PARTURITION. 
688 
like, action of the bag of waters; yet at length there 
would be fo much of l'oftnefs and dilatability, as to au¬ 
thorize the practitioner to proceed to the operation, 
which mult be flowly and cautioufly performed, as before 
defcribed. 
4. Suppofe the waters to have been early evacuated, 
the os uteri to be more or lefs dilated, the pains recur¬ 
ring often, and inordinately ftrong and forcing. To 
attempt the turning under fuch circumftances, would 
probably be unavailing, and might be attended with 
great hazard to the mother. Here then nothing remains 
but to watch the patient attentively; and either to wait 
till the uterus, having exhaufted its llrength in its fruit- 
lefs endeavours to expel the child, becomes torpid, and 
incapable of further exertion ; or to leflen the vigour of 
the fyftem by bleeding, or'other depleting means, or to 
diminifh the uterine adtion by a large dofe of laudanum. 
This is the method recommended by Dr. Hamilton of 
Edinburgh, who fpeaks of it as attended with the moll 
obvious good eft'efts. The dofe that he gives is eighty 
drops. In patients of a plethoric habit it will be fre¬ 
quently expedient to take away from fourteen to fixteen 
or twenty ounces of blood, before exhibiting the opium. 
M. Capuron recommends the warm-bath in fuch cafes; 
but it has not been extensively tried in this country. It 
feems well deferving of a trial. When, from either of 
thefe plans, the adtion of the uterus becomes fufpended, 
the earlieft opportunity is to be taken of proceeding to 
deliver. 
Some pradtitioners objedt to delay in either of thefe 
laft cafes, upon the following grounds. 
Firlt. They fay, that, where the child is thus placed 
and there are ftrong pains, much danger is incurred of a 
ruptured uterus; for that this accident frequently hap¬ 
pens in fuch cafes, from the head or one of the limbs of 
the child forming a protuberance, againft which the uterus 
is fo forcibly preffed, that at length its fibres give way, 
and a laceration enfues. Now it is contended, that the 
danger of this occurrence can be prevented by one me¬ 
thod only, viz. changing the poftureof the child, which 
mull therefore be effedted at all hazards. That the dan¬ 
ger of a rupture of the uterus under fuch circumftances 
is very great, we {hall not attempt to deny ; but how will 
it be diminiftied by the means propofed ? Will there be 
lefs hazard in the efforts of the operator, to pufh forward 
his hand, in oppofition to the powerful refiftance of the 
uterus ? Nay, is not the attempt to introduce the hand 
likely to excite the uterus to ftill more inordinate adtion, 
and confequently to increafe rather than to diminifh the 
danger? An appeal to fadts will prove, that rupture of 
the uterus has occurred, at leaft as often, from the vio¬ 
lent and perfevering attempts of the operator, as from 
the untoward pofition of the child. 
Secondly. It is argued, that, if the uterus be not rup¬ 
tured by its own powerful adtion, yet that the labour- 
pains will, by degrees, force the arm, fhoulder, bread, 
and perhaps the head, of the child, fo firmly into the 
pelvis, as to render it impoftible to pafs the hand into the 
uterus after the pains become fufpended. Dr. Hamilton, 
in his “ Seledt Cafes,” gives an inftance of this, and has 
fubjoined fome very judicious remarks upon the fubjedt. 
