Caesarean belly, and contained in a tumour of a prodigious size; the woman, however, was delivered at the end of her time, in the ordinary way. La Mott relates the history of a woman in a preternatural labour, whose uterus and child hung down pendulous to the middle of her thigh, but whom, notwithstanding, he safely delivered; and Ruysh gives a case where the midwife reduced the hernia before delivery; although it was prolapsed as far as the knee, the delivery was safely performed, and the woman had a good recovery.

Lastly, The position or bulk of the child.

Since the practice of turning the child and delivering by the feet, and the late improvement of obstetrical instruments, this operation is never to be performed on account of position, incontinency, or any other obstacle on the part of the child.

Upon the whole, when the pelvis is faulty to such a degree, that no instrument can be conducted to tear and extract the child, this perhaps is the only case wherein this operation should be performed on the living subject. Incisions through the teguments of the abdomen to extract extra-uterine foetuses, or bones of foetuses, do not properly fall under the name of Caesarean section, as that name implies incision of the uterus also.

When a woman advanced in pregnancy dies suddenly, either by accident or by natural disease, the Caesarean section is recommended as an expedient to preserve the life of the child. This is a very proper measure, provided the death of the mother be ascertained; but sometimes it is a very nice and difficult point to distinguish between a delirium and death; and therefore the accoucheur, on such an occasion, must act with the utmost circumspection. If the operation be delayed but a very short while after the mother expires, it will probably be in vain to make the attempt; for whatever fabulous stories may be related to the contrary, there are few authentic cases of the fetus of any animal surviving the mother, perhaps an hour; and therefore every thing should be in readiness to extract the child with all possible expedition, after the event of the mother's death. But, in such cases, the agonies of death often perform the part of labour, and the child is sometimes thrown off in articulo mortis; or the os uteri is so much dilated, that there is easy access to pass the hand, turn the child, and deliver. Thus one should be very cautious in having recourse to this operation, even in the above circumstances; which should never be done,

1. Till the death of the mother be ascertained beyond doubt; 2. Till the state of the os uteri be examined; 3. Till the consent of the relations be obtained;

And,

Lastly, It need not be undertaken, except where the mother dies suddenly, between the 7th and 9th month.

It is unnecessary where the disease has been lingering; in such cases the child commonly dies before the mother.

When it is doubtful whether the child be alive or not, it may be determined by applying the hand on the abdomen of the mother about the time of, and for a little while after, her death, when the life of the child will be discovered by its motions and strug-

VOL. VII. it first from without inwards, and then from within outwards, securing with a double slip a knot, to be ready to untie, lest violent tension or inflammation should ensue; under the knot a soft compress of lint, sharpe, or rolled plaster, should be applied, and the whole dressings must be secured by a proper compress and bandage. The patient must be afterwards treated in the same manner as after lithotomy, or any other capital operation.

Queritur, To what cause is the unsuccessful event of this operation to be imputed? When the operation proves fatal, to what immediate cause are we to ascribe the death of the patient? Is it nervous, or uterine irritation, from cutting, that kills? Is it internal hemorrhage, or the extravasation of fluids into the cavity of the abdomen? Or are not the fatal consequences rather to be imputed to the access of the air on the irritable viscera? This can only therefore be prevented by exposing these parts for as short a space of time as possible. Dr Mouro, the present anatomical professor at Edinburgh, in making experiments on young small animals, such as bitches, cats, frogs, &c. by opening the cavity of the abdomen, and tying the biliary ducts, remarks, that though a large opening into the abdomen be made by incision, if the wound be quickly closed and stitched, the animal will recover, and no bad consequences follow; but if exposed a few minutes to the air, dreadful pain soon comes on, which the creature expresses by the severest agonies; convulsions at last ensue, and death within four or six hours after the operation. On opening the abdomen after death, the whole viscera are found to be in an inflamed state, and universally adhering to one another. He has often repeated the experiment, and the same appearances as often take place.

May not the analogy here justly apply to the human subject? And, in performing the Caesarean operation, should we not be very careful that the viscera be exposed as little as possible, and that the wound be covered with the utmost possible expedition?

The ill success which generally attends the Caesarean operation some years ago, induced some French practitioners to try a new method of extracting the child when, through the narrowness of the pelvis, or any other cause, it is impossible to deliver the woman either naturally or by means of instruments. This was by cutting the symphysis of the os pubis; by which operation it was thought that the bones would separate to a sufficient degree to make room for the passage of the child. This operation is found not to be so fatal in itself as the Caesarean section; but unhappily it doth not promise with any certainty to afford the necessary relief to the woman. Dr Vaughan remarks, 1. That it is extremely difficult to execute it with a thick knife, however sharp in the edge. The ligamentous and grilly substance between the bones is so incomprehensible that it will hardly make room for the thicker part of the knife to follow its edge; but a thin knife goes through it with great ease.

2. Whoever has had a little practice, will find, that it may be executed without any danger of wounding the bladder or urethra; because, in cutting cautiously with a thin knife, from above downwards and inwards, the instant that the whole is cut through, there is both a particular sound, which informs us that the business is done, and the two bones fly asunder to a sensible distance.

