of relief, but it is necessary, afterwards, to
keep up the action of the bowels, and occasionally to take
away blood, by cupping between the shoulders. This is also
of excellent effect, in that variety of puerperal delirium,
which I have described as analagous to this. If the first
symptoms be not, instantly, attacked with the lancet, and
paralysis have come on, nothing gives so speedy relief as
caustic applied to the neck ; or, any very strong and rapid
stimulus, as hot water, might have the same effect. Before
the pain of the caustic have been long felt, I have known the
patient able to move her arms, and open her eyes, but the slow-
ness of the pulse usually continues long, if the pulse have
become pretematurally frequent, before caustic be used, I have
remarked, that during its action, the pulse falls, and becomes
either natural or too slow. Anomalous and protracted sjrmptoms,
ma^ succeed to this partial cure, or may follow, where less
active treatment, has allowed the disease to remain in more
force. The power of walking, for instance, may be slowly,
though not perfectly restored, but slightly convulsive agitation
of the muscles, witn insensibility, may tale place at uncertain

750

periods ; or, by the slightest noise, universal spasm may be
excited, foUowed by lipothymia; or, every night, or every
second day, for a time, the patient may complain for a few
minutes of headach, or vertigo, or is observed to be dull, and
then sinks down in a state oi coma or catalepsey ; there is no
flushing, no stertor, and little affection of the puke* From this
she partially awakes, or is roused by convulsive motions of the
arms, or muscles of the trunk ; the eye turns spasmodically,
and the jaw is opened to its utmost extent, and fixed for a
time.* Then the spasm relaxes, and if the patient have
been supported, she sinks down, as if quite exhausted and in a
senseless state ; but the pulse is not weak, though sometimes
frequent. Soon, in general, another attack comes on, and
then she is relieved. It is usual, during some part of the
paroxysm, for the stomach and bowels to seem prodigiously
inflated, and feel very hard ; but in an instant, and without
any evident discharge of flatus, the inflation vanishes. This
tumefaction, however, is often, apparently, increased by the
spine being bent back, and the abdomen protruded. The
paroxysm does not go off, by much eructation, but often by iiK
effective efforts to vomit, it is usually accompanied with dis-
tressing feeling of stuffing, particularly after eating. Some-
times paralysis of particular members or organs, suddenly takes
place, and as suddenly goes off; one side may be affected, or
the sphincter of the bladder, or the tongue, or pharynx, may
be paralytic, and continue so for manv hours. The patient
cannot speak, and, although tormented by thirst, cannot swal-
low, but spontaneously these symptoms go off for a time ;
anaesthesia generally exists as long as the disease lasts, and
narticularly in the lower extremities. Sometimes the paJtienk,
for a long period, cannot sit up, without feeling a distressing
sense of failure, sinking or dragging in the upper part of the
abdomen, and near the chest, or she has more temporary
attacks, of strong sensation of depression and faintishness, as
if she were going to die, ai)d yet the pulse is not affected.
This temporary feeling, is often relieved, by ammonialed
tincture of valerian. At last, after many months, all these
affections subside; and although thev may be replaced by
others, connected with a different set of nerves, yet, in generaiy
the health is slowly restored. It may» however, be years b^
fore it be perfected, if ever. For a long time, periodical at-

* ThcM strong, and apparently oonTuliive, oantractioni of the muadci, art
greatly, and In some finttanees altogether, dependent on transient paralysb of their
antagonists.

751

taoks of weight in the head, with pain, sometimea increaaing
to agony, and followed b^ tetanic convulsions, may take place
at the end of every fortnight or month, and often attack re*
gularly to a day, and even an hour. They are frequently
preceded, for some days, by craving appetite, and general ful-
ness or oedema of the cellular membrane, particularly of the
face, with inflation of the bowels. The craving which I have
noticed, is not attended with digestion, for all the food taken
for a day, or more, may be retained in the stomach, and, after
a length of time, vomited in an undigested state, probably
from the condition of the 8th pair of nerves. Pain is also
often felt in the stomach and bowels, sometimes like cramp,
sometimes cutting.

The most speedy, and the only certain way, of checking the
paroxysm, is to open a vein. But as this is very debilitating.
It is better, in such periodical "lattacks, to watch their accession,
and, in an early stage, before severe symptoms have taken
place, to apply a number of leeches to the head, or, what is
more useful, to cup the neck. This, although weakening, is
less so than venesection, and prevents the exhaustion by the
spasms and pain. I could wish that some means were dis«
covered, of giving relief, with equal certainty, and less objec«
tionable. Opiates of different descriptions, and cold appUca^
tions have been tried, sometimes with good effect, but oitener
they feul. From the periodical nature of the attack, it will
naturally occur that tne menstrual discharge requires much
attention, and certainly the patient often is obstructed ; but in
other cases, if the health be not broken down, she is more or
less regular, and the attacks are not more frequent at thai
period, than at other times. Nevertheless, it may happen
that an intimate connexion takes place, between this disease,
and an abortive attempt to menstruate ; and in that case, if
menstruation can be effected, and made regular, much good is
done. Some suffer, almost solely, from general oedema and
oppression, for the first fortnight after menstruation, and feel
comparatively well during the last two weeks.

To prevent this tedious and uncertain issue, it is evidently
important, to attack the disease at the first, in the most vigorous
way, by depletion and the means proposed. At this second
stage, the plan must be general, such as the administration of
laxatives, tne regulation of the diet, the use of arsenic, foBtids,
mild tonics, &c., and gentle exercise in the country. But I
confess, in most cases, I have not known decided advantage,
firom any medicine^ beyond what was required for symptoms

752

as they arise, time appearing to be the chief remedy. In a
few instances, where the disease approached more to the nature
of hysteria, and there was less determination to the head, the
paroxysm has been stopped, by dashing cold water on the
patient* But when there is a horror at cold water, this must
not be risked. Another variety of this, is attended with
violent pain in the head, and extreme weight or throbbing,
alternating with palpitation, incessant cough, pain in the side,
or excessive griping, sometimes a feeling as if melted lead were
poured on the brain, or as if the limbs were roasting. The
occasional wheezing, the tetanic state of the trunk, the con-
vulsive affection of the members, the partial paralysis, and fits
of stupor, or insensibility, are similar to the former variety.
Mercury, copper, arsenic, purgatives, tonics, and antispas-
modics have been tried in this case, with little apparent
benefit. Venesection, for the more severe affection of the
larynx, or pain in the side, leeches or blisters, for the feeling
of Ailness in the head, large doses of laudanum, or full doses
of prussic acid, for relief of pain in the head or bowels, blisters
on the head, issues in the neck, and friction, for the paralytic
affection, have seemed to do only temporary good ; but, as in
the former case, time has been the grand restorer ; and it is
satisfactory to know, that most deplorable and protracted cases,
have thus, though not always certainly, been relieved. In the
wane of the disease, the recovery may be accelerated, by
redoubling the attention to the bowels, giving, almost daUy,
some purgative potion, and at night, extract of hellebore.
When there is a renewal of the sensation of fulness in the head,
or any suffusion of the eye, cupping is useful. This, or the
use of leeches, is also proper, when the patient sits weeping.
In other cases, the symptoms have been at first, at least, and
sometimes altogether, more concentrated toward one organ.
In some, for instance, there has been, from the invasion, pain
in the head, gradually increasing to the greatest degree, at
least, if the plaints of the patient, be admitted as a criterion of
severity. The pulse has been frequent, and then slow or irre-
gular, and the same gaping, coma, and inflation of the bowels,
attending on a former variety, appear here. In others, there
is chiefly throbbing in the head and neck, with much vertigo,
so that she cannot sit. Some, again, refer the sensation to
the stomach, complaining of much feelhig of sinking there, on
sitting up, which is soon followed, by frequency of pulse and
headach. In many of these patients, if ffreat attention be not
paid to the limbs, the knees become Bent, and the thighs

753

raised to the belly, so that it is long before the contraetion of
the muscles can be overcome ; but this is generally at length
effected by friction, and efforts to stretch the limbs, or walk.
In some cases, benefit has seemed to follow the application of
firm stays ^nd machinery, but I look on many of these as
fallacious, and impute the apparent improvement, to change
of air, time, and other circumstances. I may still mention
some other modifications, for there are many. The com-
plaint may begin with great oppression in the side, as if the
patient could not breathe, firom a heavy load on it. The body
soon feels as if dead, and she says she has no command over
it. Then, she has tremor of the system, an agitation which
may be called both mental and corporeal, she screams invo-
luntarily without knowing why, the pulse is frequent, the
skin hot, but the legs cold, the face flushed, and the head
confused. The lancet docs not always give immediate relief
here. Time and purgatives are ultimately more useful.
Sometimes different nerves suffer in succession. The whole
fury of the storm may be poured forth, on those of the intes-
tines, and incessant diarrhoea take place. Then, the current
changes, and the head suffers from pain, perhaps insupporta-
ble, with delirium. Next, the lungs are attacked, or the larynx,
and we have cough or wheezing; or the stomach becomes
the scene of suffering, and there is inordinate craving, with
freouent vomiting. Whatever may be the temperature of the
surface, the patient may feel sometimes cold within, or as if on
fire, and these sensations, I think, are most frequently referred
to the course of the spine. In other cases, the first svmpton
is uneasiness in the throat, but nothing wrong can be seen.
Then it extends down the neck, and the cervical vertebrae
are tender when pressed on. There are thirst, giddiness,
lassitude, frequent pulse, irregular chills and twitching, or
fidgets in the feet and toes, and, even after the patient, by
venesection and purges, and blisters to the spine, is eased, he
has long a swelled appearance of the tace^ and walks like a
gouty man. In aU cases, we ought carefuUy to examine the
spine, and ascertain whether any spot be tender. When the
affected part is low, we still have the head affected with pain,
or confusion. The eye is red, or heavy and turbid. There
is pain, often in the course of the accessorius. The abdominal
muscles, as well as the thighs, become tender to the touch,
and soon, the inferior extremities lose their power. The pulse
is variable, being at one time slow and irregular, at another
hour very frequent. There are depression of the spirits, and

734

fits of crying, for which the patient cannot account. The
body wastes, the appetite fails, tne pulse becomes more steadily
frequent, and appearance of hectic takes place, with increas-
ing paralysis of the lower extremities. Issues generaUy effect
a complete cure, but it often requires much care, to ascertain
the spot where to form them. If they do not soon succeed,
we may be sure we are not right, generally too high. In
other cases, the first symptom is much pain in the neck and
shoulders, passing, too often, for rheumatism. External head-*
ach also is complained of. Presently, general paralysis, from
the head downward, takes place, and the urine cannot be
voided. The pulse becomes more and more slow, and the
breaihing oppressed ; but the mind remains entire till the
last. Issues are the remedies, but in the last stage do no
good; we must therefore attend early to the symptoms. The
duration is variable. In some, the disease proves fatal within
a week ; others, linger on for several weeks, and, at last, the
paralysis becomes more decided, and in a few days carries off
the patient, by interrupting respiration and circulation*
Adult males, are not exempted from this disease, which, in
one of its forms, attacks them with fits of breathlessness,
great variability in the frequency and regularity of the pulse,
want of sleep, dropsical effusions, perturbation of mind,
ending in fits of an epileptic nature, which carry off the
patient. On dissection in this, and other modifications of
spinal disease, perhaps nothing is found, except patches of
steatomatous depositions on the basilary artery ; or we may
find evident marxs of inflammation of the sheath of the cord,
or vascular turgescence, or some change of texture in the cord
itself, which may be either softer or firmer than it ought to
be. The connexion of this disease with dropsy, is wortk
attending to, for in some cases, whilst concomitant symptoms*
point out the nature of the disease, the anasarca and other
dropsical affections, appear to be the most prominent, and
more immediately fatal, parts of the complaint.

There is one feature of this disease, still to be noticed, which
fortunately is not invariable, but nevertheless is very com-
monly an attendant, I mean temporary mental aberration.*

* This U to be distinfulthed frmn a common attack of intanlty, vrhidi wamj
affect young girle, as well as others, both by the previous symptoms, and by tM
periods it obserres. Insanity may be preceded by cephalic symptoms, and attMod-
ed with firequent pulse, inflation of the bowels, more or less at different times, ao4
even involuntary discharge of urine ; but the mental affection is continued, and
the prominent corporeal symptoms mentioned above are absent. Early rmu

tion, followed by purgatives and tepid bathing, and mild diaphoretics, eomtitnta
the practice, and generally in a few weelcs the attack goes off. insanity is mors
frequent in infancy than many suppose, as it passes for fever. The cfafid, bofr-

765

A very early manifestation of this consists in obstinate deceit*
In some cases, the patient pretends to be asleep, in others to
be blind, and this I have known persisted in for months, with
great pertinacity. Others will not eat although pinched with
hunger, or will only eat in a whimsical way. Then, the mind
suffers more, the patient being as if in a waking dream, or
sometimes melancholy, sometimes in high spirits. She forgets
the names of persons and things, as well as their relation to
her, and forms new opinions concerning them, or there may
be religious melancholy, as it is called. This state sometimes
continues without interruption, for many weeks; in other
cases, it comes on at regular intervals ; so many days, for in-
stance, at the end of a fortnight, or perhaps even every second
or third day : and it is observable, that often the appetite is
voracious, during these days.* Like the bodily distemper,
this yields rather to time than to management ; nevertheless,
prudent exercise of the mind, and, in a state of convalescence^
vigilant efforts to prevent a relapse into any former bad habit,
along with strict attention to the diet, and the alvine discharge,
will be useful. The best prophylactic of these distressing dis*
eases, is to avoid whatever can irritate the brain, particularly
costiveness ; and those who have the charge of young females
cannot be too careful in this respect.

Allied to this, is the melancholy, or perhaps excited state,
which some females are liable to, at every menstrual period.
The aberration which takes place, sometimes, in pregnancy,
may be, partly, owins to the state of the spinal circulation,
partly, to that of the bowels. I have known the illusory idea
continue for some weeks, during pregnancy, that a person
lately dead was constantly present.

It is a circumstance deserving attention, that in these dis-
eases, although different parts become suddenly paralytic, and
although the stomach itself be much affected, and perhaps
may, even, as well as the bowels, partake of the torpor, if not
of the paralysis, for a time, as we see in the sudden inflation,
yet the heart and lungs never lose entirely their {>ower. The
heart may beat slowly, and the lungs may act with difficulty,
but life goes on. In another affection, however, death sud-
denly takes place, either, from the heart and lungs ceasing, at
once, to act, or from the brain losing its activity. The patient

«Ter, has litde ferer, and the promioent lymptoin !■ the etiite of the mind, ezoee.
•ire irritability, or even rB|e. Leechee applied to the head, and foUowed by the
regalar lue of purgatives, effect a cure.

• In many of the modifications of this disease, whether the mind be affaeted or
■ot, every ezaeerbation Is attended with increased appetite.

756

merely says she is not very well, and is not disposed to rise,
tind tihen suddenly expires, without a groan or struggle. In
a few cases, a kind of general uneasiness or languor, has pre-
ceded this for a day or two. Dissection often discovers no-
thing unusual in any of the cavities, or in the spine, for if not
very carefully performed, the turgescence of the vessels may
be lost, or the small quantity of water effused, may run off
unobserved. A very fatal modification of this disease, ends in
pufanonaiy consumption, compHcat«d with, and preceded by,
the peculiar symptoms of the complaint ; and often even a few
hours before dissolution, the patient complains alternately,
and at intervals only of a few seconds, of beat in the head,
and bursting at the heart.

Children, and even adults, are liable to a very dangerous
and insidious form of this disease, which is not considered as
important till the fatal instant. In general they complain for
some days, perhaps, for a week or two, of slight and varying
fever. The pulse is frequent, there is some headach, the
nights are restless, there are thirst and anorexia, and a foul
tongue. In the evening, the cheeks are a little flushed, and
the fever increases, but abates toward morning. The water
is not much altered, but sometimes it is thick and white.
The bowels are costive. There is either no headach, or very
little. Then, all at once, without any material increase of
the complaint, nay, even when the patient has seemed to be
better, and the appetite has begun to return, the tongue to
become cleaner, and with appearance of speedy recovery, he
has been seized with a convulsion, and suddenly expired ; or
repeated fits, with rapid motion of the eyelids, and extreme
gaping, have taken place, and in a few hours he has died. In
some cases, a little fulness of the veins in the bead, has been
observed, or I have detected a very little water, at the base of
the skull, or in the spinal canal ; but in other instances, no-
thing could be discovered by dissection ; and it may be well
for the reader, to connect this account, with the subseqo^it
chapter on hydrocephalus. More than one child, in the same
family, has died thus. The treatment consists in lessening
the cerebral irritation, by venesection or leeches, in the regu-
lar exhibition of laxatives, and in determining gently to the
surface by mild diaphoretics. If the symptoms do not yield
soon, a buster to the back part of the head is usefuL

This fever bears a strong afiinity to, or rather is onlj a
modification of, that, improperly caUed the infantOe remittent
fever, which may very properly be considered at this time, as

757

it really proiceeda from cerebral and spinal irritation, or ex-
citement, in whatever way that may be produced, and is con-
nected, more or less, with a similar state of the sympathetic
nerve. It will be useful to divide it, into that variety, which
occurs in early infancy, and that, which takes place in child-
hood. The first, is very similar to the early stage of hydro-
cephalus, but the remissions are more distinct in the morning,
and the exacerbations greater in the evening. There cannot,
however, be much difference, for in both we have much cere-
bral excitation, and the difference is more in the result, than
in the early condition. The pulse is extremely quick,* the skin
hot, the mouth warmer than usual. The child is at first
fretful, restless, costive, and inclined to vomit ; then, he be-
comes more oppressed, and in some cases has slight cough,
with increased secretion of phlegm in the trachea ; perhaps
he does not for hours lift his eyes, till the remission come^
when he looks up, and attends to the objects presented to him
for a short time. He sucks in general freely, and sometimes
bites the nipple, and very often aphthae appear in the mouth.
The bowels are irregular, but whether the stools be frequent
or seldom, they are generally green or brown, and offensive*
The urine is usually high-coloured and scanty, and sometimes
the feet swell a little, and very often become cold. If the
disease prove fatal, it is generally attended, in the end, with
symptoms of effusion into the ventricles of the brain, or the
infant is exhausted, gradually, by the continuance of the fever,
or, more quickly, by the accession of obstinate diarrhoea. A
favourable change takes place, sometimes about the fifth day,
sometimes later, the child looking up for a longer space of
time than formerly, and seeming more free from sickness.
After this, the symptoms subside, and the strength is gra-
dually restored. It is very common to find, that at this time,
one or more teeth have made their appearance. In many
cases, the fever may proceed from affections of the bowels ;
but frequently it is caused by dentition, the irritation in the
jaw operating either alone, or in conexion with a morbid
state of the bowels. In this kind of fever, the gums should
be carefully inspected, and, if necessary, cut. Small doses of
calomel should be given, morning and evening, mixed with
maCTesia, to prevent costiveness, or evacuate irritating faeces.
A few drops of tincture of hyoscyamus, with a saline julap,
may be given occasionally to abate irritation. The tepid bath

* 111 the early stage of hydrocephaliia, the pulse is more irrrgular, and oAen
beats alternately quick and slow, (or two or tlirce pulsations.

758

should be employed once Srd&y^ when the exacerbation takes
place, and the strength supported by the breast milk, or beef
tea. If the child be plethoric, a leech should be early applied
on the forehead ; and if a favourable crisis do not soon take
place, the head ought to be blistered. In some cases, al-
though the acute symptoms go off, the child does not recover,
but remains fretful, languid, and emaciated. The eyes are
sufiiised, the feet swell, and the stools are not regular nor
naturaL In some instances, tumour of the mesenteric glands
seems to be excited, though probably they were originally
affected.

The remittent fever of older children, is met with, from the
age of two, to ten or twelve years, and is generally found to
be produced, either, speedily, after eating some improper sub-
stances, which have not been immediately removed, from the
stomach or bowels, or, gradually, by the induction of a costive
state, or the accumulation of irritating faeces in the bowels.
In the first case, the fever attacks suddenly, sometimes through
the day, but, generally, at night, and the child is sick, pale,
very restless, extremely hot, disturbed in the sleep, and thirs^.
•Sometimes, he vomits, or complains of headacb, or pain m
the belly. The tongue is, at this time, tolerably clean, but
next day, it becomes furred, and the fits of vomiting or sick-
ness are pretty frequent, They are generally preceded by
headach, which goes off, or abates, after throwing up. If this
disease be attacked, immediately, with an emetic, followed,
in the morning, with a smart purge, the health is soon restor-
ed ; but if the remedies be delayed till the next day, I have
generally found, that although the emetic, with purging,
mitigates the disease, it does not arrest it speedily, and not-
withstanding the regular use of laxatives, with diaphoretics,
it continues for several days. Emetics and purgatives, in this
disease, generally bring off some half digested substance, such
as almonds, orange peel, &c. It is astonishing how torpid
the bowels sometimes are, large doses of medicine, either pro-
ducing no effect, or, lying for some time inactive in the sto-
mach, they are then vomited. In such cases, strong clysters
are proper to assist the physic. In this fever, if the symptoms
be acute, and there be much headach, advantage may be de-
rived from the use of the lancet. Experience convinces me,
that this is safer and better than the application of leeches,
which, in cerebral diseases of the febrile kind, may weaken,
but seldom do good, unless in the slightest cases. Where the
constitution, however, is rather feeble, the lancet must be used

759

with caution, and, here, leeches may be admissible, or in infancy
they may be applied.

In the second case,* the attack is often more gradual, the
child being, for several days, somewhat feyerish and unwell.
The pulse is frequent, and in the course of the day, he has
several attacks of feverishness, during which he is dull, and
disposed to sleep or lie down ; but these do not last very long,
and in the interval he seems tolerably well, but is easily put
out of temper, and complains when ufted or touched, though
he be not hurt. The appetite is not steady, he has little thirst,
and the tongue is clean. The bowels are sometimes very
open, but oftener bound. These symptoms appear, more or
less distinctly, for about a week, though sometimes not so
long. Then, an acute paroxysm of fever takes place, preceded
by shivering, and attended generally by vomiting. The pulse
becomes much more frequent, sometimes 140 in a minute.
The cheeks are flushed, and the patient is very drowsy, but
complains of little pain in the head, or indeed any where,
except occasionally in the belly, which may at times be very
severely pained ; or if he complain of headach, it is evidently
from his stomach, for it is followed by sickness or vomiting.
There are, however, cases, where the headach is both violent
and permanent. The fever does not continue alike severe,
during the whole of the day ; it remits a little, but not at very
regular hours. The exacerbation, which usually occurs in
the afternoon, is generally accompanied with drowsiness.
Very soon after the attack of fever, the tongue becomes
covered with a white or brown coat, and both the stomach
and the bowels seem to be extremely torpid. The appetite
indeed, is soon almost totally lost, or the food which is taken,
is not digested. The bowels are generally, but not always,
costive ; and the stools are foetid, dark-coloured, sometimes
like pitch, or thin and olive-coloured, or green and curdy-
looking, or clay-coloured, indicating a deficiency of bile.
This last state, sometimes, alternates with too copious secretion
of bile. There is a great desire to pick the nose and lips ;
and if the child be not watched, sometimes an ulcer is thus
produced, upon the lips or angle of the mouth.

The face is flushed during the exacerbation ; but except
at this time it is pale. The eyes are dull and white : though
sometimes, in the course of the disease, they are unusuaUy
clear. Generally, delirium occurs in the advanced stage of

* This is oommonly called a ironn ferer, all hough wormt are not ncceMarily
paaecd in thia diaeaar.

760

the diBea8e, and, in some cases, it is ^fficult to keep the child
in bed. From this state, however, he can osually oe recalled
for a few minutes, and will then answer questions distinctly.
If the debility be considerable, the countenance becomes
vacant, the child picks at the bedclothes, and though he do
not speak much, makes a constant inarticulate noise. In some
instancesi convulsions have taken place ; but these are rare,
and. are chiefly met with in young children. Sometimes the
stools are passed in bed, without any intimation being given*
In severe cases, the patient becomes paralytic on one side^
and perhaps convulsed on the other, moans much, has fits of
screaming, and almost maniacal yelling, strabismus, loss of
memory and of sight, or that extreme degree of gaping I
have noticed above. This disease runs on for a week or two,
or even for several weeks, and may at last destroy the patient
by universal debility, or exhaustion, or diminution of the
cerebral function ; events which will take place earlier, if the
proper remedies be not employed, than if they be, even al-
though they may ultimately fail. In general, success attends
their use. Tumefaction of the belly, with great and constaat
fever, are very unfavourable, and the symptoms usually sup-
posed to indicate pressure on the brdn, as paralysis, &c., are
still more so ; nevertheless, these are not absolutely mortal,
for they by no means certainly indicate efiusion. Even in
cases of effusion, or pressure, these symptoms proceed from
the impaired functions of the brain and nerves, consequent to
pressure, and any other causes, capable of producing a sunilar
diminution of function, will have precisely the same effect.
We see this exem{)lified by the effects of concussion of the
brain ; by that instantaneous loss of power, causing univer-
sal palsy and death ; and those diseases, producing sudden
palsy, of particular sets of muscles, that I have already de-
scribed. It is also exemplified in the effect of bums, and
surgical injuries, where stupor or paralysis takes place, and
often proves fatal. All these cases show, that pressure is only
one cause of these ^^ptoms, and merely an exciting, not the
proximate, cause. This fact, and a recurrence to some of the
cases noticed above, afford strong evidence that we have no
dia^ostic mark, of structural and irremovable, injury of the
bram, in these diseases ; and therefore, we are encouraged te
proceed in an attempt at a cure, in circumstances where we
would otherwise abandon all hope.

This bears a strong resemblance to hydrocephalus, and it
cannot be otherwise. The chief assistance, perhaps, in the

761

diagnosis, is derived from the intensity of the symptoms, but
this is not a certain rule to go by. In hydrocephalus, there
is a more frequent vomiting, and as often a tossing of the
hands above the head, as picking of the nose, or lips. There
is generally constant pain of the head, which in this fever is
sometimes altogether wanting, or is slight, or, if severe, comes
in paroxysms connected with sickness, or affection of the
stomach. There is screaming and strabismus, and often a
more constant delirium, from which the patient cannot be
recalled, after it has continued for some time, and convulsions
are accompanied with great injury of the mental facnlties.
There is, in general, in this fever, more complete remission of
the symptoms, at some time of the day, than in water of the
head, the pulse not only being slower, but the child more
lively and easier. T^he stools are more foetid and darker,
than in hydrocephalus, in which they are often thin and
bilious, ana sometimes glossy. The pulse, in hydrocephalus^
is more irregular, and, in the second stage, usually becomes
slow and intermittent. It must, however, be repeated, that,
in manv instances, it is very difficult to make the diagnosis,
especially, if we have not attended the child from the first. I
have had the happiness of seeing children recovered, from
situations apparently desperate, when there was every reason
to fear that there was water in the head, though the result
proved the contrary. Fortunately, in such ambiguous cases,
the exact diagnosis is of more consequence, in determining
the prognosis, than the treatment. For in these circum-
.stances, the application of blisters to the head, the use of
laxatives, and supporting the strength, are the means to be
chiefly resorted to, in both diseases.

This disease very generally, but by no means invariably,
proceeds from disorder of the bowels irritating the brain.
Derangement of the functions of the stomach and intestines,
or liver, &c., unquestionably re-acts on the origin of the nerves^
and produces, as has been already stated, various eflfects.
We are not yet enabled to say, what jparticular mode of irri->
tation, gives rise to the different modifications of phenomena ; >
or why, in one case, the same apparent exciting cause, should

{produce spasmodic, and in another, febrile affection. The
act, however, is incontestible, that in some cases, unripe fruit,
or much pastry, or costiveness, shall sometimes cause a fever,
sometimes chorea, &c. In the present disease, the cause is
generally resident in the bowels ; but assuredly other exciting
causes may affect the brain, in a similar way ; and, therefore,

764

but after this, it is not proper to give so much medicine as
will operate strongly.* Drastic purges, particularly large
doses of calomel, must not be employed at this time, tor they
induce subsequent weakness or torpor of the bowels. It is
requisite, however, to give regularly such doses, as shall keep
tbe bowels open, and support their action. When the stools
are loose, purgatives are still proper, in prudent doses, to
evacuate them ; for they are not natural in their appearance,
and injure the action of the intestines. The exhibition of one
blue pill, for one or two days, alone or with a little rhubarb,
is useful in the view of improving the action and secretion of
the bowels. Whether this disease have been originally excited
by disorder of the bowels, or by some other cause acting on
tne brain, and the bowels have thereby become affected in a
secondary way, still, purgatives will be found useful on y&ry
obvious principles.

Opiates, in the wane of the disease, frequently allay irrita-
tion and accelerate recovery, by procuring sleep. Anodyne
clysters are useful in this respect, and, especially if conjoined
with fomentations, also for abating griping or abdominal pain*
Pain in the side, if not removed by rubefacients or anodyne
balsam, requires a small blister. The tepid bath sometimes
allays general irritation. When there is continued pain in
the hecld, or uneasiness of any description there, it is proper,
at an early stage, to apply leeches, and at a more advanced
period, to shave the head and bathe it with cold vinegar,
blisters, particularly on the back part of it, are also proper,
especially when there is delirium. If symptoms of torpor, or
loss of vigour in one part, and undue excitement in anoUier
part of the brain appear, blisters, either to the back of the
nead or nape of the neck, are requisite ; but they give leas
irritation in the first situation, and should generally be only
of moderate size ; at the same time the bowels are, diligently,
yet prudently, to be stimulated by purgatives. In such
cases, it is useful also to employ mercurials, such as tbe blue
pill, combined with aloes, so as both to excite the bowels, and
produce what is called an alterative effect on the system;
taking care not to push the remedy too far. Occasionally,
small doses of James' powder may be conjoined. By these
means, most unexpected recoveries may take place, where the

* Dr. Pcmbeitoo Jodiciooslf remarka, that if strong pnrgativet be girwn^ tiM
iiitestiDM are apt to become dietended vrlth air, and tbe patient ia deotrojred with
tympanites, Practical Treatise, ftc, p. 165. It is worthy of notice, that dlawc»
tion often dlscoTcrs nothing but great inflation of tbe intestines.