But fince, in the pradtice of midwifery, as in other 
branches of the art of healing, we have fometimes only 
a choice of difficulties, much muft of neceffity be left to 
the difcretion and judgment of the pradlitioner, in each 
individual cafe that he attends. We are not difpofed to 
think lightly of the hazard that attends having the fcetus, 
thus preternaturally prefenting, wedged into the pelvis ; 
yet we are ftrongly inclined to believe, that there is lefs 
danger in this, than in forcing the hand into the rigid 
unyielding uterus, in a ftate of adlive contradfion and ir¬ 
ritability. “ Upon the whole, therefore, (fays Dr. Mer- 
riman,) I am of opinion, that there is a greater probabi¬ 
lity of doing good by delay, and by ufing fuch means 
as are likely to control the exceffive adfion of the uterus, 
than in perfifting to introduce the hand, when the uterus 
oppofes a refiftance fo obftinate and impetuous. But, as 
foon as this exceffive adtion is fubdued, the turning fhould 
be cautioufly undertaken.” The dodtor has added, in 
the Appendix to his “ Synopfis,” two cafes to fhow the 
eft’edt of patience and laudanum : in one of which, owing 
to an over-dofe, the uterine adtion was fo completely fuf¬ 
pended, that it could not afterwards be excited fo as to 
expel the placenta, and the patient died ; in the other 
cafe, the treatment had the happieft iffue, though under 
the molt untoward circumftances. 
A curious phenomenon, firft accurately noticed by Dr. 
Denman, and fince by other authors, may perhaps, un¬ 
der fome circumftances, be admitted as a farther juftifica- 
tion of delay. It has occafionally happened, in thefe pre- 
fentations, that the labour-pains have had the effedf of 
forcing the nates or feet fo low into the pelvis, that they 
have been precipitated through the os externum, and 
thus the turning of the child has been produced without 
the interference of the operator. In one or two fuch 
cafes, the children have even been born alive. This Dr. 
Denman calls “ the fpontaneous evolution” of the child. 
Dr. Douglas, of Dublin, has publiflied a very intereftir.g 
pamphlet on this curious fubjeft, the procefs of which he 
explains moft fatisfadforily and clearly; and he is rather 
fanguine in his belief, that the fpontaneous evolution 
would more frequently take place, if it were more fre¬ 
quently trufted to by the obftetric attendant. The re¬ 
currence of the fpontaneous evolution has however been 
comparatively fo rare, that no man would be juftifiable 
in implicitly relying upon it. The knowledge that it 
has fometimes happened, may indeed, under fome cir¬ 
cumftances of extreme refiftance to the paflage of the 
hand into the uterus, reconcile us to delay, as above re¬ 
commended ; but we fhould never allow it to operate 
upon our minds, fo as to induce us to negledt the proper 
means and proper time of turning, when we have it in 
our power. 
Dr. Denman, although, in the later editions of his 
valuable work, he lays lefs ftrefs upon this point, yet his 
obfervations on the management of preternatural labour 
of the fecond order, are evidently influenced by his for¬ 
mer opinion. He fays, “ The knowledge of this fadt, 
however, unqueftionably proved, does not free us from 
the neceffity and propriety of turning children prefenting 
with the fuperior extremities, in every cafe in which that 
operation can be performed with fafety to the mother, or 
give us a better chance of faving the child. Under fuch 
circumftances, the inftruflions given by former writers, 
and the obfervations we have before made, muft ftill be 
confidered as proper to guide our conduct. But, when 
we are called to a patient with a preternatural labour, in 
which there is no room to hope for the prefervation of 
the child, or in which we are afiured of its death, or when 
the operation of turning cannot be performed without 
violence, and fome danger to the mother, then the know¬ 
ledge of this probability of a fpontaneous evolution will fet 
our minds at eafe, and difengr-ge us from the confidera- 
tion of making any hafty attempts to perform a hazardous 
operation, from which no poffible good can be derived, 
except that of extrafting a dead child, and which at all 
events might be effedted by a method much more fafe to 
the mother.” Introdudtion to Midwifery, vol. ii. p. 249. 
We have not attempted to lay down any rules for the 
pofition of the patient, while the operator is endeavouring 
to turn the child; becaufe that pofition, which gives him 
the moft free ufe of his hand and arm, is to be preferred j 
and under fome circumftances one pofition, tinder others 
a different pofition, will be found moft convenient. 
In all cafes of turning, it will be found neceflary for 
the operator to make the entire arm bare, becaufe the 
feet will feldom be within the grafp of the operator’s hand 
till his elbow is even with, or has pafled through, the os 
externum. The hand and arm fhould be well fmeared 
over with lard or pomatum, or other greafy fubftance, 
before 