3. When the symphysis is completely divided, the osa pubis-separate so little a way, that some force is necessary to produce an interval of half an inch; and upon increasing the force till the space of interval comes to two inches and an half, there is a continued crash, from the tearing of the ligamentous fibres at the posterior joints, viz at the sides of the sacrum. This, though requiring great force, is easily affected, by bringing the thighs to right angles with the trunk of the body, and pressing the knees gradually outwards and backwards. In that way, a small force has a great effect, because it has the advantage of a long lever, and is assisted by almost the whole weight of the lower extremities.

4. When such a violent separation of the osa pubis has been produced, the sacrum and osa innominata remain in contact only at their posterior parts; the ligaments that connect them at the fore-part being all, more or less, torn asunder.

5. The mischief that may ensue upon cutting one joint of the pelvis, and tearing the other two asunder, can be ascertained by experience only. It is proposed, that the incision at the pubes shall not penetrate into the cavity of the abdomen. If, by accident, that should happen, the operation would of course be very dangerous. Lacerations of tendons, ligaments, and fleshly parts, when not complicated with an external wound, generally heal up in a kindly manner, as we see in cases of the ruptured tendo achillis, dislocations, and fractures.

But, on the other hand, at the time of parturition, the body is remarkably disposed to an inflammatory fever, which is always very dangerous when it rises to any height; and therefore, whatever exposes the body to considerable inflammation at that time, we may presume, must be attended with some danger. And it must likewise be remembered, that women who are exceedingly crooked, are commonly so weak that they easily sink under any great disease.

At the same time our author allows, that the Caesarean section, though it may save the child, yet will almost always be fatal to the mother. The cutting of the symphysis, on the other hand, hath no probability of saving the child, and the effect on the mother must be doubtful. He indeed gives no instance of the bad success of the cutting the symphysis, though he gives an additional one of the fatality of the Caesarean operation. As a decisive proof of the inefficacy of the cutting the symphysis to save the child, he gives the figures of the dilated pelvis of two women; by which it appears, that the utmost dilatation used by this means could have amounted to no more than to enlarge the passage to a circle of two inches and a quarter, which is not at all sufficient to afford an exit to a living child. In all cases therefore, when the mother cannot be delivered without destroying the child, he gives the preference to the crotchet; after the use of which, he says, if the operation is slowly performed, by allowing intervals of ease, as in the natural labour, women recover almost as soon as in other cases. Yet, notwithstanding all that can be argued against this operation, it is plain, that as it gives a probable chance of saving the mother's life, though at the expense of the child, it ought always to be preferred to the Caesarean section, which saves the child, but destroys the mother. Nevertheless, it would be shocking to think of performing even this operation where there was a possibility of accomplishing the delivery by any other means.

**CHAP. XVI. Of the Management of Women after delivery.**

The woman being delivered of the child and placenta, let a soft linen-cloth, warmed, be applied to the external parts; and if she complains much of a fainting forenoon, some pomatum may be spread upon it. The linen that was laid below her, to sponge up the discharges, must be removed, and replaced with others that are clean, dry, and warm. Let her lie on her back, with her legs extended close to each other; or upon her side, if she thinks she can lie easier in that position, 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 administering this powder, which among the good women is seldom neglected, is to supply the want of some cordial draught, when the patient is too weak to be raised, or supposed to be in danger of retchings from her stomach's being overloaded. When she hath in some measure recovered her strength and spirits, let the cloths be removed from the parts, and others applied in their room; and, if there is a large discharge from the uterus, let the wet linen below her be also shifted, that she may not run the risk of catching cold.

When the patient is either weak or faintish, she ought not to be taken out of bed, or even raised up to have her head and body shifted, until she is a little recruited; otherwise she will be in danger of repeated faintings, attended with convulsions, which sometimes end in death. To prevent these bad consequences, her skirt and petticoats ought to be loosened and pulled down over the legs, and replaced by another well warmed, with a broad head-band to be slipt in below, and brought up over her thighs and hips: a warm double cloth must be laid on the belly, which is to be surrounded by the head-band of the skirt pinned moderately tight over the cloth, in order to compress the viscera and the relaxed parietes of the abdomen, more or less, as the woman can easily bear it; by which means the uterus is kept firm in the lower part of the abdomen, and prevented from rolling from side to side when the patient is turned: but the principal end of this compression is to hinder too great a quantity of blood from rushing into the relaxed vessels of the abdominal contents, especially when the uterus is emptied all of a sudden by a quick delivery. The pressure being thus suddenly removed, the head is all at once robbed of its proportion of blood, and the immediate revulsion precipitates the patient into dangerous hypotymia.

For this reason the belly ought to be firmly compressed by the hands of an attendant, until the bandage is applied; or, in lieu of it, a long towel, sheet, or roller, to make a suitable compression: but for this purpose different methods are used in different countries, or according to the different circumstances of the patients. The head-cloths and shift ought also to be changed, because with sweating in time of labour they are rendered wet and disagreeable. Several other applications are necessary, when the external or internal parts are rent or inflamed, misfortunes that sometimes happen in laborious and preternatural cases.—We shall conclude this chapter with giving some necessary directions with regard to air, diet, &c.

