PREFA C E.
I
At first intended to have published this treatise in different lectures, as they were delivered in one course of Midwifery; but I found that method would not answer fo well, in a work of this kind, as in teaching: because in the course of my lectures, almost every obfervation has a reference to the working of those machines which I have contrived to resemble and reprefent real women and children; and on which all the kinds of different labours are demonftrated, and even performed by every individual student.
.
I have, therefore, divided the whole into an Introduction, and four Books, diftinguished by Chapters, Sections, and Numbers; and have induftriously avoided all theory, except fo much
as may ferve to whet the genius of young practitioners, and be as hints to introduce more valuable discoveries in the art.
The Introduction contains a fummary account of the practice of Midwifery, both among the ancients and moderns, with the improvements which have been hitherto made in it; and this I have exhibited for the information of those who have not had time or opportunity to peruse the books from which it is collected; that by feeing at once the whole extent of the art, they may be the more able to judge for themselves, and regulate their practice by thofe authors who have written moft judiciously upon the fubject. The knowledge of these things will also help to raise a laudable fpirit of emulation, that never fails to promote useful enquiries, which often redound to the honour of art, as well as to the advantage of fociety.
Though
Though I have endeavoured to treat every thing in the most distinct and concise manner, perhaps many directions that may occur in the third Book, may be thought too minute and trivial by thofe who have already had the advantage of an extensive practice; but the work being principally undertaken with a view to refresh the memory of thofe who have attended me, and for the inftruction of young practitioners in general, I thought it was neceffary to mention every thing that might be useful in the courfe of practice.
At first, my defign was to have inferted cafes, by way of illuftration, according to the method of La Motte; but, upon further deliberation, I thought fuch a plan would too much embarrass the ftudent in the progress of his reading: and therefore I have refolved, in imitation of Mauriceau, to publish a second volume of hiftoa 3 ries,
1
ries, digested into a certain number of claffes or collections, with proper references to the particular parts of this treatise; so that the reader, when he wants to fee the illustration, may turn over to it at his leifure, according to the directions that fhall be laid down.
Thofe claffes will confift of the most useful cafes and obfervations, partly culled from the most approved authors, but chiefly collected from my own practice, and that of my correspondents and former pupils, by whom I have been confulted.
Nor will the reader, I hope, imagine, that fuch a fund will be infufficient for the purpose; or that this treatise is cooked up in a hurry, when I inform him, that above fix years ago I began to commit my lectures to paper, for publication: and from that period, have from time to time altered, amended, and digested what I had written, according to the new
1
lights I received from study and experience. Neither did I pretend to teach Midwifery, till after I had practised it successfully for a long time in the country; and the observations I now publish, are the fruits not only of that opportunity, but more immediately of my practice in London, during ten years, in which I have given upwards of two hundred and eighty courses of Midwifery, for the inftruction of more than nine hundred pupils, exclufive of female ftudents and in that feries of courfes, one thousand one hundred and fifty poor women have been delivered in prefence of those who attended me; and supported during their lying-in, by the stated collections of my pupils: over and above those difficult cafes to which we were often called by midwives, for the relief of the indigent.
These confiderations, together with that of my own private practice, which a 4 hath
INTRODUCTION.
WT must be a fatisfaction to those
who begin the study of any art or fcience, to be made acquainted with the rife and progrefs of it; and therefore I fhall, by way of Introduction, give a short detail of the practice of Midwifery, with the improvements which have been made in it, at different times; as I have been able to collect the circumstances, from thofe authors,. ancient as well as modern, who have written on the subject.
By thefe accounts it feems probable, that in the firft ages, the practice of this art was
B
alto
altogether in the hands of women, and that men were never employed but in the utmost extremity indeed it is natural to suppose, that while the fimplicity of the early ages remained, women would have recourse to none but perfons of their own fex, in diseases peculiar to it; accordingly, we find that in Egypt Midwifery was practised by women.
Hyginus relates, that in Athens a law was made, prohibiting women and flaves from practising phyfick in any fhape: but the mistaken modesty of the fex rendered it afterwards absolutely neceffary to allow free women the privilege of fharing this art with the men.
In the Harmonia Gynaciorum, there are extant feveral directions and recipes on the fubject of Midwifery, collected from the writings of one Cleopatra, interfperfed with those of Mofchion and Prifcian; and fome people imagine this was no other than the famous Cleopatra queen of Egypt, because in the preface Arfinoe is mentioned as the author's fifter.
Galen,
3
Galen, who lived two hundred years after this Egyptian queen, advifes the reader to confult the writings of one of that name, but does not inform us whether the was or was not that celebrated princefs; fo that in all probability, it was fome other person of the fame name, as the ftudy and exercife of fuch an art was not at all. fuited to the difpofition of fuch a gay voluptuary as queen Cleopatra is defcribed to have been.
V
Etius tranfcribes fome chapters from the works of one Afpafia, touching the method of delivering and managing women in natural labours; but gives no account of the place of her refidence, nor of the time in which she wrote. Several other female practitioners are mentioned by different historians; but, as none of their writings are extant, and the accounts given of them are moftly fabulous and foreign to our purpose, I fhall forbear to mention them in this place, and referring the curious to Le Clerc's hiftory of phyfick, begin with Hippocrates the most antient writer now extant, upon
B 2
Our
our fubject, who may be ftiled the father of Midwifery as well as medicine; because all the fucceeding authors, as far down as the latter end of the fixteenth century, have copied from his works the most material things relating to the diseases of women and children, as well as to the obstetric art. I shall therefore give a fuccinct account of his practice, and in my detail of the other authors, only obferve the improvements they have made, and the circumstances in which they have deviated from his method and opinion.
Hippocrates, who practifed medicine in Greece, about 460 years before the chriftian Æra, no doubt availed himself of the obfervations of those who went before him in the exercise of the fame profeffion. He acquired the highest reputation by his wife predictions and fuccefsful practice, and by his uncommon fagacity and experience greatly improved the healing art.
In his book de natura Muliebri, and thofe de Mulierum Morbis, he mentions and de
scribes
fcribes many diseases peculiar to the female fex, according to the theory of those times, and prescribes more medicines for the diseases of women, than for any other diftempers. 
Many of his remedies, indeed, are very ftrange and uncouth, but a number of them are still accounted excellent in the present practice, unless his names of them have been mistaken and misapplied to other medicines : and although his theory is frequently odd and erroneous, his diagnosticks, prognosticks, and method of cure, are often juft and judi
cious.
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In fuppreffions of the Menfes, he firft of all, orders vomits and purges, then sharp peffaries in form of fuppofitories, compofed of lint or wool, with divers kinds of deobftruent powders, wax and oil, to be introduced into the Vagina: he likewife prescribes fumigations, fomentations, and hot baths, together with internal medicines. He obferves, that fuch obftructions produce a pain and seeming weight in the lower part of the Abdomen, extending to the loins and Ilia,
attended
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attended with a vomiting at intervals, and longings like thofe of a pregnant woman. If thefe fymptoms of pain and weight affect the Hypochondria, producing fuffocation and pain in the Head and Neck, the patient is to be relieved by the application of fœtid things to the Nose with Caftor and Fleabane given internally in wine, &c.
When the Menfes flow in too great a quantity, he propofes a contrary method: he advises her to abstain from bathing and all laxative and diuretic things; orders af tringent peffaries for the Vagina, and cold applications to the lower parts; prescribes internally, several kinds of aftringent medicines, with the peplium or poppy-feed, and cupping glaffes to be applied to the breafts. When the violence of the difcharge is abated, he propofes purges and vomits, then affes milk and a nourishing diet, and various kinds of internal and external medicines.
In a Fluor albus, he fays the urine is like that of an afs; the patient labours under a pain in the lower part of the Abdomen, loins and
and Ilia, together with a fwelling in the hands and legs; her eyes water, her complexion becomes wan and yellow, and in walking fhe is oppreffed with a difficulty of breathing: In this cafe he prefcribes emeticks and catharticks, affes milk, whey, fomentations, and different kinds of medicines,, to deterge and ftrengthen the parts affected.
He mentions many complaints which (in his opinion) proceed from different motions and fituations of the Uterus, and propofes a good many medicines for the cure. As to his theory of conception, and his opinions about the birth in the seventh or eight month of geftation, they were actually espoused by all medical writers, till the laft century.
In his first book of the difeafes of women he treats of difficult labours; obferving, that if a woman is at her full time, feized with labour-pains, and cannot, after a long time, be delivered, the child either. lies acrofs, or prefents with the feet: for, B 4
when
when the head prefents, the cafe is favourable; whereas if the child lies across, a difficult labour enfues. This affertion he illuftrates by the example of an olive in a narrow mouthed jar, which cannot be fo eafily extracted by the middle, as when it prefents with one end. He likewife fays, that the birth will be difficult when the feet prefent, in which cafe, either mother or child, or both (for the most part) perish: Nor is the birth without difficulty when the Fatus is dead, apoplectic or double. He then proceeds to direct us how to relieve the woman of feveral complaints to which the may be fubject after delivery: he defcribes the method of excluding the Fetus, and of affifting in difficult labours; if the child prefents fair, and is not easily delivered, he orders fternutatories to be adminiftred, and the patient to stop her mouth and nose, that they may operate the more effectually: She muft alfo be shaken in this manner; let her be faftened to the bed by a broad band croffing her breast, her legs being bended to the lower part of the bed, the other end of which must be ele
vated by two affiftants, who gently shake her by intervals, until her pains expel the child: The parts must be anointed with some unctuous medicine, and cautiously separated; and care must be taken, that the Placenta immediately follow the child. If the Fatus lies across, prefenting to the Os uteri, whether it be alive or dead, he orders it to be pushed back and turned, fo as that it may present with the head in the natural pofition; and, in order to effect this purpofe, the woman must be laid fupine on a bed with her hips raised higher than her head. If the child is alive, and presents with the arm or leg, he advises us to return them as foon as poffible, and bring down the head, or if it lies across, presenting with the fide or hip, the fame methods must be used; then the woman may be refreshed by fitting over the fteams of hot water. The child is to be managed in the fame manner, when it is dead, and prefents with leg or arm, or both; but if the Fatus cannot be conveniently delivered, on account of the body's being fwoln, he directs us to bring it away piece-meal, in the following manner: If the
head
1
head prefents, let it be opened with a small knife, and the bones of the skull being broken, must be extracted with a pair of forceps, for fear of hurting the woman; or by an embryulcus, firmly fixed on the Clavicles, it may be extracted by little and little. After the head is delivered in this manner, fhould the child stick at the fhoulders, he directs us to divide the arms at the articulations; and they being brought away, the rest of the body, generally, follows with eafe: but if it will not yet give way, the whole breast must be divided; and great care taken that no part of the intestines be denudated or wounded, left the guts, or their contents, falling out, fhould retard the operation; then the ribs being broken, and the Scapula extracted, the rest of the Fatus will eafily follow, unless the Abdomen is fwoln; in which cafe the belly must be punctured, and on the exit of the Flatus, the child will be brought along. If part of the child is already delivered, and the rest will not follow, nor can that which is out be returned, he orders the operator to take
away
away as much as he can of it, and pushing up the remainder, turn the head downwards: but, previous to this operation, he advises him to pare his nails, and to use a crooked knife, the point and back of which, must be covered with the fore finger, at it's introduction, left it fhould hurt the Uterus.
In his book de Superfætatione, he directs us, when the child's head appears without the Os uteri, and the reft of the body does not follow, the Fatus being dead, to wet our fingers with water, and introducing them between the Os uteri and head, put one into the mouth, and laying hold of it bring it along. When the body is delivered, and the head remains behind in those cafes when the child comes by the feet) he advises the operator to dip both his hands in water, and introducing them between the Os uteri and head of the child, grafp this laft with the fingers, and extract it. If the head is in the Vagina, it may be delivered in the fame manner. When the child remains dead in the Uterus, and cannot be de
delivered, either by the force of nature or medicines, he directs us to introduce the hand, anointed with fome unctuous cerate, and dividing the parts with an unguis fixed on the great finger, bring the Fatus along, as before.
In the first book of the diseases of women, he gives directions for excluding the Secundines, provided they are not expelled in the natural way. He fays, if the fecundines come not away immediately after the birth, the woman labours under a pain in her belly and fide, attended with rigors and a fever, which vanish when they are discharged; though, for the most part, the after-birth putrifies and comes away about the fixth or feventh day, and sometimes later. In this cafe, he orders the patient to hold her breath, and prescribes internally, mugwort, cretan dittany, flowers of white violets, leaves of agnus caftus, with garlick boiled or roafted, small onions, caftor, spikenard, rue, and black wine.
In the book de Superfatatione, after having described the methods of delivering a dead child, he fays, if the Secundines come not away easily, the child must be left hanging to them, and the women feated on an high ftool, that the Fetus by its weight may pull them along; and left this should be too fuddenly effected, the child may be laid on wool newly plucked, or on two bladders filled with water, and covered with wool, which being pricked, as the water evacuates, they will fubfide, and the child finking gradually, will gently draw the Secundines away: but fhould the navel-string happen to be broke, proper weights must be tied to it, in order to answer the fame purpofe; these being the eafieft and leaft hurtful methods of extracting the Placenta.
He afterwards obferves, that if the woman has had a difficult labour, and could not be delivered without the help of machines, the child is generally weak, and therefore the navel-ftring ought not to be divided, until it fhall have either urined, fneezed, or cried aloud; and in the mean
time, it must be kept very near the mother! for, though the child does not seem to breathe at first, nor to give any other figns of life, the navel-string by remaining uncut, may be in a little time inflated, and the life of the infant faved.
rors.
With regard to the Lochia or Menfes af ter delivery, he takes notice, that if they are altogether fuppreffed, or the discharge infufficient, and the Uterus is indurated, the patient is afflicted with pains in the loins, groins, fides, thighs and feet, together with an acute fever, accompanied with horWhen the pains happen, unattended with a fever, he orders bathing, and the head to be anointed with oil of dill; and a decoction of mallows with oil of Cyprus, to be applied externally, in order to affuage the pain. He fays, in all disorders where fomentations are neceffary, the parts ought, afterwards, to be anointed with oil: but, when there is a fever in the cafe, bathing must be avoided, warm fomentations used, the uterine medicines prescribed in draughts, and garlick, caftor or rue boiled with oatmeal: he
,
likewife
likewise obferves, that if the Uterus is inflamed after delivery, the patient is in imminent danger of her life, unless a stool can be procured, or the symptom removed by bleeding. He likewife afcribes feveral complaints and disorders of women, to the different pofitions and motions of the Uterus, of which laft, Plato who lived immediately after Hippocrates, gives a very odd and romantic description, in his Timaus. After affirming that there is implanted in the genitals of man, an imperious, headftrong, inobedient power that endeavours to fubject every thing to its furious lufts; he says, the Vulva and Matrix of women is also an animal ravenous after generation, which being baulked of its defire for any length of time, is so enraged at the disappointment and delay, that it wanders up and down through the body, obftructing the circulation, stopping the breath, producing fuffocations and all manner of diseases.
Although we have a piece in English, called Ariftotle's Midwifery, I find little or nothing of the practice in his works: he
hath
hath written on the generation of animals; and we find in him, feveral hints curious enough, even upon our fubject: he tells us, that women fuffer more than other animals, from uterine gestation and labour; that those women who take most exercise, endure both with the greatest ease and safety; and that the Fœtus in all animals naturally comes by the head, because there being more matter above than below the navel, the head neceffary tilts downwards. For this reafon, he'fays, every birth in which the head prefents, is natural, and thofe unnatural in which the feet, or any other part of the body, come foremost.
We have nothing written on the fubject of Midwifery, from his time, to that of Celfus, who is fuppofed to have lived in the reign of the emperor Tiberius. This author hath given a chapter on the delivery of dead children, and the Placenta, in which he hath copied from Hippocrates, though he is more full than his mafter, and mentions feveral improvements on his practice. After having given directions with regard to the woman's pofition, he advifes the operator
to
to introduce one finger after another until the whole hand fhall gain admittance; he fays, that the largeness of the Uterus, and the ftrength and courage of the patient, are great advantages to the birth; that the woman's Abdomen and extremities must be kept as warm as poffible; that we must not wait until an inflammation, is produced, but affift her without delay; because should her body be swelled, we can neither introduce our hands, nor deliver the child, without great difficulty; and vomitings, tremors, and convulfions often enfue. When the crotchet is fixed upon the head, he directs us to pull with caution, left the inftrument should give way, and lacerate the mouth of the womb; by which means, the woman would be thrown into convulfions and imminent danger of her life. When the feet prefent, he fays the child is eafily delivered, by laying hold on them, with the hands, and fo bringing them along. If the Fatus lies across, and cannot be brought down, he orders the crotchet to be fixed on the armpit, and drawn along by little and little; by these endeavours the neck
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neck will be almost doubled, and the head bent backwards; in which cafe, this laft must be separated from the body, and the whole extracted piece-meal. The operation (he fays) must be performed with a crotchet, the internal furface of which is edged, and the head be brought away before the body; because, if the greateft part be extracted first, and the head left alone in the Uterus, the cafe will be attended with great difficulty and danger. Nevertheless, should this misfortune happen, he directs a double cloth to be laid on the woman's belly, and a fkilful affiftant to ftand at her left fide, and with both hands on the Abdomen, to prefs from fide to fide, with a view of forcing the head against the Os Uteri; which being effected, it must be delivered by fixing the crotchet in the skull. With regard to the Placenta, he directs us to deliver it in this manner: The child being delivered, must be given to a fervant, who holds it on the palms of his hands, while the operator gently pulls the umbilical cord, for fear of breaking it, and tracing it with his right hand as far as the Secundines, feparates the Pla
.
. xix Placenta from the Uterus with his fingers, and extracts it intire, together with the grumous blood: then the woman's thighs being placed clofe together, the must be kept in a moderately warm room, free from wind, and a cloth dipped in Oxyrrhodon must be laid on her Abdomen: the reft of the cure confifting in the application of those things which are used in inflammations and wounds of the tendons.
Mofchion, who is fuppofed to have lived at Rome in the reign of Nero, fays, That in difficult births, the parts are firft of all to be relaxed with oil: if the paffage of the urine is obftructed by a ftone in the neck of the bladder, he advises us to draw off the water with a catheter; if the Faces are indurated, he prescribes a clyfter, and orders the membranes to be pierced with a lancet. He fays, the best position is that of the head prefenting, the hands and feet being mingled and difpofed along the fides. If the pofition is not right, and cannot be amended by putting the woman in proper postures, he advifes us to introduce the hand, when the Os Uteri is C 2 opened
opened, and turn the child.                            If a foot pre- fents (fays he) push it back, and bring the Fetus by both feet, the arms being preffed down along the fides: if the knee or hip prefents, they must be also pushed back, and the child brought by the feet: if the back prefents, introduce the hand, and al- ter the pofition, by turning to the feet or to the head, if it be nearest; and if the head is large, it must be opened, &c. 
Rufus Ephefius, who lived in the reign of Trajan, gives a fhort account of the Uterus and its appendages, and defcribes those tubes which are now called Fallopian, as opening into the cavity of the womb; though Galen arrogates this difcovery to himself, fo particularly, as to fay upon this fubject, that he was surprised to find they had escaped the notice of the common herd of anatomists; but more especially amazed that a man of Herophilus's accuracy, fhould be ignorant of them: and Rufus has exprefly mentioned the opinion of Herophilus, on this particular.
Galer
Galen was born in the time of the emperor Adrian, Anno Dom. 131. about fix hundred years after Hippocrates, upon whose works he writes commentaries, and gives some reasonable aphorifms relating to women and children: we have two books of his writing, de Semine; (the third being accounted fpurious) one, de Uteri Diffe&tione, de Fatuum Formatione, de Septimeftri Partu, Lib. 14 & 15: de ufu Partium. He hath also written several books on anatomy and phyfiology, but nothing de Morbis Mulierum. In his phyfiology he is prolix and inaccurate his anatomy is pretty exact in many things; but, upon the whole, he contains little or nothing to our purpose.
In Oribafus, who was phyfician to Julian, we have a description of the parts, and in feveral places of his works, an account of the medicines used by the antients in the diseases of women and children: he has alfo a chapter on the choice of a nurse, and another upon the milk, but fays nothing of the operation.
Etius, who (according to Le Clerc) lived in the end of the fourth, but in the opinion of Dr. Friend, in the end of the fifth century, was likewife a collector from the antients: for neither he nor Oribafius can be ftiled original writers: the laft indeed, copied from none (almost) but Galen, and was therefore ftiled Simia Galeni; whereas the other compiled from all the authors that went before him, many of whom would have been loft in oblivion, had not they been mentioned in his works; he is very particular the diseases and management of women; his fourth Sermo of the 4th Tetrab, being exprefly written on this subject, and containing almost every thing which had been faid before him.
upon
In his first chapter, De uteri fitu, magnitudine ac forma, he diftinctly divides the womb into a fundus and neck, and defcribes the Os Tinca, as ending in the Sinus Muliebris, five Pudendum, which plainly appears to be no other than what we now call the Vagina; for, he says, it is above fix inches in length; but his defcription of the figure
of
of the Uterus is imperfect. His feventh chapter treats of conception, from Soranus. The tenth of the Pica, taken from fome of Galen's works that are loft.                         His defcripti- on of this disease, is to the following pur- pofe. Young women with child have viti- ated appetites, and long for earth, afhes, coal, fhells, &c. The diftemper continues till the fecond or third month of gestation; but commonly abates in the fourth.                          To remedy the nausea and vomiting that attend it, he orders aloes, dried mint, and other ftomachics. 
In his twelfth and fifteenth chapters, he gives a detail of Afpafia's practice in the care and management of women, during pregnancy, and in time of labour; but, the greatest part of these and the other chapters, are taken from Hippocrates, to whom he has made a few infignificant additions, until we come to the twentieth and fecond, in which there is a very full and diftinct account of difficult births.
Among the causes that produce difficult labours, he enumerates weakness of mind
or body, or both, a confined Uterus, a narrow paffage, natural smallness of the parts, obliquity of the neck of the Uterus, a fleshy fubftance adhering to the Cervix or mouth of the womb, inflammation, abscess or induration of the parts, rigidity of the membranes, premature difcharge of the waters, which ought to be detained for moistening and lubricating the parts, a ftone preffing against the neck of the bladder, and extraordinary fatness; an Anchylofis of the Ossa Pubis at their juncture, by which they are hindered from separating in time of parturition, too great preffure of the Uterus on the cavity of the loins, or too great quantity of Faces and urine retained in the Rectum and bladder, an enfeebled constitution, advanced age, flender make, and greenness of years, attended with weakness and inexperience.
He obferves, that difficult labours likewife proceed from circumftances belonging to the child that is to be born: from the extraordinary fize of the body, or any part of it; from its being unable (through weaknefs)
ness) to facilitate the birth by its leaping and motion: from the crowding of two or three Fatufes from twins prefenting together at the mouth of the womb: from the death of the child, as it can give no affiftance in promoting labour: from its tumefaction after death, and wrong presen
tation.
He says, the natural pofition is when the head prefents and comes forwards, the hands being extended along the thighs; and the preternatural, that in which the head is turned either to the right or left fide of the Uterus; when one or both hands prefent, and the legs within are separated from one another: that the danger is not great when the feet prefent, efpecially if the child comes forwards with the hands along the thighs; and that if, while one leg presents, the other is kept up or bent in the Vagina, this laft must be brought down nor is the difficulty great in thofe that lie across, a circumftance that may happen in three different ways; namely, when the child prefents with either fide, or
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with the belly: Nevertheless, he obferves, that the cafe is eafieft when the fide prefents, because there is more room for the operator to introduce his hand, and turn the Fatus fo as that it may come either by the head or feet. The worst pofition, he fays, is when the child prefents double, efpecially if the hip-bones come foremost: This double prefentation happens with the hips, the head and legs, and the belly; in which laft cafe, he obferves, that if the Abdomen is opened, and the intrails taken out, the parts collapfe, and the pofition- is éafily altered.
Over and above the fore-mentioned caufes of difficult labour, he affirms, it may be owing to an over thicknefs or thinness of the membranes, which break too late or too foon; as alfo to external caufes, fuch as cold weather, by which the pores and paffages of the body are conftringed; or very hot weather, by which they are too much relaxed. All these circumftances (he fays) ought to be minutely enquired into, and duly confidered by the phyfician who di
1
rects
rects the midwife; nor ought this last to be permitted to tear or ftretch the parts with violence. If the difficulty proceeds from the form of the Pelvis, he directs the woman to be feated on a ftool, her knees being bent and kept afunder; by which means the Vulva will be dilated, and the Cervix extended in a freight line: And thofe that are grofs or fat, are to be placed in the fame manner. If the difficulty arises from ftraitnefs, ftupor or contractions, he fays, it will be proper to relax the parts, by feating the patient over warm fteams and fumigations, in a place conveniently warmed; by pouring into the Vagina warmed oils, and by the application of emollient ointments aud cataplafms: For this purpose, he likewise recommends the warm bath, unless a fever or other complaint render it improper. Some, he obferves, are carried about in a litter, in a warm place; and others have been fubjected to violent concuffions: but, those who, by a weak, loofe habit, are too much enfeebled to undergo labour, ought to be treated with prescriptions that consolidate; ftrengthen, and conftringe: They ought
to
to be sprinkled with perfumes and vinegar, anointed with cooling ointments of wine and oil of rofes, and fit over infufions of rofes, myrtle, pomegranates, and vine twigs, If the difficulty is owing to the præternatural pofition of the Fatus, it must be as much as poffible reduced into the natural way. If the foot or hand is protruded, the child muft not be pulled by either; the limb must be returned, twisted, or lopt off, and the fhoulder or hip moved with the fingers into a more convenient fituation. When the whole body of the Fatus is ftrongly preffed down in a wrong pofition, he advises us to raise it to the uppermost part of the Uterus, and turn it downwards again in a right pofture: This operation must be performed gently and flowly, without violence; oil being frequently injected into the parts, that no injury may be substained by either mother or child. If the mouth of the womb continues close fhut, it must be foftened and relaxed with oily medicines: If there is a stone in the neck of the bladder, it must be pushed up with the catheter, and the urine (if in great quantity) drawn off.
If the Rectum
Rectum is filled with Faces, it must be evacuated by clyfters: And proper methods are to be taken, when delivery is prevented by inflammation, abfcefs, ulcer, soft or hard tumors, or any other fuch obftacles.
If the difficulty proceeds from a fleshy. fubftance adhering to the neck of the womb, or from a thick membrane found in those women who are imperforated, the obstacle in both cases, must be removed by the knife; and if the membranes that furround the child are too rigid to give way at the proper time, they must be cut without delay: If, on the contrary, the waters are discharged too foon, fo as that the parts are left dry, the want of them must be supplied with lubricating injections, made with the whites of eggs, decoctions of mallows, fenugrec and the cream of barley ptisan.
If the difficulty proceeds from the smallnefs or ftrong contraction of the Uterus, the parts are likewise to be rendered soft and diftenfile with lubricating ointments and fomentations; the mouth of the womb must
be dilated with the fingers, and the child extracted by force; but fhould this method fail, the Fatus must be cut in pieces, and brought away by little and little. This (he fays) is the only refource when the Fetus is too large, and the most proper when it is dead; and its death may be certainly pronounced, when the prefenting part is felt cold and without motion. When two, or three children present in the neck of the Uterus, thofe that are highest, must be raised up to the Fundus, until the lowest be first delivered.
If the difficulty is owing to the exceffive largeness of the head, breast, or belly, he says, it will be abfolutely neceffary to open these cavities; and obferves, that the most proper time for placing the woman in labour, upon the ftool, is when the membranes are felt presenting in a round extended bag.
His twentieth and third chapter contains the method of extraction and exfection of the Fatus, from Philumenus; and is an accurate detail of the operations recommended
above. He says, before the operator begins to deliver by exfection, he ought to confider the strength of the patien, and determine with himself, whether or not there is a probability of faving her life; because, if the is exhausted, enervated, lethargic, feized with convulfions, fubfultus tendinum, with a dif ordered pulfe, it is better to decline the operation, than run the rifque of her perishing under his hands: But, if he thinks her ftrength and courage fufficient for the occafion, let her be laid in bed, on her back, her head being low, and her legs held afunder by ftrong experienced women; the may take by way of cordial, two or three mouthfuls of bread dipped in wine, in order to prevent her fainting; for which purpose, her face may be alfo fprinkled with wine during the operation. The chirurgeon having opened the Pudenda with an instrument, and obferved the fource of the difficulty, whether tumor, callus, or any of the caufes already mentioned, he must take hold of it with a forceps, and amputate with a biftory: If a membrane obftructs the mouth of the womb, it must be divided: If the delivery
is prevented by the rigidity of the mem branes that invelop the Fatus, they must be pinched up with a pair of small forceps, and cut with a sharp knife; then the perforation may be dilated with the fingers, so as to effect a fufficient opening for the paffage of the child.
If the paffage is obstructed by the head of the Fatus, it must be turned and delivered by the feet; but, if the head is fo impacted, as that it cannot poffibly be returned, a hook or crochet must be fixed in the eye, mouth, or over the chin, and in this manner the child may be extracted with the operator's right hand; but, befides this crochet, which ought to be gently introduced, and guarded with the fingers of the left hand, another must be infinuated in the fame manner, and fixed on the oppofite fide, that the head may be extracted more equally, without sticking in one place, and one of the instruments hold, in case the other fhould flip; and when these crotchets are properly applied, the operator must pull, not only in a streight
line, but also from fide to fide.
He directs us to introduce our fingers besmeared with unctuous medicines, betwixt the mouth of the womb and the impacted body, in order to lubricate it all round. When the Fatus is delivered as far as the middle, the extracting inftrument must be fixed in the upper parts: if the head is either naturally too large or dropfical, it must be opened with a sharp-pointed knife, that it may be evacuated, contracted, and delivered But, if, notwithstanding this operation, it cannot be brought along, the skull must be fqueezed together, the bones pulled out with the fingers or bone-forceps, and the crochet fixed for delivery. If, after the head is extracted, there fhould be a contraction round the thorax, a perforation must be made near the clavicles, into the cavity of the breast, that the bulk may be diminished by the evacuation of the contained humours: If the child is dead, and the belly diftended with air or water, the Abdomen muft alfo be opened, and, if need be, the intestines extracted.
If the arm presents, it must be separated at the joint of the fhoulder: For this purpose, a cloth must be wrapt round it, that it may not flip, while it is pulled down to the shoulder; then opening the Labia, the joint will appear at which the limb may be taken off: This amputation being performed, the head must be pushed up, and the Fatus delivered. The fame method muft be pursued when both arms present, and when, though the feet are forced out, the reft of the body will not follow; in which cafe, the legs must be feparated at the groins.
If, when the Fatus prefents double, and cannot be raised up, the head is fartheft down, the bones of the skull are to be fqueezed together, without opening the fcalp or fkin, and the crochet being fixed in fonie part of it, will bring it forth, the body following in a ftreight line: but if the legs are neareft, they must be amputated at the Coxa, and the hips pushed up, fo as to allow the head to be fqueezed and pre
I
pared
When the Fœtus
pared for extraction. prefents double, he fays, it is better to di- vide the head from the body, than to push up the Thorax, and deliver by the feet: But fhould the reft of the body be delivered, and the head left behind, the left hand anointed, must be introduced into the Uterus, and the head being brought down with the fingers to the mouth of the womb, one or two crochets must be fixed on it, in order to bring it along; the most proper places in the head for the application of this in- ftrument, being the eyes, ears, mouth, or under the chin. For the extraction of the Thorax, it         may be fixed in the armpits, cla- vicles, Præcordia, breaft, and joints of the back and neck: For the lower parts, on the Pubis, or in the Pudenda of female chil- dren. 
If the mouth of the womb be shut by an inflammation, he cautions us against using any violence; but, orders it to be softened and relaxed by oily medicines, fumigations, baths, cataplafms; by thefe means, the inD 2 flammation
flammation will be leffened or removed, and the Os internum dilated fo as to allow the Fatus to be delivered. If the body hath been extracted piece-meal, he directs the parts to be laid together, in order to obferve if the whole is delivered, and if any thing remains, it must be extracted without delay.
In his twentieth and fourth chapter, (the fubftance of which is also taken from Philumenus) he lays down the following directions for extracting the Secundines.
The Os internum (when the Secundines are detained) is fometimes fhut, fometimes open, and often inflamed; the Placenta fometimes adhering to the Fundus, and fometimes in a fate of feparation. If the Os internum is open, and the Secundines, feparated from the Uterus, lie rolled up like a ball, they are easily extracted by introducing the left hand warmed and anointed; and after having taken hold of them, drawing them gently down from fide to fide, and not ftreight
ftreight forwards, for fear of a Prolapfus vulva. If the Os uteri is fhut, it must be opened flowly with the finger, after it hath been lubricated with oil, or auxunge: If this method should fail, a poultice of barleymeal malaxed with oil, must be applied to the belly, the oily injections repeated, and if the patient's ftrength will permit, fhe must take fternutatories of caftor and pepper, and potions of thofe medicines that bring down the Menfes, fitting at the fame time, over a fumigation.
All these things must be tried on the firft and fecond days, and if they fucceed, fo as to open the mouth of the womb, the Secundines will be eafily extracted as above: but, if all these methods fail, the woman must be no longer fatigued; they will in a few days putrify and come off in a diffolved fanies; and fhould the fœtid fmell affect the head and ftomach, he prefcribes fuch medicines as are used in obftructions of the Menfes.
His next chapter, which is taken from Afpafia, treats of the management of women after delivery; and he writes several more on the difeafes incident to women, fuch as inflammations, impoftumes, and cancers of the breaft and uterus; compiled from Philumenus, Leonides, Archigenes, Philagrius, Soranus, Rufus, Afpafia, and Afclepiades,
The next confiderable author on this subject, is Paulus Egineta, whom Le Clerc supposes to have lived in the latter end of the fourth century; though Dr. Friend brings him down to the seventh; He was the last of the old Greek medical writers.
His method of practice is much the fame with that of Etius and Philumenus, as above defcribed; and though not fo full as they, he is very distinct and particular. He tells us in his preface, that he had collected from others; and although he was the first who had the name of man-midwife from the Arabians, the writings of
Etius plainly fhew, that there had been many male-practitioners before him. In the feventy-fixth chapter of his third book, which treats of difficult births, he gives the appellation of natural to all thofe in which the head or feet prefent; and all other pofitions he deems præternatural.
In another place, he obferves, that the woman ought to be feated on the stool or chair, when, by the touch, the mouth of the womb is felt open, and the membranes pushed down. As to his method of extracting a dead child and the Placenta, it is much the fame with that already described from Philumenus, in the preceding article.
Paulus is fupposed to have studied at Alexandria: for, long before his time, the Roman empire in the weft had been overrun and ruined by the Goths and Vandals. Soon after this period, learning began to decline in the east; the schools of Alexandria were removed to Antioch and Haran by the Saracens, who fubdued Egypt, and deftroyed the Roman empire in Afia, and D 4
then
then the Greek phyficians were translated into the Syriac and Arabic: at least, the Arabians copied from them. This subject is fully difcuffed by Dr. Friend, in his hif tory of phyfick.
Serapian, one of the first Arabian writers, in his Tractatus Quintus has feveral chapters on the diseases of pregnant women, with the method of cure.
The next author of any note, belonging to this country, was Rhazes; who in the latter end of the ninth century, lived at Bagdat. Like other fyftematic writers in phyfick, he hath treated of the diseases of women; and written one book exprefly on
the diseases of children.
In the last chapter of his Liber Divifionum, he orders the membranes, when they are too tough, to be pierced with the nail of the finger, or with a little knife: And if the waters are difcharged a long time. before delivery, fo that the parts remain
dry,
dry, he directs us to anoint them with oily
cerates.
Avicenna lived at Ifpahan about the year one thousand, and was fo famous for his writings all over Afia and Europe, that no other doctrine was taught in the schools of phyfick, till the restoration of learning. He is a voluminous author, treats largely of every part of Midwifery, fo far as it was known in his time; copying from those that went before him: the operation for the dead child he takes from Paulus; the extraction of the Secundines from Philúmenus; and the use of the fillet from his countryman Rhazes. He is very full on all the diseases of women, relating to the Menfes, uterine gestation, and delivery.
In all præternatural cafes, he fays, the head ought to be reduced into the natural pofition; but, fhould this be found impracticable, he advises us to deliver by the feet. He alledges, that the head is the only natural way of presenting, and that all other pofitions are præternatural; though of these,
the
1
the eafieft is when the Fatus prefents with the feet.
He recommends all the old methods for affifting in natural labours, and if the woman cannot be delivered by thefe, he orders a fillet to be fixed over the head: If that cannot be done, to extract with the forceps; and should these fail, to open the skull; by which means, the contents will be evacuated, the head diminished, and the Fatus eafily delivered.
The next Arabian medical writer is Albucafis, who, in the eleventh or twelfth century, lived at Cyropolis, a city of Media, on the Caspian Sea; and it appears from an Arabian manuscript, in the Bodleian library, that this is the fame perfon who was alfo known by the name of Alfaharavius.
He hath written on natural labours in the fame way with his predeceffors, advifing us to affift the birth with fomentations, and ointments, and by reducing the child into the natural pofition, when any other part than
than the head prefents. His operation for extracting the dead child, is literally the fame with that defcribed by Etius; but whether he copied it from that author, or from other Arabians his predeceffors, is uncertain.
vens.
What is most particular in this author is, the description and figures of the inftruments then used in midwifery; namely, a vertigo for opening the matrix, which feems to be much of the fame contrivance with that which Rhazes calls the Torculum volHe likewife exhibits the figures of two other inftruments for the fame purpose; but not one of the three in the leaft refembles the Speculum matricis, described in later writers: An Impellens, to keep up the body of the child while the operator endeavours to reduce the head into the natural pofition: Two kinds of forceps, of a circular form, furnished with teeth on the infide, to squeeze and crush the head, when it is of an extraordinary bignefs; the larger he calls Almifdach, the other Mifdach: And two different kinds of crochets.
After
After the twelfth century, phyfick began to decline in Ajia. Theodore Gaza brought the Greek manuscripts from Conftantinople, after that city was taken in the year 1453; and about this time, the art of printing being found out, all the knowledge of the ancients was foon difpersed over Europe.
In the next century, the practice of phyfick began to be encouraged in England. Linacre, born at Canterbury, and chosen Fellow of All-fouls, in Oxford, in the year 1484, was a man of learning, and projected the foundation of the college of phyficians in London; for which he obtained a patent from King Henry VIII. and was himself prefident of it till the day of his death.
In the year 1565, one Dr. Raynalde published a book on Midwifery, which he had tranflated into English from the original Latin. He informs the reader in his proluge (as he terms it) that the book, which was called De partu hominis, had been tranflated
tranflated, about two or three years before, at the request of fome women, by a studious and diligent clark, who having performed the talk incorrectly, he (Dr. Raynalde) had been at great pains to revise and enlarge it in another translation: He alfo obferves, that the Latin edition had been formerly published in Dutch, French, Spanish, and other languages*.
The author of this performance (contrary to the opinions of all other writers) fays, when the child prefents in the natural way with the head, that the face and foreparts of the Fetus are towards the foreparts of the mother; and that if any other part prefents, the pofition is præternatural. He obferves, that in France and Germany, the woman is commonly placed in a fitting position,
This author was Eucharius Rhodion, whose book was in great esteem all over Germany, and in the year 1532 being tranflated into Latin and other languages, from the original High Dutch, became univerfally the woman's book over all Europe, and was introduced into England; where it was tranflated by this Dr. Raynalde, who, nevertheless, has taken great liberties with his author.
on
on a stool made in form of a compass; and advises us, in all præternatural cafes, to turn the child to the natural position, even when the feet present: But if this should be impracticable, to bring it footling, and, in extracting, to bind the feet together with a linen cloth. This, however, he pronounces a very jeopardous labour. He directs us to provoke and promote the delivery with fumigations and peffaries, and to prescribe internally, affa-fœtida, myrrh, castor, and storax: From which circumftances, he seems to have copied from the ancients writers.
Several authors of note lived, and wrote in the fixteenth century, or betwixt the and years 1530 1590, upon the diseases of pregnant women, and the different methods of delivery. A collection of the most remarkable among these writers, who are called the old moderns, was published at Bafil 1586. in quarto, intitled Gynaciorum Commentaria; and afterwards, in 1597, republished at Strafburg in folio, by Ifrael Spackius, profeffor of medicine in that city, with the addition of two authors, who
who had not been mentioned in the first. At the head of this collection, is Felix Platerus, born at Bafil: He published tables, explaining the use and structure of the parts of generation proper to women.
The next is the Harmonia Gynaciorum, collected from Cleopatra, Mofchion, Theodorus Prifcianus, and another uncertain author, freed from repetitions and fuperfluities, by Cafparus Vulpbius.
Then follows Eros or Trotula, first published among the old Latin writers at Venice, by the fons of Aldus.
The fourth place is held by Nicholaus Rosheus a Frenchman, whofe works, published at Paris, are taken from the Greeks and Arabians; though he hath added fame obfervations of his own. In his twentieth and eighth chapter, he fays, if the child is large, the Os Uteri must be dilated; if the hand or foot prefents, neither must be laid hold on; but the operator, introducing his hand to the buttock or fhoulder, must reduce the Fatus
into the natural fituation, that is, fo as to prefent with the head. His thirtieth chapter contains directions for extracting the Placenta when it adheres: The Os Uteri must be dilated, and the accoucheur taking hold of the Funis, muft pull gently from fide to fide, left the Uterus fhould be brought down; then more strength must be exerted by degrees, until the Secundines are brought away. His thirty-second chapter treats of monsters.
Ludovicus Bonaciolus of Ferrara, is the fifth: His works were published at Strafbourg.
The fixth is Jacobus Silvius of Amiens in Picardy.
Then comes Jacobus Rueff, who publifhed at Zurich, in Switzerland, and afterwards at Frankfort. He is the first gives a draught of the Speculum Matricis, for dilating the Os internum, which he directs to be stretched in width; but by no means lengthways, left, the ligaments breaking, the womb fhould fall down. When the feet
prefent, and the hands are ftretched along the fides, he advifes us to deliver footling; but if the hands are up over the head, he fays the child ought not to be brought by the feet, unless the head be very small. If the knees present, he orders them to be pushed up, and the child to be delivered by the feet: but if the breech comes first, it must be reduced, and the Fatus brought by the head. The same practice he recom- mends in the presentation of the hands, fhoulder, or hands and feet together. 
He is fucceeded by Hieron. Mercurialis, who lived at Padua, Venice, and Bologna, and practised much in the same manner.
The ninth is Johannes Baptifta Montanus, of Padua.
Victor Trincavillius, of Venice, is the next.
Albertus Bottonus, of Padua, is the eleventh.
After him comes Joannes le Bon Heteropolitanus.
E
The
The author, who holds the next place in this collection, is Ambrofius Paræus, the famous restorer and improver of Midwifery: He lived at Paris, and his works were tranflated into Latin by Jacob. Guillemeau.
Next to him Spachius places Albucafis, the Arabian, already mentioned. Then
Francifcus Rouffetus, who wrote on the Cæfarian operation: His work was translated from French by Cafparus Baubinus; and several of his cafes are published in the memoirs of the academy of furgeons, by M. Simon.
There is alfo the figure of a petrified child, extracted from the womb after the death of the mother; a particular account of which is added to Cordeus's comment upon Hippo
crates.
Cafparus Baubinus, profeffor at Bafil, is
the fixteenth.
Then Mauritius Cordæus, of Rheims and Paris.
The
The next is Martinus Akakia, of Paris; and the laft is Ludovicus Mercatus, a Spaniard.---This author fays, if the child does not prefent with the head or feet, the cafe is dangerous, and præternatural; nor is the prefentation of the feet without hazard and difficulty. In laborious cafes, if the woman be young and vigorous, he prefcribes bleeding in the foot, after Hippocrates; but is against the use of the bath.
If the Fatus comes double, or prefents wrong, he directs us to push it to push it up, and bring down the head, if poffible; which ought alfo to be our aim, when the hand or foot prefents. He orders the fingers to be introduced as Paulus directs, (digitis in unum conductis) that is, the fingers and thumb. formed into the fhape of a cone. He exclaims against the Cafarian operation as an unchriftian undertaking; directs us, when the Placenta adheres, to introduce the hand, and pull the Funis gently from fide to fide; and recommends fneezing to the woman, as conducive to its expulfion.
When he treats of the manner of extracting a dead child, he fays, with Etius, we ought first to confider whether or not the woman has ftrength fufficient to bear the operation; then gives the method of Hippocrates, and in the next page describes the manner of Etius.
Having thus giving a short fketeh of the authors collected by Spachius, I fhall return to Paraus, who (as I have already hinted) was the first modern that made any confiderable improvements in Midwifery; which continued, to his time, without any material alteration, even after the other branches of phyfick had been improved. For example, if the child did not present in the natural way, they fhook and altered the position of the woman, by which means they imagined the Fatus would turn to the right posture; or they attempted to move it fo as that it fhould prefent with the head: If this could not be effected, and the feet were near at hand, they brought it footling; but, if they failed in this attempt, the child was supposed
te
to be dead, and extracted with crotchets and hooks of various kinds; and if it could not be delivered in that manner, on account of its extraordinary fize, or the narrowness of the Pelvis, they difmembered and feparated the body with crooked and ftreight knives, and then extracted it piecemeal.
Paraus was the firft that deviated from this practice, and exprefsly orders the child to be turned and brought away by the feet, in all præternatural cafes. He fays, the most natural cafe is that in which the child prefents with the head, and is delivered immediately on the discharge of the waters: it is more difficult when the Fatus comes by the feet, and ftill more fo, in the presentation of the arm and legs together, the back, belly, arm alone, or any other unnatural pofition. He directs us to bring away the Secundines immediately after the child is delivered: He retains the old notions relating to the difeafes and medicines; for, the antient theory was not alter'd till after the great Harvey found out the circulation of the blood.
1
E 3
CotemR
1
Cotemporary with him, was the above mentioned Jacobus Rueff, who practised at Franckfort, and in his writings recommends the method of the antients: A circumftance from which we learn, that the improvements had not then reached Germany. Indeed they were very much retarded by the false modefty of the women, who were fhy of male practitioners; and by the mistaken notions which were at that time entertained of the ftructure of the Uterus; for, all the descriptions till the time of Vefalius, were very imperfect; and the womb in women fuppofed to be formcd of different cells, refembling that of the brute fpecies.
facobus Guillemeau was the pupil of Ambrofius Paraus, adopted and confirmed his master's practice, and has written with learning and judgment.
About the end of the fixteenth century, or in Paraus' time, furgery in general was more cultivated and improved in Paris than any other part of the world, by means of
in
the
the hospitals which had been from time to time erected, especially the Hotel Dieu, into which poor women with child, deftitute of the neceffaries of life, were admitted.
By fuch opportunities, the furgeons improved their knowledge in Midwifery; and, by degrees, established a better method of practice: The fuccefs that attended which, together with the progrefs of polite literature that began to flourish about this time in France, got the better of those ridiculous prejudices which the fair fex had been used to entertain, and they had recourse to the affiftance of men, in all difficult cafes of Midwifery. This conduct was juftified by experience; and the lives of many women and children were faved by the fkill of the man-practitioner.
In the year 1668, Francis Mauriceau, after an extenfive practice for feveral years, in the Hotel Dieu and city of Paris, published a treatise on Midwifery, which exceeded every thing before made public on that fubject. He defcribes the bones of the PelE 4
vis,
vis, and all the parts fubfervient to generation; the diseases incident to pregnant women, with the methods of prevention and cure; and, after having given a full and diftinct account of all the different labours, and the way of delivering in each case, concludes his work with the difeafes of women and children.
His method of practice was nearly the fame with that of Paraus and Guillemeau; but he is much fuller than either. In laborious cafes, when the head presents, and cannot be delivered by the labour-pains, he orders a fillet, or stripe of linen, to be flit in the middle, and flipped over the head: This contrivance hath fince been improved with laces, by which it is contracted on the head. It is introduced by three different inftruments, fixed with a great deal of trouble, and, after all, of very little ufe.
He alfo invented a tire-tête, which cannot be applied until the fkull is opened with a knife; confequently can be of no fervice in faving the child: And granting the Fatus
to be dead, other methods are much more effectual. He was ignorant of the forceps. When the head is left in the Uterus, he ad vises us to extract it, by introducing over it a broad fillet, like a fling, on
He is fo full on the diseases, that Boerhaave recommended him and Mercatus to his scholars, on that fubject. In his theory of conception, he hath not deviated from the opinions of Hippocrates; and in his fecond volume, he hath published a great many judicious aphorifms, that are now tranflated into English by Mr. Jones: Indeed his writings were fo univerfally approved, that they have been tranflated into several different languages.
3865
Cotemporary with Mauriceau were Dr. Chamberlain and his three fons, who practifed Midwifery in London with great reputation. One of these three fons, father to the late Dr. Hugh Chamberlain, tranflated the first volume of Mauriceau into English; and in a note upon that author's method of extracting the child by the help of the crotchet and
64
and tire-tête, affirms, that his father, brothers, and himself, were in poffeffion of a much better contrivance for that purpose.
