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PRINCIPLES OF MIDWIFERY. 



THE 



PRINCIPLES 



or 



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. 



I 



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 
i wd i 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. 



Xi 

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, se em s 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 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 



XV 





Page 


Sbctiom 3. Excrescences on the labia . 


64 


4. Scirrhous tumours 


65 


5. Polypous tnmonrs 


ib. 


6. CEdenaa . . . . . 


66 


7. Hernia, laceration, &c. 


ib. 


8. Diseases of the nymphe 


67 


9. Diseases of the clitoris 


69 


10. Diseases of the hymen 


70 


1 1. Laceration of the perinffium 


72 


12. Imperfection oi the yagina 


75 


Id. Inflammation and gangrene of the vagina 


76 


14. Induration, ulceration, and polypi 


77 


15. Inversion . . . . . 


78 


16. Watery tumour • . . . 


79 


17. Hernia • • • • . 


ib. 


18. Encysted tumour and varices 


81 


19. Spongoid tumour . . . . 


ib. 


20. Erysipelatous inflammation 


82 


2L Fluor albus . . . . 


83 


22. Affections of the bladder 


90 


23. Excrescences in the urethra 


96 


24. Deficiency and mal-formation of uterus 


98 


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 


1 


■ 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 



or 



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- 

B 



1 



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. 

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 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. 

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 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 
onl y 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. 

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 
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. 

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 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 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 



8 



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. 



10 

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 



11 

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. 

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 sjrmphysis 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 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, 



12 

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 



13 

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. * 



i 



14 

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 



15 

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 



16 

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. 



17 

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- 



18 

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 



19 

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 



20 



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 



21 

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. 



22 

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 



23 

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 



24 

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 : 



25 

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 



26 

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. 



27 

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 



28 

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 



29 

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. 



i 



30 

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 



31 

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- 



32 

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. 



33 

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, 



34 

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 



35 

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. 



36 

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 



37 

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 



38 

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 



40 

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 m sa s yfftn ts 
of which are as hu-ge, although the spine is rtrj much distorted. 



41 

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 



42 

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. 



43 

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 



44 

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 



45 

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 



46 

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. 



47 

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. 



48 

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 



49 

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 

E 



52 

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 



53 

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. 



54 

•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 



55 

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- 



56 

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. 



57 

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 



56 

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 



59 

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. 



60 

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. 



61 

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. 



62 

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 



63 

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- 



64 

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 



65 

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. 

F 



66 

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 



67 

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 p e iform 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 p r sd nc ed 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,'- • 



68 

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. 



69 

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, 



70 

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 e mr e mUy, 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 cona i tt a only of eorpeim 
caTCTnoia, and the orethra opene b etween 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. 



71 

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 



72 

' 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. 



73 

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 



74 

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. 



75 

SECTION TWELFTH. 

The yagma may be unusually small. I have known it not 
q uite 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 



76 

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. 



77 

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. 



78 

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 



79 

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. 



80 

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. 



81 



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. 



82 



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. 



83 

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 



84 

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 



85 

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 



86 

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 



87 

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- 



88 

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. 



89 

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 



90 

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. 



91 

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. 



92 

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. 



93 

{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 



94 

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 



95 

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. 



96 

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. 



97 

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. 

H 



98 

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. 



99 

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 



c 



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 enpp oeed 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. 

K 



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 
acc n mnl at e d 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 a ii i ^tlren 
the e'varinai fer the womh. 

f Viganns^ Mabid. Ton; L p. 4l2.*Mr. Ceeluoo meotiooa a ease, where 
Bs a g g u<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. 



i 



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 prmm tly 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. 

M 



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 
effec tof 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 



IM 

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 hamorrii agy^ 
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 



lU 

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 



1 

I 



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 

e 



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 Bya agt j o mB 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 re o tnsa 
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 b ow< 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, 

m 

R 



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 Cu a timk i i 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« 

s 



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 d yate r 
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>ffl y 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 womc o 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 
b e e eflt , 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 g e sta t io n ^ 
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 ceat l t a aass, or, bgr want of sleep oeeasioned by toothach; 
&c Itms^ aaoeeed some Htiie esertion, or speedy motion 
ar e aynia 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 



I 



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 

papoM d 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 
gsMiwM y 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 
impairin g 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. 

T 



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» ty maalaaU aa 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. 



I 



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 prola pse d, 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 irftoff w Hfc 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. 



\ 

i 

■ 

/ 

1 



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 

X 



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« 



I 



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. 

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 serriceable ; or a few drops 
of the 
aerated 
patient 

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 Ttn c nmi hierac^ or bAS du* be«n cwpletelT 
cored, ibe child is c^ideotlv af«ci^ and ofiea dies, beAire 
tbe proc e jB 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 |g eagn t 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 crig iu al 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 



I 



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. 

Z 



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 f