765

BjrmptomB were such, as to lead to strong apprehension, that
water had been effused in the head.

In the course of the disease, the liver is apt to have its
function impaired, and even more chronic diseases may be
excited in it. Mercurials and purges are useful in this case,
and doubtless, if these, or other means were not early employed,
for exciting a healthy action of the bowels, this hepatic affec-
tion would be more frequent, and more dangerous. If the
region of the liver be tender on pressure, then, besides the
other means, we should either apply leeches, or a blister to
the part, or both, according to the acuteness of the symptoms.

The diet should be light, but it is not proper to force the
patient to eat. In the progress of the disease, mfusion of bark,
or other tonics are sometimes beneficial, and ought always to
be tried. Wine may also be given in small doses, when
there is much debility. If it do not produce flushing,
headach, and exacerbation of the fever, but rather promote
sleep, it will do good. When the disease is protracted, it is
often of advantage to intermit the use of purgatives, and
employ only clysters, and, at the same time, begin the use of
steel. Under this plan, the bowels though formerly not
moved by strong medicine, act more regulariy, and recovery
goes on fast. As this happens in the progress of protracted
cases, it is probable that, sometimes, the purgative and mer-
curial medicines are pushed too far, and keep up an undue
irritation. Great attention should be paid to cleanliness and
ventilation, and, when convalescent, a removal to the country
is highly useful.

In mild, but protracted, cases of this fever, the patient pei*-
haps is confined to bed only part of the day, and becomes
cheerful in the afternoon. Tne stools, for a day or two,
improve, and then become very offensive; the appetite re-
turns soon, but the fever, emaciation, tumour otthe belly,
and other symptoms, may continue for several weeks, the
disease resembling marasmus. In this case, the pulse is
small, sometimes languid, or nearly imperceptible. The skin
often is cold, and the appetite is either very httle, or voracious.
Occasionally, especially when this modification affects adults,
there is an almost paralytic weakness of the legs. Laxatives
are proper, and I have known the copper pill useful. Benefit
also is derived, from rubbing the back, with a stimulating
embrocation, or, if any one part be tender on pressure, from
an issue there.

In consequence of dentition, irritation of the bowels, ob-

766

straction to the pulmonary circulation, exertion, or more
obscure causes, the yessels of the brisun may become very
turgid. This is productive of fever, generally acute, heat of
the surface, particularly of the forehead, red, and rather full
countenance, quick, or oppressed breathing, vomiting of gkury
fluid, immobility of the pupil, followed either by giddiness^
drowsiness, and insensibility, or violent convulsions, succeeded
by coma and death. In some instances, the disease is mani*
fested, purely, by symptoms of congestion in the head. la
others, the bowels are affected, perhaps first costive, then
loose, but in either case the belly is tender ; in other cases, it
seems to be connected, with disease in the lungs or liver, and,
is not unusual, in hooping-cough, in which case it always
causes convulsions. On examination, the smaller vessels of
the brain, are found injected with blood, so that a section
exhibits numerous red parts, but the congestion is chiefly
remarked in the veins and sinuses, which are gorged. In
some instances, a little serum is effused into the ventricles, or
blood is extravasated under the arachnoid membrane.

The treatment consists, in immediate recourse, either, to the
lancet, or leeches, according to the age of the child, free
purging, and clysters, with the occasional use of the tepid
bath. If the gums be distended, they must be cut.* .

CHAP. VI.

Of Hydrocephaly.

Hydrocephalus, is one of the most insidious diseases, to
which children are subject. It sometimes makes its attack
suddenly, cutting the patient off in a few days ; sometimes
more gradually, and is protracted for many weeks or months.
It has, therefore, been divided into the acute and chronic ;
and as it may either appear as an idiopathic disease, or come
on, in the course of other diseases, at first quite different, it
may likewise be distinguished, into the primary and secon-
dary. Some have described many species or subdivisions,
according to minute variations, in the progress or intensity

• Some very g^ood oues ofthU aiFeetlon are related by M. Galbertjn ArehiTcs
Oeneralee, Tom. xt. p. 91.

767

of the symptoms, but this is more perplexing than useful or
correct-
Acute hydrocephalus, begins very like a common fever,
but there is, usually, greater pain in the head, especially on
one side. After the febrile symptoms have continued for some-
time, marks of oppressed or debilitated brain appear, and the
patient dies comatose, or convulsed. Such is the outline of
the disease, which, however, it will be necessary to describe,
more minutely. The patient for some time previous to the
attack, may be languid, peevish and uncomfortable, without
any well defined complaint. The appetite is impaired, he
has frequent sick fits, or vomits bile, and the bowels are
generally costive, though, sometimes, he purges f(Btid, dark-
coloured, or green faeces, and he complains, occasionally, of
pain of bis head, or giddiness, or is either drowsy or unable
to sleep. Towards evening, the face is a little flushed, and
the skin is hot, and very soon the disease becomes distinct.

In other instances, however, and these the most frequent, the
disease invades suddenly, or, with scarcely any previous indis-
position. The patient feels chilly, whilst his skin is hot ; he
generally complains greatly of his head, especially, at the fore-
head, causing him to frown, or, at one side ; sometimes very
much of his neck. Headach is one of the earliest, and most
regular svmptoms, and it is always a very alarming circum-
stance, where there is severe pain, accompanied by vomiting
of bile, and not removed, or speedily relieved, by tnat evacu-
ation. In a few cases, I have found the patient denying,
that he had much, or even, any, pain in the head, and, with
infants, we have no means of judging, whether they have, or
have not, pain. Short and sudden attacks of spasmodic
croup, as it has been caUed, are, occasionally, precursors of
this disease, and are the more to be dreaded, if attended, or
followed, by convulsions. These, in ordinary cases of hydro-
cephalus, sometimes, appear as one of the first symptoms, but
more frequently, they do not come on, till an advanced stage.
Where there is no convulsion, there is often a contraction, of
one of the extremities, or of the thumb. Sometimes there is
spasmodic cough, or pain in a distant part. From the com-
mencement, the patient can seldom keep out of bed, his eyes
are usually very sensible to the light, and when examined,
the iris oscillates, the pupils are contracted, perhaps irregu-
larly, and the eye, in some cases, is troubled, in others, as
clear as usual. I must, however, observe, that, sometimes,
there is not the smallest increase of sensibility to light. The

768

headadi is constant, and produces moaning, or the patient
lies silent, and unwilling to speak a word, or often even to
take a drink. The stomach is very early affected, and often,
for some days, he vomits bile and whatever he swallows ; but
this vomiting, is neither so constantly met with, nor so long
continued as the headach ; he has no appetite ; the thirst is
variable ; the tongue white, the bowels generally costive, but
sometimes loose, and the stools, in that case, green and foetid ;
infants, are generally purged, frequently from first to last,
older children, usually tne reverse, at first, and, in most cases,
pain is felt in the belly. The sleep is broken, and frequently
mterrupted, as if the patient had a frightful dream ; he starts,
grinds bis teeth, and picks his nose, which makes Uie disease,
sometime, pass, for the consequence of worms. The pulse, in
a few cases, is not very frequent ; but in general, especially if
the disease be rapid, it is at first very quick, being about 120
in the minute, but subject to pretty rapid, and considerable,
variation, within a short time, in pomt of frequency. In
about eight or ten days, the pupils are somewhat dilated, and
the patient squints a little. In some cases, the vomiting is
renewed, but more frequentiy it is not. The pulse, at this
time, often becomes slow, beating only 60 in the minute, and
being generally irregular. The pupil is more dilated, and
the eye less sensible, than formerly, to light. The headach is
oflten diminished, but the patient frequently cries out, or even
screams. In some cases, delirium comes on, m others, the
patient continues sensible and intelligent, until stupor super-
vene. More food is often taken in this stage than formerly.
In the course of either two or three days, the pulse becomes,
again, quicker, the pupil more dilated ; but still the patient
may continue to see, and complain of the light, and <^ten
answers, distincdy, every question. Presently, however, the
symptoms of oppressed brain become greater; the pulse is
weaK, and gradually increases to 160 in the minute. The
eye scjuints, vision is at last lost, the urine is either retained,
or, with the faeces, passed involuntarily. The breathing be*
comes stertorous, and the patient dies ; or he may sink from
weakness, and remun sensible to the last, or, having been
delirious, or even comatose, he may recover his intellect and
sensibility, for a short time before death. Even the power
of vision and hearing have been thus recovered ; and it is not
unusual, for such an apparent amendment, to take place, as
to inspire false hopes, in one, who is not aware of the nature
of the disease. In the course of this malady, the cheeks

769

alternately flushed and pallid; and, after the second stage^
one side is often paralytic, whilst the other may be convuls^ ;
indeed conTulsions may come on, at any perioa of the disease,
even in its commencement, but in this respect there is a great
difference, in different cases. The symptoms are generally
aggravated during the night. When the patient sleeps,
the eyelids are often only half closed, and the eyes turned
up. He complains much, or becomes giddy, when the head
is riused.

Hydrocephalus, has been diyided into three stages, charac-
terized by the state of the pulse, and of the sensibility. In the
first, the pulse is frequent, and the sensibility great. In the
second, the pulse becomes slow, with marks of oppressed brain.
In the third, it is again rapid, there is great debility and cere-
bral irritation. But it is to be recollected, that these stages
are not always well defined ; sometimes the pulse never be-
comes slow, and the division cannot be relied on.

This disease runs on, generally, till the twenty-first day, if
the patient be above two years old ; but if the child be younger,
it often terminates more speedily, sometimes, so early as the
third, fourth, or fifth; and this is more especially the case,
when the disease is preceded by convulsions, or spasmodic
croup. There is another form, which also proves, or appears
to prove, rapidly fatal. In this, the symptoms are insidious,
and cannot be distinguished from common and not severe
fever, and there is seldom much, if any PAin* iu the head.
Water, however, is, either during this, emised into the ven-
tricles, or, by some previous and obscure cause, has already
formed there, and caused fever. Were I to speculate farther,
I would say, that the fluid is at first confined to the lateral
ventricles, or at most, goes not beyond the third, till the mo-
ment of death, when any obstruction that existed is removed,
and it is, at once, poured into the fourth ventricle, and acts
fatally on the medulla oblongata.

From this account, it appears, that the symptoms, when
the patient can describe them, are, in the first stage much the
same with those of the fever of the adult, or the remittent
cerebral fever of children, and that upon these, supervene those
of oppressed brain. Nor do I know, after all the attention I
have been able to give, any marks, diagnostic, between the
two diseases, more especially at the age of infancy. There
are, however, indications of higher excitement in hydroce-
phalus, than we generally meet with in the other fever. In
some cases, water has been found in the ventricles, when no

770

symptoms indicated it during life,* or when many of tbe usual
symptoms were absent.f Seyere or obstinate headach, with
bilious vomiting and fever, are always dangerous symptoms.

Infants cannot give any account of their sensations, and
therefore we are more uncertain, until the symptoms of op-
pressed brain appear. We may, however, dread the nature
of the disease, when the infant has a high fever, vomiting,
with costiveness or diarrhoea, lies oppressed, and apparently
sick, with the eyes obstinately shut, dislikes the light, puts the
hand frequently up to the temples, as if going to rub some-
thing oiOf the head, has starting and spasms, and awakes sud-
denly as if terrified, and sucks or drinks, at first, with great
rapidity. The diagnosis, however, is difficult ; for, in disor^
ders of the bowels, from dentition and other causes, spasms,
starting, drowsiness, and strabismus, may take place.! Dark
green stools, forming a gelatinous mass, not possessed of a
foetid smell, have been considered as peculiar to the disease,
whilst some assert, that this appearance depends on the use
of calomel.§ This state of the stools is not to be disregarded,
but it cannot be depended on, as pathognomonic, much less»
can the micacious disposition, from the urine, noticed by Dr.
Coindet. Rapid, and frequent variations, in the frequency
of the pulse, connected with other symptoms, narticularly,
with vomiting and somnolency, are very suspicious. It is
prudent, whenever there is much fever, with any ambiguous
symptoms, to proceed as if the patient were threatened with
hydrocephalus ; more especiaUy, as the early use of the reme-
dies, thus indicated, shall generally be serviceable, in the
complaints, with which this disease, may be confounded; and
if we delay, till the last stage, to obtain a more certain dia-
gnosis, we have scarcely any hope of doing good. When
children can give an account of their sensations, we may, with
great justice, fear this disease, when they compkdn much of
the head, have vomiting, and quick pulse. It ianot, however,

« Vide Qain*i TreaUse, p. 43.

f Dr. Rush mention! cues where there was no pain in the bead, or wh«re it
began lilte a catarrh, or wanted the strabismus, dilated pupil, dckoeM^ and l«aa of
appetite. Med. I no. Vol. ii. p. 210.

{ A very interesting case, where strong symptoms of hydroeephaloa were pr».
duced by accumulation of the faeces, and a speedy core obtained by purging witk
senna, is related by the late Mr. BenJ. BelL— Hamilton on Forgaiiva^ p. 917.
Other cases might be pointed out, where strabismus, double Vision^ parmlysia*
screaming, headach, &c., all yielded to the same means.

§ It is supposed, that hydrocephalic stools, may be distingulshad fnm thaw
changed by calomeU from the former being nearly inodorous, and not tinging wa-
ter when mixed with it. Calomel, howcrer, is often giren in hydroorpbalm, aii4
ought to affect tbe stools.

771

possible) always, to determine, at once, whether the disease
be that fever, already described, or hydrocephalus, nor is it
so essential, as may be supposed, for prudence dictates, even
in the milder disease of the two, the prompt use of yigorous
remedies.

Dissection, shows the brain, and its membranes, in some
cases, to be inflamed, and covered with coagulable lymph;
but in a great many instances, if inflammation, had at an
early stage existed, its appearances have gone off before death.
A much more frequent, if not universal circumstance, is con-
gestion of the veins. This, in some instances, is combined with
induration of the whole medullary part, or of the tuber, &c.,
and, in a few of these, no increased vascularity is observa-
ble. Betwixt the dura mater, and the brain,* but still more
frequently in the ventricles of the brain, there is an accumu-
lation of transparent water, sometimes to the extent of several
ounces ; urea has sometimes been found in it. Small tuber-
cular granulations are described by Laennec, and other late
dissectors, as being dispersed through the brain ; but these,
assuredly, are not essential to the disease. The spinal mar-
row, or its covering, sometimes participates in the affection,
and water may be formed there, or pass from the basis of the
skull. This appears sometimes to be productive, in the early
stage, of pain and rigidity of the neck, or peculiar sensations
about the larynx, or slight irritation there, as if a small fila»
ment were tickling it. The intestines, occasionally, have an
inflamed appearance, or portions are constricted, or intus-
susceptio is met with. The liver also may be somewhat en-
larged.

Hydrocephalus, is more readily excited in some children,
than in others, and this predisposition is very remarkable in

fyarticular families. Those who are of a scrofulous habit, are
iable to it ; but it also attacks children who have no other
manifestation of that constitution, and none, not even the most
healthy, are altogether exempted from it. In infancy, both
sexes are alike i^ected ; but it is certain, that about the pe-
riod of puberty, or a little before it, females are more fre-
quently attacked. Coindet, has stated the proportion, at the
age of twelve years, to be as eight to one.

Exciting causes, acting evidently and directly on the brain,

• In this CMC the diwaae St called byd. externus, to dlstin^lth It from the
•peciea in which the water It In the Tentrldei, which la called hyd. Interiiut. By
the former term^ some of the ancient writers merely understood oedema of tho
scalp.

772

can sometimes be detected, as blows, or otber injuries, expo-
sure to cold, violent exertion, passions of the mind, the sud-
den removal of a continued irritation or discharge, firom the
scalp, or neighbourhood, &c. In other instances it is excited
by previous diseases, acting in a secondary way on the brain,
such as hooping-cough, scarlatina, &c. Any long continued
fever, by keeping up a constant over-action, in the vessels of
the brain, which contain so large a proportion of blood, has
been viewed as a cause, and, doubtless, where there is strong
predisposition, it will so act. Transition of action, it is also
probable, is a cause. The continued irritation of important
or very sensible nerves, is perhaps one of the most frequent
causes ; hence, it may follow dentition, and very often arises
from a bad state of the chylopoetic viscera. We have, from
excitation of the extremities of the nerve, a similar state not
only produced at the origin, but to some extent around that,
so that nerves coming off near it are affected. After death,
the parts, about the origin of these nerves, are found highly
vascular and infiltrated. Having noticed this pathological
fact, in the last chapter, I have little to add here. It is an
important inquiry, however, why, in one set of cases, mere
fever is excited, often stimulating, no doubt, hydrocephalus,
but rarelv ending in it, whilst, in another, this disease is
speedily mduced, in its most formidable characters. This
would lead to a belief, that either, in many cases supposed to
arise from the state of the bowels, the original disease has
been seated in the brain, and the apparent disease in the
bowels, has been only an early symptomatic affection ; or,
that the nature of the irritation, communicated to the brain,
is different, essentially, in the one case and in the other : per-
haps both suppositions may at times be true, and much, also,
depends on predisposition. I may at this time, take an oppor-
tunity of remarking, that, although, in many cases, where the
bowels appear first to be in fault, and are looked on as excit-
ing diseases of the nervous system, yet, in many others, the
disease, really, at first, existed in the brain or spinal cord, the
earliest symptoms exhibited, being the effect of this state,
manifested by the altered ftmction of the bowels. In the
same waV) croup, cough, &c. followed by convulsion and
hydrocephalus, depend on the state of the origin of the nerves
at the base of the skull.

The next inquiry is, what is the state occasioning hydrooe-

Ehalus ? Is it in&mmation, and is the effusion analogous to
ydrothorax succeeding pleurisy ? An acute and considerable

773

degree of inflammation, ends in suppuration^ and this is the
termination of many cases of phrenitis. This formidable dis-
ease is not rare, but is oftener met with in childhood than in-
fancy. It is marked by high fever, pain, general or local, in
the head, perhaps excruciating, followed by stupor, and prov-
ing very rapidly fatal. We may find, on dissection, muco-
purulent secretion, or a softening of part of the brain. A
more moderate degree, capable of greater prolongation, ends
in serous effusion. Even a state of action inferior to inflam-
mation produces this ; and it is this sub-inflammation, which
I believe most frequently exists in hydrocephalus.* During
this state of excitation, amounting, at most, to what may be
termed sub-inflammation, the pulse is frequent, and the fever
generally acute. It ends in a state of exhaustion, weakness,
or torpor, in which the cerebral functions are impeded, or
diminished, in their performance. Symptoms, supposed to
arise from compressed brain, take place at this period ; but
they do not arise from that source, but from the condition of
the brain just described. They take place before effusion, in
all probability, exists ; they are similar to those produced by
concussion of the brain, or any cause capable of mterrupting,
or interfering with, the performance of its functions. The train
of symptoms are various and uncertain, in as much, as one
part may fall into torpor, whilst another remains still in a state
of excitement. Where efiusion has taken place, the parts are
often thereby irritated, and the frequency of the pulse re-
newed, whilst usually the stupor augments. In a few instances,
the nature of which we cannot yet ascertain, this pressure
seems to excite, rather to temporary advantage, for there have
been instances of the intellect returning, and the patient being
better, a short time before death. It is probable, then, that
those symptoms, attending what has been called the second
stage, and supposed to indicate effusion, merely evince the
commencement of that exhausted or enfeebled condition,
which leads to effusion, and it is not too late, even at this
time, to entertain faint hopes of recovery, hopes founded,
however, on the possibility of our being mistaken as to the
existence of effusion, which, of itself, independently of the

!)revious condition, usually, is sooner or later productive of
atal consequences. After effusion takes place, in acute

* My learned and indefatigable friend. Dr. Monro, contests, in his late work
on the brain, this opinion, and considvrs hydrocephalus to be most frequently
produced by scrofula, (not incompatible with this doctrine.; or by those causes
which five rise to a derangement of the circulation within the braioy chetl, or
belly.

774

hydrocephalus, I hold recovery to be next to impossible : the
few instances that have not ended in death, have terminated
in fatuity, accompanied with enlarged head. The term
hydrocephalus is, therefore, perhaps improper, as it is appli-
cable only to the ultimate ana incurable stage of thb disorder :
but, as it is universally accepted, it would be wrong to
change it.

In considering the best mode of treatment, it is evident
that we must, in the first stage, or that of excitation, use the
most prompt and vigorous means for allaying action ; and in the
second, or stage oi diminished function, use such remedies as
may safely excite, to more healthy and vigorous action, with-
out stimulating to inflammation. In the stage of effusion,
we may lay down the, almost, hopeless indication of promoting
absorption, or artificially procuring the evacuation of the
fluid.

In the first stage, much may be done by vigorous treat-
ment, and many lives are saved thus, which should otherwise
have been lost ; or, in different terms, many are prevented
from having the disease, or stage, properly called hydroce*
phalus, who otherwise should faJl victims to effusion. The
most efficacious means consist, if the child have been pre-
viously healthy, in the detraction of blood by venesection,
cupping, or leeches, or both, according to the age of the
patient, and the severity of the disease.* In no such instance,
ought leeches at least, to be neglected, and they cannot too
early be applied. Evacuations of this kind, carried promptly,
to a moderate extent, ought instantly to be followed, or rather
accompanied, bv the administration of smart purgatives ; and
I wish it could be impressed, sufficiently, on the minds both of
parents and practitioners, that the loss of one day, in this
active treatment, may be the loss of the patient. 1 am Cor
from advising debilitating depletion, or late evacuations, but,
in acute cases, eai*ly venesection, or leeching, or both, if not
carried the length of exhaustion, will do good, or at least
prove safe. At the same time that these means are adopted^
the head ought to be shaved, and bathed frequently with cold
water ; and in a few hours thereafter, a blister ought to be
applied, to the back part of it. When I advise cold water,
I wish it to be understood, that this is to be applied efficientlv*
not by wetting cloths once or twice, but by keeping the scalp

• It hat been propowd to bleed nearly to the extinction of life ; but It is far.
hideiid, from being proved, that hydroctphalua depends on acute Inflamnwdon.

Exhaustion, ooiiveru doubtful, into hopeJew cases.

775

constantly cool, or even cold, by the diligent repetition of wei
cloths. Some have advised the application of pounded ice,
but, from the pain this gives, if ever it do good, it must be in
those cases where there is rather collapse, and the necessity
of stimulating the brain by speedy sympathy with the scalp.
In this case it acts, though perhaps, not so safely, like a sina-
pism. The affusion of cold water on the head, I consider as
a very hazardous practice, for it is often followed by alarm-
ing collapse ; but if it is to be practised, it must be very early,
and when there is much heat, and, immediately after, but
never antecedent to, evacuations, and, lastly, with great pru-
dence and moderation. Blisters, when not too large, I am
confident, are useful ; although some, whose judgment I re-
spect, place little reliance on them. Caustic has been applied
to the scalp, or tartar emetic, but I do not think with any
superior advantage.

Hoping that these means have given a check to the disease,
our next object, is to keep up, and improve our ground, and
this is done by strict attention to tne bowels. The best
remedy, I believe, is calomel, in small doses, or such doses as
excite or keep up the action of the bowels, without purging
too much. This not only acts on the bowels, but also exer-
cises an influence on the nervous system. Two grains in the
twenty-four hours, in divided doses, continued with some
other mild laxatives, may be given to a child a year old. If
this do not agree, we substitute the blue pill, dissolved in a
little warm water. One pill may be given for a dose, to a
child of eighteen months old. If the mercury irritate the
bowels, producing griping, we should add a smsdl quantity of
opium, at the same time that we preserve the bowels open, by
the addition of another laxative. We are more likely to do
harm than good, with calomel, if we allow it to produce grip-
ing, and teazing excitation of the bowels. I am not an advo-
cate for drastic purges. Small blisters ought also to be ap-
plied, successively, to the scalp, and all stimulatbg diet is to
be avoided.

In the next stage, when symptoms appear, of inaction, or
loss of energy, in one part of the brain, perhaps with a con-
tinuance of excitement in another, remedies have little effect ;
but still, as our diagnosis is not always certain, and as they
sometimes succeed, they ought invariably to be tried, as sedu-
lously, as if we expected certain success. They consist in a
repetition of small blisters, the use of mild purgatives, and
the continued exhibition of mercury, by friction, or, rather,

776

internally, so as to act on the briun. Antimonials have been
used, in conjunction with mercury, but I do not think with
advantage, uiough James' powder, has been advised, by high
authority. In this stage, we must be careful not to exhaust
the strength, and are more likely to do good by mild nourish-
ment, suitable cordials, and the prudent use, when required,
of opiates.

Paracentesis* has been chiefly resorted to in the chronic
species. In acute hydrocephalus, the fotitanelle is often so
prominent and elastic, as to give rise to a belief, that water is
really lodged in contact with it. A puncture, cautioasly
made, has shown the mistake.

Opiates are hurtful at first, but in conclusion they may some-
times render the scene less distressing, by abating the convul-
sions. These are also sometimes relieved by sprinkling the
face with cold water, or administering a large clyster. Opiates
are also useful when there is great restlessness, irritability, or
suffering, apparently from pain. In ambiguous cases, resem-
bling hydrocephalus, they, in such circumstances, give a fa-
vourable turn to the disease, which might otherwise have
proved fatal.

When hydrocephalus is known to be a family disease, it
will be proper to use every mean to strengthen the constitu-
tion, such as the cold bath, light nourishing food, and strict
attention to the bowels, not that I believe hydrocephalus ever
to proceed directly from debility, but because whatever weak-
ens the constitution, gives predisposition to disease. If the
child be plethoric, or have momentary fits of insensibility, or
the slightest, and most transient paralytic affections, or eclamp-
sia, or spasm of the glottis, the bowels should be kept loo8e»
and a small issue must be kept on the head ; from this I have
observed great advantage. We should be particularly care*
fill not to heal, too suddenly, any eruption, especially about the
head. The first symptoms of disease must be watched, and
we had better be blamed for using remedies too early, than
have to regret that we employed them too late.

The chronic hydrocephalus makes its attack more slowly,
and runs its course with much less speed. It seems some-
times to be gradually approaching from birth,- the child
being dull, languid, subject to frequent fits of stupor or drowsi-

* Mr. Brovrn reUtet' a' cam where water was repeatedly drawn oif by punc-
ture, and always with advantage^ and temporary restoration of the sight, and tbe
faculty of attention, but it ultimate) v ended fatally. Med. Pbys. Journal, Vol*
Kli. p. 102.

777

ness, uid the head enlarging faster than it ought to do ; or
it may even begin in utero. In other cases, die child is at
first tolerably healthy, and it is many years before symptoms
of the disease appear. First of all, we observe him to be
duller than usual, with a slight degree of fever, attended with
pain in the head, sometimes constant but moderate, some-
times attacking like paroxysms of headach, attended with
sickness and vomiting. He is amused, for a short time, with
the entertainments of his age, but is soon tired, and generally
is found, after a little play, lying on a chair. The appetite is
gradually impaired, and bis food is apt to sicken him, or to
be rejected by vomiting. The headach becomes more con-
stant, and sometimes severe, often attended with giddiness,
and pain or stifiness in the neck. The skin is rather hot, the
pulse, at first, is frequent and irregular, although, in some
instances, it very early becomes unusually slow, and continues
so for a long time. The bowels are constipated ; the urine
sometimes passed with pain and difficulty. The eye is dull
and languid, and, at times, the patient sees double or indis-
tinctly. After these symptoms have continued some time, the
bones of the head enlarge greatly, if the sutures have not
united, and the veins on the scalp become very distinct. The
body wastes, and the muscular powers are more or less im-
paired. In this state the patient may live many months ; or,
occasionally, the disease seems to receive a check, and the
patient lives for years, with an enlarged cranium, and sometimes
in a state of idiotism. In general, however, in a few weeks,
or at most a few months, uie symptoms of compressed brain
become more distinct; and it has been supposed, but not
always correctly, that these take place, whenever the head
ceases to enlarge, and not sooner. The pupils are dilated,
the patient squints, the limbs are paralytic and convulsed, the
urine is suppressed, so that the catheter is required, the pulse
full and slow, but presently it becomes weak and fluttering,
and the patient dies comatose, with stertorous breathing.
When the patient can give an account of his sensations, we
may early be led to suspect some disease in the head, but, in
infancy, we can receive no account of the sensations. We may
discover it,* however, by the unhealthy look of the child, the
frequent application of the hand to tne head, which often is
larger, and feels heavier than usual, even before water be
formed ; drowsy fits, and sometimes convulsions ; vomiting,
and awaking terrified from sleep ; at the same time, that there
seems to be no tendency to dentition. Afterwards, the size

778

of the head, and other 8ymptoms» indicate the disease more
decidedly.

On opening the head, we generally find a great quantity of
water in the ventricles, and some even on the surface of the
brain. Sometimes the ventricles are so much enlarged, that
the cerebrum resembles two vesicles, lying on the cerebellum.
The bones of the cranium are, occasionally, very thin and
softened, sometimes very irregular on their inner surface, w
a girl, who died, after having been ill for about five months,
I found the inside of the cranium, at the lower part, covered
with sharp bony processes or spines. There is seldom, if ercr,
any indication of previous inflammation. This disease, there-
fore, differs from acute hydrocephalus.

The practice consists in the application of blisters to the
head, or the formation of an issue on the scalp, by means of
savin ointment : or a more general irritation may be kept
up, by rubbing with garlic ointment, or ointment with tar-
trate of antimony. The bowels are to be kept open, or *t
least regular, by the use of purgative medicines ; and it wiu
be proper to give a course of calomel and mercury, combuwa
with (Jdgitalis, nearly in the same doses we would use lor
dropsy. By this plan, some children are cured, and ouieB
have the head reduced in size for a time.* These have had we
urine considerably lessened in quantity ; and when the medi-
cines do good, they increase the flow of urine* It has been
proposed, by bandages and other means, to support the bones
of the head, and prevent distension, but of this I can sbj
nothing from my own observation ; and am persuaded it would
be hurtful. .