This was no other than the forceps, which they kept as a noftrum, and was not generally known till the year 1733, when a description of the inftrument was published by Chapman. Long before that period, indeed, feveral kinds of forceps, or extractors, different from thofe mentioned by the Arabians, were used in France, Germany, and other places; but, all of them, fell short of the inftrument used by the Chamberlains, and faid to be contrived by the uncle.
In the last century, although there were fuch excellent practitioners in London, and even. before the tranflation of Mauriceau, Guillemeau's book on Midwifery had been tranflated into English; and in it all the abfurd notions about fpells and amulets were left out: Nevertheless, one Nicholas Culpepper, who ftiles himself gent. ftudent in phyfick and astronomy, published at London, a book intitled, A Directory for Midwives
in which, he has copied the theory and practice of the old writers, many of whom he mentions, namely, Hippocrates, Galen, Etius, &c. and frequently advises the reader to confult his tranflations of Sennertus, Riverius, Riolanus, Bartholin, Johnston, Veflingius, Rulandus, Sanctorius, Cole, the London Difpenfatory, and a book which he himself had published under the title of The English Phyfician. His performances were for many years in great vogue with the midwives, and are still read by the lower fort, whose heads are weak enough to admit fuch ridiculous notions.
He was fucceeded in that way of writing by one Dr. Salmon, who was alfo a great tranflator and compiler. He was partly author of a fpurious piece called Ariftotle's Midwifery, which hath undergone a great many editions, and contributed to keep up the belief of the marvellous effects of various medicines.
Mauriceau, in 1706, published a fecond volume, containing about 800 obferva
tions;
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tions; but, long before that period, he had gained fuch reputation by his writings, as encouraged others of the fame nation to write on the fame fubject: Accordingly, we have the works of Portal, Peu, and Dionis; but all of them fall fhort of Mauriceau. About this time alfo, Saviard wrote feveral obfervations on the fame art.
Henry Daventer practifed at Dort, in Holland, and in 1701, published a book on Midwifery. He observed, that an imaginary ftreight line falling down from the navel, would pass through the middle of the Pelvis: This will nearly hold true, when the Abdomen is not diftended; but in the last month of uterine geftation, in order to pafs through the middle of the Pelvis, fuch a line -must be let fall from the middle space, betwixt the navel and Scrobiculus cordis. This, however, was a good hint, and useful in practice.
He pretends to have made feveral useful discoveries, which feem feafible enough to those who have not had the opportunity of
an
an extenfive practice; fuch as the fide or wrong positions of the Os internum, and Fundus uteri, which (according to him) are chiefly the occafion of lingering, difficult, and dangerous labours: He feems to have been led into mistake, by fuppofing that the Placenta always adhered to the Fundus uteri. As to the difficulties proceeding from the. wrong pofition of the Os internum, a practitioner would be apt to believe he had never waited for the effect of the labour-pains, which generally open it, by pushing down. the waters, or head of the child.
He was feldom called, except in difficult cafes, often proceeding from a distorted Pelvis, which is common in Holland. When this is the cafe, the head of the child is commonly caft forwards over the Pubis, by the jetting in of the Sacrum: Or, if one Ilium is higher than the other, the Os internum and Fundus are thrown to different fides; but even then, the chief difficulty is owing to the narrowness of the Pelvis. The Uterus is very feldom turned fo oblique as he fuppofes
it
it to be; or, if it were, provided the child is not too large, nor the Pelvis narrow, I never found thofe difficulties he seems to have met with: And fhould the labour prove tedious, on account of a pendulous belly, by altering the woman's pofition, the obftacle is commonly removed.
For example: Let her breech be raised higher than her fhoulders; or, fhe may be laid upon her fide, in a præternatural case, when it is neceffary to turn and deliver the child by the feet. Nevertheless, though he has run into extremes about the wrong pofitions of the Uterus, in which he is the more excufable, as he had the fondness of a parent for a theory that he alledges was his own, yet there are fome very ufeful hints in his book, particularly, that about floodings; in which, he directs us to break the membranes in order to restrain the Hamorrhage; and his method of dilating the Os externum.
The next noted writer in this way, is Lamotte, who lived at Valognes, near Caen in Normandy; and in 1715 published a book
on
on Midwifery, which feems to be the best of the kind fince Mauriceau, and is tranflated into English by Mr. Tomkyns. It contains about 400 obfervations, the greatest part of which are illuftrated with many judicious reflections.
In defcribing a cafe in which the head prefented, he mentions the great fatigue it had coft him to turn and deliver by the feet; and hopes that fome easier method will be found out, for extracting the child in fuch circumstances: So that, although he wrote fo lately, he must have been ignorant of the forceps. He, as well as Daventer, exclaims against the use of inftruments; and in moft laborious cafes, when the head presented, turned and extracted the Fatus by the feet.
A number of such cases he has recounted; but, I am afraid that, like other writers, he has concealed those that would have been more useful to the young practitioner, and only given a detail of his own that were fuccessful: For, certain it is, the head of the
child is often fo large, or the Pelvis fo narrow, that labour-pains cannot poffibly force it away; and frequently, when the Fatus hath been turned with great fatigue, and the body actually extracted, the force required to deliver the head with the hands alone, is fuch as destroys the child; and fometimes it is abfolutely impoffible to bring it along without the help of inftruments.
For my own part, when I first began to practise, I determined to follow the method of those gentlemen; but having by these means loft several children, and fometimes the mother, I began to alter my opinion, and confult my own reafon: In confequence of which, in cafes of fuch emergency, I opened the head, with a view of faving the women, if I could not preserve the life of the child. In the course of my deliberations on this subject, I likewife tried to improve upon the forceps, which feemed to me an inftrument more mechanically adapted, and easier applied than any other contrivance hitherto ufed: And furely experience juftifies the use of this expedient, by which we are enabled
abled to fave many children, which otherwife must have been destroyed.
Not that I would be thought to exult over those authors whom I have mentioned, as moftly enemies to all inftruments whatever: In other things they have written very judicioufly, and are blame-worthy in nothing fo much, as in having fuppreffed those unfuccefsful cafes which must have happened to men of their extenfive practice.
I own, indeed, when the woman has not ftrength nor pains fufficient to force along the child, and the difficulty does not proceed from a large head or narrow Pelvis, the method of turning will prove fuccessful; but, if in the other extreme, I appeal to all candid practitioners, whether many children are not loft, even when the head does not prefent, and when the body is first brought down, because the Fetus cannot be delivered in another manner.
The next writer in Midwifery is Mr. Amand of Paris, who describes the method F of
of extracting the head, when left in the
Uterus, by means of a net. The contrivance is ingenious, but is not applied without great trouble, and cannot fucceed when the Pelvis is too narrow, or the head too large to país.
Edmund Chapman practifed Midwifery several years in the country, before he fettled in London; where, in 1733, he published a fhort account of the practice of Midwifery, illuftrated with about fifty cases; and is the first person who made publick a description of the forceps used by the Chamberlains. Giffard's obfervations were published in the following year, by Dr. Hody, containing many useful remarks and hiftories of cafes in which he had ufed the extractors or forceps.
Heifer, profeffor at Helmftadt, a little town in the dukedom of Brunfwick, in the year 1739 published at Amsterdam, a treatife on furgery; in which we find a very concife and diftinct account of the practice of
of Midwifery, as well as of the Cæfarean operation.
Mr. Ould, furgeon in Dublin, in the year 1742, published a treatife on the practice of Midwifery, in which there are two good obfervations: One relating to a cafe in which the head prefents; and the other specifying what is to be done, when delivery is retarded by the twifting of the Funis round the neck of the child. He prefers his Terebra occulta to the fciffars, probably becaufe he did not know the proper dimensions of this laft inftrument. The very next year, Mefnard publifhed, at Paris, a book on the fame fubject, by way of question and answer; and is the firft who contrived the curved, in lieu of the ftreight crotchets which is a real improvemeut.
Over and above the writings of thofe authors whom I have mentioned, there are à great many curious and extraordinary obfervations on the practice of this art, in Schenckius, Hildanus, Bonetus; the Philofophical Tranfactions, the Academies of Sciences and
of Surgeons, and the medical effays of Edinburgh: And befides thefe, the best modern authors who have written on the diseases of women and children, are Sydenham, Harris, Boerhaave, Friend, Hamilton, Hoffman, and Shaw.
On the whole, that the young practitioner may not be misled by the useless theories, and uncertain conjectures of both antient and modern writers, it may be neceffary to obferve in general, that all the hypotheses hitherto efpoufed, are liable to many material objections; and that almost every system hath been overthrown by that which followed it.
This will, probably, be always the cafe; and, indeed, as theory is but of little fer. vice towards afcertaining the diagnostics and cure of diseases, or improving the practice of Midwifery, fuch enquiries are the less material. What Hippocrates has written about the form of the Uterus, and its various motions, conception, the formation of the child, the feventh and eight month's births,
was
was believed as infallible till the last century, when his doctrine of conception, and the nu- trition of the Fatus was overthrown; and many new and uncertain theories, on the fame fubject, introduced. 
་
1
Some of the moderns conclude, that the antients never turned and brought children by the feet, because Hippocrates directs us in all cafes, to bring the head into the natural fituation; and fays, that when delivery is performed by the feet, both mother and child are in imminent danger. Celfus, and all the writers till the time of Paraus, adopted this practice of bringing the head to prefent: But, at the fame time, many of them obferve, that if this be not practi cable, we must search for the feet, and deliver the Fatus in that manner. Celfus fays, if the feet are at hand, the child is eafily delivered footling; And Philumenus goes ftill farther, faying, that if even the head fhould prefent, and the child cannot be delivered in that pofition, we must turn and bring it by the feet.
F 3
With
1
With regard to the fillets and forceps, they have been alledged to be late inventions; yet, we find Avicenna recommending the use of both: And although, by the figures of the forceps given by Albucafis, who represents them furnished with long fharp teeth, one would imagine the inftrument was defigned for fqueezing the bones and bringing the child along at any rate, without endeavouring to fave its life, yet the forceps recommended by Avicen, is plainly intended to. fave the Fatus; for he fays, if it cannot be extracted by this inftrument, the head must be opened, and the fame method used, which he describes in his chapter on the delivery of dead children.
To conclude, we find among the ancients feveral valuable jewels, buried under the rubbish of ignorance and fuperftition; because the affiftance of men was feldom folicited in cafes of Midwifery, till the laft extremity: And those disadvantages being confidered, we ought to be furprised at
finding fo many excellent obfervations in the course of their practice; and be ashamed of ourfelves for the little improvement we have made in fo many centuries, notwithstanding our opportunities, and the advantages we had from their experience.
True it is, we have established a better method of delivering in laborious and præternatural cafes; by which many children are faved, that must have been destroyed by their manner of practice: but are not many of our modern practitioners juftly branded. for their fordid and unfocial principles, in profeffing noftrums, both with regard to medicines and methods of delivery? Infomuch, that I have heard a gentleman of eminence in one of the branches of medicine affirm, that he never knew one perfon of our profeffion, who did not pretend to be in poffeffion of fome fecret or another: From whence he concluded, that we were altogether a body of empirics. Such reflections ought to make a suitable impreffion upon the minds of the honeft and ingenuous, prompt them to lay afide all fuch pitiful, F 4 felfish
selfish confiderations, and, for the future, act with openness and candour; which cannot fail of redounding to the honour of the profeffion, and the good of fociety, as well as their own advantage.
CHA P. I.
The structure and form of the Pelvis, fo far as it is necessary to be known in the practice of Midwifery.
SE C T. I.
Of the BONES.
HE Pelvis is compofed of three bones; the Os Sacrum, with its appendix, known by the name of Coccyx, and the two Offa innominata. The Sacrum in children is divided into five diftinct bones, and the Coccyx into four cartilages; but, in adults thefe laft are formed into as many moveable
bones,
bones, and the divifions of the Sacrum offi
fied fo as to become one bone.
Each Os innominatum is, in infants, compofed of three different bones, under the appellation of Os Ilium, Ifchium, and Pubis; which are joined to one another at the Acetabulum, or cavity, that receives the round head of the thigh-bone. This compofition is, in point of figure, fo irregular, that although in adults the three are offified into one bone, those different names are still fed, in order to diftinguifh one part of it from the other.
The Offa innominata of the oppofite fides are joined to one another in the fore-part, at the Pubes, by a thick cartilage and strong ligaments; and the pofterior part of each Os ilium is connected with the upper and lateral part of the Sacrum by the fame apparatus.
Divers authors and practitioners in this art have alledged, that towards the latter end of geftation, when all the parts of the Abdomen are strongly preffed by the increased Uterus, an extraordinary quantity of Mucus is fecreted, not only by the glands of the Os
}
internum and Vagina, but also by thofe belonging to the cartilages and ligaments, that connect the bones of the Pelvis; by which means, the ligaments and cartilages are foftened and relaxed, and the bones are feparated from one another in time of labour: But, from experience and obfervation I may venture to affert, that this feparation is by no means an ufual fymptom, though fometimes it may happen; in which cafe, the patient fuffers great pain, and continues lame in thofe parts for a confiderable time after delivery.
In fome women, indeed, a kind of obfcure motion may be perceived, when the child's head is forced into the Pelvis, by ftrong pains: The junctures of the Sacrum with the Offa ilium, as well as that of the Offa pubis, feem to yield a very little alternately, in order to accommodate themselves to the shape of the head, as it is fqueezed down and paffes through the Pelvis ; but the bones are not feparated to any confiderable distance.
The Coccyx is moveable at its connection with the Sacrum; as are alfo the four bones that
that compose it, in their articulations one with another; and this motion continues in adults, as well as in thofe of more tender years: In old age, indeed, and even in young people who have fuffered bruifes upon the part, attended with great pain and inflammation, we frequently find the different pieces of this bone rigidly cemented together: But, this Anchylofis the more feldom happens, because they undergo a gentle motion at every excretion of the Faces, which helps to preferve their mobility.
SECT. II.
THE brim or upper part of a wellfhap'd Pelvis reprefents a kind of imperfect oval, or fomething that approaches a triangular figure: If we confider it as an oval, the long axis paffes from fide to fide; but as a triangle, the pofterior part forms one fide, and the Offa pubis conftitute the oppofite angle; fo that behind it is compofed of the broad part of the Sacrum, where it joins with the last Vertebra of the loins; on each fide by the inferior parts of the Ilia;
and
and before, by the fuperior parts of the Offa pubis.
The lower circumference of the Pelvis is formed, behind, by the inferior part of the Sacrum and its appendage; on each fide, by the lower part of each Ichium and a broad ligament which rifes from the spine of that bone, and, with the Coccygaus mufcle, is inferted into the edge of the Coccyx and the lower part of the Sacrum; and before, by the inferior parts of the Offa pubis and the two proceffes that defcend on each fide, to join with those that rise from the Ischia; by which conjunction the Foramen Magnum Jfchii, is formed on each fide.
b
When the body of a woman is reclined backwards, or half-fitting, half-lying, the brim of the Pelvis is horizontal, and an imaginary freight line defcending from the navel, would pass through the middle of the cavity; but, in the last month of pregnancy, fuch a line must take its rife from the middle fpace between the navel and Scrobiculus cordis, in order to pafs through the fame point of the Pelvis.
SECT: III.
IN the confideration of the Pelvis, three circumstances are to be principally regarded and remembered; namely, the width, the depth, and form of the cavity on the infide.
1. The extent of the brim from the back to the forepart, commonly amounts to four inches and one quarter; and from one fide to the other, the distance is five inches and a quarter: So that this difference of an inch in the different axes, ought to be carefully attended to in the practice of Midwifery. But, the width of the lower part of the Pelvis is the reverse of this calculation, when the Os coccygis is pressed backward by the head of the child: because, in that cafe, the distance between the Coccyx and the lower part of the Os pubis, is five inches and a quarter; whereas, the inferior and pofterior parts of one Os ifthium, are no more than four inches and a quarter, from the fame parts of the other. Indeed, the width of the lower part of the Pelvis is naturally the fame, in both diameters; so that this
difference of an inch is occafioned by the yielding of the Coccyx in the birth.
2. The depth of the Pelvis, from the upper part of the Sacrum, where it is articulated with the laft Vertebra of the loins, to the lower end of the Coccyx, is about five inches in a streight line; but when this appendix is ftretched outward and backward, the distance will be one inch more.
The depth from the fides of the brim towards its fore-part, to the lower parts of the Ifchia, is four inches; and from the upper to the lower parts of the Offa pubis, where they join, the distance is no more than two inches: So that in the dimenfions of the Pelvis, the fide is twice, and the back part three times the depth of the forepart.
3. Nor is the form and fhape of the infide of the Pelvis to be neglected by the practitioners of Midwifery.
8
The Sacrum and Coccyx being convex on the outfide, exhibit a concave figure on the nfide; the curve being increased towards the lower end, fo as that from the extremity of the Coccyx to the middle of the Sacrum, the fweep nearly reprefents a femicircle;
and
and from thence the bone flopes upward and forward.
From the upper part of the brim on cach fide, (but nearer the fore than the back part) to the lower parts of the Ifthia, the defcent is perpendicular: And the opening on each fide, betwixt the lower parts of the Sacrum and the pofterior part of each Ifchium is about three inches deep, and two and ah half in width. The upper part of this vacuity on each fide, gives paffage and lodgement to a muscle, veffels, nerves, &c. At its lower part, the Coccygaus mufcle and ligament above mentioned, are stretched acrofs from bone to bone; and this ligament is on the outfide ftrengthened with another strong expanfion, rifing from the tuberofity of the Ifchium, and fixed into the edge of the Sacrum and Coccyx. All these parts yield and ftretch, forming a concave equal to that of the Sacrum, when the fore or hind-head of the child is pushed down at the fide and back part of the Pelvis.
From the upper to the under-parts of the Offa pubis, which form the anterior angle of the Pelvis, the defcent is almost perpendicular
dicular, or rather inclining a little backwards: So that the infide of the bafin is bent into a concave behind, and defcends in almost a ftreight line before; while the Ilia flope outwards as they rife, and the Vertebra of the loins turn backwards, making an obtufe angle with the Sacrum.
On the whole, it is of the utmost confequence to know, that the brim of the Pelvis is wider from fide to fide, than from the back to the forepart; but, that at the under part of the bafin, the dimensions are the reverse of this proportion; and that the backpart, in point of depth, is to the fore-part as three to one, and to the fides as three to two.
Though those dimensions obtain in a wellfhaped Pelvis, they fometimes vary in different women; and the reafon of this remark will be more fully explained, when we treat of the method of delivery, in the different kinds of labours,
1
SECT.
IV.
Of a diflorted PELVIS.
THE Pelvis, in decrepit women, is not always diftorted, because the distortion of the fpine, in many women, does not happen till the age of eight, ten, twelve, or fourteen; when, being tall and flender, it is occafioned by mifmanagement in their drefs, lying too much on one fide, and other accidents ; without having any effect upon the Pelvis, the shape of which is by that time ascertained.
But, most of those who have been ricketty in their infancy, whether they continue little and deformed, or, recovering of that disease, grow up to be tall ftately women, are commonly narrow and distorted in the Pelvis; and confequently subject to tedious and difficult labours: For, as the Pelvis is more or less distorted, the labour is more or lefs dangerous and difficult.
In ricketty children, the bones are soft and flexible; and as they cannot run about and exercise themselves like thofe of a more hardy make, the Pelvis, in fitting upon stools or the nurse's knees, is by the weight of
of the head and body, often bent and dif torted in the following manner:
1
The Coccyx is preffed inwards towards the middle of the cavity of the Pelvis; the adjacent or lower part of the Sacrum is forced outwards, while the upper part of the fame bone is turned forward with the laft Vertebra of the loins, approaching too near to the upper part of the Pubes: So that the distance in fome women, from the back to the fore-part of the brim, is not above three inches; in others, no more than two; and fometimes, though rarely, not above one inch and an half.
In others, the lower Vertebra of the loins, with the upper end of the Sacrum jet inwards and to one fide: The Offa pubis, inftead of being inwardly concave, are fometimes convex; and the lower part of each Ifchium fo near to one another, that the dif tance, inftead of four inches and one quarter, will not amount to more than three, and in fome cafes not fo much.
Sometimes, the Vertebra that compose the Sacrum ride one another, and form a large protuberance in that part which ought to be G 2
con
concave; but the most common circum_ stance of distortion, is the jetting forward of the laft Vertebra of the loins with the
upper end of the Sacrum, forming a more acute angle with the spine; and in this part of the paffage, the head moft commonly fticks.
SECT. V.
THE Pelvis in women is wider than in men, the Ilia fpreading more outward, in order to fuftain and allow free space for the stretching of the Uterus; the Sacrum is more concave, and the proceffes of the Offa pubis, at their junction with the Ischia, are not fo near to one another.
In order to demonftrate the advantage of knowing the wideness, depth, and figure of the infide of a well-formed Pelvis, it will be neceffary to afcertain the dimenfions of the head of the child, and the manner of its paffage in a natural birth.
The heads of thofe children that have paffed easily through a large Pelvis, as well as of those that have been brought by the feet, without having suffered any altera
alteration in point of shape, by the uncommon circumstances of the labour; I fay, fuch heads are commonly about an inch narrower from ear to ear, than from the forehead to the under-part of the hind-head.
That part of the head which presents, is not the Fontanelle (as was formerly fuppofed) but the fpace between the Fontanelle and where the Lambdoidal croffes the end of the Sagittal future, and the hair of the fcalp diverges or goes off on all fides: For, in most laborious cafes, when the head is fqueezed along with great force, we find it preffed into a very oblong form, the longest axis of which, extends from the face to the Vertex. From whence it appears, that the crown or Vertex is the first part that is preffed down, because in the general preffure, the bones at that part of the skull make the leaft refiftance, and the face is always turned upward; fometimes, indeed, this lengthening or protuberance is found at a little diftance from the Vertex, backward or forward, or on either fide; and fometimes (though very feldom) the Fontanelle, or forehead prefents; in which cafe
G 3
cafe they protuberate, while the Vertex is preft, and remains quite flat: But these two inftances do not occur more than once in fifty or an hundred cafes that are laborious.
Now, fuppofing the Vertex is that part of the head which prefents itself to the touch, in the progress of its descent, the Fontanelle is commonly turned more upwards, and to one fide of the Pelvis; and when the hindhead comes down to the Os ifchium of the contrary fide, one may feel the Lambdoidal future where it croffes the end of the Sagittal, and, unless the fcalp is very much fwelled, diftinguifh the Occiput at its junction with the parietal bones, by the angle, which is more obtufe than those that are formed on the other parts of the skull: Befides, in this pofition, the ear of the child may be easily perceived at the Os pubis. As the head is forced farther along, the hindhead rises gradually into the open fpace below the Offa pubis, which is two inches higher than the Ifchium, while at the fame time, the forehead turns into the hollow of the Sacrum.
This, therefore, is the manner of its progreffion: When the head first presents itfelf at the brim of the Pelvis, the forehead is to one fide, and the hindhead to the other, and fometimes it is placed diagonal in the cavity: Thus the wideft part of the head is turned to the wideft part of the Pelvis, and the narrow part of the head, from ear to ear, applied to the narrow part of the Pelvis, between the Pubis and the Sacrum. The head being fqueezed along, the Vertex descends to the lower part of the Ifchium, where the Pelvis becoming narrower at the fides, the wide part of the head can proceed no farther in the fame line of direction: But, the Ifchium being much lower than the Os pubis, the hindhead is forced in below this last bone, where there is leaft refiftance. The forehead then turns into the hollow at the lower end of the Sacrum, and now again the narrow part of the head is turned to the narrow part of the Pelvis The Os pubis being only two inches deep, the Vertex and hindhead rise upward from below it; the forehead presses back the Coccyx, aud the head rifing upG4
ward
ward by degrees, comes out with an half round turn, from below the share bone: The wide part of the head being now betwixt the Os pubis and the Coccyx, which being pushed backwards, opens the wideft fpace below, and allows the forehead to rife up also with a half round turn, from the under part of the Os externum.
From these particulars, any perfon will perceive the advantage of remembring, that the Pelvis at the brim is wider from fide to fide, than from the fore to the back-part, while below it, is the reverfe, in point of dimenfion: that the Pelvis is much shallower at the Os pubis than at the fides and back-part; and that the Sacrum and Coccyx form a large concave in their descent, whereas that of the Os pubis is perpendicular : Neither is it lefs neceffary to consider the form of the head, as above described; for the knowledge of these things will convey a diftinct idea of the manner in which the head is to be brought along in laborious cases; on what occasions the use of the forceps may be neceffary; and when the method must be varied, as the form of the head or Pel
chance to vary from our defcrip
may
vis
tion.
Although the pofition of the head, in natural and laborious births, is commonly fuch as we have obferved, it is not always the fame, but fometimes differs, according to the different figures of the Pelvis and head, and the posture of the child in utero: For, when the waters are in small quantity, or the membranes broke, fo that the body of the child is close confined by the womb, if the fore-parts are towards the belly of the mother, that position may hinder the head from making the proper turns as it is pushed down, and the forehead may be forced towards the groin or Pubes. Sometimes, even in a well-formed Pelvis, if the Fontanelle prefents itself, with the forehead to one fide of the brim, and the hindhead to the other, when the head is forced down by the increasing pains, there will be less refistance at the Vertex than at any other part; confequently, the diameter from the fore to the hindhead will be leffened; and this last, by accommodating itself to the circumftances of the preffure, be firft squeezed
down,
4
down, and at length, come forward in the natural way: Or fhould the ear present itfelf, the Vertex will be firft forced down in the fame manner. But if the forehead be nearer than the Vertex, to the middle of the brim of the Pelvis, every pain will force it farther down; and, when delivered, it will rife in form of an obtufe cone or fugar-loaf; and, in that case, the crown of the head will be altogether flat. But, if inftead of the Vertex or forehead, the Fontanelle fhould first appear, the space from the forehead to the crown, will then rife in form of a fow's back; and in all these cafes, the head is brought along with greater difficulty, than in thofe where the Vertex is first produced: And in all laborious cafes, the Vertex comes down, and is lengthened in form of a fugar-loaf, nine and forty times in fifty instances. When the forehead prefents, the face is fometimes pressed forwards. If the Pelvis be as wide from the back to the forepart, as from fide to fide, (though this feldom happens) the crown may be pushed down at the Pubes, and the forehead afterwards fqueezed into the hollow of the Sacrum,
Sacrum, without making the foregoing turns. If the belly of the child is to the forepart of the Uterus, the Vertex may be towards the Sacrum, and the forehead to the Pubes or groin: So that all these uncommon pofitions are attended with dif ficulty.
CHA P. II.
Of the external and internal parts of Generation proper to women.
SECT. I.
The external parts and VAGINA.
THE
HE Mons Veneris is fituated at the upper part of the Pubes, from which also begin the Labia pudendi, stretching down as far as the lower edge where the Frænum labiorum or Fourchette is formed; and here it will not be amifs to obferve, that the œdematous fwelling of the Labia, which often happens, is no manner of obftruction to delivery.
The Clioris, with its Præputium, is found between the Labia, on the middle and forepart
1
part of the Pubes; and from the lower part of the Clitoris, the Nympha rifing, spread outwards and downwards, to the fides of the Os externum, forming a kind of Sulcus or furrow, called the Foffa magna or Navicularis, for the direction of the Penis in coition, or of the finger in touching, into the Vagina.
The Meatus urinarius is immediately below the under-edge of the Symphysis of the Offa pubis, and at the upper part of the Os externum, which is the orifice of the Vagina, fituated immediately below the faid bones of the Pubes; the lower edge of which bones, is equal to the lower edge of the Frænum or Fourchette, which bounds the inferior part of the Foffa magna and Os externum, restraining it as if with a bridle.
The Perinæum extends from this border to the Anus, being about one inch, or one and an half in length; the wrinkled part of the Anus is about three quarters of an inch in diameter; from thence to the Coccyx the distance is about two inches; fo that the whole extent, from the Fourchette to this bone,
bone, amounts to about four inches, or four and a quarter.
What remains of the lower part of the Pelvis, is covered and filled up with the integuments, adipofe membrane, and the muscles called Levatores Ani; while within these, are contained the muscles belonging to the Clitoris, mouth of the bladder, Os externum, and Anus.
In young children there is a thin membrane called the Hymen, extended over the lower part of the Os externum, representing the figure of a crefcent; the concave and open fide being turned towards the Meatus urinarius. In fome the middle of this concave is attached to the lower part of the Meatus, forming two fmall openings, which in grown women, will fcarce admit a fmall probe, unless the membrane has been previously broke in coition: Nay, in fome adults this membrane has entirely fhut up the entrance of the Vagina, fo that they have been altogether imperforated; but when broke, it recedes and forms the Caruncule myrtiformes.
On
On each fide of the Meatus urinarius, are two small Lacunæ or openings, the tubes of which ending in a kind of Sacculus, come from the prostate gland: From these a thin fluid is ejected in time of copulation, and that from fome women with confiderable force; and fometimes, though feldom, to the quantity of several drachms.
The Urethra in women, is about one inch and an half in length. The Vagina is formed of a strong, thick membrane, of a spungy texture, more contracted in virgins than in married women: When stretched to its full extent, it may be about five, fix, or feven inches long, and two in width, according to the difference of ftature in different women; but when the Uterus hangs down in the Vagina, the length will not be more than two or three inches; and it may be ftretched with the finger to the wideness of three or four. The infide of it in young women, is full of ruga, folds or wrinkles, which are partly oblite rated in those who have bore children: The upper end of the Vagina is joined to the circumference of the lips of the Os uteri,
I
which
which resemble the mouth of a puppy, or tench; and a thin expanfion of this membrane being reflected inwards, covers the exterior part of thefe lips, which in virgins are smooth and of an oval form: It is also continued along the infide of the Uterus, conftituting the internal membrane of the neck and Fundus, which is likewise full of Plica, especially in young fubjects.
As to the different names of those parts, the book of Schurigius, published at Drefden in the year 1729, may be confulted. The entry of the Vagina is commonly called the Sphincter vagina, and the mouth of the womb is often diftinguished by the appellation of Os tinca: but, as the mention of these parts will frequently occur in the course of this treatise, I fhall, in order to avoid confufion or mistake, call the firft Os externum, and the other Os internum, through the whole book.
SECT.
SECT. II: Of the UTERUS. 
THE Uterus is about three inches long, from the Os internum to the upper
part of the Fundus, and one inch in thickness from the fore to the back-part. It is divided into the neck and Fundus, the length of the neck being an inch and three quarters, while that of the Fundus is one inch and one quarter. The width of the Uterus at the neck is about one inch, but at the Fundus, twice as much. The Uterus is fmaller in young women.
The outside shape of the Uterus, in some measure, resembles a flattened cucurbit, or that kind of pear which hath a long neck.
The canal or entrance from the Os internum to the cavity of the Fundus uteri, will admit a common director; being a little wider in the middle and more contracted at the upper end.
The cavity of the Fundus is, in point of figure, fomething between an oval and triangle; one of the angles commencing at the upper end of the forefaid canal, and
the
the other two expanding the fides of the Fundus, from which arise the Fallopian tubes. Thefe tubes are about three inches long, and fo narrow at their entrance from the Uterus, as fcarcely to admit an hog's bristle; but the cavity of each turns gradually wider, and ends in an open mouth or sphincter, from the brim of which is expanded the Fimbria or Morfus diaboli, that generally bears the likeness of jagged leaves, and in some refembles an hand with membranous fingers, which is supposed to grafp the Ovum when ripe and ready to drop from the Ovarium.
The Uterus is formed, firft of the infide membrane that rifes from the Vagina, and lines all the interior part of the womb: Immediately above this coat is the thick fubftance of the Uterus, compofed of a Plexus of arteries, lymphaticks, veins and nerves, and the veffels on its furface, when injected, feem to run in contorted lines. It appears to be of the fame glandular texture (though not fo compact) as that of the breafts, without any mufcular fibres, except fuch as compofe the coats of
H
the
1
the veffels: neither is there any neceffity for that muscle which Ruysch pretended to difcover at the Fundus, for the convenience of forcing off the Placenta; because this cake as frequently adheres to other parts of the womb as to the Fundus.
"
The fubftance of the Uterus appears more compact and pale than that of mufcles; or if it be mufcular, at least the fibres are more close, and more intricately difpofed, than in other muscular parts. The blood veffels of the womb, in the virgin or unimpregnated ftate, are very small, except just at their approach to its fides, at the roots of the Ligamenta lata; but, as soon almost as they enter its substance, they are difperfed into such numbers of smaller branches through the whole, that when it is cut, we can obferve but few, and thofe very small orifices, much less any cavities that deserve the name of Sinuses. Indeed, when this part is minutely injected, it seems to be almost nothing but a mass of veffels; a circumstance common to it, with other parts of the body: And anatomists are agreed, that the greater number of veffels visible in fuch nice injec
tions, are thofe through which the ferum or lymph of the blood circulate in the living body, whence the Error loci in an Opthalmia, is imitated by fubtile injections of coloured matter into the arteries of the dead fubject.
When the Uterus ftretches in time of geftation, the veffels are proportionably di lated by an increase of the fluid they contain; fo that, at the time of delivery, fome of them are capacious enough to admit the end of the little finger. Yet the fubftance of the womb, inftead of growing thinner, as Mauriceau alledges, or thicker, according to Darventer, continues of its natural thickness during the whole term of pregnancy; and this equality is maintained by the gradual diftenfion of the veffels that enter into its compofition. In time of labour, indeed, as the waters are discharged, the Uterus contracts itself and grows thicker; and the refistance ceafing at the delivery of the child and after-birth, it becomes smaller and smaller, until it has nearly resumed its natural dimenfions.
For.
H 2
For, as the Uterus contracts itself after parturition, the arterial blood cannot flow into it in the fame quantity as that with which the veffels were filled in their state of diftention. The fluids are gradually emptied into the Vena cava afcendens, but chiefly through the mouths of the veffels that open into the cavity of the womb; and the veffels themselves that were ftretched, elongated, and seemed to recede from one another, are also contracted by degrees, and that in such a direction, as to reduce the Uterus into the same shape and fize which it bore before impregnation: Nay, the fibres are again fo compacted, that they, and even the veffels, are fcarce difcernable.
The Vagina on its out-fide is covered with a thick adipofe membrane: by means of which it is on the forepart attached to the lower part of the bladder, and on the back part to the lower end of the Rectum and Anus; and by the fame means all these parts are connected with the Peritonæum, or internal furface of the Pelvis.
The Uterus is contained in a dublicature of the Peritoneum, which covers it every
where
where above, and is connected with its fubftance by a very thin cellular membrane; as for the Peritoneum in itself, it is a smooth membranous expanfion, that covers all the infide of the Abdomen, and gives external coats to all the Vifcera contained in that cavity. On the fore-part, it lines the muscles of the Abdomen and Diaphragma; backwards, it covers the abdominal Viscera in general, the Aorta and Vena cava descendens, the kidneys, ureters, and spermatick vessels, the external and internal Iliacs, the Pfoas and muscles that cover the infide of the Ilium; whence it rifes double, and forms the Ligamenta lata, in which are contained the Ovaria and Fallopian tubes. This duplicature, where it meets in the middle, invelops all the Uterus, as before observed, and gives a covering to the round ligaments that rife from each fide of the Fundus uteri, and are inferted or loft about the upper and external part of the Pubis and groin. The Peritoneum is alfo reflected from the forepart of the Uterus, over the upper-part of the bladder; and upon the back-part of the Uterus, it defcends even upon the Vagina, H
from
from which it is again reflected upwards over the Rectum, By these attachments, especially the broad and round ligaments, the Uterus is kept between the Vefica urinaria and rectum, loofely fufpended in the Vagina, within two or three inches of the Os externum; the Os internum being turned back in the lower part of the Vagina, towards the Anus or lower part of the Rectum; fituated in the course of the ftreight line, paffing through the middle of the Pelvis. In coition, the Uterus yields three or four inches to the preffure of the Penis, having a free motion upwards and downwards, fo that the reciprocal ofcillation which is permitted by this contrivance, increases the mutual titillation and pleasure.
The ligaments undergo no extraordinary extenfion in time of uterine geftation, because they fink down two inches with the Uterus in an unimpregnated state; and when the Fundus rifes, they will be raised at the fame time, to the height of not only these two inches, but as much more, without being stretched in the leaft: Befides, as the Uterus rifes ftill upwards, the fides of it ap
approach the Ilia, from whence the broad ligaments take their origin; and this circumftance is equal to an acquifition of three inches more: fo that, upon the whole, thefe ligaments feem to be to be very little stretched, even in the last month of pregnancy.
SECT. III.
Of the Ovaria, veffels, ligaments, and Fallopian tubes.
THE Ovaria are two small oval bodies, one of which is placed behind each Fallopian tube; fuppofed to be little more. than a cluster of Ova, whence they derive their prefent name: for, by ancient authors they are mentioned by the appellation of the female tefticles. Each Ovarium is about one inch in length, half as broad, and one quarter of an inch in thickness; more convex on the fore than on the back part, of a smooth surface, covered with the Peri
tonæum.
The blood veffels are, firft, the spermatick arteries and veins, which have nearly the fame origin as thofe in men, are mostly
diftributed upon the Ovaria and tubes, and at the upper part of the Uterus communicate with the hypogaftricks, from the branches of which the body of the womb is furnished. All these arteries anastomose, and are fuppofed to detach small ramifications that open into the cavity of the Uterus, The veins are large, communicate one with another, with the Hæmorrhoidals and Vena portarum, and have no valves.
The Ligamenta rotunda are two vafcular ropes compofed of veins and arteries inclosed in the duplicature of the Ligamenta lata ; feemingly arifing from the crural artery and vein, from whence they are extended to the fides of the Fundus uteri.
The nerves come from the intercostals, Lumbares, and Sacri; as defcribed in Boerhaave's inftitutes, and Winflow's anatomy.
CHAP,
CHAP. III.
105
SECT. I.
Of the CATAMENIA and FLUOR ALBUS, in an unimpregnated ftate.
T
HE Uterus, according to fome, and all the parts fubfervient to generation, arrive at full growth about the age of fifteen; The veffels are then fufficiently dilated, and those that end in the cavity of the womb, fo diftended with blood, that their mouths are forced open, they empty themselves gradually, and for that time the Plethora in the Uterus and neighbouring parts is removed.
Several ingenious theories have been erected, to account for the flux of the Menfes; particularly by Doctors Friend, Simpson, and Aftruc, the two last of whom, with many others, alledge, that there are Sinufes in the Uterus, furnished with fide-veffels opening into its cavity; which Sinufes are gradually ftretched by the blood they receive from the
ar
arteries, until the fourth or beginning of the fifth week, the lateral veffels are forced open, and the accumulated blood evacuated into the cavity of the womb. But, if this were the cafe, the fame mechanism must prevail in other parts of the body, through which the like periodical discharge is made, when the Uterus is obftructed; as from the nofe, hairy fcalp, lungs, ftomach, mefenteric and hæmorrhoidal veffels, and even through the skin of the legs, and other parts of the body. Befides, fuch an accumulation in large Sinuses, though the blood were not entirely stagnated, would produce a vifcofity like that which obtains in rheumatisms and other inflammatory diftempers,
Those who live in hot climates, are frequently visited with the Menfes at the age of twelve; and women who are kept warm, and live delicately, undergo this discharge earlier than thofe who ufe a different regimen: And if the Catamenia do not flow at the stated time, the patient is soon after feized with the Chlorofis, unless fome other evacuation happens in lieu of the Menfes.
They
They commonly ceafe to flow about the age of forty-five, except in those with whom they began at twelve, or in fuch as have born a great many children; in which cafe, they ceafe about the age of two and forty, or fooner.
In young people the Momentum of the circulating fluid is greater than the refifting force of the folids; fo that the veffels continue. to be gradually ftretched, until, by their number, capacity, and length, this Momentum is diffipated, fo as to become no more than equal to the refiftance. About this time the fuperplus of blood begins to be discharged, and thus the Equilibrium is preferved till the age of forty five; when the fibres growing rigid, the Incrementum is lessened, the evacuation is no longer neceffary, nor has the blood force enough to make good its wonted paffage into the cavity of the womb. In the fame manner are produced the symptoms of old age. The Catamenia are, therefore, no more than a periodical discharge of that superplus of blood, which is collected through the month, and towards the crifis, attended
·
with pains in the loins, breaft, and head, more or less acute, according to the circumftances of the Plethora; all which complaints gradually vanish when the Menfes begin to appear.
This evacuation commonly continues till the fifth or fixth day, in fome to the third only, and in others to the feventh: The quantity discharged being, according to Hippocrates, two heminæ, equal, by the computation of fome, to eighteen or twenty, and, in the opinion of others, to twenty-four ounces: but, this must certainly be a mis take; for they rarely exceed four ounces, except when they flow in too great quantity.
Women that are delicately kept and plentifully fed, have this difcharge more frequently, and in greater quantity, than those who are inured to much exercife, or subject to copious perspiration; yet, both these conftitutions may be healthy, and ought not to be tampered with by prescriptions for altering the period or quantity of this evacuation. Indeed, if the flux be fo frequent or immoderate as to exhauft the ftrength of the patient, it will be neceffary to prefcribe bleed
ing before the return of the period, reft, cooling and aftringent medicines, not only taken internally, but likewife applied externally, and injected into the Vagina.
On the contrary, if they flow too seldom, in too small quantity, or do not appear at all, fo that a dangerous plenitude enfues, the Plethora must be leffened by plentiful bleeding and repeated purges, and the discharge follicited by warm baths, fumigation, and exercise. But if the patient has been long obstructed, from a Lentor, viscosity, and retarded motion of the fluids in the Uterus and neighbouring parts, the fullness must be taken off by the abovementioned evacuations, unless the conftitution be already weakened; then every thing that will gradually attenuate the fluids and quicken their circulating force, ought to be administred; fuch as chalybeat and mercurial medicines, together with warm, bitter, and ftomachic. ingredients, affifted with proper diet and exercife, according to the prescriptions to be found in Hoffman, Friend's Emmenologia, and Shaw's practice of phyfick.
Of
Of the FLUOR ALBUS.
The infide membrane of the Uterus, `according to Atruc, is thick fet with fmall glands, which he calls the Colatura lactea : These in an unimpregnated Uterus, separate a Mucus that lubricates the cavity and canal of the neck, by which means the fides are prevented from coalefcing or growing together. The Fluor Albus is no other than this Mucus difcharged in too great quantity, from the Uterus as well as from the Vagina; and this excefs, when it happens from plenitude, in those who feed plentifully, without taking fufficient exercise, is often remedied by general evacuations, fuch as venæsection, catharticks, and a more abftemious diet, with a greater share of exercise than usual. But the cure is more difficult when the complaint is of a long standing, and proceeds from a bad habit, the conftitution being weakened by the inordinate discharge: In this cafe, it will be neceffary to use repeated emeticks, gentle exercife, and all thofe medicines that contribute to ftrengthen a lax habit of body; or, if the distemper be cancerous,
it must be palliated with anodynes: As to the form of prefcription in all the fe cafes, Hoffman may be confulted.
SECT. II.
Of CONCEPTION.
THE Minutia, or first principles of bodies, being without the sphere of human comprehenfion, all that we know is by the obfervation of their effects; fo that the modus of conception is altogether uncertain, especially in the human fpecies, because opportunities of opening pregnant women fo feldom occur.
Although the knowledge of this operation, is not abfolutely neceffary for the practice of Midwifery, an investigation of it may not only gratify the curious, but also promote further enquiries; in the course of which, many material discoveries may be made, in the fame manner as many valuable compofitions in chemistry were found out in the last century, by thofe who exercised themselves in fearch of the philofopher's
tone.
From the time of Hippocrates, to the fixteenth century, it was generally believed that the Embryo and Secundines were formed by the mixture of the male and female femen in the Uterus; but, during the last hundred years, anatomy received great improvements by the frequent diffection of human bodies; and in fome female fubjects, the Fatus was found in one of the Fallopian tubes, in others, it was discovered in the Abdomen, with the Placenta adhering to the furface of the Vifcera.
Malphigius and others, between the years 1650 and 1690, wrote exprefly upon the incubation of eggs, their formation, and the gradual increase of oviparous animals: The great Harvey observed the progress of the viviparous kind, in a great number of different animals which he had opportunities of opening. De Graaf diffected near one hundred rabbits, and is very particular and accurate in the observations he made. Ruysch, Aldes, Needham, Steno, Kerkringius, Swammerdam, Bartholine the son, and Drelincourt, employed themselves in the fame enquiries ; and in confequence of their different remarks,
a variety of theories have been erected: Yet, all of them, have been fubject to many objections, and even the following, though the most probable, is ftill very uncertain. When the parts in women, fubfervient to generation, attain their Acme or full growth, one or more of the Ova being brought to maturity, that part of the Peritoneum which covers the Ovarium begins to ftretch; the nervous fibres are accordingly affected, and contract themselves fo as to bring the Fimbria of the Fallopian tube, in close contact with the ripe Ovum: by which mechanism, this laft is squeezed out of its Nidus or husk, into the cavity of the tube, through which it is conveyed into the Uterus, by a vermicular or peristaltic motion; and if it is not immediately impregnated with an Animalcule of the male femen, must be diffolved and loft, because, it is now detached from the veffels of the Ovarium, and has no Vis vite in itself.
The external coat of the Ovum, is the membrane Chorion, one fourth part of which is the Placenta, fupposed to be the root by which it was formerly joined to the veffels
of the Ovarium; and the navel-ftring is no other than a continuation of the veffels belonging to this cake.
The Chorion is on the infide lined with another membrane called Amnion, and both are kept distended in a globular form by a clear ferous fluid, or thin Lymph.
As for the male femen, according to the obfervation of the celebrated Lewenhoek, it abounds with Animalcula, that swim about in it, like fo many tadpoles; and these are larger and more vigorous the longer the femen hath remained in the Veficula feminales.
The parts of both male and female being thus brought to maturity, the following circumstances are fuppofed to happen in coition, especially in those embraces which immediately follow the evacuation of the Menfes In the woman, the friction of the Penis in the contracted Vagina, the repeated preffure and shocks against the external parts, the alternate motion upwards and downwards, of the Uterus, with its appendages the Ovaria, Fallopian tubes, and round ligaments, produce a general titillation and turgency; in confequence of which, the nervous fibrils
2
fibrils are convulfed, and a fluid ejected from the proftate or analogous glands, as well as from those of the Uterus and Fallopian tubes. The Fimbria belonging to one of which, now firmly grafps the ripened Ovum, which at the fame inftant, is impregnated with the male feed that in the orgasm of coition, had been thrown into the Uterus, and thence conveyed into the cavity of the tube, by fome absorbing or convulfive power. When the two matured principles are thus mingled, one of the Animalcula infinuates itself into the Ovum, and is joined with its belly, to that ruptured part of it, from which the navel-ftring is produced; or, entering one of the veffels, is protruded to the end of the Funis, by which a circulation is carried on from the Embryo to the Placenta and membranes. The Ovum being impregnated, is fqueezed from its Nidus or hufk, into the tube, by the contraction of the Fimbria, and thus difengaged from its attachments to the Ovarium, is endowed with a circulating force by the Animalculum, which has a Vis vita in itfelf: the veffels on the furface of the Ovum, being opened, in confequence of I 2 its
its detachment from the Ovarium, abforb the furrounding fluid which is fecerned by the glands, in the cavity of the tube and Uterus, or forced into them by motion, heat, and rarefaction, and carried along the umbilical vein, for the nourishment and increase of the impregnated mass.
Of the femen that is injected or abforbed into the Uterus, part is mixed with the fluid fecreted by the glands, in the canal of the neck, which is blocked up with a fort of gluten formed by this mixture; fo that the Ovum is thereby prevented from finking too far down, and being discharged.
This theory of conception, though very ingenious, and of all others, the beft fubported with corroborating confiderations, fuch as, that Fatufes and Embryos have been actually found in the cavity of the tube, and Abdomen, without any marks of exclufion from the Uterus; befides other prefumptions that will be mentioned when we come to treat of the nutrition of the Fatus; I fay, notwithstanding the plaufibility of the scheme, it is attended with circumstances which are hitherto inexplicable; namely,
the
the manner in which the Animalculum gains admiffion into the Ovum, either while it remains in the Ovarium, fojourns in the tube, or is depofited in the Fundus Uteri; and the method by which the veffels of the navel-firing are inofculated with those of the Animalculum. Indeed, these points are fo intricate, that every different theorift has started different opinions concerning them, fome of which are rather jocular than instructive.
SECT. III.
Of the increase of the UTERUS after conception.
IT is fuppofed, that the Ovum swims in a
fluid, which it abforbs fo as to increase gradually in magnitude, 'till it comes in contact with all the inner furface of the Fundus; and this being distended in proportion to the augmentation of its contents, the upper part of the neck begins alfo to be stretched.
About the third month of geftation, the Ovum in bigness equals a goofe egg; and then, nearly one fourth of the neck at its upper part, is diftended equal with the Fundus,
At the fifth month, the Fundus is increased to a much greater magnitude, and rises upwards to the middle space betwixt the upper part of the Pubes and the navel, and at that period, one half of the neck is extended. At feventh months, the Fundus reaches as high as the navel; at the eight month, it is advanced midway between the navel and Scrobiculus cordis; and in the ninth month, is raised quite up to this last mentioned part, the neck of the womb being then altogether distended.
