MIDWIFERY

M I D W I F E R Y,

THE art of assisting women in the birth of children. It is supposed to comprehend also the management of women both before and after delivery, as well as the treatment of the child in its most early state.

HISTORY of Midwifery. The art of midwifery is certainly almost coeval with mankind. The first midwife of whom mention is made under that name, assisted at the second labour of Rachel, the wife of Jacob. Another midwife is spoken of in Genesis, at the lying-in of Thamar, who was delivered of twins. But the most honourable mention of midwives is that in Exodus, when Pharaoh king of Egypt, who had a mind to destroy the Hebrews, commanded the midwives to kill all the male children of the Hebrew women; which command they disobeyed, and thereby obtained a recompence from God.

From all the passages in Scripture where midwives are mentioned, it is plain, that women were the only practitioners of this art among the Hebrews. Among the Greeks also women assisted at labours. Phanaete, the mother of Socrates, was a midwife. Plato speaks at large of midwives, explains their functions, regu-

lates their duties, and remarks that they had at Athens the right of proposing or making marriages. Hippocrates makes mention of midwives, as well as Aristotle, Galen, and Actius. This last even frequently quotes a woman called Aspasia, who was probably a midwife. They were called among the Greeks Manoi or Ιατρικαι; that is to say, manna, or grand-mamma.

We are still better acquainted with the customs of the Romans, and know that they employed women only. This may be deduced from the comedies of Plautus and Terence alone. We there see that they are women only who are called to assist persons in labour. Besides, Pliny, in his Natural History, frequently speaks of midwives and their duties; and names two, Sotira and Sulpe, who had apparently the greatest reputation. Women were also employed after the fall of the empire; and it is certain, that, till lately, all civilized nations have employed women only as midwives. This appears even from their names in many different languages, which are all feminine. There were, however, especially in great cities, surgeons who applied themselves to the art of midwifery, and made it their peculiar study. They were sent for

in difficult cases, where the midwives found their incapacity; and then the surgeon endeavoured to deliver the woman by having recourse to instruments useful in those cases, as by crotchets, crow-bills, &c.; but as these cases happened but seldom, women remained in possession of this business. It is certain, according to Astruc, that Maria Theresia wife of Louis XIV. employed women only in her labours; and the example of the queen determined the conduct of the princesses and court-ladies, and likewise of the other ladies of the city. The same author tells us, that he has been assured, that the epoch of the employment of men-midwives goes no farther back than the first lying-in of Madame de la Valiere in 1663. As she desired it might be kept a profound secret, she sent for Julian Clement a surgeon of reputation. He was conducted with the greatest secrecy into an house where the lady was, with her face covered with a hood; and where it is said the king was concealed in the curtains of the bed. The same surgeon was employed in the subsequent labours of the same lady; and as he was very successful with her, men-midwives afterwards came into repute, and the princesses made use of surgeons on similar occasions; and as soon as this became fashionable, the name of accoucheur was invented to signify this class of surgeons. Foreign countries soon adopted the custom, and likewise the name of accoucheurs, though they had no such term in their own language; but in Britain they have more generally been called men-midwives.

In opposition to this account, which is taken from Astruc, that author tells us, that he is aware of an objection from Hyginus, who asserts, that the ancients had no midwives; which made the women, through modesty, rather choose to run the risk of death than to make use of men on this occasion. For the Athenians, he adds, had forbid women and slaves to study physic, that is to say, the art of midwifery. A young woman, named Agnodice, desirous of learning this art, cut off her hair, dressed herself in the habit of a man, and became a scholar to one Hierophilus. She afterwards followed this business. The women at first refused assistance from her, thinking she was a man; but accepted thereof when she had convinced them that she was a woman.

To this account our author replies, that the authority of Hyginus is by no means to be depended upon. His book is full of solecisms and barbarisms; and therefore cannot be attributed to any writer who lived before the fall of the empire; but must have been the work of an author who lived when the Latin tongue was corrupted; that is, about the seventh or eighth century. The contradictions met with in this book also give room to suspect that it is not the work of one hand, but of several. The authority of such a work, therefore, is by no means sufficient to destroy the testimonies of those writers who affirm, that among the Greeks the care of lying-in women was committed entirely to others of their own sex.

The art of midwifery seems not to have been so soon improved as that of physic. Hippocrates, though an excellent physician, seems to have been a very bad midwife. He was acquainted with no other kind of natural labour than that in which the head presents; and condemns footling labour as fatal both to mother

and child: he would have the children in such cases turned, so that the head may present. If, says he, the arm, or leg, or both, of a living child present, they must, as soon as discovered, be returned into the womb, and the child brought into the passage with its head downwards. For this purpose he advises to roll the woman on the bed, to shake her, and make her jump: he proposes the same expedients to procure the child's delivery; and if they do not succeed, he advises to extract it with crotchets, and, whatever happens, to dismember it.

From the time of Hippocrates to that of Celsus, who lived in the reign of the emperor Tiberius, we have no accounts of any improvements in midwifery; but this author gives two very useful directions. 1. In dilating the womb: "We must (says he) introduce the fore-finger, well moistened with hog's lard, into the mouth of the womb when it begins to open, and in like manner afterwards a second, and so on until all the fingers are introduced, which are then to be used by separating them, as a kind of dilater, to distend the orifice, and facilitate the introduction of the hand which is to act in the womb. 2. Children may be delivered by the feet easily and safely, without crotchets, by taking hold of their legs. For this purpose we must take care to turn children, which are otherwise placed in the womb, with their head or feet downwards." It is true, Celsus speaks of a dead child only; but it was easy to conclude from thence, that the same practice might be used with success to deliver a living child. Nevertheless, this was not done; and, notwithstanding the authority of Celsus, the former prejudice continued for a long time. Though Pliny, who lived under the emperors Vespasian and Titus, was not a physician himself, yet by condemning footling labour he attests the opinion of the physicians of his time. He asserts, as a known fact, that footling labour was a preternatural kind of labour: he adds, that children which came into the world in this manner were called Agrippa, that is to say, born with a great deal of difficulty.

But however common this opinion was, it was never universally received; and several physicians of character rose up, who, without suffering themselves to be dazzled with the common prejudice, or seduced by the authority of Hippocrates or Galen, recommended and approved of footling delivery. The question then was a long time undecided; and even in 1657, Rivierus, a physician of reputation, condemned footling labour. Mauriceau also remarks, in the first edition of his book on the disorders of pregnant women, printed in 1664, that many authors were still of opinion, that when the child presented with its feet, it should be turned to make it come with its head foremost; but after having observed that it is difficult, if not impossible, to execute this, he concludes, "it is much better to extract the child by its feet when they present, than to run the hazard of doing worse by turning it." All practitioners, however, are now of the same opinion; and the knowledge of midwifery has been so much increased within this century, that it seems to have nearly attained its ultimate perfection, and its operations reduced almost to a geometrical certainty. And this, says Astruc, is not surprising; for, after all, the art of midwifery is reduced to the following mechanical

chanical problem, "An extensible cavity of a certain capacity being given, to pass a flexible body of a given length and thickness through an opening dilatable to a certain degree." This might be resolved geometrically, if the different degrees of elasticity of the womb, and strength and weakness of the child, the greater or lesser disposition of the blood to inflammation, and the greater or lesser degree of irritability of the nerves, did not occasion that uncertainty which physical facts constantly produce in all physico-mathematical questions.

The study of midwifery in Britain as a science is not of very ancient date. The first book published on the subject appeared in the year 1540, and was intitled The Birth of Mankind, otherwise named, The Woman's Book, by Thomas Raynold, physician. It underwent a second edition by Thomas Ray, a printer whose name is not much known. It was adorned with prints, and went through several editions, and appears to have been held in high estimation. In 1653, the celebrated William Harvey published his treatise on generation; and afterwards engaging in the practice of midwifery, published his Exercitatio de partu. Some notice is also taken by Sydenham of the diseases incident to child-bed women, and of those of young children. About this time several other tracts on subjects relating to midwifery appeared, by Wharton, Charleton, Mayow, &c.; but till about the year 1634, Dr Denman considers the treatise of Raynold already mentioned as being the standard. The appearance of the works of Ambrose Paré, which were now first published, depressed the reputation of Raynold's book; and Dr Chamberlen, a celebrated physician, likewise applied himself about the same time to midwifery. He introduced an instrument into the art called a forceps, but which Dr Denman supposes to have been a velis. He had three sons who likewise practised midwifery, and, as well as himself, obtained considerable character; and one of the young men went over to Paris with a view to sell the secret, or advance his fortune by a practice which he had found so successful in England. In this, however, he was disappointed; the first case in which he was engaged proved unsuccessful, and he suffered much reproach in consequence. Returning to England, therefore, in 1672, he published a translation of Mauriceau's midwifery, which continued in great estimation for many years.

Dr Willoughby, who wrote a treatise on midwifery, quoted in manuscript by Dr Denman, complains of the practice of midwives about this time. He says, that the books upon the subject all copied one another, recommending methods which could not but be prejudicial to the woman; and that particularly they did not attend to the efforts of nature, but endeavoured to force the birth before the proper time. He was the grandson of Sir Francis Willoughby, so much celebrated in the time of queen Elizabeth; and Dr Denman is of opinion, that the fame and fortune acquired by Dr Chamberlen, induced so many gentlemen as now practised midwifery to undertake the study of it, and to make use of instruments as he did. Among these was Dr Bamber; but others attempted to raise their reputation by a quite contrary practice. In 1723, Dr Maubray published a book on midwifery, intitled, The Female Physician, or the Whole Art of New In-

proved Midwifery, in which he violently declaims against the use of instruments; and next year he published an appendix, under the title of Midwifery brought to perfection, in which he sets forth in a pompous manner the improvements he had made. This, however, was no more than a syllabus of his lectures, he having been the first public teacher of midwifery in Britain.

Dionis's midwifery made its appearance in 1719, and Deventer's in 1729. The latter, in Dr Denman's opinion, was more esteemed than it deserved, as he generally condemns the use of instruments; notwithstanding which, he thinks it a considerable acquisition to the science in this country.

In 1727 appeared Dr Simson's work, intitled, The System of the Womb; "a work (says Dr Denman) of sufficient ingenuity, but not of much use in practice, even if his theory had been true." Chapman's Treatise on the Improvement of Midwifery appeared in 1733. He was the second public teacher of midwifery in London, and was the first who described the forceps; the description appearing in the third volume of the Edinburgh Medical Essays. His work contains many useful observations. Next year Dr Hody published a collection of cases in midwifery, written by Mr William Giffard. They are 275 in number, occurred in his own practice, and appear to be written with great fidelity. He also gave a plate of the forceps; and, in Dr Denman's opinion, was among the first who asserted that the placenta might be attached over the uteri. In 1736, Thomas Dawke published a book, intitled, The Midwife rightly Instructed; and, the following year, The Midwife's Companion, by Henry Bracken; but these, as well as some others which made their appearance about the same time, are of no importance.

About the same time also, Sir Richard Manningham quitted the profession of pharmacy, and applied to the study and practice of midwifery. He had received the honour of knighthood in 1730; and in 1739 he established a small hospital or ward for lying-in women, which was the first thing of the kind in the British dominions. Here also he gave lectures; and at the same time qualified his students for practice. He became very eminent in his profession, which he exercised with great humanity, and was accounted a man of great learning. He published a work, intitled Compendium Artis Oestetricæ; and another, called Apborisimata Medica, relating also chiefly to the art of midwifery. In 1741, Sir Fielding Oulde of Dublin published A Treatise of Midwifery; the most important parts of which are some observations on the continuance of the thickness of the uterus during pregnancy, with his description of the manner in which the head of the child passes through the pelvis at the time of the birth; the truth of which observations have since been universally acknowledged.

From this time the English, according to Dr Denman, might be said to have been in full possession of Introduction to the Practice of Midwifery, the subject; all the books written in the neighbouring countries being translated, public lectures given, and an hospital established for the further improvement of the art; and as all the books printed since that time may readily be procured, every gentleman has an opportunity of forming his own opinion of their respective merits. But the college of physicians (adds he), having

having been pleased, in the year 1783, to form a rank in which those who dedicate themselves to the study of midwifery should be placed, I trust that future accounts will be more correct; and that this measure adopted by the college will promote the public benefit, by confining the industry and abilities of one class of men to this branch of the profession."