It has been proposed to draw off the fluid by puncture; ^
this has been done, and sometimes, it must be acknowledgodj
with success. One case of this kind, is related by I^^*» *?
another more lately by Dr. Vose, who relieved a child hj
puncturing three times with a couching needle.f ^^^^J^
also oozed away by the nostril through a foramen, but without
benefit to the patient. ,

There is an affection, which is liable to be con*oundea
with chronic hydrocephalus. The patient complains of ^
head and neck, for a length of time, has the pain increaseo
by exercise, agitation, or reading long, and sometimes n

* In a case attended by my brother, he succeeded lo far with the '"f^T^S
and digitalia, ae to render the fontaneUe alack, whereas, before, it was tem^ v^
prominent. But whenever this slackness was produced, convulsions (»^
and the natient died.

t Mcdlco-Chir. Trans., Vol. is. Part 2d* The child afterwafds dlsd*

779

Suints. The pain, however, is rheumatic, follows the course
that disease, is not constant, and shifts its place. The
squinting is either habitual, and consequently accidental, with
regard to the disease, or it is caused by a temporary affec-
tion of the muscles of the eye, and is increased by looking
long at any object. The patient is easily agitated, and there
is an approach to the disease described in the last chapter.
Laxatives, bark, a seton in the neck, and sear-bathing, are
useful.

The secondary hydrocephalus is a very insidious disease.
In one respect, perhaps, the majority of cases of acute hydro-
cephalus may be called secondary, inasmuch as they are
excited by other irritations, in the Dowels or gums, &c. But
by this term, I wish particularly to understand the attack
which succeeds to some, previously, well-formed and prolonged
disease, such as scarlatina, hoopmg-cough, &c. It too often
happens, that in the progress, or sequel of such diseases,
hydrocephalic symptoms supervene, and the child is cut off.
That this should take place, is not wonderful, when we con-
sider the remarkable sympathy existing betwixt the brain aed
other organs, and the great vascularity of the brain, as well
as its delicacy in children. But, however the fact is to be
explained, its existence is undoubted. It is highly necessary,
in all diseases of children, to watch the safety of the head ; and
whenever symptoms appear, indicating an affection of that
organ, to have recourse to the application of leeches, blisters,
and other means, which have been pointed out. Indeed, in
all the protracted diseases of children, especially if attended
with considerable fever, it will be prudent to shave the head,
and apply a small blister upon it. Calomel purges, when
mild, are of great utility.

CHAP. VII.

Of Convutsions and Eclampsia.

Convulsions proceed from various exciting causes, dur-
ing infancy, but they always depend on an affection of the
origin of the muscular nerves, produced either by direct or
sympathetic causes. (See Chap. V.) They very frequently
arise from irritation in the bowels, from dentition, or in the
course of eruptive fevers, or along with hooping-cough. Some-

780

times they proceed from immediate affections of the brain
itself, and very often they occur in the commencement or
progress of hydrocephalus. They may be diTided into those
proceeding from a primary affection of the brain, and those
occasioned by sympathy with some other organ, in a state of
irritation. But in either case, the immediate cause is the
state of the origin of the nerres. There is, however, a differ-
ence in the probable result, for the most fatal are those which
depend on mrect affection of the brain or medulla spinalis.
In such cases, the child may die during the fit, or in conse-
quence of that state of collapse or torpor, which, as in epilepsy
of the adult, may succeed the fit, or from more protracted
consequences of the cause which at first gave rise to the con-
vulsions. It is not, however, easy to make the diagnosis, in
every instance ; and, when convulsions continue long, what-
ever may have been their origin, the brain ultimately suffers,
and if the disease be protracted, the patient becomes ema-
ciated, and perhaps paralytic, or even hydrocephalus may
very early be excited, by the state which at first caused con-
vulsions.

We may be assisted in our judgment, by examining the
gums, especially if the child be about the time of life when
teeth appear; by inquiring into the state of the bowels,
whether they be loose or bound, or the child be troubled with
worms ; by learning if an eruption have suddenly disappear-
ed; or if the child have been frightened, or had heavy food,
or too much food, or been sucking a woman whose mind had
been recently agitated ; or if none of these causes be discov-
ered, we should inquire if the child have, already, had those
febrile eruptive diseases, which are often preceded by convul-
sions, especially small-pox. In many cases, convulsions pro-
ceed from irritation of the bowels, the stools being generally
unnatural, or the digestive functions impaired. This obser-
vation is of much importance, in practice, as it points out
both the means of prevention and ofcure.

Very young infants are subject to a slight degree of spasms,
called inward fits, in which the mouth is, during sleep, drawn
into a smile ; the eyelids are not quite closed, and the eyes
are turned about, so as at times to discover the white; the
breathing seems occasionally to flutter, and the child is very
easily startled. These fits, appear to be occasioned, by wind
in the stomach or bowels, for they are relieved by a discharge
of wind, and require some carminative, such as oil of anise,
with a gentle laxative. They generally go off in a short time,

781

but sometimes they are succeeded by yomiting or purging, or
drowsiness, ending in convulsions.

Some children, very early after birth, appear languid, moan,
and pass dark-coloured fsBces, different from meconium, and
after it, in the usual course of things, ought to be removed.
Presently, they fall into a state, rather resembling syncope
than convulsions, and die, perhaps, in forty-eight hours after
they are bom. The early use of calomel, in small doses,
conjoined with some gentle aromatic, is proper.

Others, soon after birth, are seized with a violent fit of cry-
ing, and they become more or less distinctly convulsed, and
the muscular irritation may repeatedly recur. This is relieved
by the warm bath, gentle laxatives, and rubbing the belly
with a little laudanum. I have sometimes thought, that this
state was induced, by tying the cord too near the belly, by
which, an irritation was communicated to the abdominal vis-
cera. Infants of a month old, who are subject to severe fits
of crying from colic, which is often induced by bad nursing,
may be suddenly carried off by a convulsion, after a violent
and continued paroxysm of screaming. This state, requires
great attention to the bowels and to diet.

There is a state of restlessness, and irritation, almost allied
to insanity, sometimes met with in children, a few months old,
and, in thb case, at particular times, the child cries bitterly,
and lonff, as if in much pain. This is sometimes followed by
a convulsion, or we observe a finger or toe contracted. Dur*
ing the cnring, the only relief is momentary, and obtained by
giving drink. The bowels should be freely opened, a small
blister applied to the head, and occasionally repeated, and at
the time of most restlessness, an opiate should be given, which
seems to be the most beneficial remedy we employ.

Regular convulsions, may occur at a very early period of
infancy, and in this case attack those children, who, from the
time of birth, have been subject to heavy sleep, or to whine
and moan, or to violent screaming, or to start suddenly from
their sleep, and who have twisting of the extremities while
awake, or spasmodic contraction of the thumb or toes.

Convulsions vary much in their degree and duration.
Generally, the child is seized, quickly, with a spasm of the
muscles of the arms and legs, which are agitated to and fro,
the fists are clenched, the body bent back, the features dis-
torted, the eyelids open, the pupils dilated, and the eves
either fixed in the socket or rolled about. The face is eitner
pale or livid. These convulsions may prove very suddenly

782

fatal ; but sometimes after the fit has lasted a mmiite or two,
it goes off and does not return* In other cases, it returns
very frequently for several days, or, at uncertain intervals, for
many weeks. In general, the longer the fits, and the shorter
the mterval, the greater is the danger. The occurrence of
paralytic symptoms or emaciation, in those cases where fits
are frequently repeated, adds greatly to the danger, and
generally indicates hydrocephalus. When the child is very
much stretched or bent back, some call the disease tetanus,
and give the appellation of eclampsia to the other cases. In
many instances, the first symptoms are a kind of wheezing or
croupy breathing, immediately succeeded by a general con-
vulsion. Many cases of apparent convulsions, are rather de»
pendent on temporary or momentary paralysis, of a set of
muscles, than on spasm of their antagonists.

When a child is seized with convulsions, a great alarm
prevails ; and it is expected, that, if the practitioner arrive
before the child be carried off, or have recovered from the fit,
very prompt and active means must be employed. The first
thing to be done, is to order a warm bath and clyster to be
^ot ready immediately ; and whilst these are preparing, we
mquire into the circumstances of the case, and examine the
gums, tf the child be at the time of teething, and no other
cause be discovered, it will be proper to cut the gum, freely,
over that part, where the teeth ought, according to the usual
order of dentition, to appear, even although no swelling be
discovered. Then, the child is to be put into the warm bath,
the head alone being kept above the water, and he is to be
retained there for a few minutes, if the fit do not pass off
sooner. Cloths wet with cold water, may, at the same time,
be applied to the head, so as to cool it, but not to such an
extent as to make it cold. Smart aspersion of the face, with
cold water, has also done good, and even pouring cold water
on the head has been advised. I am not, however, very par-
tial to this, for I have seen a state resembling syncope pro-
duced by it. If the bath do not g^ve speedy relief, I have
seldom found much advantage from resorting to it again, if the
fits should be repeated. In some instances, the admtion of a
little mustard, to the bath is useful. When the child is taken
out of the bath, a cloth is to be applied over the stomach, or
great part of the abdomen, wet with strong spirits, and lightlv
sprinkled with pepper, and the spine should be nibbed with
hartshorn and spirits, or some other stimulant embrocation.
A clyster is, at the same time, to be thrown up, so as to operate

783

speedily ; and this is to be followed by a calomel purge, and
tne subsequent use of laxatives, to keep the bowels open. It
may be proper, however, to state to the parents, that it is not
unusual for the fit to return, about the time of having a stool.
If the child have diarrhoea, and the stools be not natural in
appearance, laxatives will still be proper, according to the
directions given in considering diarrhoBa.* Emetics have also
been employed, during the fits, as soon as the child was able
to swallow ; but unless we have reason to suspect, that some
indigestible, or improper, substance has been taken, they are
not so beneficial as laxatives, and may, from their efiect on
the circulation, in the head, be detrimental. But when fits
are only apprehended, in dentition, from starting, feverish-*
ness, and circumstances ascertained, by former experience, to
precede convulsions, I have sometimes found a gentle emetic
of service, and it ought to be foUowed by the warm bath, and
some antispasmodic, such as assafoetida, conjoined with a lax-
ative, if necessary. Tincture of assafoetida, with the addition
of oil of anise, is a very useful remedy ; or we may give tino
ture of hyoscyamus, with oil of anise. Camphor has been
strongly advised, either by the mouth or in clysters, by Stork,
but I do not know that it is very useful. I must say the same
of musk.

K the face be flushed, or the arteries of the neck beat
strongly, or the child have been previously healthy, it, next,
will be proper to apply one or more leeches to the forehead,
according to the age and constitution of the child, or, if
possible, to take blood with a lancet from the arm. In all
such cases, the loss of more or less blood, instantly, is of
importance ; but if the face be pale, and the child weak, a few
drops of the aromatic spirit of ammonia may be given repeat*
edly. Opium is hurtful when the face is flushed ; and even
when it is pale, is only useful when there seems to be consid*
erable irritation, about the bowels or from the gums, or an in-
cessant crying or restlessness. In such cases, an anodyne is
often very useful, more especially after the bowels have been
freely opened. Oil of rue, is strongly recommended by Dr.
Underwood ; and when the fits are repeated, it will be pro-
per to make use of this, or assafoetida, or other antispasmo*
dies. The spine should, in such cases, be repeatedly rubbed,

* The propriety of giving pargatiyee in eoDriUeion% when the bowele are eoe-
tiTe, or the stoole unnaturali is confirmed bj experiencei and the effecte of tlieie
Inehorea.

784

with some stimulant embrocation, or oil of amber ; and a small
blister should be applied to the head, if the recovery firom the
first attack be not complete, and especially if there be a repe*
tition. Blisters and smapisms hare been i4)plied to the ex-
tremities, but they only add to the irritation. Yfh&i the
child remains in a state of stupor, after the convulsion, such as
we see succeeding epilepsy, in adults, a sinapism, to one half
of the head, left on for ten minutes, often excites the brain, to
the performance of its functions. Blisters, on the other huidv
are intended to act more slowly, and, partly, by their discharge,
partly, on the principle of sympathy of equilibrium, allay in-
ordinate action within the cranium. The one, acting quickly,
on the principle of the sympathy of assodation, excites, the
other, diminishes excitement within, by slowly increasing it
without. When the attack has been preceded by spasm about
the larynx, which I shall notice in considering croup, one or
more leeches, should be applied to the temple, or nape of the
neck, or a vein should be opened, according to the age and
other circumstances; purgatives should be given, and a blister
applied to the occiput. Even after the apparent danger is
over, it is useful, for some time, to keep an issue on the back
of the head, for there has been either undue vascularity, or
inflammation, existing about the origin of the eighth pair of
nerves, which is very apt to return, although, for the time, it
have been mitigated. In all cases, the diet must be attended
to, and it may even be necessary to change the nurse.

When a child has repeated convulsions, and almost con*
stant moaning, and bending back of the neck or spine, the
disease is incurable, as it proceeds from water in the head*
It may, however, be protracted for several weeks. Repeated
small blisters on the nead, and the daily use of calomel, may
be tried in such chronic cases, but, at last, the only relief is
obtained by opiates.

• Children disposed to hydrocephalus, sometimes ftdl down,
for a few seconds, in a state of insensibility, without much, or
even any, spasm. By purgatives, and keeping an issue on
the scalp, toe danger is often averted.

Trismus nascentium, is not a very frequent complaint, in
this country, but it is not uncommon in warm climates. It
makes its attack, within the first fortnight of life, very rarely
before the sixth day, and has been supposed, by some, to be
connected with a costive state of the bowels, by others, with
the falling off of the navel-string, and the state of the umbili-

785

CU8.* In some instances, the spasm is confined to the jaw»
which is riffid and closed ; in otners, it extends to the neck,
or trunk which is stiff and bent back. The disease is very
fatal, notwithstanding that the warm and cold baths, opiates,
purgatiyes, and blisters have been fully tried. The state of
the navel should be attended to, and proper dressings applied,
so as to avoid irritation.

After the period of infancy is past, and, during the time,
when the second set of teeth are coming out, convulsions are
generally of the eclamptic kind, attack suddenly, the patient
screaming as if terrified, and then he falls down convulsed.
When the fit goes off, he becomes nearly quite well. These,
do not indicate, that the patient shall be subject, after puberty,
to epilepsy. They are relieved, by attending to the state of
the gums, removing decayed teeth, and cutting the gum, over
the grinder which is coming out, but, especially, by keeping
the bowels open, which must be done with perseverance, in
the most efficient way. We thus remove a frequent exciting
cause ; but we must not confine our attention to the bowels
alone, but must inquire whether any other source of irritation
exist. Near the time of puberty it may occur in either sex,
from irritations which exist at thiat period, but it is particularly
frequent in the female. Sedulous attention must be paid to
the bowels ; and, as in other cases, we must call in the aid of
remedies of a different description. 01. succini, valerian, sea^
bathing, and tonic medicines, as zinc, have been found of
service ; assafoetida or camphor, given by the mouth, or in
clysters, have also been useful; when attended with facial
neuralgia, the removal of a decayed tooth has removed them.
When there is much determination to the head, especially in
the first attack, either the lancet or leeches ought to be used.
IS these means be not successful, an issue ought to be estab-
lished in the neck. But, in obstinate and protracted cases,
organic alterations have generally taken place, and the patient
becomes £atuitous, a state, sometimes preceded by morbid
perversity of disposition. This condition of the brain, is more
apt to take place, if suitable evacuations have not been made
early. Bleeding and purging, timely employed, may be of
the most signal service, in preventing organic changes.
Eclampsia, occurring at the menstrual period, although par-
taking much of the nature of hysteria, requires the same treat-
ment. Convulsions have sometimes been caused by impure

* Vide a Paper by Dr. Bartram, in Trans, of Coll. of Phya. at Pliiladelphia,
Vol. i. p. 827, and by Dr. Collo, Dub. Hosp. Rep. Vol. 1. p. 83ft.

786

air, and can only, in such cases, be relieved by a remoTal to
a purer atmosphere. This is a tact which it may be of aeap-
vice to remember.

I do not mean to enter on the consideration of epilepsy

here.

. Catalepsy often depends on the state of the spinal cord,
and alternates with convulsions. The same tonic and anti-
spasmodic medicines, already noticed, with sedulous atten-
tion to the bowels, and the application of repeated blisters to
the nape of the neck, or the formation of an issue there, will
be proper.

CHAP. VIII.

Of Chorea and Paralysis.

The convulsions, called chorea sancti Viti, attack childieo,
most frequently, from the age of eight years, to that of puber-
ty. This disease, makes its approach, with languor and dis-
like to the entertainments of the age ; a variable and some-
times very keen appetite ; in general, continued costiveness,
attended usually with a hardness and swelling of the abdomen,
especially at the lower part, though, occasionally, the belly is
flabby, and rather small, instead of tumid. Sometimes the
bowels are open, but the stools are not of a natural appear-
ance. Presently, convulsive twitches, and motions of the
muscles of the race, take place, and are succeeded by more
marked convulsive affections, of the muscles of the extremities
and trunk, so that the patient cannot sit still, nor carry a cup
of tea safely to the mouth ; and this motion, in different cases,
and different periods, varies greatly in extent and degree, from
a mere fidget, to a universal agitation. There is constant
restlessness, and sometimes in place of involuntary jerkii^,
there is an irresistible desire to dance, jump, or whirl. In
some cases, the twitches and contractions, evidently, proceed
from spasm of the fibres, but in others, and these not the least
frequent, they depend on temporary paralysis of the antago-
nist fibres. These are often almost constant ; even when the
patient is asleep, the limbs are in motion, and the sleep is
greatly disturbed. He does not walk steadily, and sometimes
seems to be palsied, or the motion may be very rapid, the

787

head shakiiig like a rattle. The patient is sensible during
the oonyulsiye motion. At a more advanced period, the
countenance becomes vacant, the eyes dull, the speech is a&
fected, and, in some cases, the patient cannot even swallow
without difficulty. Emaciation takes place, and a febrile state
may be induced*

This disease generally originates from the state of the ali-
mentary canal, which is irritated by bad or indigested faeces,
and thus the extremities of the nerves are acted on. These,
influence their origins, or the brain itself, and the same
convulsive motions are produced, as if the encephalon were
directly affected. It sometimes seems to be dependent on
the irritation of dentition, or on a decayed tooth, and has
been cured by extracting that. Other irritants have the
same effect, and, hence, chorea has followed the exhibition of
strong saline or poisonous substances. But independent of
all irritation by feeces, the condition of the bowels themselves,
considered as organs, capable, by their sympathetic influence,
of acting on the nervous system, particularly, on the origin of
the spinal nerves, may produce this state.

Chorea may also be produced, by direct irritation of the
brain, by tumours, or change of structure, in some part of it.
In this case, it terminates in hydrocephalus. I have known
blindness, and ability to see, alternate each other, daily, for
a considerable time. It has also been dependent on high
vascularity, or inflammation, of the spinal sheath, or of im-
portant nerves.

A variety of remedies has been tried in this disease, but
none with so much advantage as purgative medicines, which
have been prescribed with the happiest effect by Camper,*
Sydenham, and Hamilton. These, if given early, and before
the disease be fully formed, will; very effectually relieve the
patient, and at this time they only require to be gentle, and
repeated as the state of the bowels may require. But when
the disease is confirmed, ** powerful purgatives must," as Dr*

* ** HftTinf described the nerret, 1 now oome to the tyinptoins, which are
ciisily explained by their connexion. I will begin with tremor of the f(per, which
!• common In hyeterical eaeea. But 1 ought in the ftrtt place to mention, that
the dreadful hysterical symptoms, which we daily see either in indWidnal parts,
or in the vt hole body, are altogether dependent upon the accumulation of acrid
matter in the prima r\m ; for the intolerable fcetor, the scantiness and unnatural
•ppearance of the faces, always warn us of an approaching paroxysm of rigors
and convulsions.

« Ought not purgatiTS medicloes, and even the most drastic ones, to he exhibit-
ed 7 '1 hey probabTv might euro spurioas epilepsy, chorea saoetl VIti, aod other
ftpasmodic diseases, oitharto generally deemed hopeless bv medtosl men.**

Camper on th§ P*hiit Chspter HL section 7t

788

Hamiltx>ii observes, " be given in successive doses, in such a
manner tbat the latter doses may support the effect of the
former, till the movement and expulsion of the accumulated
matter are affected, when symptoms of retuming^ health
appear." Calomel and jalap are useful purgatives, in this
disease, and Dr. Hamilton is in the habit oi using aloetic pills,
on the days when these are not employed, which is a useful
practice wnen the patient can swallow pills. My own expe-
rience leads me, decidedly, to agree with Dr. Hamilton, in the
employment of the aloetic pills, which must be given in suffi-
cient number, daily, to produce a full effect. Infusion of
senna, alone, or with the addition of sulphate of magnesia, may
be occasionally substituted. Dr. Underwood recommends
aloetic and mercurial purges. By these means, chorea is
perhaps cured in a fortnight, or, in obstinate cases, within two
months, if there be no organic disease. Boys«are said to be
more readily cured than girls. If no great amendment take
place soon, we must not on that account desist, but continue
the purging plan for several weeks ; but it is a great mistake
to suppose, that purgatives can, infallibly, cure the disease.
Removing irritating fseces, and, more particularly, exciting
the action of the alimentary canal, are essential to the cure,
but cannot always alone effect it. In obstinate cases, we
must take the assistance of tonics, arsenic, nitrate of silver,
carbonate of iron, and the other remedies, which, formerly,
were chiefly trusted to, for the cure of convulsions. But of
all these, none, I think, equals the copper pill : or a prescnp-
tion may be given for a smaller dose of the cuprum ammon.
If the patient be not very young, a pill should be given twice
a-day, if the bowels bear it. Sulphate of zinc, is also a very
useful medicine. The food should be light and nourishing,
and due exercise taken in the open air. If other means &1I,
the scalp and spine should be rubbed with tartar emetic
ointment, which has been found useful, or blisters should be
applied.

There is a variety of chorea, in which the patient, generally
a female, has paroxysms of starting, and convulsive contrac-
tion of the muscles, particularly after eating, sometimes ac-
companied with pain in the region of the stomach. When
this state has continued for some time, she is seized, more
acutely, with an attack of severe general spasms, in which the
whole bodv feels as if it were cramped. The face is flushed,
the pulse nrequent, and much weight is felt in the head, but
th^ patient does not become insensible. It participates, in its

789

nature, with an obstinate spasmodic disease, considered in
Chap. VI., and may attack those who have recovered, for
some time, from that. The acute paroxysm, which may be
mistaken for a common hysterical fit, demands the instant use
of the lancet, and the application of a blister to the neck ;
afterwards, the usual treatment of chorea, is to be strictly
adopted. A gentle mercurial course is sometimes of service,
and the assistance of varied tonics is not to be neglected.
Fcetids are also occasionally serviceable.

When chorea occurs in a child, of a family prone to hydro-
cephalus, we ought, if it do not speedily yield to the usual
remedies, to establish a small issue on the scalp or neck, and
redouble our attention to the bowels.

Some children are apt to awake during the night, scream-
ing violently, or in great agitation, as if in dreadful terror.
Thb proceeds from a dream, but the imaginary scene con-
tinues after awaking ; the child, for example, insisting that
snakes are crawling along the curtains. This is cured by a
smart purgative, given every two days, for some time, and
avoiding much supper.

A weak, or even completely paralytic state, of one of the
superior or inferior extremities, may take place, in consequence
of a bad state of the bowels, in which case the stools are offen-
sive, and the belly tumid. This is cured by purgatives and
friction. But it may also proceed from some slight disease of
the briun, or medulla spinalis, though no mark of this can^e
discovered locallv, unless it be, that often the head is rather
larger than usual, but even then the eye is lively. Sometimes
one arm appears to be either powerless or weak, for many
days, and yet, otherwise, the child is in health. This, gene-
rally, yields to a purge and friction with oil of amber. In other
cases, one leg is long weak, and the child drags it slightly.
Whimsical practitioners have mistaken this for diseased hip-
joint, though the bone were precisely the same with that on
the other side. It goes off in course of time, and only re-
quires the cold bath and laxatives.

When paralysis occurs, as a prominent symptom in chorea,
or in the sequel of that disease, brisk purgatives are to be
employed, along with the hot bath, friction, small blisters to
the spine, nux vomica, electricity, &c.

The violent and involuntary jumping, tossing, or dancing,
described by some authors, are to be referred to the same
cause as chorea. It is not easy to point out a cure, but the

790

disease sometimes ceases suddenly, nithoat any very erident
reasoD.*

CHAP, XI.
Of Croup.

Croup, is divided, by some writers, into two species, the
inflammatory and spasmodic or rather paralytic ; but there is
perhaps no case oi croup, in which muscular action is Bot
concerned, only, in some cases, the inflammatory symptoms,
are more prominent, than in others. Croup begins with
shivering, and other symptoms of fever, which, when the child
is old enough, can be very well described by him ; but in
infancy, we discover them by thirst, restlessness, starting, hot
skin, and a tendency to vomit. Along with iiiese symptoms,
but sometimes even for a day or two proceeding them, the
child has a dry hoarse cough. Often, however, the attack is
very sudden, the previous indisposition being short and scarcely
observable. The local disease manifests itself, by a difficult
of breathing, attended with a wheezing noise; the voice is shrill,
the cough is of a very particular sound, somewhat resembling
the barking of a little dog, others describe it as resembling
a cough, sounding through a trumpet. The barking hoarse
cough, however, is of much less importance, than the symptom
of difficulty in breathing. It is not uncommon, for vomiting
to attend this cough, in the early stage. The pulse from the
first is frequent, the patient is restless and anxious, and the
face flushed, the eyes often watery and inflamed, and the mouth
frequently filled with viscid sabva or phlegm. Very soon,
especially in those cases where the face is much flushed, a
great degree of drowsiness comes on, from which the child
is frequently aroused by the cough, and fits of suffocation,
and great agitation ; for this disease has exacerbations, during
which, the heavy sonorous breathing, is exchanged for a violent
struggle, in which the child makes a crowing noise, and, if old
enough, starts up, and clings instantly to the nearest object,
and stares most piteously. If the disease be more mild, the

* A cane which occurred in this city is described by Dr. Watt, Med. Chir.
Trans. Vul. il., and another by Mr. Wood. Ibid. y\\, SS7.

791

fiBu^e, in this remission is sometimes pale, otherwise it is flushed,
and before death it assumes a blue and purple colour, whilst
the lips become livid ; in the early stage they may be rather
pale. If it do not prove suddenly fatal, the face and lips
become tumid in the progress of the disease. Convulsions
sometimes succeed the cough, and, in most cases, more or less
coma takes place, one cause of which is, that the blood cir-
culating in the brain, is not properly arterialised.

The duration of the complaint is various ; in some cases^ it
proves fatal in a few hours, in others, not for a week, but most
nrequently within two days. Much depends, in this respect,
on the degree of inflammation, the violence of the spasm, and
the strength and constitution of the child. Sometimes there
is much more of spasm, than imflammation, in the disease, in
which case, we have less fever, less parmanent dyspnoea, and
less frequent cough, but the attacks of suffocation are not
milder. Much also depends on the degree of cerebral affeo-
tion, which is quite sufficient, of itself, to produce fever, and, as
I shall immediately observe, excite inflammation of the larynx.
Those cases end best, where the breathing is least sonorous,
the fever most moderate, the cough early attended with
expectoration, and the symptoms seem, at times, to become
so slight as to constitute intermission, and where there is
no mark of cerebral disease, which is more intimately con-
nected, with the spasmodic respiration, than many imagine.

Dissection has always discovered, on the inside of the
larynx, an exudation, or layer of fibrinous substance, which is
sometimes coughed up in considerable portions. This, though
it add greatly to the danger and distress of the patient, is not
to be considered as the cause of the disease, for it is merely
an effect of inflammation, which, togetiier with spasm, could
produce all the svmptoms without its aid. This is evident from
observing, that the exudation is often only partial, and, some*
times, it consists only of a very thin layer of soft muco-purulent
looking substance, whilst we, always, find the membrane red
and inflamed, or altered in its structure. Often, the principal
seat of the disease, is about the epiglottis, vestibule, and very
top of the larynx, and the chief obstruction, seems to be from
swelling of the membrane at the glottis. This also, with the
parts for some way down, is covered with effusion. If the
disease do not prove very rapidly fatal, the lungs are found
to be inflamed, although there were no pain felt in the chest.*

* A pretty- good epitome of the symptomy, causes, and treatment of this diaeaw.

792

The BtethoBcope has been propoBed, to ascertain the esistenoe
of this state oi the lungs.

The most frequent cause of the immediate production of
inflammatory croup, is the application of cold and damp.
But it is very often a speedy sequel to what is called the
spasmodic form, which arises from different causes. Infants
under six months are not often affected with croup, and I have
never known a child soon after birth seized with it. Childrea
are peculiarly liable to it soon after being weaned. The
largest proportion of cases occur under a year old; and
although peculiar circumstances may, in particular families,
or months, alter the case, yet, in general, males are more
liable to it than females. So far as the registers of this city
can be depended on, for the proportion of fatal disease, it
appears that out of 233 deaths, there were 84 under one year,
78 one, but under two years of age, 51 between four and five,
and 20 between fire and ten. Although we should expect
croup to be most frequent in winter, yet, in one table, the
number of deaths was, next to January, greatest in June.