Now that the whole fubftance of the Uterus is ftretched, the neck and Os internum, which were at first the strongest, become the weakest parts of the womb, and the stretching force being still continued by the increafe of the Fatus and Secundines, which are extended by the inclosed waters in a globular form, the Os Uteri begins gradually to give way. In the beginning of its dilatation, the nervous fibres in this place, being more senfible than any other part of the Uterus, are irritated, and yield an uneafy fenfation; to alleviate which, the woman fqueezes her Uterus, by contracting the abdominal muscles, and at the same time filling the lungs with
;
air, by which the Diaphragm is kept down the pain being rather increased than abated by this ftraining, is communicated to all the neighbouring parts, to which the ligaments and veffels are attached, fuch as the back, loins, and infide of the thighs; and by this compreffion of the Uterus, the waters and membranes are fqueezed against the Os Uteri, which is, of confequence, a little more opened.
The woman being unable to continue this effort, for any length of time, from the violence of the pain it occafions, and the ftrength of the muscles being thereby a little exhausted and impaired, the contracting force abates, the tenfion of the Os Tinca being taken off, it becomes more foft, and contracts a little; fo that the nervous fibres are relaxed. This remiffion of pain the patient enjoys for fome time, until the fame increafing force renews the ftretching pains, irritation, and fomething like a tenefmus at the Os Uteri; the compreffion of the womb again takes place, and the internal mouth is a little more dilated, either by the pressure of the waters and membranes, or when the I 4
fluid
fluid is in fmall quantity, by the child's head forced down by the contraction of the Uterus, which in that cafe, is in contact with the body of the Fatus.
In this manner, the labour pains begin and continue to return periodically, growing ftronger and more frequent, until the Os Uteri is fully dilated, the membranes are depreffed and broke; so that the waters are discharged, the Uterus contracts, and with the affiftance of the muscles, the child is forced along and delivered.
;
Although this account may be liable to objections, especially in those cafes when the child is delivered before the full time it nevertheless seems more probable than that hypothesis, which imputes the labour pains, to the motion of the child calcitrating the Uterus: for it frequently happens, that the woman never feels the child ftir during the whole time of labour, and dead children are delivered as easily as thofe that come alive, except when the birth is retarded by the body's being fwelled to an extraordinary fize.
SECT
SECT. IV.
Of the magnitude, weight, and different appellations given to the OVUM and CHILD.
HEN the Ovum defcends into the Uterus, it is fuppofed to be about the fize of a poppy-feed, and in the third month augmented to the bignefs of a goofe egg. Ten days after conception, the child (according to fome authors) weighs half a grain, at thirty days, is increased to the weight of twenty two grains, at three months, weighs betwixt two and three ounces; and at nine months, from ten to twelve, and sometimes fixteen pounds by which calculation, it would appear, that the progress of the Fetus is quickest in the beginning of its growth: for, from the tenth to the thirtieth day, (according to this fuppofition) it increases to three and forty times its weight. All these calculations are uncertain.
V
The conception is called an Embryo, until all the parts are diftinctly formed, generally in the third month, and from that period to delivery, is distinguished by the appellation of Fætus,
SECT.
SECT. V.  of TWINS. 
WHEN two or more children are in
cluded in the Uterus, at the fame time, each has a separate Placenta, with umbilical cords and veffels: fometimes, thefe Placenta are altogether diftinct, and at other times they form but one cake.
Yet by an inftance that lately fell under my obfervation, it appears, that fometimes twins have but one Placenta in common: whether or not there were two fets of membranes, I could not difcover, becaufe they had been tore off by the gentleman who delivered the woman; but, when the artery in one of the navel-ftrings was injected, the matter flowed out at one of the veffels belonging to the other, and the communication between them is ftill visible, though they are separated at the distance of three or four inches.
When two children are diftinct, they are called twins; and monfters, when they are joined together; the firft (according to the foregoing theory) are produced when differ
ent
ent Animalcula impregnate different Ova; and the last are engendered when two or more Animacula introduce' themselves, and are included in one Ovum,
   SECT. VI. Of SUPERFOETATION. 
IT was formerly imagined that a woman
might conceive a fecond time during pregnancy, and be delivered of one child, fome weeks or months before the other could be ready for the world; but this opinion is now generally excluded; because, the Ovum fills the whole Fundus Uteri, and the gelatinous fubftance already mentioned, locks up the neck and Os Internum, fo as to hinder more femen from entering the womb and impregnating a fecond egg, in any fubfequent coition. Wherefore, in all those cafes which gave rife to this fuppofition, it may be taken for granted, that the woman was actually with child of twins, one of which, lying near the Os Internum, might chance to die and mortify, fo as that the membranes give way, and the dead Fœtus is difcharged, while the other remains in the Uterus,
Uterus, and is delivered at the full time. On the other hand, by fome accident, the first and largest may be born fome days or weeks before the full time, and afterwards the Os Tinca contract fo as to detain the other till the due period. At other times, the child that lies next to the Fundus, is the fmalleft, and follows after the birth of the other, fometimes dead and putrified, and fometimes in an emaciated condition.
Miscarriage that happens before the tenth day, was formerly called an efflux, because the Embryo and Secundines are not then formed, and nothing but the liquid conception, or Genitura is difcharged. From the tenth day to the third month, it was known by the term expulfion, the Embryo and Secundines being ftill fo fmall, that the woman is in no great danger from violent flooding.
If the parted with her burden betwixt that period and the seventh month, she was faid to fuffer an abortion; in which cafe, fhe underwent
underwent greater danger, and was delivered with more difficulty than before; because, the Uterus and veffels being more distended, a larger quantity of blood was loft in a shorter time, the Fatus was increased in bulk, and the neck of the womb not yet fully stretched: befides, should the child be born alive, it will be so small and tender that it will not fuck, and scarce receive any fort of nourish
ment.
When delivery happens between the feventh month and full time, the woman is faid to be in labour: but, instead of these diftinctions, if the lofes her burden at any time from conception to the seventh or eighth, or even in the ninth month, we now fay indifcriminately, fhe has mifcarried.
Hippocrates alledges, that a child born in the feventh month, fometimes lives; whereas, if it comes in the eighth, it will probably die, because all healthy children (fays he) make an effort to be delivered in the seventh month, and if they are not then born, the Nifus is repeated in the eighth, when the
child must be weakened by its former unsuccessful attempt, and therefore not likely
to
to live; whereas, fhould the fecond effort be deferred 'till the ninth, the Fatus will, by that time, be fufficiently recovered from the fatigue it had undergone in the seventh. Experience, however, contradicts this affertion; for, the older the child is, we find it always (cæteris paribus) the stronger, confequently the more hardy and eafily nurfed: neither is there any fufficient reason for adhering to the opinion of Pythagoras on this fubject, who declares that number eight is not fo fortunate as seven or nine.
The common term of pregnancy is limited to nine folar months, reckoning from the last discharge of the Catamenia: yet in fome, tho' very few, uterine geftation exceeds that period; and as this is a poffible cafe, we ought always to judge on the charitable fide, in the perfuafion, that it is better several guilty persons should escape, than one innocent woman fuffer in point of reputation.
SECT.
SECT.
VIII.
Of falfe CONCEPTIONS and MOLES.
IT
T was formerly fuppofed, that if the parts of the Embryo and Secundines were not feparated and diftinctly formed from the mixture of the male and female femen, they formed a mass, which when discharged before the fourth month, was called a false conception; if it continued longer in the Uterus, fo as to increase in magnitude, it went under the denomination of a Mola. But thefe things are now to be accounted for, in a more probable and certain manner. Should the Embryo die (suppose in the first or second month) fome days before it is discharged, it will sometimes be intirely diffolved, fo that when the Secundines are delivered, there is nothing elfe to be feen. In the first month, the Embryo is fo fmall and tender, that this diffolution will be performed in twelve hours; in the fecond month, two, three, or four days will fuffice for this purpose; and even in the third month, it will be diffolved in fourteen or fifteen: befides, the blood frequently forms thick La
mina round the Ovum, to the furface of which they adhere so strongly, that it is very difficult to distinguish what part is Placenta, and what membrane. Even after the Embryo and Placenta are difcharged, in the second or third month, the mouth and neck of the womb are often fo closely contracted, that the fibrous part of the blood is retained in the Fundus, fometimes to the fifth or feventh day; and when it comes off, exhibits the appearance of an Ovum, the external furface, by the strong preffure of the Uterus, resembling a membrane; fo that the whole is mistaken for a falfe conception.
This fubftance, in bignefs, commonly equals a pigeon or hen egg; or if it exceeds that fize, and is longer retained, is distinguished by the appellation of Mola: but, this laft generally happens in women betwixt the age of forty five and fifty, or later, when their Menfes begin to disappear; sometimes from internal or external accidents that may produce continued floodings. If the Catamenia have ceased to flow for fome time, in elderly women, and return with pain, such a fymptom is frequently the fore-runner of a
cancer;
cancer;
before or after this happens, fometimes a large flesh-like fubftance will be discharged with great pain, resembling that of labour; and upon examination, appears to be no more than the fibrous part of the blood, which affumes that form by being long preffed in the Uterus or Vagina.
、
In this place, it will not be amiss to obferve, that the glands of the Uterus and Vagina will fometimes increase, and distend the adjacent parts to a furprising degree: if (for example) one of the glands of the Uterus, be fo obstructed as that there is a preffure on the returning vein and excretory duct, the arterial blood will gradually stretch the smaller veffels, and confequently increase the size of the gland, which will grow larger and larger, as long as the force of the impelled fluid is greater than the refiftance of the veffels that contain it; by which means, a very fmall gland will be inlarged to a great bulk, and the Uterus gradually ftretched as in uterine geftation, though the progrefs may be fo flow as to be protracted for years instead of months. Nevertheless, the Os Internum will be dilated, and the gland (if not too K large
large to pafs) will be fqueezed into the Vagina, provided it adheres to the Uterus, by a small neck; nay, it will lengthen more and more, fo as to appear on the outfide of the Os Externum; in which cafe, it may be eafily separated by a ligature. This disease will be the fooner known and eafier remedied, the lower its origin in the Uterus, is. But, fhould the gland take its rife in the Vagina, hard by the mouth of the womb, it will shew itself still sooner, and a ligature may be eafily introduced, provided the tumor is not fo large as to fill up the cavity, and hinder the neck of it, from being commodioufly felt. Though the greateft difficulty occurs, when the gland is confined to the Uterus, being too much enlarged to pass through the Os Internum.
Sometimes, all, or moft of the glands in the Uterus, are thus affected, and augment the womb to fuch a degree, that it will. weigh a great many pounds, and the woman is destroyed by its preffure upon the furrounding parts: but, fhould this indolent state of the tumor, be altered by any accident that will produce irritation and inflammation,
mation, the cancer enfue.
parts will grow schirrous, and a
This misfortune, for the moft part, happens to women, when their menftrual evacuations leave them; and fometimes, (though feldom) to child-bearing women, in confequence of fevere labour.
Some people have affirmed, that the Placenta being left in the Uterus, after the delivery of the child, grows gradually larger; but, the contrary of this affertion, is proved by common practice, from which, it appears, that the Placenta is actually preffed into fmaller dimenfions, and fometimes into a fubftance almost demi-cartilaginous: for, after the death or delivery of the child, the Secundines receive no farther increase or growth. Dropfies and hydatids are also supposed to be formed in the Uterus, and difcharged from thence, together with air or wind: the Ovaria are fometimes affected in the fame manner, are inflamed, impoftumate, grow schirrous, cancerous, and the patient is destroyed by the discharge, which gradually fills the Abdomen with Pus and Ichor; so that all K 2 thefe
thefe complaints, if known, ought to be obviated in the beginning.
SECT. IX.
Of the PLACENTA.
I
Have already obferved, that the Ovum is formed of the Placenta, with the Chorion and Amnion, which are globularly distended by the inclosed waters that surround the child. The Placenta is commonly of a round figure, somewhat resembling an oat-cake, about fix inches in diameter, and one inch thick in the middle, growing a little thinner towards the circumference: it is compofed of veins and arteries, which are divided into an infinite number of fmall branches, the venous part of which, unite in one large tube, called the umbilical vein, which brings back the blood, and is fuppofed to carry along the nutritive fluid from the vessels of the Chorion and Placenta, to the child, whose belly it perforates at the navel; from thence paffing into the liver, where it communicates with the Vena Portarum and Cava. It is furnished with two arteries, which arise from the internal
nal Iliacs of the child, and running up on each fide of the bladder, perforate the belly. where the umbilical vein entered; then they proceed to the Placenta, in a fpiral line, twining around the vein, in conjunction with which, they form the Funiculus Umbilicalis, which is commonly four or five handbreadths in length, fometimes only two or three, and sometimes it extends to the length of eight or ten. The two arteries, on their arrival at the inner furface of the Placenta,
are divided and fubdivided into minute branches, which at laft end in fmall capillaries that inofculate with the veins of the fame order. These arteries, together with the umbilical vein, are fuppofed to do the fame office in the Placenta, which is afterwards performed in the lungs, by the pulmonary artery and vein, until the child is delivered and begins to breathe and this opinion feems to be confirmed by the following experiments. If the child and Placenta are both delivered fuddenly, or the laft immediately after the first, and if the child, though alive, does not yet breathe, the blood may be felt circulating, fometimes flowly, at other times with great K 3 force,
force, through the arteries of the Funis, to the Placenta, and from thence back again to the child, along the umbilical vein. When the veffels are flightly preffed, the arteries fwell between the preffure and the child, while the vein grows turgid between that and the Placenta, from the furface of which no blood is obferved to flow, although it be lying in a bafin, among warm water. As the child begins to breathe, the circulation, though it was weak before, immediately grows ftronger, and stronger, and then in a few minutes, the pulfation in the navel-ftring becomes more languid, and at last, intirely ftops. If, after the child is delivered, and the navel-string cut, provided the Placenta adheres firmly to the Uterus, which is thereby kept extended; or, if the womb is ftill diftended by another child; no more blood flows from the umbilical veffels, than what feemed to be contained in them at the inftant of cutting; and this, in common cafes, does not exceed the quantity of two or three ounces; and finally, when in confequence of violent floodings, the mother expires, either in time of delivery, or foon after
it, the child is fometimes found alive and vigorous.
The external furface of the Placenta, is divided into several lobes, that it may yield and conform itself more commodiously to the inner furface of the Uterus, to which it adheres, so as to prevent its being feparated by any fhock or blows upon the Abdomen, unless when violent.
Thofe of veins and arteries which groupes enter into the compofition of the Placenta, receive external coats from the Chorion, which is the outward membrane of the Ovum, thick and strong, and forms three fourths of the external globe that contains the waters and the child; the remaining part being covered by the Placenta; fo that these two in conjunction constitute the whole external furface of the Ovum. Some indeed, alledge, that these are inveloped with a cribriform or cellular fubftance, by which they seem to adhere by contact only, to the Uterus; and that the inner membrane of the womb, is full of little glands, whofe excretory ducts opening into the Fundus and neck, fecrete a foft, thin mucus (as formerly obferved) to K 4 lubricate
·
1
!
lubricate the whole cavity of the Uterus, which beginning to stretch in time of gestation, the veffels that compofe these glands, are also diftended; confequently, a greater quantity of this mucus, is feparated and retained in this supposed cribriform and cellular substance, the absorbing veffels of which, take it in, and convey it along the veins, for the nourishment of the child. The womb being therefore, diftended in proportion to the increase of the child, thofe glands are alfo proportionably enlarged; by which means, a larger quantity of the fluid is separated, because, the nutriment of the child, must be augmented in proportion to the progrefs of its growth and this liquor undergoes an alteration in quality as well as in quantity, being changed from a clear, thin fluid, into the more viscous confiftence of milk. In fome cafes, this mucus hath been discharged from the Uterus, in time of pregnancy, and both mother and child weakened by the evacuation, which may be occafioned by the Chorion's adhering too loofely, or being in one part actually feparated from the womb.
Formerly, it was taken for granted by many, that the Placenta always adhered to
the
the Fundus uteri; but, this notion is refuted by certain obfervations, in confequence of which, we find it as often sticking to the fides, back, and foreparts, and fometimes, as far down as the infide of the Os uteri. When the Placenta is delivered, and no other part of the membrane tore except that through which the child paffed, the opening is generally near the edge or fide of the Placenta, and feldom in the middle of the membranes; and a hog's bladder being introduced at this opening, and inflated, when laying in water, will fhew the shape and fize of the inner furface of the womb, and plainly discover the part to which the Placenta adhered.
1
The Chorion is on the infide, lined with the Amnion, which is a thin, tranfparent membrane, without any veffels fo large as to admit the red globules of blood: it adheres to the Chorion by contact, and feems to form the external coat of the Funis umbilicalis.
This membrane contains the Serum in which the child fwims, which fluid is fuppofed to be furnished by lymphatic veffèls that open into the inner surface of the Am
nion. If this liquid is neither absorbed into the body of the Fatus, nor taken into the ftomach, by fuction at the mouth, there must be absorbing vessels in this membrane, in the fame manner as in the Abdomen and other cavities of the body, where there is a constant renovation of humidity.
The quantity of this fluid, in proportion to the weight of the Fatus, is much greater in the first, than in the last month of gestation, being in the one, perhaps ten times the weight of the Embryo; whereas, in the other, it is commonly in the proportion of one to two: for, fix pounds of water furrounding a Fatus that weighs twelve pound, is reckoned a large proportion, the quantity being often much less; nay, fometimes there is very little or none at all.
In most animals of the brute fpecies, there is a third membrane called Allantois, which resembles a long and wide blind gut, and contains the urine of the Fatus: it is fituated between the Chorion and Amnion, and communicates with the Urachus that rifes from the Fundus of the bladder, and runsalong with the umbilical veffels, depofiting
the
the urine in this refervoir, which is attached to its other extremity. This bag hath not yet been certainly discovered in the human Fatus, the Urachus of which, though plainly perceivable, feems hitherto, to be quite imperforated.
From the foregoing obfervations upon nutrition, it seems probable, that the Fatus is rather nourished by the abforption of the nutritive fluid into the veffels of the Placenta and Chorion, than from the red blood circulated in full ftream, from the arteries of the Uterus, to the veins of the Placenta, and returned by the arteries of the last to the veins of the firft, in order to be renewed, refined, and made arterial blood in the lungs of the mother.
Yet, this doctrine of abforption, is clogged with one objection, which hath never been fully answered; namely, that if the Placenta adheres to the lower part of the Uterus, when the Os internum begins to be dilated, a flooding immediately enfues; and the fame fymptom happens upon a partial or total feparation of the Placenta from any other part
part of the womb; whereas, no fuch confequence follows a feparation of the Chorion.
The new theorifts indeed, observe, that there is no neceffity for a supply of red blood from the mother; because, the circulating force in the veffels of the Fatus, produces heat and motion fufficient to endue the fluids with a fanguine colour; that neither is there occafion for returning and refining this blood in the lungs of the mother, because that office is fufficiently performed in the Placenta, until the Fatus is delivered, when its own lungs are put to their proper ufe; and lastly, that the blood of the mother is too grofs a fluid to answer the occafions of the Fatus. Certain it is, the chick in the egg, is nourished by the white which is forced along the veffels, and the quantity of red blood increases in proportion to the growth of the contained Embryo or Fatus, without any fupply from the hen.
On the whole, the opinions broached upon the nutrition of the Embryo and Fœtus in Utero, have been various, as well as thofe that are adopted concerning the modus of conception.
BOOK
BOOK II.
CHA P. I.
Of the difeafes incident to pregnant women, being either fuch as 'immediately proceed from pregnancy, or Such as may happen at any other time, and if not carefully prevented or removed, may be of dangerous confequence both to mother and child.
SECT. I.
Of NAUSEA and VOMITING.
T
HE firft complaint attending pregnancy, is the naufea and vomiting, which in fome women, begins foon after conception, and frequently continues 'till the end of the fourth month. Most women are troubled with this fymptom, more or less, particularly vomitings in the morning:
morning: fome who have no fuch complaint in one pregnancy, fhall be violently attacked with it, in another; and in a few, it prevails during the whole time of uterine gestation.
The vomiting (if not very violent) is feldom of dangerous confequence; but, on the contrary, is supposed to be serviceable to the patient, by unloading the stomach of superfluous nourishment, thereby carrying off or preventing too great a turgency in the veffels of the Viscera and Uterus; and by creating a kind of straining or Nifus in the parts, which will affift the Fundus and neck of the womb, in ftretching. Nevertheless, if the straining is too great, it may endanger a miscarriage.
Perhaps, this complaint is chiefly occafioned by a fullness of the veffels of the Uterus, owing to the obftructed Catamenia, the whole quantity of which, cannot as yet be employed in the nutrition of the Embryo: over and above this cause, it has been fupposed that the Uterus being stretched by the increase of the Ovum, a tenfion of the parts enfues, affecting the nerves of that Viscus; especially those that arise from the Sympathetici maximi, and communicate with the Plexus, at the mouth of the ftomach. What
ever be the cause, the complaint is best relieved by blooding, more or lefs, according to the Plethora and ftrength of the patient, and if she is coftive, by emollient glyfters and opening medicines, that will evacuate the hardened contents of the Colon and Rectum; fo that the Vifcera will be rendered light and easy, and the stretching fullness of the vessels taken off. A light, nutritive and fpare diet, with moderate exercife, and a free open air, will conduce to the removal of this complaint. ·
SECT. II.
Of difficulty in making water, coftiveness, fwelling of the Hæmorrhoids, legs, and Labia Pudendi; and the Dyfpnoea and vomiting at the latter end of pregnancy. TOWARDS the end of the fourth
month, or beginning of the fifth, the Uterus is fo much diftended as to fill all the upper part of the Pelvis, and then it begins to rife upwards into the Abdomen: about the fame time, the Os internum is likewife raised and turned backwards towards the Sacrum, because the Fundus is inclined forwards in its rife. The Uterus, according to the different 6 directions
directions in which it extends, produces va rious complaints by its weight and preffure upon the adjacent parts, whether in the Pelvis, or higher in the Abdomen. In the fourth or fifth month, it preffes against the Sphincter of the bladder, in the Pelvis, and produces a difficulty in making water, and sometimes (though feldom) a total fuppreffion. This complaint will happen, if the womb is funk too low in the Vagina, or if the Ovum, instead of adhering to the Fundus, descends into the wide part in the middle of the neck, which accordingly first undergoes distension. This difpofition of the Ovum, is frequently, the cause of abortion, because, the mouth and neck being in this cafe, from the stretching, the weakest parts of the Uterus, the Os internum begins to be opened too soon: yet, fometimes, this will continue strong and rigid, and after the neck is enlarged, the Fundus will be laft of all, ftretched till the end of geftation, and the woman be happily delivered *
*This is one probable reafon to account for the Placenta's fometimes adhering over the infide of the mouth of the womb, and helps to fupport the theory of the neck's turning fhorter and fhorter, as the full time approaches.
But,
But, as the stretching begins lower down in this, than in a common cafe, the Uterus must consequently press against all parts of the Pelvis, before it can rise above the brim; and this preffure fometimes produces an obftruction of urine, and difficulty in going to ftool the general compreffion of all these parts will be attended with a degree of inflammation in the substance of the Uterus, the Vagina, mouth of the bladder and Rectum; from whence violent pains and a fever will enfue. In order to remove or alleviate these symptoms, recourse must be had to bleeding and glyfters, the urine must be drawn off by the catheter, fomentations and warm baths. be used, and this method occafionally repeated, until the complaints abate; and they commonly vanish in confequence of the womb's rifing higher, fo as to be fupported on the brim of the Pelvis.
By the preffure of the Uterus, upon the upper part of the Rectum, and lower part of the Colon, where it makes femicircular turns to the right and left, the Faces are hindered to pass, and by remaining too long in the guts, are indurated, the fluid parts being
L
abforbed.
absorbed. Hence arises violent straining at ftool, and a compreffion of the womb, which threatens abortion. When the patient, therefore, has laboured under this fyınptom, for feveral days, let emollient, laxative, and gently ftimulating glyfters be injected: but, if the Rectum be fo obftructed, as that the injection cannot pafs, fuppofitories are first to be introduced; for, frequently, when the Colon and Rectum are compreffed by the Uterus, the peristaltic motion is weakened and impeded, fo that the guts cannot expel their contents; in which cafe, the fuppofitory by irritation quickens this faculty, and in diffolving, lubricates the parts, thereby facilitating the difcharge of the hardened Faces. This previous measure being taken, a glyfter ought to be injected, in order to diffolve the collected and indurated contents of the Colon, as well as to lubricate and ftimulate the infide of that inteftine, so as to effect a general evacuation; and for this purpofe, a fyringe fhould be used instead of a bladder, that the injection may be thrown up with greater efficacy and force.
Thefe glyfters ought to be repeated until the hardened Faces are altogether brought
away,
(
away, and the last discharge appears to be of a foft confiftence: neither ought the prefcriber to truft to the reports of the patient or nurse, but to his own fenfes in examining the effects of these injections: for, if the complaint hath continued several days, a large quantity of indurated Faces ought to be discharged. To avoid fuch inconvenience for the future, an emollient glyfter must be injected every fecond night; or, if the patient will not fubmit to this method, which is certainly the easiest and best, recourse must be had to thofe lenients mentioned at the latter end of this fection; for, when the Faces are long retained, the air, rarifies, expands, and ftretches the Colon, producing fevere cholic pains; this being the method followed by nature, with a view to difburthen herself when he is thus encumbered.
The preffure of the Uterus upon the hæmorrhoidal and internal Iliac veins, produces a turgency and tumefaction of all the parts below, fuch as the Pudenda, Vagina, Anus, and even the Os internum, and neck of the womb. This tumefaction
of the hæmorrhoidal veins, appears in those fwellings at the infide and outside of the Anus, which are known by the name of the external and internal Hæmorrhoids, or piles. This is a complaint to which women are naturally more fubject than the other fex; but it is always most violent in time of pregnancy, when the fame method of cure may be administered as that practifed at other times, though greater caution must be used in applying leeches to the parts; because, in this case, a great quantity of blood may be loft before the discharge can be reftrained.
About the latter end of the fifth, or in the beginning of the fixth month, the Uterus being ftretched above the brim, and the Fundus raised to the middle space betwixt the Os pubis and navel, is confiderably increased in weight; and even then (though much more fo near the full time) lies heavy upon the upper part of the brim, preffes upon the Vertebræ of the loins and Offa ilia, and rising still higher with an augmented force, gradually stretches the Parietes of the Abdomen, pufhing the intestines upwards and to each fide.
The
The weight and preffure on the external Iliac veins, is attended with a furcharge or fullness in the returning veffels that come from the feet, legs, and thighs; and this tumefaction produces oedematous and inflammatory fwellings in these parts, together with varicous tumours in the veins, that fometimes come to fuppuration.
The fame weight and preffure occafion pains in the back, belly, and loins, efpecially towards the end of the eight, or in the ninth month: if the Uterus rifes too high, a Dyspnæa or difficulty in breathing, and frequent vomitings enfue; the first proceeds from the confinement of the lungs and Diaphragm in refpiration, the liver and Vifcera of the Abdomen being forced up into the Thorax; and the laft is occafioned by the extraordinary preffure upon the ftomach.
All the complaints above defcribed; namely, fwelling of the legs, thighs, and Labia pudendi, pains in the back, loins, and belly, with Dyspnea and vomiting, are removed or palliated by the following method: The patient (if he can bear fuch evacuations) is generally relieved by bleeding at the arm or ancle, to the amount of eight
or ten ounces; but the quantity must be proportioned to the emergency of the cafe ; the belly must be kept open and easy with emollient glyfters and laxative medicines, fuch as a spoonful or two of a mixture compofed of equal parts of Ol. Amygd. d. and Syr. Violar. taken every night; or from two drachms to half an ounce of manna, or the fame quantity of lenitive electuary; a small dofe of rhubarb, or five grains of any opening pill, unless the patient be troubled with the Hæmorrhoids, in which cafe all aloetic medicines ought to be avoided: the patient must not walk much, or undergo hard exercise, but frequently reft upon the bed, and lie longer than ufual, in the morning. When the fwelling of the legs is moderate, and only returns at night, rollers or the laced stocking may be ferviceable; but, when it extends in a great degree to the thighs, Labia pudendi, and lower part of the belly, in a woman of a full habit of body, venæsection is neceffary, because this oedematous swelling proceeds from a compreffion of the returning veins, and not from laxity, as in the Anafarca and leucophlegmatick constitutions:
here
here moderate exercife, and (as I have already observed) frequent refting on a bed or couch, is beneficial; or, if the skin of the legs and Pudenda is exceffively ftretched, fo as to be violently pained, the patient will be greatly relieved by puncturing the parts occasionally but, these complaints cannot be totally remoyed till delivery, after which they commonly vanish of themselves.
The bellies of those that are indolent and ufe no exercise, ought to be moderately compreffed, so that the Uterus may not rife too high, and occafion difficulty in breathing, and vomiting, in the last months; but they must not be too ftraitly fwathed, left the womb should be determined, in ftretching, over the Pubes, and produce a pendulous belly, which is often the cause of difficult labours. A medium ought, therefore, to be preserved in this article of compreffing, and no woman lace her jumps or stays fo as to make herself uneafy while the diet, air, and exercife, ought to be regulated according to the conftitution, cuftom, and complaints of the patient.
L 4
СНАР,
4
CHA P. II.
Of the Difeafes incident to pregnant
Women.
SECT. I.
Of the STONE in the KIDNEYS and BLADDER,
W
TOMEN are frequently afflicted with small stones and gravel in the kidneys, being less fubject than men to this complaint in the bladder, because their Urethras are fhort and wide, and fuffer the calculous concretions to pafs with the urine, more easily.
In pregnancy, it is often difficult to diftinguish gravelly pains from those that are felt in the small of the back and loins, proceeding from the preffure of the Uterus upon these parts in both cafes, when the pains are violent, the urine is high coloured, and the difference is, that in the gravel a quantity of fand generally falls to the bottom; though the fediment commonly depofited by high coloured urine is often mistaken for
gravel:
gravel: this mistake, however, is the lefs material, because both complaints are relieved by the fame method, namely, venæfection, emollient glyfters, emulfions, with gum arabic, infufions of Althea, Sem. Lini and Opiates, and an application of Emplaft. Roborans to the back.
Pains in the loins and belly, extending to the false ribs, occafioned by the fretching of the Uterus, are eafed by rubbing and anointing the parts every night, before the fire, with emollient unguents, fuch as that of Althea, &c.
In pregnant women, the complaints from a ftone in the bladder (which is fometimes, though feldom, the cafe) are to be treated in the fame manner as at any other time; except that when the patient is near delivery, it is not adviseable to endeavour to extract it, left the operation fhould be attended with an inflammation of the Urethra and Vagina: if therefore the stone should be rough, angular, or furrounded with fharp prickles, the woman fuffers greatly from the preffure of the Uterus upon the bladder, especially in time of labour, when the membranes are broke,
broke, and the head of the child is pushed into the upper part of the Pelvis; because the stone is then preffed before it, upon the neck of the bladder, fo as to occafion exquifite torture, and infallibly retard the labour-pains. If the stone hath defcended into the Meatus urinarius, perhaps it may be eafily extracted; but if it ftill remains within the bladder, the only way of relieving the patient, is by introducing a Catheter, also one or two fingers into the Vagina, to push up the stone above and behind the head of the child; or, if this cannot be done, to turn and deliver by the feet, before the head is preffed too far down in the Pelvis.
SECT. II.
Of HERNIAS, or RUPTURES.
WOMEN are alfo afflicted with rup
tures in different parts, fuch as the navel, groin, and Pelvis; but, as the Uterus in time of gestation ftretches higher and higher, the Omentum and intestines are prefsed more and more upward and to each fide; and about the fifth or fixth month, the tomb
womb rises fo high, that the intestine cannot descend into the groin, and the rupture in that part, ceases for the prefent. About the eighth month, the Uterus is fo high advanced, that the inteftine or Epiploon is kept from pufhing out at the navel, confequently the umbilical Hernia is likewife fufpended till after delivery; but this will not happen in either cafe, unless the rupture be of that kind that fuffers the Omentum and inteftine to be easily reduced.
Women are chiefly fubject to ruptures of the Umbilicus, and thofe of the groin most incident to the other fex; but, there is a third kind peculiar to women, though it rarely happens even in them: this is produced from the intestine falling down betwixt the back-part of the Uterus and Vagina, and the fore-part of the Rectum. The Peritoneum defcends much lower in this place than at the anterior defcent, where it covers the upper part of the bladder, or, at the fides of the Pelvis, where it forms the Ligamenta lata; for it reaches to within one or two inches of the Perineum, and the intestines preffing it farther down, or burfting it in
this part, are pushed out in the form of a large tumour, at the fide of the Perineum, betwixt the lower part of the Ischium and Coccyx. The gut being fo fituated in time of labour, when the child's head is squeezed into the Pelvis, may fuffer ftrangulation if the case should prove lingering and tedious, and the preffure continue for any length of time. In order to prevent or remedy this accident, let the Os externum be gradually opened with the hand, which being introduced in the Vagina, fhall raise the child's head, fo as to fuffer the intestine to be pushed above it, by the affiftance of the other hand, which preffes upon the outside: in this manner, both hands may be used alternately, till the purpose be effected; or, fhould this method fail to reduce and retain the intestine, the child must be delivered with the forceps, or turned and brought by the feet, as we have directed in the cafe of a stone in the bladder. The ruptures of the Umbilicus and groin may be reftrained and kept up by proper compreffion, but it is very difficult to contrive an effectual bandage for the descent in the Perineum.
SECT.
SECT. III,
Of DROPSIES.
Difficulty in breathing, in pregnant wo
men, may be occafioned by collections of matter in the cheft or Thorax, as well as in the Abdomen, from abfceffes in the Vifcera, co-operating with the preffure of the Uterus upon the organs of refpiration: these complaints (which are generally fatal) must be treated by the fame method in pregnancy, which is used at other times. The cavity of the Abdomen is also fubject to an Afcites or dropfy, with or without Hydatides, which, in conjunction with the ftretching Uterus, may diftend the belly to a prodigious fize, producing great oppreffion and anxiety. Here too, the common method of curing or palliating dropfies, must be used, with this difference, that the purging medicines are to be cautiously prescribed.
But, this disorder is not fo incident to pregnant women, as the Anafarca, which is a dropfy of the cellular membrane, that extends over the whole furface of the body, in
invelloping every individual muscle, veffel and fibre. This disease is the effect of univerfal laxity and weakness, and if not timely obviated, may endanger the patient's life, being fometimes attended with a fatal rupture of the Uterus in time of labour: in order to prevent which catastrophe, every thing ought to be prescribed in point of diet, medicine, and exercife which may contribute to strengthen the solids and quicken the circulation. Let her, for example, take repeated doses of the Confect. Cardiac. drink moderate quantities of ftrong wine, in which the warm spices have been infused, eat no meat but fuch as is roasted and high seafoned, and abstain altogether from weak diluting fluids, fuch as fmall beer and water.
SECT. IV.
Of incontinence of URINE, and difficulty in making water at the latter end of pregnancy, and in time of labour.
THE Vefica urinaria in pregnant women
near their full time, is often fo much preffed by the Uterus, that it will contain but
but a very fmall quantity of water; a circumstance, though not dangerous, extremely troublesome, especially when attended with a vomiting or cough: in which cafe, the ftraining forces out the water involuntarily, with great violence. The cough may be alleviated by proper remedies, but the vomiting can feldom be removed. Sometimes a bandage applied round the lower part of the belly, and fupported with the Scapular, is of fingular fervice, particularly when the Uterus lies pendulous over the Os pubis, thereby compreffing the urinary bladder.
But this complaint is not of fuch dangerous confequence as a difficulty in making water, or a total fuppreffion, which (as we have already obferved) happens, though very feldom, in the fourth or beginning of the fifth month of pregnancy; but most frequently occurs in time of labour, and after delivery. In the beginning of labour, before the membranes are broke, and the head of the child funk into the paffage, the woman commonly labours under an incontinence of urine from the preffure upon the bladder; but the membranes being broken, and
and the waters discharged, the Uterus contracts, and the child's head is forced down into the Pelvis, where if it continues for any length of time, the Urethra and Sphincter veficæ are fo compressed that the urine cannot pass; while the preffure on the other parts of the bladder, being removed in confequence of the diminished fize of the Uterus, and the laxity of the Parietes of the Abdomen, the Vefica urinaria is the more easily ftretched by the increafing quantity of urine, which diftends it to fuch a degree, that the fibres are over-ftrained: and after delivery, when the preffure is removed from the Sphincter and Meatus urinarius, it cannot contract fo as to discharge its contents, efpecially if any fwelling or inflammation remains from the preffure upon the neck and Urethra; in which case, the patient is afflicted with violent ftretching pains in the loins, back, groins, and particularly above the Os pubis.
This complaint is immediately removed by drawing off the urine with a catheter. ; and indeed this expedient ought to be tried before delivery, as it muft infallibly promote labour,
labour, because one pain interferes with the other. If the inflammation continues or increases, and the obftruction of urine recurs after delivery, the external parts ought to be fomented with warm ftupes, bladders half filled with warm water, or emollient decoctions may be applied as hot as the patient can bear them, to all the lower part of the belly, and the catheter be used twice a day, or as often as neceffity requires, until the bladder shall have recovered its tone,' fo as to perform its office without affiftance.
SECT.
V.
Of the FLUOR ALBUS in pregnant Women. THIS discharge, to which women are
more fubject at other times, than during uterine gestation, if in a large quantity, may hinder conception. In those who are usually troubled with it, the complaint generally ceases all the time of pregnancy :,in fome, however, it continues to the last, provided the feat of it is in the Vagina; and the evacuation is fometimes fo great, as to weaken both mother and child, and even to M pro
produce a miscarriage. Every thing that strengthens and nourishes the body is here of fervice. This is also fupposed to happen when fome part of the Chorion being feparated from the Uterus, the fluid that is fecreted by the Colatura lactea for the nutrition of the Fatus, forces its way through the Os internum; and the greater this separation is, and the nearer the full time, the larger the discharge will be.
SECT. VI.
Of the GONORRHEA and LUES VENEREA.
THOUGH women are not so foon in
fected with this diftemper as men, they are commonly cured with greater difficulty, because of the great moisture and laxity of the parts affected; especially in pregnant women, who nevertheless are to be treated in the fame method practifed at other times, except that in this case, mercurials and cathartics ought to be very cautiously used: for, if the Gonorrhea is neglected, or unskilfully managed, the Virus will increase, and actually
:
actually degenerate into a confirmed pox. It is often difficult to diftinguish a Gonorrhea from the Fluor Albus, because the colour and quantity of the discharge is nearly the same in both in the laft, however, we seldom meet with inflammation or ulcers within the Labia or entrance of the Vagina, whereas, in the first, these generally appear foon after the infection, about the Meatus urinarius, the Carunculæ myrtiformes, and infide of the Labia, producing a violent pain in making water. The Gonorrhea is likewise distinguished from the Fluor Albus, by its continuing all the time of the menftrual difcharge, during which the other complaint is commonly fufpended; but this mark is at best but uncertain, and can be of no fervice in pregnancy, because then the Menses themfelves are obftructed. The cure is beft attained by bleeding, repeated doses of gentle cathartics mixed with mercurials, a low diet, emulfions impregnated with nitre, and lastly, balfamic, ftrengthening, and aftringent medicines.
If the diftemper hath proceeded to an inveterate degree of the fecond infection, atM 2 tended
tended with cancerours ulcerations of the Pudenda, bubos in the groin, ulcers in the nofe and throat, fo that the life of the patient or constitution of the parts are endangered, mercurials must be given, so as to raise a gentle degree of falivation; which ought to be immediately restrained, and even carried off, by mild purgatives, and renewed occafionally, according to the strength of the woman, until the Virus be utterly difcharged. Here, however, a great deal must depend upon the judgment and discretion of the prescriber, who rather than propose any thing that might occafion, abortion, ought to try by palliating medicines, to alleviate and keep under the fymptoms till after delivery.
CHA P. III.
SECT. I.
Of MISCARRIAGES.
Mo
OST of the complaints, above described, if violent and neglected, may occafion a miscarriage; aud it would
Of MISCARRIAGES.
165
be almost an endless tafk to enumerate every accident from which this misfortune may proceed I fhall therefore content myself with defcribing in what manner abortion happens; first, in the death of the child; fecondly, in the feparation of the Placenta ; and lastly, in whatever may occafion too great extenfion of the neck, and of the Os internum.
SECT. II.
Of the CHILD's Death.
THIS may proceed from diseases pecu
liar to itself, not to be accounted for, as well as from divers accidents that befal it in the womb if for example, the navelftring be long, and the quantity of surrounding waters great, the Fatus while young, may, in swimming, form a noose of the Funis, through which, if the head only paffes, a circumvolution will happen round the neck or body but, fhould the whole Fetus pafs or thread this noofe, a knot will be formed on the navel-ftring, which if tight drawn, will abfolutely obstruct the M 3 cir
circulation. This may likewise be the cafe, when the waters are in very fmall quantity, and the Funis Umbilicalis falls down before the head, by which it is violently compreffed. In fhort, the death of the Fatus will be effected by all circumvolutions, knots, or preffure upon the navel-ftring, which deftroy the circulation betwixt the Placenta and the child.
The Fœtus may fuffer death from diseases and accidents that happen to the mother; from violent paffions of joy, fear or anger, fuddenly raised to fuch transports as occafion tremors, fainting, or convulfion's; and from a Plethora, and all acute diftempers in which the circulating force of the fluids is too violent.
The child being dead, and the circulation in the Secundines confequently destroyed, the Uterus is no longer ftretched, the Fetus (if large) is no longer felt to move or stir; all the contained parts run gradually into a ftate of putrefaction; the refiftance of the membranes becomes weaker than the contracting force of the Uterus, joined with the preffure of the contents and parietes of the Abdomen;
Abdomen; the contained waters of confequence, burst through their mortified inclofure, and the Uterus is contracted close to its contents, which are therefore preffed down lower and lower; the neck and mouth of the womb being gradually stretched, labour comes on, and a miscarriage enfues.
At other times, gripings, looseness and labour pains, even before the membranes break, are occafioned by obftruction or resistance of the veffels of the Uterus; in these cafes, if no flooding happens, the woman is feldom in danger, and though the child is known to be dead, the progress of nature is to be waited for with patience: if the woman is weak, exhausted or timorous, she must be encouraged and fortified with nourishing diet; if plethoric, fhe muft undergo evacuation by bleeding and laxative medicines, and when labour begins, be affifted according to the directions specified in the sequel.
SECT. III.
Of the feparation of the PLACENTA from the UTERUS.
THIS feparation may proceed from all the foregoing diseases and accidents that happen to the mother: from violent shocks, ftrains, over-reachings, falls and bruifes on the Abdomen; as alfo from vehement coughs, vomitings or ftrainings at ftool when the body is coftive. The feparation of the Placenta is always accompanied with a difcharge of blood from the veffels of the Uterus, more or lefs, according to the term of pregnancy, or as the Placenta is more or less detached.
This discharge is diftinguished from the Menfes by the irregularity of its period, by its flowing in a larger quantity, and after a fmall intermiffion, its return upon the least motion of the patient.
The younger the woman is with child, the danger is the lefs; becaufe, though a confiderable quantity of blood be loft, it does not flow with fuch violence as to exhaust her immediately, and therefore, fhe may be
supported
fupported and her fpirits kept up with proper cordials and nutritive diet. But, when such an hæmorrhage happens in any of the three or four last months of pregnancy, the danger is much more imminent, especially towards the full time; because, the veffels of the Uterus, being then largely diftended, a much greater quantity of blood is loft in a fhorter time; yet in both cafes, the flooding will be more or lefs, as there is more or lefs of the Placenta feparated from the womb; and when this happens in a very finall degree, the discharge may, by right management, be fometimes stopped, and every thing will happily proceed to the full time; but if this purpose cannot be effected in a woman young with child, the principal intention ought to be a mitigation of the hæmorrhage, leaving the reft to time and patience, as a miscarriage in the first five months is feldom attended with hazard on the contrary, nothing can be more dangerous than fuch an effution in any of the four laft months, provided it cannot be immediately reftrained. In this cafe, we are often deceived by a fhort intermiffion, occafioned by coagulated blood that locks up the
:
the mouth of the womb, which being pushed off, the flooding returns: and hence we ac count for its returning fo commonly, upon motion, a fit of coughing, ftraining at stool, or any effort whatever.
It is happy for the woman in this case, when she is so near the full time, that she may be fuftained 'till labour is brought on; and this may be promoted, if the head prefents, by gently stretching the mouth of the womb, which being fufficiently opened, the membranes must be broke; fo that the waters being evacuated, the Uterus contracts, the flooding is restrained, and the patient fafely delivered. At any rate if the hæmorrhage returns again with great violence, there is no other remedy than that of delivering with all expedition, according to the me- . thod described in book III. chap. 4. fect. 3. and book IV. chap 1. fect. 3.
Although the great danger is from floodings when near the full time; yet if labour can be brought on, the Os Uteri is easily dilated with the labour, or the hand; but, in the fixth or seventh month, it takes longer time, and is stretched with greater difficul
ty,
ty, which is fometimes the occafion of the danger at that period.
The edge or middle of the Placenta fometimes adheres over the infide of the Os Internum, which frequently begins to open feveral weeks before the full time; and if this be the cafe, a flooding begins at the fame time, and feldom ceases intirely, until the woman is delivered: the discharge may indeed, be intermitted by coagulums that stop
up the paffage, but, when these are removed it returns with its former violence, and demands the fame treatment that is recommended above.
In all cafes, and at all times of pregnancy, if the woman receives any extraordinary fhock either in mind or body; if she is attacked by a violent fever, or any complaints attending a Plethora, bleeding ought always to be prescribed by way of prevention or precaution, unless a low, weak, lax habit of body renders fuch evacuation unadviseable; but these are not so subject to fevers from fullnefs.
On the first appearance of flooding, the patient ought immediately to be blooded to
the
the amount of eight or twelve ounces, and venæfection repeated occafionally, according to the ftrength of the conftitution, and emergency of the cafe: fhe ought to be confined to her bed, and be rather cool than warm; if coftive, an emollient glyfter must be injected, in order to diffolve the hardened Faces, that they may be expelled eafily without ftraining: internally, emulfions with nitre, must be used, and mixtures of the tinct. rofar. rub. accidulated with fp. of vitriol, as the cooling or reftringent method fhall feem to be indicated; but above all things, opiates must be adminiftred, to procure reft, and quiet the uneafy apprehenfions of the mind: for diet, let her ufe panada, weak broth, and rice gruel; fhe may drink water in which a red hot iron has been several times quenched, mixed with a fmall proportion of red burnt wine; fhe muft abftain from all the high-feafoned foods, and even flesh meat or ftrong broths, that will inrich the blood too faft, and quicken the circulation. But if, notwithstanding this regimen, the flooding fhall continue and increase, fo that the patient becomes faint and low, with lofs
lofs of blood; we muft, without further delay, attempt to deliver her, as in book III. chap. 9. fect. 3. though this is feldom practicable, except in the last months of pregnancy, and then will be the easier performed the nearer fhe is to her full time, unless labour pains shall have affifted or begun a dilatation of the Os Internum.
SECT. IV.
MISCARRIAGES may alfo be produced
1
from every force that will ftretch the neck and mouth of the womb; fuch as violent coughs, vomitings, coftive ftrainings at ftool, catharticks that bring on a fuperpurgation, and tenefmus, together with frequent convulfions. All these symptoms must be treated in the ufual method: the cough and vomiting may be abated or removed chiefly by venæfection and opiates; the constipation, by glyfters and gentle laxative medicines; the fuperpurgation, by opiates; the tenefmus, by these, and oily injections; the convulfions, by blooding and blifters; and as the more violent convulfions happen generally when the woman is near her full time, if they are not foon
foon removed, but continue and increase, to the manifeft hazard of the patient's life, fhe ought to be delivered immediately, in the fame manner as in the cafe of a flooding in the last months.
SECT. V.
ABORTION may be likewife occafioned by uncommon longings for things that cannot be foon or eafily got, or fuch as the woman is afhamed to afk for, especially in her first child, namely different kinds of food and drink. These appetites, if not gratified, fometimes produce a mifcarriage, and indeed are fuppofed to affect the child in fuch a manner, that the body of it fhall be impreffed with marks refembling the figure or colour of what the mother longed for. Thefe cravings, therefore, though they appear unreasonable and improper, must be fatisfied, and the mother ought to shun every thing that is difagreeable to the fenfes, because miscarriage may alfo proceed from furprize at fight of strange and horrible objects.
BOOK
BOOK III.
CHAP. I.
SECT. I.
Of the CHILD's fituation in the UTERUS.
