No. 230.

LONDON, SATURDAY, JANUARY 26. [1827-8.

LECTURES

ON THE

THEORY AND PRACTICE OF MIDWIFERY,

DELIVERED AT GUY’S HOSPITAL BY

DR. JAMES BLUNDELL.

LECTURE XVI.

Management of the more copious Flooctings.GETi.EMt;,—It was observed to you in aformer lecture, that we sometimes meetwith cases of the earlier months, especially,in which the discharge from the womb issparing , but in practice, we also meet withannl]ier varietv of the disease, that, I mean,in which the discharge of blood is more co-pious, more dangerous, and more pertitiacioits-a sort of bleeding occurring occasionally inthe earlier months, but still more frequentin the middle and later periods of preg-nancy. --

As in those cases where the dischargeof blood from the uterus is sparing, it is

alvays proper, when the discharge becomescopious, that the patient be placed in therecumbent posture, and that she be keptperfectly still ; nor, if she lie in a very smallroom, or in a confined situation, providedthe strength will allow, ought we to neglecther removal to a larger and more airy apart-ment, for the stimulus of heat has an obvious

tendency to keep up the bleeding.-1 -ain, in those cases where the discharge

fr3iii the uterus has been copious, as in themore sparing discharges, you are not to

Df-Jf’ct the administration of nourishment.:B’;ul’dmlent the patient can scarcely takeWith advantage, provided the large gushesof !J:úoù are still upon her; but it happensncr.tHy, in the cases under consideration,that at’Ll’ one or two large gushes, one, two,fir more pints of blood escaping, the patient: a::1.5 into a state approaching deliquium,a small drain of blood alone remaining ; anduadcr these circumstances nourishment mav

be administered with a fair prospect of ad.vantage. Often, it is true, the digestivepowers are in great measure lost; but gene-rally, I conceive, a part of the food is di-gested, and contributes more or less to theformation of chyle and blood, in quantitiesnot to be despised when the patient is en-danaered by inanition.

I In the earlier months of pregnancy, wherethe discharge of blood is small, the oil ofturpentine is recommended, on authoritiesin matters of experience well deserving ourdeference. By Denman, and others, thissame oil is recommended in the more ob-stinate cases of flooding, now under con-sideration ; and although I have not myselftried the oil sufficiently often to enable mepersonally to vouch for its efficacy, yet onthe whole, from the experiments which Ihave made with it, the impression, left onmy mind is favourable to its powers. Ihave told you already, that the quantitywhich different stomachs will bear is ex

ceedingly diversified: from half an ounceto an ounce in the course of twenty-fourhours may be considered as an average dose;sometimes you may exceed this, and some-times even a smaller daily quantity will berejected by the stomach. A drachm or twoat once may be administered, floating ondistilled water, a form less offensive than.that of emulsion. sometimes recommended.

Further, when there are large dischargesof blood from the uterus, the patient beingprone to sink into a state of asphyxia, it

may then, no doubt, become necessary tokeep up the action of the heart by stimuli,(spirits more especiallv,) administered in amanner which I shall hereafter prescribe ;but if, on the other hand, you are persuadedthat the faintness is fugacious, beware ofrousing the patient too hastily. Of the vas-cular action a certain degree of reduction issafe and to be wished tor in these cases,because, under this faintness, the stream ofblood loses its impetuosity, and the inhe-rent disposition to concretion is augmented,the quantity of blood passing through thevessels in a given time, and consequentlythe quantity ot blood in given time discharge-ed from these vessels, when torn open,being smaller in consequence ; and on all

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these accounts, if the faintness be not very Igreat, it is to be looked upon as a natural,and very powerful, and very desirable re-medy, for staunching the discharge.

In flooding from the uterus, considerableadvantage appears to be derived from theuse of lead taken into the stomach, or ad-ministered by the rectum. To omit less

weighty authorities, this remedy, Dr. Haigh-ton used to mention with great commenda-tion, conceiving that he had himself used itwith decided advantage. If you make trialof the lead, it is in the larger doses youshould employ it, the quantity being fromfour to six grains of the super-acetate in the icourse of S4 hours; six grains being a" large daily dose," and four grains in the24 hours, a dose more moderate. With