From the nature of the disease, blood-letting, evidently, is
the appropriate remedy, and ample experience has convinced
me, that it is the only one on which, in such cases, depen-
dence can be placed. There are two facts, however, which
I wish earnestly to impress on the reader. The one is,
that this remedy icT onlv useful, in the very commencement
of the disease; for if it be neglected untd the symptoms
become severe, and, more especially, till they have lasted
for many hours, it only increases the suffocation, and hastens
death. The other is, that the blood ought to be taken,
at once from the arm, by a lancet, and not by leeches. I
am not prepared to affirm, that leeches applied to the throat
itself, are of no avail ; and, therefore, when a vein cannot
be opened, this is the practice to be adopted. But I
am quite at liberty to pronounce, that leeches applied to a
distant part, as for instance to the foot, are worse than
useless; and the practitioner who advises or acquiesces in this
application, is guilty of a great crime. In a disease so formic
dable as croup, it is not to be expected that anv remedy
shall be uniformly successful; an<^ therefore, 1 am not
surprised, that venesection may have fallen into discredit;
but I would wish to learn from the practical physician, what

up till th« yew 1806, will be found in tlie tract of Schwilf u^. Sec aIm obacrr*.
tiona by I^bntein, in iMem. de la Soc. Med. d'fimul. Tom. Tiii. p. dOO.

793

remedy has proved more beneficial, or better deserving of
confidence.

Emetics have been greatly recommended by some, whilst
others, have little faith in their utility. I have sometimes
observed great benefit from them, if employed very early ; and
would advise them to be given in every instance. Even in
the advanced stage of the disease, emetics sometimes do ser-
vice, appearing mechanically to remove some of the exudation,
but this is very rare^ and their principal utility, is from their
action on the eighth pair of nerves ; and, therefore, they are
chiefly beneficial, in the early stage of what is called spasmodic
croup. Decoction of seneka, and preparations of squills,
have been used to assist the expectoration of the membrane,
but they do not equal emetics for this purpose.

Antispasmodics have been trusted to, almost exclusively,
by many ; but I apprehend that their exhibition ought to be
confined to a difierent disease, which I shall immediately
notice.

Blisters applied to the throat, though rarely useful, yet,
should not be absolutely rejected. They add prodigiously to
the irritation, and, if they fail to do good, they do positive
harm, by exhausting the child. If the other means, particu-
larly bleeding, do not five immediate relief, a blister should
either be instantly applied, or not at all, and it never should
be allowed to remain on, above four or five hours. It can do
nothing but harm in the end of the disease, and even, in the
beginnm^, I look on it with suspicion. Dr. Lehman advises
the apphcation of a sponge, wrung out of hot water, to the
throat, on the first appearance of croup. The warm bath is
of service in slight cases. The afiusion of cold water on the
body, has been advised by a Russian practitioner. I tried it
without doing evident harm ; it certainly did no good.

Calomel, would appear, in some instances, to be a powerful
remedy in this disease. I do not, however, recommend it, to
the exclusion of other remedies, with which it is by no means
incompatible, and to which, in general, it is onlv subsidiary.
It is most likely to do good, when given early, in that very
frequent species of croup, which appears to owe its immediate
origin, to the state of tne eighth pair of nerves, and which I
shdl immediately notice as spasmodic croup. The early
detraction of blood, followed by an emetic, and the subsequent
use of calomel, will afford the greatest hope of removing the
disease. But I think it my duty to state, that in some cases,
no alleviation was obtained by any remedy but the calomel ;

794

and in others, it was trnsted to alone, and with suooess. To
an infant of six months, a grain and a half of calomel may be
given every hoar, nntil it pnrge fireely ; to a child a year old,
two grains ; and to one of two years, sometimes even four
grains, are given every hour, until the bowels are acted on,
and the child purges freely, or vomits repeatedly. The stools
are generally green in colour, and their discharge is usually
accompanied with an alleviation of the symptoms. When
this is observed, the dose must be repeated less frequently,
perhaps, only once in two hours, for some time, then, still
seldomer, and finally abandoned. Should the chUd be greatlv
weakened, either by the disease or the medicine, the strength
must be, afterwards, carefully supported, by nourishment and
cordials. It is astonishing how great a quantity of calomel is
sometimes taken in a short time, without affecting the bowels,
or purging violently afterwards. Occasionally above 100, and
often 50 or 60 grains have been given in this disease. But it
is seldom, if ever, pushed now to this extent. Salivation is not
produced in children.

That experienced practitioner. Dr. James Hamilton, jun.,
to whom we are chiefly indebted, for the introduction of the
use of calomel, in croup, into this country, from the practice
of Dr. Rush, is extremely unwilling to bleed children, freely,
in their diseases, from its subsequent debilitating effects ; and
in croup, begins at once with the calomel, after having used
the warm bath. He observes, that ^* in every case where it
was employed, previous to the occurrence of lividness of the
lids, and other mortal symptoms, (amounting now to above
forty,) it has completely succeeded, both in curing the disease,
and in preventing any shock to the child's constitution." He
adds, that he has now seen two cases, where, although the
croup was cured, the patient sunk from weakness; and
therefore, very properly, gives a caution to stop the calomel,
whenever the symptoms begin to yield. The alleviation, in
true croup, follows the discharge of dark green stools, like
boiled spinage ; in spasmodic croup, it takes place whenever
vomiting has occurred. When much debility is produced,
he, besides using cordials, applies a blister to the breast. I
have a good opinion of the efficacy of calomel, but I cannot
speak, by any means, so strongly as Dr. Hamilton ; for even
when it was early, pointedly, and exclusively employed, and
brought away green stools, it frequently failed, and I most
earnestly caution the reader, against trusting to it, exclusively:
at the same time, I must add, that in one or two cases, I have

795

known it procure recovery, under very desperate circumstances,
even without evacuation by stool; and when, after a great
quantity of calomel was given, and relief obtained, it was
necessary to open the bowels by clysters. In those who are
old enough to express their feelings, we generally find, that
relief is not obtained, till the medicine gripe, as well as
purge. Whether it act by positively diminishing inflamma-
tion, or principally, if not entirely, by relieving that part of
the disease, which is muscular or spasmodic, is not determined;
but I am inclined to the latter opinion, as it is not of much
efficacy in the laryngitis of adults. 1 expect most benefit
from it, as I have already stated, in the early stage of croup,
which is dependent on the condition of the base of the brain,
whether induced directly, or through the medium of the
bowels. Calomel has been combined with ipecacuanha, to
produce vomiting, but I cannot satisfy myself that I have
ever seen this combination do more good, than ipecacuanha
would have done singly.

In cases, otherwise hopeless, it has been proposed to per-
form the operation of bronchotomy, and it is, in certain cir-
cumstances, justifiable, on every principle, both of science and
prudence. Assuredly, we would not wish rashly, or too early,
to have recourse to this operation, but if relief be not early
obtained, by the vigorous means I have advised, and more
especially, if these have not been employed, and the disease
have run on, with little effectual check, we are too well war-
ranted in saying, that death must be the result. If this state
of danger, arise from the mere existence of inflammation of a
sensible or vital part, acting by sympathy on the system, as
that of the lungs or stomach would do, then, an operation,
as it cannot remove that, should do no ffood, and it must be
worse than folly to propose it. But ii it proceed, not so
much from this source, as from the effect produced on respir-
ation, and the organs concerned in that function, some hope
may be entertained, that if we can obviate this immediate,
and urgent, effect of the disease, time may be allowed for the
subsidence of the complaint. I acknowledge the great diffi-
culty of deciding, as to the precise degree of danger, to be
ascribed, in any one case, to either or these sources. But if
the disease be very early severe, and the symptoms rapidly
and steadily increasing, in spite of the remedies used, and, at
the same time, the child be not already so ill, as to extinguish
hope, and be free from appearance of cephalic and pulmonic
disease, the operation, as the only, and last resource, may.

796

though with little hope of success, be performed. It should
not, when it is to be resorted to, be delayed long, for the risk
is increased, by the tendency which exists, to the induction of
inflammation, or disease, of the lungs ; and, independently of
this, by the debility, produced by the continuance of the dis-
ease. It has also been objected to the operation, that there
may be extensive coating of fibrin, like membrane ; but we
have no symptom which can, in any sure way, inform us on
tills point. Many fatal cases exhibit, after death, only a thin
coating of soft secretion from an inflamed surface, with a
swelling of the membrane at the riottis. I would, howeyerf
dissuade most decidedly from making the trial on an infant,
who cannot be expected to bear the violence, both of the dis-
ease and the operation. I think the chance of success, ceteris
paribus, is greater after three years than sooner. Parents
naturally recoil from an operation, and practitioners too often
shrink from responsibility. Let such timid people, brinjs^
forward the opinion of Dr. Baillie, and the conduct of emi-
nent men in our profession, as a shelter from reproof, if they
fail ; and above ail, let them solace themselves with the grati-
fying reflection, that if they have not succeeded, where there
was enouffh of hope, to warrant a trial, they, at least, have
done all that skill could suggest, or art accomplish. One of
the earliest, successful cases of tracheotomy, in this disease,
is that of the boy, five years of age, operated on by Mr,
Andree.* Another boy, two years older, was operated on by
Mr. Chevalier, on the afternoon of the third day, when vene-
section, and other means had been tried in vain. His breath-
ing was difficult, his pulse 160, countenance livid, he was
covered with cold sweat, and although still sensible, was evi-
dentiy sinking. On dividing two rings of the trachea, one
ounce and a half of frothy-coloured mucus was discharged.
Next day, his pulse fell to 144, and in the same evening the
breathing became easy. The third day he coughed up some
tough mucus, and soon recovered.t In this case surely the
operation was too long delayed, if it were at all in contem-
plation. Far, indeed, be it from me to make thb remark,
with a view to blame the operator, who, so fortunately, per-
formed it, with Uttie encouragement before him. But 1 make
it, with the hope, of others profiting by the case, and being
excited, to a still earlier operation, where circumstances indi-
cate, that there is no other alternative, than that of death. I

• Med. Chir. Tntn. Vol. Hi. p. aSo. f Ibiil. Vol. W. p. 115.

797

firanUy say, I could not have expected any good, to result
from an operation, so long delayed, and under so desperate
symptoms*

Spasmodic, is often, but not necessarily, connected with
inflammatory croup. There is, perhaps, no case of the latter
disease, unattended with affection of the muscles of the larynx,
but there are many cases of this affection without inflammap-
tion ; yet if it continue long, there is a great risk of inflam-
mation taking place, and of a membrane being formed. The
spasmodic croup, attacks children, chiefly, but it may also
affect women, especially about the age of puberty, and harass
them, occasionally, for many years afterwards. It makes its
attack very suddenly, generally at night, and sometimes for
many nights in succession, especially if the child be agitated,
or the mind of the young woman anxious respecting it.
The patient breathes with difficulty, and with a wheezing
sound, has a hard barking cough, with paroxysms of suffoca-
tion, as in inflammatory croup. The extremities become

* At birth, the timeheft !• aboat ooftpfoorth of an Inch broad. It ia almoat en-
tirely covered with glands ; for the lateral lobca of the thjrroid descend, and the
upper extremities of the thymus gland ascend, so as to meet. At this period, the
distance from the croes lobe of the thjrroid gland, to the sternum, is three-fourths,
but in that space* we can only expose the trachea, by going down, in front, between
the prolongation of the thymus and thyroid glands. The crico-thyroid membran-
one space, is one-fourth across, and one-eighth perpendicular. The rlma glottidb
Is three-sixteenths long. From the back of the epiglottis, to the end of the chink
between the arytenoid cartilages, is three-eighths. The diameter of the trachea
one-fourth. The measnrementa do not rapidly change. At three years of age,
the length of the slit, between the arytenoid cartilage is still three-eighths ; that
of the rima glottidis three-sixteenths. The diameter of the trachea, externally,
is seren-sixteenths ; intemaUy, one-fonrth. The crico-thyroid space measursa,
transTsrsely, one-half; perpendicularly, three-^ixteenths. From the lower part
of the thyroid gland, in front, to the sternum, one and a half. The thymus
mounts, ftve-eigbths, aboTC the sternum. From the lower part of the cricoid
cartilage, to the sternum, full ssTen-eighths.

At seren years, the breadth of the trachea Is ooe-half ; the crico-thyroid space*
transrerseW, three-eighths ; perpendicularly, three-sixteenths. Lsngth of the
rima, one-rourth ; from the base of the epiglottia, to the back of the chink between
the arytenoid cartilages, three-eighths, llie distance from tlie notch, in'.the thy*
roid cartilage, to the lower margin. Is three-eighths.

In the adult, the length of the rlma Tarlea, m»m llTe-eighths to ssTenth-eightha.
The internal diameter of the trachea, laterally, from llTe-elgbths to thrse-fourthe.
The distance of the cross slip of the thyroid gland, from the sternum, Tarlea cx-
cecdiiwly, from fiTO-elghths to two inches.

In forming an estimate of the eomparatiTe merits* of lairngolomy and tracha
otomy, I would say that the former is oertalnlv more easily performed, and the
aperture more rcMlily kept open. The sixe of the crlco-thyroid membrane, we
have seen, is such as to afford, if properly divided, an opening fully as large as the
rlma glottidis. The only objection is, that we may be more likely to come on a
diseased, or thickened part of the membrane, than if we opened the trachea lower.
After three years of age, tracheotomy ie more eadly perlormed than earlier, but,
on the whole, I am more partial to laryngotomy. if we chooee the former, we
must, after separating the muscles, explore the situation of the fflanda, and also of
the arteries, for sometimes the carotid creeeee the trachea, where the Incision
should be made. The Innomlnata may also rise high.

798

cold, the pulse during the struggle, is frequent, but in the
remission it is lower; and if the remission be great, it b^
comes natural, unless kept up by agitation* There is little
or no viscid phlegm in the mouth, some drowsiness, but more
terror, and tne eye stares wildly during the paroxysm. The
disease is often suddenly, for a time, relieved by sneezing,
vomiting, or eructation. It diiOPers, then, from the inflamma-
tory croup, in the suddenness of its attack, in there being at
first little fever, but only quickness of pulse, greatly abating
when the child does not struggle for breath, less drowsiness,
and little phlegm about the mouth. The cough is less shrill,
and the fit often goes off suddenly and completely, either spon-
taneously, or by the use of the remedies acting quickly. Some-
times, however, even in adults, inflammation takes place, and
in infants, this disease, if neglected, is almost invariably con-
verted into true croup.

It is, at times, brought on by exposure to cold, and in that
case, it is occasionally preceded by slight sore throat, or
hoarse cough ; but oftener the spasm comes on without any
precursory symptoms, and seems to arise, sometimes, from
direct affections of the brain, at the origin of the eighth pair
of nerves, but much more frequently, indirectly, from the state
of the fifth pair of nerves in dentition, or from irritation or
injury dependent on abdominal disorder. The recurrent of
the eighth pair, seems to be often chiefly affected ; and when
we call the disease spasmodic,* we probably are wrong ; its
nature being, in most instances a temporary paralytic state of
that nerve, or, at least, a condition unfitting it for its func-
tion, and the modus operandi of emetics, may be to excite the
nerve. Bleeding, on the other hand, relieves the cerebral
affection, or state of the origin of the nerves. I have, in a
former chapter, noticed this symptom, in a particular and
very obstinate affection, dependent on abdominal disorder;
and am inclined to think, that a great majority of cases of

' • I retain the name of spasmodio croup, both beeauae it ii fcnerallv reeelved.
And as it is proliable that spasm* may, in certain oases, be the cause. There, how-
ever, is often a mistalce made, by considering the contraction of one set of muscle^
produced by torpor or paralysis of the antagonists, as spasm ; and it is this kind
of contraction which orten takes place in croup, and pniduoes doubtless tha sama
feeling and effects as spasm. Inaction of both seU of muscles about the glottis
would have the same effect. When l>oth the recurrents are cut, the rima i lusii^
and the animal dies, in my lectures 1 have lone Illustrated this disease by tha
effect of dividing the piieumogastric nerves, or their recurrent branches, in tha
rabbit ; at the same time I am not prepared to disprove that In certain cases tka
nerve supplying the constrictors may be irritated, and these muscles andalj
contracts ; but these 1 hold to be rare. From what I have stated in tha eeaa-
menosment of Chap. V., It Is easy to nnderstand how tha same part may be partly
weakened or paralysed, and partly Irritated*

799

croup, in infants, are of this description at first, and that in*
flammation is only an efiect. If we divide the recurrent of a
rabbit, croup is produced, and after death, we find the larjrnx
and trachea inflamed, and smeared over with fibrinous exuda*
tion. The drowsiness which often attends this complaint, is
owing to that affection of the base of the brain, which fre-
quently exists, and which might prove fatal independently
either of laryngeal paralysis or of the inflammation, often by
the secretion of serum** Sometimes this disease is excited,
if the patient be older, by passions of the mind. Not unft*e-
quentlv a renewal of the paroxysm is excited, in those who
are subject to it, by eating a full meal in the evening.

With regard to the treatment, I shall briefly state the result
of my observation. In young girls, venesection has uniformly
given relief, the spasm suddenly abating, and very soon going
entirely off, after a certain quantity of blood has flowed. To-
pical blood-letting has not the same effect, and indeed is nearly
useless. But if the paroxysm should be repeated for many
nights, venesection cannot be employed on every attack, as
it debilitates and predisposes to the disease. Emetics, such
as sulphate of zinc, or ipecacuanha, have the effect of abating,
and, occasionally, of removing the paroxysm, but not of stop-
ping it so soon, and so suddenly, and entirely, as blood-letting.
They debilitate less, however, and may be oftener repeated.
In this species, and in the commencement of inflammatory
croup, they act probably through the eighth pair of nerves,
or the recurrent, which is much affected ; but sometimes the
fit, though impeded during their operation, returns, and in
such cases has yielded to venesection. When the emetic has
been very long of operating, the stomach not being easily act-
ed on, blood-letting has produced speedy vomiting and imme-
diate relief. Opiates, and antispasmodics, such as ether,
given in large doses, have, if exhibited in the very commence-
ment of the attack, occasionally checked it, but have not
always that effect, and, if not given soon, are longer of pro-
curing relief. A full dose of prussic acid, determined by the
age of the patient, has sometimes had the effect of checking
the fit, by inducing a species of carus, without which it does

• I baye great pleasure In referring to a raloable dinection, published hj Dr.
' Monro, In bis work on the Morbid Anatomy of the Brain, Vol. I. p. 76. All the

nerves at their origins were sound, except the fifth aud eighth, which were of a
deep snarlet colour, and there was water in the spinal canal. The whole cord
was affected. The cerrical portion was of a yermUion colour, the lumbar dark
red. The eighth pair of nerret was of a deep red colour, as far at ita braocbes to
the lungs.

800

no good. If there be much spinal excitement, I have already
noticed that it may induce tetanic spasm. Calomel, in croup
affecting girls and women, is out of the question ; for the par-
oxysm is so severe, that we cannot, and must not, trust alone
to its operation.

A relapse is to be prevented, by giving purgatives, and
avoiding exposure to cold damp air, and in imancy, great
attention must be paid to the state of the head. When there
is any suspicious symptom, a small blister should be applied
to the back of the nead, and a part of it kept open, for some
time. When the paroxysms return every night, in older
children, there is strong ground to suspect that the bowels
are in fault. Aloes, combined with a little calomel, or with
the mass of the blue pill, ought to be given, so as to operate
freely and effectually, and we are not to relinquish this plan,
because it does not immediately cure the disease. In young
girls, a course of tonic medicines alone, or combined with
assafcetida, or valerian, will be useful ; and, when the attacks
have been kept off for some time, sear-bathing will be proper.

With infants, we generally succeed, by giving instanUy an
emetic, and afterwards calomel in considerable doses, so as to
produce sickness and vomiting, or free purging. But if the
emetic do not decidedly and immediately mitigate the disease,
then, in place of trustmg solely to the calomel, we premise
venesection. I have already expressed my opinion, that calcK
mel is more likely to be useful, in this case, than when there
is much inflammation. Assafoetida* has been strongly recom-
mended in this disease, and has sometimes a very good effect.
Sulphate of copper has been extolled ; but when a cure was
accomplished, it was either given so as to produce vomiting ^
or was preceded by the use of leeches. The warm bath la
always proper. If the child be about the period of dentition,
the gum should be examined, and cut if tumid. If the disease
do not soon yield to these remedies, there is ground to sup-
pose, that it will be converted into the other species of croup ;
but this affects the prognosb rather than the treatment.

Some children are subject to slight wheezing, continuing
for a day or two, with intermissions, and accompanied with

* Dr MiUar hu given an ounce of thii gnm, to a ehUd of etg bten montlw
old, in foitv-eifht hoara, and almoet as mueli at the eame time In form of
elytter. Hit formnla ia aa follows:—^ G. aHafcetida, < ij. ; Spt. MindenrE,
21.; Ap. piilcf. I ilj. M. ■. a. A table-tpoonful of tmt ia to be given ercrv
Baif bour. Vide Obaenrationa on Aatbma, p. 4S. Tbto medicine ia aieo prepared
aa a noatram» nnder tbe name of Dalby'a Carminative, widcb baa been naed for
children.

801

a hoarse coiigU, but without fever. Emetics, laxatives, and a'
large Burgundy pitch plaster, applied to the back, remove the
disease.

Infants, during dentition, are subject to sudden attacks of
spasm about the windpipe, producing a temporary feeling of
suffocation, with a crowing sound, but there is no hoarse cough.
It is apt to take place suddenly at night, or when crying. It
is relieved, by giving a combination of tincture of assafoetida,
and of hyoscyamus, and using laxatives. The tepid bath is
also useful. The gum should be cut, and, if there be any
tendency to return, particularly, if the child be hot and the
pulse quick, the eye heavy, and the face unusually pale or
flushed, leeches should be applied, and then a blister to the
back of the head.

I have, in the seventh chapter, noticed the spasmodic
breathing, which is complicated with convulsions. This
sudden, and perhaps transient, attack of spasmodic croup,
requires constant attention, as it is often the prelude, to incur-
able disease in the brain or spinal cord, and is more imme-
diately alarming, if complicated with, or succeeded by, general
convulsions, ft is too often connected with an inflammatory,
or highly disordered, state of the origin of the neiYes, doming
off at the base of the skull, and this points out the imperative
demand for prompt treatment. Immediate detraction of blood,
by the lancet or leeches, is essential, then, a purgative, and
next, an issue should be kept open, for some time, on the under
and back part of the heaid. The diet and bowels must be
regulated.

Dr. Ley describes, with some modification, this under the
name of Laryngismus Stridulus, and ascribes it to enlarged
cervical or thoracic glands pressing on the nerve. He treats the
case, by attention to the general health, the use of iodine, &c.r
This view may in some cases be correct, but not so frequently
as is supposed. That intelligent physician, Dr. Marsh, besideq
attending to the gums, bowels, &c., prescribes quinine, and ^
removal to the country.

Some children, very nearly from the time of their birth,
have a constant wheezmg, or sonorous breathing, subject to
exacerbation. This does not indicate the existence of an
organic affection, for I have known it removed by change of
air. An enlarged thymus gland may not only cause dyspnoea^
but sudden and often fatal fits, called thymic asthma. This
has been described by Drs. Hood and ftlontgomery, and also

802

by Kopp and Hirsch. Leeches, blisters, and iodine, are tbe
remedies.

Besides these affections, ending acutely, there are othera
which produce more slow effects. The parts about the larynx
inflame, and this may doubtless cause speedy death, by suffo-
cation ; but in oth^ instances, necrosis of the cartilages, or
abscess, or ulceration, takes place, and the patient is Uirown
into the disease called laiyngeal phthisis. This is to be pre-
Tented, in the outset, by vigorous antiphlogistic treatment; but
when it takes place, if issues do not giye relief, we have only
to consider the probable effects of laryngotomv.

The osdeme de la glotte, described by the late M. Bayle,*
is merely laryngitis, attended with serous effu^on.

CHAP. X.

€f Hooping-Omgh.

Thb hoopmg-cough, often, begins like a common cold, the
child coughing frequently, and having more or less fever. In
some cases, the fever is slight, going off in the course of a
week, in others, very severe and long continued, attended
with great oppression, or sickness, and want of appetite. I
believe, that this fever, may sometimes, be strictly, and essen-
tially connected, with the specific disease of hooping-cough^
but the most alarming degrees of it, are, I suspect, connected
with, and greatly dependent on, an inflammatory state of the
lungs. The cough generally comes on very abruptly, and is
sometimes early attended with that sonorous, spasmodic inspi*
ration, denominated hooping ; in other cases, not for a con-
siderable time ; and this is considered as a favourable circum-
stance, but it is not always so, for, in younff children, death
may take place, although the disease never nilly form. The
fits are generally most frequent, and most severe, during the
night. When the cough becomes formed, the paroxysm con-

* J^oni. General, AttH, 1S19.
f ThiB disease is supposed to baye been first distinguished in Franoet 1414. and
reoeiyed the name or ooqueluche, from a oowl, to lieep the bead warm* bdac
thought useful. Sauyages, who calls it tussis oonvuJsiya sen feiina» says U eaaatja
in paroxysms called qulntas, from the old Frra«h word quinte, a great coaglu
Tbis may be corrupted into kinlcoougb.

803

ftists of a number of short expirations, closdy following each
other, so as to produce a feeling of suffocation, relieved at
last, for an instant, by a yiolent, full, and crowing inspiration ;
then, in general, the cough or spasmodic expirations recom-
mence, and the paroxysm, consisting of these two parts, con-
tinues until a quantity of phlegm be coughed up or vomited,
alone, or with the contents of the stomach, and this ends the
attack. The expirations sound like a conunon cough, but
are more rapid, and frequently repeated, as in violent laughing.
Sometimes the sound is lower, or the cough resembles the
chattering of a monkey, quickly repeated. These paroxisms
vary in frequency and duration. Sometimes they are slight ;
at other times, and especially during the night, they are at-
tended with a most painful sensation, and appearance of suf-
focation, the face becoming turgid and purple, the sweat
breaking, and blood gushing from the nose or other parts.
The extremities become cold, during the fit, and the whole
frame is much agitated. But even severe as the paroxysms
are, if the disease be not attended with fever, the patient seems
quite well after the fit, and begins to eat with a renewed ap-

Ctite. A fit of crying will, at times, even after the disease
ve been apparently removed, excite the cough. The features
often remain swelled for a considerable time.

Hooping-cough is very dangerous for infants, as they often
die suddenly in a fit of suffocation ; elder children escape more
safely, though, even they, are sometimes carried off, the fever
contmuing, or anasarca coming on, with exhaustion. Some-
times the lungs become diseased, and hectic fever takes place,
or peripneumony is produced, or the lungs become oedema-
tons, or some of the ceUs are ruptured, and emphysema takes
place. Convulsions may also occur, and carrv off the child.
These may either precede the fit of coughmff, and go on
along with it for a short time, and then leave Uie cough, in
full possession of the child, or the cough first begins, and,
almost immediately, the convulsions take place, and suspend
the cough, or the respiration is arrested, and death takes
place. When the face and extremities are swelled, the danger
18 greatest, and scrofulous children suffer most. There is an
intimate connexion, between this cough and the state of the
brain and medulla spinalis, and sometimes an ill formed hoop-
ing-cough, ends in an obstinate spasmodic cough, as already
noticed.

The danger arises from various sources. The fever may
exhaust the chUd, without much cough ; the inflammation of

804

the lungs, or secretion of phlegm, owing ioa brbndiitic state,"
may d^troy hfan, or pus may form, and hectic feTer be pro-
duced, or cephalic disease and conyul»ons may take place, or
the child may be suffocated.

Generally speaking, the main source of danger is firom in-
flammation of the lungs or bronchial tubes. The membrane
lining the latter, is found, after death, to be red, and the rami-
fications filled with mucus. The lungs are engorged and in«
filtrated. The brain seems to be affected only in a secondary
way. The vessels may be congested, or even effusion found,
but it also suffers from the blood being imperfectly arterialised,
and this does not necessarily produce any change visible on
dissection. Immediate death may be thus produced.

Many remedies hare been employed in this disease, which
it will be proper to divide, into those intended to abate the
fever, and those given to relieve the cough. Venesection has,
for the first of these purposes, been recommended ; but it is
very rarely requisite, and only when the patient is plethoric,
and we apprehend that some vessel may burst in the lungs,
from the violence of the cough, or when there are symptoms
of inflammation. Leeches may, in these circumstances, be
applied to the chest, but this practice falls rather to be con-
sidered, as a mean of removing a partial complication. The
most generally useful remedies, are laxatives and the saline
julap, which, often, in a few days, moderate the fever greatly^
The tepid bath is useful, and, if there be much irritation and
restlessness, hyoscyamus sometimes does good. The diet
ought to be mild.

For the relief of the cough, nothing is so beneficial as gentle
emetics. These, have been given in nauseating doses so as to
make vomiting be readily excited, by the cough ; but, in
general, a full dose of ipecacuanha, will be as effectual, and
18 less distressing. At first, the emetic should be frequently
repeated, especially to infants, perhaps once a^lay, or once in
two days, according to circumstances ; and this degree of fire-
quency is by no means injurious. Antimony has been highly
praised by many, but it is more apt to weaken the stomach,
and, in very young children, it sometimes produces violent
effects. Stimulating substances, such as a combination of
soap, camphor, and oil of turpentine ; or juice of garlic, or oil
of amber, or of thyme, &c., rubbed over the spine, particularly
the cervical portion, so as to produce tenderness of the skin,
have a good effect. Opiated frictions, over the thorax, are
also proper ; and stimulating applications, to the soles of the

805

'feet, Have, certainly, in some cases, done much ffood. Anti-
.spasmodlcs, such as assafcBtida, ol. succini, music, &c., have
been recommended, and in some cases are successful. Opi-
ates are also of service. Dr. Willan says, that he found the
•watery infusion of opium, more useful than any other narco-
tic. When the disease is protracted, cicuta has been recom-
mended, but it does not seem to have any advantage, over
opium or hyoscyamus. It has also been applied externally.
Prussic acid given three times a-day in small doses, that is to
say, in such doses as do not produce strong or sensible effects,
has been praised, but, although I have seen it sometimes use-
ful, it cannot be relied on. Lactuca virosa, and belladonna,
have also been employed. The most effectual remedy, how-
ever, b change of air, which often has a marked effect on the
disease, in a few hours. When the patient becomes restless,
or feverish, and coughs more, it should again be changed.
The diet ought to be light.