T
HE Embryo or Fatus, as it lies in the Uterus, is nearly of a circular or rather oval figure, which is calculated to take up as little space as poffible: the chin refts upon the breast, the thighs are preffed along the belly, the heels applied to the breech, the face being placed between the knees, while the arms cross each other; round the legs. The head for the most part, is down to the lower part of the Uterus; and the child being contracted into an oval form, the greatest length is from head to breech: but the diftance from one fide to the other, is much lefs, than that from the
fore to the back part; because the thighs and legs are doubled along the belly and stomach, and the head bended forwards on the breast. The Uterus being confined by the Vertebra of the loins, the distance from the back to the forepart of it, must be less than from fide to fide; fo that, in all probability, one fide of the Fatus is turned towards the back, and the other to the forepart of the womb: but, as the back part of the Uterus, forms a little longish cavity on each fide of the Vertebra, the foreparts of the Fatus may therefore, for the most part, tilt more backwards than forwards.
It has been generally fuppofed, that the head is turned up to the Fundus, and the breech to the Os uteri, with the foreparts towards the mother's belly; and that it remains in this fituation, till labour begins, when the head comes downwards, and the face is turned to the back of the mother. Some alledge, that the head precipitates about the end of the eighth or beginning of the ninth month, by becoming fpecifically heavier than the reft of the body. Others affirm, that as the child increases in bulk, espe.
especially during the two laft months, the proportion of furrounding water must be diminished, fo as that it is confined in its
"
inst
15
motion, and in struggling to alter its pofition, the head is moved to the Os tince, where it remains till delivery. The particulars of this and other theories, may be found in Mauriceau, La Motte, Simpfon and Old. But, from the following obfervations it seems more probable, that the head is, for the moft part, turned down to the lower part of the Uterus, from conception to delivery.
In the first month, according to fome writers, the Embryo exhibits the figure of a tadpole, with a large head and small body or tail, which gradually increases in magnitude, till the arms and thighs begin to bud or ftrut out, like small nipples, from the shoulders and breech: two black specks appear on each fide of the head, with a little hole or opening between them, which in the fecond month, are easily distinguished to be the eyes and mouth. The legs and arms are gradually formed, while the body turns larger, but the fingers are not feparated or diftinct, till the latter end of the second, or N
Text →
beginning
beginning of the third month. This is commonly the cafe, but fometimes, the bulk and appearance differ confiderably in different Embryos of the fame age. The younger the Embryo, the larger and heavier is the head in proportion to the rest of the body, and this is the case in all the different gradations of the Fatus; fo that when dropt or suspended by the navel-string in water, the head muft fink lowermoft, of course. Befides, when women miscarry, in the fourth, fifth, fixth and seventh months, the head, for the most part, presents itself, and is first delivered. By the touch in the Vagina, the head is frequently felt in the seventh, fometimes in the fixth, but more frequently in the eighth month; and if the fame women are thus examined, from time to time, till the labour begins, the head will always be felt of a round firm substance, at the fore part of the brim of the Pelvis, betwixt the Os internum and Pubes, through the substance of the Vagina and Uterus. But all these opinions are liable to objections. If the descent of the head proceeded from its specific gravity, we should always find it at the Os internum, because
this reafon would always prevail: if it were owing to a diminished proportion of water, why should we often find the breech prefented, even when there is a quantity of that fluid large enough to give the head free liberty to rife again towards the Fundus, or (according to the other opinion) to fink down, by its specific gravity, to the Os Internum? Some, indeed, suppose, that the head always prefents itself, except when it is hindered by the Funis Umbilicalis twisting round the neck and body, fo as to impede the natural progrefs: but, were this fuppofition juft, when we turn and deliver by the feet, thofe children that prefented in a præternatural way, we should always find them more or lefs circumvoluted by the navel-string: whereas I have as often found the Funis twisted round the neck and body, when the head prefented, as in any other cafe; and when other parts offered, have frequently delivered the child without finding it in the leaft entangled by that cord. That the head is downwards all the time of gestation, seems on the whole, to be the most reafonable opinion, though it
be liable to the objection already mentioned, and seems contradictory to the observation of fome authors, who alledge, that in opening women that died in the fifth, fixth, or seventh month, they have found the child's head towards the Fundus Uteri. But as it lies as eafy in one posture as in another, till the birth, this dispute is of less confequence in the practice of Midwifery.
SECT. II. Of TOUCHING. 
T     OUCHING is performed by intro-       ducing the fore finger lubricated with  pomatum, into the Vagina, in order to feel  the Os Internum and neck of the Uterus;  and sometimes, into the Rectum, to discover the stretching of the Fundus. By fome, we  are advised to touch with the middle finger, as being the longest; and by others, to em- ploy both that and the firft; but the middle is too much encumbered by that on each fide, to answer the purpose fully, and when two are introduced together, the patient ne- ver fails to complain. The defign of touch- ing is to be informed whether the woman 
is, or is not with child; to know how far she is advanced in her pregnancy; if the is in danger of á mifcarriage; if the Os Uteri be dilated; and in time of labour to form a right judgment of the cafe, from the opening of the Os Internum, and the preffing down of the membranes with their waters; and lastly, to diftinguifh what part of the child is prefented.
It is generally impracticable to difcover by a touch in the Vagina, whether or not the Uterus is impregnated, 'till after the fourth month: then the best time for examination is the morning when the woman is fafting, after the contents of the bladder and Rectum have been discharged; and fhe ought, if neceffary, to fubmit to the inquiry in a standing posture; because in that cafe, the Uterus hangs lower down in the Vagina, and the weight is more fenfible to the touch than when the lies reclined. One principal reason of our uncertainty is, when we try to feel the neck, the womb rifes up on our preffing against the Vagina, at the fide of the Os Internum; and in fome, the Vagina feels vetenfe ; but, when the Fundus Uteri is advanced near the navel, the preffure from N 3
ry
above,
that
above, keeps down the Os internum so much, you can generally feel both the neck, and, above that, the stretching of the under part of the Uterus.
There is no confiderable variation to be felt in the figure of the Os internum, except in the latter end of pregnancy, when it sometimes grows larger and fofter; nor do the lips feem to be more clofed in a woman with child than in another, especially in the beginning of pregnancy: but, in both cafes, the Os uteri is felt like the mouth of a young puppy or tench, as we have before observed. In fome, the lips are very small, in others, large, and fometimes, though feldom, smoothed over or pointed. In many women, who have formerly had children and difficult labours, the lips are large, and fo much separated, as to admit the tip of an ordinary finger; but, a little higher up, the neck seems to be quite closed.
In the first four months, the neck of the womb may be felt hanging down in the Vagina, by pushing up the finger by the fide of the Os internum; but the stretching of the Uterus and upper part of the neck cannot be per
perceived till the fifth, and fometimes the fixth month; and even then, the Uterus muft be kept down, by a ftrong preffure upon the belly.
The ftretching of the Fundus, is fometimes felt by the finger introduced into the Rectum, before it can be perceived in the Vagina; because, in this last method, the Uterus recedes from the touch, and rifes too high to be accurately diftinguished, whereas the finger being introduced into the Rectum, paffes along the back of the womb almost to the upper part of the Fundus, which in an unimpregnated state, is felt flat on the backpart, and jetting out at the fides; but, the impregnated Uterus is perceived like a large round tumour.
-1
About the fifth or fixth month, the upper part of the Uterus is fo much ftretched, as to rife three or four inches above the Os pubis, or to the middle space between that and the navel; fo that, by preffing the hand on the belly, especially of lean women, it is frequently perceived; and if, at the fame time, the index of the other hand be introduced in the Vagina, the neck will feem fhortened, N 4 par
1
particularly at the fore-part and fides, and, as I have already obferved, the weight will be sensibly felt: but, if the parietes of the Abdomen are ftretched after eating, one may be deceived by the preffure of the ftomach, because weight and preffure are the fame. But all these signs are more perceptible towards the latter end of pregnancy; and in fome women the Os internum is felt a little open some weeks before the full time, though generally it is not opened till a few days before labour begins.
From the fifth to the ninth month, the neck of the Uterus becomes fhorter and fhorter, and the stretching of the womb grows more and more perceptible. In the seventh month, the Fundus rifes as high as the navel; in the eighth month, to the middle fpace, betwixt the navel and Scrobiculus cordis; and in the ninth, even to the Scrobiculus, except in pendulous bellies: but all these marks may vary in different women; for when the belly is pendulous, the parts below the navel are much more ftretched than those above, and hang over the Os pubis; the Fundus will then be only equal to,
or
or a little higher than the navel; at other times, the Uterus will rife in the latter end of the feventh or eighth month to the Scrobiculus cordis. The neck of the womb will, in fome, be felt as long in the eighth, as in others, in the fixth or feventh month. This variation, fometimes, makes the examination of the Abdomen, more certain than the touch of the Vagina; and fo vice versa. At other times, we must judge by both.
SECT.
III.
Of the figns of CONCEPTION, and the equivocal figns of pregnant and obstructed
women.
THE   HE figns of pregnancy are to be di-      stinguished from those that belong to obstructions, by the touch in theVagina and motion of the child in the fifth or fixth month; fometimes, by the touch in the Rectum, before and after the fifth month, when the tumor of the Abdomen is plainly perceived. 
Moft women, a day or two before the irruption of the Catamenia, labour under com
plaints
plaints proceeding from a Plethora; such as ftretching pains in the back and loins, infide of the thighs, breast and head; a sickness and oppreffion at the ftomach, and a fullnefs of all the Viscera of the Abdomen: and all these symptoms abate, and gradually vanish, when the discharge begins and conti-, nues to flow. But, if the woman be obftructed by any accident or error in the nonnaturals, all thofe complaints continue and increase, and are hardly distinguishable from the symptoms of pregnancy, till the end of the fourth month; at which period, women with child grow better, and all the complaints of fullness gradually wear off; whereas, those who are only obftructed, grow worse and worse, from the increase of the Lentor in the fluids, which will in time produce various and dangerous diseases. The Fundus uteri, in the obstructed patient, is not ftretched, the disorder in her ftomach is not fo violent as in a pregnant woman, and feldom accompanied with reachings; while the woman with child is afflicted with a reaching every morning, and subject to longings, befides. The first labours under a fullness of
of the veffels; the last, over and above this complaint, fuffers an additional one from the diftenfion of the Uterus by the impregnated Ovum. Obftructions and pregnancy are both accompanied by a ftretching fullness in the breasts; but in the laft only, may be perceived the Areola, or brown ring, round the nipples, from which, in the last months, a thin ferum diftills: but this circle is not
always fo difcernible as in the first pregnancy, and even then is uncertain, as well as the others.
About the fifth or fixth month, the cir'cumfcribed tumour or ftretching of the Uterus, is felt above the Os pubis; and by this circumfcription and confiftence, eafily diftinguished from the Afcites or dropfy of the Abdomen: it is also rounder and firmer than those swellings that accompany obftructions, which proceed from a general fullness of the veffels belonging to the ligaments and neighbouring Vifcera.
On the whole, the difficulty of diftinguishing between obstruction and pregnancy in the first months, is fo great, that we ought to be cautious in giving our opinion; and never
pre
prescribe such remedies as may endanger the fruit of the womb, but rather endeavour to palliate the complaints, until time fhall difcover the nature of the cafe; and always judge on the charitable fide, when life or reputation is at stake.
In the fifth or fixth month of uterine gestation, by the touch in the Vagina, we perceive the neck of the womb confiderably fhortened, and the ftretching of the lower part of the Uterus, is then fenfible felt between the mouth of the womb and the Pubis, and on each fide of the neck.
In the feventh month, the head of the child is frequently felt refting against the lower part of the Uterus, between the Pubis and Os internum; and being pushed upward towards the Fundus, finks down again by its own gravity. All these diagnosticks are more plain and certain, the nearer the patient approaches to the time of delivery.
Sometimes, the head is not felt till the eighth or ninth month, and, in fome few cafes, not till after the membranes are broke, when it is forced down by the contraction of the Uterus, and strong labour-pains. This
circumftance may be owing to the head's refting above the bafin, especially in a narrow Pelvis; or to the diftention of its belly with air after death, by which the Fætus being rendered fpecifically lighter than the furrounding waters, the body floats up to the Fundus, if there is a large quantity of fluid in the membranes: nor is the body always felt, when the child lies across the Uterus.
SECT. IV.
How to diftinguish the falfe labour from the true, and the means to be used on that occafion.
IF
the Os Uteri remains clofe fhut, it may be taken for granted, that the woman is not yet in labour, notwithstanding the pains fhe may fuffer; with regard to which, an accurate inquiry is to be made, and if her complaints proceed from an overstretching fullness of the Uterus, or veffels belonging to the neighbouring parts, blooding in the arm or ancle, to the quantity of fix or eight ounces, ought to be prefcribed and repeated occafionally. If the pains are occafioned by
3
a looseness or Diarrhea, it must be immediately restrained with Opiates, as in lib. II. chap. 3. fect. 4. Cholic pains are distinguished from those of labour, by being chiefly confined to the belly, without going off and returning by distinct intervals: they are for the most part produced by Faces too long retained in the Colon, or by fuch Ingesta as occasion a rarefaction or expanfion of air in the intestines; by which they are violently stretched and vellicated. This complaint must be removed by opening glyfters, to empty the guts of their noxious contents: and this evacuation being performed, opiates may be administred to asswage the pains; either to be injected by the Anus, taken by the mouth, or applied externally, in form of Epithem or embrocation.
Sometimes, the Os internum may be a little dilated, and yet it may be difficult to judge whether or not the patient be in labour; the cafe, however, may be ascertained after fome attendance, by these confiderations: if the woman is not arrived at her full time; if no foftor glary Mucus hath been discharged from the Vagina; if the pains are limited to the region of
;
of the belly, without extending to the back and infide of the thighs; if they are flight, and continue without intermiffion or increafe; nay, if they have long intervals, and recur without force fufficient to push down the waters and membranes, or child's head, to open the Os internum if this part be felt thick and rigid instead of being foft, thin, and yielding, we may fafely pronounce, that labour is not yet begun and those alarms are to be removed as we have directed in the cafe of falfe or cholic pains. Befides, if the pulfe be quick and ftrong, and the patient attacked by ftitches in the fides, back, or head, blooding will be likewife neceffary.
SE C T. V.
The Divifion of LABOURS. HIPPOCRATES, and almost all the
writers upon this fubject, from his time to the fifteenth century, divided labour into two kinds; namely, natural and præternatural : the first comprehended thofe cafes in which the head, (others fay the head and breech) prefented, though the prefentation of the head
was
was always deemed the most natural; the other included all births in which any other part of the body first offered itself: and although they did not, like us, use a third diftinction, they seem to have understood it in their practice; for, among their chirurgical operations, we always find a chapter on the method of delivering dead children, by opening the head, and extracting with the crotchet. At present, labours are divided into natural, according to the ancients, when the head or breech prefents; laborious, when, notwithstanding this fituation of the child, the delivery goes on fo tediously, that the woman is in danger of lofing her life, unless she is affifted with the operator's hand, fillet, forceps, blunt hook, or crotchet; and præternatural, when neither head nor breech presents; so that for the most part, there is a neceffity for turning the child, and bringing it away by the feet. But the divifion of labours, hath been varied according to the opinions of different people: fome think, that all those cases ought to be deemed præternatural, in which any part of the body (the head itself not excepted) prefents in an un
ufual
ufual way. Others affirm, that whatever part prefents, or however the posture of the child may be, if it is delivered without any other affiftance than that of the labour-pains, the birth ought to be called natural; laborious, when in these cafes the child is born with difficulty; and præternatural, when lying across the Uterus, it must be turned and delivered by the feet.
For my own part, having in teaching, found all thefe divifions liable to objections, I have followed a method which is more fimple than the others, and will fave abundance of repetition.
중
I call that a natural labour in which the head prefents, and the woman is delivered by her pains and the affiftance commonly given: but, fhould the cafe be fo tedious and lingering, that we are obliged to use extraordinary force, in ftretching the parts, extracting with the forceps, or (to fave the mother's life) in opening the head and delivering with the crotchet, I diftinguish it by the appellation of laborious: and in the præternatural, comprehend all those cafes in which the child is brought by the feet, or the body
delivered before the head. Neither do I mind how the child presents, so much as the way in which it is delivered: for, there are cafes in which the head prefents, and for feveral hours we expect the child will be delivered in the natural way; but if the woman has not strength enough to force down the child's head into the Pelvis, or in floodings, we are at length obliged to turn and bring it by the feet, because it is so high that the forceps cannot be applied; and if the child is not large, nor the Pelvis narrow, it were pity to destroy the hopes of the parents, by opening the skull and extracting with the crotchet. In this cafe, therefore, although the child prefents in a natural way, we are obliged to turn and deliver it in the fame manner as if the shoulder, breast, or back, had presented; and generally, this operation is more difficult than in either of those cases, because if the waters are all discharged, and the Uterus clofe contracted round the Fatus, it is more difficult to raise the head to the Fundus. When the breech prefents, we are frequently obliged to push it up and search for the
the legs, which being found, we proceed to deliver the body, and laftly the head.
4
For a farther illuftration, and to inform young practitioners that difficult cafes do not frequently occur, suppose, of three thousand women in one town or village, one thousand shall be delivered in the space of one year, and in nine hundred and ninety of these births, the child fhall be born without any other than common affistance: fifty children of this number fhall offer with the forehead turned to one fide, at the lower part of the Pelvis, where it will ftop for fome time; ten fhall come with the fore head turned towards the groin, or middle of the Pubes five shall present with the breech, two or three with the face, and one or two with the ear; yet, all these shall be safely deliver ed, and the cafe be more or lefs lingering and Jaborious, according to the fize of the Pelvis and child, or ftrength of the woman: of the remaining ten that make up the thou fand, fix fhall present with the head diffe rently turned, and two with the breech; and these cannot be faved without ftretching the parts, ufing the forceps or crotchet,
or pushing up the child, in order to bring it by the feet; this neceffity proceeding either from the weakness of the woman, the rigidity of the parts, a narrow Pelvis, or a large child, &c. the other two fhall lie acrofs, and neither head nor breech, but fome other part of the body present, so that the child must be turned and delivered by the feet. Next year, let us fuppose another thousand women delivered in the fame place not above three, fix, or eight, shall want extraordinary affiftance; nay, sometimes, though feldom, when the child is young, or unusually small, and the mother has strong pains and a large Pelvis, it fhall be delivered even in the very worft pofition, without any other help than that of the labour-pains.
As the head, therefore, prefents right in nine hundred and twenty of a thousand labours, all fuch are to be accounted natural; those of the other feventy, that require affiftance may de deemned laborious; and the other ten, to be denominated laborious or præternatural, as they are delivered by the head or feet.
In order, therefore, to render this treatise as diftinct as poffible, for the fake of the reader's memory, as well as of the dependance and connection of the different labours, they are divided in the following manner: that is accounted natural, in which the head presents and the woman is delivered without extraordinary help; thofe births are called laborious or nonnatural, when the head comes along with difficulty, and must be affifted either with the hand in opening the parts, or with the fillet or forceps, or even when there is a neceffity for opening and extracting it with the crotchet; and those in which the child is brought by the breech or feet, are denominated præternatural, because the delivery is performed in a præternatural way.
CHA P. II.
Of NATURAL LABOURS:
SECT. I.
Of the different Pofitions of Women in Labour.
IN
N almost all countries, the woman is allowed either to fit, walk about, or rest upon a bed, until the Os uteri is pretty much dilated by the gravitation of the waters, or (when they are in fmall quantity) by the head of the Fatus, fo that delivery is foon expected; then the is put in fuch position as is judged most fafe, eafy, and convenient for that purpose: but the patient may be put upon labour too maturely, and bad confequences will attend such mistakes.
Among the Egyptians, Grecians, and Romans, the woman was placed upon an high ftool; in Germany and Holland they use the chair which is defcribed by Daventer and Heifter; and for hot climates the ftool is perfectly well adapted, but in nor
thern
thern countries and cold weather, fuch a pofition must endanger the patient's health.
In the West Indies and fome parts of Britain, the woman is feated on a ftool made in form of a femicircle: in other places she is placed on a woman's lap; and fome kneeling on a large cufhion, are delivered backwards.
In France the pofition is chiefly that of half fitting and half lying, on the fide or end of a bed; or, the woman being in naked bed, is raised up with pillows or a bedchair.
The London method is very convenient in natural and eafy labours: the patient lies in bed upon one fide, the knees being contracted to the belly, and a pillow put between them to keep them asunder. But the most commodious method is to prepare a bed and a couch in the fame room, a piece of oiled cloth or dreffed fheep-fkin is laid across the middle of each, over the under sheet, and above this are spread several folds of linen, pinned, or tied with knittings to each fide of the bed and couch; these are defigned to fpunge up the moisture in time
of labour and after delivery, while the oiled cloths or sheep-fkins below, preferve the feather-bed from being wetted or spoiled: for this purpose, fome people lay befides upon the bed, feveral under-fheets over one another, fo that by fliding out the uppermost every day, they can keep the bed dry and comfortable.
The couch must be no more than three feet wide, and provided with cafters; and the woman, without any other dress than that of a short or half fhift, a linen skirt or petticoat open before, and a bed-gown, ought to lie down upon it, and be covered with cloaths according to the feafon of the year. She is commonly laid on the left fide, but in this particular fhe is to confult her own cafe; and a large sheet being doubled four times or more, one end must be slipt in below her breech, while the other hangs over the fide of the couch, to be fpread upon the knee of the accoucheur or midwife, who fits behind her on a low feat as foon as fhe is delivered, this sheet must be removed, a soft, warm cloth applied to the Os externum, and the pillow taken from betwixt her knees: fhe
then
:
then must be shifted with a clean, warm, half shift, linen-fkirt, and bed-gown, and her belly kept firm with the broad headband of the skirt, the ends of which are to be pinned acrofs each other. These meafures being taken, the couch must be run close to the bed-fide, and the patient gently moved from one to another; but, if there is no couch, the bed must be furnished with the fame apparatus. Some again, are laid across the foot of the bed, to the head of which the cloaths are previously turned up till after delivery, when the woman's posture is adapted, and then they are rolled down again to cover and keep her warm: by this expedient, the place of a couch is supplied, and the upper part of the bed preserved foft and clean; whereas, thofe who are laid above the cloaths, must be taken up and fhifted while the bed is put to rights; in which cafe, they are fubject to fainting, and to fuch as are very much enfeebled this fatigue is often fatal.
Women are most easily touched, least fatigued, and kept warmeft, when they lie on one fide; but if the labour should prove te
dious, the Parifian method feems most ellgible; because, when the patient half fits, half lies, the brim of the Pelvis is horizontal, a perpendicular line falling from the middle space between the Scrobiculus cordis and navel, would país exactly through the middle of the bafin, as observed in book I. chap. 1. In this pofition, therefore, the weight of the waters, and, after the membranes are broke, that of the child's head, will gravitate downwards, and affift in opening the parts; while the contracting force of the abdominal muscles and Uterus, is more free, ftrong, and equal in this than in any other attitude. Wherefore, in all natural cafes, when the labour is lingering or tedious, this or any other position, fuch as standing or kneeling, ought to be tried, which by an additional force, may help to push along the head and alter its direction, when it does not advance in the right way. Nevertheless, the patient must by no means be too much fatigued.
When the woman lies on the left fide, the right hand must be used in touching, and vice verfa, unless the is laid across the
bed;
bed; in which cafe, either hand will equally answer the same purpose: but, if she lies athwart, with the breech towards the bed's foot, it will be moft convenient to touch with the left hand when she is upon the left fide, and with the right when in the oppofite pofition. And here it will not be amiss to observe, that in the description of all the laborious and præternatural deliveries treated of in this performance, the reader must fuppofe the woman lying on her back, as directed in chap. 3. fect. 3. and chap. 4. fect. except when another pofture is prescribed; and that in natural and laborious labours, whether the be upon her fide or back, the head and shoulders are a little raised into a reclining posture, fo that he may breathe eafily, and affift the pains.
4.
But, in præternatural labours, when there is a neceffity for ufing great force in turning the child, the head and fhoulders muft lie lower than the breech, which being close to the fide or foot of the bed, ought to be raised higher than either, because when the Pelvis is in this fituation, the hand and arm are eafier pushed up in a right line, along the
the back-part of the Uterus, even to its Fundus. Sometimes, however, when the feet of the child are towards the belly of the mother, they are more eafily felt and managed when the lies on her fide, At other times, placing the woman on her knees and elbows on a low couch, according to Daventer's method, will fucceed better, by diminishing in part the ftrong refiftance from the preffure and weight of the Uterus and child; by which the feet will fometimes be easier found and delivered: but then it is fafer for the child, and eafier to the operator and mother, to turn her to her back before you deliver the body and head.
SECT. H.
Of the management of women in a NATURAL
LABOUR.
IN a woman come to full time, labour commonly begins and proceeds in the following manner.
The Os uteri is felt foft and a little opened, the circumference being fometimes
thick, but chiefly thin; from this aperture is discharged a thick Mucus, which lubricates the parts and prepares them for stretching. This discharge usually begins fome days before, and is accounted the forerunner of real labour: at the fame time, the woman is feized at intervals with flight pains that gradually stretch the Os uteri, fitting it for a larger dilatation; and when labour actually begins, the pains become more frequent, ftrong, and lasting.
At every pain, the Uterus is ftrongly.compreffed by the fame effort which expels the
contents of the Rectum at ftool, namely,
盆
the inflation of the lungs, and the contraction of the abdominal muscles.
If the child be furrounded with a large quantity of waters, the Uterus cannot come in contact with the body of it, but at every pain, the membranes are pushed down by the fluid they contain, and the mouth of the womb being fufficiently opened by this gradual and repeated diftention, they are forced into the middle of the Vagina; then the Uterus contracts, and comes in contact with the body of the child, and if it be small,
3
the
the head is propelled with the waters. Here the membranes ufually break; but, if that is not the case, they are puflied along towards the Os externum, which they alfo gradually open, and appear on the outfide, in the form of a large round bag: mean while, the head advances, and the Os externum being by this time fully dilated, is alfo protruded, when, if the membranes, inftead of bursting in the middle of the protuberance, are tore all round at the Os externum, the child's head is covered with fome part of them, which goes under the name of the caul, or king's hood. If the Placenta is, at the fame time, feparated from the Uterus, and the membranes remain unbroken, the Secundines, waters, and chile, are delivered together; but, if the Placenta adheres, they muft of course give way: and fhould they be tore all round from the Placenta, the greatest part of the body, as well as the head of the child, will be invelloped by them, from which it must be immediately difengaged, that the air may have a free paffage into the lungs.
When the head is large, fo that it does not descend immediately into the Pelvis, the
mem
membranes are forced down by themselves; and being stretched thinner and thinner, give way; when all the waters which are farther advanced than the head, run out; then the Uterus coming in contact with the body of the child, the head is fqueezed down into the mouth of the womb, which it plugs up fo as to detain the reft of the
waters.
Sometimes, when the quantity of waters is very small, and the Uterus embraces the body of the child, the head, covered with the membranes, is forced downwards, and gradually opens the Os internum; but, at its arrival in the middle of the Pelvis and Vagina, part of the waters will be pushed down before it, fometimes in a large, and fometimes in a small proportion, towards the back-part of the Pelvis. At other times, when the waters are in fmall quantity, no part of them are to be diftinguished farther than the head, which defcending lower and lower, the attenuated membranes are split upon it; while, at the fame time, it fills up the mouth of the womb and upper part of the Vagina, in fuch a manner as hinders the few
few remaining waters from being discharged at once; though in every pain, a fmall quantity diftils on each fide of the head, for lubricating the parts; fo as that the child may flip along the more easily.
The Uterus contracts, the pains become quicker and stronger, the crown of the head is pushed down to the lower part of the Pelvis, against one of the Ifchia, at its lower extremity; the forehead being at the upper part of the oppofite Ifchium, is forced into the hollow of the under part of the Sacrum, while the Vertex and hindhead is preffed below the Os pubis; from whence it rifes in a quarter turn, gradually opening the Os externum: the Frænum labiorum, or Fourchette, Perinæum, fundament, and the parts that intervene betwixt that and the extremity of the Sacrum, are all ftretched outwards in form of a large tumour. The Perinæum, which is commonly but one inch from the Os externum to the Anus, is now ftretched to three, the Anus to two, and the parts between that and the Coccyx are stretched from two inches to about three or more. The broad Sacrofciatic ligaments reaching from each
éach fide of the lower part of the Sacrum, to the under part of each Ischium, are also outwardly extended, and the Coccyx is forced backward; while the crown of the head, where the lambdoidal croffes the end of the fagittal future, continues to be pushed along, and dilates the Os externum more and more.
When the head is fo far advanced, that the back-part of the neck is come below the under-part of the Os pubis, the forehead forces the Coccyx, fundament, and Perinæum backwards and downwards; then, the hindhead rises about two or three inches from under the Pubes, making an half round turn in its afcent, by which the forehead is equally raised from the parts upon which it preffed, and the Perineum efcapes without being split or torn at the fame time, the fhoulders advance into the fides of the Pelvis at its brim, where it is wideft, and, with the body, are forced along and delivered; mean while, by the contraction of the Uterus, the Placenta and Chorion are loofened from the inner furface to which they adhered, and forced through the Vagina, out at the Os exter→
hum
When
P
When the head refts at first, above the brim of the Pelvis, and is not far advanced, the Fontanelle may be plainly felt with the finger, commonly towards the fide of the Pelvis this is the place where the coronal croffes the fagittal future, and the bones are a little feparated from each other, yielding a softness to the touch, by which may be distinguished four futures, or rather one croffing another. These may be plainly perceived, even before the membranes are broke, yet the examination must not be made during a pain, when the membranes are stretched down and filled with waters; but only when the pain begins to remit, and the membranes to be relaxed, otherwife they may be broke too foon, before the Os internum be fufficiently dilated, and the head properly advanced.
When the Vertex is come lower down, the fagittal future only is to be felt; because, as the hindhead defcends in the Pelvis, the Fontanelle is turned more backwards, to the fide, or towards the concavity of the Sacrum: but, after it has arrived below the un der part of the Offa pubis, the lambdoidal may
may be felt croffing the end of the fagittal future, the Occiput making a more obtufe angle than that of the parietal bones, at the place where the three are joined together. But, all these circumftances are more eafily diftinguished after the membranes are broke, or when the head is fo compreffed that the bones ride over one another, provided the hairy fcalp be not exceffively fwelled.
SECT.
III.
How to behave when the birth is obftructed by the navel-ftring or fhoulders of the child. Vide book II. chap. 2. fect. 3.
Although the head is pushed down into the Pelvis, and the Vertex employed in opening the Os externum, the forehead being lodged in the concavity formed by the Coccyx and lower part of the Sacrum; yet frequently after the labour-pain is abated, the head is again withdrawn by the navelftring happening to be twited round the neck; or when the fhoulders, inftead of advancing, are retarded at the brim of the Pelvis, one refting over the Offa pubis, while P 2
Ca
the
the other is fixed at the Sacrum; or when (the waters having been long evacuated) the under-part of the Uterus contracts round the neck and before the fhoulders, keeping up the body of the child.
When the head is therefore drawn back by any of these obstacles, and the delivery hath been retarded during feveral pains, one or two fingers being introduced into the Rectum before the pain goes off, ought to prefs upon the forehead of the child at the root of the nofe, great care being taken to avoid the eyes this preffure detains the head till the return of another pain, which will fqueeze it farther down, while the fingers pushing flowly and gradually, turn the forehead half round outwards and half round upwards. By this affistance, and the help of ftrong pains, the child will be forced along, although the neck be entangled in the navel-string; for, as the child advances, the Uterus contracts, and confequently the Placenta is moved lower: the Funis umbilicalis will also stretch a little, without obstructing the circulation.
The
The head being thus kept down, the fhoulders too are preffed in every fucceeding pain, until they are forced into the Pelvis, when the whole comes along, without further difficulty. And this expedient will, moreover, answer the purpose, when the under-part of the Uterus or Os internum is contracted round the neck of the child, and before the shoulders; alfo, when the head is very low, preffing a finger on each fide of the Coccyx externally, will frequently affift in the fame manner,
Over and above these obstacles, the head may be actually delivered and the body retained by the contraction of the Os externum round the neck, even after the face appears externally. In this cafe it was generally alledged, that the neck was close embraced by the Os internum; but this feldom happens when the head is delivered, because then the Os internum is kept dilated on the back-part and fides by the breaft and arms of the Fatus, unless it be forced low down with or before the head,
When the head is delivered, and the reft of the body retained from the largeness or
wrong
P 3
4
wrong presenting of the fhoulders, or by the navel-string's being twisted round the body or neck of the child, the head must be grafped on each fide, the thumbs being applied to the Occiput, the fore and middle fingers extended along each fide of the neck, while the third and fourth of each hand fupport each fide of the upper jaw; thus embraced, the head must be pulled freight forwards, and if it will not move eafily along, the force must be increased, and the direction varied from fide to fide, or rather from shoulder to fhoulder, not by fudden jirks, but with a flow, firm, and equal motion. If the body cannot be moved in this manner, though you have exerted as much force as poffible, without running the risk of over-ftraining the neck, you must endeavour to flip the turns of the navel ftring over the head: but, fhould this be found impracticable, you ought not to trifle in tying the ftring at two places, and cutting betwixt the ligatures, as fome people have advised: fuch an operation would engrofs too much time; befides, the child is in no danger
4
of fuffocation from the ftricture
ftricture of the Funis, because it seldom or never breathes before the breaft is delivered.
1
The better method is, immediately to flide along one or two fingers, either above or below, to one of the arm-pits; by which you try to bring along the body, while, with the other hand, you pull the neck at the fame time; if it ftill continues unmoved, shift hands, and let the other arm-pit sustain the force; but, if this fail, cut the navelftring, and tie it afterwards. If the shoulders lie fo high that the fingers cannot reach far enough to cut or take fufficient hold, let the flat of the hand be run along the back of the child; or fhould the Os externum be strongly contracted round the neck, push up your hand along the breaft, and pull as before and fhould this method fail, you must have recourfe to the blunt hook, introduced and fixed in the arm-pit; but this expedient must be used with caution, left the child should be injured or the parts lacerated.
The child being born, the Funis umbili calis must be divided, and the Placenta delivered, according to the directions that will occur in the fequel.
P4
SECT.
SECT. IV.
How and when to break the MEMBRANES.
I
Have already observed, that if the child be furrounded with a large quantity of waters, the Uterus cannot come in contact with the body fo as to prefs down the head, until the membranes are pushed a confiderable way before it into the Vagina; nor even then, until they are broke, and the fluid diminished in fuch a manner as will allow the womb to contract, and, with the affiftance of the pains, force along the child. When the membranes, therefore, are strong or unadvanced, and continue fo long unbroke, that the delivery is retarded, provided the Os internum be fufficiently dilated, they ought to be broke without further delay; especially if the woman hath been much fatigued or exhausted with labour, or is seized with a violent flooding: in which cafe, the rupture of the membranes haftens delivery, and the hæmorrhage is diminished by the contraction of the Uterus, which leffens
>
fens the mouths of the veffels that are alfa compreffed by the body of the child.
F.
The common method of breaking the membranes is by thrufting the finger against them when they are protruded with the waters during the pain, or by pinching them with the finger and thumb; but if they are detained too high to be managed in either of these methods, the hand may be introduced into the Vagina, if the Os externum is fo lax as to admit it eafily: and if this cannot be done without giving much pain, the fore and middle fingers being pushed into the Vagina with the other hand, let a probe or pair of pointed fciffars be directed along and between them, and thrust through the membranes, when they are pushed with the waters, below the head. This operation muft be cautiously performed, left the head shouldbe wounded in the attempt; and as for the membranes, let the opening be never so small, the waters are discharged with force fufficient to tear them asunder.
SECT.
SECT. V.
NUMB. I.
When the Vertex prefents, and when little or       no waters are protruded thereby. 
IF
F the Vertex, instead of refting at the fide of the brim of the Pelvis, or at the Os pubis, is forced farther down to the Os internum, and the waters happen to be in small quantity, the head is pushed forwards, and gradually opens the mouth of the womb without any fenfible interpofition of the waters; then it advances by degrees into the Vagina, and the membranes being split or tore, little or nothing is discharged until the body of the child be delivered; and in this cafe, the hair of the head being plainly felt, will be a fufficient indication that the membranes are broke. If no hair is to be felt, but a smooth body prefents itself to the touch, and the woman has undergone many ftrong pains even after the mouth of the womb hath been largely dilated, and the head forced into the middle of the Pelvis, you
you may conclude, that delivery is retarded by the rigidity of the membranes, that there is but a fmall quantity of waters, and that if the containing Sacs were broke, the head would come along, without further hefitation.
Sometimes, no waters can be felt while the head is no farther advanced than the upper part of the Pelvis, because it plugs up the paffage and keeps them from defcending; but, as it advances downwards, the Uterus contracts, and they are forced down in a fmall quantity towards the back-part: from thence, as the head defcends, or even though it should stick in that fituation, they are pushed farther down, and the membranes may be eafily broke; but the task is more difficult when no waters come down, and the membranes are contiguous to the head. In this cafe, they must be scratched a little during every pain, with the nail of a finger, which, though fhort and smooth, will by degrees, wear them thinner and thinner, until they fpilt upon the head by the force of labour. Yet this expedient ought never to be used until you are certain that delivery is
16
retarded by their rigidity; for, if that be not the hindrance, the difficulty muft proceed from the weakness of the woman, a large head, or narrow Pelvis: in which cafe, the delivery is a work of time, and will be obstructed by the premature discharge of the waters, which, by gradually paffing by the head, ought to keep the parts moist and flippery, in order to facilitate the birth; for, when the membranes are not broke, until the head is forced into the middle of the Pelvis, the largest part of it being then past the upper part of the Sacrum, is commonly fqueezed along, opens the Os externum, and is delivered before all the waters are difcharged from the Uterus; so that what remains, by moistening and lubricating the parts, help the shoulders and body to pass with more ease. When the membranes are too foon broke, the under-part of the Uterus contracts fometimes fo ftrongly before the fhoulders, that it makes the resistance still greater.
NUMB,
NUMB.
II.
How to manage when the forehead is turned to one fide.
1
In most natural labours, the fpace betwixt the fore and back Fontanelles, viz. the Vertex, prefents to the Os internum, and the forehead is turned to the fide of the Pelvis; because, the bafin at the brim is wideft from fide to fide, and frequently, before the head is pushed in and faft wedged among the bones, the child (after a pain) is felt to move and turn it to that fide or fituation in which it is leaft preffed and hurt, if it was not presenting in that position before: but, this pofition of the head, may alter, viz. in thofe where it is as wide, or wider, from the back-part to the fore-part of the brim, · than from fide to fide, the forehead may be turned backwards or forewards. Eut this form of the Pelvis feldom happens. This pofture is always obferved in a narrow Pelvis, when the upper part of the Sacrum jets forward to the Pubes; but, as the child is forced lower down, the forehead turns into the hollow at the inferior part of
of the Sacrum, because the Vertex and Occiput find less refiflance at the lower part of the Offa Pubis, than at the chium to which it was before turned, the Pelvis being at the Pubes, as formerly described, no more than two inches in depth, whereas at the Ischium it amounts to four. If, therefore, the forehead sticks in its former fituation, without turning into the hollow, it may be affifted by introducing fome fingers, or the whole hand, into the Vagina, during a pain, and moving it into the right position.
When the head of the Fatus presents, and is forced along in any of thofe pofitions, the labour is accounted natural, and little elfe is to be done, but to encourage the woman to bear down with all her ftrength in every pain, and to reft quietly during each interval: if the parts are rigid, dry, or inflamed, they ought to be lubricated with Pomatum, hog's lard, butter, or Ung, althea; the two firft are moft proper for the external parts, and the two laft (as being harder and not so easily melted) ought to be put up into the Vagina, to lubricate that and the Os internum.
NUMB.
1
III.
NUMB.
How to affift in LINGERING LABOUR.
The mouth of the womb and Os externum, for the moft part, open with greater difficulty in the first than in the fucceeding labours, more especially in women turned of thirty. In these cafes, the Os externum muft be gradually dilated in every pain, by introducing the fingers in form of a cone, and turning them round, fo as to fretch the parts by gentle degrees; and the whole hand being admitted into the Vagina, it will be fometimes found neceffary to infinuate the fingers with the flat of the hand between the head and Os internum: for, when this precaution is not taken in time, the Os uteri is frequently pushed before the head, (efpecially that part of it next the Pubes) even through the Os externum; or if the head paffes the mouth of the womb, it will protrude the parts at the Os externum, and will endanger a laceration in the Perinæum. This dilatation, however, ought to be cautiously performed, and never attempted except when it is abfolutely neceffary; even then it must
1
be
be effected slowly, and in time of a pain; when the woman is least fenfible of the dilating force:
When the labour happens to be lingering, though every thing be in a right posture, if the affiftants are clamorous, and the woman herself too anxious and impatient to wait the requifite time, without complaining, the labour will be actually retarded by her uneafinefs, which we must endeavour to furmount by arguments and gentle persuasion; but if she is not to be satisfied, and strongly impreffed with an opinion, that certain me dicines might be adminiftred to haften delivery, it will be convenient to prescribe fome innocent medicine, that he may take between whiles, to beguile the time and please her imagination: but, if she is actually weak and exhausted, it will be neceffary to order fomething that will quicken the circulating fluids, fuch as preparations of amber, caftor, myrrh, volatile fpirits, the pulv. myrrh. compofit. of the London, or pulv. ad partum of the Edinburgh Pharmacopeia, with every thing in point of diet and drink that nourishes and strengthens the body. If the patient
is of a plethoric habit, with a quick, ftrong pulse, the contrary method is to be used, fuch as venæfection, antiphlogistic medicines, and plentiful draughts of weak, diluting fluids.
1
How to manage the CHILD after DELIVERY, THE Child being delivered, ought to be kept warm beneath the bed-cloaths, or immediately covered with a warmed flannel or linen-cloth if it cries and breathes, the umbilical cord may be tied and cut, and the child delivered to the nurfe without delay; but, if the air does not immediately rush into the lungs, and the circulation continues between it and the Placenta, the operation of tying and cutting muft be delayed, and every thing tried to ftimulate and fome times to give pain. If the circulation is languid, refpiration begins with difficulty, and proceeds with long intervals; and if it be entirely ftopped in the Funis, the child, if alive, is not eafily recovered: fometimes, a great many minutes е
are
are elapfed before it begins to breathe. Whatever augments the circulating force, promotes refpiration, and as this increases, the circulation grows ftronger, fo that they mutually affift each other. In order to promote the one and the other, the child is kept warm, moved, fhaken, whipt; the head, temples, and breaft, rubbed with spirits, garlick, onion, or mustard applied to the mouth and nofe; and the child has been fometimes recovered by blowing into the mouth with a filver Canula, fo as to expand the lungs.
When the Placenta is itself delivered, immediately or foon after the child, by the continuance of the labour-pains, or hath been extracted by the operator, that the Uterus may contract, so as to restrain too great a flooding; in this cafe, if the child has not yet breathed, and a pulfation is felt in the veffels, fome people (with good reason) order the Placenta, and as much as poffible of the navel-string, to be thrown into a bafin of warm wine or water, in order to promote the circulation between them and the child; others advise us to lay the Placenta on the child's
child's belly, covered with a warm cloth; and a third set order it to be thrown upon hot ashes but, of thefe, the warm water feems the most innocent and effectual expedient. Nevertheless, if the Placenta is ftill retained in the Uterus, and no dangerous flooding enfues, it cannot be in a place of more equal warmth, while the operator endeavours, by the methods above described, to bring the child to life.
NUMB. II.
In lingering labours, when the head of the child hath been long lodged in the Pelvis, fo that the bones ride over one another, and the shape is præternaturally lengthened, the brain is frequently fo much compreffed, that violent convulfions enfue before or foon after the delivery, to the danger and oft-times the deftruction of the child. This diforder is frequently relieved and carried off, and the bad confequences of the long compref fon prevented, by cutting the navel-ftring before the ligature is made, or tying it fo flightly as to allow two, three, or four large fpoonfuls to be discharged.
;
If the child has been dead one or two days before delivery, the lips and genitals (especially the Scrotum in boys) are of a livid hue if it hath lain dead in the Uterus two or three days longer, the fkin may be easily stript from every part of the body, and the navel-string appears of the fame colour with the lips and genitals: in ten or fourteen days, the body is much more livid and mortified, and the hairy scalp may be sepa.. rated with ease; and indeed, any part of the child which hath been strongly preffed into the Pelvis, and retained in that fituation for any length of time, will adopt the fame mortified appearance.
NUM B. III.
How to tie the FUNTS UMBILICALIS.
DIFFERENT practitioners have used different methods of performing this operation: fome propofing to tie and feparate the Funis before the Placenta is delivered; to apply one ligature close to the belly of the child, with a view to prevent a rupture of the navel; and making another two inches above the former, to divide the rope between the
two tyings: by the fecond ligature, they mean to prevent a dangerous hæmorrhage from the woman, provided the Placenta ad- heres to the Uterus. But, all these precau- tions are founded upon miftaken notions, and the following feems to be that which is easiest and best: if the Placenta is not im- mediately delivered by the pains, and no flooding obliges you to haften the extraction, the woman may be allowed to reft a little, and the child to recover; if it does not breathe, or the refpiration is weak, let the methods above prefcribed be put in practice, with a view to ftimulate the circulation but, if the child is lively, and cries with vi- gour,        the Funis may be immediately tied in this manner; having provided a ligature or two, composed of fundry threads waxed to- gether, fo as to equal the diameter of a pack-  thread, being feven inches in length, and  knotted at each end, tie the navel-ftring  about two fingers breadth from the belly of  the child, by making at first one turn, if the  Funis be fmall, and fecuring it with two  knots; but if the cord be thick, make two  more turns and another double knot, then                                        cut 
Q 3
1
cut the Funis with a pair of fharp fciffars one finger's breadth from the ligature towards the Placenta; and in cutting, run the fciffars as near as poffible to the root of the blades, elfe the Funis will be apt to flip from the edge, and you will be obliged to make feveral fnips before you can effect a separation at the fame time, guard the points of the fciffars with your other hand. The child being washed, a linen rag is wrapped round the tied Funis, which being doubled up along the belly, a fquare compress is laid over it, and kept firm or moderately tight with what the nurfes call a belly-band, or roller round the body.
any
This portion of the Funis foon fhrinks, turns first livid, then black, and about the fifth day, falls off clofe to the belly; and let the navel-string be tied in any part, or at distance whatsoever from the belly, it will always drop off at the fame place: fo that ruptures in the navel feldom or never depend upon the tying of the Funis, but may happen when the compreís and belly-band are not kept fufficiently firm, and continued fome time after the feparation of the wither'd portion,
portion, especially in those children that cry much the bandage ought always to be applied fo flight as not to affect refpiration.
:
#
The ligature upon the Funis muft always be drawn fo tight as to shut up the mouths of the veffels; therefore, if they continue to pour out their contents, another ligature must be applied below the former; for, if this precaution be neglected, the child will foon bleed to death: yet, if the navel-ftring is cut or tore afunder at two or three handbreadths from the belly, and expofed to the cold without any ligature, the arteries will contract themselves, fo as that little or no blood fhall be loft; nay, fometimes, if the Funis hath been tied and cut at the diftance of three finger-breadths from the child's belly, fo as that it hath been kept from blooding for an hour or two, although the ligature be then untied, and the navel-string and belly chafed, and foaked in warm water, no more blood will be discharged.
SECT. VII.
Of delivering the PLACENTA.
THE HE Funis being separated, and the child committed to the nurse, the next care is to deliver the Placenta and membranes, if they are not already forced down by the labour-pains. We have already obferved, that if there is no danger from a flooding, the woman may be allowed to rest a little, in order to recover from the fatigue fhe has undergone; and that the Uterus may, in contracting, have time to fqueeze and separate the Placenta from its inner furface : during which paufe alfo, about one, two, or three tea cups full of blood is discharged through the Funis, from the vessels of the Placenta, which is thus diminished in bulk, fo that the womb may be the more contracted; and this is the reason for applying one ligature only upon the cord. In order to deliver the Placenta, take hold of the navelftring with the left hand, turning it round the fore and middle fingers, or wrapping it in a cloth, that it may not flip from your
i.
grafp;
grafp; then pull gently from fide to fide, and defire the woman to affift your endea- your, by ftraining as if he were at ftool, blowing forcibly into her hand, or provoking herself to reach by thrufting her finger into her throat. If by these methods the Pla- centa cannot be brought away, introduce your hand flowly into the Vagina and feel for the edge of the cake, which when you have found, pull it gradually along; as it comes out at the Os externum, take hold of it with both hands and deliver it, bringing away at the fame time, all the membranes, which, if they adhere, must be pulled along with leisure and caution. 
When the Funis takes it origin towards the edge of the Placenta, which is frequently the cafe, the cake comes eafier off by pulling, than when the navel-ftring is inferted in the middle, unless it be uncommonly retained by its adhesion to the womb, or by the ftrong contraction of the Os internum. If the Funis is attached to the middle of the Placenta, and that part presents to the Os internum or externum, the whole mafs will be too bulky to come along in that position:
in
in this cafe, you must introduce two fingers within the Os externum, and bring it down with its edge foremost.
When the Placenta is feparated by the contraction of the Uterus, in confequence of i's weight and bulk, it is pushed down before the membranes, and both are brought away inverted.