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 salutary temper, by rendering it warm or cold, moist or dry, according to the circumstances of the occasion. With regard to diet, women, in time of labour, and even till the ninth day after delivery, ought to eat little solid food, and none at all during the first five or seven: let them drink plentifully of warm diluting fluids, such as barley-water, gruel, chicken-water, and teas; caudles are also commonly used, composed of water-gruel boiled up with mace and cinnamon, to which, when strained, is added a third or fourth part of white wine, or lefs, if the patient drinks plentifully, sweetened with sugar to their taste: this composition is termed white caudle; whereas, if ale is used instead of wine, it goes under the name of brown caudle. In some countries, eggs are added to both kinds; but, in that case, the woman is not permitted to eat meat or broths till after the fifth or seventh day: in this country, however, as eggs are no part of the ingredients, the patient is indulged with weak broth sooner, and sometimes allowed to eat a little boiled chicken. But all these different preparations are to be prescribed weaker or stronger, with regard to the spices, wine, or ale, according to the different constitutions and situations of different patients: for example, if she is low and weak, in consequence 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 least tendency to a fever, or if the season is excessively hot, these drinks ought to be of a very weak consistence, or the patient restricted to gruel, tea, barley and chicken water, and these varied according to the emergency of the case.

Her food must be light and easy of digestion, such as panada, biscuit, and sago; about the fifth or seventh day she may eat a little boiled chicken, or the lightest kind of young meat; but these last may be given sooner or later, according to the circumstances of the case and the appetite of the patient. In the regimen as to the eating and drinking, we should rather err on the abstemious side 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 nourishing and salutary diet is that which we have above prescribed. Everything that is difficult of digestion, or quickens the circulating fluids, must of necessity promote a fever; by which the necessary discharges are obstructed, and the patient's life endangered. As to the article of sleeping and watching, the patient must be kept as free from noise as possible, by covering the floors and stairs with carpets and cloths, oiling the hinges of the doors, silencing the bells, tying up the knockers, and in noisy streets stowing the pavement with straw; if, notwithstanding these precautions, she is disturbed, her ears must be stuffed with cotton, and opiates administered to procure sleep; because watching makes her restless, prevents perspiration, and promotes a fever.

Motion and rest are another part of the nonnaturals to which we ought to pay particular regard. By tossing about, getting out of bed, or sitting up too long, the perspiration is discouraged and interrupted; and in this lazy attitude the uterus, not yet fully contracted, hangs down, stretching the ligaments, occasioning pain, cold shiverings, and a fever; for the prevention of these bad symptoms, the patient must be kept quiet in bed till after the fourth or fifth day, and then be gently lifted up in the bed-cloths, 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 so subject to fevers as immediately after delivery. Some there are who, from the nature of their constitutions, or other accidents, recover more slowly; and such are to be treated with the same caution after as before the ninth day, as the case seems to indicate: others get up, walk about, and recover, in a much shorter time; but these may some time or other pay dearly for their foolhardiness, by encouraging dangerous fevers; so that we ought rather to err on the safe side than run any risk whatever.

What next comes under consideration is the circumstance 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 an easy passage in her belly that same day, the rectum and colon ought to be emptied by a glyster, which will assist the labour, prevent the disagreeable excretion of the faeces before the child's head, and enable the patient to remain two or three days after, without the necessity of going to stool. However, should this precaution be neglected, and the patient very colitive after delivery, we must beware of throwing up stimulating glysters, or administering strong cathartics, lest they should bring on too many loose stools, which, if they cannot be stopped, sometimes produce fatal consequences, by obstructing the perspiration and lochia, and exhausting the woman, so as that she will die all of a sudden; a catastrophe which hath frequently happened from this practice. Wherefore, if it be necessary to empty the intestines, we ought to prescribe nothing but emollient glysters, or some very gentle opener, such as manna, or elect. lenitivum. But no excretion is of more consequence to the patient's recovery than a free perspiration; which is so absolutely necessary, that unless she has a moisture continually on the surface of her body, for some days after the birth, she seldom recovers to advantage: her health, therefore, in a great measure, depends upon her enjoying undisturbed repose, and a constant breathing sweat, which prevents a fever, by carrying off the tension, and assists the equal discharge of the lochia: and when these are obstructed, and a fever ensues with pain and restlessnes, nothing relieves the patient so effectually as rest and profuse sweating, procured by opiates and sudorifics at the beginning of the complaints; yet these last must be more cautiously prescribed in excessive heat than in cool weather.

The last of the nonnaturals to be considered are the passions of the mind, which also 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 such information hath been known to carry off the labours pains entirely, after they were begun, and the woman has sunk under her dejection of spirits; and, even after delivery, these unseasonable communications have produced such anxiety as obstructed all the necessary excretions, and brought on a violent fever and convulsions, that ended in death.

**Chap. XVII. Of violent Floodings.**

All women, when the placenta separates, and after it is delivered, lose more or less 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 hemorrhage 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, she sinks into faintings, and, if the discharge is not speedily stopped or diminished, is seized with convulsions, which often terminate in death.