In Scotland, though there has for a long time been professors of midwifery, yet the surgeons likewise practice that art as well as their own. Several approved

treatises on the subject have appeared in this country; particularly a system by the late Dr Smellie, which has been long held in the highest estimation in both kingdoms; and, within these few years, several excellent performances by Dr Alexander Hamilton of the university of Edinburgh: And, indeed, we may venture to affirm, that both theory and practice of midwifery are as well understood in this kingdom as in any part of the world.

PART I. THEORY OF MIDWIFERY.

THE subject of this Part comprehends, in a particular manner, the anatomical structure of the pelvis, and other parts concerned in the formation of the child, the theories of conception, generation, &c. of the nutrition, growth of the fetus, and of the powers by which it is expelled. Of all these some account has been given under other articles; but as the particular description of the pelvis belongs peculiarly to this subject, we shall here give an account of its various conformations, as they in a great measure affect women at the time of child-bearing, and very particularly contribute to the ease or difficulty of the labour.

from the sacrum with a noise loud enough to be distinctly heard. In general, however, some regressive motion is preferred between the bones of which the os coccygis is composed; and that which is produced between the sacrum and os coccygis, when the latter is pressed by the head of a child passing through the pelvis, occasions a considerable temporary enlargement of the inferior aperture of the pelvis. Any lateral motion is prevented by the insertion of the coccygei muscles, part of the levatores ani, and some portions of the sacro-iliac ligaments into the sides of the os coccygis.

The os innominatum, in a woman of the ordinary size, is about six inches broad from the anterior to the posterior superior spine. The height is nearly six inches and an half from the anterior spine to the bottom of the tuberosity of the ischium, and seven and an half if taken from the middle of the crista of the ilium; and hence we may in some measure be enabled to determine the depth of the cavity of the pelvis laterally from the superior to the inferior strait.

"The ossa pubis (says M. Baudelocque) are joined together by means of a substance which has always been described by the name of cartilage, though it differs as much from that as from a ligament. According to some anatomists, each os pubis is covered by its own cartilage. Their junction not a true synchondrosis; but a close articulation, which admits only of insensible motions. By carefully examining this symphysis, we observe that each os pubis is really covered by a cartilage at its anterior extremity; that this cartilage is thicker before than behind, and in its superior and inferior parts than in the middle of its length; that these bones, thus covered, are bound together by means of a substance which seems ligamentous, and whose fibres, which are mostly transverse, go from one to the other; that these fibres are so disposed, that the deepest are the shortest, and the most superficial the longest; that they leave between one another a kind of meshes filled with reddish corpuscles, very like those which are seen about the moveable articulations, and which are commonly thought to be synovial glands. We observe farther, that this fibrous and ligamentous substance does not occupy the whole thickness of the symphysis, and does not bind the bones together through the whole extent of the surfaces presented by their anterior extremities; but that there exists a true articulation of the species known by the name of arthrodesis. If we open this symphysis towards the inside of the pelvis, after a cellular tissue very thin and loose, which we meet with first, we discover a capsular membrane, whose most apparent fibres are transversal; afterwards

CHAP. I. Description of the Pelvis in general.

Dr DENMAN observes, that the term pelvis has been applied indiscriminately to the inferior cavity of the abdomen, and to the bones which form that cavity; but he thinks it most proper to confine it to the bones, and to distinguish the hollow by the name of the cavity of the pelvis. In the state of infancy, the pelvis is composed of five or six bones, most of which in the fetus are soft and flexible; some of them being, in a manner, quite cartilaginous; while the edges of others are found covered with a substance of the same kind. This construction is thought by some to facilitate delivery, as the pelvis of the fetus can thus change its figure like the cranium; but M. Baudelocque thinks this an erroneous opinion, "consonant neither to reason nor experience."

In the adult the pelvis consists only of four bones, viz. the sacrum, the os coccygis, and the two ossa innominata. These being already described under the article ANATOMY, we shall here content ourselves with observing, that an anchylosis is not unfrequently formed between the os sacrum and the ossa innominata; and sometimes an imperfect joint in consequence of their separation; whence the part is very much weakened, and the person ever afterwards walks with difficulty.

The os coccygis in infancy is cartilaginous; but in the adult it is composed of three, or more frequently of four bones, connected by intermediate cartilages, the uppermost of which is somewhat broader than the lower part of the os sacrum. In some subjects these bones coalesce, and form a single one: in others an anchylosis is formed between the sacrum and os coccygis; in consequence of which the latter is shortened and turned inwards, so as to obstruct the head of the child in its passage through the pelvis. But the impediment thereby occasioned at the time of labour may be overcome by the force with which the head of the child is propelled, and the os coccygis again separated

towards two cartilaginous facettes, smooth, polished, and moist, from six to eight lines long and two broad, of a figure a little semilunar, lightly convex on one bone and concave on the other. These facettes comprehend nearly the middle third of the length of the symphysis and the posterior third of its thickness.—This symphysis then presents in one third of its extent, or thereabouts, a true articulation; and in the rest a synneurosis and synchondrosis at the same time.

"This compound and articular substance, being detached from the bones, forms a kind of wedge, whose base constitutes the anterior part of the symphysis, and its edge the posterior; so that these bones seem to touch towards the inside of the pelvis, and appear separated to the distance of several lines without: The base of this kind of wedge is generally from four to six lines broad towards the middle of the length of the symphysis, and from eight to ten in the inferior and superior parts, while the edge at most does not exceed one line. Its thickness, taken according to that of the bones, is greater above than below; where this substance, become thinner, forms what is called the triangular ligament.

"This first means of union was not sufficient to give these bones the firmness necessary for the free exercise of the functions to which the pelvis is destined. It is covered and fortified in all parts, but especially before, by bundles of ligamentous and aponeurotic fibres. Independently of the thick and very strong ligamentous structure which forms the fore-part of the symphysis, we observe bundles of tendinous fibres which decussate each other a thousand ways, some of which arise from the interior graciles and the external obturators, and others from the external portions of the inguinal rings. The triangular expansion which terminates the symphysis inferiorly, and which forms the top of the arch of the pubes, seems to have other uses than that of binding the bones together.

"The manner in which the os sacrum is connected with the ossa innominata, differs considerably from that in which the ossa pubis are joined. Here each articular facet is covered by a true cartilaginous layer, and there are inequalities on each side, which mutually receive one another, while nothing of that kind is observed in the junction of the pubes; neither are there in any part of these articular facettes any of the transverse fibres which go from one bone to the other in the ossa pubis: these articulations, therefore, derive all their strength from the great numbers of ligaments which surround them. Most of these are very short, and do not extend beyond the edges of the articular facettes: but there are others longer to be seen above, below, and behind these symphyses.

"The os sacrum is not only articulated with the ilia, but with the spine and coccyx. It is joined in three places to the spine: 1. By an oblong and cartilaginous impression in the middle of the basis, which unites it to a similar impression in the body of the last lumbar vertebra, by means of an elastic substance. 2. By two little articular masses fixed in the posterior edge of that first impression, and which answer to similar substances in the vertebra above-mentioned.

"The elastic substance which unites the middle of the base of the sacrum to the spine, is entirely similar in its nature to that seen between the bodies of

all the vertebrae. Being very thick before and thin behind, the angle resulting from the disposition of the articular facettes of these two parts is rendered more obtuse. This sacro-vertebral junction is surrounded by an infinity of ligaments, some without and others concealed within the spinal canal. All motion is not prohibited by this kind of junction; but, as it only depends on the compression of the intermediate substance, it can be but very small. The motion between the body of the last lumbar vertebra and the base of the sacrum, is never extensive enough to make any alteration in the degree of acuteness of the angle which results from their junction; but the convexity of the lumbar column may be augmented or diminished by means of a compound motion, formed of those which take place between each of the lower lumbar vertebrae and between the lower ones of the back. This augmentation or diminution of the convexity, in proportion as the trunk is bent backward or forward, or by raising or lowering the breech when the woman lies on her back, deserves particular attention in the practice of midwifery; for thus we may make a favourable change in the direction of the axis of the pelvis, relatively to that of the trunk, to that of the uterus, and in the direction of the expulsive forces of the latter, which may be rendered more or less efficacious according to circumstances, by making the woman preserve a proper attitude.

"The junction of the coccyx with the sacrum permits the former to move, and yield to the different degrees of pressure it undergoes in different circumstances. The mobility is very great in youth; but diminishes insensibly as the patient grows older, and at last is totally lost. If entirely lost, or considerably diminished, before a woman is past child-bearing, it produces sometimes, though very rarely, an obstacle to delivery. The connections of the pelvis with the inferior extremities are not of much importance in midwifery. The natural course of labour cannot be disturbed by any fault in their conformation when the pelvis itself is well formed; but in general they are consequences of a deformity of it. They are enarthroses, which allow of motion in every direction."

The pelvis is divided into two parts, called the upper and lower, by a ridge sometimes elliptical, and sometimes of other shapes. The breadth of the upper part from the anterior superior spine of one ilium to another, is usually eight or nine inches, and its depth from three to four. At the back part of it is the projection of the lumbar vertebrae, and at the sides the iliac fossæ. The lower part forms a kind of canal, whose entrance and outlet are somewhat narrower than the middle; whence it has been distinguished into the superior strait, the inferior strait, and an excavation.—The superior strait is a kind of circle forming the entrance of the canal; its form, however, is various, as is also its obliquity from behind forwards. M. Levret has fixed this last at an angle of from 35 to 40 degrees.

The smallest diameter of this strait is generally about four inches, extending from the middle of the projection of the sacrum to the superior and internal part of the symphysis of the pubes. The other diameter

description of the pelvis in general. diameter is usually about an inch longer, extending from one side of the strait to the other. The oblique diameters are a medium betwixt the two former, extending diagonally from each acetabulum to the sacro-iliac junction of the opposite side. The pelvis is cut at right angles by the two former, and into acute ones by the latter; but the diameters, considered in relation to delivery, are somewhat different from those just mentioned, some changes in them being occasioned by the soft parts within the pelvis.

The inferior strait is in general smaller, and of a more irregular figure than the other, being not formed like it entirely of bones. The edge, rendered unequal by three deep and large notches, is completed behind and at the sides by the sacro-ischial ligaments, forming a kind of circular notch before, called the arch of the pubes. The diameters of it are commonly about four inches in length; and though the transverse, which extends from one ischium to the other, be often a little longer than that which extends from the fore to the back part, it must be reckoned the smallest with regard to delivery; because the latter augments in proportion as the point of the coccyx recedes from the pubes. We must also remember, that the great diameter of the inferior strait is parallel to the smallest of the superior, and that it crosses the longest of that strait at an angle more or less acute; and by carefully attending to this, we may, in many cases, with the finger alone, when properly directed, remove obstacles which could not have been overcome even by means of instruments, without exposing the child to great inconveniences. It is likewise favourable to delivery that the middle part of the pelvis is a little larger from before backwards than the straits; which disposition proceeds from the curved figure of the os sacrum.— On one side this curve diminishes the numerous and long-continued frictions which the child's head would necessarily undergo if the pelvis were equally broad in all its parts; and on the other side it is equally useful in preventing the effects of a long and forcible pressure on the sacral nerves, which a flat form of the sacrum would have rendered unavoidable during the whole time of the passage of the head. The cavity of the pelvis is commonly from four to five inches deep behind, three and an half at the sides, and one and an half at most before.

The arch of the pubes, which at the top is only from one inch and a quarter to one and two-thirds in breadth, augments gradually as it descends; so that at the bottom its sides are three inches and an half, or even four inches, separated from one another; that is, if we take the line which is looked upon as the transverse diameter of the inferior strait for its base; the height being about two inches.

The axis of the superior strait of the pelvis cannot well be determined; but that of the inferior one, with regard to delivery, must be considered as passing through the centre of the opening of the vagina dilated by the child's head. Its direction is then so much inclined from behind forward, that its superior extremity traverses the lower part of the first false vertebra of the sacrum, and crosses that of the other strait at a very obtuse angle.

Hitherto we have treated only of that form of the pelvis which is most favourable for delivery: but the proportions and forms of it are various; and as it differs from those above described, the delivery is attended with more or less difficulty.