When part of the Placenta hath passed the Os internum, and the reft of it cannot be brought along by eafy pulling, because the Os uteri is close contracted round the middle of it, or part of it still adheres to the womb, flide the flat of your hand below the Placenta, through the Os internum; and having dilated the Uterus, flip down your hand to the edge of the cake and bring it along: but, if it adheres to the Uterus, push up your hand again, and having feparated it cautiously, deliver it as before.
If, instead of finding the edge or middle of the Placenta prefenting to the Os externum or internum, you feel the mouth of the womb closely contracted, you must takę hold of the navel-ftring as above directed, and flide your other hand along the Funis
into the Vagina; then flowly push your fingers and thumb, joined in form of a cone, through the Os uteri, along the fame cord, to the place of its infertion in the Placenta : here let your hand reft, and feel with your fingers to what part of the Uterus the cake adheres; if it be loose at the lower edge, try to bring it along; but if it adheres, begin and separate it flowly, the back of your hand being turned to the Uterus, and the fore part of your fingers towards the Placenta: and for this operation the nails ought to be cut short and fmooth. In feparating prefs the ends of your fingers more against the Placenta than the Uterus, and if you cannot distinguish which is which, because both feel foft (though the Uterus is firmer than the Placenta, and this laft more folid than coagulated blood) I fay, in this case, flide down your fingers to its edge, and conduct them by the feparated part, preffing it gently from the Uterus, until the whole is difengaged. Sometimes, when part of it is separated, the rest will loosen and come along if you pull gently at the detached portion; but, if this is not effected with ease, let the whole
*
whole of it be separated in the most cautious manner: fometimes, alfo, by grasping the infide of the Placenta with your hand, the whole will be loofened without further trouble. As the Placenta comes along, flide down your hand and take hold of the lower edge, by which it must be extracted, because it is too bulky to be brought away altogether in a heap; and let it be delivered as whole as poffible, keeping your thumb or fingers fixed upon the navel-firing, by which means laceration is often prevented.
When the woman lies on her back, and the Placenta adheres to the left fide of the Uterus, it will be most commodious to feparate the cake with the right hand; whereas the left hand is most conveniently used when the Placenta adheres to the right fide of the womb but, when it is attached to the forepart, back, or Fundus, either hand will anfwer the purpose.
That part of the Uterus to which the Platenta adheres, is kept ftill diftended, while all the reft of it is contracted.
The nearer the adhefion is to the Os internum, the easier is the Placenta separated,
and
t
and vice verfa; because it is difficult to reach up to the Fundus, on account of the contraction of the Os internum and lower part of the womb, which are not stretched again without great force, after they have been contracted for any length of time.
When, therefore, the Placenta adheres to the Fundus, and all the lower part of the womb is strongly contracted, the hand must be forced up in form of a cone into the Vagina, and then gradually dilate the Os internum and inferior part of the Uterus. If great force is required, exert it flowly, refting between whiles, that the hand may not be cramped, nor the Vagina in danger of being tore from the womb; for in this cafe, the Vagina will lengthen confiderably upwards.
While you are thus employed, let an affiftant press with both hands on the woman's belly; or while you push with one hand, press with the other, in order to keep down the Uterus, else it will rife high up, and roll about like a large ball, below the lax parietes of the Abdomen; fo as to hinder you from effecting the neceffary dilatation.
When
-
When you have overcome this contraction, and introduced your hand into the Fundus, feparate and bring the Placenta along, as above directed; and fhould the Uterus be contracted in the middle like an hour-glass, a circumstance that fometimes, though rarely, happens, the fame method must be practised.
your
In every cafe, and especially when the Placenta hath been delivered with difficulty, introduce hand after its extraction, in order to examine if any part of the Uterus be pulled down and inverted; and if that be the cafe, push it up and reduce it without loss of time, then clear it of the coagulated blood, which otherwife may occafion vio lent after-pains.
For the most part, in ten, fifteen, or twenty minutes, more or lefs, the Placenta will come away of itself; and though some portion of it, or of the membranes, be left in the Uterus, provided no great flooding enfues, it is commonly discharged in a day or two, without any detriment to the woman: but at any rate, if poffible, all the Secundines ought to be extracted at once, and be
fore
239 fore you leave your patient, in order to avoid reflections.
I find that both amongst the ancients and moderns there have been different opinions and directions about delivering the Placenta; fome alledging, that it fhould be delivered flowly, or left to come of itself; others, that the hand fhould be immediately introduced into the Uterus, to feparate and bring it away. Before we run into extremes of either fide, it fhould be confidered how Nature of herfelf acts in thefe cafes: we find in the common course of labours, that not once in fifty or an hundred times there is any thing more to be done than to receive the child. Some of the ancients have alledged, that no danger happens on this account oftner than once in one thousand labours; and as nature is, for the moft part, fufficient of itself in fuch cafes, it is very rare, perhaps not once in twenty or thirty times, that I have occafion to leparate, as it generally comes down by the common affiftance of pulling gently at the Funis, and the efforts of the woman: I alfo find, that the mouth of the womb is as eafily dilated fome hours after delivery, as at any other
other time; fo in my opinion we ought to go in the middle way, never to affist but when we find it neceffary: on the one hand, not to torture nature when it is felf. fufficient, nor delay it too long, because it is poffible that the Placenta fhould be fometimes, though feldom, retained feveral days; for if the Uterus fhould be inflamed from any accident, and the woman be loft, the operator will be blamed for leaving the after-birth behind.
CHA P. III.
Of LABORIOUS LABOURS.
SECT. I.
How LABORIOUS LABOURS are occafioned.
IN
N the foregoing sheets, which treat of natural labours, I have defcribed the most eafy and fimple method of managing the woman, delivering the child, and extracting the Placenta; but, as it fometimes happens, that we must use extraordinary affistance for the prefervation of the woman or child, or both,
I must proceed to give directions how to behave in the laborious births, which more frequently occur than the præternatural.
A general outcry hath been raised against gentlemen of the profeffion, as if they delighted in ufing inftruments and violent methods in the courfe of their practice; and this clamour hath proceeded from the ignorance of fuch as do not know that inftruments are sometimes abfolutely neceffary, or from the interested views of fome low, obfcure, and illiterate practitioners, both male and female, who think they find their account in decrying the practice of their neighbours. It is not to be denied, that mischief has been done by inftruments in the hands' of the unfkilful and unwary, but I am perfuaded, that every judicious practitioner will do every thing for the fafety of his patients before he has recourse to any violent method either with the hand or inftrument; though cafes will occur, in which gentle methods will abfolutely fail. It is therefore neceffary to explain those reinforcements which must be used in dangerous labours; though they ought by no means to be called in, except when
R
when the life of the mother or child, or both, is evidently at ftake; and even then managed with the utmost caution: for my own part, I have always avoided them as far as I thought confiftent with the safety of my patients, and strongly inculcated the fame. maxim upon those who have fubmitted to inftructions.
my
All those cases in which the head of the child presents, and cannot be delivered in the natural way described in chap. 2. fect. 2. of this book, are accounted more or lefs laborious, according to the different circumftances from which the difficulty arises: and these commonly are, firft, Great weakness, proceeding from lofs of appetite and bad digeftion; frequent vomitings, diarrhoeas or dyfenteries, floodings, or any other disease that may exhaust the patient; as alfo the fatigue he may have undergone by unskiful treatment in the beginning of labour.
Secondly, From exceffive grief and anxiety of mind, occafioned by the unfeasonable news of fudden misfortune in time of labour; which often affect her so, as to carry off
off the pains, and endanger her finking un
der the shock.
Thirdly, From the rigidity of the Os uteri, Vagina, and external parts, which commonly happens to women in the first birth, efpecially to those who are about the age of forty: though it may be alfo owing to large callofities, produced from laceration or ulceration of the parts; or to glands and fchirrous tumours that block up the Vagina. Fourthly, From a too fmall or distorted Pelvis, which often occurs in very little women, or such as have been ricketty in their childhood.
Fifthly, From the extraordinary offification of the child's head, by which the bones of the fkull are hindered from yielding, as they are forced into the Pelvis; and form a Hydrocephalus or dropfy, diftending the head to fuch a degree, that it cannot pass along until the water is discharged.
Sixthly, From the wrong prefentation of the child's head; that is, when the forehead is towards the groin or middle of the Os pubis; when the face prefents with the chin to the Os Pubis, Ifchium, or Sacrum; when the
R 2
crown
crown of the head refts above the Os pubis, and the forehead or face is preffed into the hollow of the Sacrum; and laftly, when one of the ears presents.
Seventhly, When the under-part of the Uterus is contracted before the fhoulders, or the body intangled in the navel string.
In all these cafes, except when the Pelvis is too narrow and the head too large, provided the head lies at the upper-part of the brim, or (though preffed into the Pelvis) can be easily pushed back into the Uterus, the beft method is, to turn the child and deliver by the feet, according to the directions which fhall be given in the sequel: but, if the head is pressed into the middle or lower part of the Pelvis, and the Uterus ftrongly contracted round the child, delivery ought to be performed with the forceps; and in all the feven cafes, if the woman is in danger, and if you can neither turn nor deliver with the forceps, the head must be opened and delivered with the crotchets. Laborious cafes, from fome of the above recited caufes, happen much oftener than those we call præternatural; but, thofe which proceed from a
nar
narrow Pelvis, or a large head, are of the worft confequence. These cafes demand greater judgment in the operator than those in which the child's head does not prefent; because in these last we know, that the best and safest method is to deliver by the feet; whereas in laborious births, we must maturely confider the caufe that retards the head from coming along, together with the neceffary affiftance required; we must determine when we ought to wait patiently for the efforts of nature, and when it is abfolutely neceffary to come to her aid. If we attempt to fuccour her too foon, and use much force in the operation, fo that the child and mother, or one of the two, are loft, we will be apt to reproach ourselves for having acted prematurely, upon the fuppofition, that if we had waited a little longer, the pains might have, by degrees, delivered the child; or at least, forced the head fo low, as that we might have extracted it with more safety, by the affiftance of the forceps. On the other hand, when we leave it to nature, perhaps by the strong preffure upon the head and brain, the child is dead when delivered, and R 3
the
the woman fo exhausted with tedious labour, that her life is in imminent danger: in this cafe, we blame ourselves for delaying our help fo long, reflecting, that had we delivered the patient sooner, without paying fuch fcrupulous regard to the life of the child, the woman might have recovered without having run fuch a dangerous rifk. Doubtless it is our duty to fave both mother and child, if poffible; but, if that is impracticable, to pay our chief regard to the parent: and in all dubious cases, to act cautiously and circumfpectly, to the best of our judgment and fkill.
If the head is advanced into the Pelvis, and the Uterus ftròngly contracted round the child, great force is required to push it back into the womb, becaufe the effort must be fufficient to stretch the Uterus, so as to readmit the head, together with your hand and arm; and even then, the child will be turned with great difficulty.
Should you turn when the head is too large, you may bring down the body of the child, but the head will stick fast above, and cannot be extracted without the help of the
crotch
L
crotchets; yet the cafe is ftill worse in a narrow Pelvis, even though the head be of an ordinary fize. When things are so fituated, you should not attempt to turn, because in fo doing you may give the woman a great deal of pain, and yourself much unneceffary fatigue: you ought, therefore, to try the forceps, and if they do not fucceed, diminish the fize of the head, and extract it as fhall be afterwards fhewn.
SECT. II.
Of the FILLETS and FORCEPS.
WE have already obferved, that the
great
eft number of difficult and lingering labours proceed from the head's sticking fast in the Pelvis, which fituation is occafioned by one of the feven caufes recited above: when formerly this was the cafe, the child was generally loft, unless it could be turned and delivered by the feet; or if it could be extracted alive, either died foon after delivery, or recovered with great difficulty from the long and fevere compreffion of the head, while the life of the mother was endangered R 4 from
from the fame cause as above described: for, the preffure being reciprocal, the fibres and veffels of the foft parts contained in the Pelvis are bruifed by the child's head, and the circulation of the fluids obftructed; fo that a violent inflammation, and fometimes a fudden mortification, enfues. If the child could, not be turned, the method practised in these cafes, was, to open the head and extract with the crotchet; and this expedient produced a general clamour among the women, who obferved, that when recourfe was had to the affiftance of a man-midwife, either the mother or child, or both, were loft. This cenfure, which could not fail of being a great discouragement to male practitioners, stimulated the ingenuity of feveral gentlemen of the profeffion, in order to contrive fome gentler method of bringing along the head, so as to fave the child, without any prejudice to the mother.
Their endeavours have not been without fuccefs: a more safe and certain expedient for this purpose hath been invented, and of late, brought to greater perfection in this, than in any other kingdom; fo that if we are
4
called
called in before the child is dead, or the parts of the woman in danger of a mortification, both the Fatus and mother may frequently be happily faved. This fortunate contrivance is no other than the forceps, which was, as is alledged, firft used here by the Chamberlains, by whom it was kept as a noftrum, and after their decease, so imperfectly known, as to be feldom applied with fuccefs fo that different practitioners had recourfe to different kinds of fillets or lacks. Blunt hooks alfo of various make, covered with leather, were invented in England, France, and other parts. The forceps, fince the time of Dr. Chamberlain, have undergone feveral alterations, particularly in the joining, handles, form, and compofition.
The common way of ufing them formerly, was by introducing each blade at random, taking hold of the head any how, pulling it straight along, and delivering with downright force and violence; by which means, both Os internum and Externum were often tore, and the child's head much bruifed. On
On account of these bad confequences, they had been altogether disused by many practitioners, fome of whom endeavoured, in lieu of them, to introduce divers kinds of fillets over the child's head; but none of them can be so easily used, or have near so many advantages as the forceps, when rightly applied and conducted, according to the directions that shall be laid down in the next fection.
;
Mr. Chapman, as mentioned in the introduction, was the firft author who defcribed the forceps, with the method of using them and we find in the obfervations of Giffard, feveral cafes in which he delivered and faved the child by the affiftance of this instrument. A forceps was alfo contrived at Paris, a drawing of which may be seen in the medical effays of Edinburgh, in a paper communicated by Mr. Butter, furgeon: but after Mr. Chapman had published a delineation of his inftrument, which was that originally used by the Chamberlains, the French adopted the same species, which among them went under the denomination of Chapman's forceps. For my own part, finding in prac
tice, that by the directions of Chapman, Giffard, and Gregoire at Paris, I frequently could not move the head along without contufing it, and tearing the parts of the woman; for they direct us to introduce the blades of the forceps where they will easiest pass, and taking hold of the head in any part of it, to extract with more or lefs force, according to the refistance; I began to confider the whole in a mechanical view, and reduce the extraction of the child to the rules of moving bodies in different directions: in confequence of this plan, I more accurately surveyed the dimenfions and form of the Pelvis, together with the figure of the child's head, and the manner in which it paffed along in natural labours; and from the knowledge of these things, I not only delivered with greater cafe and safety than before, but also had the fatisfaction to find in teaching, that I could convey a more diftinct idea of the art in this mechanical light than in any other; and particularly, give more fure and folid directions for applying the forceps, even to the conviction of many old practitioners, when they
they reflected on the uncertainty attending the old method of application. From this knowledge, too, joined with experience and hints which have occured and been communicated to me, in the courfe of teaching and practice, I have been led to alter the form and dimenfions of the forceps, [as now. made by Mr. Beft, in Lombard-Street] fo as to avoid the inconveniencies that attended the use of the former kinds.
The confideration of mechanics applied to Midwifery, is likewife in no cafe more useful than when the child must be turned and delivered by the feet; because there we are principally to regard the contraction of the Uterus, the pofition of the child, and the method of moving a body confined in such a manner: but I have advanced nothing in mechanics, but what I find useful in practice, and in conveying a diftinct notion of the feveral difficulties that occur, to those who are or have been under my inftruction, for whom this treatise is principally designed.
The lacks or fillets are of different kinds, of which the most simple is a noofe made
on
1
on the end of a fillet or limber garter: but, this can only be applied, before the head is faft jammed in the Pelvis, or when it can be pushed up and raised above the brim. The Os externum and internum having been gradually dilated, this noose must be conveyed on the ends of the fingers, and flipped over the fore and hind head. There are alfo other kinds differently introduced upon various blunt inftruments, too tedious either to defcribe or use: but, the most useful of all these contrivances, is a fillet made in form of a sheath, mounted upon a piece of flender whale-bone, about two feet in length, which is easier applied than any other expedient of the fame kind.
When the head is high up in the Pelvis, if the woman has been long in labour, and the waters discharged for a confiderable time, the Uterus being strongly contracted, so as that the head and shoulders cannot be raised, or the child turned to be delivered by the feet, while the mother is enfeebled and the pains fo weak, that unless affifted, she is in danger of her life; alfo, when the Os internum, Vagina, and Labia Pudendi are inflamed and
tume.
tumefied; or, when there is a violent dif charge of blood from the Uterus, provided the Pelvis is not too narrow, nor the head too large, this fillet may be fuccessfully used; in which cafe, if the Os externum and internum are not already fufficiently open, they must be gradually dilated as much as poffible, by the hand, which at the fame. time must be introduced and paffed along the fide of the head, in order to ascertain the pofition thereof. This being known, let the other hand introduce the double of the whale-bone and fillet over the face and chin, where you can have the best purchase, and where it will be least apt to flip and lose its hold. This application being effected, let the hand be brought down, and the whale bone drawn from the fheath of the fillet, which (after the ends of it are tied together) must be pulled during every pain, preffing at the fame time with the other hand, upon the oppofite part of the head, and using more or less force, according to the resistance.
The disadvantage attending all fillets, is the difficulty in introducing and fixing them; and though this last is easier applied than the others,
others, yet when the Vertex presents, the child's chin is so preffed to the breast, that it is often impracticable to infinuate the fillet between them, and if it is fixed upon the face or hind head, it frequently flips off, in pulling: but, granting it commodiously fixed, when the head is large, or the Pelvis narrow, so that we are obliged to pull with great force, the fillet will gall, and even cut the foft parts to the very bone, and if the child comes out of a fudden, in confequence of violent pulling, the external parts of the woman, are in great danger of fudden laceration; but, if the head is small, and comes along with a moderate force, the child may be delivered by this contrivance, without any bad confequence: though in this cafe, we find by experience, that unless the woman has fome very dangerous fymptom, the head will in time, flide gradually down into the Pelvis, even when it is too large to be extracted with the fillet or forceps, and the child be safely delivered by the labour-pains, although flow and lingering, and the mother feems weak and exhaufted, provided the be fupported with nourishing and ftrengthening cordials.
1
From
From what I have faid, the reader ought not to imagine, that I am more bigotted to any one contrivance then to another: as my chief study hath been to improve the art of Midwifery, I have, confidered a great many different methods, with a view of fixing upon that which should beft fucceed in practice: I have tried several kinds of lacks, which have been from time to time recommended to me, and in particular, the laft mentioned fillet, which was communicated to me by the learned Doctor MEAD nine years ago. As this fillet could, in all appearance, be more eafily introduced than any other, I, for several years, carried it with me, when I was called in difficult cafes, and frequently used it accordingly; but, I generally found the fixing of this, as well as all other lacks, fo uncertain, that I was obliged to have recourse to the forceps, which being introduced with greater ease, and fixed with more certainty, feldom failed to answer the purpose, better than other method hitherto found out: but, let not this affertion prevent people of ingenuity from employing their talents in improving these or any other methods that may be fafe and useful for, daily experience
any
proves, that we are till imperfect and very far from the Ne plus Ultra of discovery in arts and sciences: though I hope every gentleman will despise and avoid the character of a selfish secret-monger.
As the head is forced along the Pelvis, commonly in these laborious cafes, the bones of the Cranium are fo compreffed, that they ride over one another, fo that the bulk of the whole is diminished, and the head as it is pushed forward, is from a round, altered into an oblong figure: when therefore it is advanced into the Pelvis, where it sticks fast for a confiderable time, and cannot be delivered by the labour pains, the forceps may be introduced with great cafe and fafety, like a pair of artificial hands, by which the head is very little (if at all) mark'd, and the woman very feldom tore. But, if the head is detained above the brim of the Pelvis, or a fmall portion of it only farther advanced, and it appears, that the one being too narrow, or the other too large, the woman cannot be delivered by the strongest labour pains; in that cafe, the child cannot be faved, either by turning and bringing it by the feet, or delivered by the application of fillet or for$
ceps;
ceps; but, the operator must unavoidably use
the difagreeable method of extracting with the crotchet. Nevertheless, in all these cafes, the forceps ought first to be tried, and sometimes they will fucceed beyond expectation, provided the birth is retarded by the weaknefs of the woman, and the second, third, fixth, or seventh obftructions: but, they cannot be depended upon, even when the Vertex presents, with the forehead to the fide or back part of the Pelvis, and (tho' the woman has had ftrong pains for many hours after the membranes are broke) the head is not forced down into the Pelvis, or at least, but an inconfiderable part of it, refembling the fmall end of a sugar loaf. For, from these circumstances, you may conclude, that the largest part of it is ftill above the brim, and that either the head is too large, or the Pelvis too narrow. Even in these cafes, indeed the laft fillet or a long pair of forceps may take fuch firm hold, that with great force and the ftrong purchase, the head will be delivered: but fuch violence is commonly fatal to the woman, by caufing fuch an inflammation, and perhaps laceration of the parts, as is attended with mortification. In order
•
to difable young practitioners from running fuch risks, and to free myself from the temptation of ufing too great force, I have always used and recommended the forceps fo fhort in the handles, that they cannot be used with fuch violence as will endanger the woman's life; though the purchase of them is fufficient to extract the head, when one half or two thirds of it are equal to, or past the upper or narrow part of the Pelvis. When the head is high, the forceps may be locked in the middle of the Pelvis; but, in that case, great care must be taken in feeling with the fingers all round, that no part of the Vagina be included in the locking. Sometimes, when the head rests, or is preffed too much on the fore-part or fide of the Pelvis, either at the brim or lower down, by introducing one blade, it may be moved farther down, provided the labour-pains are ftrong, and the operation affifted by the fingers of the other hand applied to the oppo→ fite fide of the head; but, if the fingers cannot reach high enough, the best method is to turn or move the blade towards the ear of the child, and introduce the other along the oppofite fide.
In a narrow Pelvis I have Pelvis I have fometimes found the head of the child thrown fo much forward over the Os pubis, by the jetting in of the Sacrum and lower Vertebra of the loins, that I could not push the handles of the forceps far enough back, to include, within the blades, the bulky part of the head which lay over the Pubes. To remedy this inconvenience, I contrived a longer pair, curved on one fide, and convex on the other but these ought never to be used except when the head is small: for, as we have aleady obferved, when the head is large, and the greatest part of it remains above the brim, the parts of the woman may be inflamed and contufed by the exertion of too much force. Nevertheless, this kind of forceps may be advantageously used when the face prefents and is low down, and the chin turned to the Sacrum; because in that cafe, the Occiput is towards the Pubes, so that the ends of the blades can take firmer hold of the head; but, then, the chin cannot be turned below the Pubes fo eafily with these as with the other kind, nor the hind
head be brought below these last bones.
SECT.
SECT. III.  ECT. 
General rules for using the FORCEPS.
261
THE farther the head is advanced in the Pelvis, the eafier is it delivered with the forceps; because, then it is changed from a round to an oblong figure, by being forced along by the labour pains: on the contrary, when the head remains high up, refting upon the brim of the Pelvis, the forceps are used with greater difficulty and uncertainty.
The Os externum must be gradually opened by introducing the fingers one after another, in form of a cone, after they have been lubricated with pomatum, moving and turning them in a femicircular motion, as they are pushed up. If the head is fo low down that the hand cannot be introduced high up in this form, let the parts be dilated by the fingers turned in the direction of the Coccyx, the back of the hand being upwards, next to the child's head: the external parts being fufficiently opened to admit all the fingers, let the back of the hand be turned to the Perineum, while the fingers and thumb being flat
1
$ 3
flattened, will slide along betwixt the head and the Os Sacrum. If the right hand be ufed, let it be turned a little to the left fide of the Pelvis, because, the broad ligament and membrane that fill up the space between the Sacrum and Ifchia, will yield and allow more room for the fingers to advance; for the fame reason, when the left hand is introduced, it must be turned a little to the right fide. Having gained your point fo far, continue to push up, until your fingers pass the Os internum; at the fame time, with the palm of your hand, raise or scoop up the head, by which means, you will be more at liberty to reach higher, dilate the internal parts, and distinguish the fituation and fize of the head, together with the dimenfions of the Pelvis: from which investigation, you will be able to judge, whether the child ought to be turned and brought by the feet, or delivered with the forceps; or, if the labour-pains are ftrong, and the head presents tolerably fair, without being jammed in the Pelvis, you will refolve to wait fome time, in hope of feeing the child delivered by the labour-pains, especially, when the woman is
in no immediate danger, and the chief obstacle is the rigidity of the parts.
The pofition of the head, is diftinguished by feeling for one of the ears, the fore or smooth part of which, is towards the face of the child; if it cannot be afcertained by this mark, the hand and fingers must be pushed farther up, to feel for the face or back part of the neck; but, if the head cannot be traced, the observation must be taken from the Fontanelle, or that part of the Cranium where the lambdoidal croffes the end of the Sagittal future. When the ears of the child are towards the fides of the Pelvis, or diagonal,' the forehead being either to the Sacrum or Púbes, the patient muft lie on her back, with her breech a little over the bed, her legs and thighs being fupported as directed in chap. 2. fect. 1. and chap. 4. fect. 4. If one ear is to the Sacrum, and the other to the Pubes, she must be laid on one fide, with her breech over the bed, as before, her knees being pulled up to her belly, and a pillow placed between them except when the upper part of the Sacrum jets too much forward, in which cafe, the must lie upon her back, as above defcribed. S 4
;
The
The blades of the forceps ought always, if poffible, to be introduced along the ears; by which means, they approach nearer to each other, gain a firmer hold, and hurt the head less than in any other direction: frequently, indeed, not the leaft mark of their application, is to be perceived; whereas, if the blades are applied along the forehead and Occiput, they are at a greater distance from each other, require more room, frequently at their points prefs in the bones of the skull, and endanger a laceration in the O's externum of the woman.
The woman being laid in a right pofition for the application of the forceps, the blades ought to be privately conveyed between the feather-bed and the cloaths, at a small diftance from one another, or on each fide of the patient that this conveyance may be the more eafily effected, the legs of the inftrument ought to be kept in the operator's fidepockets. Thus provided, when he fits down to deliver, let him fpread the fheet that hangs over the bed, upon his lap, and under that cover, take out and dispose the blades on each fide of the patient; by which means,
he
SC
he will often be able to deliver with the forceps, without their being perceived by the woman herself, or any other of the affiftants. Some people pin a fheet to each shoulder, and throw the other end over the bed, that they may be the more effectually concealed. from the view of those who are prefent: but this method is apt to confine and embarrass the operator. At any rate, as women are commonly frightened at the very name of an inftrument, it is adviseable to conceal them as much as poffible, until the character of the operator is fully established.
SECT. IV.
The different ways of ufing the FORCEPS.
NUMB. I. When the Head is down to the Os externum.
WHEN the head prefents fair, with the forehead to the Sacrum, the Occiput to the Pubes, and the ears to the fides of the Pelvis, or a little diagonal; in this cafe, the head is commonly pretty well advanced in the bafin, and the operator seldom miscarries
in
in the use of the forceps. Things being thus fituated, let the patient be laid on her back, her head and shoulders being fomewhat raifed, and the breech advanced a little over the fide or foot of the bed; while the affiftants fitting on each side, fupport her legs, at the fame time, keeping her knees duly separated and raised up to the belly, and her lower parts always covered with the bed-cloaths, that she may not be apt to catch cold. In order to avoid this inconvenience, if the bed is at a great distance from the fire, the weather cold, and the woman of a delicate constitution, a chafing-dish with charcoal, or a veffel with warm water, fhould be placed near, or under the bed. Thefe precautions being taken, let the operator place himself upon a low chair, and having lubricated with pomatum, the blades of the forceps, and alfo his right hand and fingers, flide first the hand gently into the Vagina, pushing it along in a flattened form, between that and the child's head, until the fingers have paffed the Os internum; then, with his other hand, let him take one of the blades of the forceps from the place where it was depofited, and intro
duce
duce it betwixt his right hand and the head; if the point or extremity of it, should stick at the ear, let it be flipt backward a little, and then guided forwards with a flow and delicate motion: when it fhall have paffed the Os uteri, let it be advanced ftill farther up, until the reft at which the blades lock into each other, be close to the lower part of the head, or at least within an inch thereof.
1
Having in this manner, introduced one blade, let him withdraw his right hand, and infinuate his left in the fame direction, along the other fide of the head, until his fingers fhall have paffed the Os internum; then taking out the other blade from the place of concealment, with the hand that is difengaged, let it be applied to the other fide of the child's head, by the fame means employed in introducing the firft: then, the left hand must be withdrawn, and the head being embraced between the blades, let them be locked in each other, and the handles firmly fastened together, with a fillet or garter. Having thus fecured them, he must take a firm hold with both hands, and when the pain comes on, begin to pull the head along from fide to
7
fide, continuing this operation during every pain, until the Vertex appears through the Os externum, and the neck of the child can be felt with the finger, below the Os pubis; at which time, the forehead pushes out the Perinæum like a large tumour: then let him ftand up, and raifing the handles of the for ceps, pull the head upwards also, that the forehead being turned half round upwards, the Perinæum and lower parts of the Os externum may not be tore.
In ftretching the Os externum or internum we ought to imitate nature; for, in practice we find, that when they are opened flowly, and at intervals, by the membranes with the waters, or the child's head, the parts are feldom inflamed or lacerated: but, in all natural labours, when these parts are fuddenly opened, and the child delivered by strong and violent pains, without much intermiffion, this misfortune commonly happens, and the woman is afterwards in great pain and danger.
We ought, therefore, when obliged to dilate those parts, to proceed in that flow, deliberate manner; and though upon the first
trial, they feel fo rigid, that one would imagine they could never yield or extend; yet, by ftretching with the hand, and refting by intervals, we can overcome the greatest resistance. We must also, in fuch cafes, be very cautious, pulling flowly, with intermiffions, in order to prevent the fame laceration: for which purpose too, we ought to lubricate the Perinæum with pomatum, during those fhort intervals, and keep the palm of one hand, close prefs'd to it, and the neighbouring parts, while with the other, we pull at the extremity of the handles of the forceps; by which means, we preferve the parts, and know how much we may venture to pull at a time. When the head is almost delivered, the parts thus ftretched, must be flipped over the forehead and face of the child, while the operator pulls upwards with the other hand, turning the handles of the forceps to the body of the woman. This method of pulling upwards, raifes the child's head from the Perinæum, and the half-round turn to the Abdomen of the mother, brings out the forehead and face from below: for, when that part of the hindhead which is joined to the neck,
neck, refts at the under-part of the Os pubis, the head turns upon it, as upon an axis. In præternatural cafes alfo, the body being de livered, must in the fame manner, be raised up over the belly of the mother; and at the fame time, the Perinæum flipt over the face and forehead of the child.
In the introduction of the forceps, let each blade be pushed up in an imaginary line from the Os externum, to the middle space betwixt the navel, and Scrobiculus cordis of the woman; or, in other words, held as far back as the Perinæum will allow. The introduction of the other hand to the oppofite fide, will, by preffing the child's head against the first blade, detain it in its proper place till the other can be applied; or, if this preffure fhould not feem fufficient, it
may
be
fupported by the operator's knee.
NUMB. II.
When higher in the Pelvis.
When the head prefents, but remains very high, the forehead being at or above the upper-part of the Sacrum, and on account of the narrowness of the Pelvis at that part,
cannot be brought along at the firft or fecond trial, let the operator turn the forehead a little on one fide; but, if it is fo fixed in the Pelvis, as not to be moved in that manner, let him try to push the head above the brim with the forceps, and then turn it to one fide, in order to profit by the width of the bafin, which, in this place, is commonly about one inch greater from fide to fide, than from the fore to the back-part: this being done, let him pull along, until the head arrives at the lower part of the Pelvis, then turn the forehead into the hollow of the Sacrum, and the Vertex in below the Os pubis, and deliver with an half-round turn, as above directed.
When the head is come low down, and cannot be brought farther, because one of the shoulders refts above the Os pubis, and the other upon the upper-part of the Sacrum, let the head be ftrongly grafped with the forceps, and pufhed up as far as poffible, moving from blade to blade as you push up, that the shoulders may be the more eafily moved to the fides of the Pelvis, by turning the face or forehead a little towards one of them; then, the forehead must be brought back
back again into the hollow of the Sacrum, and another effort made to deliver: but, should the difficulty remain, let the head be pushed up again, and turned to the other fide; because, it is uncertain which of the fhoulders refts on the Os Pubis or Sacrum. fuppofe, for example, the right shoulder of the child sticks above the Os Pubis, the forehead being in the hollow of the Sacrum; in this cafe, if the forehead be turned to the right-hand fide of the woman, the shoulder will not move; whereas, if it be turned to the left, and the head at the fame time pushed a little upwards, fo as to raise and difengage the parts that were fixed, the right fhoulder being towards the right-hand fide, and the other to the left fide of the brim of the Pelvis, when the forehead is turned back
again into the hollow of the Sacrum, the obftacle will be removed, and the head be more easily delivered. This being performed, let the forceps be unlocked, and the blades difpofed cautiously under the cloaths, fo as not to be difcovered; then proceed to the delivery of the child, which, when the navel-string is cut and tied, may be commit
ted
ted to the nurse. The next care is, to wipe the blades of the forceps, fingly, under the cloaths, flide them warily into your pockets, and deliver the Placenta.
Though the forceps are covered with leather, and appear fo fimple and innocent, I have given directions for concealing them, that young practitioners, before their characters are fully established, may avoid the calumnies and mifreprefentations of those people who are apt to prejudice the ignorant and weak-minded against the use of any inftrument, though never fo neceffary, in this profeffion; and who, taking the advantage unforeseen accidents which may afterwards happen to the patient, charge the whole miffortune to the innocent operator.
NUM B. III.
When the forehead is to the Os pubis. WHEN the forehead, inftead of being towards the Sacrum, is turned forwards to the Os pubis, the woman must be laid in the fame pofition as in the former cafe; becaufe, here alfo, the ears of the child are towards the fides of the Pelvis, or a little diagonally T fituated,
fituated, provided the forehead is towards one of the groins. The blades of the forceps being introduced along the ears, or as near them as poffible, according to the foregoing directions, the head must be pushed up a little, and the forehead turned to one fide of the Pelvis; thus let it be brought along, until the hindhead arrives at the lower part of the Ifchium: then the forehead must be turned backward, into the hollow of the Sa-. crum, and even a quarter or more to the contrary fide, in order to prevent the shoulders from hitching on the upper part of the Os pubis or Sacrum, fo that they may be still towards the fides of the Pelvis; then let the quarter turn be reverfed, and the forehead being re-placed in the hollow of the Sacrum, the head may be extracted as above. In performing thefe different turns, let the head be pushed up or pulled down occafionally, as it meets with leaft refiftance. In this cafe, when the head is fmall, it will come along as it prefents; but, if large, the chin will be fo much preffed against the breast, that it cannot be brought up with the halfround turn, and the woman will be tore if it comes along.
NUMB.
NUM B. IV.
When it prefents fair at the brim of the
PELVIS.
;
WHEN the forehead and face of the child are turned to the fide of the Pelvis, (in which cafe it is higher than in the firft fituation) it will be difficult, if the woman lies on her back, to introduce the forceps fo as to grasp the head with a blade over each ear because, the head is often preffed fo hard against the bones, in this pofition, that there is no room to infinuate the fingers between the ear and the Os pubis, fo as to introduce the blades fafely, on the infide of the Os internum, or push one of them up between the fingers and the child's head. When things are fo fituated, the best posture for the woman, is that of lying on one fide, as formerly directed, because the bones will yield a little, and the forceps (of confequence) may be the more easily introduced.
Suppofe her lying on her left fide, and the forehead of the child turned to the fame fide of the Pelvis; let the fingers of the operator's right hand be introduced along the
T 2
ear,
ear, between the head and the Os pubis, until they pass the Os internum: If the head is fo immoveably fixed in the Pelvis, that there is no paffage between them, let his left hand be pushed up between the Sacrum and the child's head, which being raised as high as poffible, above the brim of the Pelvis, he will have room fufficient for his fingers and forceps; then let him flide up one of the blades, with the right hand, remembering to press the handle backwards to the Perinæum, that the point may humour the turn of the Sacrum and child's head: this being effected, let him withdraw his left hand, with which he may hold the handle of the blade already introduced, while he infinuates the fingers of his right hand at the Os pubis, as before directed, and pushes up the other blade, flowly and gently, that he may run no risk of hurting the Os internum or bladder; and here also keep the handle of it as far backwards, as the Perinæum will allow: when the point has paffed the Os internum, let him flide it up farther, and join the legs by locking them together, keeping them still in a line with the middle space betwixt the
navel and Scrobiculus cordis. Having tied the handles as before directed, let him pull along the head, moving it from fide to fide, or from one ear of the child to the other when it is fufficiently advanced, let him move the forehead into the hollow of the Sacrum, and a quarter turn farther, then bring it back into the fame cavity; but, if the head will not eafily come along, let the woman be turned on her back after the forceps have been fixed; let the hind head be pulled half round outwards, from below the Os pubis, and the inftrument and child ma naged as before.
In all thofe cafes that require the forceps, if the head cannot be raised above the brim of the Pelvis, or the fingers introduced. within the Os internum, to guide the points. of the forceps along the ears, especially at the Offa pubis, Ifchia or Sacrum; let the fingers and hand be pufhed up as far as they will go, along the open space betwixt the Sacrum and Ifchium; then, one of the blades may be introduced, moved to, and fixed over the ear, the fituation of which is already known; the other hand may be introduced, and the T 3 other
other blade conducted in the fame manner, on the opposite fide of the Pelvis; but, before they are locked together, care must be taken that they are exactly oppofite to each other, and both fufficiently introduced. In this cafe, if the operator finds the upper part of the Sacrum, jetting in fo much, that the point of the forceps cannot pafs it, let him try with his hand to turn the forehead a little backwards, fo that one ear will be towards the groin, and the other towards the fide of that prominence; confequently, there will be more room for the blades to pafs along the ears but, if the forehead should remain immoveable, or though moved, return to its former place, let one blade be introduced behind one ear, and its fellow before the other, in which cafe, the introduction is fometimes more cafily performed when the woman lies on her back, than when she is laid on one fide,
NUMB. V.
When the FACE prefents.
WHEN the face prefents, refting on the upper part of the Pelvis, the head ought to
be
f
be pushed up to the Fundus uteri, the child turned and brought by the feet, according to the directions that will be given, when we come to treat of præternatural deliveries; be caufe, the hind head is turned back on the fhoulders, and unlefs very fmall, cannot be pulled along with the forceps; but should it advance pretty faft in the Pelvis, it will be fometimes delivered alive, without any affift ance. But, if it defcends flowly, or after it is low down, fticks for a confiderable time, the long preffure on the brain, frequently destroys the child, if not relieved in time, by turning or extracting with the forceps.
When the head is detained very high up, and no figns of its defcending, appear, and the operator having ftretched the parts with a view to turn, difcovers that the Pelvis is narrow, and the head large, he must not proceed with turning, becaufe after this hath been performed, perhaps with great difficulty, the head cannot be delivered without the affiftance of the crotchet. No doubt, it would be a great advantage in all cafes where the face or forehead prefents, if we could raise the head fo as to alter the bad pofition, and I 4
1
1
move
move it fo, with our hand, as to bring the crown of the head to prefent; and indeed, this should always be tried, and more especially, when the Pelvis is too narrow, or the head too large; and when we are dubious of faving the child by turning: but, frequently, this is impoffible to be done, when the waters are evacuated, the Uterus strongly contracted on the child, and the upper part of the head fo flippery as to elude our hoid ; infomuch, that even when the preffure is not great, we feldom fucceed, unless the head is small, and then we can save the child by turning. If you fucceed, and the woman is ftrong, go on as in natural labour; but, if this fails, then it will be more adviseable to wait with patience for the descent of the head, fo as that it may be delivered with the farceps; and confequently the child may be faved; but, if it still remains in its high fitu ation, and the woman is weak and exhaufted, the forceps may be tried; and should they fail, recourse must be had to the crotchet; because the mother's life is always to be more regarded than the fafety of the child.
When
When the face of the child is come down, and sticks at the Os externum, the greatest part of the head is then squeezed down into the Pelvis, and if not speedily delivered, the child is frequently loft by the violent compreffion of the brain: befides, when it is fo low down, it feldom can be returned, on account of the great contraction of the Uterus. In this cafe, when the chin is turned towards the Os pubis, at the lower part of that bone, the woman must be laid on her back, the forceps introduced as formerly directed in the first case, and when the chin is brought out from under the Os pubis, the head must be pulled half round upwards; by which means, the fore and hind head will be raised from the Perinæum, and the under part of the Os externum prevented from being tore.
When the chin is towards the Sacrum, the hindhead preffed back betwixt the shoulders, fo that the face is kept from rifing up below the Os pubis, the head must be pushed up with the hand, to the upper part of the Pelvis, and the forceps introduced and fixed on the ears; the hindhead must be turned to one fide of the Pelvis, while the
chin is moved to the other fide, and if poffible, to the lower part of the Ifchium; then the hindhead must be brought into the hollow of the Sacrum, with the chin below the Os pubis, and delivered as above directed. If this cannot be done, let the operator try, with the forceps, to pull down the hindhead below the Os pubis, and at the fame time, with the fingers of the other hand, push the face and forehead, backwards and upwards into the hollow of the Sacrum. If the chin points to either fide of the Pelvis, the woman muft be laid on her fide, the blades of the forceps introduced along the ears, one at the Os pubis, and the other at the Sacrum; and the chin, when brought lower down, turned to the Pubes, and delivered; for, the Pelvis being only two inches in depth, at this place, the chin is easily brought from under it, and then the head is at liberty to be turned half round upwards; because, the chin being difengaged from this bone, can be pulled up over it externally; by which means, two inches of room, at least, will be gained, for the more easy delivery of the fore and hindhead, which are now preffed against the Perinæum.
But,
But, if the chin points to the back part of the Pelvis, the forehead is fqueezed against the Os pubis, while the hindhead is preffed upon the back, betwixt the fhoulders; so that the head cannot be delivered, unless the Occiput can be brought out from below the Os pubis, as formerly described.
The fum of all that has been faid on this head, may be comprehended in the following general maxims.
Young practitioners are often at a lofs to know and judge by the touch in the Vagina, when the head is far enough down in the bafin, for ufing the forceps. If we were to take our observations from what we feel of the head, at the Os pubis, we fhould be frequently deceived, because, in that place the Pelvis is only two inches in depth, and the head will feem lower down than it really is: but, if in examining backwards, we find little or no part of it towards the Sacrum, we may be certain, that all the head is above the brim: if we find it down as far as the middle of the Sacrum, one third of it is ad-' vanced; if, as far down as the lower part, one half; and in this cafe, the largest part is equal with the brim. When it is in this fi
tuation,
tuation, we may be almoft certain of fucceeding with the forceps; and when the head is fo low as to protrude the external parts, they never fail. But these things will differ according to different circumstances, that may occafion a tedious delivery.
Let the operator acquire an accurate knowledge of the figure, fhape, and dimensions of the Pelvis, together with the fhape, fize and pofition of the child's head.
Let the breech of the woman be always, brought forewards, a little over the bed, and her thighs pulled up to her belly, whether fhe lies on her fide or back, to give room to apply, and to move the forceps up or down, or from fide to fide.
Let the parts be opened and the fingers pafs the Os internum; in order to which, if it cannot be otherwise accomplished, let the head be raised two or three inches, that the fingers may have more room; if the head can be raised above the brim, your hand is not confined by the bones: for, as we have already obferved, the Pelvis is wider from fide to fide, at the brim, than at the lower part if the fingers are not paft the Os uteri,
it is in danger of being included betwixt the forceps and the child's head.
The forceps, if poffible, should pass along the ears, because, in that cafe, they seldom or never hurt or mark the head.
They ought to be, pushed up in an imaginary line, towards the middle space between the navel and Scrobiculus cordis, otherwise, the ends will run against the Sa
crum.
The forehead ought always to be turned into the hollow of the Sacrum, when it is not already in that fituation.
When the face prefents, the chin must be turned to below the O's pubis, and the hindhead into the hollow of the Sacrum.
When the fhoulders reft at the Pubes, where they are detained, the head must be turned a large quarter to the oppofite fide, fo as that they may lie towards the fides of the Pelvis.
The head must always be brought out with an half round turn, over the outfide of the Os pubis, for the prefervation of the Perinaum, which muft, at the fame time, be supported
ported with the flat of the other hand, and flid gently backwards over the head.
When the head is fo low as to protrude the parts, in form of a large tumour, and the Vertex hath begun to dilate the Os externum, but instead of advancing, is long detained in that fituation, from any of the forementioned causes of laborious cafes, and the operator cannot exactly distinguish the position of the head, let him introduce a finger between the Os pubis and the head, and he will frequently find the back part of the neck, or one ear,
1
at the fore-part, or towards the fide of the Pelvis: when the fituation is known, he needs, not stretch the Os externum, and raise the head, as formerly directed; but he may introduce the forceps, and they being properly joined, and their handles tied, pull gently during every pain; or if the pains are gone, at the interval of four or five minutes, that the parts may be flowly dilated, as they are in the natural labour: but, when the fituation cannot be known, the head ought to be raifed. The fame method may also be taken when the face presents, and is low in the Pelvis, except when the chin is toward the back
part:
part in this cafe the head ought to be raifed likewife.
Almost all thefe directions are to be followed, except when the head is small, in which cafe it may be brought along by the force of pulling: but, this only happens when the woman is reduced, and the labourpains are not fufficient to deliver the child ; for, the lower part of the Uterus may be fo ftrongly contracted before the fhoulders, and fo close to the neck of the child, as to prevent its advancing, even when the head is for loofe in the Pelvis, that we can sometimes push our fingers all round it: and this is oftneft the occafion of preventing the head's being delivered when low in the Pelvis. The difficulty, when high up, is from the reftraint at the brim, and when it paffes that, the head is féldom retained in the lower part, unless the patient is weak. In this cafe, we need not wait, because we are com. monly certain of relieving the woman immediately, with the forceps, by which you prevent the danger that may happen both to the mother and child, by the head's continuing to lodge there too long. This cafe fhould
4
fhould be a caution against breaking the membranes too foon, because the Uterus may contract too forcibly and too long before the fhoulders; when the head in this cafe is advanced one third or half way on the outfide of the Os externum, if the pains are strong, this laft inconvenience is frequently remedied by introducing your two fingers into the Rectum, as formerly directed: by these rules, delivery may (for the most part) be performed with eafe and fafety: nevertheless, the head is fometimes fofqueezed and locked in the Pelvis, and the hairy scalp so much swelled, that it is impracticable to raise up the head, fo as to come at the ears or Os internum; or to distinguish the futures of the skull, fo as to know how the head prefents. In this cafe, the forceps must be introduced at random, and the uncertainty of the position, generally removed by remembring, that in thofe cafes, where the head is fqueezed down with great difficulty, the ears are for the most part, towards the Os pubis and Sacrum; and that the forehead seldom turns into the hollow of the Sacrum, before the Occiput is come down to the lower part of the Ichium; and then rifes gradually towards
3.
wards the under part of the Os pubis, and the Perineum and Anus are forced down before it, in form of a large tumour.
On fuch occafions, the woman being laid on her fide, if one ear is to the Sacrum and the other to the Os pubis, the blades of the forceps are to be introduced; and if they meet with any resistance at the points, they muft not be forcibly thruft up, left they pafs on the outfide of the Os uteri, and tear the Vagina, which, together with the womb, would be included in the inftrument, and pulled along with the head: for this reafon, if the blade does not eafily pafs, let it be withdrawn a little downwards, as before directed, and pushed up again, moving the point close to the head; if the ear obstructs its paffage, let the point be brought a little outwards and by thefe cautious effays, it will at length pass without further resistance, and ought to be advanced a confiderable way, in order to certify the operator that he is not on the outside of the Os internum.
1
When the forceps are fixed, and the ope rator uncertain which way the forehead lies, let him pull flowly, and move the head with
a quarter turn, firft to one fide and then to the other, until he fhall have found the direction in which it comes moft eafily along.
:
If at any time we find the forceps begin to flip, we must reft, and push them up again gently but, if they are like to slide off at a fide, untie the handles, and move them fo as to take a firmer hold, fix as before, and deliver. If we are obliged to hold with both hands, the parts may be fupported by the firm application of an affiftant's hand; for, without fuch cautious management, they will run a great risk of being lacerated: a misfortune which rarely happens, when the Perinæum is properly preffed back, and the head leifurely delivered. Sometimes, when the head is brought low down, you may take off the forceps, and help along with your fingers on each fide of the Coccyx, or in the Rectum, as directed in the natural labour.
If the head is low down, the ears are commonly diagonal, or to the fides; and when the head is brought down one third, or one half, through the Os externum, the operator can then certify himself, whether the forehead is turned to the Coccyx or Os pubis, by feeling with his
Rules for ufing the CROTCHET. 291 finger for the back-part of the neck or ear, betwixt the Os pubis and the head; and then move the head as above directed.