If there be fixed pain in the chest, difficulty of breathing,
and fever, indicating inflammation, either venesection or
leeches, according to the age and circumstances of the child,
will be absolutely necessary ; but our evacuation must be pru-
dently conducted. Blisters, in such cases, are useful, but
once for all, I would observe that they are never to be used,
rashly, in infantile diseases, nor repeated, if they do not at
first do good, for, with the exception of those applied to the
scalp, they generally produce much irritation and subsequent
debility. They ought not to be allowed to remain nearly so
long, on a child, as on an adult, and may even be prepared,
with a smaller proportion of cantharides. Pain, produced
merely by the violence of the cough, remitting, or going, at
times, entirely off, and generally seated about the upper part
of the sternum, is relieved by those means which relieve the
cough. If fever be the prominent symptom, I would advise
saline julap alone, or with a little tincture of opium and of
ipecacuanha, laxatives, leeches, if there be pain, and, if the
weather permit, change of air.

When the paroxysms have been very severe, the breathing
oppressed, the cheeks livid, and the pulse very weak, some
children have been saved by the application of leeches to the
chest, blisters and small doses of the compound powder of ipe-
cacuanha, with diuretics.

When the patient is threatened with hectic, or becomes
emaciated and weak, nothing is of so much benefit as country
air, and milk diet, at the same time that we keep the bowels

806

open. Small blisters should be applied to the breast, if there
be fixed pain or dyspnoea. If there be anasarcous swdling,
digitalis, conjoined with squill and cordials, will be usefiJ,
but, digitalis never ought to be given, to the extent of pro-
ducing weakness, nor persisted in, if it do not act on the
kidneys.

Convulsions accompanying the fits are very alarming, and
may suddenly carry off the infant, especially if he be very
young. They depend, generally, on turgescence of the Tea-
sels in the head, and, therefore, unless the child be previously
much reduced, we ought, always, in the first instance, to ap-
ply leeches to the head, the number to depend on the age and
strength. Older, and more robust children, may require the
lancet. The bowels should be opened, and the head shaved,
and even a small blister applied to it, if the fits be repeated*
The tepid bath is also to be had recourse to, when the fits
come on. The air ought also to be, if possible, immediately
changed* In some cases, tincture of hyoscyamus given in a
mixture, or clysters containing camphor, seem to allay the
tendency to spasm ; and, in every instance, it is proper tomb
the back and belly with anodyne balsam.

If the cough return, after it had gone off for a time, a gen-
tle emetic is the best remedy. A sudden change of weather
from warm to cold, is very apt to renew the cough. If the
face or lips remain swelled, gentle laxatives are proper.

Inflammation of the lungs may occur, by very slignt caoses,
after hooping-cough, in consequence of the predisposition by it»

During the continuance of the disease, the diet must be
light, but nourishing, if the patient be weak ; but more spar-
ing at first, if he be, on the other hand, plethoric and inclin-
ed to inflammation. Toward the conclusion of the disease,
quinine, and tonics are useful, to re-establish the health.

There is a cough very like hooping-cough, and which gives
rise, sometimes, to the groundless fear, that the child is going
to take that disease; or, on the other hand, if somewhat pro-
longed, it may pass for hooping-cough, and afterwards the
child being exposed to infection, takes the disease, and is said
to have had it twice. This kind of cough, has less of the
suffocating appearance, than the hooping-cough ; the expira-
tions are fewer, and do not follow each other so quickly, and
the inspiration is not performed so rapidly, and with the dis-
tinct hooping sound. It sometimes succeeds measles, or
appears as a Idnd of influenza. It is cured by an emetic and
anodynes.

807

CHAP. XI.

OfCaiarrh^ BrcnchiHsj Inflammation of the Pleura^ andqfthe

Stomach and Intestines.

Infants are subject, as in after life, to catarrh, either com
mon or epidemic It is attended with fever and inquietude,
redness of the cheeks, watery discharge from the eyes and
nostrils, disposition to sleep, frequent and sometimes irregular
pulse, panting and shortness of breathing, with frequent couffh,
which, however, is not severe. It, generally, goes off, within
a week, by the use of ffentle purges, antimoniab, and, if the
fever be considerable, leeches applied to the breast ; i£ more
obstinate, a venr small blister should be applied to the sternum.
A hoarse barkmg cough, is cured by an emetic, and wearing
flannel round the throat.

Bronchitis, is far from being an uncommon disease of infants,
but it is seldom met with, m a severe degree, alone,' for the
lungs, soon, become affected. It sometimes takes place, very
early, after birth ; in other instances, not for several weeks.
It begins with fever, cough, and pretty copious secretion of
mucus or phlegm, which, however, the child will not allow to
come out of the mouth, but swaDows. The cough is frequent,
but not uniformly so, coming on in paroxysms. It has a
jBtifled sound, and is somewhat hoarse, or occasionally even
shrill, from slight inflammation at the top of the windpipe,
and at first it is dry. The breathing is oppressed, hurried,
or rattling, but not permanently so. Vomiting is also not
an uncommon attendant, the epigastrium often is distended,
the stools are generally bad, the face is pale, and the child
sick and oppressed. He takes the breast, but dislikes all
meat.

Presently, if death be not produced by the accumulation of
phlegm, the secretion becomes more of a purulent appearance.
The respiration is more oppressed, and tne noisy breathing is
more frequent. There is a degree of stupor. The hands,
but especially the feet, swell a little, whilst the body becomes
emaciated. The cheeks, are occasionally flushed in the evening,
and the pulse, which was always frequent, becomes still more
so, and irr^^ular. The fits of coughing are severe, and
attended with appearance of suffocation, and at last the child
dies. On opemng the body, we find the ramifications of the
trachea, filled with purulent-looking matter, and, in soma

parts, tbere is an approach toward the formation of tubercles.
The lungs are sometimes paler, than usual, but, generally,
darker, and more solid.

This is a very obstinate disease, but it does not prove very
rapidly fatal: seldom sooner than in a week, or ten days,
sometimes, not for several weeks* Milder cases, terminate
favourably within a week. In the commencement, it resembles
common catarrh, and requires the same treatment. A gentle
emetic of ipecacuanha should be given, followed by a purffative,
and if these do not give decided relief, a very small blister
should be immediately applied, for a few hours, till it redden
the skin, which generally rises after the blister is removed.
Venesection, or even leeches, are only to be resorted to, io
severe cases, at an early stage, and in children who are robust,
and rather beyond infancy. In the advanced stage, and under
various circumstances, I have tried emetics, blisters, calomel,
and expectorants, but without decided benefit. The ose of
calomel, combined with ipecacuanha, to act both on the bowels,
«nd also as an expectorant, together with the occasional
application of a very small blister, and a removal to the
country, i^pear to constitute the best practice. I think it
right to mention, that though the pectoral disease may be
flight, yet, by the sickening effect of a purgative, especial^
castor oil, great panting, paleness, and other appearances of
danger, have been produced, which have all gone off, after
having the bowels opened, freely, by a clyster, which bronglit
off the purgative.

Inflammation of the pleura, is more frequent with children
than many suppose, and like the former disease, soon affects
the substance of the lungs. The skin is very hot, the faoe
flushed, the pulse quick, the breathing short and oppressed;
there is a cough, aggravated by crving, bv motion, and by
laying the child down on bed. He is likewise more disposed,
to cough, and is more uneasy on the one nde, than on the
other. If not relieved soon, Uie breathing becomes laborious,
the extremities cold, the cou^h stifling, with rattling in the
throat and stupor : or, the pmse becomes irregular and uiter-
mittent, the extremities swell, the countenance is sallow or
dark-coloured, the breathing difScnlt, with short cough, and
frothy expectoration, which oozes from the mouth. On in-
specting the chest, the inflammation is, sometimes, found to
have terminated in hydrodiorax, oftener, in adhesions, not
unfrequently, in hepatization. This disease requires veneseo*
tion, or the early application of leches to the sternum.

809

according to the iage and constitution of the child ; the subse-
quent use of a blister, calomel purges, and the tepid bath.
Antimonials, given in a pleasant saline julap, are also some--
times of service, but never ought to be given, to such an extent,
as to produce decided sickness. In the last stage, diuretics
are proper, especially a combination of squill and digitalis,
whilst the strength is to be supported, by the breast-imlk, or
light diet.

This disease, sometimes terminates in abscess, and purulent
spitting, with hectic ; but much more frequently, the pulmo-
nary consumption, of infants and children, begins, as in adults,
more slowly, is marked by a short dry cough, flushings of the
face, frequent small pulse, difficult breathing, wasting, and
nocturnal sweats. The expectoration is generally swallowed,
but sometimes it is rejected, or it is vomited up, and is found
to be purulent. There is seldom any cure for this state ; all
that can be done is to send the child to the country, apply
small blisters to the breast, keep the bowels in a proper state,
give a mixture containing opium and diuretics, and support
the strength with suitable nourishment. If the expectoration
be only phlegm, then, although all the other symptoms be
present, there is considerable hope of saving the child. But
if it be purulent, and the parents be consumptive, the danger
is much greater. This state, however, does not in general
succeed pleurisy. It is generally induced, more slowly, by
tubercles, accompanied with enlargement of the bronchial
glands.*

Inflammation of the stomach, is not a common disease of
infancy, nor is it discovered, without considerable attention.
There is great fever, frequent vomiting, the mildest fluid
being rejected soon after it is swallowed, the throat is first
inflamed, and then covered with aphthse, which spread to the
mouth. The child cries much. The region of the stomach
is full, and very tender to the touch. The bowels are generally
loose. If the child be old enough to describe the sensations,
he complains of heat or burning, about the stomach and
throat; if younger, it is known by the incessant crying, fever,
thirst, with constant vomiting, and increase of crying on
pressing the abdomen. It is not necessary, to be too minute,

* Although it is not exactly connected with mj preeent eaUect, I mey mention
that aometimes the bronchial cells are much enlarged, the child has cough and
difficult breathing. The air escapes, and passes from the root of the lungs to the
mediastinum, insinuating itself betwixt its layers, and thence to the neck, where
it produces emphysema. Punctures ought immediately to be made^ if the external
swelling be inconveniently great.

810

in drawing the distinction^ between the inflamnuition of the
stomach, and enteritis, as they both require the same treat-
ment, and I have seen both prove fatsJ, in a few hours.
There is sometimes, from the firat, cough and short breathing,
but the constant vomiting, shows the disease to be in the
stomach. It is not easy to say what causes this, for it cannot
always be traced to acrid, or stimulating substances, swallowed.
It is proper immediately to bleed, or apply leeches to the pit
of the stomach, according to the age and strength of the child;
then, a blister is to be applied, and stools are to be procured
by clysters, and afterwards by mild laxatives. Fomentations
and the warm bath are also useful. M. Saillant recommends
the juice of lettuce, to be given in spoonfuls every hour, but
I do not know any advantage, this can have, over mucilage
and opiates.

There is another state of the stomach, which, from the
softness of the texture, is apt, after death, to be confounded
with gangrene. There are, however, no marks of inflamnui-
tion ; but the stomach seems, as if it had become so soft, by
maceration, that it gives way on being handled. This state,
is sometimes confined to one part of the stomach,* sometimes,
it extends, even, to the small intestines, and, more than one
child, in the same family, have died of this disease. It is not
easily discovered before death, for its most prominent symp-
toms, namely, purging, with griping pains, occur in other
diseases of the oowels. It is, however, very early attended,
with coldness of the face and extremities, and the counte-
nance is shrunk and anxious. It affects the intestines, oftener,
than the stomach. This state of the stomach, cannot always
be attributed to the effect of the gastric juice. When the
stomach is acted on, by this solvent, after death, we find, that
it is very soft, some of it, in a state of semi-solution, the inner
surface being dissolved, and some of it actually removed, so
as to make a hole. When the preparation is put into spirits,
and held between the eye and the Ught, the flocculent appear-
ance, of the inner surface is distinct, and numerous elooules
are seen within the peritoneal coat, which are probably the
glands undestroyed.

Peritoneal inflammation, or enteritis, is not an uncommon
complaint with children. It begins, with violent pain in the

* Dr. ArmstroDf mentions » eaae of this kind, where the npper pert of the
etomech was thus diseased, bat the pylorus sound. The stomaoh waa distMded
with food, but the intesUnee were Yery empty, which might be owing to dimiaiihfd
power of oontractlon in the stomach.

811

belly like colic, bat is more constant and continued, and is
accompanied with a considerable degree of fever, costireness,
and tenderness in the belly. If this disease do not proye
speedily fatal, and, if, on the other hand, it be not perfectly
removed, the child remains long ill, perhaps for some weeks»
and the nature of the complaint, may, for a length of time, be
mistaken. There is constant fever, but it is subject to exa-
cerbation in the evening. There is increasing emaciation,
and, at first,'occasional attacks of pain in the belly. The stools
are usually obstructed, and when they are procured, they are
slimy, bloody, ill-coloured, or scybalous, afterwards, there is,
frequently, a diarrhoea. On examining the belly, externally,
induration may sometimes be discovered. The appetite is
lost, the thirst is considerable, the pulse becomes more fre*
quent and feeble, the debility increases, and the extremities
become cold, and in this exhausted state, the child sometimes
lies for many hours before dissolution. On inspecting the
abdomen, the bowels are found adhering, or forming knots,
and sometimes the liver or omentum partakes of the disease.
A less severe degree of inflammation, is productive of general
secretion of purulent fluid, swelling the belly like ascites, and
attended with hectic fever.

In younger infants, the consequences of peritoneal inflam-
mation, when it does not prove rapidly fatal, or excite con-
vulsions, are abdominal pain or tenderness, obstinate slimy
purging, vomiting, and increasing emaciation.

In young infants, we cannot carry evacuation far. But
whenever, there is a prolonged attack of colic, we may appre-
hend a severe disease, and must use the warm bath, clysters
to open the bowels immediately, and then, an opiate clyster,
to allay morbid sensibility ; a rubefacient should be applied
to the belly, and if the symptoms be very urgent, this should
be preceded by the application of two or more leeches to the
abdomen. In elder children, the attack is often brought on,
by cold, or by eating indigestible substances, as for instance,
nuts. No time is to be lost in opening the bowels, by clysters
and laxatives, and, in detracting blood from a vein. Fomen-
tations, and blisters are useful ; but the latter are not to be
repeated. If these means be neglected, or do not succeed,
there is little hope, afterwards, of saving the patient, unless
the bowels adhere to the abdominal muscles, and an abscess
take place, which is indeed very rare. When abscess forms,
near the pelvis, or about the rectum, the child cries much, on
going to stool, seems afraid to pass the faeces, and may, at

the time, be seized with spasm or convulsions. The
are very offensive, and occasionally purulent matter is dis-
charged, and sometimes comes continually away, or constitutes
the whole, or the greatest part, of the stool. In such cases,
occurring in infancy, I have found magnesia useful as a
laxative, and hyoscyamus, with oil of anise, of great benefit as
an anodyne. Older children, may have castor oil, senna or
any other laxative, they prefer. If the appetite be not lost,
there is hope of a cure, and I have known cases, apparently
desperate, recover. Mild tonics with suitable nourishment
promote this.

Sometimes, this produces a contraction of the rectum ; or
a stricture may exist there naturally, and produce great pain
on going to stool. In either case, a cure is effected by cut-
ting the stricture, which is generally membranous and easily
divided. Tnis symptom, however, of exquisite pain on going
to stool, oftdner depends on fissure, and is effectually relieved
by dividing the sphincter. The pain is sometimes so great
as to produce convulsions at the time.

The accumulation of purulent matter, in the abdominal
cavity, preceded by mUd symptoms of inflammation, is gener-
ally cured by paracentesis, at least, every case I have seen of
this kind has recovered.

Inflammation of the mucous coat, if situated high, causes
purging of slimy and watery stuff, with griping. If in the
large intestines, the symptoms are those ot dysentery, the
treatment is that of dysentery.

Cystisis, also, may occur m infants, and is known by the
frequent and painful micturation, pain on pressing the pubis,
and fever. It requires leeches to the pubis, or venesection,
and the tepid bath, with laxatives.

CHAP. XII.

Cy Vomiting.

Vomiting, is very seldom an idiopathic disease of children*
Many puke their milk after sucidng freely, especially if
shaken or dandled. This is not to be counted a disease, for
all children vomit, more or less, under these circumstances.
A fit of frequent and repeated vomiting, soon after sucking
or drinking, if unattended with other symptoms, and the
^esta be of natural appearance, may be supposed to depend

813

on irritability of the stomach, which can be cured by applying
to the stomach, a cloth dipped in spirits, and slightly dusted
with pepper, or an anodyne plaster. Sometimes a spoonful
or two of white wine whey settles the stomach. If, howeyer,*
the egesta be sour or iU smelled, and the milk very firmly
curdld like cheese, and the child be sick, it is probable that
more of that caseous substance remains, and a gentle puke of
ipecacuanha will giye relief. On the other hand, should the
egesta be green and bilious, gentle doses of calomel will be
serviceable, especially after an emetic. The sickness which
sometimes precedes yomiting, especially if it be caused by
bile, is accompanied with great oppression, panting, deadly
paleness, and an appearance altogether as if the child were
going to expire. The relief giyen in this state, by vomiting,
is great and sudden.

Vomiting, connected with purging or febrile disease, is to
be considered merely as symptomatic. It is, however, de«
sirable to restrain it, which is done by giving small doses of
saline julap, and removing the primary disease. When it is
immediately succeeded by a stool, there is reason to suppose
it to be dependent on the state of the bowels, but if accom*
panied merely by fever, we must look to the state of the
head. Sometimes the oesophagus is found ruptured in
children, and the contents ol the stomach poured into the
thorax. This probably happens from spasm taking place, at
the upper part of the oesophagus, whilst the stomach is reject*
ing its contents.

CHAP. XIII.

Of Diarrhcea.

Whbn we consider the great extent of intestinal surface,
its delicacy, and the intimate connexion, which exists, betwixt
the bowels and other organs, we shall not be surprised, at the
powerful, and important effects, produced on the system at
lar^e, by disorder of the alimentary canal.

In attending to diarrhoea, we must consider the structure
of the intestine, and the purposes it is destined to perform.
The bowel itself consists of muscular fibres, of glandular
apparatus, of nerves and blood vessels, and of a system of
lacteal vessels, which probably do more than absorb, assisting
&ko, by glandular action, in the formation of chyle, which

814

does not, likely, eiust, in a perfect state, in the contents of
the bowels. Now, altiiough these different parts, constitute
one organ, yet, they are not so blended in action, that all
must be alike affected, when the organ is deranged. All
may be disordered, but one sooner, and to a greater d^ree,
than tiie rest. The fibres, may be excited to inordinate action,
producing rapid contraction, and speedy expulsion of the
contents, and this may, or may not, be accompanied with
spasms and great pain. The exhalents, may be greatly
affected, producing copious discharge of intestinal secretion,
which may be watery, mucous, slimy, or, when the vessels are
abraded or open, tinged with blood. The absorbents, may
have their action impeded, and the chyle be not duly absorl^
ed. The injury of one of these systems of organization, not
only affects the rest, but this intestinal disease, influences
parts immediately connected with the intestines, such as the
stomach, liver, pancreas, &c. This leads us to consider the
contents of the bowels. If the food be good, and the stomach
digest properly, the chyme is good and natural. But, if the
food be bad, or in exuberant quantity, or the power of the
stomach be impured, the chyme is not properly formed, and
the food is found, in the intestines, not thoroughly changed or
digested, perhaps, littie altered in its appearance. If the
bowels, have the same torpor with the stomach, it is retained,
and forms accumulations, ending in great mischief. If the
bowels be irritable, as in diarrhoea, it is generally passed
speedily. The egesta, from the stomach, are naturaUy mixed
with the bile, pancreatic juice, and intestinal secretion ; and
the colour of the compound is yellow, or yellow with a brown
tinge ; and during its passage downwards, a certain quantity
of gas, possessing a peculiar smell, is extricated.* In young
infants, however, when they are pr<^erly suckled, the stools
are somewhat different, from their state at a more advanced
period. They are of a yellow colour, are something like
custard, or are curdy, and have by no means the offensive
smell, they afterwards possess. If the stools have a very curdy
appearance, or are too liquid, or green, or dark-coloured, or
ill-smelled, they are unnatural. The changes effected in the
passage of the chyme, are not merely chemical, but dependent
on animal action ; for the contents of the stomach, mixed with
the fluids found in the intestines, and exposed to the same

t.n* ^^1.^^ ""^^^^ '"^ the colour of the fieoes are found to depend greatly on tbo
bile. When the bile is obstructed, the stools are day-cdoured or pale, and have
•»» the fceulent tmeU.

813

degree of heat, will not form natural looking fteced, bat thd
substances, will simply assume, the acetous or putrefactive
fermentation. If the powers of the stomach and intestines be
impaired, then, this fermentation goes on to a great degree,
in the stomach and bowels ; much gas is extricated, inflation
is produced, and the aliment becomes sour or putrid. If too
much bile be added, the feces are green, sometimes dark*
coloured. This redundancy of bile may be produced by causes
acting immediately on the UTcr, at least, not through the inters
position of the intestines, and the bile comes even to be a
source of irritation to the bowels, and excites diarrhcea ; or the
affection of the bowels may influence the liver, and excite it
to a greater secretion. Some children are more bilious than
others, and are subject to fits of paleness, sickness, and bilious
vomiting. The pancreatic juice and intestinal secretion, when
not changed in quality, but only increased in quantity, are
probably not like the bile, a source of irritation, but only the
produce of it. But these discharges, sometimes mixed with
bile, sometimes with blood efiused from a small vessel, may
accumulate, together with the egesta of the stomach, and form
a Uack, pitchy-looking substance, which sooner or later pro-
duces very bad effects. In other instances, these form a more
watery substance, which is passed off with griping, and purg-
ing of stools like moss water.

The colour of stools in diarrhoBa, varies according to the
violence of the disease. In slight cases, where the action of
the bowels is only increased in degree, but not altered m kind,
and the stomach is not injured, the faeces are of a yellow
colotir, but thin, owmg to the increased discharge, and have
not run into fermentation. When, in children, the digestive
faculty is somewhat impaired, and the aliment is improper,
fermentation goes on more strongly, and the faeces become
acid, which, although the bile be not increased in quantity,
may give them a green colour, and the intestines are distended
with air. Very green stools, however, imply a redundancy
of bile, and the darker the shade of green, the greater is the
quantity of bile. When the irritation is great, and universal,
the stools are very watery, and of a dark green colour ; or,
if the irritation be still greater, they are brown; and, in
either case, if the child be on the breast, portions of coagu-
lated milk, are found swimming in the fluid ; if not, we have
either bits of any solid food, taken by the child, or small
masses of dark-coloured faeces, which had been accumulated
in the bowels. When the digestive faculty is almost gone.

816

tfab dtobls consist of the aliment mixed with bUe. Thus, if
the child be drinking millL and water, or be not weaned, the
stools consist of green watery fluid, with clots of milk, streaked
with bile. When the irritation is greatest, at some particular
part of the intestines, it is not unusual for these appearances,
to alternate with discharge of slime and blood, as we see in
intus*susceptio. When the secretion of bile is diminished,
the stools have a cineritious appearance ; but this state is not
often met with in diarrhoBa. Sometimes, when the liyer is
affected, or tiie bowels much diseased, the faeces may, among
other changes, put on the appearance of pale yolk of egg^ or
are almost like pus.

Diarrhoea may be injurious in different ways* The increased
peristaltic motion, of so extensive a tract of sensible muscular
substance, must, like other great muscular exertion, weaken
the bowels, and, thus, the whole body, which sympathizes with
it. Great debility is often rapidly excited, by affections of
the intestinal fibres, though there have been little evacuation.
DiarrhcBa likewise injures the system, by the irritation and
great secretion, which often accompany it ; add to this, the
diminution of the powers of digestion, and the obstacle
afforded, to the absorption of the due quantity of chyle, toge^
ther with the derangement, which other parts of the system
may suffer, and the diseases thus excited, such as convulsions,
anasarca, &c.

On inspecting the bowels, after death, they are sometimes
found in a state of inflammation, but, oftener, greatiy inflated
and relaxed, or with more or fewer intns-suscepted portions*
In one case, no fewer than 47 intro-susceptions, were found
in the same body. On examining these portions, the valvulae
conniventes, are found to be rather more prominent, than
usual, but the parts are not inflamed. Invagination of the
intestine, is a very frequent cause of fatal diarrhcsa, not less
than 50 cases havmg occurred to my brother, in the course of
his dissections. Intus-susceptio, may be produced suddenly,
in consequence of spasm, and may occasion great pain, with
purging ; or, it may be caused by acrid purgatives, or those,
which produce much griping, as senna tea, made by boiling
the leaves ; or, it may take place in diarrhoea, when attended
with considerable irritation, and it adds to the violence of the
disease. It is sometimes accompanied with a diseased state
of the fflands. In this case, there may be a swelling of the
external glands, and there is often a tendency to cough.
There may be a double intus-susceptio, and the tumour, so

817

formed, may lodge in the pelvis and fill it. Inflammation is
very far from being a necessary attendant on this state ; it is
even uncommon.

The diagnostic of intus-susceptio is very obscure, and, what«
ever may be said to the contrary, I believe we have no certain
mark by which to judge. It has been discovered, when no
previous circumstances, led to a supposition of its existence.
But, in general, there are considerable pain, and marks of
local irritation, such as slimy stools, with or without blood ;
sometimes a little frothy slime is passed, sometimes, a substance
like rotten eggs, and, at times, the contents of the intestines
are vomited. It is attended with stretching and crying, as
in colic, with occasional attacks of great paleness, like syncope;
the belly is tender to the touch, and sometimes, in infants, the

Iiulse is slower than ordinary. When the disease continues
ong, the emaciation is very great, the face resembling the
bones, with merely a skin covering them, whilst the eyes are
sunk. On the extremities, the skin is lax, and seems much
too wide for the bone and muscles. Sometimes the intus-
suscepted portion is thrown off, and passes by the rectum.

Dissection, likewise shows, that a mseaaed state of the liver,
not unfrequently accompanies diarrhoea, and this may be a
cause of purging, oftener, than is supposed. It is to be sus^
pected, wnen the biliary secretion is most affected, and the
region of the liver is fuUer than usual, when there are cough,
frequent fits of sickness, and vomiting or purging of bile. It
is most effectually remedied, by small doses of calomel,
alternated with opiates.

Obstinate diarrhoea, also depends, on inflammation of the
mucous coat of the bowels, marked by fever, pain on pressing
the belly, bloody and slimy stools, tenesmus, and tormina.
When protracted, the whole mucous membrane upwards to
the nose and eyes, is inflamed, and aphths or crusts line the
cheeks, and cover the tongue and fauces. If not attacked,
early, by leeching and nmd laxatives, followed by opiates,
it is apt to become chronic, and, often, incurable.

In some cases, the intestines become very soft, white, or
almost diaphanous, and easily torn, and contain a substance
somewhat like purulent matter, or thin custard.

Diarrhoea appears under various circumstances, not only
with regard to toe nature of the stools, but their frequency,
the pain which attends them, the duration of the complaint,
and the effect on other parts. In some cases, the stools are
extremely frequent, and uniformly so. In others, the dejec^*

818

tions come in ^wtoxjsaiBf being worse, either through the
night, or through the day* Some children are greatly griped ;
others are sick, oppressed, and do not cry, but moan. In
severe cases, the stomach is very irritable, rejecting the food;
but it is not equally so, in every stage of the disease, though,
the stools may be the same in frequency. The appetite is
more or less impaired, and, in bad cases, the aliment qai(Uy
passes off, and every time the child drinks, he is excited to
purge. The mouth, in obstinate bowel complaints, generally
becomes aphthous, and the anus excoriated or tender, and it
is not uncommon for the feet to swell. Sometimea the child
is flushed, at certain times of the day, or the face is uniformly
pale, and the skin waxy in appearance. In general, if the
disease be severe, a considerable degree of fever attends it ;
and a continued fever, in this disease, is always un&vourable.
The stools may come away with much noise from wind, or
may be passed as in health. When there is great irritalioii,
they are either squirted out, forcibly, or come in small quantity,
with much pressing. Diarrhoea sometimes proves fatal, in 48
hours, but it may be protracted, for several weeks, as ia oftes
the case, when intus-eusceptio has taken place, la such pro-
tracted cases, the emaciation is prodigious, the face ia lank, the
eyes sunk, and the expression anxious : the strength gradually
sinks, the eyes become covered with a glossy pellicle, the ex*
tremities cold, the respiration heaving, and the child dies,
completely exhausted.

Diarrhoea may be excited by a variety of causes ; such as
too much food, or sudden change of the kind of aliment, and,
hence, it is often caused by weaning a delicate child. Attempts
to bring up children, altogether, on spoon meat, some injurioiB
quality of the nurse's milk, improper diet after weaning, the
irritation of ill-diffested food, redundancy of bile, previous
costiveness, dentition, the application of cold to the surfiuse,
or a morbid state of the bowels, connected with general
debility, produced either by bad air, or natural delicacy of
constitution, are causes of diarrhoea. Irritation of the origin
of the nerves, is another cause ; hence, diarrhoea often precedes
more marked disease in the bead. The first, might perhqis
have been cured, and the second, prevented f^om running its
fatal course, by timely recourse to an issue, on the bau of
the head, preceded by leeching, if there were fever. Those
children suffer most, who are feeble, puny, or delicate.

As diarrhoea is a frequent cause of death, we cannot be too
attentive to its treatment, nor too early in the use of remedies.

819

especially, as we find, that if it be neglected in its commence-
ment, it is apt to end in a most obstinate, if not incurable state.
On this accomit, I have been led to consider this disease very
carefully, and shall briefly mention the treatment I haye found
most effectual. When the stools are natural in colour, but
more liquid than usual, the frequency moderate, the continu-
ance short, and no feyer is present, it will be useful to give
small doses of rhubarb, conjoined with an aromatic, taking
care, however, that these do not end in producing the oppo-
site extreme, or costiveness. In many cases, the disease will
subside of itself ; but if it do not abate spontaneously, or by
the use of small doses of rhubarb, then it comes to be con-
sidered, how far it is proper to check the inordinate action of
the fibres of the intestines. This is readily done by an ano-
dyne clyster* But if the diarrhoea have been excited by im-
proper food, or redundancy of food, or if it be attended with
acute fever, and especially if the child be plethoric, it will be
useful to give some mild laxative, such as magnesia and rhu-
barb, or an emulsion containing castor oil, or small doses of
calomel. The tepid bath is also beneficial. If there be op-
pression, with fever or sickness, a gentle emetic will be a pro-
per prelude to the laxatives. Afterwards, if the disease con-
tinue, and there be marks of much irritation of the fibres,
anodjme clysters will be of signal service.