The defects of the pelvis, with regard to facility of delivery, consists in its being either too large or too small. At first sight it might be imagined, that a large pelvis would make the delivery more easy, as the head of the child will thus be exposed to fewer frictions, be more easily expelled, and the labour be less painful. But women who have a very large pelvis, are subject to those inconveniences which arise from an obliquity of the uterus, or even to a descent of it altogether; especially in the time of labour, when that viscus, being already charged with the weight of the child, is entirely subjected to the expulsive power of the abdominal muscles. In women who have had several children, the uterus is but weakly retained by its ligaments; and in subsequent pregnancies it descends still lower, until at last it rests on the margin of the pelvis. This, however, does not take place before the conclusion of the first four or five months: before that time its weight lies principally on the extremity of the rectum; and by this, as well as by its bulk, the discharge of the urine and faeces is impeded, and accidents sometimes ensue from the compression of the veins which pass through the pelvis. These symptoms sometimes vanish about the middle of pregnancy, but re-appear towards the latter end; because the head of the child is early engaged in the pelvis, and acts on the same parts that the whole uterus did before. Besides all these accidents, there are others which may take place at the time of delivery; so that, upon the whole, it cannot be reckoned any real advantage for a woman to have a large pelvis.

The accidents, however, which arise from too great a size of the pelvis, are much more easily remedied, and in themselves less dangerous, than such as arise from its narrowness. This defect may be considered as either relative or absolute. The former arises from an excess of size in the head of the child; the latter from a bad conformation of the pelvis itself. The absolute narrowness of the pelvis rarely affects all parts of it at once: it is generally found only in one of the straits; in which case, the other is usually of the natural size, nay, sometimes even larger than natural. The fault is more frequently in the superior than the inferior strait; and it is remarkable, that it most commonly affects the strait in its small diameter; very rarely in its transversal; sometimes affecting only one side. In the inferior strait it is generally caused by the approximation of the tubercles of the ischia.

"It is easy (says M. Baudelocque) to determine why the superior strait is more frequently deformed than the inferior; and why it is almost always between the pubes and sacrum that it is defective respecting delivery. If we consider the direction of the forces which act on the pelvis of rickety children, in whom the bones are at the same time softer and more loosely connected than in the natural state, we shall see, that the greater part of those forces tend to carry the base of the sacrum forward and the os pubis

pelvis backwards. Whether the child be standing or sitting, if we attend to the direction of the spinal column, we shall see that the weight of the body must insensibly push the base of the sacrum towards the pubes; and that it acts in the same manner on the inner parts of the acetabula, which serve as a fulcrum to the inferior extremities when the child is standing or walking. The ossa pubis, particularly in these latter cases, must be pushed towards the sacrum; in such a manner, however, that their posterior extremities often approach a little nearer to the projection of the base of that bone than their anterior extremities, or the symphysis. If the superior strait does not constantly present the same figure in deformed pelvises; if it is sometimes larger on one side than the other; if one of the acetabula is nearer to the sacrum, while the other approaches less; if the symphysis of the pubes is removed, in many cases from a line which would divide the body into two equal parts—it is because the rickets have not equally affected all the bones of the pelvis, nor equally hurt all their junctions; and because the attitude which the child takes in walking or sitting may change a little the direction of the compressing powers just mentioned. The weight of the body may also equally hurt the form of the inferior strait, but variously, according to the most usual attitude of the child and the direction taken by the spinal column. For example: If it sits much, the sacrum will be more curved, and the strait more contracted from before backwards: in this attitude, if it inclines habitually to one side, one of the ischiatic tuberosities will be thrown inwards, the os ilium will be more elevated, &c. The action of the muscles which are attached to the pelvis, the pressure of cloaths, and that which the arms of the nurse exert on this part, contribute also something to the deformities in question, but much less than the weight of the trunk: whence we see, of what importance it is to keep rickety children in bed, and leave them at liberty; instead of obliging them to walk, to sit up, or have them constantly in the arms, as is done almost every where."

The dimensions of the pelvis itself vary no less than the contour of the straits. If the diameter of some, taken from the pubes to the middle of the projection of the os sacrum, be only a few lines; in others the defect is several inches, so that scarcely a single inch is left between these bones. These extremes, however, are not frequently met with; and the latter of them is never so great in the inferior as in the superior strait. On comparing the dimensions of a well-formed pelvis with those of a child's head, we shall find that the former might admit of being some inches less in circumference, and yet be large enough for an easy delivery. The circumference of a common head is usually no more than ten inches and a quarter, or ten and an half. The first degree of narrowness in any pelvis therefore must be, when each diameter is something less than three inches and an half. M. Baudelocque says, that he has seen pelvises in which the distance of the pubes from the sacrum superiorly was no more than six or eight lines; and he had in his possession two others, in one of which the distance from the back of the right acetabulum

to the projection of the sacrum was only three or four lines, and the other had but 14 lines between that projection and the symphysis of the pubes.

The narrowness of the pelvis is to be accounted one of the principal causes of difficult delivery.—When an opening of only three inches and a quarter is left, the labour must be more difficult than when it is three inches and an half, as the number of frictions which the child's head must undergo are then more numerous and frequent. When there is an opening only of three inches, the labour must be still more difficult; but still there are instances of natural deliveries without any assistance, notwithstanding the disproportion betwixt the size of the child's head and pelvis. This may even happen when the diameter of the pelvis is still smaller, such as two inches and three quarters, or two and an half. M. Solayres observed in a case of this kind, that the head was lengthened in such a manner, that its longest diameter was eight inches all but two lines, that which goes from one parietal protuberance to the other being reduced to two inches five or six lines; and M. Baudelocque has observed similar changes in the form of the head, and the respective lengths of its diameters at the instant of birth, where the child was equally deformed, the long diameter being seven inches, and the transverse one two inches six or seven lines. The children were in good health; and the day after their birth their heads wanted very little of the usual proportions.

But when the small diameter of the pelvis is less than two inches and an half, the head of the child cannot pass; and then some of the dangerous surgical methods must be undertaken, which frequently prove fatal both to the mother and child. Even when the pelvis is two inches and an half in diameter, the natural delivery is not always without danger to both; as, on one hand, the soft parts which cover the pelvis are subjected to such violent pressure that they become inflamed, exquisitely painful, and at last are even threatened with gangrene; on the other, the bones of the child's cranium riding over one another, or sometimes fractured and depressed, wound the brain, and produce internal extravasations which generally prove fatal. The bad consequences resulting from a deformed pelvis, show themselves sooner or latter, according as the superior or inferior strait is vitiated. When both are so, the obstacles to the birth begin to manifest themselves as soon as the labour begins; and sometimes those at the superior strait are so great, that the expulsive powers are exhausted, and the head stops there; or if it be pushed farther into the pelvis, and stopping there, it will remain incapable of being delivered without the assistance of art. The head cannot pass this strait without being in a considerable degree elongated; and when it enters the pelvis, the cavity being there sufficient for it, it naturally returns to its former dimensions, at least in part, and more or less so as it stays a longer or shorter time. The same conformation of the head, however, which enabled it to pass the first strait, is still more necessary to enable it to pass the second: and hence the symptoms which had come on with the first pains, sometimes disappear in a great measure during the time that the head stays in the excavation; but increase to

Description of the Pelvis in general. a greater degree than ever when the strong labour comes on.

When the superior strait alone is contracted, the head advances at first with great difficulty; but as soon as the parietal protuberances have cleared the strait, the other parts of the pelvis being relatively or absolutely larger, the head passes them with so much ease, that the delivery is frequently terminated by a few pains. The contrary is observable when the fault is in the inferior strait, if the first be of the usual size. The head then descends easily into the lower part of the pelvis; but cannot proceed any farther, until it overcome the obstacles which obstruct its course, and render it difficult and laborious. In this case, the symptoms attending obstruction appear later than in the former. In these cases, however, it is necessary that the practitioner should accustom himself by practice to form a just estimate of the powers of nature, otherwise he may easily deceive himself; in the former, supposing that a delivery is impossible; and in the latter, that a delivery will be easy which cannot be effected without the assistance of art. An instance of this is given by our author, in a case to which (he says) more than forty persons were witnesses.

The operator pronounced that the woman would be speedily delivered, on account of the facility with which the child's head had engaged with the first pains; and attributing the obstacles which soon after obstructed its course to another cause, rashly destroyed the child by using the crotchet, when its life might have been preserved by other means, having waited two days in blind security, expecting a natural delivery. M. Baudelocque obtained possession of the pelvis of this woman after she died; and tells us, that the circumference of the superior strait of the pelvis, when divested of all its coverings, measured 14 inches, but the inferior only nine. The distance from the point of the os sacrum to the symphysis of the pubes, as well as the interval between the ischiatic tuberosities, was but three inches. The cavity of this pelvis diminished insensibly in breadth from one strait to the other, and was as regular as possible in its contour.

The excavation, or middle part of the pelvis, is much more seldom defective in its form than the straits; and when this is the case, it must arise from some exostosis, or from the sacrum describing a right line in its anterior part, instead of being curved as usual. The straight and flat form of the sacrum generally produces fewer obstacles to delivery than the too great curvature of it. The former fault generally affects only the cavity of the pelvis, and cannot hinder the passage of the child, if the canal be otherwise well disposed: but the latter, or too great a curve of the sacrum, commonly proves injurious to both straits, contracting them from before backwards, and at the same time diminishing the depth of the pelvis at the back part, as well as the respective height of the arch of the pubes. In these cases the head, though it passes the first strait with difficulty, cannot pass the second; being stopped in its course by the inferior part of the sacrum before the occiput is long enough to engage under the arch.

VOL. XI. PART II.

Labours may also be rendered difficult by too great Description of the Pelvis in general. length of the symphysis of the pubes; a want of elevation, or breadth of the arch of these bones; the length and wrong direction of the ischiatic spines, as well as a consolidation of the coccyx with the point of the sacrum. These faults, however, are very rare, if we except the consolidation of the coccyx: they are scarce ever met with alone, and are generally the consequences of a bad conformation of the rest of the pelvis. Even this consolidation, however, though more common than the other faults, yet cannot obstruct delivery so frequently as has been imagined; and when it does so, it is only in women who have a narrow pelvis. Our author denies the position laid down by some, that the head of the child, in all cases, pushes back the point of the coccyx half an inch, or even a whole inch. Those who assert this (he says) know not the relation betwixt the dimensions of the head and the inferior strait in most women. Whence he cannot recommend a precept founded upon this principle, by which it is directed to push back the coccyx, when the head, though low down, cannot disengage itself easily.

We must now consider a subject on which the writers upon midwifery have been greatly divided, viz. the separation of the bones of the pelvis in the time of labour. Some have imagined that this separation took place in all labours; others that it happened only in difficult cases; some, that it indicates a morbid state; and some that it was quite impossible.—M. Baudelocque allows the possibility of such a separation, but denies that it happens so frequently as is imagined. "Experience (says he) demonstrates, that this separation, far from being common, is very rarely met with, and is not more usual after a laborious than after an easy labour, nor in a distorted pelvis than in one well formed. I have sought for it twenty times in all these cases, by opening the bodies, and have scarcely met with one which could remove all doubt of its existence." In those cases where it takes place, he is of opinion, that the filtration of serum into the ligamentous tissue of the symphysis, must be regarded as the usual predisposing cause. The remote cause, of consequence, must be whatever produces this filtration. This, he thinks, cannot be done merely by the pressure of the gravid uterus on the trunks of the vessels which are distributed to these symphyses. An alteration in the fluids themselves he supposes likewise to be necessary.

But though the predisposing cause of this separation must be the relaxation of the symphyses by the infiltration of serum, we are not to look upon the swelling of the cartilages by means of this infiltration to be the immediate cause: For however the ligaments may be relaxed, the cartilages which insert the extremities of the ossa pubis, as well as the articular facets of the ossa ilia and the sacrum, are no thicker; so that they cannot, as some have supposed, act like wetted wedges by which large blocks of stone may be cleaved. "The wedge by which the bones of the pelvis are separated (says our author), does not act between the extremities of these bones, but in the circle formed by their assemblage in the pelvis itself: it is the uterus charged with the produce of concep-

tion in the latter periods of pregnancy, and the child's head forced down by the action of the uterus, and of the abdominal muscles in time of labour."