This dangerous efflux is occasioned by every thing that hinders the emptied uterus from contracting, such as great weakness and listlessness, in consequence of repeated floodings before delivery; the sudden evacuation of the uterus; sometimes, though seldom, it proceeds from part of the placenta's being left in the womb; it may happen when there is another child, or more, still undelivered; when the womb is kept distended with a large quantity of coagulated blood; or when it is inverted by pulling too forcibly at the placenta.

In this case, as there is no time to be lost, and internal medicines cannot act so suddenly as to answer the purpose, we must have immediate recourse to external application. If the disorder be owing to weaknesses, by which the uterus is disabled from contracting itself, so that the mouths of the vessels are left open; or, though contracted a little, yet not enough to restrain the hemorrhage of the thin blood; or if, in separating the placenta, the accoucheur has scratched or tore the inner surface or membrane of the womb; in these cases, such things must be used as will assist the contractile power of the uterus, and hinder the blood from flowing so fast into it and the neighbouring vessels; for this purpose, cloths dipped in any cold stringent fluid, such as oxycratic, or red tart wine, may be applied to the back and belly. Some prescribe venefaction in the arm, to the amount of five or six ounces, with a view of making revulsion: if the pulse is strong, this may be proper; otherwise, it will do more harm than good. Others order ligatures, for compressing the returning veins at the hams, arms, and... After-pains and neck, to retain as much blood as possible in the extremities and head. Besides these applications, the vagina may be filled with tow or linen rags, dipped in the abovementioned liquids, in which a little alum, or saphar-saturni hath been dissolved; nay, some practitioners inject proof-spirits warmed, or, soaking them up in a rag or sponge, introduce and squeeze them into the uterus, in order to constringe the vessels.

If the flooding proceeds from another child, the retention of the placenta, or coagulated blood, these ought immediately to be extracted; and if there is an inversion of the uterus, it must be speedily reduced. Should the haemorrhage, by these methods, abate a little, but still continue to flow, though not in such a quantity as to bring on sudden death, some 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, administered in the same manner, for fear of overloading the weakened stomach, and occasioning retchings: these repeated in small quantities, will gradually fill the exhausted vessels, and keep up the circulation. If the pulse 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, dissolved in aqua cinnamomi tenuis, and given in small draughts, or exhibited in any other form, will be serviceable; at the same time, lulling the patient to rest 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.

**Chap. XVIII. Of the After-pains.**

After-pains commonly happen when the fibrous part of the blood is retained in the uterus or vagina, and formed into large clots, which are detained by the sudden contraction of the os internum and externum, after the placenta is delivered: or, if these should be extracted, others will sometimes be formed, tho' not so large as the first, because the cavity of the womb is continually diminishing after the birth. The uterus, in contracting, presses 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 consequence of this uneasiness, the woman squeezes the womb as in real labour; the force being increased, the clots are pushed along, and when they are delivered she grows easy. The larger the quantity is of the coagulated blood, the feverer are the pains, and the longer they continue.

Women in the first child seldom have after-pains; because, after delivery, the womb is supposed to contract; and push off the clots with greater force in the first than in the following labours: after-pains may also proceed from obstructions in the vessels, and irritations at the os internum. In order to prevent or remove these pains, as soon as the placenta is separated 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 usual, it may be taken for granted that there is either another child, or a large quantity of this clotted blood; and, which forever it may be, there is a necessity 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 sleeping and sweating plentifully, the irritation is removed, the evacuations are increased, the os uteri is insensibly relaxed, and the coagula slide easily along. When the discharge of the lochia is small, the after-pains, if moderate, ought not to be restrained; because the squeezing which they occasion promotes the other evacuation, which is necessary for the recovery of the patient. After-pains may also proceed from an obstruction in some of the vessels, occasioning a small inflammation of the os internum and ligaments; and the squeezing thereby occasioned may not only help to propel the obstructing fluid, but also (if not too violent) contribute to the natural discharges.

**Chap. XIX. Of the Lochia.**

We have already observed, that the delivery of the child and placenta is followed by an efflux of more or less blood, discharged from the uterus, which, by the immediate evacuation of the large vessels, is allowed to contract itself the more freely, without the danger of an inflammation, which would probably happen in the contraction, if the great vessels were not emptied at the same time: but as the fluids in the smaller vessels cannot be so soon evacuated, or returned into the vena cava, it is necessary that, after the great discharge is abated, a slow and gradual evacuation should continue, until the womb shall be contracted to near the same size which it had before pregnancy; and to this it attains about the 18th or 20th day after delivery, though the period is different in different women.

When the large vessels are emptied immediately after delivery, the discharge frequently ceases for several hours, until the fluids in the smaller vessels 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 serous from the beginning: but, about the fifth day, it flows off a clear, or sometimes (though seldom) of a greenish tint; for, the mouths of the vessels growing gradually narrower by the contraction of the uterus, at last allow the serous part only to pass: as for the greenish hue, it is supposed to proceed from a dissolution of the cellular or cribiform membrane or mucus, that surrounded the surface of the placenta and chorion; part of which, being left in the uterus, becomes livid, decays, and, dissolving, mixes with and tinctures the discharge as it passes along.