respect to the mode of administration, it

may either be dissolved in distilled vine-gar, with a proper mixture of distilled water,or it may be formed into pills. And asthe lead sometimes offends the bowels, giv-ing rise to very severe spasms there, en-deavours may be made to correct this evil,by the conjunction of the lead with opium.To two grains of the super-acetate, addhalf a grain of opium, to be formed intopill, and this the patient may take two orthree times a day; or again, to five grainsof the super-acetate of lead, add 60 dropsof the tincture of opium, three ounces ofdistilled vinegar, and the same quantity ofdistilled water, mixing and dissolving; thepatient afterwards taking, four times a day,one quarter part for a dose. The lead, thoughreputed a powerful medicine, especiallywhere there is a tendency to draining, is, itmust be acknowleged, an unwieldy sort ofremedy,-a kind of elephant in the battle.For this reason, the lead ought not to beused, unless the case seems peremptorily torequire the more active treatment. It is noton every occasion that I would advise youto sit down, and, as a matter of course,to prescribe the super-acetate. If, how-ever, you find the discharge copious anddangerous, and, above all, degenerating intoobstinate drainings ; if, to use a strong ex-pression, death stare the patient in theface, under such circumstances, the activeuse of the lead might be recommended, andI think you would be fully justified in givingthose large, and somewhat dangerous, dailydoses, of which the measure was before

given.Under the action of lead, a paralytic af-

fection, affecting the brachial muscles, isliable to be produced, occasioning a weak-ness of the wrist, denominated the dangles.In painters, and those whose occupationslead them to handle the more active formsof the lead, this obstinate paralysis is nowand then produced. Whether the internaluse of the lead have the same efect, am

not prepared to decide ; but I never saw orheard of a single case of flooding or otherbleeding, where, under the use of the super-acetate, this distressing disease has threat.ened the patient ; and although I conceivethat this fact ought to put you on yourguard, there is no reason why you shouldbe intimidated or deterred by it. Colica pic-tonum is certainly produced, sometimes bythe lead in larger doses ; a very severe painextending itself along the bowels, as thelead makes its way through them, harass.ing the patient much, but lasting a fewhours only. From 20 to 30 grains of thecompound extract of colocynthis, with 2 or3 or 4 grains of opium, is a useful remedyin these cases ; or provided you deem the painto be seated principally in the larger bowels,an ounce of the olellm t’tct):!, and half adrachm, or a drachm by measure, of thetincture of opium, may be injected into thebowel with advantage.Where the lead is given with due caution

in the larger doses, it may be given in safety;but you may ask me, in what do these cau-tions consist If you are administering thelead largely, you should observe the bleed.ing, and if you have effectually stopped it,let the lead be laid aside. Active and dan.

gerous as the remedy is, a single dose morethan seems to be justified by the urgency ofthe flooding, ought not to be administered.When the lead is administered, watch;if intestinal pains are not produced, it iswell; while, on the other hand, if you findsevere pains in the bowels, the remedyshould be laid aside, for, under these cir.cumstances, its continuance is not, perhaps,wholly unattended with danger. Again, inadministering the lead, you ought to bearin mind, as you proceed, the aggregate quan.tity which may have been already given,Till, from your own experience, you find thatmore may be safely administered, do notrashly exceed the aggregate of 2O or 30, or,at most, 3D or 40 grains of the super-acetate,relinquishing the further use of the remedyif these quantities are inadequate to affordrelief. So that by not exceeding a certainaggregate, which may be fixed by your ownobservations, by relinquishing the lead assoon as intestinal spasms become manifest,by refraining from the further use of theremedy, as soon as the bleeding is effectu.ally checked, however small the quantitywhich may have been administered, yousecure to yourselves, I think, the active useof the remedy without its danger.When discharges of blood from the uterus

are’sparing, it is not my custom to applycold, powerfully and extensively, to thelower parts of the abdomen-the hact,thighs, buttocks, and so on ; although, inconformity with popular feeling, I have reocourse to vinegar and water, particularly if

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the temperture of the patient be warm.But when the discharges of blood are moreabundant, cold, a very powerful remedy, mustbe called to our aid, and ought to be

effectually applied, though not without duecaution. When a woman has lost so muchblood, that she is, in every part of her body,cold already, which, in dangerous bleedings,is no uncommon occurrence; the applica-tion of cold, though, in conformity to popu-lar prejudice, it may be recommended, is, I i,fear, of small advantage ; but if you have agreat deal of blood coming away, and if, withthis, there is a certain warmth of the system,and a sort of febrile hurry of the circulation,in such cases cold may, perhaps, be adminis-tered with decisive advantage. Cold wateris sometimes sprinkled over the body ; coldwater is occasionally injected into the rec-tum ; and ice, naked or wrapped in linen, isoccasionally pushed into the vagina, theremedy not being without its dangers, forif you freeze the vagina it dies. To omitthese practices, however, there are, for or-dinary purposes, two modes in which thecold may be administered; the one is by lay-ing bare the abdominal surface, and dashingover it cold water from the cup, or by meansof the hearth-brush dipped in a pailful ofwater, a rough, yet effective, practice ; theother, a gentler method, conducted as fol-lows :-From the cistern, or the well, you procure J