This separation, however, is not always the effect of a relaxation and stretching of the ligamentous tissue of the symphysis. In some cases, where the obstacles which obstruct the passage of the child are very great, and the efforts for its expulsion very strong and lasting, the symphysis tears, and permit the bones to separate much farther than they could have done by a simple relaxation. "I must add (says our author) that it is not the symphysis of the pubes, properly speaking, which tears; for no effort can break the ligamentous substance which unites these bones to each other; the symphysis detaches itself from one of them, and leaves the bone naked." The separation in question has likewise frequently taken place in instrumental deliveries, to which the natural efforts seemed to contribute nothing; and it has also been found in consequence of a stroke or fall.

"Being deceived in the principle of this separation (says M. Baudelocque), they necessarily erred in the consequence deduced from it. It has been so firmly believed to take place in all labours, that it was thought to be absolutely necessary; and that without it many women could not be delivered without extreme difficulty. Having thus mistaken the necessity and pretended advantages of this separation, the natural resistance of the symphysis, and above all the dryness and rigidity necessarily induced in them by age, were consequently reckoned among the causes of difficult and laborious births. Obstacles have been attributed to the state of these symphyses, which merely depended on the resistance of the neck of the uterus, and of the external parts; and it has been recommended to moisten and relax them by the use of baths, cataplasms, lineaments, fomentations, &c. But what can be expected from such methods, when delivery is obstructed by a narrow pelvis? Will any one venture to assert, that he has once by such means obtained the effect he expected, and that he has thus assisted labours which could not otherwise have been terminated but by the Cæsaræan operation, as has so often been published? I should have dispensed with demonstrating the fallacy which has prevailed on this point, if it had not led some practitioners into a very serious consequence. In order to appreciate all these means, and fix the degree of confidence to be placed in them, supposing that they could operate to the relaxation of the symphysis of the pelvis, it is necessary to determine what degree of amplitude can be given to that cavity by the separation of the bones which constitute it. The ossa pubis cannot separate without augmenting the circumference of the pelvis; but how much will its diameter be increased? If the circumference were perfectly circular, every possible diameter would partake a third of that augmentation: but as the entrance of the pelvis is in general the more elliptic as it deviates more from its natural state, it follows, that its different diameters cannot increase in the same proportion; and we may say that there is none but the transverse one which can become larger. In a moderate separation the antero-posterior diameter is scarce at all augmented; and it has been repeatedly demonstrated, that the ossa pubis must sepa-

rate at least an inch to procure two lines in that direction; while the transverse diameter shall be increased six lines, and often more.

"The pelvis being larger in most women than is necessary for their delivery, the separation of the bones could be of no advantage to them, nor render their delivery more easy. Far from regarding it, with some ancient authors, as a benefaction of nature, we ought to consider it as an additional source of inconveniences in those women who are subject to it: for, on one side, we see that a pelvis too large exposes the woman to a number of accidents; and on the other, that there are some which inevitably accompany the separation, and the mobility of the bones which form that cavity. Far from favouring delivery in all these cases, it could not but render it more tedious and painful to the woman, as experience has convinced me. If we ought to expect any real advantage from it, considering it only with respect to the passage of the child, it could only be in those women who have the pelvis deformed, and where the defect which rendered delivery impossible did not exceed two lines at the most; since a separation of an inch cannot procure an augmentation of more than two lines in the small diameter of the superior strait, which is almost always that which occasions the greatest obstacles to the exit of the child. If from a separation of an inch, which has never taken place between the ossa pubis without a rupture of their symphysis, we are not to expect an augmentation of more than two lines in the direction of the little diameter of the superior strait, what can we obtain from a separation always much less, and so little apparent in most women that we may doubt its existence? The examination of a great number of women who have died in child-bed, has proved to me that it is excessively rare for the separation in question to amount to two lines; and I never found it exceed that but once. But supposing (what is impossible) that art could procure a separation of an inch between the ossa pubis without dividing their symphysis, what practitioner would dare to affirm, without fear of being deceived, that the volume of the child's head did not exceed the little diameter of the superior strait by more than two lines? If it is difficult to estimate justly the degree of opening in the pelvis, it is much more difficult still to judge of the child's head; and it is only by taking the mean between the largest and the smallest that we usually establish the relation of its dimensions to those of the pelvis; but a thereabouts, in the case supposed, cannot supply the place of that precision which would be necessary."

From his reasoning upon this subject, M. Baudelocque concludes directly against the operation of cutting the symphysis of the pubes, as being not only useless, but attended with very dangerous consequences. "When this separation (says he) has been suddenly made, severe pains in the parts divided, an impossibility of walking, and sometimes even of moving the inferior extremities, inflammation, fever, abscesses, caries, and lastly death itself, have generally been the effects of it: but when a relaxation only takes place, the consequences are less severe; a painful and tottering walk being the only symptom attending it. If the relaxed symphysis at last grow firm again, if the bones of the pelvis recover their former stability, if

Description of the Pelvis in general.

the lameness goes off entirely in some women, how often, on the contrary, have we not observed an inability to walk, or even to move the legs, without violent pain, continue for years afterwards?"

These violent symptoms frequently attend even slight separations of the bones in question. M. Baude-locque gives an instance of a woman who had kept her bed ten months, being all that time afflicted with the most excruciating pains in the junction of the ossa pubis, and of one of the ilia, with the sacrum, whenever she attempted to move the inferior extremities, though no separation of the symphysis could be discovered, nor any thing besides a slight mobility in that of the pubes. The accident had been perceived during the time of labour, and the midwife had been accused of luxating the bones.

Dr Denman has also treated this subject at considerable length. He informs us, that for many centuries it was believed that these bones were always separated during the time of labour; or that there was a disposition to separate, and an actual separation, if the necessity of any particular case required that enlargement of the cavity of the pelvis which was consequent to it. The degree of separation was also supposed to be proportioned to such necessity; and when this did not happen naturally, instruments were made use of for distending the parts: and, on the same principle, the section of the symphysis of the pubes has been recommended. "This opinion (says he) ought probably to be assigned as one reason for the superficial notice taken by the early writers on midwifery of those difficulties which are sometimes found to occur in parturition from the narrowness or deformity of the pelvis. To this may also be referred much of the popular treatment of women in child-bed, and many popular expressions in use at present. But this opinion has been controverted by many writers, who assert, that there was neither a separation nor a disposition to separate; but that, when either of them did happen, they were not to be esteemed as common effects attendant on the parturient state, but as diseases of the connecting parts. The disputants on each side have appealed to presumptive arguments, and to facts proved by the examination of the bodies of those who died in child-bed, in justification of their several opinions. But, notwithstanding all that has been said, I know not that we are authorized by the experience of the present time to say, that a separation, or a disposition to separate, prevails universally at the latter part of pregnancy, or at the time of labour: yet that these effects are often, if not generally, produced, may be gathered from the pain and weakness at the parts where the bones of the pelvis are joined to each other before and after delivery. In some cases also pregnant women are sensible of a motion at the junction of the bones, especially at the symphysis of the ossa pubis; and the noise which accompanies it may sometimes be heard by the bystanders.

"A strong presumptive argument in favour of the separation of the bones has been drawn from quadrupeds. In these the ligaments which pass from the obtuse processes of the ischia to the sacrum, on which the firmness of the junction of the bones very much depends, and which at all other times resist any im-

pression attempted to be made upon them, are for several days previous to parturition gradually deprived of their strength, and the animal walks in such a manner as would incline us to believe could only be produced by a separation of the bones of the pelvis. Now it is not reasonable to conclude, that a circumstance which generally takes place in one class of viviparous animals should never occur in another, especially in a matter in which there is not essential difference."

Notwithstanding these arguments, however, Dr Denman does not look upon the matter to be yet absolutely decided. No person, he says, who has been conversant in the dissection of women who have died in child-bed, can have wanted opportunities of seeing every intermediate state of these parts, from a separation in which the surfaces of the bones were loosened and at a considerable distance from each other, to that in which there was not the least disposition to disunite.

When this separation takes place beyond a certain degree, it is to be looked upon as morbid: and, he says, that it may be produced by the two following causes. "1st, A spontaneous disposition of the connecting parts. 2dly, The violence with which the head of the child is protruded through the pelvis." Of each of these cases he gives an example.—The first was of a young lady of a healthy constitution, who had been married in the 21st year of her age, and in 1774 was delivered of her third child, which was unusually large, and the labour was severe and tedious. For several days before delivery she had been so much afflicted with pain and weakness in her loins, that she could not walk without assistance. She recovered without any unfavourable circumstance, excepting that for several weeks she was incapable of standing upright, or putting one foot before the other; the attempt to do either being attended with pain and a sensation of looseness and jarring, both at the parts where the ossa innominata are joined to the sacrum, and at the symphysis of the ossa pubis. By the use of strengthening medicines she recovered, and in a few months was perfectly well."

It being suspected that the complaints above mentioned had proceeded from too frequent parturition, she was advised to suckle her child for a longer time than usual; and accordingly continued a nurse for 15 months. Soon after this she became with child a fourth time. The complaints which had accompanied her former pregnancy now came on sooner, and with greater violence than before, insomuch that for three weeks before delivery she could neither walk nor stand; and there was reason to suppose that the bones of the pelvis were separating. She was delivered on the 7th of July 1777, the labour being accompanied with faintings, great irritability, and a total inability to move her inferior extremities. A few days after her delivery she had a fever, which terminated in an abscess in one of her breasts, by which she was confined to her bed for near seven weeks. In nine weeks she could walk with crutches, and received considerable benefit by being sent into the country; and likewise, as she imagined, by drinking half a pint of infusion of malt twice a day. In about five months she was able to walk without assistance; though sometimes sensible

Description of the Pelvis in general.

of the motion of the bones, which seem never to have been perfectly uniced. About Christmas the same year, this lady became again pregnant; and in the month of July 1778 she began to feel an inability to move; which, however, was attributed to the heat of the weather: but on a sudden the pain and weakness of her back returned to such a degree, that she could walk no more till the 11th of October, when she was delivered of a fine child, but after a most severe and tedious labour, occasioned in a great measure by her being totally unable to move. The symptoms after her delivery became very extraordinary and alarming. On the fourth day a fever came on; and though this was soon removed, the pain at the junction of the bones still continued. She had no command of her inferior extremities; and the pain, when she was moved, became so excruciating, that she felt as if tearing asunder. Her stomach was at all times much disturbed; but when the pain became violent, a nausea, vomiting, or hiccough came on. Strange sympathies were produced in various parts; as a tearing cough, freezing, sense of weight in her eye-lids, which could not be kept open though there was no inclination to sleep. There was a noise in the bowels, and other nervous affections, all of which ceased when the pain was allayed by opiates.

Having remained for several months in this deplorable situation, it was at last thought proper to raise her from her bed, and cause her to make an effort to stand or walk, lest her complaints should be made worse by such a long course of inactivity. She had now, however, totally lost the power of supporting herself; the motion of the bones was plainly perceived; and the consequences of every trial were so painful, that there was a necessity for desisting. In 1779 she was removed, upon a couch, in a boat to Margate, for the benefit of the air and sea-bathing, from which she was always sensible of receiving advantage. In this place she continued to reside; and in eight years after her delivery became able to walk without crutches.

The second case was of a young woman of a healthy but delicate constitution, who was in labour of her first child. The pains were so strong, that the head of the child was forced through the external parts, and the perineum supposed to be lacerated, in spite of all the opposition which could be made. At the instant when the head of the child was expelled, the operator perceived something to jar under his hand, and was even sensible of a noise, which he attributed to the laceration of the perineum. In a little time the placenta was extracted without hurry or violence; and a few drops of tinctura opii were given to allay the uneasiness which took place, and was supposed to be occasioned by after pains. On the following days, however, she complained of an uneasiness in the region of the abdomen; but no particular notice was taken of it, as the milk was regularly secreted, and there was no symptom of fever; but on the fourth day, when taken out of bed, she was found to be unable either to stand or sit on her chair by reason of the pain and weakness in the part of which she originally complained. This was afterwards conjectured to arise from a separation of the bones of the pubes; to which conjecture the long continuance of the com-

plaint seemed to give countenance. The conjecture was founded on the positions and attitudes in which the patient sought to find relief. The symptoms were as follow:—When she endeavoured to stand upright, which she could do better upon one foot than both, and with her feet close than at a distance, together with the pain at the symphysis, she had a sense of extreme weakness, accompanied with a faintness. When she first sat down on her chair, resting her elbows upon the arms, the complaints became tolerable. When she had remained a little time in this position, they again became importunate, and she supported herself with her hands upon her knees, and presently bent forwards, so as to lean her elbows upon her knees: this position becoming irksome, she was obliged to return to her bed, where she became immediately easy. When she first attempted to walk, she was compelled to bend forwards in such a manner as to rest her hands upon her knees, making a straight line from her shoulders to her feet. At the end of 14 weeks, whilst she was in a coach, into which she had often been lifted for the benefit of air and exercise, she had a discharge which she supposed to be menstruous; but which, though it ceased before her return, gave immediate relief. From this time she became better every day, and in six weeks was able to walk. She had afterwards three children, with which her labours were easy, and she never had any return of the above mentioned complaints.