Though the lochia, as we have already observed, commonly continue till the 18th or 20th day, they are every day diminishing in quantity, and soonest cease in those women who suckle their children, or have had an extraordinary discharge at first; but the colour, quantity, and duration, differ in different women: in some patients, the red colour disappears on the first or second day; and in others, though rarely, it continues more or less to the end of the month: the evacuation in some is very small, in others excessive: in one woman it ceases very soon, in another flows during... Milk fever during the whole month; yet all of these patients shall do well.

Some allege, that this discharge from the uterus is the same with that from a wound of a large surface; but it is more reasonable to suppose, that the change of colour and diminution of quantity proceed from the flow contraction of the vessels; because, previous to pus, there must have been lacerations and impotences, and, in women who have suddenly died after delivery, no wound or excoriation hath appeared upon the inner surface of the womb, which is sometimes found altogether smooth, and at other times rough and unequal, on that part to which the placenta adhered. The space that is occupied before the delivery, from being six inches in diameter, or 18 inches in circumference, will, soon after the birth, be contracted to one third or fourth of these dimensions.

CHAP. XX. Of the Milk-fever.

About the fourth day, the breasts generally begin to grow turgid and painful. We have formerly observed, that, during the time of uterine gestation, the breasts in most women gradually increase till the delivery, growing softer as they are enlarged by the vessels being more and more filled with fluids; and by this gradual dilatation they are prepared for secreting the milk from the blood after delivery. During the two or three first days after parturition, especially when the woman has undergone a large discharge, the breasts have been sometimes observed to subside and grow flaccid; and about the 3rd or 4th day, when the lochia begin to decrease, the breasts swell again to their former size, and stretch more and more, until the milk, being secreted, is either sucked by the child, or frequently of itself runs out at the nipples.

Most of the complaints incident to women after delivery, proceed either from the obstruction of the lochia in the uterus, or of the milk in the breasts, occasioned by any thing that will produce a fever; such as catching cold, long and severe labour, eating food that is hard of digestion, and drinking fluids that quicken the circulation of the blood in the large vessels; by which means the smaller, with all the secretory and excretory ducts, are obstructed.

The discharge of the lochia being so different in women of different constitutions, and besides in some measure depending upon the method of management, and the way of life peculiar to the patient, we are not to judge of her situation from the colour, quantity, and duration of them, but from the other symptoms that attend the discharge; and if the woman seems 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 symptoms of inanition; but as the lochia seldom flow so violently as to destroy the patient of a sudden, she may be supported by a proper nourishing diet, assisted with cordial and restorative medicines. Let her, for example, use broths, jellies, and asses milk; if the pulse is languid and sunk, she may take repeated doses of the cordial cardiac, with mixtures composed of the cordial waters and volatile spirits; subastringents and opiates frequently administered, with the cort. Peruvian, in different forms, and aulere wines, are of great service.

On the other hand, when the discharge is too small, or hath ceased altogether, the symptoms are more dangerous, and require the contrary method of cure: for now the business is to remove a too great plentitude of the vessels in and about the uterus, occasioning tenion, pain, and labour, in the circulating fluids; from whence proceed great heat in the part, reflexions, fever, a full, hard, quick pulse, pains in the head and back, nausea, and difficulty in breathing. These complaints, if not at first prevented, or removed by rest and plentiful sweating, must be treated with venesection and the antiphlogistic method.

When the obstruction is recent, let the patient lie quiet, and encourage a plentiful diaphoresis, by drinking frequently of warm, weak, diluting fluids, such as water-gruel, barley-water, tea, or weak chicken-broth.

Should these methods be used without success, and the patient, far from being relieved by rest, plentiful sweating, or a sufficient discharge of the obstructed lochia, labour under an hot, dry skin, anxiety, and a quick, hard, and full pulse, the warm diaphoretics must be laid aside; because, if they fail of having the desired effect, they must necessarily increase the fever and obstruction, and recourse be had to bleeding at the arm or ankle to more or less quantity, according to the degree of fever and obstruction; and this evacuation must be repeated as there is occasion. When the obstruction is not total, it is supposed more proper to bleed at the ankle than at the arm; and at this last, when the discharge is altogether stopped, her ordinary drink ought to be impregnated with nitre.

If she is costive, emollient and gently opening glysters may be occasionally injected; and her breasts must be fomented and sucked, either by the mouth or pipe-glasses. If by these means the fever is abated; and the necessary 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 breasts, or by a critical evacuation by sweat, urine, or stool, and the woman is every now and then attacked with cold shiverings; an abscess or abscesses will probably be formed in the uterus or neighbouring parts, or in the breasts; and sometimes the matter will be translated to other situations, and the seat of it foretold from the part's being affected with violent pains: these abscesses are more or less dangerous, according to the place in which they happen, the largeness of the suppuration, and the good or bad constitution of the patient.

If, when the pains in the epigastric region is violent, and the fever increased to a very high degree, the patient should all of a sudden enjoy a cessation from pain, without any previous discharge or critical eruption, the physician may pronounce that a mortification is begun; especially if, at the same time, the pulse becomes low, quick, wavering, and intermittent; if the woman's countenance, from being florid, turns dusky and pale, while she herself, and all the attendants, conceive her much mended; in that case, she will grow delirious, Milk-fever rions, and die in a very short time.

