I will not say that every woman who gives birth to a child while laboring under smallpox must inevitably perish, since my clinical experience has shown me that the contrary may, however rarely, be the case. But I do hold to the opinion that a pregnant woman, laboring under a considerable attack of smallpox, is far more likely to be lost than saved, whether she miscarries, whether she be prematurely confined, or whether she give birth to her child at the full term of utero-gestation. A pregnant woman may be attacked with smallpox even in its most direful confluent form, and yet recover well, provided labor does not come on in the course of the disease; but if she be confined or suffer abortion, she shall hardly escape death by hemor rhage from the womb, or by metro-phlebitis coming on early after the detachment and expulsion of the placenta.

Late authors on obstetrics have expressed the opinion that the bleeding orifices upon the inner aspect of the womb-those, to wit, which give issue to the lochia-cannot be restored to health save by the intervention of adhesive inflammation of those vessels. That adhesive inflammation, how slight soever it may be, is phlebitis. They further express the opinion that the milk-fever of women, and the milk-fever which is known to affect our domestic quadrupeds after parturition, is the constitutional disorder developed by the purely topical and limited phlebitis affecting the uterine orifices above mentioned. This opinion appears to me to be worthy of respect upon a bare annunciation of it, as well as from the confidence to be reposed in the judgment of the authors in question.

My earnest desire, in introducing this section here is, in the first place to point out the great necessity there is for pregnant women scrupulously to avoid the contagion of variola; for I think I am quite correct in stating that the sentiment of the profession is almost unanimous, that the woman who is confined during smallpox dies; and secondly, to let the Student beware not to expose his gravid patient to the least danger of variolous infection; and, therefore, never to venture, under any circumstances, to vaccinate a pregnant woman, or one recently confined. To give this precept is the essential motive I had for introducing this article into my work, and I am the more desirous to attract the attention of the Student to this point, because I know that the brethren in general are not in the least suspicious, that to vaccinate a pregnant woman is to expose her to great hazard. If the virus of smallpox is eminently inimical to the life of the pregnant female, I aver that the virus of the vaccine inoculation is little less so than that of unmitigated smallpox.

If the Student will take two clean lancets, and insert the points of

them into a mature smallpox pustule, he may send one of them a hundred leagues eastward, and with it inoculate an unprotected individual, who will receive from it the infection of variola; and consecutive inoculation from this line would repeat variola for centuries. Let him send the other lancet a hundred leagues westward, and with it inoculate the udder of a healthy cow. He will in this way communicate to the animal a vaccine infection, from which vaccine inoculation of human beings may be consecutively repeated for centuries. So that the variolous pustule in the human being has communicated the vaccine infection to the cow, which vaccine infection may likewise be repeated, without modifying it further, through an unknown series of human bodies. The generical force of the inferior animal has modified a poison produced by the generical force of the human being. It has changed it, not destroyed it. It retains a portion of its variolous power which is inimical to the pregnant woman, and to expose one to its rage is a gross imprudence and misapprehension which I hope no Student reading this book will ever be guilty of. The shocking spectacles of distress that I have witnessed, from the vaccination of pregnant females, have so impressed my mind with the enormity of the imprudence, that nothing, I think, could tempt me to commit it myself. The most furious phlebitis, which is endangitis, and which becomes pyæmic fever, is one of the consequences likely to result from every true or spurious vaccination of a pregnant female. I am firmly convinced that it is far better for the physician, during an epidemic of smallpox, to leave his pregnant patient to the chance of a natural infection, than to certainly bring her within the range of its virulent power by a vaccine inoculation, which is but a variolous inoculation modified by the generical force of an inferior zoological genus.

If I venture to put forth such opinions as the above, it is hardly incumbent upon me further to protest against the temerity of those who, during the existence of a smallpox epidemic, recommend, and even proffer, what is called revaccination to those who, having been already vaccinated, might be held to be protected; I mean, to preg nant women. I have seen pregnant women very nigh to term, unnecessarily revaccinated, with consequences so terrific that I think I would not, for a thousand golden crowns, either vaccinate or revaccinate any woman knowing her to be pregnant.

Scarlatina.-A woman who should have the misfortune to be seized with scarlet fever, and to be brought to bed while affected with it, would be more apt to die than to recover. Dr. Dewees used to say:

"The woman who has scarlatina in her Lying-in, dies." This, though true in general, presents exceptional cases. I have had four such cases, in which all the patients recovered, to my great surprise and pleasure. In my work on Children, I gave, in the article on Scarlatina, my views as to the nature of that malady. If, as I there suppose, scarlatina is essentially an inflammation of the vasa vasorum, and derm capillaries, we need not be surprised at the tendency of it in women newly delivered, to result in pyæmic or other forms of the puerperal fever.

Twins and Triplets.-In Churchill's System of Midwifery, Phila. ed. 1846, p. 411, there are statistical statements on the subject of twin and triplet pregnancies. Dr. Churchill states that out of 448,993 cases of pregnancy, we have 5,776 cases of twins, or one in 77, and 77 cases of triplets, or one in 5,831 cases. A case that occurs only once in 77 labors, and in the course of some men's practice not so frequently, will be esteemed to be preternatural; for that is natural which occurs constantly, that is most nearly natural which occurs frequently, and that is preternatural which occurs very rarely. A triplet labor, which, according to Dr. Churchill, occurs only once in 5,831 cases, will certainly be admitted to be an unnatural labor, or, to use a technical phrase, a preternatural labor. I shall not err, then, in setting down twin and triplet cases as cases of preternatural labor; at least, I find it more convenient to arrange them here than to give a separate chapter on the subject.