Let him try to alter with his hand, every bad pofition of the head; and if it be detained high up in the Pelvis, in confequence of the woman's weaknefs, the rigidity of the parts, the circumvolutions or fhortnefs of the Funis, or the contraction of the Uterus over the fhoulders of the child, the forceps will Frequently fucceed when the Fatus cannot be turned but, if the head is large, or the Pelvis narrow, the child is feldom faved either by turning or urfing the forceps, until the head fhall be farther advanced. And here it will not be amifs to obferve, that the blades of the forceps ought to be new cov ed with ftripes of washed leather, after they shall have been used, efpecially in delivering a woman fufpected of having an infectious distemper.
Cover
SECT. V.
When and how to use the CROTCHET.       NUMB. I. 
WHEN the head prefents, and cannot be delivered by the labour-poins; when all the common methods have been used U 2 with
without fuccefs, the woman being exhausted, and all her efforts vain; and when the child cannot be delivered without fuch force as will endanger the life of the mother, because the head is too large or the Pelvis too narorw; it then becomes abfolutely necessary to open the head, and extract with the hand, forceps, or crotchet. Indeed, this last method formerly was the common practice when the child could not be eafily turned, and is ftill in ufe with those who do not know how to fave the child by delivering with the forceps for this reafon, their chief care and study was to diftinguish, whether the Fatus was dead or alive; and as the figns were uncertain, the operation was often delayed until the woman was in the most imminent danger; or when it was performed fooner, the operator was frequently accused of rafhness, on the fuppofition, that the child might in time have been delivered alive by the labour-pains: perhaps he was fometimes conscious to himself of the juftice of this imputation, although what he had done was with an upright intention.
The figns of a dead Fetus were, first, the child's ceafing to move and stir in the Uterus. Secondly, The evacuation of meconium, though the breech is not preffed into the Pelvis. Thirdly, No perceiveable pulfation at the Fontanelle and temporal arteries. Fourthly, a large fwelling or tumour of the hairy scalp. Fifthly, An uncommon laxity of the bones of the Cranium. Sixthly, The discharge of a fœtid Ichor from the Vagina, the effluvia of which furround the woman, and gave rife to the opinion, that her breath conveyed a mortified smell. Seventhly, Want of motion in the tongue, when the face prefents. Eighthly, No perceivable pulfation in the arteries of the Funis umbilicalis, when it falls down below the head; nor at the wrift when the arm prefents; and no motion of the fingers. Ninthly, The pale and livid countenance of the woman. Tenthly, A collapfing and flaccidity of the breasts. Eleventhly, A coldness felt in the Abdomen, and weight, from the child's falling like a heavy ball to the fide on which the lies. Twelfthly, A feparation of the hairy fcalp
on the flightest touch, and a diftinct percep- tion of the bare bones.
All or most of these figns are dubious and uncertain, except the laft, which can only be obferved after the Fatus hath been dead feveral days. One may alfo certainly pronounce the child's death, if no pulfation hath been felt in the navel-ftring for the space of twenty or thirty minutes; but the fame certainty is not to be acquired from the arm, unless the skin can be ftripped off with ease.
NUMB. II.
MIDWIFERY is now fo much improved, that the neceffity of deftroying the child does not occur fo often as formerly; indeed it never should be done, except when it is impoffible to turn, or to deliver with the forceps; and this is feldom the cafe, but when the Pelvis is too narrow, or the head too large to pafs, and therefore refts above the brim for this reafon, it is not fo neceffary for the operator to puzzle hinself about dubious figns; because in these two cafes, there is no room for hefitation: for if the woman cannot poffibly be delivered in any other way,
way,
and is in imminent danger of her life, the best practice is undoubtedly to have recourse to that method which alone can be ufed for her preservation, namely, To diminish the bulk of the head.
SECT.
VI.
The old method of extracting the HEAD.
VARIOUS have been the contrivances intended for this purpose: fome practitioners, when the head did not advance in the Pelvis, introduced the Speculum matricis, in order to stretch the bones afunder, and thereby increase the capacity of the bafin: if, after this operation, the woman could not be delivered with her pains, they fixed a large screw in the head, by which they pulled with great force. Others, opened the head with a large bistory, or a fhort broadbladed knife, in form of a myrtle leaf; or with a crooked biftory, with a long handle; then a small pair of forceps with teeth were introduced, and one blade being infinuated into the opening, they laid hold on the skull, and pulled the head along. If this method U A
failed,
failed, according to Albucafis, they used another kind much larger, to grafp the whole head: they, likewise, made use of different kinds of crotchets, both fharp and blunt; and when the head was lower down, they practised the fame expedients, together with circular extractors.
Albucafis has alfo given the draught of an inftrument, which is both for opening and extracting the head; the point and wings are forced through the Cranium, and, when turned the contrary way, the two wings or hooks take hold of the inside.
There are other later contrivances used and recommended by different gentlemen of the profeffion, fuch as Mauriceau's tiretête, Simpson's fcalp-ring, and Old's Terebra occulta, with the improvement made in it, by Dr. Burton of York: and all these inftruments may be used with success if cautiously managed, fo as not to injure the woman, except the Speculum matricis, which far from answering the supposed intention of it, namely, to extend the bones of the Pelvis, can ferve no other purpose than that of bruifing or inflaming the parts of the woman.
The
The following method, if exactly followed according to the circumftances of the cafe, feems, of all others hitherto invented, the eafieft, fafeft and moft certain; efpecially when it requires great force to extract the head.
SECT. V.
The method of extracting with the CROTCHET.
WHEN the head presents, and such is
the cafe, that the child can neither be delivered by turning, nor extracted with the forceps, and it is abfolutely neceffary to deliver the woman to fave her life, this operation must then be performed in the following manner.
The operator must be provided with a pair of curved crotchets, made according to the improvements upon thofe proposed by Mefnard, together with a pair of fciffars about nine inches long, with refts near the middle of the blades, and the blunt hook.
NUMB. I.
Of the Woman's Pofture.
The patient ought to be laid on her back in the fame pofition directed in the use of the forceps; the operator must be seated on a low chair, and the inftruments concealed and difpofed in the fame manner, and for the fame reason, mentioned in treating of the forceps. The parts of the woman have already, in all likelihood, been fufficiently dilated by his endeavours to turn or deliver with the forceps; or if no efforts of that kind have been used, because by the touch he had learned that no fuch endeavours would fucceed, as in the case of a large hydrocephalus, when the bones of the Cranium are often separated at a great distance from each other; or, upon perceiving that the Pelvis was extremely narrow: If, upon these confiderations, he hath made no trials in which the parts were opened, let him gradually dilate the Os externum and internum, as formerly directed.
NUMB.
NUM B. II.
THE head is commonly kept down pretty firm, by the ftrong contraction of the Uterus round the child; but fhould it yield to one fide, let it be kept steady by the hand of an affiftant, preffing upon the belly of the woman; let him introduce his hand, and prefs two fingers against one of the futures of the Cranium; then take out his fciffars from the place in which they were deposited, and guiding them by the hand and fingers till they reach the hairy fcalp, pufh them gradually into it, until their progrefs is stopped by the rests.
If the head flips afide, in fuch a manner, as that they cannot be pushed into the skull at the future, they will make their way. through the folid bones if they are moved in a femicircular turn, like the motion of boring, and this method continued till you find the point firmly fixed; for, if this is not obferved, the points flide along the bones.
The fciffars ought to be fo fharp at the points, as to penetrate the integuments and bones when pushed with a moderate force
;
but not fo keen as to cut the operator's fingers, or the Vagina, in introducing them.
The fciffars being thus forced into the brain, as far as the refts at the middle of the blades, let them be kept firm in that fituation; and the hand that was in the vagina being withdrawn, the operator must take hold of the handles with each hand, and pull them asunder, that the blades may dilate and make a large opening in the skull; then they must be shut, turned, and again pulled afunder, fo as to make the incifion crucial; by which means the opening will be enlarged and fufficient room made for the introduction of the fingers: let them be afterwards closed, and introduced even beyond the refts, when they must again be opened, and turned half round from fide to fide, until the ftructure of the brain is fo effectually deftroyed, that it can be evacuated with ease. This operation being performed, let the fciffars be fhut and withdrawn; but, if this inftrument will not anfwer the laft purpose, the business may be done by introducing the crotchet within the opening of the skull. The brain being thus de
destroyed, and the inftrument withdrawn, let him introduce his right hand into the Vagina, and two fingers into the opening which hath been made, that if any fharp fplinters of the bones remain, they may be broken off and taken out, left they should injure the woman's Vagina, or the operator's own fingers.
NUMB. III.
In the cafe be an hydrocephalus, let him fix his fingers on the infide and his thumb on the outfide of the opening, and endeavour to pull along the fkull in time of a pain; but, if labour is weak, he must desire the woman to affift his endeavours by forcing down; and thus the child is frequently delivered; because, the water being evacuated, the head collapses of course.
NUM B. IV.
BUT when the Pelvis is narrow, the head requires much greater force to be brought along; unless the labour pains are ftrong enough to prefs it down and diminifh it, by fqueezing out the Cerebrum: in
this cafe, let the operator withdraw his fingers from the opening, and flide them along the head, paft the Os uteri, then, with his left hand, taking one of the crotchets from the place of its concealment, introduce it along his right hand, with the point towards the child's head, and fix it above the chin in the mouth, back part of the neck, or above the ears, or in any place where it will take firm hold; having fixed the instrument, let him withdraw his right hand, and with it, take hold on the end or handle, of the crotchet, then introduce his left to feize the bones at the opening of the fkull (as above directed) that the head may be kept steady, and pull along with both hands.
If the head is ftill detained by the uncommon narrowness of the Pelvis, let him introduce his left hand along the oppofite fide, in order to guide the other crotchet, which being alfo applied and locked or joined with its fellow, in the manner of the forceps, he muft pull with fufficient force, moving from fide to fide, and if the head does not prefent fair, turn the forehead into the hollow of the Sacrum, and extract as with the forceps,
ceps, humouring the fhape of the head and Pelvis, during the operation, which ought to be performed flowly, with great judgment and caution; and from hence it appears abfolutely neceffary to know how the head prefents, in order to judge how the crotchet must be fixed, and the head brought along to the beft advantage.
Sometimes, in thefe cafes, when I find, that I cannot fucceed by pulling at the opening with my fingers; and if the woman has not had strong pains, I introduce the small end of the blunt hook into the opening, and placing my fingers against the point on the outfide of the fkull, pull with greater and greater force; but, as we can feldom take a firm hold in this manner, if it does not foon answer the purpose, I introduce my fingers as above, farther, and flide the point up along the outfide, above the under jaw; and have fucceeded feveral times, with this inftrument, except when the Pelvis was fo narrow as to require a greater force; then we muft ufe the others. No doubt, it is better firft to try the blunt hook, because the managing the point gives lefs trouble,
trouble, and it can be eafier introduced with the point to one fide. When the inftrument is far enough advanced, this point may be turned to the head, and as a very narrow Pelvis feldom occurs, the blunt hook will commonly fucceed.
I
If, when the head is delivered in this manner, the body cannot be extracted, on account of its being much fwelled, of a monftrous fize, or (which is most common-. ly the cafe) the narrowness of the Pelvis ; let him defist from pulling, left the head should be separated from the body, and introducing one hand fo as to reach with his fingers to the shoulder blades or breast, conduct along it, one of the crotchets, with the point towards the Fatus, and fix it with a firm application; then, withdrawing his hand, employ it in pulling the crotchet, while the other is exerted in the fame manner, upon the head and neck of the child: if the inftrument begins to lofe its hold, he must push it farther up, and fixing it again, repeat his efforts, applying it ftill higher and higher, until the body is extracted.
Some
Some writers direct us to introduce the crotchet within the fkull, and preffing one hand against the point on the outfide, pull along: but this is a trifling expedient, and if a good deal of force is ufed, the inftrument tears through the thin bones, and hurts the operator's hand or the woman's Vagina, if not both. Whereas, in the other method, there is much more certainty, and a better purchase to force along the head, which collapfes, and is diminished as the brain is discharged, and never comes down in a broad fattened form, according to the allegations of fome people, whose ideas of these things are imperfect and confufed: for, if this were the cafe, the fame would happen when the head is forced down from behind with labour pains, into a narrow Pelvis, because the preffure in both cafes, acts in the fame direction, whereas, we always find both in the one and the other, that the Vertex is protruded in a narrow point, and the whole head squeezed into a longish form.
•
*
Although many people have exclaimed against the crotchets as dangerous inftruments, from ignorance, want of experience,
or a worse principle, as formerly obferved; yet I can affure the reader, that I never either tore or hurt the parts of a woman with that inftrument. I have indeed, feveral times, hurt the infide of my hand, by their giving way; till I had recourse to the curve kind, which in many respects have the advantage of the ftreight; and I am perfuaded, if managed as above directed, will never injure the patient.
2: Indeed, young practitioners, till they are better informed by cuftom and practice, may, after the head is opened, try to extract it with the small or large forceps, and if it is not very large, or the Pelvis very narrow, they may deliver by fqueezing and leffening the head but, in my courfe of practice, I have been concerned in many cafes, where the Pelvis was fo diftorted and narrow, that even after opening the head largely, I have pulled at the bones, in time of ftrong pains, but all to no purpose, although fome of them actually came away. Nay, after fixing a crotchet firmly above, and near the chin or bafis of the fcull, and ufing a good deal of force, I have not been able to move the
head
head lower, till at last I have been obliged to introduce the other, and by intervals increafe the force of pulling, to the utmoft of my ftrength; and before we had the curve crotchet, I have been fo fatigued from the ftreight kind flipping their small hold so often, that I have fcarcely been able to move my fingers or arms, for many hours after; and if this force had not been used, the mother must have been loft as well as the child.ilob #
CHA P. IV.
Of PRÆTERNATURAL LABOURS.
SE C T. 1.
PR
T
Ræternatural labour, according to the divifion-mentioned, chap. I. fect. 5. happens, when instead of the head, fome other part of the body prefents to the Os uteri. It has been thought by fome, that all labours in which the forceps and crotchet are used, ought to be ranked in this clafs; because, the head is certainly delivered by
X 2
præter
præternatural means; and that when the feet or breech prefent, and the woman is delivered without any other affiftance than that of labour pains, the cafe ought be accounted natural. However, this divifion would embarrass and confufe young beginners, more than the other which I have chofen to follow, namely that of reckoning by the manner in which the child is delivered, and calling all thofe births præternatural, in which the body is delivered before the head. Preternatural labours are more or less difficult according to the presentation of the child, and the contraction of the Uterus round its body. The nearer the head and shoulders are to the Os internum, or lower part of the Uterus, the more difficult is the cafe; whereas, when the head is towards the Fundus, and the feet or breech near the Os internum, it is more easy to turn and deliver.
To begin with the eafieft of these first, it may be proper to divide them into three claffes. First, how to manage when the feet, breech, or lower parts prefent. Secondly, how to behave in violent floodings; and
when
when the child prefents wrong before the membranes are broke, how to fave the waters in the Uterus, that the Fatus may be the more eafily turned; and what method to follow even after the membranes are broke, when all the waters are not evacuated. Thirdly, how to deliver when the Uterus is ftrongly contracted, the child presenting either with the fore or back parts, and lying in a circular form; or with the fhoulders, breaft, neck, face, ear, or Vertex, and lying in a longish form, with the feet and breech towards the Fundus of the womb, which is contracted like a long fheath, close to the body of the Fatus; and when the foreparts of the child lie towards the fide, Fundus, fore or back part of the Uterus. Daventer, who practifed at Dort in Holland, alledges that præternatural as well as laborious cafes proceed from the wrong pofition of the Os and Fundus uteri; that if the Fundus hangs forwards over the Os Pubis, the Os uteri is turned backwards towards the Sacrum, and that in whatsoever direction the Fundus inclines, the Os uteri will be always turned to the oppofite fide. This opinion he grounded upon X 3
the
310 Of PRETERNATURAL LABOURS, the fuppofition, that the Placenta always ad- heres to the Fundus; but experience fhews, that it adheres to different parts of the womb, fometimes even to the infide of the Os uteri. For the most part, indeed, the Os internum  is turned backwards towards the Coccyx, be- ing in a ftreight line with the Fundus up to the middle space betwixt the navel and Scro- biculus cordis. 
Daventer was also of opinion, that if upon touching, the mouth of the womb was not felt in the middle, the woman ought to be affifted by opening the parts; and if this did not fucceed, by turning and delivering by the feet, without delay. We sometimes, indeed, meet with pendulous bellies, in which the Os uteri is farther back than usual; but, even in these cafes, when the head is not very large, nor the Pelvis narrow, and the patient is yigorous and the labour-pains ftrong, the woman with a little patience, is, for the moft part, fafely delivered without any other than common affiftance: or, fhould the cafe prove tedious, the may be, affifted in time of a pain, by introducing one or two fingers into the Os uteri, and gra
dually
When
dually bringing it more forwards. the belly is very pendulous, change of pofition from time to time, is of fervice, especially lying upon her back, with the fhoulders low and the breech raised.
In women that are diftorted, when one Ilium is much lower than the other, the Fundus uteri will be turned to the low fide but there the chief difficulty will proceed from the narrowness of the Pelvis.
;
SECT. II.
The firft Class of PRÆTERNATURAL LABOURS. When the Feet, Breech, or lower parts of the Foetus prefent, and the Head, Shoulders, and upper parts are towards the Fundus.
THESE, for the most part, are accounted the easiest, even although the Uterus fhould be ftrongly contracted round the body of the child, and all the waters difcharged.
If the knees or feet of the child present to the Os internum, which is not yet fufficiently dilated to allow them and the body to come farther down; or, if the woman is weak, X 4
wore
wore out with long labour, or endangered by a flooding, let the operator introduce his hand into the Vagina, push up and stretch the Os uteri, and bring along the feet; which being extracted, let him wrap a linnen cloth round them, and pull until the breech appears on the outside of the Os externum: if the face or fore-part of the Fatus is already towards the back of the Uterus, let him perfift in pulling in the fame direction; but, if they are towards the Os Pubis, or one fide, they must be turned to the back-part of the Uterus, and as the head does not move round equal with the body, he must make allowance for the difference in turning, by bringing the last one quarter farther than the place at which the head is to be placed; so that the face or forehead which was towards one of the groins, will be forced to the fide of the Sacrum, where it joins with the Ifchium. This quarter turn of the body must be again undone, without affecting the pofition of the head; a cloth may be wrapped round the breech, for the convenience of holding it more firmly; then, placing a thumb along cach fide of the fpine, and with his fingers grafp
grafping the belly, let him pull along the body from fide to fide, with more or less force, according to the refiftance: when the child is delivered as far as the fhoulders, let him flide his hand flattened (fuppofe the right, if the lies on her back) between its breaft and the Perinæum, Coccyx, and Sacrum of the woman, and introduce the fore or middle finger (or both, if neceffary) into the mouth of the Fatus; by which means, the chin will be pulled to the breast, and the forehead into the hollow of the Sacrum. And this expedient will also raise upwards the hindhead, which refts at the Os Pubis.
When the forehead is come fo low as to protrude the Perinæum, if the woman lies on her back, let the operator ftand up, and pull the body and head of the child upwards, bringing the forehead with an half round. turn from the under-part of the Os externum, which will thus be defended from laceration. The application of the fingers in the child's mouth will contribute to bring the head out in this manner, prevent the Os externum from hitching on the chin, help along the head, and guard the neck from being over-ftrained;
а
a misfortune which would infallibly happen, if the forehead should be detained at the upper-part of the Sacrum: nor is there any great force required to obviate this inconvenience, or the leaft danger of hurting the mouth, if the head is not large; for, if the head cannot be brought along with moderate force, and the operator is afraid of injuring or over-ftraining the lower jaw, let him push his fingers farther up, and prefs on each fide of the nofe, or on the inferior edges of the fockets of the eyes. If the legs are come out, and the breech pulled into the Vagina, there is no occafion for pufhing up to open, but only to pull along and manage as above directed; ftill remembring to raise the forehead flowly from the Perineum, which may be preffed back with the fingers of his other
hand.
In the cafe of a narrow Pelvis, or large head, which cannot be brought along without the risk of over-ftraining the neck, let him flide up his fingers and hand into the Vagina, and bring down one of the child's arms, at the fame time pulling the body to the contrary fide, by which means the fhoulder
will be brought lower down: let him run his fingers along the arm, until they reach the elbow, which must be pulled downwards with an half-round turn to the other fide, be- low the breast. This muft not be done with a jirk, but flowly and cautiously, in order to prevent the dislocation, bending, or breaking of the child's arm. 
$
1
Let him again guide his fingers into the child's mouth, and try if the head will come along if this will not fucceed, let the body be pulled to the other fide, fo as to bring down the other shoulder; then flide up his left hand, and extracting the other arm, endeavour to deliver the head. If one finger of his right hand be fixed in the child's mouth, let the body reft on that arm; let him place the left hand above the shoulders, and put a finger on each fide of the neck : if the forehead is towards one fide at the upper-part of the Pelvis, let him pull it lower down, and gradually turn it into the hollow of the Sacrum; then ftand up, and in pulling, raise the body, fo as to bring out the head in an half-round turn, as above directed.
Da
"
Daventer, and others, from a mistaken notion, that the chief refiftance is at the Coccyx or lower part of the Pelvis, have directed us to prefs the fhoulders of the child downwards, fo as to bring the hindhead first from below the Os pubis; not confidering that the refistance is occafioned by the thickest part of the head being detained at the upperpart of the Pelvis, where the lowest Vertebra of the loins, and the upper-part of the Sacrum jet inwards; and that until the forehead hath paffed into the hollow of the Sacrum, this method cannot fucceed: the bufinefs, therefore, is to pull upwards at the back part of the neck, which refts against the under-part of the Os pubis, and by this exertion, the forehead, which is high up, will be brought down with a circular turn; after which, the head seldom stops, and the same circular motion is ftill the moft proper, though now we can bring out the head the other way, but not before. Sometimes, indeed, I have found Daventer's method fucceed better than the other, when the head is low down, and the chief refiftance is in the lower parts; but this is very feldom the cafe; how
however, when the forehead is hindered from coming down into the lower part of the Sacrum by an uncommon fhape of the head or Pelvis, and we cannot extract it by bringing it out with an half-round turn at the Os pubis, we must try to make this turn in the contrary direction; and instead of introducing our fingers into the child's mouth, let the breaft of it reft on the palm of your left hand, (the woman being on her back) and placing the right on its fhoulders, with the fingers on each fide of the neck, press it downwards to the Perinæum. In confequence of this preffure, the face and chin being within the Perinæum, will move more upwards, and the head come out with an halfround turn from below the Os pubis: for, the center of motion, is now, where the forepart of the neck preffes at the Perinæum; whereas, in the other method, the back-part of the neck is against the lower part of the Os pubis, on which the head turns.
If the forehead is not turned to one fide, but fticks at the upper-part of the Sacrum, especially when the Pelvis is narrow; ler him endeavour with his finger in the mouth,
•
to
to turn it to one fide of the jetting in of the Sacrum, because the Pelvis is wider at the fides of the brim, and bring it along as before.
If one of the child's arms, inftead of being placed along the fides of the head, is turned in between the face and Sacrum, or between the hindhead and Os pubis, the fame difficulty of extracting occurs, as in a large head or narrow Pelvis; and this pofition frequently enfues, when the fore-parts of the child's body are turned from the Os pubis down to the Sacrum: If they are turned to the left fide of the woman, the left hand and arm are commonly brought in before the face, and vice verfa; but, in these cafes, the elbow is, for the most part, eafily come at, because it is low down in the Vagina, and then there is a neceffity for bringing down one or both arms before the head can be delivered: from whence we may conclude, that thofe authors are sometimes in the wrong, who exprefly forbid us to pull down the arms. Indeed, if the Pelvis is not narrow, nor the head very large, and the arms lie along the fides of the head, there is feldom occafion to
pull
pull them down; becaufe, the Pelvis is wideft at the fides, and the membranes and liga- ments that fill up the fpace betwixt the Sa- crum and Ifchia, yield to the preffure, and make room for the paffage of the head: but, when they are fqueezed between the head and Sacrum, Ifebia, or Offa pubis, and the head sticks in the Pelvis, they certainly ought to be brought down; or, even when the head comes along with difficulty. Neither is the alledged contraction of the Os internum round the neck of the child, fo frequent as  hath been imagined; becaufe, for the most  part, the contraction embraces the head and  not the neck: but, fhould the neck alone fuf  fer, that inconvenience may be removed by  introducing the hand into the Vagina, and a  finger or two into the child's mouth: by  which means alfo a fufficient dilatation will  be preserved in the Os externum, which fre  quently contracts on the neck, as soon as the  arms are brought out.                           ad 
The diameter, from the face or forehead to the Vertex, being greater than that from the forehead to the back-part of the hindhead or neck, when the hindhead refts at the Os pubis,
and the forehead at the upper part of the Sacrum, the head can feldom be brought down, until the operator, by introducing a finger into the mouth, moves the fame to the fide, brings the chin to the breast, and the forehead into the hollow of the Sacrum ; by which means, the hindhead is raised and allowed to come along with greater ease: and in pulling, half the force only is applied to the neck, the other half being exerted upon the head, by the finger which is fixed in the mouth; fo that the forehead is more eafily brought out, by pulling upwards, with the half-round turn from the Perinæum. When the operator, with his fingers in the child's mouth, cannot pull down the forehead into the hollow of the Sacrum, let him push the fore finger of his left hand betwixt the neck and Os pubis, in order to raise the hindhead upwards; which being done, the forehead will come down with lefs difficulty, especially if he pushes up and pulls down at the fame time, or alternately.
"
If it be discovered by the touch, that the breech prefents, that the membranes are not yet broke, the woman in no danger, the Os
internum not yet fufficiently dilated, and the labour-pains strong; the midwife ought to wait until the membranes, with the waters, are pushed farther down, as in the natural labour; for, as they come down through the Os uteri into the Vagina, they ftretch open the parts contained in the Pelvis, and the bulk within the Uterus being diminished, it contracts and comes in contact with the body of the child; fo that the breech is pushed along by the mechanical force of the abdominal muscles operating upon the womb.
The fame confequence will follow even although the membranes are broke; for the waters lubricate the parts as they flow off, and the breech, if not too large, or the Pelvis narrow, is pushed down: In this cafe, when the Nates present equal and fair to the Os uteri, (as was formerly obferved when treating of the pofition of the child, book III chap. 1. fect. I. it was most probable, that one fide of the Fetus was towards the forepart, and the other to the back-part of the Uterus ;) fo it is alfo reasonable to conclude, that when the breech prefents, it lies in the fame manner, but that the fore-parts of the Y child
child are rather turned backwards to one fide of the Vertebra of the loins: in this pofition, one hip will prefent, and the other reft on the Os pubis; but, when forced along with pains, the last will be gradually moved more and more to the groin of that fide, and from thence flip down at the fide of the bafin: the lower at the fame time will be forced to the other, and the hollow betwixt the thighs, will reft upon the jetting-in of the Os facrum, and come down in that manner; the thighs, on each fide, and the back and round part of the breech paffing in below the arch of the Os pubis, which is the best position: but if the back of the child is tilted backwards, then it will be forced down in the contrary direction, and come along with more difficulty, viz. the thighs to the Os pubis, and back to the Sacrum: when it is come down to the middle or lower part of the Pelvis, let the operator introduce the forefinger of each hand, along the outfide, to the groins, and taking hold, pull gently along, during a strong pain.
If the Os externum is fo contracted, that he cannot take fufficient hold, let it be opened flowly, fo as to allow his hands to be pushed
pushed up with ease; when he has infinuated a finger or two in each groin, let him place his thumbs on the thighs, if they are towards the Offa pubis, fo as to obtain a firm hold; then pull along from fide to fide, and if the back of the child is to the Os pubis, continue to affift in this manner, until the body and head are delivered the legs being commonly stretched up along the belly and breast, when the child is extracted as far as the shoulders, they come out of themselves, or are easily brought down; but, if the belly of the child is turned to one fide, or to the Os pubis, in that cafe, when the breech is delivered, he ought to turn the belly down to the Sacrum, and the back to the Os pubis; and that the face be alfo turned to the back of the mo→ ther, let him remember the quarter extraordinary, which must be again reversed, and then he may pull along, and deliver.
may
If the body cannot be turned until the thighs and legs are brought down, either on account of the bulk, or because the hold on the breech is not fufficient, let him continue to pull along, until the hams appear on the outfide of the Os externum; then feize one of Y 2 the
the knees with his finger and thumb, and extract that leg; and let the other be brought down in the fame manner. If he attempts to pull out the legs, before the hams arrive at this place, the thighs are always in danger of being bent or broke. When the legs are delivered, let him wrap a cloth round the breech of the child, and as the body was pulled down almoft as far as the breast, before the legs could be brought out, it must be pushed up again to the navel, or above it; becaufe, without this precaution, the shoulders would be fo much engaged in the Pelvis, that it would be impracticable to make the motions formerly directed, fo as to turn the face to the back of the mother; whereas, when the body is pushed up, those turns can be effected with greater ease, because the belly being in the Pelvis, it yields easier to the form of the bafin. When the face is turned properly down, let him proceed to deliver, as above directed.
If the breech is detained above the Pelvis, either by its uncommon magnitude, or the narrowness of the bafin; or if one of the Nates is pushed in, while the other rests
above the Os pubis, Sacrum, or to either fide if the woman is low and weak, the pains lingering and infufficient to force the child along; or if she is in danger from a violent flooding in any of these cafes, let him (during every pain) gradually open, first the Os externum, and then the Os internum, with his fingers and hand. Having thus gained admiffion, let him push up the breech to the fore or back part, or to one fide of the Uterus, that his hand and arm may have room to flide along the foreparts or belly of the child, fo as to feel the thighs, that will direct him to the legs, which must be brought down with his fingers, while at the fame time, he pushes up the hams with his thumb, that in cafe the legs lie ftreight up, they may be extracted with more ease by the flection of the knee, and run the less risk of being bent, broke, or overftrained: for, if they are folded downward, they are the more eafily brought out.
If the breech be ftrongly preffed into the upper part of the Pelvis, let him also push it upwards and to one fide, that his hand and arm may have free paffage; for, the Y 3
higher
i
higher the breech is raised out of his way, he will be at more freedom to extract the legs.
If both legs cannot be easily brought down,. he may fafely deliver with one, of which taking hold with a linnen cloth wrapped round it, let him flide up his other hand into the Vagina, and a finger or two into the outfide of the groin which is bent: by these means, the hip will come down the easier, and the leg which is already extracted will not be overstrained by sustaining the whole force of pulling the body along.
If the legs lie towards the left fide of the woman, who is laid on her back, the right hand must be introduced into the Uterus: if they lie to her right fide, the left hand will better answer the purpose; and if they are towards her back or belly, either hand may be indifferently used.
In all cafes where the breech prefents, the fafeft practice is always to push up and bring down the legs, provided the Os uteri is fufficiently dilated, and the waters not wholly discharged. discharged. If the waters are evacuated, the Uterus ftrongly contracted
around
around the child, the breech low, fo as that it cannot be returned, or fo fmall as to come eafily along, we ought then to deliver it accordingly; but, if fo large as neither to be pushed up or brought along with the affiftance of the fingers, let the operator introduce the curved handle of the blunt crotchet into one of the groins, his fingers into the other, and pull very cautiously, in order to prevent a fracture or dislocation of the thigh bone, which might otherwise happen from the use of this inftrument, the blunt point of which must be fufficiently past the groin. A fillet may also be used for the fame purpose.
I have in the foregoing cafes of this fection, fuppofed the woman laid on her back, her legs fupported, and breech to the bedfide; this being generally the best position for delivering the body and head: indeed, when the child is fmall, fhe may lie on her fide, and the fame methods be used in delivering, provided the operator ftill remembers that in this pofition, the Ilium and Ischium of one fide, are down, and the others up. Befides, when the breech is pushed up, in or Y 4 der
der to bring down the legs, if they lie forwards towards the forepart of the Uterus, and the belly is pendulous, he can reach them with the greatest ease, when fhe lies on one fide: but, when the legs are delivered, if the child is large, or the Pelvis nar row, fhe ought to be turned upon her back, because the body and head can be better and fafer delivered, by pulling up and down; and in that posture fhe is alfo kept more firm, and her thighs lefs in the operator's way, than when the lies upon her fide.
•
SECT. III.
The fecond class of PRÆTERNATURAL La
BOURS.
1
WHEN the membranes are broke, but the face, fhoulder, or fome other part of the child, being pushed into the Pelvis, locks up the Os internum, fo as that a small quantity of the waters hath been discharged, the Uterus is kept from contracting strongly round the child, which is therefore more cafily turned than it poffibly can be when they are all gone;
When,
་
When, before the membranes are broke the child is felt through them, presenting wrong, and at the fame, time the pains push them down fo as to dilate the Os internum, more or lefs:
When the woman, at any time in the four last months, is feized with a violent flooding that cannot be restrained, and unless speedily delivered muft lofe her life; if labourpains cannot be brought on by ftretching the parts, delivery must be forced; but, if the is in labour, and the membranes have been pushed down with the waters, they may be broke; by which means, the flooding is frequently diminished and the child delivered by the labour-pains.
In these three different cafes, if we can prevent the ftrong contraction of the Uterus, by keeping up the waters, we can alfo for the most part turn the child with great ease, even in the very worst positions.
NUMB. I.
IN In the firft cafe, let the operator flowly introduce his hand into the Vagina, and his fingers between that part of the child which
is
is pushed down, and the Os internum : if in so doing he perceives fome of the waters coming along, he must run up his hand as quick as poffible into the Uterus, betwixt the infide of the membranes and the child's body; the lower part of his arm will then fill up the Os externum like a plug, fo that no more of the waters can pafs; let him turn the child with its head and shoulders up to the Fundus, the breech down to the lower part of the Uterus, and the foreparts towards the mother's back; let the hand be pushed no farther up than the middle of the child's body, because, if it is advanced as high as the Fundus, it must be withdrawn lower, before the child can be turned; and by these means the waters will be discharged, and the Uterus of confequence contract so as to render the turning more difficult.
NUMB. II.
In the fecond cafe, when the membranes are not broke, and we are certain that the child does not present fair, if the Os internum is not fufficiently dilated, and the woman is in no danger, we may let the labour go
go on, until the parts are more stretched; lubricating and extending the Os externum, by degrees, during every pain. Then introducing one hand into the Vagina, we infinuate it in a flattened form, within the Os internum, and push up between the membranes and the Uterus, as far as the middle of the womb: having thus obtained admiffion, we break the membranes by grafping and squeezing them with our fingers, flide our hand within them, without moving the arm lower down, then turn and deliver as formerly directed.
NUMB. III.
IF the woman (in the third cafe) is attacked with a violent flooding, occafioned by a feparation of all or any part of the Placenta from the Uterus, during the last four months of method has every pregnancy, and in vain been tried to leffen and reftrain the discharge, according to the directions in book II. chap. 3. fect. 3. the operator ought to pronounce the cafe dangerous, and prudently declare to the relations of the patient, that unless she is speedily delivered, both she
and the child muft perifh, obferving, at the fame time, that by immediate delivery they may both be faved; let him alfo defire the affistance and advice of fome perfon eminent. in the profeffion, for the fatisfaction of her friends, and the fupport of his own reputati
on.
When there are no labour-pains, and the mouth of the womb is not dilated, it is fometimes very difficult to deliver, more efpecially if the Os internum is not a little lax, but feels rigid.
If the Os uteri is fo much contracted, that the finger cannot be introduced, fome authors have recommended a dilator, by which it may be gradually opened fo as to admit a finger or two. Doubtless, fome cafes may happen, in which this may be neceffary: though in all thofe to which I have been called, when there was a neceffity for forcing delivery, the mouth of the womb was open enough to receive the tip of my finger, fo that by gradual efforts I could effect a fufficient dilatation; and it is certainly a safer method to dilate with the fingers and hand, than with an inftrument. If in ftretching the Os internum, labour
pains are brought on, let the operator flowly proceed and encourage them: when the mouth of the womb is opened, if the head prefents and the pains are ftrong, by breaking the membranes the flooding will be diminished; but, if she floods to fuch a degree as to be in danger of her life, and the dilatation does not bring on labour, at least not enough for the occafion, she must be immediately delivered in the following manner: but in the first place let her friends be apprized of the danger, and the operator beware of promifing to fave either mother or child; for I have known the woman die in a few minutes after delivery, although to all appearance she seemed able to undergo the operation, and the child loft from the head's fticking in the Pelvis: Others again, who were apparently much more weak and exhaufted, have recovered, and the child hath been faved.
The operator having performed his duty in making the friends acquainted with the fituation of the cafe, must gently open the Os externum, by introducing his fingers gradually, turning them half round and pushing
upwards; then forming them, with the thumb, into the figure of a wedge or cone, continue to dilate flowly and by intervals, until his hand is admitted into the Vagina: having thus far gained his point, let him infinuate, in the fame flow cautious manner, firft one, then two fingers, into the Os internum, which may be dilated fo as to admit the other two and the thumb in the fame conical form, which will gradually make way for fliding the hand along between the outfide of the membranes and infide of the Uterus; then he must manage as directed in the second cafe: If, upon fliding up his hand upon the outfide of the membranes, he feels the Placenta adhering to that fide of the womb, he muft either withdraw that hand and introduce the other on the oppofite fide, or break through the membranes at the lower edge of the Placenta.
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The greatest danger in this cafe frequently proceeds from the fudden emptying of the Uterus and belly; for when labour comes on of itself, or is brought on in a regular manner, and the membranes are broke, the flooding is gradually diminished, and first the
child, then the Placenta, is delivered by the pains; fo that the preffure or refiftance is not all at once removed from the belly and Uterus of the woman, which have time to contract by degrees; confequently, thofe fainting fits and convulfions are prevented which often proceed from a fudden removal of that compreffion, under which the circulation was performed.
In order to anticipate these fatal fymptoms, I have (fometimes fuccessfully) ordered an affistant to prefs upon the woman's belly while the Uterus was emptying; or, after having broke the membranes, turned up the head to the Fundus, and brought down the legs and breech, I withdraw my arm a little, to let the waters come off, though I keep my hand in the Uterus for a few minutes, and do not extract the legs until I feel the womb close contracted to the child; nay, if the flooding is stopped or even diminished, I let the child remain in the Uterus perhaps ten or fifteen minutes longer, then deliver; and if the hæmorrhage is stayed, leave the Placenta to be expelled by nature. In all thefe ftages, however,
when
when the flooding is violent, we must deliver without lofs of time, remembring ftill the preffure upon the abdomen; for the woman is frequently so very weak, that although labour could be brought on, fhe would not have strength fufficient to undergo it,
The younger the woman is with child, the greater is the difficulty in opening the Os internum; and more fo in the first child, especially if she is past the age of thirty-five.
We should never refuse to deliver in these dangerous cafes, even although the patient feems expiring for, immediately after delivery, the Uterus contracts, the mouths of the veffels are shut up; fo that the flooding ceases, and fhe may recover, if she lives five or fix hours after the operation, and can be fupported by frequent draughts of broth, gelly, caudle, weak cordial, and anodyne medicines, which maintain the circulation and gradually fill the empty veffels.
If in time of flooding, fhe is feized with labour-pains, or, if by every now and then ftretching with your fingers the Os internum, you bring on labour, by which either the membranes or head of the child is pushed down,
down, and opens the Os internum, the membranes ought to be broke; fo that some of the waters being difcharged, the Uterus may contract and squeeze down the Fatus. This may be done fooner in those women who have had children formerly, than in such as have been in labour before. If, notwithstanding this expedient, the flooding ftill continues, and the child is not like to be foon delivered, it must be turned immediately; or, if the head is in the Pelvis, delivered with the forceps; but, if neither of these two methods will fucceed, on account of the narrowness of the Pelvis, or the bignefs of the head, this last must be opened, and delivered with the crotchet. In all
these cafes, let the parts be dilated flowly
and by intervals, in order to prevent lace
ration.
SECT. IV.
The third Class of PRÆTERNATURAL-            LABOURS. 
WE have already obferved, that the prin
cipal difficulties in turning children and bringing them by the feet, proceeded from
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the contraction of the Uterus, and bad pofition of the Fatus. If the child lies in a round form, whether the fore-parts are towards the Os internum, or up to the Fundus uteri, we can, for the most part, move it with the hand, fo as to turn the head and shoulders to the upper part, and the breech and legs downwards; but, if the child lies lengthways, the womb being contracted around it, like a long sheath, the task is more difficult; efpecially, if the head and shoulders of the child are down at the lowest part of the Uterus, with the breech and feet turned up to the Fundus.
Before I proceed to the method of delivery in the following cafes, it will not be improper to premise, that the woman ought to be laid on her back, her breech upon the fide or foot of the bed, a bolster or pillows being laid between the feather-bed or matrefs, in order to raise it so as that the breech may be higher than the shoulders; while an assistant fits on each fide, to support her legs and thighs, as directed in chap. II. fect. 1. and chap. III. fect. 3. and one or two more affiftants ought to fit behind, or on each fide of
of her shoulders, to keep her firm in that pofition. The operator ought to avoid all formality in point of drefs, and never walk about the room with fleeves and apron; for, although fuch apparatus may be neceffary in hofpitals, in private practice it conveys a frightful idea to the patient and female spectators: the more genteel and commodious drefs is, a loose washing night-gown, which he may always have in readiness to put on when he is going to deliver; his waistcoat ought to be without fleeves, fo that his arms may have more freedom to flide up and down under cover of the wrapper; and the fleeves of his shirt may be rolled up and pinned to the breasts of his waistcoat. tural labours, the sheet that hangs over the bedfice is fufficient to keep him clean and dry, by being laid in his lap; but, in those cases where he is obliged to alter his pofition, a sheet ought to be tucked round him, or an apron put on, but not before he is about to begin his work. If the patient is laid on a low bed, and he intends to introduce his right hand, his beft and firmeft pofition is to kneel with his left knee on a cushion,
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keeping up the right to support his arm; if the left hand is introduced, the reverse of this difpofition muft take place: if the bed or couch is high, he ought to stand, but still remember to support the elbow on the knee. Thefe directions, howsoever trivial they may seem to old practitioners, may be ferviceable to young beginners.
The hand of the accoucheur or operator being introduced into the Uterus, if he finds the breech below the head and fhoulders, let him fearch for the legs and bring them down; but if the breech be higher than the upper parts of the child, or equal with them, he must try to turn the head and shoulders to the Fnndus, and the breech downwards by pushing up the firft, and pulling down the laft; then proceed with delivery as be→ fore directed. This is commonly executed with ease, provided fome part of the waters ftill remain in the Uterus; but, if the woman has been long in labour, and the waters. discharged, the contraction of the womb is fo ftrong, that the child cannot be turned without the exertion of great force frequently repeated. In this cafe, the easiest method
both for the patient and operator, is to push up the hand gradually on that fide to which the legs and thighs are turned, and even after he has reached them, if they are not very high up, let him advance his hand as far as the Fundus uteri; he will thus remove the greatest obstacle, by enlarging the cavity of the womb, fo as more easily to feel and bring down the legs; then he may push up and pull down, as we have prescribed above: but, if the head and fhouldem ftill continue to hinder the breech and body from coming along, and the feet cannot be brought fo low as the outfide of the Os externum, while they are yet in the Vagina he may apply a noose upon one or both; for, unless the child is fo fmall that he can turn it round by grafping the body when the head and fhoulders are pushed up, and he endeavours to bring down the other parts, they will again return to the fame place, and retard delivery: whereas, if he gains a firm hold of the feet, either without the Os externum, or in the Vagina, by means of the noofe fixed upon the ancles, he can with the other hand push up the head and shoulder, and be able in that man
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ner
1
ner to bring down the breech. He muft continue this method of pushing up and pulling down, until the head and shoulder are raised to the Fundus uteri; for, fhould he leave off too foon, and withdraw his hand, although the child is extracted as far as the breech, the head is fometimes so preffed down and engaged with the body in the paffage, that it cannot be brought farther down without being tore along with the crotchet; for, the breech and part of the body may block up the paffage in fuch a
as that the hand cannot be intro
manner,
duced to raise the head.
In all cafes where the accoucheur forefees that great force will be requifite, he ought to fave his strength as much as poffible, beginning flowly, and resting his hand between whiles, during the operation of pushing up and turning the child in the Uterus: for, if he begins to work in a hurry, and exerts his utmost strength at first, his hands will be fo cramped and enervated, that he will be obliged to defift, and give them some respite; fo that it may be a long time before he recovers the use of them, and even then they
will be fo much weakened as to be fcarce able to effect delivery, which is thus impeded and delayed.
Those cafes are commonly the easiest in which the fore parts prefent, and the child lies in a round or oval form, across the Uterus, or diagonally, when the head or breech is above and over the Os pubis, with the legs, arms, and navel-ftring, or one or all of them, at the upper or lower part of the Vagina, or on the outfide of the Os externum. Those are more difficult in which, though the child lies in the fame round or contracted form, the back, fhoulders, belly, or breast, are over the Os internum; because if we cannot move the child round, fo as to place the head to the Fundus, the legs are brought down with much more difficulty than in the other cafe: but, if the fhoulder, breaft, neck, ear, face, or crown of the head prefents, and the legs and breech are up to the Fundus uteri, the cafe is ftill more difficult; because, in the other two, the Uterus is contracted in a round form, fo that the wrong pofition of the child is more easily altered than in this, when the womb is con24
tracted
1
tracted in a long shape, and fometimes requires vaft force to ftretch it, fo as that the head may be raised to the Fundus, and the legs and breech brought down.
The crown of the head is the worst part that can prefent, because in that cafe the feet and breech are higher, and the Uterus of a longer form, than in any other. The prefentation of the face is, next to this, attended with the greateft difficulty: but, when the neck, shoulder, back, or breast present, the head is turned upwards, and keeps the lower part of the womb diftended; fo that, upon ftretching the upper part, the child's head is more easily raised to the Fundus.
To
NUMB. I.
WHEN the fore-parts of the child present, if the feet, hands, and navel-ftring are not detained above the Os uteri, fome or all of them defcend into the Vagina, or appear on the outfide of the Os externum. If one or more of them come down, and the child at the fame time lies in a round form across the Uterus, let the accoucheur introduce his hand between them and the Sacrum, as directed
in fect. 3. When it is past the Os internum, let it reft a little, while he feels with his fingers the pofition of the Fatus: if the head and fhoulders lie higher than the breech, he must take hold of the legs and bring them down withoutfide the Os internum: if the breech is detained above the brim of the Pelvis, let him flide up the flat of his hand along the buttocks, and pull down the legs with the other hand; by which method the breech is difengaged and forced into the middle of the Pelvis.
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In most of those cafes where the child is preft in an oval form, if neither the head or breech present, the head is to one fide of the Uterus, and the breech to the other; because, as was formerly obferved, it is wider from fide to fide, than from the back to the fore part, and if either the head or breech is over the Os pubis, the other is turned off to the fide in moving the head or fhoulders to the Fundus, they are raised with greater cafe along the fides, than at the back or fore parts, for the fame reasons.
If the head and shoulders lie lower down, fo as to hinder the breech from coming
along,
along, and the legs from being extracted, let him push up the head and shoulders to the Fundus, and pull out the legs; then try as above directed to bring in the breech, and if it ftill fticks above, because the head and fhoulders are again forced down by the contraction of the Uterus, he must with one hand take hold of the legs that are now without the Os externum, and fliding the other into the Uterus, pufh the head and fhoulders again up to the Fundus, while, at the fame time, he pulls the legs and breech along with the feet. If the legs cannot be brought farther down than the Vagina, because the breech is high up, let him flip a noose over the feet round the ancles, as before obferved; by which he may pull down the lower parts with one hand, while the other is employed in pushing up, as before. By this double purchase, the child may be turned even in the most difficult cafes: but the operator, in pulling, muft beware of over-ftraining the ligaments of the joints.
If the legs can be extracted through the Os externum, let a fingle cloth, warmed, be wrapped round them, in order to yield a
firmer hold to the accoucheur; but, when they can be brought no lower than the neck of the Uterus or Vagina, he may ufe one of thefe following nooses,
Let him take a ftrong limber fillet or soft garter, half worn, about one yard and an half in length, and moderately broad and thick; if thick, an eye may be made at one end of it, by doubling about two inches and sewing it strongly; and the other end paffed through this doubling, in order to make the noose, which being mounted upon the thmub and fingers of his hand, must be introduced, and gently flipped over the toes and feet of the child, fo as to embrace the ancles; and thus applied, it must be drawn tight with his other hand.
If the foot or feet fhould be fo flippery, that his fingers cannot hold them, and work over the noose at the fame time, it must be withdrawn and mounted round his hand or wrift; with which hand, when introduced, he may take firm hold on both feet, if they are as far down as the Vagina; then with the fingers of his other hand, he can flide the noofe along the hand and fingers that hold the
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the feet, and fix it round the ancle; but, if one foot remains within the Uterus, the fingers of his other hand cannot push up the noofe far enough to flide it over the ancle; fo that he must have recourse to a director, like that for Polypufes, mounted with the noose, which will push it along the hand and fingers that hold the foot. The noose being thus flipped over the fingers upon the ancle, he must pull the extremity of the fillet which hath paffed the eye at the upper end of the director, and after it is close drawn, bring down the inftrument.