What we have said on this subject regards that fever which proceeds from the obstructed lochia, and in which the breasts may likewise be affected: but the milk-fever is that in which the breasts are originally concerned, and which may happen tho' the lochia continue to flow in sufficient quantity; nevertheless, they mutually promote each other, and both are to be treated in the manner already explained; namely, by opiates, diluents, and diaphoretics, in the beginning; and, these prescriptions failing, the obstructions must be resolved by the antiphlogistic method described above. The milk-fever alone, when the uterus is not concerned, is not so dangerous, and much more easily relieved. Women of a healthy constitution, who suckle their own children, have good nipples, and whose milk comes freely, are seldom or never subject to this disorder, which is more incident to those who do not give suck, and neglect to prevent the secretion in time; or, when the milk is secreted, take no measures for emptying their breasts. This fever likewise happens to women who try too soon to suckle, and continue their efforts too long at one time; by which means the nipples, and consequently the breasts, are often inflamed, swelled, and obstructed.

In order to prevent a too great turgency in the vessels of the breasts, and the secretion of milk, in those women who do not choose to suckle, it will be proper to make external application of those things which, by their pressure and repercussive force, will hinder the blood from flowing in too great quantity to this part, which is now more yielding than at any other time; for this purpose, let the breasts be covered with emp. de minia, diapalma, or emp. simp. spread upon linen, or cloths dipped in camphorated spirits, be frequently applied to these parts and the arm-pits; while the patient's diet and drink is of the lightest kind, and given in small quantities. Notwithstanding these precautions, a turgency commonly begins about the third day; but by rest, moderate sweating, and the use of these applications, the tension and pain will subside about the fifth or sixth 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 afflatus, the tension and pain increasing, will bring on a cold shivering succeeded by a fever; which may obstruct the other excretions, as well as those of the breast.

In this case, the sudorifics above recommended must be prescribed; and if a plentiful sweat ensues, the patient will be relieved; at the same time the milk must be extracted from her breasts, by sucking with the mouth or glaisses: should these methods fail, and the fever increase, she ought to be blooded in the arm; and instead of the external applications hitherto used, emollient liniments and cataplasm must be substituted, in order to soften and relax. If, in spite of these endeavours, the fever proceeds for some days, the patient is frequently relieved by critical sweats, a large discharge from the uterus, miliary eruptions, or loose stools 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 imposthume, which is to be brought to maturity, and managed like other inflammatory tumours; and no astringents ought to be applied, lest they should produce ichirrous swellings in the glands.

As the crisis of this fever, as well as of that last described, often consists in miliary eruptions over the whole surface of the body, but particularly on the neck and breast, by which the fever is carried off, nothing ought to be given which will either greatly increase or diminish the circulating force, but such only as will keep out the eruptions. But if, notwithstanding these eruptions, the fever, instead of abating, is augmented, it will be necessary to diminish its force, and prevent its increase, by those evacuations we have mentioned above. On the contrary, should the pulse sink, the eruptions begin to retreat inwardly, and the morbid matter be in danger of falling upon the viscera, we must endeavour to keep them out by opiates and sudorific medicines; and here blisters may be applied with success.

CHAP. XXI. Of the Evacuations necessary at the end of the Month after Delivery.

Those who have had a sufficient discharge of the lochia, plenty of milk, and suckle their own children, commonly recover with ease, and, as the superfluous fluids of the body are drained off at the nipples, seldom require evacuations at the end of the month; but if there are any complaints from fullness, such as pains and stitches, after the 20th day, some blood ought to be taken from the arm, and the belly gently opened by frequent glysters, or repeated doses of laxative medicines.

If the patient has tolerably recovered, the milk having been at first sucked or discharged from the nipples, and afterwards discussed, no evacuations are necessary before the third or fourth week; and sometimes not till after the first flowing of the menes, 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.

EXPLANATION of the PLATES.

Fig. I. gives a front-view of the uterus in situ Plate suspended in the vagina; the anterior parts of osfa CLXXVIII-ischium, with the osa pubis; pudenda, perineum, and anus, being removed in order to shew the internal parts.

A, the last vertebra of the loins. BB, the osa illium. CC, the acetabula. DD, the inferior and posterior parts of the osa ilchium. E, the part covering the extremity of the coccyx. F, the inferior part of the rectum. GG, the vagina cut open longitudinally, and stretched on each side of the collum uteri, to shew in what manner the uterus is suspended in the same. HH, part of the vesica urinaria stretched on each side of the vagina, and inferior part of the fundus uteri. I, the collum uteri. K, the fundus uteri. LL, the tubi Fallopiani and simbriæ. MM, the ovaria. NN, the NN, the ligamenta lata and rotunda. OO, the superior part of the rectum.

Fig. 2. gives a front-view of the uterus in the beginning of the first month of pregnancy; the anterior part being removed that the embryo might appear through the annios, the chorion being dissected off.