a pailful of water, to which a pint or two of 1vinegar, recommended by popular opinion, l

may be added ; then, taking some napkins,you effectually refrigerate them, ’by dip-ping into this cold mixture, or by tho-roug’hly besprinkling their surface. This

done, you apply them extensively to thecentral parts of the body, front and poste-riorly, as soon as they become warm; it

may be every two or three minutes, ofteneror seldomer as the communication of warmthfrom the body of the patient may require.In some cases, the local application of coldseems really to be of considerable advan-tage; jhave in my mind, at this moment,one case of draining, where other remedieshad been tried with but little effect, andwhere the cold alone appeared to be effica-cius in checking the discharge.

If the fœtus be come away, and if youhave removed the placenta, in general prac-tice it is unwise, where there are large dis-charges, to plug the vagina; for this, in manycases, might occasion an internal bleed-ing, the bleeding continuing, though theefflux is prevented, and the blood, of con-sequence, accumulating in the cavity of theuterus. Where, however, in the more co-pious floodings, the womb is not emptied,and the placenta is not yet away, the plug-ging of the vagina may be tried with con-siderable advantage. The purpose of plug-

ging is, that of allowing the blood to accu-mulate in the vagina and the uterus, so asto form there clots, which may close up themouths of the bleeding vessels. This objectmay be variously obtained : taking a napkinand folding, you may lay it upon the genitalfissure, closing the orifice of the vaginawithout the introduction, or the irritation,of a plug. Thlore conveniently, however, inmany patients who are not irritable in theseparts, you close the canal, by introducing aplug of tow, or sponge, or soft cloth. Clothor sponge, is the plug which I am my-self in the practice of introducing, moreor less, according to the capacity of thecavity, recollecting that the smallest masswhich will inhibit the discharge of bloodfrom the vagina, is the best for the purpose.Of women, there are some in whom the

vagina is so destitute of irritability, that in-troduce what you will there, the organ bearsit without reaction ; ’of others on the con-trary, and more especially of young females,the vagina is sometimes so exceedingly sus-ceptible, that the plug cannot be borne, un-less, perhaps, for a few hours ; and, in thesecases, the application of a napkin to thegenitals externally, may be substituted.When the plug can be borne for a fewhours only, apply it nocturnally ; this mayprevent your being called up in the middleof a cold December night. When the plugremains quiet, don’t be in too much haste toremove it ; recollect, that the longer it isleft there, the more completely will thevessels become contracted and closed up.

In the earlier and middle months of preg-nancy, as in the end of gestation, you willfind, as I explained to you in a precedinglecture, that to empty the uterus is a mosteffectual mode of stopping the blood, andhence the use of deobstruents for it gene-rally happens, when floodings have occur-red previously to the birth of the ovum,that on the abstraction of the ovum and thecomplete evacuation of the uterus, the dis-charge wholly, or in great measure, ceases.Where a patient is labouring under flood-ings in the earlier or middle months, andmore especially under obstinate floodings,recurrent again and again ; the emergencyjustifies us in having recourse to this re-

medy, unjustifiable perhaps in cases less

pressing. In such cases, the thorough eva-cuation of the uterus is the only remedyon which we can certainly rely. The uterus,however, it is not in our power to emptywith the same facility and certainty as theintestines or the stomach ; but there are

three remedies of the deobstruent class de-

servina a trial in these cases, and these threedeobstruents are-succussion, injection, andthe secale cornutum. A jolting ride on arough road, in an uneasy carriage, wherethe propensity to miscarriage is strong, may