Some use a small flender pair of forceps, to grasp the ancles and flide the noose along them; others make use of a fillet with a noofe upon one end of it, fixed on a hollow tube that carries it up to be flipt over the ancles; and this being done, it is drawn close by pulling the other end of the fillet down through the cavity of the tube: but, there is feldom occafion for any of these inftruments, because we can, for the most part, bring the feet down into the Vagina.
If the fillet or garter is too narow or thin, let it be doubled in the middle, and the
noofe
noose made by paffing the two ends through the doubling.
When the belly prefents, and the head, shoulders, breech, thighs, and legs, are turned up over the back to the Fundus uteri when the back presents, and all these parts are upwards; when the fide prefents, with the head, shoulders, breech, thighs, and legs turned to the fide, back, or forepart of the Uterus in all these cafes, when the child is preffed into a round, or (more properly) an oval figure, it may be, for the most part, moved round, with one hand introduced into the Uterus, the head and shoulders pushed to the Fundus, and the legs and breech to the Os internum; which being effected, the legs are easily brought down. But these cases are more or lefs difficult as the feet are farther up, or lower down, because the business is to bring them downwards.
When the breaft, fhoulders, neck, ear, or face present to the Os internum, the breech, thighs, and legs being towards the Fundus, with the fore-parts of the Fatus turned either to the fide, back, or fore-part of the woman's belly; and the whole lying in a longish
longish form, the Uterus being clofely contracted around its body like a fheath, let the accoucheur introduce his hand into the Va
gina, and open the Os internum by puthing up the fingers and hand flattened between the parts that present and the infide of the membranes; and rest his hand in that fituation, until he can distinguish how the child lies, and form a right judgment how to turn and deliver for, if these circumstances are not maturely confidered, he will begin to work in a confused manner, fatigue himself and the patient, and find great difficulty in turning and extracting the child.
If the feet and legs of the Fatus lie towards the back, fides, or Fundus uteri, the woman ought to be laid on her back, with her breech raised and brought a little over the bed, as formerly obferved; because, in that position, he can more cafily reach the feet than in any other.
If they lie towards the fore part of the Uterus, especially when the belly is pendulous, the ought to lie upon her fide; because, in the other posture, it is often difficult to turn the hand up to the fore-part of the womb :
womb: whereas, if she is laid on the left fide, the right hand may be introduced at the uper-part and left fide of the brim of the Pelvis, where it is wideft, and then along the fore-part of the Uterus, by which means the feet are more eafily come at. If it is more convenient for the accoucheur to use his left hand, the patient may be turned on her right fide. The only inconvenience attending these positions, is, that the woman cannot be kept fo firm and fteady, but will be apt to tofs about and shrink from the be a necefmay operator; and befides, there fity for turning her upon her back, after the body is delivered, before he can extract the head, especially if it be large, or the Pelvis
narrow.
The fituation of the child being known, and the pofition of the mother adjusted, let the proper hand be introduced, and the first effort always made in pufhing the prefenting part up towards the Fundus, either along the fides, back, or fore-part of the Uterus, as is moft convenient. If this endeavour fucceeds, and the breech, thighs, or legs come down, the body may be delivered with çafe: but, if the
the head, fhoulder, breaft, or neck present, the other parts of the body being ftretched up lengthways, and the Uterus fo ftrongly contracted around the child, that the prefenting part cannot be raised up, or, though pushed upwards, immediately returns before the legs can be properly feized or brought down; the operator ought, in that cafe, to force up his hand flowly and gradually between the Uterus and the child: if the refiftance is great, let him reft a little, between whiles, in order to fave the ftrength of his hand and arm, as formerly directed, and then proceed with his efforts until he fhall advance his hand as far as the feet; for the higher his hand is pushed, the more will the Uterus be ftretched, and the more room granted for bringing the legs along and if, in pushing up his hand, the fingers should be entangled in the navel-string or one of the arms, let him bring it a little lower, and pass it up again on the outside of fuch incumbrance.
The hand being advanced as high as the Fundus, let him, after fome paufe, feel for the breech, flide his fingers along the thighs
in fearch of the legs and feet; of which taking hold with his whole hand, if poffible, let him bring them down either in a ftreight line or with an half turn: or should the contraction of the Uterus be so strong, that he cannot take hold of them in that manner, let him seize one or both ancles between his fingers, and pull them along; but, if he cannot bring them down to the lower part of the Uterus, fo as to apply the noose, he must try again to push up the body, in order still more to stretch the Uterus, and obtain freer scope to bring them down lower: then he may apply the noofe, and turn the child as above directed, until the head and shoulders are raised up to the Fundus, and the feet and breech delivered.
If one leg only, can be brought down, the child being turned, and that member extracted through the Os externum; let the accoucheur flide his hand up to fetch the other; but, if this cannot be done, he must fix a finger on the outfide of the groin of that thigh which is folded up along the belly, and bring along that buttock, as in the breech cafe, while he pulls with his other hand at A 2
the
the other leg; and the body being thus advanced, deliver as before directed.
When the shoulder prefents, and the arm lies double in the Vagina, let him push them both up; but, if this cannot be done, and the hand is prevented from paffing along, he must bring down the arm, and hold it with one hand, while the other is introduced; then let go and push up the fhoulder, and as the child is turned, and the feet brought down, the arm will, for the most part, return into the Uterus: but, if the arm that is come down, be fo much fwelled, that it is impracticable to introduce the hand, fo as to turn and deliver the child, he must separate it at the joint of the fhoulder, if it be fo low down; or at the elbow, if he cannot reach the fhoulder. If the limb be much mortified, it may be twisted off; otherwise, it may be fnipt and separated with the fciffars.
If the shoulder, by the imprudence and ignorance of the unfkilful, who pull in expectation of delivering in that way, is forced into the Vagina, and part of it appears on the outfide of the Os externum, a vast force is required to return it into the Uterus; because
cause in this cafe, the fhoulder, part of the ribs, breaft, and fide, are already pulled out of the Uterus, which must be extended so, as not only to receive them again, but also to admit the hand and arm of the accoucheur. If this diftenfion cannot poffibly be effected, he muft flide his fingers to the neck of the child, and with the fciffars divide the head from the body; then deliver first the feparated head, or bring along the body by pulling at the arm; or, if need be, with the affistance of the crotchet: after the body is delivered, the head must be extracted according to the rules that will be laid down in fect. 5.
When the forehead, face, or ear prefents, and cannot be altered with the hand into the natural pofition; or is not advanced to the Os externum, fo as that we can affift with the forceps; the head must be returned, and the child delivered by the feet: but, if this cannot be done, and the woman is in imminent danger, recourfe must be had to the crotchet. If the navel-ftring comes down by the child's head, and the pulfation is felt in the arteries, there is a neceffity for turning, with
A a 2
out
out lofs of time; for unless the head advances faft, and the delivery is quick, the circulation in the veffels will be intirely obftructed, and the child confequently perish. If the head is low in the Pelvis, the forceps may be fuccessfully used.
No doubt, if the Pelvis is very narrow, or the head too large, it would be wrong to turn in that cafe, we ought to try if we can poffibly raise the head, fo as to reduce the Funis above it, and after that, let the labour go on; but, if the waters are all gone, and a large portion of the Funis falls down, it is impoffible to raise it, so as to keep it up, even although we could easily raise the head; because, as one part of the Funis is pushed up with the fingers, another part falls down, and evades the reduction; and to raise it up to the fide, and not above the head, will be to no purpose; when a little only jets down at the fide of the head, our endeavours will, for the most part, be successful.
The antients, as well as fome of the moderns, advise, in all cafes when the upperparts, fuch as the fhoulders, breast, neck, face, or ear of the child, prefent, to push
them
them upwards, and bring in the head as in the natural way; obferving, that the Fatus ought never to be delivered by the feet, except in the presentation of the lower parts, fuch as, the fmall of the back, belly, fide, breech, or legs. Were it practicable at all times to bring the head into the right position, a great deal of fatigue would be faved to the operator, much pain to the woman, and imminent danger to the child: he therefore ought to attempt this method, and may fuc
ceed when he is called before the membranes are broke, and feels, by the touch, that the face, ear, or any of the upper parts, prefents; in that cafe, let him open the Os externum flowly during every pain, and when the Os internum is fufficiently dilated by the descent of the waters and membranes, let him introduce his hand into the Uterus, as directed in fect. 3. betwixt the womb and the mem-branes, which must be broke; and if he finds the head so large, or the Pelvis so narrow, that it will be difficult to fave the child; provided the woman is vigorous and has ftrong pains, he may with little difficulty bring in the crown of the head, then with
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draw
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draw his hand; and if the pains return and continue, the child has a good chance to be delivered alive. Even after the membranes are broke, if the presenting part hath fo locked up the Os internum, as to detain fome portion of the waters (a circumftance easily known in pushing up the part that presents) he may run up run up his hand speedily to keep them from being discharged, and act in the fame manner: but, if the child is not large, nor the Pelvis narrow, it were pity, while his hand is in the Uterus, to defift from turning the child and bringing it by the feet because, in that cafe he may be pretty certain of faving it. Befides, after the head is brought into the right position, should the pains go off entirely (and this frequently happens) or a flooding come on, in confequence of the force which hath been exerted, he will find great difficulty in turning after the waters have been discharged; for, it is harder to turn when the Vertex prefents, than in any other pofition; whereas, in the case of a large head or narrow Pelvis, when the head is forced down by the labour-pains, and will not farther advance, the child may be faved by
by the forceps; nay, though the pains do not act fo as to force it down, to be delivered either by the forceps or in the natural way, the head may be opened and extracted with the crotchet, which is the last resource.
But this neceffity feldom occurs, because the cafes in which we are most commonly called, are after the membranes have been long broke, the waters difcharged, and the Uterus ftrongly contracted around the body of the child, which it confines, as it were, in a mould fo that I have frequently tried in vain, to bring the head into the natural pofition; for, this cannot be effected without firft
pushing up the part that prefents, for which purpose, great force is required; and as one hand only, can be introduced, when the ope rator endeavours to bring in the head, the pushing force is abated, to allow the pulling force to act; and the parts that hindered the head from prefenting, are again forced down: befides, the head is fo large and flippery, that he can obtain no firm hold. He might, indeed, by introducing a finger into the mouth, lay hold of the under jaw, and bring in the face, provided the fhoulder prefents; but, A a 4
in
instead of amending, this would make the cafe worse, unless the child be very fmall: yet, granting the head could be brought into the natural pofition, the force neceffarily exerted for this purpose would produce a flooding, which commonly weakens the patient and carries off the pains; and after all, he must turn with lefs advantage: and if that cannot be performed when the head is brought in, he must have recourse to the laft and most disagreeable method; whereas, when any other part presents, we can always turn the child, and deliver it by the feet. This we cannot promife after the head is brought in; and once the operator's hand is in the Uterus, he ought not to run fuch risks.
When I first began to practise, I frequently endeavoured to adjust the pofition of the head in this manner, but meeting with those infupportable difficulties I have mentioned, I adhered to that method which I have always found more certain and safe. I have likewise used the impellens of Albucafis, in order to keep up the shoulders or body until I could bring in the head; but, the contrac
tion was always fo great that the instrument flipt, and was in danger of hurting the Uterus. Indeed, when the ear, forehead, or the Fontanelle prefented, I have, by pushing found the head come into the right poup, fition: I have likewise, when the forehead was towards the groin or fide of the Pelvis, moved it more backwards, by which means the forceps were fixed with more ease; but I have much oftener failed, by the head's re-. turning to its former fituation.
The child is often in danger, and fometimes loft, when the breech prefents, and is low down in the Pelvis, provided the thighs are fo ftrongly preffed against the Funis and belly, as to ftop the circulation in the rope; as also, when the child is detained by the head, after the body is delivered: in both cafes, the danger must be obviated by an expeditious delivery; and if the body is entangled in the navel-ftring, it must be difengaged as well as poffible, especially when the Funis happens to be betwixt the thighs. As I have before obferved, many of thefe minute directions in laborious and præternatural cafes, may be thought idle and trifling
by those practitioners, who without minding any stated rules, introduce the forceps, and taking hold on the head at random, deliver with force and violence; and who, in præternatural deliveries, thruft up their hands into the Uterus, and without confidering the pofition, search for the feet, pull them down, and deliver in a hurry. Such practice may fometimes fucceed, but will often destroy the child, and bruise and injure the parts of the mother, even to the hazard of her life.
SECT. V.
THE legs and breech of the child being brought down, and the body properly turned with the foreparts to the mother's back, let the accoucheur endeavour to bring it along; but, if it is detained by the fize of the belly, diftended with air or water, (a cafe that frequently happens when the child has been dead for several days) let the belly be opened, by forcing into it the points of his fciffars; or, he with the open may tear it fharp crotchet.
The body of the child being delivered, the arms brought down, and every method
hitherto
hitherto directed, unfuccessfully used for the extraction of the head, which is detained by being naturally too large, over offified, or dropfical, or from the narrowness and diftortion of the Pelvis; if the belly was not opened, and the child is found to be alive by the motion of the heart, or pulfation of the arteries in the Funis, the forceps ought to be tried; but, if he finds it impracticable to deliver the head, fo as to fave the life of the child, he muft, according to fome, force the points of the fciffars through the lower part of the occipital bone, or through the Foramen magnum; then dilate the blades, fo as to enlarge the opening, and introduce a blunt or sharp hook. This operation rarely fucceeds when the head is over offified; but may anfwer the purpose when the bones are foft and yielding, or in the cafe of an hydrocephalus : because, in the firft, the aperture may fome.. times be enlarged, and in the other the water will be evacuated fo as to diminish the bulk of the head, which will, of confequence, come along with more cafe.
Whet
2m2
Some recommend an inftrument to perforate the fcull, with double points curved and
joined together; which, when pushed into the Foramen, are separated, and take hold on the infide; but, as the opening with the fciffars, and introducing the blunt hook, as above, will answer the fame end, it is needless to multiply inftruments, especially as this method is not so certain as the following.
If, notwithstanding these endeavours, the head cannot be extracted, let the operator introduce his hand along the head, and his fingers through the Os uteri; then flide up one of the curved crotches along the ear, betwixt his hand and the child's head, upon the upper part of which it must be fixed: this being done, let him withdraw his hand, take hold of the inftrument with one hand, turning the curve of it over the forehead, and with the other, grafp the neck and fhoulders, then pull along. The crotchet being thus fixed on the upper part, where the bones are thin and yielding, makes a large opening, through which the contents of the scull are emptied, the head collapfing is with more certainty extracted, and the inftrument hath a firm hold to the laft, at the forehead, Os petrofum, and bafis of the fcull.
In introducing the crotchet, let the operator remember the caution given in chap. III, fect. 5. he must not begin to pull, until he is certain that the point of the inftrument is properly fixed the Vertex; and he must upon keep the handle back to the Perinæum. The excellency of Mefnard's contrivance is more confpicuous here than when the head prefents; because the curvature of the crotchet allows the point to be fixed on the upper part of the fcull, which is to be tore open; and in pulling, the contents are evacuated, and the head is leffened by these means, the principal obftruction is removed; whereas, the ftreight crotchets take fo flight a hold, and flip fo often, that feveral times. I have been very much fatigued before I could effect the delivery; but have always fucceeded to my fatisfaction fince I adopted the other kind.
If one crotchet be found infufficient, let him introduce the other in the fame manner, along the oppofite fide, lock and join them together, and pull along, moving and turning the head, fo as to humour the shape of the Pelvis. This method feldom fails to ac
complish
complish his aim, though fometimes very great force is required; in which cafe, he muft pull with leifure and caution.
But, if all these expedients fhould fail, by reafon of the extraordinary offification or fize of the head, or the narrowness and diftortion of the Pelvis, after having used the crotchets without fuccefs, he muft separate the body from the head with a biftory or pair of fciffars; then pufhing up the head into the Uterus, turn the face to the Fundus, and the Vertex down to the Os internum and brim of the Pelvis: let him direct an affistant to press upon the woman's belly with both hands, in order to keep the Uterus and head firm in that pofition; then open the fcull with the fciffars, deftroy the structure of the brain, and extract with the crotchets, as directed in chap. III. fect. 5.
1
The head is frequently left in the Uterus by thofe practitioners, who not knowing how to turn the fore-parts and face of the child towards the back-part of the Uterus, or how to bring it along, although it presented in that pofition, pull at random with all their strength; fo that the neck is ftretched
PRÆTERNATURAL LABOURS. 367 ftretched and separated, and the head left behind. This may also happen to an expert accoucheur, when the child hath been dead for many days, and the body is much mortified, even though he hath ufed all the neceffary precautions.
In fuch a cafe, provided the head is not very large, nor the Pelvis narrow, and the forehead is towards the facrum, let him slide up his hand along the back-part of the Pelvis, and introducing two fingers into the mouth, with the thumb below the chin, try to pull the forehead into the hollow of the Sacrum: if it sticks at the jetting in of that bone, he must endeavour to move it, firft to one fide and then to the other. If the head is small it will come along; if any fragment of the neck remains, or any part of the loofe fkin, he may lay hold on it, and affift delivery, by pulling at it with his other hand; if the head is low down, it may be extracted with the forceps.
Should all these methods fail, let him push up his hand along the fide of the head, until it fhall have paffed the Os internum; with the other hand, let him introduce one of the 4 curved
curved crotchets, and fix it upon the upper part of the head; then, withdrawing the hand which was introduced, take hold on the inftrument, and fliding the fingers of the other hand into the mouth, he must pull down with both, as above directed. If the head is not over offified, the crotchet will tear open the fcull; and the bulk being of confequence diminished, the whole may be brought along, even in a narrow Pelvis: but, if it cannot be moved, even by this expedient, he must introduce the other crotchet along the other fide of the head, and fixing upon the fcull, lock them together; then in pulling, turn the forehead down into the hollow of the Sacrum, and extract with an half-round turn upwards, as when delivering with the forceps.
it
If the forehead is towards the Os pubis, and cannot be brought into the right pofition, let him, with his hand, push up the head into the Uterus; turn the forehead from the anterior to the fide or back-part of it, and try to extract as before. If the child hath been dead fome time, and is much mortified, he must pull cautiously at the under jaw;
be
because, should that give way, he will have no other hold for pulling, or keeping the head steady when he attempts to extract with one crotchet.
When the head is fo large, or the Pelvis fo narrow, that none of thefe methods will fucceed, let him push up, and turning the upper parts downwards, direct an affiftant to prefs the patient's belly with both hands, moving them from fide to fide, and squeezing in fuch a direction, as will force the head towards the Os internum, and retain it firmly in that pofition; then it must be opened and extracted, according to the directions given in chap. III. fect. 7. numb. 2.
Although by these means I have fucceeded in a few cafes of this kind, which have happened in my practice: yet, as great difficulties may occur from inflammations of the Pudenda, contraction of the Uterus, flipperinefs or largeness of the head, and the narrownefs of the Pelvis, it will not be improper to inform the reader of other methods that appear to me ufeful, particularly when the parts are much contracted and swelled. Let the hand be introduced into the Vagina, B b and
and if it cannot be admitted within the Uterus, the fingers being infinuated, may move the head fo as to raise the face and chin to the Fundus, the Vertex being turned to the Os internum, and the forehead towards the fide of the Sacrum. This being effected, let the operator flide up along one ear a blade of the long forceps, which are curved to the the fide; then change hands, and fend other blade along the oppofite ear: when they are locked, and the handles fecured with a fillet, he must pull the head as low as it will come; then putting them into the hands of an affiftant who will keep them in that pofition, let him make a large opening with the fciffars, fqueeze the head with great force, and extract slowly and by degrees.
up
There is an old inftrument with two fides which turn on a pivot, formerly recommended in this case, and fince improved with the addition of another fide, by Mr. Leveret, who gives it the denomination of tire-tête: but, as I thought the contrivance was too complex, and the blades too much confined to a circular motion, I have altered the form
of
of it, in a manner that renders it more fimple, convenient, and lefs expenfive. Having turned down the Vertex, as above directed, let this inftrument, with the three fides joined together, be introduced along the accoucheur's hand to the upper part of the head; then let the fides or blades be opened with the other hand, fo as to inclofe the head, moving them circularly and lengthways in a light and easy manner, that they may pafs over the inequalities of the fcalp, and avoid the refiftance of the head and Uterus: when they are exactly placed at equal distances from one another, let him join the handles, withdraw his hand, and tying them together with a fillet, pull down, open, and extract, as directed above; and let it be remembered, that the farther the hand can be introduced into the Uterus, the more eafily will both inftruments be managed.
When the Pelvis is large, or the head fmall (in which cafes this misfortune feldom happens) without doubt we might fucceed with Mauriceau's broad fillet or fling, provided it could be properly applied: but, upon trial I found my hand fo much cramped by the Bb 2
con
contraction of the Uterus, and was fo much incommoded by the flipperinefs of the head, upon which I could not fix it fo as to have fufficient hold, that after many fruitless efforts I was obliged to have recourse to the sciffars and crotchets, as above.
Amand's net is attended with the fame difficulties, and rather more troublesome, as it is more compounded: for, when it is mounted on the operator's hand, it will be found fcarce practicable to bring over the head the narrow fillet by which it is pulled along; because it commonly flides off on one fide or
the other.
If the Placenta adheres to the Uterus, let him first extract the head: if the cake is feparated, and in his way, let him deliver it before he begins to deliver the head.
When the head is fmall, or the Pelvis large, dilating the Foramen magnum with the fciffars, and introducing the blunt hook, may be of ufe either to pull the head along, or keep it down until we can fix the forceps, curve crotchet, or Leveret's tire-tête.
CHAP.
CHA P. V.
Of TWINS.
373
SECT. I.
Τ
WINS are fuppofed to be the effect of a double conception in one coition, when two or more Ova are impregnated with as many animalcula; which defcending from the Ovarium, through the Fallopian tube, into the Fundus uteri, as they increase, come in contact with that part, and with one another, and are fo preffed as to form one globular figure, and stretch the womb into the fame form which it affumes when diftended by one Ovum only, and that during the whole term of uterine geftation, it is impoffible to diftinguish twins, either by the figure and magnitude of the Uterus, or by the motion of the different Fatufes: for, one child, when it is large, and furrounded with a great quantity of waters, will fometimes produce as large a prominence (or even larger) in the woman's belly, than is commonly obferved when the is big with twins. One child will alfo, by moving its legs, arms, and other Bb 3
parts
parts of its body, against different parts of the Uterus, at the fame instant, or by intervals, yield the fame fenfation to the mother as may be observed in two or more children; for, part of the motion in twins is employed on each other, as well as upon the Uterus.
There is therefore no certain method of diftinguishing in these cafes, until the first child is delivered, and the accoucheur has examined if the Placenta is coming along. If this comes of itself, and after its extraction the mouth of the womb be felt contracted, and the operator is unwilling to give unnecesfary pain by introducing his hand into the Uterus; let him lay his hand upon the woman's Abdomen, and if nothing is left in the womb, he will generally feel it, just above the Os pubis, contracted into a firm round ball of the fize of a child's head, or lefs: whereas, if there is another child left, the fize will be found much larger. If the Placenta does not come down before the fecond child, which is frequently the cafe, upon examining, he will commonly feel the membranes with the waters pushed down through the Os uteri, or, if they are broke, the head, pr
fome
fome part of the body will be felt. If, therefore, the woman has ftrong pains, and is in no pronger from floodings or weakness, vided the head prefents fair, and seems to come along, fhe will be delivered of this alfo in the natural way.
If the membranes are not broke, if the head does not immediately follow, or if the child prefents wrong, he ought to turn and bring it immediately by the feet; in order to fave the patient the fatigue of a fecond labour, that may prove tedious and even dangerous, by enfeebling her too much. Befides, as the parts are fully opened by the firft delivery, he can introduce his hand with eafe; and as the membranes are, for the most part, whole, the waters may be kept up, and the Fatus eafily turned, as in chap. IV. fect. 2. but, if the Pelvis is narrow, the woman ftrong, and the head prefents, he ought to leave it to the efforts of nature.
If the firft child prefents wrong, and in turning that, he feels another, he must beware of breaking the membranes of one, while he is at work upon the other: but, should they chance to be broke, and the legs B b 4 of
*
of both entangled together, (though this is feldom the cafe, because they are commonly divided by two fets of membranes) let the operator, when he has got hold on two legs, run up his fingers to the breech, and feel if they belong to the fame body; and one child being delivered, let the other be turned and brought out in the fame manner. If there are more than two, the fame method muft Well take place, in extracting one after another. In cafe of twins, the Placenta of the first feldom comes along, until the fecond child is delivered: but, as this does not always happen, he ought, as formerly directed, to certify himself that there is nothing left in the Uterus, when the cake comes of itself. Both children being delivered, let him extract both Placentas, if they come not of themselves; and if they form diftinct cakes, separate first one, then the other; but if they are joined together, forming but one mafs, they may be delivered at once, as in chap. II. fect. 7.
Y
When there are three or four children, (a cafe that rarely happens) the Placentas are fometimes diftinct, and fometimes all together form
form but one round cake: but, when this is macerated in water for fome days, they, with their several membranes, may be easily feparated from one another; for they only adhere in confequence of their long preffure in the Uterus, and feldom have any communication of veffels: although fuch a communication hath lately fallen under my obfervation. Vide book I. chap. 3. fect. 5.
Twins for the moft part lie diagonally in the Uterus, one below the other; fo that they feldom obftruct one another at the Os internum.
SECT. II. Of MONSTERS. 
TWO children joined together by their bellies, (which is the most common
g
cafe of monftrous births) or by the fides, or when the belly of the one adheres to the back of the other, having commonly but one Funis, are comprehended in this clafs, and fuppofed to be the effect of two Animalcula impregnating the fame Ovum, in which they grow together, and are nourished by one na
vel-ftring, originally belonging to the Secundines; becaufe, the veffels pertaining to the coats of the vein and arteries, do not anaftomofe with the veffels belonging to the Fatus.
In fuch a cafe, where the children were fmall, the adhefion hath been known to ftretch in pulling at the feet of one, so as to be delivered; and the other hath been afterwards brought along, in the fame manner, without the neceffity of a feparation.
When the accoucheur is called to a cafe of this kind, if the children are large, and the woman come to her full time, let him first attempt to deliver them by that method; but if, after the legs and part of the body of the first are brought down, the reft will not follow, let him flide up his hand, and with his fingers examine the adhesion ¿ then introducing the fciffars between his hand and the body of the Fatus, endeavour to feparate them by fnipping through the juncture. Should this attempt fail, he muft diminish the bulk in the best manner he can think of, and bring the body of the firft, in different pieces, by pulling or cutting them afunder, as he extracts with the help of the crotchet.
No
No certain rules can be laid down in these cafes, which seldom happen, and therefore a great deal must be left to the judgment and fagacity of the operator, who muft regulate his conduct according to the circumftances of the cafe, and according to the directions. given for delivering, when the Pelvis is narrow and the children extraordinary large.
Formerly, practitioners ufed ftreight and crooked knifes, with long handles, which were introduced into the Uterus along the hand, in order to cut and divide the bodies of children, that they might be extracted piecemeal and this cruel practice obtained even in some cafes, which now we can manage with ease and fafety, by turning and delivering the Fatus by the feet. But, no doubt, fome will happen in which it is impoffible to preferve or deliver the children without the help of inftruments; and in fuch an emergency, the fciffars are much fafer than knives, with which the operator runs the risk of cutting the Uterus or himself: whereas he is expofed to no fuch hazard from the other, which cut only betwixt the points. duob 7167008
C
SECT.
Den
SECT. III.
Of the CESARIAN OPERATION.
***
WHEN
HEN a woman cannot be delivered by any of the methods hitherto defcribed and recommended in laborious and præternatural labours, on account of the narrowness or distortion of the Pelvis, into which it is sometimes impoffible to introduce the hand; or from large excrefcences and glandular swellings that fill up the Vagina, and cannot be removed or from large cicatrices and adhefions in that part, and at the Os uteri, which cannot be feparated in fuch emergencies, if the woman is ftrong, and of a good habit of body, the Cæfarian operation is certainly adviseable, and ought to be performed; because the mother and child have no other chance to be faved, and it is better to have recourse to an operation which hath fometimes fucceeded, than leave them both to inevitable death. Nevertheless, if the woman is weak, exhaufted with fruitlefs labour, violent floodings, or any other evacuation, which renders her recovery doubtful, even if he were deTOME,
livered
livered in the natural way in these circumstances, it would be rafhnefs and prefumption to attempt an operation of this kind, which ought to be delayed until the woman expires, and then immediately performed, with a view to fave the child.
The operation hath been performed both in this and the laft century, and sometimes with fuch fuccefs, that the mother has recovered, and the child furvived. The previous steps to be taken, are to strengthen the patient, if weak, with nourishing broths and cordials; to evacuate the indurated Faces with repeated glyfters; and if the bladder is diftended with urine, to draw it off with a catheter. These precautions being taken, she must be laid on her back, on a couch or bed, her fide on which the incifion is to be made, being raised up by pillows placed below the oppofite fide: the operation may be performed on either fide, though the left is commonly preferred to the right; because, in this laft, the liver extends lower. The apparatus confifts of a biftory, probe-fciffars, large needles threaded, fpunges, warm water, pledgets, a large tent or doffil, compreffes, and a bandage for the belly.
If
If the weather is cold, the patient must be kept warm, and no part of the belly uncovered, except that on which the incifion is to be made: if the operator be a young practitioner, the place may be marked by drawing a line along the middle fpace between the navel. and the Os ilium, about fix or feven inches in length, flanting forwards towards the left groin, and beginning as high as the navel.
According to this direction, let him hold the fkin of the Abdomen tenfe between the finger and thumb of one hand, and with the bistory in the other, make a longitudinal incifion through the Cutis to the Membrana adipofa, which, with the muscles, must be flowly diffected and separated, until he reaches the Peritoneum, which must be divided very cautiously, for fear of wounding the intestines that frequently start up at the fides, especially if the membranes are broke, the waters dif charged, and the Uterus contracted.
The Peritoneum being laid bare, it may either be pinched up by the fingers, or flowly diffected with the biftory, until an opening is made fufficient to admit the fore-finger, which must be introduced as a director for the bistory
3
bistory or fciffarsin making an effectual dilatation. If the intestines pufh out, let them be prefsed downwards, fo as that the Uterus may come in contact with the opening. If the womb. is ftill diftended with the waters, and at fome diftance from the child, the operator may make upon it a longitudinal incifion at once; but if it is contracted close round the body of the Fatus, he must pinch it up, and dilate in the fame cautious manner practifed upon the Peritoneum, taking care to avoid wounding the Fallopian tubes, ligaments, and bladder: then introducing his hand, he may take out the child and Secundines. If the woman is ftrong, the Uterus immediately contracts, fo as that the opening, which at first extended to about fix or feven inches, is reduced to two, or lefs; and in confequence of this contraction, the veffels being fhrunk up, a great effufion of blood is prevented.
The coagulated blood being removed, and what is ftill fluid fpunged up, the incision in the Abdomen must be ftitched with the interrupted Suture, and fufficient room left between the last stitch and the lower end of the opening, for the discharge of the moif
tur
*
ture and extravafated fluid. The wound may be dreffed with dry pledgets or doffils dipped in fome liquid balfam warmed, covered with compreffes moistened with wine, and a bandage to keep on the dreffings and fuftain the belly. Some authors obferve, that the Cutis aud muscles only should be taken up in the Suture, left bad fymptoms should arise from ftitching the Peritoneum.
The woman must be kept in bed, as quiet as poffible, and every thing adminiftred to promote the Lochia, perspiration, and fleep; which will prevent a fever, and other dangerous fymptoms. If the hath loft a great quantity of blood from the wounds in the Uterus and Abdomen, fo as to be in danger from inanition, broths, caudles, and wine, ought to be given in small quantities, and frequently repeated; and the Cort. peruvian. adminiftred in powder, decoction, or extract, may be of great fervice in this cafe. For farther information on this fubject, the reader may confult Ruffetus, the memoirs of the academy of furgeons at Paris, and Heifter's furgery.
BOOK IV.
CHAP. I.
Of the Management of Women from the Time of their Delivery to the End of the Month, with the feveral Difeafes to which they are fubject during that Period.
SECT. I.
Of the EXTERNAL APPLICATION.
TH
HE woman being delivered of the child and Placenta, let a foft linnen cloth, warmed, be applied to the external parts; and if the complains much of a smarting forenefs, fome pomatum may be fpread upon it. The linnen that was laid below her, to fpunge up the discharges, muft be removed, and replaced with others that Ce
are
are clean, dry, and warm. Let her lie on her back, with her legs extended close to each other; or upon her fide, if she thinks she can lie easier in that pofition, until she recovers from the fatigue: if she is spent and exhausted, let her take a little warm wine or caudle, or, according to the common custom, some nutmeg and sugar grated together in a spoon: the principal design of adminiftring this powder, which among the good women is feldom neglected, is to fupply the want of fome cordial draught, when the patient is too weak to be raised, or supposed to be in danger of reachings from her ftomach's being over-loaded. When she hath, in some measure, recovered her strength and fpirits, let the cloaths be removed from the parts, and others applied in their room; and if there is a large discharge from the Uterus, let the wet linnen below her, be also shifted, that she may not run the rifque of catching hold.
When the patient is either weak or faintish, the ought not to be taken out of bed, or even raifed up to have her head and body shifted,
until fhe is a little recruited; otherwise, she will be in danger of repeated faintings, attended with convulfions, which sometimes end in death. To prevent these bad consequences, her skirt and petticoats ought to be loofened and pulled down over the legs, and replaced by another well warmed, with a broad head-band to be flipt in below, and brought up over her thighs and hips: a warm double cloth must be laid on the belly, which is to be furrounded by the head-band of the fkirt pinned moderately tight over the cloth, in order to comprefs the Vifcera and the relaxed Parietes of the Abdomen, more or less, as the woman can eafily bear it; by which means, the Uterus is kept firm in the lower part of the Abdomen, and prevented from rolling from fide to fide, when the patient is turned: but, the principal end of this compreffion, is to hinder too great a quantity of blood from rushing into the relaxed, veffels of the Abdominal contents; efpecially when the Uterus is emptied all of a fudden, by a quick delivery. The preffure being thus fuddenly removed, the head is all at once robbed of its proportion of blood, and the Cc 2 im
immediate revulfion precipitates the patient into dangerous Lypothymias.
For this reafon, the belly ought to be firmly compreffed by the hands of an affiftant, until the bandage is applied; or, in lieu of it, a long towel, fheet, or roller, to make a fuitable compreffion: but, for this purpose, different methods are used in different countries, or according to the different circumftances of the patients. The head-cloths and fhift ought alfo to be changed, because with sweating in time of labour, they are rendered wet and difagreeable. Several other applications are neceffary, when the external or internal parts are rent or inflamed, misfortunes that fometimes happen in laborious and præternatural cafes.
The directions for ordering the bed in time of labour, and of the applications after delivery, are abfolutely neceffary to be known. by young practitioners; because, all these precautions are for the ease and safety of the patient, when attended by unexperienced nurses.
NUMB.
NUMB. I.
INFLAMMATIONS of the Labia pudendi, Rectum, Urethra, Vagina, and Uterus, chiefly happen when the head, fhoulder, breech, or any other part of the Fatus, hath been forced into the Pelvis, and long retained in that fituation; fo that by many and strong pains, the delivery was effected, or great force and violence were required to turn or extract the child. Thefe inflammations, if flight, are commonly relieved, or altogether refolved, by a plentiful difcharge of the Lochia, reft, and profuse sweating; but if violent, blooding, warm fomentations, cataplafms, and emollient glyfters, may be neceffary; though the first and last must be used with caution.
If the preffure hath been fo great, as totally to obftruct the circulating fluids in those parts, a mortification enfues; either total, by which the woman is foon destroyed, or partial, when the mortified parts feparate and caft off in thick floughs, then digeft and are healed as a common fore, provided the patient be of a good habit of body: but, if the oppofite parts are alfo affected in the C¢ 3
fame
,
same manner, and both fides preffed together; as for example, in the Uterus, Os internum, Vagina, or Os externum, or, if the internal membrane of the whole inner surface, floughs off, then there is danger of a coalefcence or growing together, by which are formed callofities; and thefe, if they happen in the Os internum, Vagina, or Os externum, will produce difficult and dangerous labours in the next parturition; and if in the Uterus, will altogether prevent conception, though this rarely happens, because of the continual draining of the moisture that is discharged from the womb. In order to avoid this mifchance, emollient injections ought frequently to be thrown up into the Uterus, and large tents or doffils, dipt in vulnerary balfams, applied in the Vagina and Os ex
ternum.
NUMB. II.
IF, in confequence of the long preffure of the child's head, at that part of the Vagina where its outward furface is attached to the back and under part of the bladder, the mortification affects the coats of the Vefica urina
ria, as well as thofe of the Vagina, when the floughs fall off, the urine will pass that way, and hinder the opening (if large) from being closed; this is an inexpreffible inconvenience and misfortune to the poor woman, both from the smell and continual wetting of her cloaths. The Vagina and bladder may also be lacerated by the forceps, crotchet, or any other inftrument imprudently forced up; but, in that cafe, the urine is immediately discharged through the wound; whereas, in a mortification, it comes in a natural way, until the flough begins to feparate and fall off.
As foon as this misfortune is known, the cure ought to be attempted: this (according to fome) confifts in keeping a flexible catheter always in the bladder, that the urine may be continually folicited to come through the Urethra, rather than through the Vagina; but, if this precaution hath been neglected, and the lips of the ulcer are turned callous, we are directed to pare them off with a curve knife, buttoned at the point, or confume them with lunar cauftick; and if the opening is large, to close it with a double ftitch, Cc 4
keep
keeping the flexible catheter in the bladder until it is entirely filled up: but, I wish this operation may not be found impracticable.
NUMB. III:
THE Os externum is frequently tore, particularly at the Perinæum; and sometimes, the laceration reaches to the Anus. At other times, (but more feldom) both Vagina and Rectum are tore for the space of two or three inches upwards, and the two form but one cavity at the lower part. This laceration is frequently occafioned from the exceffive largeness of the child's head; from the rigidity of the fibres in women, who are near the borders of forty when their first children are born; from the accoucheur's neglecting to slide the Perinæum over the head, when it is forcibly propelled by the pains, or from his omitting to keep up the head with the flat of his hand, that it may not come too fuddenly along; from too great violence used in laborious or præternatural labours; and from the operator's incautious manner of thrufting in his hand. If the laceration be fmall, the part foon heals up, and the only inconvenience
at
attending the wound, is a fmarting after making water; and when the laceration is large, extending to the edge of the Sphincter ani, or even farther, this pain is still more troublesome, and increased upon the least motion, by the friction of the lips against each other. This disagreeable rubbing, is (according to fome writers) prevented by making two deep ftitches that will keep the lips together but, in this cafe, we can feldom cure by the firft intention, on account of the moisture that is continually paffing that way; namely, the Lochia and urine, that infinuate themselves into the wound. Befides, the lips are tore and ragged, and the hold we have is but flender.
In the third case, it is supposed, that there is an abfolute neceffity to make, as soon as poffible, two, three, or fometimes four deep stitches through the tore Vagina and Rectum, the knots being tied in the Vagina, and two more stitches in the Perineum, to affift the re-union of the parts: for, if the Sphincter ani is entirely feparated, and continues in that condition, the patient can feldom retain her excrements for any length of time. If this
misfortune fhould remain unknown, or the operation unperformed, on account of the woman's weakness, until the lips of the wound are grown callous, these callous edges must be pared off with fciffars; or, if that should be found impracticable, scarified with the point of a lancet or biftory, and then ftitched, as above directed: and the ftitches must be made very deep, otherwise they will not hold; because, there is but little muscular flesh in the Vagina and Rectum : but, the Colon ought first to be emptied with glyfters, and the patient take little or no solid food, that the stitches may not be overstrained when she goes to ftool. When the laceration reaches fo high, as to endanger the woman's retentive faculty, this method, doubtlefs, ought to be tried; but, not otherwise, because the operation very rarely fucceeds.
When the Os internum is tore from the fame caufes, all that can be done, is to keep the patient strictly to the regimen we have directed for women after delivery, and take care that she shall move as little as poffible during the first three weeks.
The
The rents or lacerations that happen to the Uterus, are of more dangerous confequence, and, indeed, commonly accounted mortal; therefore, they demand the utmost care and circumfpection, in all the different cafes. If the patient is plethoric, fhe ought to be blooded, in order to prevent a fever, unless she hath undergone a confiderable difcharge from the Uterus; the ought to be kept very quiet and motionless, to take nothing but fpoon-meat, and even of that, a little at a time; drink diluting liquors, such as barley-water, and very weak broths.
SECT. II.
Of Air, Diet, Sleeping, and Watching, Motion and Reft, Retention and Excretion, and the Paffions of the Mind.
Although we cannot remove the patient immediately after delivery into another climate, we can qualify the air, so as to keep it in a moderate and falutary temper, by rendering it warm or cold, moift or dry, according to the circumftances of the occafion.
With regard to diet, women in time of labour, and even till the ninth day after delivery, ought to eat little folid food, and none at all during the first five or seven let them drink plentifully, of warm, diluting fluids, fuch as, barley-water, gruel, chicken-water, and teas; caudles are alfo commonly used, compofed of water-gruel boiled up with mace and cinnamon, to which, when strained, is added a third or fourth part of white wine, or less, if the patient drinks plentifully, fweetened with fugar to their tafte: this compofition is termed white caudle; whereas, if ale is used instead of wine, it goes under the name of brown caudle. In fome countries, eggs are added to both kinds but, in that cafe, the woman is not permitted to eat meat or broths till after the fifth or feventh day in this country, however, as eggs are no part of the ingredients, the patient is indulged with weak broth sooner, and fometimes allowed to eat a little boiled chicken. But, all thefe different preparations are to be prescribed weaker or ftronger, with regard to the fpices, wine, or ale, according to the different conftitutions and fituations of
¿
3
dif
112

different patients: for example; if she is low and weak, in confequence of an extraordinary discharge of any kind, either before or after delivery; or, if the weather is cold, the caudles and broths may be made the stronger: but if she is of a full habit of body, and has the leaft tendency to a fever, or if the season is exceffively hot, these drinks ought to be of a very weak confiftence; or, the patient restricted to gruel, tea, barley and chickenwater, and these varied according to the emergency of the cafe.
Her food must be light and easy of digeftion, fuch as panada, biscuit, and fago: about the fifth or feventh day fhe may eat a little boiled chicken, or the lightest kind of young meat but, these last may be given fooner or later, according to the circumstance of the cafe, and the appetite of the patient. In the regimen as to eating and drinking, we should rather err on the abftemious fide, than indulge the woman with meat and strong fermented liquors, even if these last should be most agreeable to her palate: for we find by experience, that they are apt to increase or bring on fevers, and that the most nou
rifhing
rishing and falutary diet, is that which we have above prescribed. Every thing that is difficult of digeftion, or quickens the circu→ lating fluids, muft of neceffity promote a fever; by which, the neceffary discharges are obftructed, and the patient's life endangered.
As to the article of fleeping and watching, the patient must be kept as free from noise as poffible, by covering the floors and stairs with carpets and cloths, oiling the hinges of the doors, filencing the bells, tying up the knockers, and in noisy streets ftrow_ ing the pavement with ftraw; if notwithstanding these precautions, she is disturbed, her ears must be ftuffed with cotton, and opiates administred to procure fleep; because, watching makes her reftlefs, prevents perfpiration, and promotes a fever.
Motion and reft are another part of the nonnaturals, to which we ought to pay particular regard. By toffing about, getting out of bed, or fitting up too long, the perspiration is difcouraged and interrupted; and in this last attitude, the Uterus, not yet fully contracted, hangs down, ftretching the ligaments, occafioning pain, cold fhiverings, and
a
a fever for the prevention of these bad fymptoms, the patient must be kept quiet in bed till after the fourth or fifth day, and then be gently lifted up in the bed-cloaths, in a lying posture, until the bed can be adjusted, into which she must be immediately reconveyed, there to continue, for the most part, till the ninth day; after which period, women are not fo fubject to fevers, as immediately after delivery. Some there are, who from the nature of their conftitutions, or other accidents, recover more flowly; and fuch are to be treated with the fame caution after, as before, the ninth day, as the cafe feems to indicate: others get up, walk about and recover, in a much fhorter time; but these may, fome time or other, pay dearly for their foolhardinefs, by encouraging dangerous fevers: fevers: fo that we ought rather to err on the safe fide, than run any risque whatsoever.
What next comes under confideration, is the circumftance of retention and excretion. We have formerly observed, that in time of labour, before the head of the child is locked into the Pelvis, if the woman has not had eafy
eafy paffage in her belly that fame day, the Rectum and Colon ought to be emptied by a glyfter, which will affift the labour, prevent the disagreeable excretion of the Faces before the child's head, and enable the patient to remain two or three days after, without the neceffity of going to ftool. However, fhould this precaution be neglected, and the patient very coftive after delivery, we must beware of throwing up stimulating glyfters, or administring strong catharticks, left they should bring on too many loose ftools, which, if they cannot be stopt, fometimes produce fatal confequences, by obftructing the perfpiration and Lochia, and exhaufting the woman, fo as that she will die all of a fudden ; a catastrophe which hath frequently happened from this practice. Wherefore, if it be neceffary to empty the inteftines, we ought to prescribe nothing but emollient glyfters, or fome very gentle opener, fuch as manna, or Elect. Lenitivum: for the retention of urine that sometimes happens after labour, we have already propofed a remedy in book II. chap. 2. and sect. 3. But no excretion is of more confequence to the patient's recovery,
than
than a free perfpiration; which is so abfolutely neceffary, that unlefs fhe has a moifture continually on the furface of her body, for fome days after the birth, fhe feldom recovers to advantage: her health, therefore, in a great measure depends upon her enjoying undisturbed repose, and a constant breathing fweat, which prevents a fever, by carrying off the tenfion, and affifts the equal discharge of the Lochia: and when these are obstructed, and a fever enfues with pain and restlessnefs, nothing relieves the patient fo effectually as reft and profuse sweating, procured by opiates and fudorificks at the beginning of the complaints; yet, these last must be more cautiously prescribed in exceffive hot, than in cool weather.
The laft of the nonnaturals to be confidered, are the paffions of the mind, which alfo require particular attention. The patient's imagination must not be disturbed by the news of any extraordinary accident which may have happened to her family or friends: for fuch information hath been known to carry off the labour pains intirely, after they were begun, and the woman has funk under her D d de
dejection of fpirits; and even after delivery, thefe unfeasonable communications have produced fuch anxiety as obftructed all the neceffary excretions, and brought on a violent fever and convulfions, that ended in death.
SECT. III.
Of violent FLOODINGS.
ALL women, LL women, when the Placenta separates, and after it is delivered, lofe more or lefs red blood, from the quantity of half a pound, to that of one pound, or even two ; but should it exceed this proportion, and continue to flow without diminution, the patient is in great danger of her life: this hazardous hæmorrhage is known by the violence of the discharge, wetting fresh cloths as fast as they can be applied; from the pulse becoming low and weak, and the countenance turning pale; then the extremities grow cold, fhe finks into faintings, and, if the difcharge is not fpeedily ftopt, or diminished, is feized with convulfions, which often terminate in death.
This dangerous efflux is occafioned by every thing that hinders the emptied Uterus
from
from contracting, fuch as, great weakness and laffitude, in confequence of repeated floodings before delivery; the fudden evacu- ation of the Uterus; fometimes, though fel- dom, it proceeds from part of the Placenta's being left in the womb: it may happen when there is another child, or more, ftill undeli- vered; when the womb is kept diftended with a large quantity of coagulated blood; or when it is inverted by pulling too forcibly at the Placenta.                   Vide book II. chap. 3. 
fect. 3.
"
In this cafe, as there is no time to be lost, and internal medicines cannot act so fuddenly as to answer the purpose, we must have immediate recourfe to external application. If the diforder be owing to weakness, by which the Uterus is difabled from contracting itself, fo that the mouths of the veffels are left open; or, though contracted a little, yet not enough to restrain the hæmorrhage of the thin blood; or if, in feparating the Placenta, the accoucheur has fcratched or tore the inner furface or membrane of the womb; in these cafes, fuch things must be ufed as will affift the contractile power of Dd 2 the
the Uterus, and hinder the blood from flowing so fast into it and the neighbouring veffels for this purpose, cloths dipped in any cold reftringent fluid, fuch as oxycrate, or red tart wine, may be applied to the back and belly. Some prescribe venæfection in the arm, to the amount of five or fix ounces, with a view of making revulfion: if the pulse is ftrong, this may be proper; otherwise, it will do more harm than good: others order ligatures, for compreffing the returning veins at the hams, arms, and neck, to retain as much blood as poffible in the extremities and head. Besides these applications, the Vagina may be filled with tow or linnen rags, dipped in the above mentioned liquids, in which a little allum, or Sachar-saturni hath been diffolved: nay, fome practitioners inject proof spirits warmed, or, foaking them up in a rag or spunge, introduce and squeeze them in the Uterus, in order to conftringe the veffels.