K there be accompanying fever, starting, and any change
of countenance, we ought to examine carefully into the state
of the head, and into the existence of any symptom, denoting
disease there. Many children might probably oe saved, were
we eariy to take the alarm, aad treat the disease as cephalic,
by leeching, blisters, and mild mercurials. Doubtless, we
might use, sometimes, strong measures, when the child might
have recovered without them. But if we do not go to an
imprudent length, we can rarely, if ever, do harm, and may
do much good.

If the diarrhoea come on quickly, and the stools be, from
the first, green or morbid, and the stomach be irritable, or its
functions impaired, we riiould examine the gums, and cut
them, if the child be getting teeth. This removes or lessens
a source of irritation. We also must look, attentively, to the
state of the head, and, if warranted, use the other means
just noticed.

But whether the disease be produced by teething, by change
of food consequent to weaning, or other causes, great at-
tention is necessary. If the child be sick and oppressed, a

820

few grains of ipecacuanha will be proper; and afterwards
small doses of calomel,* or some other laxatiye,t should be
given morning and evening. These carry off the morbid fecu-
lent matter, and excite a better action of the bowels. Calo-
mel, is usually, an effectual remedy, and it may be given even
to infants a few days old. To them, a quarter of a grun,
rubbed up with sugar, is a proper dose, and may be given
for several nights. To older children, we give half a grain.
If laxatives do not increase the debility and pain, and, if they
render the stools more natural, in appearance, they do good,
and may be continued, in decreasing quantity, till they be
abandoned altogether. But if they merely increase the fre-
quency of the dejections, without greatly altering their qua-
lity, the stools continuing watery, ill-coloured, and offensive,
and the strength and appetite sinking, we can expect no
good, by continuing them, and must restrain the purging, by
repeated anodyne clysters, taking care that we do not delay
their use too long. When the secretion is copious, and the
stools frequent, and perhaps squirted out, with great irrita-
tion, the strength will sink very rapidly, and a few hours may
decide the fate of the child. In these cases, there is more or
less inflammatory action, and therefore, in the conmience-
ment, we should, if there be tenderness on pressure, apply
leeches to the belly, and use fomentations. It is also, imme-
diately necessary, even although the contents of the bowels be
morbid, to moderate the fibrous and secretory action, by
anodyne clysters. Afterwards, the morbid matter is expelled,
or can be removed by gentle laxatives. Opiates, given by the
mouth, are never eqiml in benefit to clysters; stUl, when the
clysters are not retained, we must have recourse to the exhibit
tion by the stomach. When they, in moderate doses, seem to
have produced stupor, or other bad consequences, it is pro-
bable, that they only hastened the progress of disease, already
existing in the head. Cretaceous substances, joined with
aromatics, are useful when there appears to be a redundancy
of acid; but the salt formed, does not seem to be so styptic as
many suppose. Astringent medicines, such as kino, or cate-

* That excellent practitioner, Dr. Clarke of Dublin, haa itronglj advlapd half
a grain of oalomel to be ffiven oTery night, or every aeoood night, to infaata when
troubled with green stooii and griping ; obaerving, that in the courae of a week or
two, the stooubecome natural, and tnat it in rarely neceesary to give more than
from 4 to A grains altogether. Mem. of Irish Acad. Vol. vL

f Cold drawn castor oil may be given in the following form : 1^ Ol. RiciBi,
X lij.; Manns, ijss.; Spt. ammon. Arom. ^. ; Aq. Cassic, ^ a.; Aq. Font. 9 Jaa.
Fiat emulsio. Of this a tea- spoonful may be given as often as necessary.

821

chu, though they sometimes seem, in slight cases, to be of
service, yet, in more obstinate diseases fail, unless they be
combined with opium, and then the benefit is, perhaps, more
to be ascribed to that drug, than to their effect ; still, in mo-
derate doses, they are safe, and not to be neglected. If given
in great quantity, they may perhaps excite to invagination of
the intestines. In obstinate cases, small doses of the mercu-
rial-pill-mass, given morning and evening, with the use of ano-
dyne clysters at the same time, to keep the purging within
due bounds, are of more service than any other remedies ; I
can speak of this practice with confidence. Dr. Armstrong,
however, when the stools are liquid or watery, sometimes col-
ourless or brownish, or streaked with blood, and of very
offensive smell, advises antimonial vomits, repeated every six
or eight hours, till the stools change their appearance. But
this remedy operates severely, and may induce no small de-
gree of debility. If the plan be rejected, he advises a solu-
tion of Epsom salts, with a small quantity of laudanum. I
object to both plans. Dr. Underwood, in this disease, pre-
scribes emetics, then, warm purges, and, afterwards, small
doses of ipecacuanha, with absorbents and aromatics.

Dr. Cheyne, in obstinate and prolonged purging, which,
from frequently occurring about the time of weaning, he calls
atrophia ablactorum, strongly advises small, and repeated
doses of mercury, as the most effectual remedy.

When there is much fever, the use of the tepid bath, morn-
ing and evening, and small doses of saline julap, or compound
Eowder of ipecacuanha, and clothing the child in flannel, will
e of great benefit. When, along with fever, there is much
Eain, and the stools are slimy, bloody, or squirted out, forci-
ly, there is reason to fear inflammation of the mucous coat,
and leeches should precede the bath.

In every case, external applications have, I think, a claim
to be employed. These, consist of friction, with anodyne
balsam, or camphorated oil of turpentine, or, what is better,
the application of an anodyne plaster,* to the whole abdomen.
Small blisters applied to the belly are useful, if they do not
give much irritation. It is also proper, to bandage the belly
pretty firmly, but by no means tigotlV) with flannel.

During the whole course of the disease, it is proper to sup-

* Such as the foUowInj^: |^ Saponit. zj.; Empl. Lytharg. ^yj.; Ext, Cicuts,
5 IJ.; 01. Menth. pip. z n. Fiat empl. Qr, ^ Empl. resinoa. zvj.; Pulv. Opii»
jj.; Camph. ^ij.; Ol. junip. 3W. Fiat empl. Or, if tliere be much spaam, we
may ate the empl. asafcetids Phwrn. £dln. with the addition of opium.

822

port the strength with light nourishment, such as beef tea,
arrowroot jelly, toasted flour boiled with milk, &c.; or, if the
child be not weaned, it is sometimes of service, in continued
or repeated attacks of diarrhoea, to change the nurse. The
system should be supported, by small quantities of white
wine whey, given frequently. If the child, as is frequently
the case, will not take nourishment, then, clysters of beef tea,
or arrowroot, are to be employed, mixed with a few drops of
laudanum. These are of signal service, and ought to be early,
and carefully, employed, till the child can take food into the
stomach.

When the mouth becomes aphthous, it may be washed with
a little syrup, sharpened with muriatic acid ; or borax may
be employed, along with the proper internal remedies ; and^
when these restore the bowels to a healthy state, the mouth
becomes cleaner. The appearance and disappearance of the
aphthae, generally, mark the fluctuation of the bowel com-
plaint. The excoriations which appear about the anus, require
to be bathed, with solution of sulphate of sine, and call for
great tenderness, in administering clysters.

When the feet become swelled, and the urine diminished
in quantity, some diuretic must be added to the oth^ means.
The best is the spiritus etheris nitrosi.

If the child become drowsy, or have a tendency to coma,
much benefit may be derived, from shaving the head, and
applying a small blister to the scalp. Affections of other
organs, supervening on bowel compUints, must be treated,
promptly, on general principles.

It will thus appear, that the practice in diarrhoea, is chiefly
confined, to the following points:

First. To remove every exciting cause, scarifying tiie gums
in dentition, rectifying the action of the liver, when it b
deranged, lessening cerebral excitement when it exists, and
regulating the diet, when the quality of the food, may be
supposed to have disordered the bowels.

Second, To lessen sickness, and oppression of the stomach,
when considerable, and not dependent on the state of the
head, by a gentle emetic ; to remove irritating fiaeces, and
excite a better action of the intestinal surface, by small dosea
of calomel, or blue pill, in prolonged cases, or by a dose of
rhubarb and magnesia, in recent cases of purging. The cir-
cumstances, under which, the administration of laxatives, b
beneficial or injurious, have been already pointed out«

Third. To restrain inordinate peristaltic motion, and exces-

823

sive secretion, by anodyne dystero, and exteraal applications,
neither of which, are incompatible with the occasional, and
cautious use of calomel, or hydrargyrus cum creta.

Fourth, To remove, or allay coincident, or consecutive
symptoms, by appropriate remedies.

Ftfth. To support the strength, from the first, by suitable
nourishment and cordials ; and, whenever the stomach cannot
receive, or retain food, to give nutritive clysters.

CHAP. XIV.

Of Costiveness.

CosTivEHBSS is natural to some children — acquired by
others. In the former case, it often happens, that the
mother is of the same habit, and in these curcumstances, we
find that less detriment accrues, than in the other ; yet, even
here, it is necessary to prevent the costiveness from increasing,
as it may excite not only colic, but more serious diseases,
such as convulsions, or diseases in the bowels. Some children,
of a very irritable habit have the rectum spasmodically
affected, at times, on passing the faeces, which may be followed
by a convulsion. This being frequently repeated, the child
becomes afraid to go to stool, and retains the faeces as long
as possible, which induces a costive state. Sometimes the
terror is so great, that the child can only be made to pass the
faeces when half asleep. I have noticed this already, as well
as the effect of fissure.

In hereditary costiveness, it Is difficult, if not impossible,
to induce a regular state of the bowels ; and perhaps in some
cases, this, if it could be done, would, seeing that it is not
^tural to the constitution, be injurious to the child. But
we must beware, lest, by indulgence, this habit increase.
Wh^iever the child is pale and puny, or dull, and does not
thrive, there is risk of convulsions, or some severe disease
being induced. At a more advanced period of childhood,
chorea may be produced. Acquired costiveness may be
overcome by medicine, and encouraging regular attempts to
procure a stool. A variety of means have been employed in
these cases, such as suppositories, magnesia, and otner laxar
tives. The best remedy for changing the state of the bowels.

824

seems to be calomel, or blue pill, which may be ffiven in a
mild dose, even to an infant, for a day or two m snccea-
sion, and then omitted; employing, in the interim, a little
manna, alone, or combined with castor oil, and sometimes
magnesia may be substituted for a change. In more obsti-
nate cases, mild infusion of senna, may be giyen* A quar-
ter of a grain of ipecacuanha, mixed with sugar, may also be
tried. An injection of tepid water, given morning and eyeo-
ing, if not sufficient, of itself, will, at least, make less medi-
cine operate ; as, for instance, two grains of the mass of nil.
hyd. It is also proper, to change the nurse, or alter the diet
of the child, giving barley-meal porridge, veal soup, aleberry.
I wish explicitly to urge, that the milk, whetho: that of the
mother, or of a nurse, may be costive ; and, in such cases, if
another nurse be not procured, whose milk is more laxative^
the most serious effects may follow. In the early weeks of
infancy, fits are apt to occur, often attended or preceded by
fever. In later periods, hydrocephalus is induced, possibly,
also, in the earlier age.

CHAP. XV.

0/Colic.

Colic, is a frequent complaint with children, especiallv
when they are costive. It is often produced by too much
food, exposure to cold, irregularities in the diet of the nurse^
or some Dad quality of her milk. It makes its attack suddenly,
and is known by violent screaming, induced, without any
warning, alternated with short intervals of quietness, and ac-
companied with hardness of the abdominal muscles, kicking,
and drawing up of the legs, and, often, suppression of urijie.
These symptoms are soon removed by a dyster, or suppoo-
tory, which brings away both fieces and wind. The warm
batn, fomentations, and friction on the belly with anodyne
balsam or laudanum, will be serviceable ; and, if the pain con-
tinue, two or three drops of tincture of opium, or a rather
larger dose of tincture of hyoscyamus, with a drop of oil of
anise, may be given. When the child is costive, a laxative is
to be exhibited after the anodyne.

If a child be subject to repeated attacks of colic, a few

825

drops of tincture of assafoetida, may be given once or twice
a-day, and we must always take care to prevent the long con-
tinuance of pain, as it may end either in visceral inflammation,
or convulsions.

CHAP. XVI.

Of Martumus.

CoNNBCTED with, and generally dependent on, a morbid
state of the bowels, is the marasmus, or wasting of children.
This disease is preceded, and accompanied, by costiveness,
sometimes alternated with a diarrhoea, in which the stools are
foetid, or unnatural in appearance. It begins with lassitude
and debility, loss of appetite, or depraved appetite, foetid
breath, and foetid stools, tumid belly, pale leucophlegmatic
countenance, with swelling of the upper lip. Presently, fever
supervenes, the countenance becomes at times flushed, and
the skin hot and dry, with frequent pulse, thirst, restlessness,
picking of the nose, and disturbed sleep, in which the patient
grinds his teeth and starts. The debility gradually increases,
and if relief be not procured, death, preceded by great ema-
ciation, takes place. This disease, is most frequent with those
who are fed on improper food, or eat many raw roots, or much
unripe fruit ; or those who have the digestive faculty impaired
by confinement, bad air, or neglect of the bowels. It very
often is considered as produced by worms ; but these, although
they may often exist in the bowek, are by no means essential
to uie disease. It is still more frequently, and more certainly,
caused by some disorder of the branches of the sympathetic
nerve, occurring, as I have noticed, in a modification of the
affection, considered in the chapter, treating of cerebral and
spinal disorders. In such a case, it is often the only very
marked symptoms, and exbts to a great degree.

This disease may, in the commencement, and before the
appearance of fever, be arrested, by a course of active purges,
at proper intervals ; at the same time that we give light
nourishing diet, and inculcate the necessity of exercise, in the
open air. In the febrile stage, the cure is more difficult, but
is to be accomplished, on a similar principle, by attending to
the state of the bowels. For this purpose, purgatives must
be frequently repeated, in such doses as the state of the bowels

826

requires. The kind of purgative to be used, must depend
much on the effect of a trial. Aloetic pills, infusion of senna,
castor oil, rhubarb and magnesia, &c., may be employed; and
occasionally we interpose a mild dose of calomel, or give small
doses of it oftener, if the appearance of the stools, indicate
that the secretions are very unhealthy. The stools are not
always hard ; they are ofiten fluid, but generally foetid, and
dark in the colour, or appear to contain indigested food. A
course of purgatives, however, by degrees, procures discharge
of faeces of natural appearance. Whilst tnis course is con-
ducting, the strength is to be supported, by proper diet, and
the prudent use of wine. The power of the stomach, may be
increased, by chalybeates or other tonics, provided these be
not nauseated by the patient. After recovery has taken place,
we must, by very gentle laxatives, preserve an open state of
the bowels, which will prevent a relapse. Searbathing is lik^
wise of advantage.*

The state of the bowels which gives rise to marasmitSy
sometimes produces, speedily, more acute symptoms. These
constitute a very frequent species of fever, which we have
already noticed.

An emaciated or general unhealthy state, may be produced
by the milk not agreeing with the child, or being deficient in
-quantity. The nurse ought to be changed immediately.

CHAP. XVII.

Of Tabes Mesenierica.

Tabes mesenterica, or hectic from disease of the mesenteric
glands, is not often met with before the time of weaning, nor
after puberty, seldom after eight or ten years, but no age is
entirely exempted. The disease consists in enlargement of
the mesenteric glands,t which are sometimes universally af*
fected, but are especially enlarged, into a hard mass, about

* TboM who wish to know what other remedies mre employed^ without miich
benefit, may consult Baumes, de ramaigrissement des enfima.

f This state is sometimes accompanid with sweUlng of the thvmos gland, ua4
the lymphatic irlands of the neclc. Swelliog of the thymus glaail, bv presaiog oo
the tracnea ana oisophagus, produces dliBcuity of breathing and of swallowiaf,
and sometimes suffocation. By pressing on the aubdarian Tela, It obatnicta tht
paasage of the chyle, and may thus excite disease in the mesenteric glaoda. Blis-
ters applied to the top of the stei*num, preceded by leeches, and conjoined with
the use of iodinci constitute the pnustice.

827

the root of the mesentery. These tend slowly to the format
tion of a cheesy substance, but death may take place before
that process be accomplished. The commencement of the
disease is slow and obscure ; the patient complains of little or
no pain, but is subject to an irregular state of the bowels ; is
either costi?e, or passes dark loose foBces ; is unhealthy in his
appearance, and liable to occasional attacks of fever. The
urine is white or turbid. The appetite is not much diminish-
ed, and digestion goes on ; but the belly is hard and some-
what tumid. The child is more fretful than usual, and some-
times, especially if yery young, is troubled with yomiting.
This is the incipient stage, and resembles very much that of
marasmus, proceeding from affection of the bowels, indepen-
dent of diseased glands. As the disease advances, the body
wastes away, the face is pale, and the features become sharp,
the abdomen gradually enlarges more, and the patient com-
plains of lancinating pains, of short duration however, within
the belly, or near the back. The stools are now sometimes
bound, but oftener loose, frothy, and mixed with bile ; occa^
sionally, the patient has diarrhoea, with vomiting. A short
troublesome cough, is generally a prominent symptom ; some-
times this is dependent on tubercles, but often it is sympar
thetic, and the lungs are found healthy. The fever, which at
first is obscure and intermitting, becomes more acute and dis-
tinct, with exacerbation in the evening, attended with restless-
ness and acceleration of the pulse, which rises to 120 strokes
in a minute, or even more. The patient is listless, and his
mind becomes gradually inactive, though he does not lose
hopes of recovery- The tongue is generally clean, but some*
times covered with a white or brown crust, especially in the
middle; and, in an advanced stage, the whole mouth and
throat become aphthous. The thirst is trifling, but the ap-
petite is usually impaired, or becomes very rastidious. As
the disease proceeds, the epaaciation of the body increases,
the eyes are sunk and glossy, the nose sharp, and apparently
elongated, the face sallow, but the lips are sometimes florid,
and the cheeks flushed at night. The abdomen is hard, and
sounds like a drum when struck upon, or if not very tense,
knots may sometimes be felt within it.* The urine is lessen-
ed in quantity, and it often deposits a white or lateritious
sediment, the feet swell, and during sleep, the forehead, scalp,

* SomefclniM a hard tumour may be felt within the beUy, pretty early in the
diiease. It is often feit in the right side, near the origin of the colon, or at the
edge of the lirer, or abOTC the navel.

828

^and sometimes the breast, are covered with a profuse sweat,
whilst the rest of the skin is hard and dry. The progress of
this disease is not always alike rapid. In some cases, the pa*
tient lives for a year or two in bad health ; bat in generalt
after hectic has appeared, a few months, sometimes weeks,
cut him off.

In the commencement of this disease, the steady, and re*
peated use, of mild purges, with the occasional addition of
calomel, conjoined with some light bitter infusion, decoction
of bark, tonic medicines, and gentle friction over the belly,
continued for a considerable length of time, morning and
evening, would appear to be of more service, than any other
plan of treatment. It has been proposed to ^ve calomel in
small doses, as a mercurial ; but it does not appear to have
great efficacy, and is chiefly of use, in so far as it acts as a
gentle purgative. Copious evacuations in this disease are not
required. It is sufficient that the bowels be brought inio,
and kept in a regular state, which, in the incipient stage, at
least, sometimes requires pretty strong doses* But in the
confirmed and advanced stage, stools are easily obtuned ; and
from the loose state of the bowels which often prevails, it
<some8 to be a question how far laxatives are proper. Upon
this important subject, I observe, that these medicines ought
not to be severe, but gentle, and given frequently, provided
they have the effect of diminishing the tumour of the belly,
making the stools more natural, and do not impair the
strength. The lax stools which take place in this disease
spontaneously, never abate the tumefaction ; but a gentle
course of laxatives often does, and this is a most favourable
effect. Farther, if the paroxysms of fever be severe, and
early in their appearance, we find it necessary to use pui^a-
tives more freely, than in opposite circumstances ; evacuation
by stool being in such cases advantageous. In the confirmed
and advanced stage, it is sufficient that such a dose of a laxative
be given every night, or every second or third night, as shall
keep the bowels open, if disposed to be costive, or, if loose,
make the stools more natural in their appearance, than they
would be, without the administration of medicine. If calomd
be employed, we must take care, that the mercury do not pro-
duce much effect on the constitution, lest debility be increased ;
it is therefore prudent, sometimes, to combine it with rhu-
barb, or to employ a little castor-oU emulsion.

Along with this plan, we may, in every stage of the disease,
derive advantage from the use of tonic medicines, such as

829

angustura bark, and other bitters or chalybeates, especially in
the form of mineral waters. But iron is to be used cautiously,
if there be marks of inflammation existing in the glands ; and
in such cases, some light bitter infusion is preferable. In
such circumstances, the laxatives are to be used more freely ;
the tepid bath is to be employed, and the belly rubbed freely
with anodyne balsam. Tincture of iodine is often useful, es-
pecially in the early stage. It aids the laxatives, and acts as
a mild tonic, but if it excite, it must be given up.

Gentle exercise in the open air is of great service, and it
is useful, in the early part of the disease, to reside near the
sea ; but if the glands seem to be in a state of inflanmiation,
discovered by shooting pain, with fever, the patient must not
bathe ; and indeed at all times, the utility and safety of the
cold bath seem to be doubtful, except when the disease is so
far removed, that we have chiefly to contend with debility.
The warm bath is more generally useful.

The diet should be light and nutritious, but all stimulating
and indigestible substances must be avoided. If an inflam-
matory state exist, milk in difierent forms, soft boiled eggs,
and vegetables, are proper. If no inflammation be present,
some animal food will be of service ; nay, as in other scrofu-
lous affections, a very considerable proportion of animal diet,
is sometimes beneficial, in preventmg the tumour from in-
flaming, and forming a cheesy substance, or in giving a favour-
able turn to the action, when the acute state of inflammation
has abated, in those cases where it is met with, for it is by no
means a universal occurrence.

In the latter end of the disease, little can be done except
palliating the symptoms, and supporting the strength by soups
and a little wine. Diarrhoea should be restrained by anodyne
clysters. Dover's powder often succeeds better, as an opiate,
than any other form.

Cicuta, and some other medicines, have been advised in
this disease, but I cannot say that they have been employed
with advantage. Electricity has been proposed, to promote
absorption, but it does not seem to have that effect.

830

CHAP. XVIII.
0/ Warms.

Worms exist in the bowels, perfaaps, of every child,* bat
especially in those, whose bowels are debilitated, by bad
management, or by acute disease ; and hence, in the end of
disease, or after recoyering from such illness, worms are often
expelled, both by children and adults. Worms are of diffe-
rent kinds, but infants are chiefly infested with lumbrici and
ascarides, the tieniae being rarely met with, until children are
four or five years old. We also sometimes meet with some
uncommon species of worms, which are ejected by vomiting.
Insects of different kinds may also be introduced, accidentally,
into the stomach and bowels, and live there for some time.

Ascarides, generally occupy the rectum, producing much
itching in that part, so that sleep is often prevented. The
irritation causes indigestion, and pain in the belly, with pick-
ing of the nose and white face, a variable appetite, and some-
times a desire for indigestible substances* The worms are
discovered in the stools, like small white threads, and occa*
sionally they creep out from the rectum. The stools are often
slimy or mucous. This kind of wonn» is removed by injec-
tions of aloes mixed with water, or decoction of semen san-
tonicum, or any strong bitter infusion, containing salt in solu-
tion, or the common turpentine injection; lime water and
olive oil also sometimes destroy them, but cannot be depend-
ed on. Calomel purges are proper likewise; and any dis-
ordered state of the alimentary canal, which exists, is to be
treated on general principles, improvement of the digestion,
being one of the best means of preventing the continuance of
the worms.

The ascaris lumbricoides, is often from six to ten inches
long. In its general appearance it resembles the earth worm,
but differs from it, in having, besides other distinctions, a
longitudinal line on each side, whereas the earth worm haa
three lines on the upper surface. It dies soon after its ex-
pulsion, but when alive, it moves like an eel, and does not
shorten the body like a worm. Dr. Hooper, in the fifth vol*
of the Mem. of Med. Soc, has a valuable paper on intestinal
worms. Lumbrici may exist in every part or the alimentary

* Worms rarely appear in tb« bowels, till after the child is weaned.

831

canal, and frequently are ejected by vomiting, as well as by
stool. Tfae symptoms are those of intestinal irritation,* pain
in the belly, frequent attacks of diarrhoea, yariable, and often
voracious appetite, the child sometimes becoming hungry,
almost immediately after having ate heartily, foetid breath,
pale complexion, tumour of the lips, with livid circle round
the eyes, swelling of the belly at night, and disturbed sleep,
the child occasionally awaking in great terror, and being
liable to starting, and grinding of the teeth. When awake,
he picks his nose^ is plagued with temporary headach, some-
times has a dry cough, with slow fever, or convulsive affec^
tions, or eclampsia. I have already pointed out several dis-
eases, proceeding from disorder of tne bowels, and these may
arise from worms, in as much as they are capable of irritating
the bowels, or injuring their action, or increasing such a de-
bilitated state, as may have predisposed to their accumulation.
A variety of anthelmintics have been advised, for an account
of which, I refer to the writers on the Materia Medica. Sul-
phur, tansy, aloes, spigelia marylandica, dolichos pruriens,
the geoffraea, worm seed, tin powder, filings of steel, &c, have
all, at times, a good effect; but in general, calomel purges,
given repeatedly and liberally, provided the constitution of
the patient will bear them, will be found very effectual ; or
these may be alternated with saline purgatives, oil of turpen-
tine, or suitable doses, of aloes or jalap. Carbonate of iron,
in considerable doses, or other chdybeates, are useful.

In obstinate cases, much benefit will be derived, by giving
a regular course of purgatives, so as to keep up a constant,
but gentle, effect on we bowels. After the worms are expel-
led, a bitter inAision, or chalybeate water, will be useful to
strengthen the bowels, or these may even be employed, whilst
we are using the purgatives.

The trichuris, or long thread-worm, is about two inches
long, and two-thirds of this form a tail like a bur. The
body is about the 16th of an inch thick, and the worm is
white like the ascaris. It is found in the rectum, and also
higher up, even in the ilium.

The taenia consists of many flat, jointed, portions, and is
divided into the T. Solium, where the orifices are placed on

* Henca it Is not easy to tay that worms are the cansa of a child'b complaint,
for other morbid affections of the bowels vroduoe the same symptoms* A oourse
of purging removes these symptoms, withoat bringing away any worms; al-
though the slimy appearance of the stoob is attributed to the worms being dit-
■olTed.

832

the margins of the joints, and the T. Lata, where they are
found on the surface. The symptoms are similar to those
attendant on the presence of the round worm, but more severe
in degree. The best remedies are smart purges of calomel
and jalap, alternated with doses of oil of turpentine, propor-
tioned to the age ; a dessert spoonful may be ffiven to a cnild
of four years of age. But to ensure its quick operation by
stool, and to prevent strangury, another laxative, such as cas-
tor oil, should be combined with it. Colchicum may also be
prescribed at a more advanced age. The t»nia is more diffi-
cult to be removed than other worms.

CHAP. XIX.

Of Jaundice.

Thb jaundice of infants, is a disease attended with great
danger, especially if it appear very soon after birth, and the
stools evince a deficiency of bile ; for we have then reason to
apprehend, some incurable state, of the biliary apparatus. I
conceive that there are two species, of this disease, which are
very opposite in their nature. In the first, there is an obstacle
to the passage of the bile into the intestine, the child is cos-
tive, and the meconium is paler than usual, and after it is re-
moved, the stools become light-coloured ; the skin, very early
after birth, becomes of a deep yellow colour, which extends
to the eyes. The child sucks very little, has occasionally a
difficult^ in swallowing, is languid, becomes emaciated, moans
much, IS troubled with flatulence, sometimes with cough and
phlegm in the trachea ; or, vomiting, convulsions, colic, and
fever, occasionallv, supervene. In some cases, the liver is
felt enlarged, and the hypochondrium is tumid. The water
is very. high-coloured. This disease often proves fatal in a
week, but it has been known to continue, in variable degrees
of violence, for a considerable time, and at last to disappear,
though such children continue long delicate. With regard
to the cause of this disease, we find, that sometimes it consists
in obstruction of the hepatic duct, or ductus communis, either
by thickeninff of the coats, or pressure, in consequence of en-
largement of some part in the vicinity of the duct : or it may
consist in imperforation of the duct. Sometimes it proceeds
from temporary obstruction in the duct, owing to viscidity of
the bile. Now, some of these cases are irremovable, others

833

are not ; but as we cannot, a priori^ say what the cause may
be, In any particular instance, we must use the means of cure
in every case. The most likely remedies, for removing this
disease, are verv gentle emetics, ffiven early, and followed by
the exhibition of half a grain of c^omel, morning and evening,
till the bowels are acted on ; or we may give this medicine
even three times a-day, in some cases ; but we must be cau-
tious not to induce much purging, or push the mercury far,
lest we bring on fits.

The second species, difi^ers from the first, in the stools being
dark coloured or green, showing that there is no obstruction,
or at least no permanent obstruction, to the passage of the
bile.* Like the first species, it appears soon after birth, and
is accompanied with great oppression, moaning, colic, and
convulsive afiTections. It is attended with much danger, and
frequently carries off the infant in a few days. The early
use of calomel, in small doses, would appear to be the most
proper practice, and the strength must be supported, in all
those cases, by the breast milk, given with the spoon, if the
child will not suck, and small doses of white wine whey.

Jaundice, appearing at a considerable period after birth,
does not require a separate consideration here, nor is it a very
common occurrence.