A, the fundus uteri. B, the collum uteri, with a view of the rugous canal that leads to the cavity of the fundus. C, the os uteri.

Fig. 3. In the same view and section of the parts as in fig. 1. shews the uterus as it appears in the second or third month of pregnancy.

F, the anus. G, the vagina, with its plicae. HH, the posterior and inferior part of the urinary bladder extended on each side; the anterior and superior part being removed.

II, the mouth and neck of the womb, as raised up when examining the same by the touch, with one of the fingers in the vagina.

KK, the uterus as stretched in the second or third month, containing the embryo, with the placenta adhering to the fundus.

Fig. 4. In the same view and section of the parts with the former figures, represents the uterus in the eighth or ninth month of pregnancy.

A, the uterus as stretched to near its full extent, with the waters, and containing the fetus entangled in the funis, the head presenting at the upper part of the pelvis.

BB, the superior part of the osa ilium. CC, the acetabula. DD, the remaining posterior parts of the osa ilium.

E, the coccyx. F, the inferior part of the rectum. GG, the vagina stretched on each side. H, the os uteri, the neck being stretched to its full extent or entirely obliterated.

II, part of the vesica urinaria.

KK, the placenta, at the superior and posterior part of the uterus.

LL, the membranes. M, the funis umbilicalis.

Fig. 5. gives a front view of twins in utero in the beginning of labour.

A, the uterus as stretched, with the membranes and waters.

BB, the superior parts of the osa ilium. CC, the acetabula. DD, the osa ilium. E, the coccyx. F, the lower part of the rectum. GG, the vagina.

H, the os internum stretched open about a finger-breadth, with the membranes and waters in time of labour-pains.

II, The inferior part of the uterus, stretched with the waters which are below the head of the child that presents.

KK, the two placentas adhering to the posterior part of the uterus, the two fetuses lying before them, one with its head in a proper position at the inferior part of the uterus, and the other situated preternaturally with the head to the fundus: the bodies of each are here entangled in their proper funis, which frequently happens in the natural as well as preternatural positions.

LL, the membranes belonging to each placenta.

Fig. 6. shews, in a lateral view and longitudinal division of the parts, the gravid uterus when labour is somewhat advanced.

A, the lowest vertebra of the back; the distance from which to the last-mentioned vertebra is here shewn by dotted lines.

CC, the usual thickness and figure of the uterus when extended by the waters at the latter end of pregnancy.

D, the same contracted and grown thicker after the waters are evacuated.

EE, the figure of the uterus when pendulous.

FF, the figure of the uterus when stretched higher than usual, which generally occasions vomitings and difficulty of breathing.

G, the os pubis of the left side. HH, the os internum. I, the vagina. K, the left nympha. L, the labium pudendi of the same side. M, The remaining portion of the bladder. N, the anus. OP, the left hip and thigh.

Fig. 7. shews the forehead of the fetus turned backwards to the os sacrum, and the occiput below the pubes, by which means the narrow part of the head is to the narrow part of the pelvis, that is, between the inferior parts of the osa ilium.

A, the uterus contracted closely to the fetus after the waters are evacuated.

BCD, the vertebrae of the loins, os sacrum, and coccyx.

E, the anus. F, the left hip. G, the perineum. H, the os externum beginning to dilate. I, the os pubis of the left side. K, the remaining portion of the bladder. L, the posterior part of the os uteri.

Fig. 1. is principally intended to shew in what manner the perineum and external parts are stretched by CLXXIX, the head of the fetus, in a first pregnancy, towards the end of the labour.

A, the abdomen. B, the labia pudendi. C, the clitoris and its preputium. D, the hairy scalp of the fetus, fvelled at the vertex, in a laborious case, and protruded to the os externum.

E, F, the perineum and anus pushed out by the head of the fetus in form of a large tumour.

GG, the parts that cover the tuberofacies of the osa ilium.

H, the part that covers the os coccygis.

Fig. 2. shews in what manner the head of the fetus is helped along with the forceps, as artificial hands, when it is necessary for the safety of either mother or child.

AABC, the vertebrae of the loins, os sacrum, and coccyx. D, the os pubis of the left side. E, the remaining part of the bladder. FF, the internum rectum. GGG, the uterus. H, the mons veneris. I, the clitoris, with the left nymph. X, the corpus cavernosum clitoridis. V, the meatus urinarius. K, the left labium pudendi. L, the anus. N, the perineum. QP, the left hip and thigh. R, the skin and muscular parts of the loins.

Fig. 3. shews the head of the foetus, by strong labour-pains, squeezed into a longish form, with a tumour on the vertex, from a long compression of the head in the pelvis.

K, the tumour on the vertex. L, the forceps. M, the velica urinaria much distended with a large quantity of urine from the long pressure of the head against the urethra. N, the under part of the uterus. OO, the os uteri.

Fig. 4. shews, in the lateral view, the face of the child presenting and forced down into the lower part of the pelvis, the chin being below the pubes, and the vertex in the concavity of the os sacrum: the water being likewise all discharged, the uterus appears closely joined to the body of the child.

Fig. 5. shews, in a lateral view, the head of the child in the same position as in the former figure.