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occasion the expulsion of the ovum. The re-medy is rude-scarcely to be recommended- fitted to a few cases only-where strengthremains- and the pregnancy is of the earliermonths-say the first two or three ; inlatter gestation it would be dangerous.--,A medical attendant should be in the car-riage,-the house of the patient should

always be at hand. Saline clysters will dolittle, if the womb is indisposed to contract ;but if the fibres are in action, an ounce ofsalts and six of the infusion of senna, orother more powerful stimuli of the rectum,may be tried with advantage. But of allthe stimuli exciting uterinecontraction, that,which, failing flatly in some cases, in others,however, seems to operate in the most de-cisive manner, is the secale cornutum, orergot. In powder, in infusion, in decoction,it may be given ; and suspecting from someexperiments made, in conjunction withMr. William South, that its virtues residein a vegetable alkaloid, I presume it mayhereafter be administered in the form ofpill, like the quinine, when probably it

may be found less offensive to the stomach : ’,- -I would invite the chemists to the inves-tigation of this point. In general, my for-mula has been, of ergot 3j. in coarse pow-der, of boiling water three ounces, to be !,decocted rapidly to one half, the patienttaking of the decoction poured off, one-third every twenty miuutes, unless someobvious effect were previously produced.In one miscarriage of the third month, to

omit others, after the administration of theergot, I remember the pains became almost Iincessant till the ovum was expelled. Theergot will not, I think, act unless the uterusbe irritable and disposed to the pains. AtButler’s, in Covent Garden, you may getsupplies of the secale cornutum; I nowshow you specimens of it. It is principallyproduced in. America, and perhaps I mayadd the South of France.

In as many as thirty cases where floodingsoccurred in the end of gestation, and wherethe placenta was not lying over the os uteri,Merriman found that the discharge of theliquor amnii either stopped the floodings,or reduced so greatly the quantity of thebleeding, that it became no longer danger-ous. By Rigby, under similar circum-

stances, the same remedy was tried, and infifty or sixty cases with the best success.Set down, therefore, the discharge of theliquor amnii among the remedies for sup-pressing the floodings of the latter months.Nor is it difficult to accomplish this; car-

Tying one or two fingers of the left handthrough the os uteri up to the membranesusnally felt with facility, take a bluntly-pointed instrument, say a female sound, forexample, sharpened for the purpose, andwith this instrument puncture the mem-

branes and discharge the liquor. Under thisoperation the hæmorrhage becomes dimi.nished, perhaps immediately ; and althoughthe ovum may now and then, perhaps, beretained till the end of the nine months,especially if opium have been given, yetmore generally in two or three days after-wards, the whole is expelled, and thewomb emptying itself, contracts thoroughly,so that the flooding becomes entirely sup.pressed. In all cases, in the middle or

later months, where there is an obstinateefflux of blood from the uterus, rememberthat you have in the discharge of the liquor !amnii a most powerful remedy ; in some ofthe worst floodings, where other remediesare failing, you lacerate the membrane, andthe hæmorrhage ceases.By manually emptying the uterus, so as

to allow of a thorough contraction of itscavity and constriction of its fibre, thebleedings may be suppressed, though notin all cases, in many. And there are

different modes in which this evacuationmay be accomplished ; sometimes in flood.ings, we find the child’s head has beenpushed down into the vagina, where we mayapply a pair of forceps upon it, and draw itforth. In other cases, and these are farmore frequent, the child is lying entirelyabove the brim of the pelvis in the cavityof the uterus, so that no parts of it, exceptthe presentation, can be felt. Now in caseslike these, the hand may be introduced intothe cavity of the uterus, and by that opera-tion of turning already explained to you,the fmtus may be brought away. Even inthe earlier months, although, the manualevacuation of the womb is undesirable, theparts being thin and lacerable, should theremoval of the ovum be deemed necessary,it may sometimes be accomplished. Withthe utmost gentleness lay the left hand inthe cavity of the vagina, passing the genitalfissure for this purpose. Then the bulk ofthe hand remaining in the vagina, let thefirst and second finger be passed up into thecavity of the uterus, so as to reach frommouth to fundus, while the womb, felt abovethe symphysis pubis, is by the action of theright hand pressed down upon the iingersofthe left. By this manœuvre, the contentsof the uterus may be brought within reachand control, and, by a small action of thefingers, may be easily got away. Thoughpracticable, this operation is of dubious use:if unskilfully or unwisely performed, it issurrounded by the risks of laceration. Thussometimes by the insertion of the fingers,sometimes by the operation of turning, and

, sometimes when the head of the child islying in the vagina, by the judicious appli-cation of the forceps, the icetus and pla-

! centa may be abstracted ; when, as before,the womb contracting, and the muscular

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fibres becoming constricted, little further

Ldischarge of blood need in most cases be

apprehended. And thus much, then, re-

specting the principal remedies to whichvou are to look, when you have the moreobstinate and dangerous discharges of bloodfrom the womb.We now, Gentlemen, pass to the con-

sideration of the third sort of cases, frequentin consultation practice, and of the utmostimportance-I mean those cases in whichlarge quantities of blood are come away ,,from the uterus, in the latter months moreespecially, and where you find, on enteringthe apartment, that ’the woman is alreadydead ; or, as more frequently happens, thatshe ia lying in a state merely approaching toasphyxia. To two dead females I have beencalled in the course of one night, both de-stroyed before my arrival by large eruptionsof blood from the womb. And should youmeet with cases of this kind, as they mustoccasionally fall within the circle of a com-prehensive practice, your first considerationrelates to the removal of the child.