From all this it is evident, that Dr Denman differs considerably in his opinion from M. Baudelocque concerning the separation of these bones. According to him, it appears that this separation, though extremely painful, does not seem to be attended with fatal consequences; and with regard to the quantity of the separation, it must undoubtedly be sometimes much greater than what M. Baudelocque supposes; for Dr Denman brings an instance from the 484th number of the Philosophical Transactions, in which the bones were separated to the distance of four inches. This happened in consequence of the starting of a horse when a gentleman was riding. He observes, however, that, in women, the violence which the connecting parts of the bones undergo when the head of the child is protruded through the pelvis with extreme difficulty, sometimes occasions an affection of more consequence than even the separation of the bones themselves. This is the formation of matter upon the loosened surfaces of the bones, preceded by great pain, and other symptoms of inflammation.

In the beginning of this complaint, it is difficult to ascertain whether the connecting parts of the bones, or some of those contiguous, be the seat of the disease; but when suppuration has taken place in consequence of the injury sustained at the junction of the ossa innominata with the sacrum, the abscess has sometimes been cured by the common treatment, having formed in the neighbourhood of the injured part. At other times, when matter has been formed about the symphysis of the os pubis, hectic symptoms have ensued, and the cause of them only discovered after the patient died. In some cases the matter has burst through the capsular ligament of the symphysis at the inferior edge, or perhaps made its way into the bladder; and

Description of the Pelvis in general
in others it has insinuated itself under the periosteum, continuing its course along the pubes, until it arrives at the acetabulum. Thus all the symptoms were aggravated; and the matter making its way towards the surface, a large abscess has been formed on the inner or fore-part of the thigh, or near the hip; so that the patients have at last sunk under the fever and profuse discharge from the ulcer. On dissecting those who have died in this manner, the track of the matter has been followed from the aperture of the abscess to the symphysis, the cartilages of which were found to be eroded, the bones carious, and the adjacent parts very much injured or destroyed. Our author imagines it possible, by means of some particular symptom, to discover whether or not there be any disposition in the parts above mentioned to suppurate, or to know when suppuration has taken place. In all cases of unusual pain attended with equivocal symptoms, the parts ought to be examined with great care and attention: for where there is any disposition to suppurate, it might perhaps be removed by proper means; and when the matter is formed, if there be a swelling in the symphysis, and, more especially, if a fluctuation could be perceived, the propriety of making an incision to evacuate the matter, and prevent farther bad consequences, might be determined.

With regard to the possibility of re-uniting the bones of the pelvis after they have once been separated, our author has the following observations.

“When the connection of the bones of the pelvis has either been impaired or destroyed, it is probable that a confirmation or re-union may take place by a restoration of the original mode, by a callus, or by ankylosis. But it is likewise possible that the bones may remain in a state of separation, and an articulation be formed by the ends of each bone, at the symphysis of the ossa pubis, and at the junction of the ossa innominata with the os sacrum.” Of this last the Doctor has seen one instance in a dead body, and has had reason to suspect the existence of it in some living persons. In the lower degrees of imperfection the former method of union probably takes place; as the complaints made by women of pain and weakness, after delivery, generally go off before their month of confinement is elapsed; but when they continue for a longer time, the best method is to enjoin the patient rest and an horizontal posture. In an increased degree of the complaint, where the health of the patient is affected, a longer time will be required for the recovery; but should the injury be too great to admit of the restoration of the original mode of union, a much longer time will be requisite for the formation of a callus, if this ever takes place except as a previous step to an ankylosis. This last has been observed frequently to take place at the junction of the ossa innominata with the sacrum, but never at the symphysis of the pubes. In this case little can be expected excepting from such remedies as tend to restore the constitution to its pristine vigour; and in the first case above related, the only thing from which the patient seemed to obtain relief was the cold-bath. She was likewise much assisted by the use of a swath, or broad belt, made of soft leather, quilted, and buckled with such firmness over the lower part of the body as to lessen, if not prevent, the motion of the

bones; and this was kept in its situation by a bandage passed between the legs, from the hind to the fore part of the belt. But when a joint is formed between the separated surfaces of the bones, all hope of recovering the patient to her former health may be given up. The only thing which can then be done for her relief must be by the use of a belt, or some similar contrivance, to substitute, as much as possible, artificial firmness, instead of natural. Dr Denman saw one case in which he suspected this to have happened, and in which the life of the patient was truly miserable: He is of opinion, however, that it very rarely occurs; having been informed of another person, who, after eight years confinement to her bed, in consequence of the separation of the bones in the time of labour, was at last restored to the perfect use of her inferior extremities. Instances also, though rare, have occurred, in which women, after labours, have suffered much pain in the region of the sacrum, and totally lost the power of moving their inferior extremities. This has been supposed a paralytic affection, and they are said to be bed-ridden; but as these patients have generally been restored, though after a very long confinement, our author thinks it reasonable to suppose that their infirmity had been occasioned by a separation of the bones, which at different periods after the accident, according to the degree of their separation, had recovered their former connection and strength.

CHAP. II. Of Pregnancy.

At the time of conception, and for some time after, the parts which form the small foetus are so blended together, that one cannot be distinguished from another. The whole mass is then called an ovum. This ovum consists of four membranes; the placenta, or after-birth; the funis umbilicalis or navel-string, leading to the child; and the surrounding watery fluid in which it floats. Before the child acquires a distinct and regular form, it is called embryo, and afterwards retains the name of fetus till its birth. For the increase and nutrition of the foetus, see ANATOMY, no 109, 110.

During the progress of impregnation the uterus suffers considerable changes; but, though it enlarges as the ovum increases, yet, in regard to its contents, it is never full; for, in early gestation, these are confined to the fundus only: and though the capacity of the uterus increases, yet it is not mechanically stretched, for the thickness of its sides do not diminish; there is a proportional increase of the quantity of fluids, and therefore pretty much the same thickness remains as before impregnation.

The gravid uterus is of different sizes in different women; and must vary according to the bulk of the foetus and involucre. The situation will also vary according to the increase of its contents and the position of the body. For the first two or three months, the cavity of the fundus is triangular, as before impregnation; but as the uterus stretches, it gradually acquires a more rounded form. In general, the uterus never rises directly upwards, but inclines a little obliquely, most commonly to the right side; its position is never, however, so oblique as to prove the sole cause

Pregnancy. cause either of preventing or retarding delivery: its increase of bulk does not seem to arise merely from distention, but to depend on the same cause as the extension of the skin in a growing child. This is proved from some late instances of extra-uterine foetuses, where the uterus, though there were no contents, was nearly of the same size, from the additional quantity of nourishment transmitted, as if the ovum had been contained within its cavity.

The internal surface, which is generally pretty smooth, except where the placenta adheres, is lined with a tender efflorescence of the uterus, which, after delivery, appears as if torn, and is thrown off with the cleanings. This is the membrana decidua of Dr Hunter.

Though the uterus, from the moment of conception, is gradually distended, by which considerable changes are occasioned, it is very difficult to judge of pregnancy from appearances in the early months. For the first three months the os tincæ feels smooth and even, and its orifice as small as in the virgin state. When any difference can be perceived, about the fourth or fifth month from the descent of the fundus through the pelvis, the tubercle or projecting part of the os tincæ will seem larger, longer, and more expanded; but, after this period, it shortens, particularly at its fore-parts and sides, and its orifice or labia begin to separate, so as to have its conical appearance destroyed. The cervix, which in the early months is nearly shut, now begins to stretch and to be distended to the os tincæ; but during the whole term of utero-gestration, the mouth of the uterus is strongly cemented with aropy mucus, which lines it and the cervix, and begins to be discharged on the approach of labour. In the last week, when the cervix uteri is completely distended, the uterine orifice begins to form an elliptical tube, instead of a fissure, or to assume the appearance of a ring on a large globe; and often at this time, especially in pendulous bellies, disappears entirely, so as to be out of the reach of the finger in touching. Hence the os uteri is not in the direction of the axis of the womb, as has generally been supposed.

About the fourth, or between the fourth and fifth month, the fundus uteri begins to rise above the pubes or brim of the pelvis, and its cervix to be distended nearly one third. In the fifth month the belly swells like a ball, with the skin tense, the fundus about half way between the pubes and navel, and the neck one half distended. After the sixth month the greatest part of the cervix uteri dilates, so as to make almost one cavity with the fundus. In the seventh month the fundus advances as far as the umbilicus. In the eighth it reaches mid-way between the navel and serobicus cordis; and in the ninth to the serobicus itself, the neck then being entirely distended, which, with the os tincæ, become the weakest part of the uterus. Thus at full time the uterus occupies all the umbilical and hypogastric regions; its shape is almost pyriform, that is, more rounded above than below, and having a stricture on that part which is surrounded by the brim of the pelvis.

The appendages of the uterus suffer very little change during pregnancy, except the ligamenta lata,

which diminish in breadth as the uterus enlarges, and at full time are almost entirely obliterated.

The most remarkable change happens in the ovarium. A cicatrice of a roundish figure and yellowish colour appears in this body, called by anatomists the corpus luteum. It is always to be found in one of the ovaria; and in cases of twins a corpus luteum often appears in both ovaria. It was formerly considered as the calyx ovi; but modern physiologists think it a gland, from whence the seminal fluid is ejected. In early gestation it is most conspicuous, when a cavity is observable, which afterwards collapses; no vessels appear at the centre of this cavity which has the appearance of cicatrix, but all around that centre the substance is vascular.

During the progress of distension, the substance of the uterus becomes much looser, of a softer texture, and more vascular than before conception; its veins particularly, in their diameters, being enlarged in such a manner as to get the name of sinuses; they observe a more direct course than the arteries, which run in a serpentine manner, anastomosing with one another and through its whole substance, especially where the placenta adheres, where this vascular appearance is most conspicuous.

The arteries pass from the uterus through the decidua, and open into the substance of the placenta in a slanting direction. The veins also open into the placenta, and by injecting these veins from the uterus with wax, the whole spongy or cellular part of the placenta will be filled.

The muscular structure of the gravid uterus is extremely difficult to be shown: in the wombs of women who die in labour, or soon after delivery, fibres running in various directions are observable more or less circular, that seem to arise from three distinct origins; viz. from the place where the placenta adheres, and from the aperture or orifice of each of the tubes; but it is almost impossible to demonstrate regular plans of fibres, continued any length without interruption.

CHAP. III. Spurious Gravidity.

THE various diseases incident to the uterine system, and other morbid affections of the abdominal viscera, will frequently excite the symptoms and assume the appearance of utero-gestration. Complaints arising from a simple obstruction are sometimes mistaken for those of breeding; when a tumor about the region of the uterus is also formed, and gradually becomes more and more bulky, the symptoms it occasions are so strongly marked, and the resemblance to pregnancy so very striking, that the ignorant patient is often deceived, and even the experienced physician imposed on.

Scirrhus, polypous, or sarcomatous tumors in or about the uterus or pelvis; dropsy or ventosity of the uterus or tubes; fleatoma or dropsy of the ovaria, and ventral conception, are the common causes of such fallacious appearances. In many of these cases the menses disappear; nausea, retchings, and other symptoms of breeding, ensue; flatus in the bowels will be mistaken for the motion of the child; and in the advanced

Advanced stages of the disease, from the pressure of the swelling on the adjacent parts. Tumefaction and hardness of the mammae supervene, and sometimes a viscid or serous fluid distils from the nipple; circumstances that strongly confirm the woman in her opinion, till time or the dreadful consequences that often ensue at last convince her of her fatal mistake.

False Conception.—Mola. Other kinds of spurious gravidity, less hazardous in their nature than any of the preceding, may under this head also be classed; diseases commonly known by the names of false conception and mola: The former of these is nothing more than the dissolution of the foetus in the early months; the placenta is afterwards retained in the uterus, and from the addition of coagula, or in consequence of disease, is excluded in an indurated or enlarged state; when it remained for months or longer, and came off in the form of a fleshy or scirrhous-like mass, without having any cavity in the centre, it was formerly distinguished by the name of mola.