AB, the vertebrae of the loins, os sacrum, and coccyx. C, the os pubis of the left side. D, the inferior part of the rectum. E, the perineum. F, the left labium pudendi. GGG, the uterus.

Fig. 6. gives a lateral internal view of a distorted pelvis, divided longitudinally, with the head of a foetus of the seventh month passing the same.

ABC, the os sacrum and coccyx. D, the os pubis of the left side. E, the tuberosity of the os ilium of the same side.

Fig. 7. gives a side-view of a distorted pelvis, divided longitudinally, with the head of a full grown foetus squeezed into the brim, the parietal bones decussating each other, and comprimbed into a conical form.

ABC, the os sacrum and coccyx. D, the os pubis of the left side. E, the tuberosity of the os ilium. F, the processus acutus. G, the foramen magnum.

Fig. 1. shews, in a front view of the pelvis, the breech of the foetus presenting, and dilating the os internum, the membranes being too soon broke.

Fig. 2. is the reverse of fig. 1. the fore-parts of the child being to the fore-part of the uterus.

Fig. 3. represents, in a front-view of the pelvis, the foetus comprimbed, by the contraction of the uterus, into a round form, the fore-parts of the former being towards the inferior part of the latter, and one foot and hand fallen down into the vagina. In this figure, the anterior part of the pelvis is removed, by a longitudinal section through the middle of the foramen magnum.

AA, the superior parts of the os ilium. BB, the uterus. C, the mouth of the womb stretched and appearing in OOOO, the vagina. D, the inferior and posterior part of the os externum. EEEE, the remaining parts of the os pubis and ischium. FFFF, the membrana adiposa.

Fig. 4. represents, in the same view with fig. 3. the foetus in the contrary position; the breech and foreparts being towards the fundus uteri, the left arm in the vagina, and the fore-arm without the os externum, the shoulder being likewise forced into the os uteri.

Fig. 5. represents, in a lateral view of the pelvis, the method of extracting, by means of a curved crotchet, the head of the foetus, when left in the uterus, after the body is delivered and separated from it; either by its being too large, or the pelvis too narrow.

ABC, the os sacrum and coccyx. D, the os pubis of the left side. EE, the uterus. F, the locking part of the crotchet. g, h, i, the point of the crotchet on the inside of the cranium.

Fig. 6. represents the forceps and blunt-hook.

A, the straight forceps, in the exact proportion as to the width between the blades, and length from the points to the locking-part; the first being two and the second six inches, which, with three inches and a half, (the length of the handles), make in all eleven inches and a half.

B represents the posterior part of a single blade in order to shew the width and length of the open part of the same, and the form and dimensions of the whole.

C, the blunt hook, which is used for three purposes:

1. To assist the extraction of the head, after the cranium is opened with the scissors, by introducing the small end along the ear on the outside of the head to above the under-jaw, where the point is to be fixed; the other extremity of the hook being held with one hand, whilst two fingers of the other are to be introduced into the foresaid opening, by which holds the head is to be gradually extracted. 2. The small end is useful in abortions, in any of the first four or five months, to hook down the fecundines, when lying loose in the uterus, when they cannot be extracted by the fingers or labour-pains, and when the patient is much weakened by floodings. 3. The large hook at the other end is useful to assist the extraction of the body, when the breech presents; but should be used with great caution, to avoid the dislocation or fracture of the thigh.

Fig. 7. A represents the whale-bone fillet, which may be sometimes useful in laborious cases, when the operator is not provided with the forceps, in sudden and unexpected exigencies.

BB, two views of a pessary for the prolapsus uteri. After the uterus is reduced, the large end of the pessary is to be introduced into the vagina, and the os uteri retained in the concave part, where there are three holes holes to prevent the stagnation of any moisture. The small end without the os externum has two tapes drawn through the two holes, which are tied to four other tapes, that hang down from a belt that surrounds the woman's body, and by this means keep up the pessary. This pessary may be taken out by the patient when she goes to bed, and introduced again the morning; but as this sometimes rubs the os externum, so as to make its use uneasy, the round kind, marked C, are of more general use. They are made of wood, ivory, or cork, (the last covered with cloth and dipped in wax;) the pessary is to be lubricated with pomatum, the edge forced through the passage into the vagina, and a finger introduced in the hole in the middle lays it across within the os externum. They ought to be larger or smaller, according to the wideness or narrowness of the passage, to prevent their being forced out by any extraordinary straining.

DD gives two views of a female catheter, to shew its degree of curvature and different parts.

Fig. 8. a, represents a pair of curved crotchetts locked together in the same manner as the forceps. The dotted lines along the inside of one of the blades represent a sheath contrived to guard the point till it is introduced high enough; the ligature at the handles marked with two dotted lines is then to be untied, the sheath withdrawn, and the point being uncovered is fixed as in fig. 5.

b, gives a view of the back-part of one of the crotchetts, which is 12 inches long.

c, a front view of the point, to show its proportional length and breadth.

d, the scissors for perforating the cranium in very narrow and distorted pelvises. They ought to be made very strong, and at least nine inches in length, with stops or rests in the middle of the blades, by which a large dilatation is more easily made.