CHAP. XX.

Of Diseased Liver.

Enlargement of the liver, is not unfrequent,'in infancy
and childhood. It is productive of vomiting, oppressed
breathing, cough, fever, and sometimes purging. Tne liver
can be felt enlarged, and extending lower down, or more to
the left side, than it ought to do, which will distinguish this
complaint from inflammation of the lungs, which is, also, not
so frequently, attended with vomiting.t I cannot say much
that will be satisfactory respecting the treatment. Mercurial
friction, and small blisters, are diiefly to be relied on. We
may also give iodine.

* It is in this species alone that the opinion can be admitted, that infantile
jaundice depends on absorption of bile from the intestines.

f On examining the liver. It is sometimes foand soft, and not mocb altered in
structure, sometimes hard, and almost eartllaf loons, with the porl biiiarii hard-
ened and obetructed, so that secretion of bile docs not take place, and the gill blad-
der becomes shriTeUed. TbU state cannot be attended with Jaundice.

834

Hepatis, m in&ncy, is frequently attended, by the symp*
tomB of enlargement of the Uver ; but there is more ^ver,
and, if the disease be acute, there is pidn, when the liTer ii
pressed on. The disease often begins, with symptoms of
disordered stomach, and colic pain. Ferer comes on, accom-
panied with cough, which is sometimes, soon, succeeded by
jaundioe. The stools are often like yolk of egg, or if there
be obstruction to the passage of the bile, they are day-
coloured, and the urine red, with much sediment. On
inspecting the body of infants, who have died of this diaeasc,
the surface of the liver, sometimes only its convex surCBure, is
often found of a deep red colour, with an exudation of white
lymph, exactly resembling the cuticle of a blistered part
Betwixt the liver and diaphragm, we find white flaky nuid,
something like pus, and similar matter, is often found among
the bowels, mixed with pieces of fatty-looking lymph. The
liver is not necessarily enlarged, nor its substance afiected.
The stomach and bowels are not inflamed, but sometimes
have a white blanched appearance, and contain a fluid like
thin custard. The bile is not changed in its colour. In some
instances of chronic inflammation, the Uver is somewhat
enlarged, of a dark colour, and the veins turgid. Leeches,
small blisters, and a gentle laxative course oi mercury, are
the means of cure.

In older children, we find hepatitis to commence, either,
acutely or slowly. When it begins acutely, the child, pro-
bably after a surfeit, or some irregularity of diet, or exposore
to cold, complains of severe pain, in the upper part of the
belly, like celic, accompanied with sickness and vomiting,
and either attended, or soon succeeded, by fever, short cough,
and pain, sometimes dull, sometimes sharp, in Uie right side,
and, occasionally, affecting the- shoulder. Jaundioe, ako,
not unfirequently, is produced, and lasts for a few days.
There is thirst, no appetite, but the child feels continually
as if he had ate too much, is subject to fits of squeamishDess,
and complins when the liver is pressed. If the r^nedies
do not check the disease, the liver enlarges, and its region is
full; abscess is formed, attended with irregular <>hilp^ffi^
hectic symptoms, and much pink-coloured sediment in the
urine* In a few weeks, sometimes in a shorter period, the
patient is sensible of a smell like rotten e^^s, whicn he thinks
comes from the stomach ; then, a little foetid matter is couffbed
up, which is followed by copious expectoration ; or he ejects
pus, as if he vomited it from the stomach. The cough and

885

8iiittiiig» with hectic symptomS) continue long, but at last,
decline and go off.

In the earlj stage, bloodrletting, if instantly resorted to,
may be of senrice, but not if delayed. Leeches are safer at
a later period^ and ought to be applied. Small blisters are
always proper. The bowels should be freely opened, and
afterwards a gentle course of mercury employed. Iodine
seems likewise to be useful, when the disease is approaching
to the chronic state, and we also may use, after it and the
mercury, solution of muriate of lime. In the suppurating
stage, mercury diould not be used, but the strengtn is to be
supported by proper diet. In the exnectorating stage, the
same plan is necessary, with the use ot tonics, such as chalv-
beates joined with myrrh, and occasionally opiates. A speedy
removal to the country, if the weather be mild, is advantageous.
Sometimes, the abscess points externally, or bursts into the
stomach or intestines, adhesion previously taking place ; or,
I have known it burst into the general cavity of the abdo-
men, and the matter accumulate there, forming a tumour
like ascites, bursting at last by the navel, which inflamed ;
or it has been drawn off with a trocar, and recovery has been
accomplished. This, I have, in the eleventh chapter of this
hodkf noticed as also following, a certain degree, ot peritonfieal
inflammation.

The more slow or chronic species, may be excited by a
torpid state of the whole cbylopoetic viscera^ consequent to
neglected bowels, or otiier causes ; ori it may occur, after some
other disease, such as peripneumonia, scarlatina, &c. The
child has fits of sickness, vomits bile in the morning, and loses
his appetite; or, if he have a strong desire for particular kinds
of food, or feel very himgry at times, he either cannot eat,
when he receives food, or is instanUy filled. The strength
diminishes, the bowels are torpid, and the stools white, in
some cases bilious, or dark and off^^ssive ; in others, there is
a constant dry cough, and inclination to hawk or spit ; the
pnlse is firequent; the upper p%rt of the belly becomes swelled
at night, but there is littie or no pain in the region of the
liver ; if any be felt, it is rather referred to the bowels. By
and bj, considerable pain, like colic, is felt near the stomach,
especiaJly at night, and that part of the belly is then swelled^
but towards morning it subsides. On examination, however,
the hypochondriac region is felt full, and the liver can be
perceived extending towards the left side, and pain, and
sometimes sickness^ are produced by pressure. The urine is

836

high-coloured, the feet swell at night, and the face has a alight
hectic flush. If the disease be not checked, it goes on to
suppuration, producing distinct hectic fever, terminating in
death, if the matter be not discharged ; or, it may be, irritfr^
tion proves fatal, even without suppuration. Repeated small
blisters, laxatives, and mercurial inunction are the remedies,
with iodine, or muriate of lime, along with sarsaparilla* We
give diuretics, if there be dropsical symptoms.

The spleen is frequently enlarged, and sometimes contains
tubercles. I do not know any other diagnostic symptom,
than the belly being tumid and hard, in the region of the
spleen ; frequently a cough attends this state, bitter laxa*
tives, and blisters are the best remedies, but most cases, I have
met with, have proved fatal.

CHAP. XXI.

Of Fever.

Fever is a frequent disease in infancy and childhood, but
it is generally symptomatic, or produced by some local
irritation, and has been considered in some of the former
chapters, particularly, in the chapter on spinal and cerebral
irritation. Typhus fever is extremely rare in infancy, but it
sometimes is communicated to children a few years old. It
is known by our evidently tracing the channel of infection.
The child at first is languid, pale, chilly, and debilitated, the
appetite is lost, the head becomes painful, the skin hot, the
tongue foul, the eye dull, or suffused, and the pulse very
quick ; and if a favourable crisia be not procured, great
oppression succeeded by stupor, precedes death. In the
course of the disease, the bowels are generally bound, the
stools foetid, and the urine thick. It reauires the early use
of emetics in the cold staffe, succeeded by saline julap. If
the hot stage, however, be nilly established, and the heat con-
siderable, cold sponging will oe of advantage, succeeded by
calomel purges and saline julap, with liffht diet, and the use
of ripe fruit. A free circubition of air, is of essential benefit*
The skin, in the course of the disease, especially among the
poor, should be sponged duly with tepid water, and the bed-
clothes, if possible, changed frequently. If the head be very
painful, in the first stage, the application of leeches to the

837

forehead, and the use of laxatives will be proper ; or if the
pulse be fuU, a little blood may be taken from the arm. If

Eain continue, or stupor, or constant drowsiness supervene,
listers will be proper. The strength, in the latter end of
the disease, is to be supported by the prudent use of wine.
Cough, in general, requires a small blister on the breast, with
the use of expectorants.

INDEX.

Abdominal inflammatioiiy .fiSI^Moa-
det, paiD in, 274.

Abortion, 294*^— ocean at different pe-
riod! of gestation, 296— proceu ataif-
ferent period*, 296 — in twin caaet, 297
— dlTeraity in duration and lymptome,
ib.»4iflrn8 of death of child in, 296 —
divided into accidental and habitual,
299— -predisposing causes, 900— ple-
thora, S06— affection of spinal nerves,
807— theory of, 908— exciting causes,
810u-death of child, ib.— medicines,
dl 1— mechanical {rritation312— prog-
nosis, SIS— prophylaxis, 814— treat-
ment, SI5^treatment when threat-
ened, 820 — ^treatment when com-
menced, 822— progress and effeets of,

Aftcrpains, 662.

AmenorrhoBa, 167.

Amnion, 221.

Antirersion of atemt, 290.

Antiflezion of uterus, 290.

Anus, imperforate, 648.

Apthtt, 701— source of danger In, 702—
causes, 70S— treatment, 704— on ton-
sils, 705— malignant, ib.

Articulation of pubis, 6— sacro-illae, 7
—with Tertebrie, 8---yielding of arti-
culation of pubis, 9— opinions re-
garding (in note), 9— occurring in ges-
tation, II— .during parturition, lb.—
case (in note), 12.

Arteries, and yelns of pdTls, 17— of
uterus, 62.

Axis of peWis, 24.

Augmented capadty of pelvis^ 89.

Back, belly, and breast, presentatiop of,

SCO*

Baldness, 602.

Bladder, situation of, 42— diseases of, 90
— «tone In, lb.— oyroptoms of, occur-
ring without stone, 91— 'Indurated or
schTrrhus, 92— chronic Inilam., ib.—
sloughing of, ib.— Astula, 98— prolap-
sus of, daring labour, 94— hernia of,
96 ■ CTenlop, 97«affBctleDS of, during

prmaney, 260 — connection between,
and uterus In retroverslo uteri, 282.

Boils in infants, 672.

Blisters, treatment of, In Infants, 672.

Bones of pelvis, I ossa innominata, 3
—sacrum, 6.

Breach, presentation of, 410— symp-
toms, ib.— varieties of, 411 — manage-
ment, 412— application of forceps Uh
489.

Bronchocele, 620.

Breasts of children, swelling of, 654.

Bronchotomy in croup, 795— -sixe of
trachea at different ages, (In noU), 797.

Bronchitis, 807.

Burns and scalds, 666.

Catarrh in infants, 807.^

Catheter, Introduction ot, 48.

Cancer of uterus, 110.

Cerebral and spinal irritation, 741.

Cheek, corroding ulcer of, 686.

Chicken-pox, T24w

Cesarean operation, 606— cases, 609—
mode of operating, 612— in rigidity of
OS uteri, 6SS.

Child's pelvis, difference between, an4
adult, 2S— head of, progress through
pelvis during labour, 24.— bones, and
sutures of, iV— dimensions of, 25—
difference between male and female,
20— comparative sise of, with pelvis,
26, 473— passage of, through pelvis,
27— dimensions of, when reduced to
greatest degree, 88, 60S— excessive mo-
tion of, 2^6 — ^signs of having been
horn alive, 687 — appearance or lungs
before and after respiration, 696— >for-
amen ovale and* ductus arteriosus, 690
—(in mote), 640— sinking of lung, 641
—marks of having born one, ^1.^
child, trestment of, immediately after
birth, 642— food, 649— substitutes for
milk, 646— comparative mortality of»
at different ages, 647.

Chancre, characters of, 02— on os uteri,

iia

ChlOTOsis, 166.

840

Chorea, IM,

Chorion, 221.

Cicatricola, 212.

CUtorii,4l — •eiirbons, 09— enlarcenwDt
of, lb.

Colic, 824

Complicated Ubonn, 515 — whh h»iii-
orrhage, ib. — ^bjeniopty«i% 516— «yn-
cope, ib.^«onTiiluiMU^ 617— apop-
lexy, 627.

Conception, 191— 4heoriea and pheno-
mena connected with, 192 — age and
season, most frequent at, 193.

Conf enite and surgical diseases, 6i7. .

Congestion in bead, 7il.

Convulsions during gestation, S66—
hysterical, during labour, 517— ec-
lamptic, 618— -precursory symptoms,
lb.— stuck, 619— causes, 621— treat-
ment, 622— propriety of deTirery, 623
-^Internal remedies, 626 — general
summary of practice, ib.

Convulsions and eclampsia In Infants,
779— causes, TSO-^premonitorv symp-
toms. 7S1— treatment, 782— in older
children connected with dentition,
7B5 — in hooping cough, 806.

Cord, 226— presentetion of, 438— bleed-
ing from, 664.

Costiveness, during testation, 266—
remedies. 267.— in children, 823.

Crotchet, 496— degree of deformity, re-
quiring use of, A?— operation, 600.

Croup, 790— duration of, 791— appear-
ances on dissection, ib.— treatment,
792— bronchotoiny, 796— spasmodic,
797— treatment, 799.

Cramp, 866, 670.

Cystitis, 812.

Cough, in pregnancy, 264— apasmodlc.
.669.

Deformity of pelvis, 29— different kinds
of, (in nott), 30— from rickeu, ib.—
malacosteon, SI— from tumours* 3S,
84, 36— practice In, 36— means of as-
certaining degree of, 87.

Delivery, uterus principal agent In,
893— treatment after, 63$— signs of
having taken place, 631.

Dentition, 662- troublesome, 664.

Despondency, 27d.

DiarrhoM, 268— after delivery, 621— In
Infants, 816— Causes, 818— treatment,
820.

Dimensions of fcBtal head, when reduced
to greatest degree, 88.

Distortions, 663.

Dropsy of uterus, 184— of ovarium, 146.

Dysmenorrhcea, 178.

Dyspnoea, 264— after delivery, 669.

Earach in infants, 668.
Ear, foBtid discharge from, 668— exco-
riation, 696.

Embryo, growth of, 200— lo mammalia,
217— In women, 218— of chldi, 209—
growth of, 214 Mood ▼eiarii mod
heart, 215.

Enteritis In iolhnts, 8ia

Embryotomj, 600.

Ephemeral fever, 572.

Ergot, use of, in tedious Uboor, 418.

Eruptions on infants, depending oo dcn-
titfon, 671.

Erysipelas, 69S.

Erysipelatons aflbeiloa of labia, 700.

Erythema, 696.

Evolution, spontaneous, 422.

Examination during labour, 382.

Excoriations about ears, 696— tongoc^
gums, and lips, 707.

Exostosis affecting capacity of pel via, S3»

Eye, inflammation o^ 669 spongold
of, ib.

Face presentation, 480— means of dis-
covering, 431.

Fallopian tubes, 66 -^malformationa,
169.

Fascia, pelvic, 16.

Feet, presentation of, 415.

Fever attending pregnancy, 260— «ph»-
meral, or weia, or remittent, 572-*
symptomi, 674— local causes, 576—
milk, 677— miliary, 678— intestinal,
579— malignant puerpo'al, 698— la
infancy, 836.

Fistula, vesioo- vaginal, 92.

Flooding, 329— internal, 347.

Fluor albus, 83.

Foetus, growth of, 200— proportion be-
tween weiffht and involucra, 202—
size of at different periods, 202— «am-
paratlve wei|{ht of^male and fensale,
203— else and weight of twins, ib —
plurality of, 204— peculiarities of, ib.
.—liver, ib. — stomach, 206— testes,
206— heart, ib.— difference between
male and female, 207— posture of, la
utero, 208.

Forceps, propriety of early employment,
467— obiiections combated, 468— re-
sults of practice, 471— rules for apply-
ing, 472^power of. In reducing sixe of
head, 474— when to he applied, 477
-.-history and description, 479 — ^modo
of applying, 483— of acting with, 486
—in .preternatoral presentations, 488
—long forceps, 490.

Frenum lingua, operation of dividing^
663.

Generation, external organs of,
mons veneris, ib. — ^labia, 40 — nymph*,
lb.— clitoris^ 41— urethra, 4*1— orifice
of vagina, 44— perinvum, 46— internal
organs of, 47— diseases of organs of,
60— of labia, 60^67— of nymphs, 67—
of clitoris, 69hp-hymeo, 70— peri-

841

lUBam, mptare of, l^^-of vagiiia,75-90
—bladder, 9<MW— nterus, 9B-146.

UMUtion, dimtion of, 101 dhfm of
246.

Gravid utems, 194.

Gnma, uloeratlon of, 697.

Hand, presentation of, 416.

Hare-lip, 648.

HAinatemesIs, and hemoptysis in gesta-
tion, 264— during labour, 616.

HiBmorrbage^ effects of, 18S— (menor-
rhagia) 180.

HieiBorrliage» uterine durinr gestation,
820— natural cure, 981.— bbod whence
derived, 892— causes, 884— effecta of,

• 939, prognosis, 841— treatment, 942
blood-letting. 944— cold, 345— plug-
ging, 346-4nternal, 947— means of
preventing return of, 340— diet, 961—
medicines, 858— attendant symptoms,
959— delivery, 965— mode of proceed-
ing, lb. — when to be performed, 967
-.-puncture of membranes, 350 — ^pre-
senUtioo of placenta, 969— dilatation
jsf OS uteri, 9b6-«oeourring during
labour, 515 — after delivery, 641—
causes, 542— want of contraction of
uterus, ib.— spasm, 549— prevention,
645— treatment, 647— modes of pro-
ducing contraction, 54t^— cold, 540—
terdials, 651.

H«morrliaf|e, from cord, 654.

Head, chiliTs, bones of, S4— dimensions,
25 difference between male and
female, 26— compared with pelvis, ib.
—passage of, through pelvis, 27— posi-
tion of, at diffsrent stages of labour,
989.

Head, preternatural presentations of,
497— forehead, ib.— fontanelle, 429—
crown of head, ib. occiput, 490—
side of head, ib— face, ibw^cxtent of
reduction of sise bv forceps, 474—
swelling of, after tedious labour, 652.

Headach, 265— treatment, ib.— ending
in apoplexy, ib.

Heart of foitos, 806— malformation of,
659.

Heartburn, 256.

Hernia, pudendal, 6&~into vagina, 79
—of bladder, 05— of uterus, Ufr^um-
bilical, flic, in children, 650.

Herpce, 677— varieties of, 679— trcau
ment, 670.

Hepatitis, in infancy, 984.

Hooping cough, 902— danger of, 909
treatment, 904— convulsions In, 906.

Hydatids, 191.

Hydrocephalus, 766— acute, 767— ap-
pearancee on dissection, 77 1.— causes,
ib.^nature of, 772— treatment, 774—
chronic, 776.

Hymen, 47«— rupture of, 46— imperfo-
rate, 70.

Hysteria, 168— syroptans, 164— treat-
ment, 165— prevention of, 167.

Hysteralgia, 664.

Hysterical convulsions during gesta-
tion, 266.

Icthyosis, 691.

Impetigo, 690.

Impracticable labour, 509.

Incubation, 20&— formation of mem-
branes in, 209.

Inflammation, abdominal puerperal,
691.

Inflammation of uterus, 564— symp-
toms, ib— treatment, 595— extausive,
696 — symptoms, ib. — treatment, 689
"-peritoneal, 69i— symptoms, 609—
treatment, 604— chronic, 607-«of mu-
cous coat of Intestine, ib..~of eyes in
infants. 650— of pleura, 909— or stom-
ach, 900.

Instrumental labour, 463— impaction,
464-^rrest of head, 467.

Intestins, fold of, between uterus and
rectum, 54.

Intestinsii fever, 670.

Intertrigo, 671.

Inoculation, 719 — vaccine, 720.

Inversion of uterus, 655 causes, 656—
treatment, 656 —extirpation, 650—
cases (in note, 660.)

Jaundice .during pregnancy, 261— in
infants, 982. '

Labia pudendl, 40— phlegmonous in->
flammation of, 60 — ulceration and ex-
coriation of, 61-^^hancre, 62— phaga-
dena, 63— warty excrescences from,
64 solid tumours, 66— esdematous
tumours, 66— hernia, ib. — ulceratiou
or sloughing in children, 700.
labours, classification of, 872 — ^propor-
tion theee bear to one another, 97^—
n«turai,976— divided into threestagee,
976— pains, ib. description and pro-
cees of, 977— duration, 970— compara-
tive length of stages varying, 960—
among women of various nailons ( in
note), 991-»progress to be ascertained
by examination, 882— oe uteri, position
and dilatation of, 894— protrusion of
membranes, 800 position of hsad,
980— the stages of, marked by mode of
expressing pain, 801— why coming on
at end of ninth month, 902— delivery
principally effected by uterine effort,
90S— preparations for, and dress of
patient, 805— management of women
during, 806— after, 68d support of
perin»um, 89^— management after
expulsion of child, 401— expulsion of
placenta, lb-
Labour, premature, 406— bklnctloa of,
^506— preternatural, 409— tediou% 489

842

— initrumeDtal, MSB ■Impracticable,

506 — oompllcatod, 516.
Leg, ■weilcd, 607.
Lepra, 681.
Lever, 4M.
Levator anl, 14»
LeueorrhoM, 83 camee of, 84 eeat of,

85— different klnde of, 86— treatment

of, 67— puralent discharige, 60.
Lichen, 670.

Lip, corroding vlcer of, 698.
LIgamenta of atemt, 58-4&5— change of

during gestation, 196^
Liquor amnii, 222-^redandaney of, 270

— lymptoms, 371— treatment, ib.—

propooal to draw off water, 278.
Linea alba, ruptore of, 277.
Liver of fcBtna, »Q4~diaeaeee of inftats,

888.
Longing, 255.
Lung, appearance of festal, before and

afMr respiration, 688— inking or

swimming of, 641.
Lymphatics wRhio pelvis, 19.

Malaoosteop, affecting pelvis, 81«
(in Mofe), 81, ae— treatment of, 83.

Malignant, puerperal fever, 606.

MamnMB, pain and tension during gMta-
tion, £67— Inflammation of, 681—
structure of, 622- Inflammation of,
three species of, 683— treatment, 624
induration, 627— ^abscess, lb.

Marasmus, 886.

Mania, puerperal, 613— treatment, 615.

Measles, 785.

Melancholy, 616.

Menses, retention of, from Imperfomte
hymen, 70.

Menstruation, 160— phenomena attend-
ing, lb.— «ge at which It commences,
161— quantity, lb.— theories respect-
ing, ]6Si— ^llseased, i 167— retention,
166— action of nerves on, 160— treat-
ment of, 171-173— suppression, ITS—
treatment,174-176— membranoussub-
stance discharged, 177— dysmenor-
rhoBa, 178— copious or frequent, 179.

Menses, cessation of, 189.

Menorrhagia, 180— eanses» 181— effects,
of, 182— management during attack,
188— treatment after, 186.

Membrana deddua, 220.

Membranes, formation of. In Ineubation,
800.

Membranes, protrusion of. In labour,
888— rupture of, in tedious labour,
445.

Milk fever, 577.

Miliary fever, 570 eruption 679.

Milk, constituent parts of, 646— anbotl-
tnte for, lb.

Mole, 180.

Marks and biMBlshes, 658.

Monstrous birth% 487.

Mono veneris, 89.
Muscles within pelvle, 14.
Muscular flbres of utcms during

tlon, 197.
Mnsdes, pain of abdominal, ftvn dia.*

tension, 274— of pdvls and hips, ib.

— yieldlog of, 278— rupture of, 877.

N«vl, 652.

Navel, prominence of. In pnfBaiicyv

277— esccorlation of, in children, 654

hamorrhage from, OS^-treatmealt

655.
Nervee of pelvis, 17— connerioQ of

spinal and symps^hetlc, 19 of vagina,

45— of uterus, 52.
Nervous and spasmodie diMaaes afker

delivery, 668.
Nipple, excoriation of, 687.
Nostril, foBtld, secretioD fima, la lafaBtSy

656.
Nymphn, 40— diseases, of 67— tumovr

of, 68— wounds of, 69.

QE^ema during gestation, 208L
Ophthalmia, pofnlent, in Intets, 668L
Os uteri, ulceration of, lOfl phagndtna^
107— gloeey ulcer of, 100 saerescMn-
oes, 100 cauliflower ezersseenee of
Clarke, 109— venereal nleeratlea, 110
—change of. In pregnancy, 195.
Ovaria, 66— comparative anatomy of, in
note, 6&— Graafian vesidsa— eorpen
lutea, 57— in fcstus, 50 ilissasss oi;
146— dropsy, effects and sympeoms,
140 treatment of, 151-4^piag, 158
—extirpation, ib.— scrofnlona tu-
mour, 157— eolid tumour,
ment, Ib. absence of, 159.

Pains, false, in pregnancy, 888.

Palpitation during gestation, ^
delivery, 5d8.

Paralysis, 618, 789.

Pelvis, bonee of^ 1— oosa Inneminata,
2— aacrum, 6 articulation of, fr«
obliquity of, 8— soft parte withlB, 14
—levator ani— pelvic fmd^ 16—
arteries and ^ veins, 17 - nerfee, ib.—
lymphatics, 19^— dimenslona ^ 91^—
brim and outlet, 20^ 21— carity, 21—
dimenelone of cavity, 82 dJmsnrions
of upper or creat, 23 dilhranea of
shape in child and adult, W axis of*
24— comparative sixe of, with ehUd^
head, 26, 478, 491, 406 paasaga eT
head through,29 dlmiaiehed oaMolty
of and deformity, 21^- from rkk«ls»
30— malaoosteon, 31«
tumours, 34, 85— mractiee in

—practiee in mmeh
01 aaesrtaininc do-

gree of defcrasity,

capacity of, 89.
PerforaUon of head, 500.
PerJnaum, 46— eupport of^ dwii^ la-

843

boar, 2SS niptitft of, 7»i tgtfctmmt,
78.

PeritoBmuB, nflectiont of, 6S— inflam-
matioo of^ 698.

Feritonitit, 692.

Phlebitis, utoriBO, 69a-trmlmeiit, 602.

Plilflffinasia dolonty 007.

FhrMiitls, 613.

PilM, 269.

Pityriasia, 686.

Pemries, 148.

Plaoenta, OT2 itrugtiira of, SSS— oon-
nexion with nttrna, 824— growth of,
S86— diacaata of, 826— praBantation of,
a6SU-azpiiIiioii of^ 401— 4«tantioD,
408, 666*-aztnctioa of, 409, 667—
retainad hy apaanti, 404^-4>7 adhadoo,
406.

Plnrallty of ohlldreD, 904.

Pnaomonia, 666, 484b

Fftsnaner, aztra-ntarina, SaC^-^jmp-
toma, 8ai...aMaa (In aalt), 861-867—
oouna of, 234— tnataaant, 888— oaaea
in Nola.

IVcfiiAnoy, aigna of, 840— IrrltaUa atata
of stomaoh, ib.— aappraation of man-
aai^ 241— appearance of abdoaaan, 842
— quickening, 848— blood, 844— ex-
amination per vaginam, 844 ■ atathoa-
oope, 846.

Pregnant women, diaaaam of, 846— af-
feetiona of the bowels, 847— d vspeptia
aymptoma, 848— treatment, 84^fo-
ver attending, 860— treatment, 861—
▼omiting, 868— treatment, 866— heart-
bom, 866— looginga, lb.— apaam, 856
— ooatiTeneei, ib.— diarrhoBa, 266—

J>ilee, 860 affectione of bladder, 860—
anndiee, 861— palpitation, 868— ajn-
oope4l68— dyapnoa, 864— hmnoptyais,
ib.— hcadacb, 866— toothaoh» 867—
eallTatien, lb.— pain of mamma, ib—
cedema, 288— aaeitee, 869 Mqoor am-
nii radondant, 870— mnacnlar pain,
874— apasm of ureter, 896— lower ex-
tremitifle, lb. axeeeiJTa motion of
child, 276— deepondeney, a7&— abor-
tion, 894.

Firematnra lahoor, 406— treatment, 407
excited in dieeaaa of pregnan<^, 408—
indoetion of. In deformity of pehrle,
606.

Pretamatoral Ubonr, 409 praeantation
of head, 487.

Preaentationa of head, 000- hreech, 410
—feet, 416— shoulder and arm, 4]fr—
bad^ belly, and breaat, 486— preter-
natural of head, 427— of ftee, 4i90^-of
cord, 488.

ProlaMus uteri, 186.

Plrooidentln uteri, 188— natoral proTon-
tion, 189— treatment of, 141— remo-
val of, 144.

Prurigo, 694.

Polypus uteri, 12^— structure of, 126.

Pompholyx, pemphigus^ 673L

Porrtgo, 686— larfalia, 687— treatment,
688— furfurans, 689— lupinoaa, 689—
acutulata, 690.

Purpura, 692.

Psoriasii^ 682— modiiiflatlana of, 688—
treatment, 684.

Puerperal fever, malignant, 608 eymp»
toBOs, ib.— contagiooa, 601— enlnione
regarding treatment (in note), 608^ 8^ 4
—treatment, 603— mania, 613.

Pubis, yielding of articulation, 6 ease
of, (in note), 18— effecte of, ib.— treat*
ment, 11— dlTiaion of symphisis In
contracted pelvis, 613.

Pudendal hernia, 66.

Rape^48.

Rectum, '.66— ephincters, ib.— obetrno-
tlon, 6fll^-epasm of, 69— blood vasasla
and nervee, 60. cancer, lb.— connec-
tion with vagina, 49.

Recto-vaginal septum, rupture of, 78.

Retention of mensee, 168.

Retroversio uteri, 879— eymptoma, Ih.
—examination per vaginam— 860
—mode of production oi, 281— eoo-
nection between uterus and bladder,
888— connexion of uterus and rectum,
888 danger of, 884— remedial pro-
cess, 886— introduction of catheter,
886— operation for replacing uterus,
887— continuing during gestation,889.

Retroflexion, of uterus, 290— after de-
Uvery,668.

Rickets, affecting pelvU, 80 cases o^
(in «0^8(», 661.

Rubeola, 736.

Rupture of gravid uterua, 890— aymp-
toma, 891— cases (in note>— treat-
ment, 893— of utema, during labour,
627— causes, 688- casee 689— eymp-
toms, 680— treatment, 688— CMireaa
operation, 688.