Mere coagula of blood, retained in the uterus after delivery, or after immoderate floodings at any period of life, and squeezed, by the pressure of the uterus, into a fibrous or compact form, constitute another species of mola, that more frequently occurs than any of the former. These, though they may assume the appearances of gravidity, are generally, however, expelled spontaneously, and are seldom followed with dangerous consequences.

CHAP. IV. Superfetation.

Soon after impregnation takes place, the cervix uteri becomes entirely shut up by means of a thick viscid gluten: the internal cavity is also lined by the external membrane of the ovum, which attaches itself to the whole internal surface of the fundus uteri: the Fallopian tubes also become flaccid; and are, as gravidity advances, supposed to be removed at such a distance, that they cannot reach the ovaria to receive or convey another ovum into the uterus. For these, and other reasons, the doctrine of superfetation is now pretty generally exploded.—A doctrine that seems to have arisen from the case of a double or triple conception, where, some time after their formation in utero, one foetus has been expelled, and another has remained; or after the extinction of life at an early period, one or more may be still retained, and thrown off in a small and putrid state, after the birth of a full-grown child.

The uterus of brutes is divided into different cells; and their ova do not attach themselves to the uterus so early as in the human subject, but are supposed to receive their nourishment for some time by absorption. Hence the os uteri does not close immediately after conception; for a bitch will admit a variety of dogs while she is in season, and will bring forth puppies of these different species: thus it is common for a greyhound to have, in the same litter, one of the greyhound kind, a pointer, and a third, or more, different from both: Another circumstance that has given rise to superfetation in the human subject, which can only happen when there is a double set of parts, instances of which are very rare.

CHAP. V. Extra uterine Foetuses, or ventral Conception.

THE impregnated ovum, or rudiments of the foetus, is not always received from the ovary by the tuba Fallopiana, to be thence conveyed into the cavity of the uterus; for there are instances where the foetus sometimes remains in the ovary, and sometimes even in the tube; or where it drops out of the ovary, misses the tubes, and falls into the cavity of the abdomen, takes root in the neighbouring parts, and is thereby nourished: But as these foetuses cannot there receive so much nourishment as in the succulent uterus, they are less, and generally come to their full growth before the common term.

Of these some burst in the abdomen; and others form abscesses, and are thereby discharged; others dry, and appear bony, and remain during life, or are discharged as above, or by stool, &c.

CHAP. VI. Monsters.

WHEN two or more ova contained in the uterus attach themselves so near one another as to adhere in whole or in part, so as to form only one body with membranes and water in common, this body will form a confused irregular mass called monstrous; and thus a monster may be either defective in its organic parts, or be supplied with a supernumerary set of parts derived from another ovum. This seems a rational conjecture; but while every thing relative to generation is a mystery, how can we account for the extraordinary phenomena? Some authors enumerate a third species of monster, the product of a mixed breed, exemplified, for instance, in the mule, produced by the mixed generation of an ass and a mare. In this animal there are organical parts different from what pre-existed in the parents; there is a defect of some parts, a luxuriant growth of others; and the defect in the parts of generation, which renders the animal unfit for propagation, constitutes a very curious and particular species.

CHAP. VII. Diseases of Pregnancy.

AFTER conception, a remarkable change is soon produced in the genital system. This is the source from whence arise different symptoms, that are however liable to considerable variation, not only in the constitution of different women, but in the same woman in different pregnancies, and at different periods of the same pregnancy.

Pregnancy,—though a natural alteration of the animal-economy, which every female seems originally formed to undergo, and hence not to be considered as a state of disease, occasions, however, sooner or later, in many women, various complaints, which evidently depend on it as a cause.

Diseases incident to the pregnant state may be considered, either, 1. As arising from sympathy in the early months; or, 2. As depending on the stretching and pressure of the uterus towards the more advanced stages.

I. Though

I. Though the former of these complaints are generally to be accounted for from other causes than that of plethora; yet, in many constitutions, a certain plethoric disposition in the early months of pregnancy seems to prevail in the vascular system: And therefore, though many inconveniences may ensue from a too frequent, a too copious, or an indiscriminate use of venesection; yet, if prudently and judiciously employed, abortion by this means will not be endangered, as some late authors have alleged; but, on the contrary, on many occasions, a seasonable bleeding will be attended with the most beneficial and salutary effects.

In young women, suddenly affected with severe sickness and loathing, febrile commotion, headache, vertigo, and other symptoms of breeding, more especially in full sanguineous habits, besides a spare light diet and suitable exercise, recourse must be had to proper evacuations, the chief of which is venesection: this may be safely performed at any time of gravidation, and occasionally repeated according to the urgency of the symptoms; small bleedings, at proper intervals, are preferable to copious evacuations, which in early pregnancy ought always to be carefully guarded against.

When the stomach is loaded with putrid bile or acrid faburra, the offensive matter should be discharged by gentle vomits of ipecacuan, or of infusions of chamomile flowers. The violent efforts to retch and vomit, and the commotions thence excited, which often occasion the expulsion of the foetus, will by this means frequently be removed, in most cases greatly diminished. During the term of breeding, the state of the belly must be also attended to. When laxative medicines become necessary, those of the mildest and gentlest kind should be administered.

In women liable to nervous complaints, where the stomach is weak, and the sickness violent and continued, the patient should be put on a course of light, aromatic, and strengthening bitters; such as infusions of bark, columbo, &c. and her diet, air, exercise, company, and amusement, should be regulated: In order to settle the stomach, and lessen the sensibility of the system, opiates will often happily succeed, when every other remedy fails.

Heart-burn and diarrhoea,—common symptoms of breeding, or of pregnancy, must be treated pretty much as at other times. Both complaints chiefly depend on the state of the stomach.

Tumefaction, tension, and pains in the mamma.—If tight lacing here be only avoided, and the breasts have room to enlarge and swell, no inconvenience ever follows: These effects arise from a natural cause, and seldom require medical treatment. If very troublesome and uneasy, bathing with oil, or anointing with pomatum, and covering with soft flannel or fur, will in most cases prove the cure.

The menstrual evacuation—is in some women regular for the first, second, or third period after conception. This seldom happens but in women of sanguineous plethoric habits, such as have been accustomed to large copious evacuations at other times, when the discharge is to be considered as beneficial.

Deliquia, nervous, or hysterical fits.—When these are
N^o 220.

occasioned by falls, frights, and passions of the mind, they frequently end in the loss of the child: But when they happen about the term of quickening, they seem to arise from the escape of the uterus from its confinement within the capacity of the pelvis; in which case they are commonly slight, of short duration, and never threaten any dangerous consequence.

II. The second class of complaints, viz. those that are incident to the advanced stages of utero-gestration, and that depend on the change of situation of the gravid uterus, its enlargement and pressure on the neighbouring parts are more painful in their symptoms, and more dangerous in their consequences, than those enumerated in the preceding class. The premature exclusion of the foetus is generally the worst inconvenience resulting from the one; the death of the mother, along with the loss of the child, is too frequently an attendant of the other.

Difficulty or suppression of urine—is sometimes occasioned by the pressure of the uterus on the neck of the bladder, before the fundus uteri escapes from its confinement within the brim of the pelvis. This complaint, if early attended to, will seldom prove troublesome or hazardous; but cannot be entirely removed till the uterus rises above the brim of the pelvis, and by its enlargement becomes supported by resting on the expanded bones of the ossa ilia. But if neglected in the beginning,

A retroversion of the uterus—is generally the consequence; a case that demands particular attention.—Here the fundus uteri, instead of being loose, falls back in a reclined state within the hollow of the os sacrum: thus a tumor is formed in the vulva, where of the os tinctæ makes the superior part; the body of the uterus, by this means, becomes strongly wedged between the rectum and bladder; and, from the enlargement of the uterus itself, and accumulating load of faeces and urine, the reduction will prove in many instances utterly impracticable. A total suppression of urine, or a rupture of the coats of the bladder, fever, inflammation, or gangrene of the uterus, often ensue; and these are succeeded by delirium, convulsions, death.

The indications of cure, in this dangerous disease, are sufficiently obvious: For, in the first place, every obstacle that prevents the reduction should be removed: thus the contents of the rectum and bladder must, if possible, be evacuated; emollient fomentations and cataplasms must be applied, if indicated by inflammation or tumefaction of the parts. Secondly, The reduction of the prolapsed uterus must be attempted, by placing the patient upon her knees, with her head low and properly supported. While this is attempted within the vagina, a finger or two should also be passed within the rectum, by which the operation in some cases may be facilitated: but, at other times, no power whatever will be sufficient for this purpose. Lastly, If the reduction be accomplished, the fever, inflammatory symptoms, and other consequences of the disease, must be subdued; and a recurrence prevented by an open belly, rest, and recumbent posture, and promoting a free discharge of urine: means that ought to be persisted in till the uterus rises within the abdomen, when the patient will be secured from future danger.

Costiveness in pregnancy—is inconvenient. It may proceed from the same cause with the preceding complaint; it may depend on the stomach; the febrile heat, that in many women prevails, will also prove an occasional cause. It may be obviated or prevented by a proper regulation of the regimen, and by such gentle laxative medicines as are best suited to the state of the woman; the chief of which are ripe fruit, magnesia, lenitive electuary, cream of tartar, sulphureous and aloeetic medicines, oleum ricini, emollient glysters.

The piles—frequently arise in consequence of costiveness, or from pressure of the gravid uterus on the hemorrhoidal veins. These are also to be removed or palliated by the same means employed on other occasions; regard being had to this distinction, which may be applied universally to the gravid state, that all violent remedies are to be avoided; a light diet should be enjoined; the belly should be kept moderately open; and topical liniments or cataplasms should be applied, such as Bals. sulphur. Bals. traumaticum, Liniment. ex ol. palmae, Ung. sambucini, cum laud. liquid. Poultices of bread and milk with opium, &c. according to the various circumstances of the case.

Oedematous swellings of the legs and labia—are occasioned by the languid state of the circulation, by the interruption of the refluxing blood from the pressure of the distended uterus on the vena cava, &c. These, though very troublesome and inconvenient, are seldom however of dangerous consequence, except where the habit is otherwise diseased; and seldom require puncture, as the swelling generally subsides very quickly after delivery. They can only, therefore, at this time, admit of palliation; for which purpose, along with a proper diet and moderate exercise, a frequent recumbent posture, open belly, and dry frictions applied to the legs evening and morning, will prove the most effectual means.

Varicous swellings in the legs and thighs—from the interruption of the venal blood in these parts, occasioned by the pressure of the gravid uterus, are to be treated in the same manner with the preceding complaint.

Pains in the back, loins, cholic-pains, cramps—occasioned by the stretching of the uterus and appendages, and from the pressure of the uterus on the neighbouring parts, symptoms that are most troublesome in a first pregnancy, are to be palliated by venesection, an open belly, and light spare diet. If the patient be of a full habit, and pre-disposed to inflammatory complaints, where the pressure is very great in the advanced months, or in twins, &c. if proper remedies are neglected, inflammation of the uterus and adjacent viscera, or dreadful epileptic fits, may quickly ensue; the event whereof is generally fatal. Crampish spasms in the belly and legs require the same palliative treatment; to which may be added friction, and the application of æther, ol. volatil. bals. anodyn. or the like, to the parts affected.

Cough, dyspnea, vomitings, difficulty or incontinency of urine, occasioned by the pressure of the bulky uterus on the stomach, liver, diaphragm, &c.—Complaints that can only be alleviated by frequent small bleedings, a light spare diet, and open belly. The patient should be placed in an easy posture, something between sitting and lying; and when the uterus rises high, a moderate degree of pressure from the superior part downwards, may in some cases prove useful. But this must be used

with great caution: for dreadful are the effects of violent pressure, or tight lacing, during pregnancy. It frequently kills both mother and child, and ought to be guarded from the earliest months.

Epileptic fits—are a very dreadful and alarming appearance. They generally depend on the same cause with the above complaints: they may also arise from irritation, excited by the motion and stirring of the fetus; and from various other causes. Such as have had convulsions when young, are most liable to have them during pregnancy: they happen most frequently in first pregnancies, or where the fetus is very large, or in twins, triplets, &c. In such cases, the distention of the uterine fibres is so great, that actual laceration is sometimes the consequence.