In some instances, the foetus, low down inthe pelvis, or lodging in a dilated os uteri,might be abstracted with little disturbanceby turning, or the forceps ; in others, the osuteri being shut more or less completely,the foetus could not be extracted withoutviolence, ;by the natural passages, and therazor, and the Caesarian incisions, would, ina scientific view, be a preferable method ofdelivery. In deaths from flooding, however,the foetus will rarely be found alive. The

interrupted placento-pulmonary function fre-quently destroys it even within the uterus,perhaps while the mother still survives.

Considering, as I do, that the foetus oughtcertainly to be saved from drowning ; ifpracticable, I should in my own family, wishthe child to be withdrawn, if this could beaccomplished without violence ; but shoulddelivery be impracticable, without lacerationof the uterus, or the Caesarian incisions, Ishould forbid it. Before the patient is

utterly dead, and past all feeling, to removethe fcetus by violence is a horrid cruelty,which we must, I am sure, all of us, withone voice, condemn; and considering howpossible it is, that some sensibility may stillinliere, even when an ordinary practitionerlittle suspects it, as the security of themother is always paramount in British mid-wiipry, in conformity with this principle,I think that severer measures ought to beforbidden altogether, interdicted even inthose cases where the woman appears to bedad. Generally, however, under these largedischarges of blood, on arriving, you 6ndyour patient still living, but in a state ap-proaching to asphyxia : she is pale andghastly, and cold and gasping, and, in greatmeasure, insensible; her heart flutters,

there is little or no pulse in the wrist ; shelives still, but the grave yawns under her,eager for its prey ; move her from one side ofthe bed to the other, she dies ; disturb theclots by passing the fingers into the vagina,she dies. It is clear that when patients arein this condition, trembling upon the verybrink of destruction, there is but little timefor you to think what ought to done ; theseare moments in which it becomes your dutynot to reflect, but to act. Think now, there-fore, before the moment of difficulty ar-

rives. Be ready with all the rules of prac-tice, which those very dangerous cases

require.Called to a case of this kind myself, the

first thing I do, is to direct my attention tothe circumstances under which these bleed-

ings occur ; for these floodings may occurin the pregnant, or the unimpregnated,-in.the earlier, or in the latter months, withoutthe placenta over the os uteri, or with aplacenta partially, or altogether coveringthis part-before the birth of thejfastus, orafterwards-before the birth of the placenta,or afterwards-or, in twin cases, one childbeing born, the other may remain in theuterus-or, when the secundines have to ap4pearance been removed, a large piece maystill remain in the uterus, the accoucheurnot suspecting in the latter, still more fre4quently in the earlier months. These pointsare of no small importance. On reaching,

therefore, the apartment of your patient,the attention should be directed imme-

diately to all of them ; this is easily done, if £

you have them on your mind, and shouldcertainly by no means be neglected.-Whatare the circumstances under which the

floodings occur.Again, if I am called to one of those

cases in which the patient approaches to

asyphyxia, I am anxious to know whetherthe bleeding has been arrested ; sometimesit is going on, more frequently it has beenarrested, or the discharge which continuesis a mere show. To determine a point soimportant, I would recommend you, withas little disturbance as may be, to clear theblood from the genitals ; and then, again, withas little disturbance as may be, to spread cau-tiously a napkin between the hips and thebed ; this done, another clean napkin, in-terposed between the thighs, may be appliedagainst the orifice of the vagina, and if thereis no further discharge the napkin will re..

tain its whiteness, but if the bleeding con-tinue, blood will make its appearance on thenapkin in the form of concretions and ared patch, broader or more circumscribed,according to the quantity of the discharge.Of the abundance of the bleeding you mayjudge from the colour ; if redder, then lar-ger orifices are open-if paler, then smaller ;or, at all events, iu the latter case the dis.

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charge is smaller, and of course less likelyto be productive of danger.