Sacrum, 6.

Salivation, 867.

Scalds and burns, 666.

Scabies, 676— trsatment, 676.

Scaly tetter, 688.

Scarlatina simplex, 780 angJnoia, 789
— ^maligna, 7S0— treatment of alm^ez
and anginoea, 731— of maligna, 183,

Scrofula, 660.

Sensibility, preternatural, of gravid
uterus, 876.

Shoulder, preeentation of, 416— prac-
tice in, 417— turning, 418— sponOUM*
ous evolution, 488.

SIgne of pregnancy, 840— of child bav*
ing been bom auv% 6S7— of awooMa
having been delivered, 681.

Skin, dieeaaes of, 666— structure of, (in
note), 666.

844

Skin bound, 71S.

Snudl-pox, tratraent of, 717— «onfla-
enCib.

Spasm, during gestation, 256— of nreter
and lowor extremities, 375.

Spasmodic, and nenrous diseases. 568.

Spina bifida, 650— treatment, 65 i.

Spongoid disease of eye, 659.

Spontaneous evolution, 482— measure-
ments in, 4Qi— operation in, 435.

Sterility, 229.

Strangury, 668.

Strophulus intertrinetus, 667— albidus,
668 eonfertus, 668— variety, 667—
caiididus, 670.

Suppression of menses, 173.

Suppression of urine, during labour,
586.

Sudamina, 674.

Swelled 1^, 607— opinions respeeting,

• 610— treatment, 61 S.

Syncope during gestation, 968 — oon-
4iecled with state of heart, 864— du-
ring labour, 516— from flooding, S58.

Syphilid 708.

Tabes mesenterloa, 896— treatment, 888.

T»nia,8dl.

Tedious labour, 488— general view of
causes and treatment, 4S39-*first order,
dependent on ineiBcient action, 441 —

• treatment, 448-^venesection, 443 ■

• opiates, 444— friction, 446— rupturv of
' membranes, ib.— change of posture^

446— artificial dilatation of os uteri,

I Ibi — eiigot, 448— tedious labour from

Irritation of some other organ, 462'~

second order, from irreguuir action,

464^— from over-action, 455— fever or

' Inflammation, 456— prolapsus, 457-^

- contracted p<*] vis, 466— rigidity of soft

• parts, 459— affeetions of os uteri, 460
—other mechanical causes, 461.

Testes in fntus, 806.

Teeth, formation of, 668 appearance

of, 66a
Tetter, 668.
Tinea, 686.
Toothach, 867.

Trachea, sixe of, (in noTs), 797.
Tk'ismus nascentlum, 7B4.
Turning, 4ia
Twins, Soa
Twin labour, 484.
Tumour affecting capacity of pelvis, 85

• -^practice in, 86.
Tympanitis, 680.

Umbilical cord, 286— structure^ 887—

length, ib.— diseased sutes of, 888.
UmbDlcal hernia, 650.
Uretar, spasm of, 875.
Urethra, 42— excrssoences In, 96— ever*
i sion of, 97— imperforate, 648.

Urioa, InoontUMiiee o^04 rsteiition of,
during pngnancy, 860 — incontinenea
during prcgnaoey, 86 1— auppressisg
of, diuring labour, 586.

Urticaria, 786.

Utrrus, 49-»cavity of, 60-4iniDg mem-
brane, ib.— dimensions of nnimpreg-
aated, ib. — ^in infancy and at pul
51^ttbstance of, £&— blood v«
and nerves of, ib.— 4vmpliatics,
peritoneal covering, ib.— broad Liga-
ments^ ib.— 4«ana ligaments,
Fallopian tubes, ib.— ovaria, 56.

Uterus, malformations of,
ib.«4nflammatioo of unimi

- 1 00 eanaes and symptoms, U
ment, 101— ramolussement, 102 —
chronic inflammation of,
natural sensibility of,
oer, IIC^— oymptoms, ill Irwlment,
1 18— operation for, 1 16 tubercles of,
117— 'treatment, 119— strumous affee-
tione of, 119— encysted tumoun^ 190
— spongoid tumour, 121— earthy ooo-
cretions, 129-^olypus, 12S— «onneof;
4b. — attachments, 124— otmeture af;
125— treatment, 196— Ugaiore, 127—
excision, 129— fungous tumour, ib.<^
mole, 180— hydatids, 181— dropsy of,
184— worms, 186— secretion of air by,
lb.— prolapsus, 186— hernia, 146.

Uterus, gravid, 194— else o^ at varlooa
periods, 196-«hanfe of podtloo of,
196— change on oervlx, ib.— muaealar
fibres of, 197— change in pooitioii of
ligaments, 198— blood vessels o^ iW—
deseripUon of, soon after cooceptlen,
199— embryo growth of, 900— oem-
brana deddna, 920— chorion, 221—
amnion, ib.^plaeenta, 822— preterna-
tural sensibility of, 975— leUotersisn,

; 979— antiverslon, 290— rupture o^ ib.
opened by ulceration, 294^

Uterus, principal agent in expuhleii of
child, 898— laoeraUon of, 529-4nv«r.
sion of, 565— >lnflammation o^ after
delivery, 586.

Uteri, OS, ulceration of, 106 ■dilatation
of, 865— poeition and dilatation of, in
labour, 884— varieties of, 886— artlfi-
oial dilatation of, 446— affsetlona of,
causing tedious labour, 467 160
rigidity of, 683— opsration for, lb.

Uterine hnmorrhage, 641— phlsUtis^
690.

Vaccination, 720L-4pnrioua, 721 tti-
caey of, 728.

Vagina, orifice of, 44— vagina, 47—
nerves of, 46— connection with rso»
tnm, 49--diseases of, 76 smallnees
of, ib.— septum aorees, ib.— slough-
ing, 76— eensitive state of sphinetcr,
77— scirrhous, ib.— eversion or

845

lapsus, 78 — wmter between reetam Veins of pelvis, 17.

and, 79— hernia in, ib.— «bseess and Vomiting daring pregnancy, 2&3— in

encysted tamours, Sl^varicose tn- infancy, 812.
mour, ib.^ spongoid tumonr, 81 —

erysipelatous inflammation, 82^pru- Warts, exereioences of labia, 64.

rigo, 8S— leuoorrhoBa, 8S~pttrttlent Water, discharge of, from vsgina daring

discharge, 89— vesico-Taginal fistula, pregnancy, 27*2 — from hydatid, 27S.

92— plugging, 846. Weld, 672.

Varicose tumours in leg dependent on Worms, 890~in uterus, 185.
pregnancy, 274.

THE END.

OLA8aOW>
Edward Khull, Prioter to the UDivcnltr, Dnnlop Street

OBSTETRIC PLATES,

WITH EXPLANATIONS,

SELBCTBO FROM

THE ANATOMICAL TABLES

WILLIAM SMELLIE, M.D.

LONDON:
SAMUEL HIGHLEY, 32, FLEET STREET.

MDCCCXXXVIt.

LONDON: PRINTED BT J. ORKBN AND CO.. BARTLSTT'S BUIUDIN08.

ADVERTISEMENT.

The acknowledged accuracy of these plates
fiilly justifies liieir repubUcation. To the
student in Midwifeiy, and also to the more
advanced practitioner they will he truly useful.
To the one, they will faithfully teach, and in
the mind of the other, they will revive what he
has in earUer times heen taught. No drawings
of the kind have ever exceeded Smellie's in
value.

A 2

PLATE I.

The last dorsal vertebra.

The OS pubis, on the left side.

C.C.

The OS uteri.

The vagina.

The 1^ nympha.

The left labium pudendi.

The renudning portion of the bladder

The anus.

1. 1. The left hip and thigh.

PLATE I.

.» -.

••

• J — J

i • I V r

. -t

» ' V

PLATE IL

Shews the natural position of the head of the
fcetus when sunk down into the middle of the
pelvis after the os internum is fiilly opened^ a large
quantity of the waters being protruded with the
membranes through the os externum^ but pre-
vented from being all discharged by the head
filling up the vagina.

The vertex of the foetus being now down at the
inferior part of the right os ischium, and the wide
part of the head at the narrow and inferior part of
the pelvis, the forehead, by the force of the pains,
is gradually moved backwards, and, as it advances
lower, the, i^erteoo and occiput turn out below the
pubes, as in the next plate. Hence maybe learned
of what consequence it is to know, that it is wider
from side to side, at the brim of the pelvis, than
from the back to the fore part; and that it is
wider from the hind to the forehead of the child
than from ear to ear.

PLATE II.

A. The uterus a little contracted, and thicker

from the partial escape of the liquor
amniu

B. The anterior superior spinous processes of

the ilia.
C The inferior part of the rectum.

D. D. The vaffina largely stretched.

E. E. The OS uteri fully opened.

F. A portion of the placenta.
6. G. The membranes.

H. H. The lig amenta lata.

1. 1. The ligamenta rotunda; — both these are
stretched upwards with the uterus.

'^,f^

"•t^

PLATE III.

A. The utertis contracted closely to the
foetus, after the evacuation of the
liquor amnii.
B. C. D. The vertebra of the loins^ os sacruniy and

coccyx.
£. . The a$ms.

F. The left hip.

G. Thej^mnceww.

H. The OS externum beginning to dilate.
I. The 0^ pubis of the left side.

K. The remaining portion of the bladder.
L. The posterior part of the os uteri.

N. B. Although, for the most part^ at or before
this period the waters are evacuated, yet it ofi;en
happens, that more or less will be retained, and
not all discharged till after the delivery of the
child, occasioned from the presenting part of the
foetus coming into close contact with the lower or
under part of the uterus, vagina, or os externum,
immediately or soon after the membranes break.

S u

. 1"'

''..: i-

or '

Mm ^

{ '

.•7

1
1 ..

• i»

f » 1'

;»

i».*

,.,^tii •:

M X

PLATE IV.

And the three following show in what manner the
head of the fietus is helped along with the forceps
as artificial hands, when it is necessary to assist
with the same for the safety of either mother or
child. In this plate,* the hand is represented as
forced down into the pelvis by the labour pains
from its former position in plate I.

The patient, in this case, may be, as in this plate.'
on her side, with her breech a little over the side
or foot of the bed; her knees being, likewise,*
pulled up to her belly, and a pillow placed between
them, care being taken at the same time that the
parts are by a proper covering defended from the
external air. If the hairy scalp of the foetus is so
swelled that the situation of the head cannot be
distinguished by the sutures^ as in plate IX. ; or if
by introducing a finger between the head of the
child and the puhes or grains , the ear or back part'
of the neck cannot be felt, the as externum must be
gradually dilated in the time of the pains with the
operator*s fingers, (previously lubricated with hog*s
lard) till the whole hand can be introduced into
the vagina, and sUpped up in. a flattish form be-

tween the posterior part of the pelvis and the
child's head. This last is then to be ndsed up as
high as possible, to allow room for the fingers to
reach the ear and posterior part of the neck.
When the position of the head is known, the ope-
rator must withdraw his hand, and wait to see if
the stretching of the parts will renew or increase
the labour pains, and allow more space for the ad-
vancement of the head in the pelvis ; if this, how-
ever, proves of no efifect the fingers are again to be
introduced as before, and one of the blades of the
forceps (lubricated with lard) is then to be applied
along the inside of the hand or fingers and left
ear of the child, as represented in the plate ; but if
the pelvis is distorted, and projects forward at the
superior part of the os sacrum, and the forehead
therefore cannot be moved a little backwards, in
order to turn the ear from that part of the pelvis
which prevents the end of the forceps to pass the
same ; in that case, I say, the blade must be intro-
duced along the posterior part of the ear, at the
side of the distorted bone. The hand that was in-
troduced is then to be withdrawn, and the handle
of the introduced blade held with it as far back as
the perifUBum will allow, whilst the fingers of the
other hand are introduced to the Os Uteri at the
pubes or right groin, and the other blade placed
exactly opposite the former ; this done, the handles
being taken hold of and joined together, the head is
to be pulled lower and lower every pain, till the ver-

teXj as in this plate, is brought down to the inferior
part of the left ischium, or below the same. The
wide part of the head being now advanced to the
narrow part of the pelvis between the tuberosities
of the ossa ischium is to be turned from the left
ischium, out below the pubes, and the forehead
backwards to the concave part of the as sacrum,
and coccyx, as in plate V. and afterwards the head
brought along and deUvered, as in plate VI. and VII.
But if it is found that the delivery will require a
considerable degree of force from the head being
large or the pelvis narrow, the handles of the for-
ceps are to be tied together with a fillet, as repre-
sented in this plate, to prevent their position being
changed whilst the woman is turned on her back,
as in plate XII., which is then more convenient for
delivering the head than when lying on the side.

This plate shows that the handles of the forceps
ought to be held as far back as the os externum
will allow, that the blades may be in an imaginary
line between that and the middle space between
the umbilicus and the scrobiculus cordis. When
the forceps are applied along the ears and sides
of the head, they are nearer to one another, have
a better hold, and mark less than when over the
occipital and frontal bones.

, i

PLATE V.

In the same view with the former, represents in
outline the head of .the foetus brought lower
with the forceps, and turned from the position in
the former plate, in imitation of the natural pro-
gression by the labour pains, which, may, likewise,
be supposed to have made this turn before it was
necessary, to assist with the forceps.

In this view, the position of the forceps along the
ears and narrow part of the head is more particu-
larly expressed. It appears, also, that when the
vertex is turned from the left os ischium^ where it
was closely confined, it is disengaged by coming
out below the pubes, and the forehead that was
pressed against the middle of the right os is^
chium is turned into the cavity of the os sacrum
and coccyx. By this means the narrow part of the

head is now between the o^sa ischia or narrow
part of the pelvis ; and as the occiput comes out
below the pubes^ the head passes still easier along.
When the head is advanced so low in ^epebns^ if
the position cannot be distinguished by the sutures j
it may, for the most part be known by feeling for
the back part of the neck of the /atus, with a
finger introduced betwixt the occiput and pubes, or
towards one of the groins if the head is squeezed
into a longish form, as in plate IX. and has been
detained many hours in this position, the pains
not being sufficient to complete the delivery, the
assistance of the forceps must be taken to save the
child, though the woman may be in no danger.
But if the head is high up in the pelvis, as in the
former plate, the forceps ought not to be used ex-
cept in the most iu*gent necessity.

This plate also shows that the handles of the for-
ceps are still to be kept back to the perinaum, and
when in this position are in a line with the upper part
of the s(icrumy and if held more backwards when the
head is a little higher, would be in a line with the
scrobiculus cordis. If the forceps are applied when
the head is in this position, they are more easily
introduced when the patient is in a supine position,
as in plate XII. ; neither is it necessary to tie the

handles, which is only done to prevent their
alteration when turning the woman from her side
to her back.

In some cases a longer sort of forceps, that are
curved upwards, are of great use to help along the
head when the body is delivered first, the same are
represented here by dotted lines ; they may be
used in laborious cases as well as 'the others, but
are not managed with the same ease*

'•/'

-', '

♦ I

. ' • I •

-' ij :■• H,f'/,y :i" f,;,! SlrmlSJJ

PLATE VI.

In the same view and section of the parts^ shews
the head of the ftetus in the same position, but
brought lower down with the forceps than in the
former plate ; for in this the os externum is more
open, the occiput come lower down from below
the pubes, and the forehead past the coccyx, by
which both the antis and perinaum are stretched
out m form of a large tumour.

When the head is so far advanced, the operator
ought to extract, with great caution^ lest the parts
should be torn. If the labour pains are sufficient,
the forehead may be kept down, and helped along
in a slow manner by pressing against it with the
fingers, on the external parts below the coccyx : at
the same time, the forceps being taken off, the
head may be allowed to stretch the os externum,
more and more, in a gradual manner, from the
force of the labour pains, as well ba assistance of
the fingers. But if the former are weak and insuf-
ficient, the assistance of the forceps must be con

B 2

tinned. (Vide the description of tiie parts in plate
IV).

S. T. in this represent the left side of the os
uteri; the dotted lines demonstrate the situation
of the bones of the pelvis^ on the right side ; and
may serve as an example of all the lateral views
of the same.

a. b. c. h. The outlines of the os ilium.

D. e. f. The outlines of the pubis and ischium.

m. n. The foramen magnum.

MUTi;^ 1/

• •»

^ •-.

"v ' \' ^'': (^'S-!-; \.- ; vt :* :* p 'v:c !

: » ••

• 4

I . 1 «

V.'i

. •

'y. I

••»

' J

;l.b..^ •^ TlV .►»'*'' 'r'.i .')t' *^ (' ">• '* '/.'r.

I » >

• '•>

» • ■

}'' ^ i ••'",. . /

PLATE VII.

In the same view and section of the pelvis is in-
tended by outlines to shew that as the external parts
are stretched^ and the os externum is dilated, the
occiput of the /tetus rises up with a semicircular
turn from out below the pubesy the under part of
which bones are as an axis or fulcrum on which
the back part of the neck turns, whilst, at the
same time, the forehead and face, in their turn
upwards, distend largely the parts between the
coccyx and the os externum.

This is the method observed by nature in stretch-
ing these parts in labour ; and as nature is always
to be imitated, the same method ought to be fol-
lowed when it is necessary to help along the head
with the forceps.

PLATE V.

A. A. B. C.

The lumbar vertebra^ os sacruniy and

coccyx.

D. '

The OS pubis of the left side.

The remaining part of the bladder.

The intestinum rectum.

G. G. G.

The uterus.

The mons Veneris.

The clitoris, with the left nympha.

The corpus cavemosum clitoridis.

L.M.

The anus.

M.N.

The perinaum.

a P.

The left hip and thigh.

The skin and muscular part of the

loins.

The left labium pudendi.

The common integuments of the ab-

domen.

The short forceps.

SmeUie's long curved forceps.

PLATE VIII.

Shews tibe head, after the completion of the turn,
in the contrary position to the three last figures,
the vertex being here in the concavity of the
sacruMy and the forehead turned to the pubes.

PLATE Vlll.

A. B. The vertebrcB of the loins, os sacrum, and

coccyx.

C. The OS ptMsy on the left side.

D. The anus.

E. The OS externum, not yet begun to dilate.

F. The nympha.

O. The labium pudendi, on the left side.
H. The hip and thigh.
L I. The uterus contracted, the liquor amnii

being aU discharged.

When the head is small, and the pelvis large, the
parietal bones and the forehead will, in this case,
as they are forced downwards by the labour pains,
gradually dilate the os externum, and stretch the
parts between that and the coccyx, in form of a I

large tumour, till the face comes down below the
puhes, when the head will be safely delivered. But
if the same be large, and the pelvis narrow, the
difficulty will be greater and the child in danger,
as in the following plate.

>'}

'/ : .

.-•»

PLATE IX.

Represents the head of the Foetus in the same
position as in the former plate, but being much
larger, it is by strong labour pains squeezed into a
longish form, with a tumour on the vertexy from
the long compression of the head in the pehis. If
the child cannot be delivered with the labour pains,
or turned footling, the forceps are applied on the
head, as described in this figure, and brought along
as it presents ; but if that cannot be done without
running the risk of tearing the perifUBumy and even
the vagina and rectum of the woman, the forehead
must be turned backwards to the sacrum ; to do
this more effectually, the operator must grasp
firmly, with both hands, the handles of the forceps;
and, at the same time, pushing upwards, raise the
head as high as possible, in order to turn the fore^
head to one side, by which it is brought into the
natural position; this done, the head may be
brought down and delivered as in plate IV.

K. the tumour on the vertex. The same com-
pression and elongation of the head as weU as the
tumour on the vertex, may be supposed to happen.

«p

in a greater or less degree, in the 4th, 5th, 6th, and
7th plates as well as in this, where the difficulty
proceeds from the head being large or the pelvis
narrow.

L. the forceps. Sometimes, the forehead may be
moved to the natural position by the assistance of
the fingers, or only one blade of the forceps. The
forceps may either be of the straight kind, or such
as are curved to one side, when it is necessary to
use one or both blades.

M. The vesica urinaria much distended with a
large quantity of urine, from the long pressure of
the head against the urethra^ which shows that
the urine ought to be drawn oS, with a catheter,
in such extraordinary cases, before you apply the
forceps, or in preternatural cases where the child
is brought footling.

N. The under part of the uterus.

0. 0. The OS uteri.

■J A ^'.- V-;.'' ; '.

» . '^•

< i

f ,

I. 14

.: • t

PLATE X.

Shows, in a front view of the parts, the fore-
head of the fiBtus presenting at the brim of the
pelvis, the face being turned to one side, the fan-
tanelle to the other, and the feet and breech to-
wards Xhib fundus uteri.

PLATE X.

A. A. The superior parts of the ossa ilia.

B. The anus.

C The perimeum.

D. The OS externum.
E. E. E. The vagina

F. The OS uteri not yet fiilly dilated.
G. G. G. The uterus.

H. The memibrana adiposa.

If the face is not forced down^ the head will,
sometimes, come along in this manner^ in which
case^ the vertex will be flattened, and the forehead
raised in a conical form ; and when the head
comes down to the lower part of the pelvis^ the
face or occiput will be turned from the side, and
come out below the pubes. But if the head is
large, and cannot be delivered by the pains, or if
the wrong position cannot be altered, the child
must, if possible, be brought footling, or delivered
with the forceps.

A.
* *

* IK • . •

a 12

J . . . » \\'

• ■>

-/ iy ^ ffylliy 3} F!,el Slf" M '/

PLATE XL

Shows, in a lateral view, the face of the child pre-
senting, and forced down into the lower part of
the pelvis f the chin being below the pubes and the
vertex, in the concavity of the os sacrum. The
liquor amniij likewise, being all discharged, the
uterus appears closely joined to the body of the
child, round the neck of which is one circum-
volution of the funis.

PLATE XL

A. B. The vertebra of the loins, os sacrum^ and
coctya^.

C. The as pubis on the left side.

D. The inferior part of the rectum,

E. The perifueum.

F. The left labium pudendi.
6. G. G. The uterus.

When the pelvis is large, the head, if small, will
come along in this position and the child be saved ;
for, as the head advances lower, the face and fore-
head will stretch the parts between the franum
laborium and coctyx in form of a large tumour. As
the OS externum^ likewise, is dilated, the face will
be forced through it ; the under part of the chin
will rise upwards over the anterior part of the pubes
and the forehead, vertex^ and occiput y turn up from
the parts below. If the head, however, is large,
it will be detained either when higher or in this
position; in this case, if the position cannot be
altered to the natural, the child ought to be
turned and delivered footling. If the pelvis, how-
ever, is narrow, and the liquor amnii not all gone^
the vertex should, if possible, be brought to present;
but if the uterus is so closely contracted that this
cannot be e£fected, on account of the strong
pressure of the same, and slipperiness of the child's
head, in this case the method directed in the
following plate is to be taken.

«*1

I ,,, .«

,»

I u

tK.

1. i

»i . ♦

' t:

;

'"S

• . - -.An

H ty S.aifU^.M.IU>t Sbma. U37.

: t

l»¥

I •

• «

.1 li.t ii' •• I

.».

1 •

( 1 1

f .

rLJTi' m

Zandim. JiMuAsd by S. Ei^hlej 5Z, TUet Strut, JdSJ .

PLATE XII

Rbpresents, in the lateral view^ the head of the
fcetus in the same position as in the former plate^
but the delivery is supposed to be retarded from
the largeness of the head^ or a narrow pelvis.

In this ease, if the head cannot be raised and
pushed up into the uterus, it ought to be delivered
with the forceps in order to save the child. This
position of the chin to the pubes, is one of the safest
cases where the face presents, and is most easily
delivered with the forceps, the manner of intro-
ducing which, over the ears, is shewn in the plate.
The patient must lie on her back, with her breech
a little over the bed, her legs and thighs being
supported by an assistant, sitting on each side.
After the parts have been slowly dilated with the
hand of the operator, and the forceps introduced
and properly fixed along the ears of the child, the
head is to be brought down by degrees, that the
parts below the os externum may be gradually
stretched ; the chin then is to be raised up over
the pubes whilst the forehead, fontanelle and occi-
put are brought out slowly from the perimeum and

fundament, to prevent the same from being lace-
rated. But if the /cstus can neither be turned nor
extracted with the forceps, the delivery must be
left to the labour pains, as long as the patient is in
no danger; but if the danger is apparent, the head
must be delivered with the curved crotchets.

When the face presents, and the chin is to the
side of the pelvis^ the patient must lie on her side ;
and after the forceps are fixed along the ears, the
chin is to be brought down to the lower part of
the as isckiumj and then turned out below the
pubesy and delivered in a slow manner, as above.

PiinU'ii iry J. Green and Co., 13, BartleiVx Ruildinfrs.

GUY'S HOSPITAL
REPORTS.

GEORGE H. BARLOW, M.A. & M.D. Turn. Cou. Cam.

JAMES P. BABINGTON, M.A. Tri». Coil. Cam.

VOL. VII.

LONDONt
SAMCJBL BIGHLEY, 32, FLEET STREET.

H DVUOXLn.

CONTENTS.

VOL. VII.

(Jases illustrative of the Diagnosis of Disease of the Kidney ; by
George H. Barlow, M.A. & M.D. (With Plate) 1

Medico-I/egal Report of a Case of Infanticide ; with additional Re-
marks on the Foetal Lungs ; by AiiFred S. Taylor ----- 23

Observations on Pelvic Tumors obstructing Parturition ; with Cases ;
by John C.W. Lever, F.S.S. 71

Observations on the Digestivb Solution of the (Ebophaoub, and on
the distinct Properties of the Two Ends of the Stomach; by
T. Wilkinson Kino 139

Two Cases of Injury to the Head, followed by Symptoms of Com-
pression produced respectively by Elxtravasation of Blood and For-
mation of Pus; relieved by Operation ; by Edward Cock - - - 157

Observations on Urinary Concretions and Deposits ; with an Account
of the Calculi in the Museum of Guy's Hospital ; by Gtolding Bird,
A.M. M.D. F.LS. (Witii Plates) - 175

On the Location of Pulmonary Phthisis, and its relation to Diagnosis,
&c. &c; by H. Marshall Hughes, MD. 233

On the Proceeding to be adopted in a Case of Injured Intestine from
a Blow upon a Hernial Sac ; by C. Aston Key ...... 261

Case of iRiDEREMiAfOr Absence of Iris: with Observations; by John
Frederick France 279

Case of £2normously-distended Gall-Bladder ; communicated by
B. G. Babinoton, M.D. F.R.& 285

On Pneumonia ; by H. M. Huohbs, M.D. 291

Cases of Hsmorrhaoe, occurring afler Delivery, and complicated with
Dbease of the Spleen and Kidneys; by John C.W. Lever, MD. F.SlS. 325

Note on the Microscopic Globules found in Urine; by Golding
Bird, A.M. M.D. F.LS. 336

Case of Poisoning by Arsenic ; by John Hilton, F.1LS. With the
Chemical Examination of the Contents of the Stomach, Blood, &c. ;
by Alfred S. Taylor 341

CONTENTS.

Pane

Case of Fatal Pleuritis, apparently the effect of the presence in the
Right Pleura of a Piece of Ivory, consisting of Four Artificial
Teeth, which had been swallowed thirteen years before; by W. 6.
Carpenter 353

Observations upon Inflammation of the Aqueous Membrane of the Eve.
Read before the Physical Society of Guy's Hospital, April 2, 1842;
by Joseph R. Bedford 359

Observations on the Diseases of the Orifice and Valves of the Aorta
by Norman Chevers, M.D. (With Plates) 387

Case of Contracted Aorta; communicated by William Muriel, Esq.
ofWickham-Market.Suffi>lk. (Widi PUte) ....... 443

Two Cases of Disease of the Larynx, requiring Laryngotomy : with
Observadons ; by John Hilton, F.RS. (With Plates) * - - -445

On the Operation for Cataract ; by John Morgan, F.L.S. (With
Plate) 461

Observations on certain Diseases originating in EUrlt Youth, illus-
trated by Cases of Defective Expansion of the Lungs. (Memoir the
Second.) By George H. Barlow, M.A. & M.D. 467

Sequel of the Case of Locrland Shiel, who was operated on for
Exostosis of the Bonis of the Face, on the 1st of August 1835
(With Plate) 491

LIST OF PLATES IN VOL. VII.

DR. barlow's cases OF DISEASED KIDNEY. Totu»

Plate. . . . Diseased Kidney, containing a Calculns - - - p. 22

DR. BIRD ON URINARY CONCRETIONS.

Plate I. Urinary Calculi - 228

Plate IL Ditto -•- --.- 230

Plate III. Crystals of Urinary Calculi, magmfied ... 232

MR. FRANCE^S CASE.

Plate. . . . Irideremia ---- 284

DR. CHEVERS ON DISEASES OF THE ORIFICE AND VALVES OF

THE AORTA.

Plate I. Diagrams of the Origin of the Aorta .... 440
Plate II. Views of different Portions of the Origin and Arch

of the Aorta 442

Plate Mr. Muriel's Case of Stricture of the Aorta - 444

MR. HILTON^S CASES.

Plate I. View of the Larynx, in which Laryng^tomy had

been performed ------..-- 458

Plate II. Ditto 460

MR. MORGAN ON THE OPERATION FOR CATARACT.

I &3. Figures illustrative of steps in the Operation - - . 466

Plate . . Drawing of a Cast of Exostosis of the Bones of the

Face 491

LA TEL Y P UBLISHED,

In One Voiume 8vo. of 1013 poffes, with a Section of the Eye^

beauHJuUy Engraved by Adlard; and 103 woodeuU^ lUuiirative

if DiseaeeSf Operationif and InHmmenis :

PRACTICAL TREATISE

OK THE

DISEASES OF THE EYE,

Bt WILLIAM MACKENZIE, M.O.

LBCTOAIK OV THE ITS IN THK UWITSftUTT OF GLAIGOW, AND ONS Or THB
■OAOBOm TO THK QLA800W ITS INPIUCAftT.

SECOND BDITION, CAREFULLY REVISED.

LONDON:

LONGMAN* ORME, BROWN» GREEN, k LONGMANS.

• ^

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