As a general rule, a twin labor is not suspected to be so until after the birth of the first child, for a woman carrying twins in the womb is frequently found not to be larger than she who carries but a single one. Two children of six pounds' weight each, do not oppress so much as a single child of twelve pounds and a half, and the liquor amnii of the double pregnancy may be far less in quantity than the liquor amnii of a unipara womb. When a woman in the latter weeks of her pregnancy becomes very lusty as it is called, or when the abdominal walls, becoming weakened, allow the uterus to fall far forward so as to make the belly a little pendulous, that circumstance may give rise to misapprehension, and the woman is apt to fear she will be so unfor tunate as to give birth to twins. In practice, the Student will find that ten women shall fear twin labor, for one that shall really suffer it; and that in ten twin labors, there shall be only three or four in which twins shall be suspected to exist. It is not difficult during the pregnancy to ascertain the existence of twins, since the stethoscope reveals the pulsations of two distinct hearts; and, moreover, during

the flaccid state of a womb, if a woman lie upon the back, the feet drawn up, it is not difficult by external palpation to detect the presence of two distinct, orbicular, hard heads.

Although I prefer to speak of twin and triplet labors in the chapter on preternatural labors, I am ready to admit that many women giving birth to twins, find themselves delivered promptly and with little pain; especially when the children, as is usually the case, are under size; nevertheless, in twin labors with large children-and I have seen two children the sum of whose weights was sixteeen pounds and a half, and where the ova contained a very extraordinary amount of liquor amnii—the process of parturition is slow, disheartening, and painful. The overloaded uterus acts feebly and irregularly; the labor is long in establishing itself, the excessive extension of the muscular tissue of the uterus preventing the organ from propelling the point of the ovum into the cervix and through the orifice of the os; the bag of waters is therefore slow to be formed.

It rarely happens that the waters of both the ova come off together. If the amniotic sac which contains the first child or the presenting child should have discharged its fluid contents, then the expulsive power of the uterus must be communicated to the advancing child through the unbroken ovum of the second birth: such an elastic and compressible medium for the transmission of the expulsive force must have the effect of decomposing it, and rendering its exertion futile. If the membranes of the first child remain whole, and those of the second child be broken and discharged, as sometimes happens, the same effect is produced. I saw a twin labor in which the first child pushed the placenta of its brother before it into the world.

In case both ova are ruptured, the lowermost child must be thrust down by the uppermost child; but, as the uppermost child is never directly above the lowermost, the force must be communicated laterally, and it acts obliquely upon the body of its mate. The practitioner who finds an os uteri ductile and not reluctant, is ordinarily embarrassed to make up his opinion as to the cause of the slowness of the labor, where the resistance is small and the woman in good health. He might be tempted on this account to exhibit ergot, or administer stimulants, or some provocative to increased uterine action. He ought to do no such thing; the duty of an accoucheur is to inquire into the cause of the slowness. Let him rise from his seat and apply his ear to the abdomen of the woman; if he finds the foetal heart, let him ascertain its place, as relative to the top of the symphysis pubis, nearer or more remote from it in the hypogastrium; and knowing where the head is, then, with his hand upon the abdo

minal uterine tumor, he will at once come to the conclusion that the womb contains one child, or more than one child. In the latter case, let him find the heart of the second child, and the position of that heart will afford him a tolerably good diagnostic as to the presentation of the second twin. If the accoucheur finds the uterus overloaded, and that it is acting at a great disadvantage in consequence of its being compelled to communicate its expulsive force through the body of the first child obliquely to that of the advancing twin, he will understand his case and act accordingly.

In twin labors, the children may present both by the head, or one by the head and the other by the breech, as in Fig. 96.

In case both the children present by the head, there is risk that when the first head shall have fairly sunk below the plane of the

Fig. 96.

superior strait, the other head may be thrust downwards near the superior strait, against the throat of the first child, which it crushes against the opposing wall of the pelvis, and thus locks the lower head, which cannot descend because the thorax to which it is attached cannot enter the brim, on account of the presence there of the second head. Let the Student imagine the difficulty of treating such a case; for the first head fills the cavity in such a way as to prevent his passing his hand up, and when the foetal head is once fairly within the excavation, it becomes an extraordinarily difficult and

often impossible thing to thrust it above the superior strait again to turn and deliver. I am happy to say that my clinical experience has never furnished me with an example of this sort. A case of the kind occurred to one of my brethren here a few years since, which embarrassed him greatly. He could neither return the first head, nor displace the second; he took the measure, therefore, of decapitating the lowermost child, and after its head was removed the second child was delivered, and the headless trunk of the first one followed it.

In case the first child should present by the breech, and descend through the pelvis, there is always great reason to fear that the second child, presenting by the head, might have its head urged down faster than the head of the breechling; if it should be jammed into the strait, alongside the throat, before the other head can get possession