In cases of this kind also, where thepatient is approaching to asphyxia, I amvery anxious to know whether the systembe on the rally or the decline-a mostimportant inquiry. Now, sometimes, youfind the patient is evidently improvingfrom half hour to half hour ; her hands andfeet are warmer-her pulse is stronger-hercountenance is brighter-her mind is live-lier-in a word, there are all those appear-ances of amendment which, after you havebeen in practice a little, you expect to

meet with when the strength is rising. Onthe other hand, however, you are some-

times meeting with different cases, in which,although the haemorrhage is stopped, thepatient is evidently on the decline. After

floodings immediately, women sometimes diein a moment, but more frequently in a

gradual manner ; and over the victim deathshakes his dart, and to you she stretchesout her helpless hands for that assistance,which you cannot give, unless by transfusion.I have seen a woman dying for two or threehours together, convinced in my own mindthat no known remedy could save her; thesight of these moving cases first led me totransfusion. Experience is the only meanof acquiring the knowledge of these mortalsymptoms. To seize the tact which willenable you to determine with promptitude andcertainty whether death must ensue or not,the cases must be seen. For a full enume-ration of the symptoms which indicate thedeath arising from inanition, I must referyou to the history of them already given ;it may not, however, be amiss in the wayof repetition, to remark here, that to myselfthe fatal termination is principally foreshownby a certain ghastliness of the countenance.--by a restless disposition to change pos-ture-by a long-continued cessation of thepulse in the wrist-by a gasping respira-tion, like that produced by running-andby a jactitation of the arms and legs, joinedwith a feeling of most oppressive anguish.From these symptoms, associated with theordinary signs of inanition, women seldomescape ; nor must it be forgotten’, that theysometimes, in a fainting fit, die suddenly,or more slowly, without the harbingers ofdissolution to foreshow the event.One more remark, and 1 conclude. If you

are called to cases in which there has been a

good deal of discharg-e from the uterus, thepatient lying in a state approaching to

asphyxia, you will sometimes find her, asyou enter the room, supplicating that herposture may be changed, and this more

especially, if under the flooding restlesnesshave supervened. Now I wish you to un-derstand, most distinctly, that the change ofposture is very drangerous, and that fre-

quently, when it is allowed, it does notafford the expected relief. When a greatdeal of blood is come away from the uterus,even where the patientis rallying and likelyto do well, and where, perhaps, for two orthree hours together, but little dischargehas occurred, were you to direct the patientto be lifted from one side of the bed to theother, you might cause a terrific disturbanceof the circulation, or a renewal of the dis.charge destructive to life. One woman, inwhom a large bleeding had been suppressed,perished, in this manner, under my own ob.servation ; to appearance all danger wasover-like a thunder-cloud it was passedaway-when, unhappily, she rose to theerect posture ; the flooding was renewed, andshe sank. Many years ago this case occurredto me, and made a strong impression on mymind. A patient, on whom I performed theoperation of transfusion, and who was veryeffectually relieved by it (ultimately re-covering) two or three hours afterwards,was so urgent with me to allow a change ofposition, that my feelings sabduingmyjudg.ment, I assented. From this disturbance ofthe body, however, such perturbation of theheart ensued, that for three or four minutestogether, I thought the patient would haresunk ; and, really, the recovery might moreproperly be ascribed to our good fortune,than our good practice. Only the other

night I was called to a patient, in whom therewas a large discharge of blood from the

uterus, and where the woman was reducedto a state approaching to asphyxia, thoughlikely to do well ; this woman, contrary to! my wishes, was moved, and for a fewminutes her life seemed, of consequence,to be in danger the most imminent. Sothat to revert to the rule with which I setout, and which these facts illustrate, remem-ber, that if you are called to cases in whichthe women are lying in a condition approach.ing to asphyxia, you ought never withoutneed to move them at all-and, above all, youought not to move them into the erect pos-ture. One change you may, perhaps, some-times make with advantage, gently and cau-tiously raising the legs, so as to bring theblood upon the e heart and central parts of the

body, you may with equal caution and gen.tleness withdraw the pillows, and suffer thehead to sink below the shoulders ; the head,if the woman chance to be already lyingclose upon the edge of the bedstead, beingallowed to hang down over it a little wa),so as to facilitate the access of the blood tothe brain. All this, I say, you may perhapsdo, in these cases, with gentleness, withcaution-shall I add, with fear and trem-bling ; but, after all, I am not altogetherconvinced of the excellence of the practice,nor dare I dogmatically pronounce, that itis either very useful or very safe.