If the flooding proceeds from another child, the retention of the Placenta, or coagulated blood, thefe ought immediately to be extracted, and if there is an inverfion of
the Uterus, it must be fpeedily reduced. Should the hæmorrhage, by thefe methods, abate a little, but ftill continue to flow, though not in fuch a quantity as to bring on fudden death, fome red wine and jelly ought to be prescribed for the patient, who should take it frequently, and a little at a time; but, above all things, chicken or mutton broths, adminiftred in the fame manner, for fear of overloading the weakened ftomach, and occafioning reachings: these repeated in small quantities, will gradually fill the exhausted veffels, and keep up the circulation. If the pulfe continues strong, it will be proper to order repeated draughts of barley-water, acidulated with Elixir vitriol: but if the circulation be weak and languid, extract of the bark diffolved in Aq. cinnamomi tenuis, and given in small draughts, or exhibited in any other form, will be ferviceable; at the fame time, lulling the patient to reft with opiates. These, indeed, when the first violence of the flood is abated, if properly and cautiously used, are generally more effectual than any other medicine,
Dd 3
SECT.
SECT. IV.
Of the AFTER-PAINS.
A Fter-pains commonly happen when the
fibrous part of the blood is retained in the Uterus or Vaging, and formed into large clots, which are detained by the fudden contraction of the Osinternum and externum, after the Placenta is delivered: or, if these should be extracted, others will fometimes be formed, though not fo large as the firft, because the cavity of the wombis continually diminishing after the birth. The Uterus, in contracting, preffes down these coagulums to the Os internum; which being again gradually stretched, produces a degree of labour-pains, owing to the irritation of its nerves: in confequence of this uneafinefs, the woman fqueezes the womb as in real labour; the force being increafed, the clots are pushed along, and when they are delivered, the grows eafy. The larger the quantity is of this coagulated blood, the feverer are the pains, and the longer they continue.
Women in the first child, feldom have after pains; because, after delivery, the womb
is fuppofed to contract, and push off the clots with greater force in the firft, than in the following labours: after-pains may alfo proceed from obftructions in the veffels, and irritations at the Os internum. In order to prevent or remove thefe pains, as foon as the Placenta is feparated and delivered, the hand being introduced into the Uterus, may clear it of all the Coagula. When the womb is felt through the Parietes of the Abdomen larger than ufual, it may be taken for granted, that there is either another child, cr a large quantity of this clotted blood; and which foever it may be, there is a neceffity for its being extracted. If the Placenta comes away of itself, and the after-pains are violent, they may be alleviated and carried off by an opiate: for, by fleeping and sweating plentifully, the irritation is removed, the evacuations are increased, the Os uteri is infenfibly relaxed, and the Coagula slide easily along. When the discharge of the Lochia is fmall, the after-pains, if moderate, ought not to be restrained; because, the squeezing which they occafion, promotes the other evacuation, which is neceffary for the recovery Dd 4 of
of the patient.
After-pains may alfo proceed from an obftruction in fome of the veffels, occafioning a fmall inflammation of the Os internum and ligaments; and the fqueezing thereby occafioned, may not only help to propel the obftructing fluid, but also (if not too violent) contribute to the natural discharges.
SECT. V.
Of the LOCHIA.
WE have already observed, that the delivery of the child and Placenta is followed by an efflux of more or lefs blood, discharged from the Uterus, which, by the immediate evacuation of the large veffels, is allowed to contract itself the more freely, without the danger of an inflammation, which would probably happen in the contraction, if the great veffels were not emptied at the same time: but, as the fluids in the smaller veffels cannot be fo foon evacuated, or returned into the Vena cava, it is neceffary, that after the great discharge is abated, a flow and gradual evacuation, fhould continue, until the womb. fhall
fhall be contracted to near the fame fize which it had before pregnancy; and to this it attains about the eighteenth or twentieth day after delivery, though the period is different in different women.
When the large veffels are emptied immediately after delivery, the discharge frequently ceafes for feveral hours, until the fluids in the smaller veffels are propelled into the larger, and then begins to flow again, of a paler colour.
The red colour of the Lochia commonly continues till the fifth day, though it is always turning more and more ferous from the beginning; but, about the fifth day, it flows of a clear, or fometimes (though feldom) of a greenish tint: for, the mouths of the veffels growing gradually narrower, by the contraction of the Uterus, at laft, allow the ferous part only to pass: as for the greenish hue, it is fuppofed to proceed from a diffolution of the cellular or cribriform membrane or Mucus, that furrounded the furface of the Placenta and Chorion; part of which, being left in the Uterus, becomes livid, decays, and
dif
diffolving, mixes with and tinctures the difcharge as it passes along.
Though the Lochia, as we have already obferved, commonly continue to the eighteenth or twentieth day, they are every day diminishing in quantity, and fooneft cease in those women who fuckle their children, or have had an extraordinary discharge at first ; but the colour, quantity, and duration, differ in different women: in fome patients, the red colour disappears on the firft or second day; and in others, though rarely, it continues more or lefs to the end of the month: the evacuation in fome is very fmall, in others exceffive; in one woman it ceases very foon, in another, flows during the whole month: yet, all of thefe patients thall do well.
Some alledge, that this discharge from the Uterus, is the fame with that from a wound of a large furface; but it is more reasonable to fuppofe, that the change of colour and diminution of quantity, proceeds from the flow contraction of the veffels: because, previous to Pus, there must have been lacerations or impofthumes, and in women who have fuddenly died after delivery, no wound or excoriation
coriation hath appeared upon the inner furface of the womb, which is fometimes found. altogether smooth, and at other times rough and unequal on that part to which the Placenta adhered. The space that this occupied before delivery, from being fix inches in diameter, or eighteen inches in circumference, will foon after the birth, be contracted to one third or fourth of these dimenfions.
VI.
SECT.
Of the MILK FEVER.
BOUT the fourth day, the breafts generally begin to grow turgid and painful. We have formerly obferved, that during the time of uterine geftation, the breasts in moft women gradually increase till the delivery, growing fofter as they are enlarged by the veffels being more and more filled with fluids; and by this gradual diftention, they are prepared for fecreting the milk from the blood, after delivery. During the two or three first days after parturition, especially when the woman has undergone a large dif
charge,
charge, the breafts have been fometimes obferved to fubfide and grow flaccid; and about the third or fourth day, when the Lochia begin to decrease, the breasts swell again to their former fize, and stretch more and more, until the milk, being fecreted, is either fucked by the child, or frequently of itself runs out at the nipples.
Moft of the complaints incident to women after delivery, proceed either from the obftruction of the Lochia in the Uterus, or of the milk in the breafts, occafioned by any thing that will produce a fever; fuch as catching cold, long and fevere labour, eating food that is hard of digeftion, and drinking fluids that quicken the circulation of the blood in the large veffels; by which means, the fmaller, with all the fecretory and excretory ducts, are obftructed.
The discharge of the Lochia being fo different in women of different conftitutions, and befides in fome measure depending upon the method of management, and the way of life peculiar to the patient, we are not to judge of her fituation from the colour, quantity, and duration of them, but from the
other
other symptoms that attend the difcharge; and if the woman feems hearty, and in a fair way of recovery, nothing ought to be done with a view to augment or diminish the evacuation. If the discharge be greater than she can bear, it will be attended with all the fymptoms of inanition; but, as the Lochia feldom flow fo violently, as to destroy the patient of a fudden, she may be supported by a proper, nourishing diet, affifted with cordial and restorative medicines. Let her, for example, ufe broths, gellies, and affes milk; if the pulfe is languid and funk, fhe may take repeated doses of the Confect. Cardiac, with mixtures compofed of the cordial waters and volatile spirits: Subaftringents and opiates frequently adminiftred, with the Cort. Peruvian. in different forms, and auftere wines are of great fervice. On the other hand, when the discharge is too small, or hath ceafed altogether, the fymptoms are more dangerous, and require the contrary method of cure: for, now the business is to remove a too great plenitude of the veffels in and about the Uterus, occafioning tenfion, pain, and labour, in the circulating fluids;
from
from whence proceed great heat in the part, restlefsness, fever, a full, hard, quick pulfe, pains in the head and back, nausea, and difficulty in breathing. Thefe complaints, if not at first prevented, or removed by rest and plentiful fweating, must be treated with venæsection and the antiphlogistic method.
When the obstruction is recent, let the patient lie quiet, and encourage a plentiful diaphorefis, by drinking frequently of warm, weak, diluting fluids, fuch as water-gruel, barley water, tea, or weak chicken broth : fhe may likewise take opiates and fudorifics in different forms, as may be agreeable to her ftomach. Theriac. Androm. from zß to 31. Laud. liquid. from gut. x. to gut. xx. Pilul. Saponac. from gr. v. to gr. x. or Syr. de Meconio. from 3B. to 3i. These may be repeated occafionally, with other forms of opiates; and if they fail to procure rest and fweating, the following diaphoretics, without opium, ought to be adminiftred.
R Pulv. Contrayerv. Com. 3B. Pulv. Caftor. Ruff. Sal. Succin. aa gr. v. Syr. Croci q. f. f. Bolus ftatim fumendus cum haust. fequent. et
rea
repetat. quarta vel fexta quaque hora ad tres vices vel ut opus fuerit.
R Aq. Cinnamom. ten 3iß. cum fpiritu. Syr. croci äā zij. adde Sal. vol. C C. gr. iv. m.
Should these methods be used without fuccefs, and the patient, far from being relieved by reft, plentiful fweating, or a fufficient difcharge of the obftructed Lochia, labour under an hot, dry fkin, anxiety, and a quick, hard, and full pulfe, the warm diaphoretics must be laid afide; because, if they fail of having the defired effect, they muft neceffarily increase the fever and obftruction, and recourse be had to bleeding at the arm or ancle, to more or lefs quantity, according to the degree of fever and obftruction; and this evacuation must be repeated as there is occafion: When the obftruction is not total, it is fuppofed more proper to bleed at the ancle than at the arm; and at this laft, when the discharge is altogether ftopped. Her ordinary drink ought to be impregnated with nitre, and the following draughts, or others of the fame kind, prescribed.
R Sal. Abfynth. 9i. Succ. Limon. 38. Aq. Cinnamom. fimp. ziß. Pulv, Contrayerv.
comp.
comp. i. Sacch. Alb. q. f. f. Hauftus ftatim fumendus, et quarta vel fexta quaque bora repetendus.
If fhe is coftive, emollient and gentlyopening glyfters may be occafionally injected; and her breasts must be fomented and fucked, either by the mouth or pipe-glaffes. If, by thefe means, the fever is abated, and the neceffary discharges return, the patient commonly recovers; but, if the complaints continue, the antiphlogistic method must still be pursued. If, notwithstanding these efforts, the fever is not diminished or removed by a plentiful discharge of the Lochia from the Uterus, the milk from the breafts, or by a critical evacuation by fweat, urine or stool, and the woman is every now and then attacked with cold fhiverings; an abscessor abfceffes will probably be formed in the Uterus or neighbouring parts, or in the breafts; and fometimes, the matter will be tranflated to other fituations, and the feat of it foretold from the part's being affected with violent pains: these abfceffes are more or lefs dangerous, according to the place in which they
hap
happen, the largeness of the suppuration, and the good or bad conftitution of the patient. If, when the pains in the epigastric region are violent, and the fever increased to a very high degree, the patient should all of a fudden, enjoy a ceffation from pain, without any previous discharge, or critical eruption, the phyfician may pronounce that a mortification is begun; especially, if, at the fame time, the pulfe becomes low, quick, wavering, and intermitting if the woman's countenance, from being florid, turns dufky and pale, while she herself, and all the attendants, conceive her much mended; in that cafe, she will grow delirious, and die in a very short
time.
What we have faid on this subject, regards that fever which proceeds from the obstructed Lochia, and in which the breafts may likewise be affected: but, the milk fever is that in which the breafts are originally concerned, and which may happen, though the Lochia continue to flow in fufficient quantity; nevertheless, they mutually promote each other, and both are to be treated in the manner already explained; namely, by opiates,
E e
diluents,
diluents, and diaphoretics, in the beginning; and, these prescriptions failing, the obstructions must be refolved by the antiphlogistic method described above. The milk fever alone, when the Uterus is not concerned, is not so dangerous, and much more eafily relieved. Women of an healthy conftitution, who fuckle their own children, have good nipples, and whose milk comes freely, are feldom or never subject to this disorder, which is more incident to those who do not give fuck, and neglect to prevent the fecretion in time; or, when the milk is fecreted, take no measures for emptying their breafts. This fever likewife happens to women who try too foon to fuckle, and continue their efforts too long at one time; by which means, the nipples, and confequently, the breasts, are often inflamed, fwelled, and obstructed.
In order to prevent too great a turgency in the veffels of the breafts, and the fecretion of milk, in those women who do not choose to fuckle, it will be proper to make external application of those things which, by their preffure and repercuflive force, will hinder the blood from flowing in too great quantity
to
to this part, which is now more yielding than at any other time: for this purpose, let the breafts be covered with Emp. de minio, Diapalma, or Emp. fimp. fpread upon linnen, or cloths dipped in camphorated fpirits, be frequently applied to these parts and the armpits; while the patient's diet and drink is of the lightest kind, and given in small quan tities. Notwithstanding these precautions, a turgency commonly begins about the third day; but by reft, moderate fweating, and the ufe of these applications, the tenfion and pain will fubfide about the fifth or fixth day, especially if the milk runs out at the nipples : but, if the woman catches cold, or is of a full habit of body, and not very abftemious, the tenfion and pain increafing, will bring on a cold shivering, fucceeded by a fever ; which may obftruct the other excretions, as well as those of the breast.
In this cafe, the fudorifics above recommended, must be prescribed, and if a plentiful fweat enfues, the patient will be relieved; at the fame time the milk must be extracted from her breasts, by fucking with the mouth or glaffes: fhould thefe methods fail, and E e 2 the
the fever increase, fhe ought to be blooded in the arm; and instead of the external applications hitherto ufed, emollient liniments and cataplafms must be fubftituted, in order to foften and relax. If, in fpite of these endeavours, the fever proceeds for fome days, the patient is frequently relieved by critical fweats, a large discharge from the Uterus, miliary eruptions, or loofe ftools mixed with milk, which is curdled in the intestines: but, should none of these evacuations happen, and the inflammation continue with increasing violence, there is danger of an impofthume, which is to be brought to maturity, and managed like other inflammatory tumours; and no aftringents ought to be applied, left they should produce schirrous fwellings in the glands.
As the crifis of this fever, as well as of that last described, often confifts in miliary eruptions over the whole furface of the body, but particularly on the neck and breasts, by which the fever is carried off, nothing ought to be given, which will either greatly increase or diminish the circulating force; but, fuch only as will keep out the eruptions. But if, not
withstanding thefe eruptions, the fever, instead of abating, is augmented, it will be neceffary to diminish its force, and prevent its increase, by those evacuations we have mentioned above. On the contrary, fhould the pulfe fink, the eruptions begin to retreat inwardly, and the morbific matter be in danger of falling upon the Vifcera, we must endeavour to keep them out, by fuch opiates and fudorific medicines as we have already prescribed in obstructions of the Lochia; and here blisters may may be applied with fuccefs. On this fubject Sir David Hamilton and Hoffman may be confulted.
SECT. VII.
Of the PROLAPSUS VAGINE, RECTI ET UTERI.
WHEN the head
the head of the child is long retained about the middle of the Vagina, the lower part of that sheath sometimes fwells; and as the head comes farther down, is pushed out at the Os externum, occafioning great difficulty in delivering the woman: fometimes, also, the lower part of the Rectum is protruded through the Sphincter ani, espeEe 3 cially
Cially if the patient is troubled with the inward piles. The cure of both these complaints, confists in reducing the Prolapfus: if this cannot be done immediately in the laft, on account of the fwelling of the protruded part, emollient fomentations and pultices must be used, in order to remove the inflammation. When it is reduced, the woman. must be confined more than ufual to her bed; and if the part falls down again, in confequence of her ftraining at ftool, or in making water, it must be reduced occafionally, and as the recovers ftrength, the complaint will in all probability vanifh: otherwise, aftringent fumigations or fomentations must be used. If the disorder be of long duration, peffaries, adapted to the part, whether Vagina or Rectum, must be applied.
A Prolapfus uteri may happen from the fame caufes, or from any thing that will too much relax the ligaments and Peritoneum, by which the womb is fufpended; fuch as, an inveterate Fluor albus, that by its long continuance and great discharge, weakens the woman, and all these parts.
This misfortune, when it proceeds from labour, does not appear till after delivery, when the Uterus is contracted to its smallest fize; nay, not for several weeks or months after that period, until, by its weight, the Os externum is gradually stretched wider and wider, fo as to allow the womb to flip through it; and in this cafe, it defcends covered with the Vagina, that comes down along with it, and hangs between the thighs: though the Os tince only can be perceived on account of this covering, the fhape and substance of the Uterus may be eafily diftinguished.
As this Prolapfus comes on gradually, the woman of herself, can (for the most part) reduce and keep it up, while in bed; but when the rifes and walks, it will fall down again. When the complaint is not of long ftanding, and the womb does not come altogether through the Os externum, the patient may be cured by aftringent injections; and in the next pregnancy, when the upper part of the Uterus is diftended, so as to fill the Pelvis, and rife above its brim, the Os internum will be raised higher in the Vagina; Ee 4 and
and after delivery, if the woman is confined to her bed for twenty or thirty days, the ligaments generally contract, fo as to keep up the womb, and prevent any future Prolapfus: but, when the complaint is of long continuance; when the Uterus and Vagina defcend quite through the Os externum, and by the friction in walking, occafioned by the Vagina's rubbing against the thighs and the Os uteri, upon the cloaths that are used for supporting it, an inflammation, excoriation, and ulceration, is produced, inviting a greater flux of fluids to the part: these symptoms, joined with a Fluor albus from the infide of the Uterus, destroy the hope of a fecond impregnation, or cure by injections, and we can only promise to palliate the disease, by reducing the Uterus, and keeping it up with a peffary; by which means used for a length of time, perhaps the parts will recover their tone, and the disease be radically cured.
If the Uterus be fo much inflamed, that it cannot be reduced, generally evacuations must be prescribed, fomentations and pultices applied, in order to diminish its bulk, so as that it may be replaced; for this complaint,
different kinds of peffaries have been used; fome of a globular form, others that open with a spring, as defcribed in the medical effays of Edinburgh. But, those most in ufe are of a flat form, with a little hole in the middle, and made of cork waxed over, ivory, box, ebony, lignum vitæ, of a triangular, quadrangular, oval, or circular shape. Thofe that are circular feem best to answer the intention, because we can more eafily introduce a large one of that than of any other figure; it les more commodiously in the Vagina, and as it always tilts a little upwards and downwards, never hinders the paffage of the urine or Faces: thefe inftruments, however, ought to be larger or fmaller, according to the laxity or rigidity of the Os externum.
There is a peffary lately invented at Paris, which hath an advantage over all others; because the woman can introduce it in the morning, and take it out at night; it is fupported and kept in the Vagina by a small ftalk, the lower end of which forms a little ball that moves in a focket; this focket is furnished with straps, which are tied to a belt
belt that furrounds the patient's body. This peffary is extremely well calculated for those who are in an easy way of life; but the other kind is beft adapted to hard working women, who have not time or conveniency to fix or mend the bandage when it wants repair.
SECT. VIII.
Of the Evacuations neceffary at the End of the Month after Delivery.
THOSE who have had a fufficient difcharge of the Lochia, plenty of milk, and fuckle their own children, commonly recover with ease; and as the fuperfluous fluids of the body are drained off at the nipples, feldom require evacuations at the end of the month: but, if there are any complaints from fullness, fuch as pains and flitches, after the twentieth day, fome blood ought to be taken from the arm, and the belly gently opened by frequent glyfters, or repeated doses of laxative medicines.
If the patient has tolerably recovered, the milk having been at first fucked or discharged from the nipples, and afterwards difcuffed;
no
no evacuations are neceffary before the third or fourth week; and fometimes not till after the firft flowing of the Menfes, which commonly happens about the fifth week; if they do not appear within that time, gentle evacuations must be prescribed to carry off the Plethora, and bring down the Catamenia.
CHA P. II.
Of the Management of new-born Children, with the Difeafes to which they are subject.
SECT. I.
Of washing and dreffing the child.
T
H E child being delivered, the navelftring tied and cut, a warm cloth or flannel cap put on its head, and its body wrapped in a warm receiver, it may be given to the nurse, or an affiftant, in order to be washed clean from that fcurf, which fometimes covers the whole fcarf-fkin, and is particularly found upon the hairy fcalp, under
3
- the
the arm-pits, and in the groins. This ablution is commonly performed with warm water, mixed with a fmall quantity of Hungary water, wine, or ale, in which a little pomatum, or fresh butter, hath been diffolved. This compofition cleans all the surface, and the oily part, by mixing with, and attenuating the Mucus, prepares it for the linnen cloth, which dries and wipes off the whole: nevertheless, milk and water, or soap and water, is preferable to this mixture.
In laborious or præternatural cafes, when confiderable force hath been used in delivering the child, the whole body ought to be examined; and if there is any mark or contufion, on the head, if will disappear, if anointed with pomatum, and gently rubbed or chafed with the accoucheur's hand: if any limb is dislocated or broke, it ought to be reduced immediately: .luxations, though they feldom happen, are more incident to the fhoulder than to any other part, the Humerus being eafily diflocated, and as eafily reduced. The bones of the arm and thigh are more fubject to fractures, than any other of the extremities: the first is easily cured, ba
because the limb can be kept from being moved; but, a fracture in the thigh bone is a much more troublesome cafe, because, over and above the difficulty of keeping the bones in a proper fituation, the part is often neceffarily moved in cleaning the child. In this cafe, the beft method is, to keep the child lying on one fide, after the thigh hath been fecured by proper bandage, fo that the nurfe may change the cloth without moving the part; and to lay it upon bolsters or pillows, raised above the wet nurse, that it may fuck with greater freedom: if any of the bones are bent, they may be brought into their proper form, by a flow, gentle, and proper extenfion.
The navel-ftring must be wrapped in a foft, linnen rag, and folded up on the belly, over which is to be laid a thick comprefs, kept moderately tight with a bandage commonly called a belly-band. This compreffion must be continued for fome time, in order to prevent an Exomphalus, or rupture, at the navel; and kept tighter and longer on children that are addicted to crying, than on those that are still and quiet: yet not so tight
as
as to be uneafy to the child, and the bandage must be loofened and the part examined, every second day. The navel-ftring fhrinks, dies, and about the fixth or seventh day, commonly drops off from the belly; though not at the ligature, as fome people have imagined. This being feparated, a pledget of dry lint must be applied to the navel, and over it, the thick compress and bandage, to be continued feveral weeks, for the purpose mentioned above.
During the time of wafhing and dreffing the child, it ought to be kept moderately warm, especially in the head and breast, that the cold air may not obftruct perfpiration: the head and body ought alfo to be kept tolerably tight with the cloaths, for the convenience of handling, and to prevent its catching cold, efpecially if the child be weakly; but, if it is vigorous and full grown, it cannot be too loosely cloathed, because the brain, Thorax, and Abdomen, fuffer by too great compreffion. The cloathing of newborn children, ought also to be fuitable to the season of the year, and the nature of the weather; the extremes of cold and heat being avoided,
avoided, as equally hurtful and dangerous. Inftead of the many fuperfluous inventions of nurfes, and those who make cloaths for chil dren, with a view to make an expenfive and pompous appearance, the dress ought to be contrived with all imaginable fimplicity: the child being washed, the navel-string secured, and the head covered with a linnen or woollen cap, as already directed, a fhirt and waiftcoat may be put upon the body, and over it a flannen skirt or petticoat, open before, with a broad head-band, as commonly used, or rather a waistcoat joined to it, fo as that they can be put on at once: this ought to be rather tied than pinned before, and, instead of two or more blankets, may be covered with a flannel or fuftian gown; while the head is accommodated with another cap, adorned with as much finery as the tire-woman shall think proper to bestow.
In short, the principal aim in this point is to keep the child's head and body neither too tight nor too flovenly, too hot nor too cold; that it may be warm, though not over-heated, and eafy, though not too loose; that respiration may be full and large; that the brain
may
may fuffer no compreffion; and that, while the child is awake, the legs may be at liberty; to reject all unneceffary rollers, crosscloths, neckcloths, and blankets; and to ufe as few pins as poffible, and those that are abfolutely neceffary, with the utmost caution.
SECT. II.
How to manage when any of the common paffages are locked up, or the tongue tied.
HEN the child cannot make water, because the paffage is filled up with Mucus; after having unsuccessfully practifed the common methods of holding the belly near the fire, and rubbing the parts with Ol Ruta, &c. we must introduce a probe, or very small catheter along the Urethra, into the bladder; an operation much more easily performed in female than in male children.
In boys, the prepuce alone is fometimes imperforated; in which cafe, an opening is eafily made: but, if there is no paffage in the Urethra, or even through the whole length of the Glans, all that can be done is to make an opening, with a lancet or biftory, near
the
the mouth or sphincter of the bladder, in the lower part of the Urethra; where the urine being obftructed, pushes out the parts in form of a tumour: or, if no fuch tumefaction appears, to perforate the bladder above the Pubis, with a trocar: this, however, is a wretched and ineffectual expedient, and the other can but at best lengthen out a miserable life. If the Anus is imperforated, and the Faces protrude the parts; or, if it be covered with a thin membrane, and a bluish or livid fpot appears, the puncture and incifion commonly fucceed; but, when the Rectum is altogether wanting, or impervious for a confiderable way, the fuccefs of the operation is very uncertain: nevertheless, it ought to be tried, by making an artificial Anus, with a biftory, remembring the courfe of the Rectum, and the entry in both fexes. For further information on this fubject, Mauriceau's and Saviard's obfervations, and the memoirs of the academy of furgeons, may be confulted.

In female children, there is a thin membrane, in form of a crefcent, called the Hythat covers the lower part of the orifice F f of
men,
of the Vagina, and is rent in the first coition. The middle of it is fometimes attached to the lower part of the Meatus urinarius, and on each fide of the bridge is a small opening, that will only admit the end of a probe, though it is fufficient for the discharge of the Menfes. This obftruction is commonly unknown till marriage, and hath often proved fatal to the unfortunate woman, who had concealed it through excefs of modesty and afterwards funk into a deep melancholy, which coft her her life; rather than fubmit to inspection, and the eafy cure of having the attachment snipt with a pair of scissars. On this confideration, Saviard advifes all accoucheurs to inspect this part in every female child they deliver; and if there should be fuch a defect, remedy it during her childhood: or, if the entry is wholly covered with the membrane, make a fufficient perforation, which will prevent great pain and tenfion in their riper years, when the Menfes being denied paffage, would accumulate every month, and at last push out this and the neighbouring parts in form of a large tumour, the
caufe
cause of which is generally unknown, until it be opened.
Sometimes, a thin membrane rifing from the under part of the mouth, ftretches almost to the tip of the tongue, bracing it down, fo as to hinder the child from taking hold of the nipple, and fucking. This diforder, which is called tongue-tying, is eafily remedied by introducing the fore finger into the child's mouth, raifing up the tongue, and fnipping the bridle with a pair of scissars.
If, inftead of a thin membrane, the tongue is confined by a thick, fleshy substance, the fafeft method is, to direct the nurse to stretch it frequently and gently with her finger; or if it appears like a foft Fungus, to touch it frequently and cautiously with lunar cauftic, or Roman vitriol: but, we ought to take care that we are not deceived by an inflammation that sometimes happens in the birth, from the accoucheur's helping the head along with his finger in the child's mouth.
SECT. III.
Of Mould-fhot Heads, Contufions, and Excoriations.
the
N laborious and lingering labours, IN child's head is often long confined, and so compreffed in the Pelvis, that the bones of the upper part of the Cranium are squeezed together, and ride over one another, in different manners, according as the head prefented. If the Offa parietalia rife over the Os Frontis, the cafe is called the mould-shot; if over the Occiput, it goes by the name of the horse-fhoe mould. When the Fontanelle prefents, (though this is feldom the cafe) and is pushed down, the form of the head is raised up in the fhape of an hog's back; whereas, in the former cafe, the Vertex or crown of the head prefented, and the whole was turned from a round to a very long figure. If the head is kept long in the Pelvis, and the child not deftroyed by the compreffion of the brain, either before or foon after delivery, it commonly retains more or lefs of the shape acquired in that fituation,
1
&C
according to the strength or weakness of the child. When the bones begin to ride over one another in this manner, the hairy fcalp is felt lax and wrinkled; but, by the long preffure and obftructions of the circulating fluids, it gradually fwells, and forms a large
tumour.
In these cafes, when the child is delivered, we ought to allow the navel-ftring, at cutting, to bleed from one to two or three fpoonfuls, especially if the infant be vigorous and full grown; and to provoke it by whipping and stimulating: for, the more it cries, the fooner and better are the bones of the Cranium forced outwards into their natural fituation: or, if the head hath not been long compreffed, and is not much inflamed, we can fometimes, with our hands, reduce it into its pristine shape. The Meconium ought also to be purged off as foon as poffible, to give freer scope to the circulating fluids in the Abdomen, and make a revulfion from the furcharged and compreffed brain. This may be effected with fuppofitories, glyfters, repeated doses of Ol. Amygdal. d. mixed with Ff3
Pulv.
Pulv. Rhabarb. or De Althaa, or Syr. de Cichoreo, cum Rheo.
If the child is feized with convulfions foon after delivery, in confequence of this compreffion; and the veffels of the navel-string have not been allowed to bleed, the jugular vein ought immediately to be opened, and from one to two ounces of blood taken away; an operation easily performed in young children: the urine and Meconium must be difcharged, and a small blister applied between the Scapule. When the fcalp is bruised, inflamed, or fwelled, let it be anointed, or embrocated, with a mixture of Ol. Chamomel. Acet. and Spt. Vin. Camphorat. and Cerates, and pultices applied to the parts.
If the tumefaction is large, and we feel a confiderable fluctuation of extravafated fluids, which cannot be taken up by the absorbent veffels, affifted with thofe applications, the tumour must be opened; though generally there is no occafion for a large incifion, because after the fluid is once discharged, the hollow fcalp, by gentle preffure, is more eafily joined in children than in older fubjects,
When
When the head is mishapen, it should not be bound or preffed, but left lax and easy; left, the brain being compreffed, convulfions fhould enfue.
•
The body of the child is fometimes covered all over with little red spots, called the red gum, and commonly proceeding from the coftiveness of the child, when the Meconium hath not been fufficiently purged off at first. And here it will not be improper to observe, that as the whole tract of the Colon is filled with this vifcid excrement, which hath been gradually accumulated for a confiderable time; and as the small intestines, stomach and gullet are lined with a glary fluid or Mucus, the child ought to take no other nourishment than pap as thin as whey, to dilute this fluid, for the firft two days; or indeed, till it fucks the mother's milk, which begins to be fecreted about the third day, and is at first, sufficiently purgative to discharge these humours; and better adapted for the purpose than any artificial purge.
If the mother's milk cannot be had, a nurse lately delivered is to be found; and if the purgative quality of her milk is decreased, Ff4
fhe
she must be ordered to take repeated small dofes of manna or lenitive electuary, by which it will recover its former virtue, and the child be fufficiently purged.
If the child is brought up by hand, the food ought to imitate, as near as poffible, the mother's milk: let it confift of loaf-bread and water boiled up together, in form of panada, and mixed with the fame quantity of new cow's milk; and fometimes with the broth of fowl or mutton. When the child is coftive, two drachms of manna, or from two to four grains of rhubarb, may be given: and when the ftools are green and curdled, it will be proper to abforb the prevailing acid with the teftaceous powders; fuch as the Chel. Cancror. fimp. or Teft. Oftrear, given from the quantity of ten grains to a fcruple: and for this purpose, the Magnefia alba is recommended, from one to two drachms a day, as being both opening and absorbent. The red gum may likewife proceed from the officiousness of the nurse, by which the scarf fkin hath been abraded, or rubbed off; in which cafe, the child must be bathed in warm milk, and the parts foftened with
ро
matum:
matum the fame bath may be also used daily in the other kind, and the belly kept open with the aforementioned medicines; with which, fome fyrup, tincture, or powder of rhubarb, may be mixed, or given by itself, if the ftools are of a greenish hue.
Excoriations behind the ears, in the neck and groin of the child, are fometimes, indeed, unavoidable in fat and grofs habits; but most commonly proceed from the carelessnefs of the nurse, who neglects to wash and keep the parts clean they are, however, eafily dried up and healed, with Unguent. Alb. Pulv. e Cerufsa, or fuller's earth. Yet we ought to be cautious in applying drying medicines behind the ears, because a difcharge in that part frequently prevents worse diseases.
SECT. IV.
Cf the APTHA.
THE Aptha, or thrush, is a disease to which new-born children are frequently fubject, and is often dangerous, when neglected at the beginning. This disease
proceeds from weakness and laxity of the contracting force of the ftomach and inteftines, by which the acefcent food is not digefted; and from a defect in the neceffary fecretion of bile, with which it ought to be mixed. This prevailing acid in the Prima via, produces gripings and loofe green ftools, that weaken the child more and more, deprive it of its proper nourishment and rest, and occafion a fever from inanition and irritation. The smallest veffels at the mouths of the excretory ducts in the mouth, gullet, stomach and inteftines, are obstructed and ulcerated in confequence of the child's weakness and acrimonious vomitings, belchings, and ftools, and little foul ulcers are formed.
These first appear in small white specks on the lips, mouth, tongue, and at the fundament: they gradually increase in thickness and extent; adopt a yellow colour, which in the progress of the distemper becomes dufkish, and the watry ftools (called the watry gripes) become more frequent. The whole inner surface of the inteftines being thus ulcerated and obftructed, no nourishment enters the lacteal veffels; fo that the weakness and
disease are increased, the milk and pap which are taken in at the mouth, paffes off curdled and green, the child is more and more enfeebled, and the brown colour of the Aptha declares a mortification, and death at hand, Sometimes, however, the Aptha are unattended by the watry ftools; and fometimes, these last are unaccompanied with the Aptha.
In order to prevent this fatal catastrophe, at the first appearance of the disorder, we ought to prescribe repeated dofes of testaceous powders, to abfofb and fweeten the predominant acid in the ftomach, giving them from ten to twenty grains in the pap, twice or three times a day; and on every third night, from three to five grains of the Pulv. Rhei, Julap. e Creta; oily and anodyne glyfters, with epithems to the ftomach, may also be adminiftred. When these, and every other prescription fail, the child, if not much weakened, is fometimes cured by a gentle vomit, confifting of pulv. Ipecacuan. gr. I. given in a spoonful of barley-water, and repeated two or three times, at the interval of half an hour between each. When the child is much enfeebled, the Oleo-Saccharum Cinnamomi,
namomi, or Anifi, mixed with the pap, is fometimes ferviceable. If the milk is either too purgative or binding, the nurse should be changed, or take proper medicines to alter its quality or, if the child has been brought up by hand, woman's milk may be given on this occafion, together with weak broths; but, if the child cannot fuck, the milk of cows, mares, or affes, may be fubftituted in its room, diluted with barley-water.
SECT. V.
Of TEETHING.
CHILDREN commonly begin to breed
their fore teeth about the feventh, and fometimes not before the ninth month; nay, in fome, the period is ftill later. Those who are healthy and lax in their bellies, undergo dentition easier than fuch as are of a contrary conftitution. When the teeth shoot from the fockets, and their fharp points begin to work their way through the Periosteum and gums, they frequently produce great pain and inflammation, which, if they continue violent, bring on feverish fymptoms and convulfions,
vulfions, that often prove fatal. In order to prevent these misfortunes, the fwelled gum may, at first, be cut down to the tooth, with a bistory or fleam; by which means, the patient is often relieved immediately: but, if the child is strong, the pulfe quick, the skin hot and dry, bleeding at the jugular will be also necessary, and the belly must be kept open with repeated glyfters. On the other hand, if the child is low, funk, and emaciated, repeated doses of Spt. C. C. Tinct. Fuligin. and the like, may be prescribed; and blisters applied to the back, or behind the ears.
CHAP.
CHA P. III.
Of the requifite Qualifications of Accoucheurs, Midwives, Nurfes who attend lying-in Women, and wet and dry Nurfes for Children.
SECT. I.
Of the ACCOUCcheur.
T
HOSE who intend to practife Midwifery, ought first of all, to make themselves masters of anatomy, and acquire a competent knowledge in furgery and phyfick; because of their connexions with the obstetric art, if not always, at least in many. cafes. He ought to take the best opportunities he can find, of being well inftructed; and of practifing under a master, before he attempts to deliver by himself.
In order to acquire a more perfect idea of the art, he ought to perform with his own hands upon proper machines, contrived to convey a juft notion of all the difficulties to be met with in every kind of labour; by which
I
་
which means, he will learn how to use the forceps and crotchets with more dexterity, be accustomed to the turning of children, and confequently, be more capable of acquitting himself in troublesome cases, that may happen to him when he comes to practife among women: he fhould alfo embrace every occafion of being prefent at real labours, and indeed of acquiring every qualification that may be neceffary or convenient for him in the future exercife of his profeffion: but, over and above the advantages of education, he ought to be endued with a natural fagacity, refolution, and prudence; together with that humanity which adorns the owner, and never fails of being agreeable to the diftreffed patient in confequence of this virtue, he will affift the poor as well as the rich, behaving always with charity and compaffion. He ought to act and fpeak with the utmost delicacy of decorum, and never violate the trust reposed in him, fo as to harbour the least immoral or indecent defign; but demean himself in all refpects fuitable to the dignity of his profeffion.
SECT.
SECT. II.
Of the MIDWIFE.
A Midwife, though the can hardly be fuppofed mistress of all these qualifications, ought to be a decent, fenfible woman of a middle age, able to bear fatigue; the ought to be perfectly well instructed with regard to the bones of the Pelvis, with all the contained parts, comprehending those that are fubfervient to generation; fhe ought to be well skill'd in the method of touching pregnant women, and know in what manner the womb ftretches, together with the fituation. of all the abdominal Vifcera; fhe ought to be perfectly mistress of the art of examination in time of labour, together with all the different kinds of labour, whether natural or præternatural, and the methods of delivering the Placenta; fhe ought to live in friendship with other women of the fame profeffion, contending with them in nothing but in knowledge, fobriety, diligence, and patience; fhe ought to avoid all reflections upon men practitioners, and when she finds her
V
herself at a lofs, candidly have recourse to their affiftance: on the other hand, this confidence ought to be encouraged by the man, who, when called, instead of openly con lemning her method of practice, (even though it fhould be erroneous) ought to make allowance for the weakness of the sex, and rectify what is amifs, without exposing her mistakes. This conduct will as effectually conduce to the welfare of the patient, and operate as a filent rebuke upon the conviction of the midwife; who finding herself treated fo tenderly, will be more apt to call for neceffary affiftance on future occafions, and to confider the accoucheur as a man of honour, and a real friend. Thefe gentle methods will prevent that mutual calumny and abuse which too often prevail among the male and female practitioners; and redound to the advantage of both: for, no accoucheur is fo perfect, but that he may err fometimes; and on fuch occafions, he must expect to meet with retaliation from thofe midwives whom he may have roughly used.
SECT. III.
Of NURSES in general.) 3. altarba NURSES, as well as midwives, ought to be of a middle age, fober, patient, and difcreet, able to bear fatigue and watching, free from external deformity, cutaneous eruptions and inward complaints, that may be troublesome or infectious.
5.73 0381
3d 16
NURSES that attend lying-in women, ought to have provided, and in order, every thing that may be neceffary for the woman, accoucheur, midwife, and child; fuch as linnen and cloaths, well aired and warm, for the woman and the bed, which the must know how to prepare when there is occafion; together with nutmeg, fugar, fpirit of hartfhorn, vinegar, Hungary water, white or brown caudle ready made, and a glyfter-pipe fitted. For the ufe of the accoucheur, fhe must hang a doubled fheet over the bed-side, and prepare warm cloaths, pomatum, thread, warm and cold water, and two hand-basins;
NUMB. I.
1
and for dreffing the child, fhe must keep the cloaths warm and in good order. After delivery, her business is to tend the mother and child with the utmost care, and follow the directions given to her, relating to the management of each.
That the mother herself fhould give fuck, would certainly be moft conducive to her own recovery, as well as to the health of the child; but, when this is inconvenient, or impracticable, from her weakness, or circumftances in life, a wet nurse ought to be hired, poffeffed of the qualifications above defcribed, as well as of those that follow.
NUM B. II.
THE younger the milk is, the better will it agree with the age of the infant. The nurfe is more valuable after having brought forth her fecond child, than after her first; becaufe fhe is endued with more knowledge and experience touching the management of children. She ought to have good nipples, with a fufficient quantity of good milk: the abundance or scantinefs of the fecretion may be distinguished by the appearance of her own Gg 2
child;
child; and the quality may be ascertained by examining the milk, which she may be ordered to pour into a wine glass, about two or three hours after she hath eaten and drank, and fuckled her own child. If, when falling in a single drop upon the nail, it runs off immediately, the milk is too thin; if the drop ftands in a round globe, it is too thick; but, when the drop remains in a flattened form, the milk is judged to be of a right confiftence: in a word, it may be as well diftinguished by its opacity or transparency, when it is dashed up on the fide of the glafs: befides, it ought to be sweet to the taste, and in colour inclining to blue rather than to yellow. Red-hair'd women, or fuch as are very fair and delicate, are commonly objected to in the quality of nurses; but this maxim is not without exceptions: and on this fubject, Boerhaave's inftitutes, with Haller's commentary, may be confulted.
Although it is certainly moft natural for children to fuck, it may be fometimes neceffary to bring them up by hand; that is, nourifh them with pap: because proper wet nurfes cannot always be found, and many
chil
1
children have fuffered by fucking diseased women. Some can never be brought to fuck, although they have no apparent hinderance; and others are prevented by fome fwelling or disorder about the mouth or throat.
NUMB. III.
UPON fuch occafions, we must choose an elderly woman properly qualified for the task, and well accustomed to the duties of a dry nurse. The food (as we have formerly observed) ought to be light and simple, in quality resembling, as nearly as poffible, the mother's milk, such as thin panada mixed with cow's milk, and fweetened with sugar: or should the child be coftive, instead of fugar, honey or manna may be used. If there is any reason to believe, that the loaf-bread or biscuit is made of flour which hath been mixed with allum, for the fake of the colour, the common panada ought in this cafe to be laid afide, in favour of thick watergruel, mixed with milk, and fweetened as above.
Gg 3
Some
Some children thrive very well on this diet; but, when it is neither agreable to their palates, nor nourishing, a wet nurse must be procured, before the child is too much emaciated and exhaufted; and if it can fuck, the good effects of the milk will foon be manifeft. But, for further information, on this head, the reader may confult Dr. Cadogan's letter on the nurfing of children.
FINI S.
ADVERTISEMENT.
D
OCTOR Smailie having, with great care and expence, employed Mr. Riemsdyk to draw anatomical figures, as large as the human fubjects themselves, for the ufe of those who attend his lectures, and in order to illuftrate his theory and practice of midwifey; and being defirous to render his drawings of more extenfive and general use, by causing them to be engraved by able artifts, a defign which cannot be put in execution without a confiderable expence; he proposes to publifh the whole fet by subfcription, in the following manner;
I.
The work will confift of twenty-fix plates, of about 18 inches by 12.
II.
A full and diftinct explanation of each plate, will be printed on a large sheet, of the fame fize with the figures, that they may be bound up together. For the use of foreigners, there will also be an explanation printed in Latin, and a lift of the fubfcribers fhall be published, if defired.
III.
The price to fubfcribers will be two guineas, one to be paid at the time of fubfcribing, and the other at the delivery of the prints, with their explanations.
IV.
The drawings will be put into the hands of the beft engravers, as foon as a number of fubfcriptions are received fufficient to defray the expence of the work, which will be executed with as great dispatch as fhall be confiftent with the nature and accuracy of the performance.
PLATE 1.
PLATE I.
Represents the bones of a well-formed Pelvis, in a front view.
2d, A fide view of the fame. This and the former, defigned to ascertain the width, depth and form of the infide.
3d, The front view of a distorted Pelvis. 4th, A view of the external parts, in order to exhibit the fituation and appearance of the Os Externum, Anus, Coccyx, and the lower ends of the Ifchia.
5th, Represents the internal parts, in three figures. FIG. 1. Exhibits a front view of the internal parts of a young woman in the first month of her first pregnancy; namely, the Uterus in the natural fituation hanging down in the Vagina. FIG. 2. Represents a fide view of the fame parts, in a woman of a middle age, who hath had children; one half cut off lengthways. FIG. 3. Gives a front view of the Uterus cut open, to shew the infide, and the em bryo appearing through the Amnium, the Uterus being as large as that in FIG. 2. and in a fecond pregnancy.
6th, Containing 2 figures.
FIG. 1. Represents the Uterus in the fecond or third month of the first pregnancy, with the Embryo inclofed, raised up, as in touching, to fhew the Vagina ftretched in length. FIG. 2. Exhibits the fame in the fourth or fifth month, the womb filling the upper part of the Pelvis, the neck fhortened, and towards the lower part of the Vagina.
7th, Represents the Uterus in the fixth or feventh month, refting on the brim of the Pelvis, with the Fatus contained; the neck still shorter than in the former figure.
8th, Represents the Uterus in the eighth or ninth month; the Fatus intangled in the Funis, and the head prefenting, part of the Placenta and membranes at the back part of the Uterus, the neck of which is totally ftretched, and the Os internum larger and fofter than in the former plate.
9th, Exhibits the representation of twins at the full time, the lowest presenting with the head; the breech of the other being turned
turned downwards, and entangled in the umbilical rope, the woman in labour, and the Os internum a little opened.
10th, Shews the membranes dilating the Os uteri, in time of a labour-pain; the furface of the Chorion and Placenta near the Fundus, and the lower part of the child feen through the Amnium, the Chorion being split at that place.
11th, Represents the mouth of the womb fully open, (the membranes being broke, and fome part of the waters discharged) the head engaged in the upper part of the Pelvis, with one ear to the Os pubis. Part of the Funis with an hand appearing before the head.
12th, Shews the head at the lower part of the Pelvis, the Vertex being turned below the Os pubis, and the fore-head into the concavity of the Sacrum. This in a fide view of the Pelvis, the waters being wholly discharged,
13th, Represents the head in a pofition quite the reverse of the former, namely, a
fide view, fhewing the Vertex in the hollow of the Sacrum, and the forehead turned to the Os pubis.
14th, Represents the Vertex dilating the Os externum, and protruding the Perinæum, Anus, and neighbouring parts, in form of a large tumour,
15th contains, The reprefentation of the forceps, fpecified by the letters a. b. a blunt hook or crotchet c.
16. The delineation of one blade of a larger pair of forceps bent to one fide, a. Leveret's tire tête altered, b, c. A polypus forceps, d.
17th, Represents the figure of the Arabian Impellens and a perforator, with two hooks or arms, a, b.
Two kinds of peffaries, c. d. The fillet and whalebone, c. 
The noofe forceps. ff.
A woman's catheter, g. A dilator, b. 
18th, Contains the figure of Mefnard's curve crotchets improved, a, b, c.
A pair of fciffars, with refts or ftops, d.
19th, Represents the breech of the child prefenting, the back being turned to the forepart of the Uterus; a knot upon the Funis umbilicalis.
20th, Exhibits another view of the fame, the breech being lower down in the Pelvis, and the thighs towards the Os pubis.
21ft, Represents the Fetus compreffed into a round form, the arms, Funis, and legs, prefenting in the Vagina.
22d, Represents the Fatus in the fame form, the back parts prefenting, the head, legs, and one arm being towards the fore part and Fundus of the womb, and the other arm in the Vagina.
23d, Shews the breast presenting, one arm protruded to the Os externum, and the other lying double in the Vagina; the head and feet reflected over the back, towards the Fundus Uteri.
24th, Shews the forehead presenting at the brim of the Pelvis; the face to one fide, and the Fontanelle to the other; the feet and breech to the Fundus, and the Ute
rus
rus contracted in form of a fheath, around the body of the child.
25th, Is a fide view of the Pelvis, fhewing the face presenting, the chin below the Os pubis, and the forehead in the hollow of
the Sacrum.
26th, Represents a pofition the reverse of the former; the Fontanelle at the Os pubis, and the chin at the lower part of the Sa
crum.
In each plate the child is represented in its own Uterus, the forepart of which is cut off, in order to exhibit the infide view, together with the fize and fituation of the Fætus.
The womb, ligaments and Vagina, are fhewn in their proper fituation and appearance, according to the time of pregnancy. Part of the bones of the Pelvis are removed, but their out-lines are marked fo as to demonftrate their fituation, with regard to the other parts.
1
N. B. These prints, and the treatise on the theory and practice of Midwifery, together with the volume of cafes hereafter to be published, will compofe a compleat system of the art.
SUBSCRIPTIONS are taken in by D. WILSON and T. DURHAM, bookfellers, at Plato's head, near Round-Court, in the Strand, where two of the drawings are to be seen, as specimens of the work; as also by the booksellers of Britain and Ireland, France and Holland, where propofals, with lifts of the prints, are to be had.
RECORD OF TREATMENT, EXTRACTION, REPAIR, etc.
1578/6194