At whatever period of pregnancy they seize, the utmost danger may be dreaded. This, however, will be in proportion to the severity, duration, and recurrence of the paroxysm, to the term of gravidation, to the constitution of the patient, and her condition during the remission. The danger is greater towards the latter end of pregnancy than in the earlier months or in time of labour.

Such as arise from inanition, from excessive and profuse hemorrhages, from violent blows, falls, &c. or from a ruptured uterus, are for the most part fatal.

Hysteric or nervous spasms must be carefully distinguished from true epileptic fits. The former are milder than the latter; they are not attended with foamings; they do not affect the posture; the pulse is smaller, feeble, and more frequent; the woman is pretty hearty after they are over; they are followed with no bad consequences, and yield to the common treatment. Women of strong, robust, vigorous constitutions, are more generally the subjects of the one; the delicate, the nervous, and the irritable, of the other.

Epileptic fits generally come on very rapidly; if any previous symptoms occur, the fit is commonly announced by an intense pain in the scrobiculum cordis, or violent head-ach.

In the pregnant state, these fits are for the most part symptomatic, and will therefore only admit of a palliative cure. They may be distinguished into three classes; those of the early months, those of the latter, and those that come on with labour-pains.

With regard to the cure, the term of pregnancy, as well as the constitution of the patient, and particular cause of the disease, must carefully be considered.

1. Convulsions at an early period of pregnancy chiefly happen to young women of a plethoric sanguine habit; and can therefore only be removed or palliated by a free and bold use of the lancet, by an open belly, cool regimen, and spare diet. After plentiful evacuations, if the stomach be loaded with acrid faburra or putrid bile, a gentle puke may be of use: but such remedies, on those occasions, must be employed with great caution. Instead of a plethoric, if the patient is of a nervous habit, a very necessary and important distinction, the intentions of cure will essentially vary. For here opiates in large doses and frequently repeated, emollient glysters, stupes applied to the legs, the femicupium, and every other means to soothe the nerves and remove spasmodic stricture, will prove the most effectual remedies. If insensible

or emetics, opium, musk, and other antispasmodics, should be exhibited by way of glyster, and the patient ought to be roused by epispastic and stimulating cataplasms applied to the legs and ham. Convulsions succeeding profuse evacuations are generally mortal. The vis viter, in such circumstances, must be supported, by replenishing the vessels with the utmost speed: this is to be done by pouring in nourishing fluids as fast as possible by the mouth and by glyster; warm applications should also be made to the stomach and feet, and nervous cordials given internally along with opium.

The treatment of epileptic fits, depending on other causes than those now mentioned, must be regulated by a proper attention to the particular symptoms with which they are attended.

2. In the advanced months, such complaints are more to be dreaded than in early gestation, as they generally proceed from the irritation occasioned by the distention of the uterine fibres, or by the pressure of the uterus on the contiguous viscera: hence the natural functions of these parts will be interrupted, the circulation of their fluids will be impeded, and the blood, being thus prevented from descending to the inferior parts, will be derived in greater proportion to the brain, and overcharge that organ.

The cure must, in this case, chiefly rest on copious and repeated bleedings, an open belly, and spare diet.

3. Lastly, when fits come on with labour-pains, a speedy delivery, if it can be done with safety, either by turning the child, or by extracting with the forceps when the head is within reach, will prove the most effectual cure.

When the bladder is distended, the contents must be evacuated: if a stone sticks in the urethra, it must be pushed back or extracted. If the fits are the effects of a ruptured uterus, immediate death is generally the consequence.

With regard to the treatment of such complaints, no other change is generally requisite, than what arises from the symptoms peculiar to this situation. In general, till after delivery, they will only admit of palliation.

CHAP. VIII. Flooding.

THESE, though confined to no particular term, may happen at every period of gravidation. The one is a frequent consequence of the other; the event of both is often hazardous, as the earlier miscarriages are generally preceded by an effusion of blood from the uterus, which, in the advanced stages of pregnancy, besides the loss of the child, always endangers the life of the mother.

The menorrhagia gravidarum—may be defined, an effusion of blood from the uterus, confined to no regular or stated periods, in quantity and duration various, and liable to recur on the slightest occasions.

The immediate cause is, a separation of some portion of the placenta or chorion from the internal surface of the uterus. Whatever occasions this separation may be considered as the remote cause, which, though various, may be reduced to

I. Those that affect the general system: as,

1. 1. External accidents changing the state of the circulation.
2. 2. Changes in the circulation from internal causes.
3. 3. Debility.
4. 4. Plethora.

II. Those that affect the uterus and placenta: as,

1. 1. Direct affections.
2. 2. Stimuli communicated from an affection of other parts.

With regard to the cure.—Though a flooding in some constitutions may happen, even in early gestation, and may remit and recur from time to time, and the woman go on to the end of her reckoning; and tho' it seldom or never happens that this complaint proves mortal to the mother in the first five weeks of pregnancy; yet every appearance of this kind, even the slightest, is to be dreaded; as in the early months it will often throw off the fetus, and, in the latter, always threatens the utmost danger both to mother and child. Floodings of gravid women we cannot propose radically to cure; they will only admit of palliation. With this view, the indications are,

I. To lessen the force and velocity of the blood in general.

II. To promote the constriction of the patulous mouths of the bleeding vessels, or the formation of coagula in their orifices.

1. To answer the first indication, rest and a recumbent posture, cool air, tranquillity of mind, a light diet, venesection, and opiates, are the chief means.

2. To restrain the violence of the hemorrhagy, internal astringent medicines are recommended; but this is to be accomplished chiefly by means of cold styptic applications to the parts and their neighbourhood. But as these floodings often arise from so various and opposite causes, it is difficult to lay down particular indications, or to point out a method of cure suited to every case that may occur. The intention of cure can only be regulated by a careful and judicious consideration of the cause, and of those particular circumstances with which the case may be attended. In early pregnancy, it may be restrained by keeping the patient quiet and cool, by giving internally cooling things and opiates; but, in the advanced stages, the deluge is sometimes so profuse as to kill very suddenly. Under such circumstances, when the woman is near her time, emptying the uterus by delivery, if practicable, is the only safe expedient both for preserving the life of the mother and of the child.

If the hemorrhagy can be restrained, a recurrence must be guarded against, by avoiding or counteracting the occasional or remote causes.

CHAP. IX. Abortion, or Miscarriage,

MAY be defined, the premature expulsion of the embryo or fetus. Some, however, make the following distinction: When a woman miscarries in early gestation, this they consider as an abortion; but if in the latter months, that they term a premature birth. The symptoms that threaten abortion are:

Flooding.

Pain

Pain in the back and belly.
Bearing down pains with regular intermissions.
The evacuation of the waters.

The death of the child, which discovers itself by the following symptoms; though in general these are so doubtful and fallacious, that none of them afford an infallible sign:

1. 1. The subsiding of the abdominal tumor.
2. 2. Cessation of motion in the fetus.
3. 3. The sensation of a heavy weight falling from side to side, as the woman turns herself in bed.
4. 4. Sickness, faintings, rigors, cold sweats.
5. 5. The breasts turning flaccid.
6. 6. Coldness of the abdomen, and putrid discharge from the vagina.

Abortions are seldom dangerous in the first five months; but a frequent habit of miscarriage debilitates the system, shatters the constitution, and lays the foundation of chronic diseases of the most obstinate and dangerous nature.

In the advanced months, the prognosis will be more or less favourable according to the patient's former state of health, the occasional cause, and symptoms with which it is attended. The proximate cause of abortion is the same with that of true labour, viz. a contracting effort of the uterus and abdominal muscles, assisted by the other expulsive powers. The remote causes cannot be explained with precision; as many circumstances, with regard to the nature of impregnation, and connection of the fetus with the placenta and uterus, are subjects still involved in darkness. They may in general, however, be reduced,

1. I. To whatever interrupts the regular circulation between the uterus and placenta.
2. II. To every cause that excites the spasmodic contraction of the uterus, or other assisting powers.
3. III. To whatever occasions the extinction of life in the fetus.

Amongst the first are:

1. 1. Diseases of the uterus.
2. 2. Imperviousness or spasmodic constriction of the extremities of the uterine blood-vessels.
3. 3. Partial or total separation of the placenta or chorion from the uterus.
4. 4. Determination to other parts.

To the second general head belong all causes that produce a strong contraction of the elastic fibres of the uterus, or of the parts that can press upon it, or that occasion a rupture of the membranes: such as,

1. 1. Violent agitation of mind or body.
2. 2. A disease of the membranes.
3. 3. Too large a quantity of liquor amnii.
4. 4. The crost position of the fetus.
5. 5. Its motion and kicking.

The last head includes the numerous causes of the death of the child, which, besides those referred to in the preceding classes, may be occasioned by,

1. 1. Diseases peculiar to itself.
2. 2. Diseases communicated by the parents.
3. 3. External accidents happening to the mother; or,
4. 4. Accidents incident to the fetus in utero.
5. 5. Diseases of placenta or funis.
6. 6. Knots and circumvolutions of the chord.
7. 7. Too weak an adhesion of placenta or chorion to the uterus; and,

8. Every force that tends to weaken or destroy this attachment.

With regard to the treatment. This must be varied according to the particular circumstances of the case; nor is it possible to point out particular indications, or propose any regular plan to be pursued for this purpose. Abortion is often preceded by no apparent symptom, till the rupture of the membranes, and evacuation of the waters, announce the approaching expulsion of the fetus. Either to remove threatening symptoms, or to prevent miscarriage when there is reason to apprehend it, often baffles our utmost skill; because it generally happens, that there is a cessation of growth in the ovum; or, in other words, an extinction of life in the fetus, some time previous to any appearance of abortion. For instance, in early gestation, a woman commonly miscarries about the 11th or 12th week; but the age of the fetus at this time is generally no more than eight weeks. At other times, when by accident the fetus perishes, perhaps about the fifth or sixth month, it will still be retained in utero, and the expulsion will not happen till near the completion of full time.

As women who have once aborted are so liable to a recurrence from a like cause, at the same particular period, such an accident, in future pregnancies, should therefore be guarded against with the utmost caution. On the first appearance of threatening symptoms, the patient should be confined to a horizontal posture; her diet should be light and cooling; her mind should be kept as tranquil as possible; a little blood from the arm may be taken occasionally; and opiates administered according to circumstances; but excepting so far as depends on these, and such like precautions, for the most part, in the way of medicine, very little can be done.

Manual assistance is seldom or never necessary during the first five months of pregnancy: the exclusion of fetus and placenta should very generally be trusted to nature.

The medical treatment of abortion must therefore be considered with a view only to the prophylactic cure; and this again will chiefly consist in a proper

CHAP. X. Regimen during Pregnancy.

WOMEN, when pregnant, should live a regular temperate life; moderation in eating and drinking should now be very carefully observed, and every thing that has any tendency to disagree with the stomach should be avoided; otherwise the manner of life should be much as usual. If complaints do occur, these should be treated as at other times; only guarding against such things as, by violent operation, may endanger miscarriage. If the woman has formerly been subject to this accident, the cause should be carefully considered, and suitable remedies applied; if plethoric, for instance, she should be blooded, live sparingly, and kept quiet, till she gets beyond the dangerous period. If she be weak, delicate, and nervous, bark, light aromatic bitters, mineral waters, and the cold bath (if able to bear it), will prove the best prophylactic remedies. The cold bath has, in many cases, cured the most obstinate fluor albus, and sometimes even sterility itself; and, in relaxed habits disposed to miscarriage, when every other

Regimen. means has failed, the cold bath has done considerable service: the practice may safely be continued for some months after conception, when it has been early begun, or when the patient has been accustomed to it. Such a shock will, however, act very differently on different systems: hence it is an expedient by no means to be indiscriminately used in the pregnant state.

Abortions that happen in early gestation, and that come on suddenly without any prefiguring sign, if ever they are to be prevented, it can only be done by avoiding all occasional causes, by counteracting morbid dispositions, and by confinement to a horizontal posture, for some time before, and till the critical period be over.

When a venereal taint in the parents is suspected to be the cause either of abortion or the death of the fetus, the like accident can only be prevented by putting both parties on a mercurial course.

Pregnant women require a free pure air; their amusement should often be varied; their company should be agreeable and cheerful; their exercise should be moderate, and suited to their inclination, constitution, and the season; they should avoid crowds, confinement,

Regimen. travelling over rough roads in a carriage, or being exposed to sea-voyages. Riding a-horseback should also be practised with great caution, that disagreeable objects may be shunned, and shocks of every kind prevented. For this reason, when riding is judged proper, the woman should be a courageous rider; she should never ride without somebody being in company; the horse should be tame and well trained; the road should be smooth as well as private; and the exercise should be gentle and easy, and never carried the length of fatigue. Women should, with the utmost care, guard against confining the breasts or belly; early recourse should be had to jumps, and they should keep themselves as loose and easy as possible through the whole term of utero-gestation. An open belly is necessary and important in the pregnant state; it keeps the stomach in good condition, prevents cholera and other complaints that may terminate in miscarriage. When the abdomen is pendulous towards the latter months, a gentle support by proper bandage will prove useful; and the woman, when fatigued, should occasionally, through the day, indulge in rest on a bed or couch.

PART II. OF LABOURS.

LABOURS are divided into three classes: natural, laborious, and preternatural.

In whatever manner the head of the child presents, where the delivery at full time is performed by nature, the labour is with great propriety called natural; when the birth is protracted beyond the usual time, or cannot be accomplished without extraordinary assistance, it is deemed laborious; and preternatural, when any other part but the head presents.

CHAP. I. Natural Labour.

By whatever power the uterus is enlarged, when any further increase is prevented, a stimulus to contraction must ensue; by this means an uneasy sensation is excited, which must, in the woman, produce an effort to procure relief: and thus arise the true labour-pains, which at first are slight and of short duration, a considerable remission intervening: the periods of recurrence soon become more frequent; the pains acquire an increased force, producing more and more change on the os uteri; which, yielding to the impelling cause, gradually opens and expands; till at length it becomes completely dilated, the membranes protruded and ruptured, and the child, by the expulsive force of the uterus, assisted by that of the diaphragm and abdominal muscles, is thus pushed along and delivered.

The symptoms of approaching labour are, The subfiding of the abdominal tumor: hence a discharge of mucus from the vagina, sometimes tinged with blood; incontinency, or suppression of urine; tenesmus; pains of the belly, loins, and about the region of the pubes; restlessness, hot and cold fits, &c.

Spurious pains are to be carefully distinguished from those of genuine labour. The former arise from the stretching of the uterus and its pressure on the neigh-

bouring parts, or from costiveness; and are to be distinguished from the latter by the following symptoms: They are most troublesome towards the evening, increase in the night, and abate through the day; they are more trifling and irregular than true uterine pains; the uterine orifice is not affected; and there is no increased flow of mucus from the parts.

True pains begin about the region of the kidneys, strike forward towards the pubes, and down the thighs: they return at regular periods: there is a copious discharge of mucus from the vagina; the os uteri gradually opens, and can be felt to dilate in time of a pain; while the membranous bag, in a tense state, forcibly pushes against the finger.

The event of labours is so precarious, that no certain judgment can be formed from almost any symptoms, till the labour itself be considerably advanced. A prognosis in general is chiefly to be formed from the age, state of health, and temperament of the patient; from the force, duration, and recurrence of the pains; and from their effect on the uterine orifice; from the time of the rupture of the membranes; from the general make and form of the woman, but, in particular, of that of the pelvis; from the bulk and position of the child, &c.

With regard to the method of delivery, and position of the woman, this has been different at different ages, and in different countries: the chief thing, however, is to guard against cold and fatigue, observing that the woman be placed in the most favourable posture for supporting the back, for the action of the abdominal muscles, &c. and most convenient for the necessary assistants: till the labour is considerably advanced, she may be indulged in whatever posture is most agreeable; after which the bed or couch is the most proper.

With regard to assistance in natural parturition, the accoucheur:

accoucheur for the most part has little to do, till the membranes are ruptured, and the head in perineo. In time of labour, the woman should be kept very cool, and every means of being overheated should be avoided. She should be put to bed in proper time, placed on her side or back, with her head and shoulders a little raised, a cloth tied to the bed-post, or held by an assistant, to support her hands in time of pain, and her feet resting against a foot-board; her knees should be drawn up towards the belly, and a folded pillow put between them. All efforts to press or strain, except what nature excites, are improper, hurtful, and should be avoided: the membranes, if possible, ought not to be ruptured till they almost protrude at the os externum; the perineum must be lubricated when formed into a tumor, and carefully supported while overstretched; for this purpose, a cloth smoothly folded should be applied over the part, to enable the accoucheur to have a firmer hold. This is an important part of his office; and must be attended to with the strictest care. From the time this protrusion begins to form till the head of the child be completely delivered, the perineum must be carefully preserved by the palm of the hand firmly applied against it, which should be carried backwards in a direction towards the anus, and kept so during every pain. Thus the miserable consequences will be prevented to which the neglect of this pressure exposes: for by this support the overstretching of the perineum will be greatly lessened, the parts will dilate gently and gradually, the vertex will easily slip from under the pubes, and the fore-head will rise from under the perineum in a safe, slow, and gentle manner. The perineum must now be released, by cautiously sliding it over the face and chin of the child; and this ought to be made further sure of, by passing a finger under it round and round. After the head has thus mechanically advanced through the pelvis and vagina, a pain or two must be waited for, when in like manner the body will follow; nothing more being necessary than to support the child while it is gradually pushed forwards by the expulsive force of the natural pains.

When the child has cried, and the change in the circulation freely taken place, the funis umbilicalis must be tied and divided, the infant must be wrapped in a warm receiver, and given to the nurse to be washed and dressed.

The parts of the woman must now be gently wiped, a warm soft cloth must be applied, and a proper time waited for the separation of the placenta.

This is also the work of nature, and seldom requires more force to bring it along than if it lay entirely loose within the cavity of the uterus. Thus, in pulling, no greater force should be employed than is just sufficient to put the funis on the stretch: for if it is already separated, no violence is necessary to extract it; and if the adhesion is very firm, all violent efforts are improper, and often followed with most dangerous consequences. Its advancing is known by the contraction of the uterus, and shifting of the abdominal tumor, and by the lengthening of the cord. By the spontaneous contraction of the uterus, this separation is effected; the expulsion will be slower or more expeditious, according to the state and condition of the woman, according to the number of children she has born,

and according to the duration or violence of the labour; it is easier and sooner separated in a first birth, when the woman is in good health, and when the labour has been properly managed. In most cases, this separation is accomplished within half an hour after the delivery of the child. It adheres most firmly after premature births, when the woman has been sickly during pregnancy, where the labour has been tedious and difficult, or when hasty attempts have been made to extract it. A finger, or finger and thumb, guided by the funis, and introduced within the vagina, to bring down the edge, will remove any difficulty occasioned by the centre or bulky part passing the uterine or vaginal orifice.

When it becomes necessary to employ force in extracting the placenta, which is never requisite but in cases of flooding, when the woman has been in bad health during pregnancy, when she has suffered much in time of labour, or when the string has been torn from it (though the first of these cases is perhaps the only one wherein the practice is absolutely proper), the method of doing it is as follows: In ordinary cases, the woman should be laid on her back or side; but when the belly is pendulous, or when the placenta is attached to the fundus uteri, she must be placed on her knees, which is the most convenient posture.

The accoucheur, though with a certain degree of courage, yet with the utmost possible tenderness, must then pass his hand well lubricated through the vagina into the uterus, and feel for the convex body of the after-birth; if the chord be entire, this will direct him; if not, he must feel for the loose membranes at the edge of the cake, and must not be deceived by coagula of blood that lie in the way; if the uterus be constricted in the middle like a sand-glass, a circumstance that sometimes, though rarely, occurs, this must be overcome by a gradual dilatation with one finger after another, till the whole hand in a conical manner can safely be passed. He must not content himself with feeling a part; he should be able to move his fingers round the whole body of the cake; the adhesion must be separated very gradually, in a direction from the sides round and round. The placenta is distinguished from the uterus, as well by its softness as by its convex puckered feel. This convexity increases in the same proportion as the uterus contracts: hence the middle part or centre of the placenta is first detached; and if the edges are carefully separated, by gently passing the fingers behind, the whole body becomes loose and dilengaged, which must now be brought along with great caution, that no part be left behind, and that no injury be done to the woman in making the extraction.

Though bad consequences sometimes follow from the retention of the placenta, yet it is much to be questioned, if these are not less to be dreaded than the dangerous floodings, convulsions, deliquia, inflammation of the uterus, fever, &c. that may be induced from the preposterous practice of passing the hand to make the extraction: and would it not in general be better to confine the practice of introducing the hand, to cases of uterine hemorrhages only? Where the adhesion is so firm as to require force, or where its place of attachment is out of the reach of the finger, by which, for the most part, the edge may be brought down;

down, is it not by far the safest and the most rational practice universally to trust to nature? Should the mouth or body of the uterus become constricted before the separation is effected, no matter; little is to be dreaded: it will afterwards kindly dilate; and the separation and expulsion will spontaneously be accomplished with as much safety as in other animals, where no force is ever used. Let every candid practitioner acknowledge, that for one instance where the retention of the placenta has been attended with dangerous consequences, a precipitate or forcible extraction has proved fatal to hundreds.

After the delivery of child and placenta, the woman must rest a few minutes; her strength and spirits may be recruited by some light nourishing cordial; the wet cloths, &c. must then be removed; the bed must be properly shifted and adjusted; and a gentle compression must be made on the abdomen.

During lying-in, the woman should avoid company and noise; her dress and bed-linens should be often changed; she should avoid every means of being overheated; and with regard to her diet, it should, for the first week at least, be very light and of easy digestion.

CHAP. II. Laborious or difficult Labour.

WHEN the birth is protracted beyond the ordinary time, or when the child's head, though naturally presenting, cannot be brought forwards without assistance, the labour is accounted difficult or laborious.

Though the causes of laborious births are various and complicated, they may in general be considered as depending,

I. On the mother.

II. On the child.

III. On the secundines.

I. The birth may be protracted, or the labour-pains interrupted, by,

(1.) Debility in the mother, arising,

a From disease, viz.

1. 1. Flooding.
2. 2. Epileptic fits.
3. 3. Crampish spasms.
4. 4. Lowness and faintishness.
5. 5. Inflammatory diathesis.
6. 6. Colic.
7. 7. Nauseating sickness and vomiting.
8. 8. Hectic or consumptive habit.

b From passions of the mind.

c From mismanagement in time of labour.

(2.) Local complaints in the parts, or their neighbourhood, viz.

a In the bones, occasioning narrowness and distortion.

b In the soft parts, viz.

1. 1. Dryness and constriction of the vagina.
2. 2. Thickness and rigidity of the os tincæ.
3. 3. Scirrhus or polypous tumors about these parts.
4. 4. Accumulated feces in the intestines.
5. 5. Stone in the urethra.
6. 6. Prolapsus of the uterus, vagina, and rectum.

7. Obliquity of the uterus.

II. Difficulties also arise on the part of the child, viz.

1. 1. From the bulk and ossification of the head.
2. 2. The situation in which the head presents.
3. 3. Large broad shoulders, or their transverse descent through the pelvis.

III. The secundines, viz.

1. 1. The rigidity of the membranes, and the contrary.
2. 2. Too great a quantity of water.
3. 3. The funis umbilicalis too long or too short.
4. 4. The prolapsus of the funis before the child's head: and,
5. 5. The attachment of the placenta towards the cervix or os uteri.

The treatment of laborious births requires a very nice and careful attention to the condition of the patient and other circumstances, from whence only we can judge when assistance becomes requisite, and how it may be applied to the best advantage. That pain and misery is the unavoidable and inseparable attendant of child-bearing, though dealt out in different proportions to different subjects, the testimony of all nations, and all ages, as well as daily experience, bear witness: nor is the easiest labour altogether exempted from pain, even under the most favourable circumstances. The delivery, however, promises to be safe and easy, when the woman is of proper age, in good health, the child presenting right, and the pelvis well proportioned; but the force of the natural pains may be interrupted, and of consequence labour be retarded, from,

I. Debility in the mother, arising from

a Disease. This may appear under various forms;

1st, A flooding. Which is very alarming, even along with labour-pains: though less so in this case than when at a distance from full time; because as the labour-pains increase, the hemorrhagy very generally abates: or if not, breaking the membranes when the aperture of the os uteri is sufficient to admit the hand, seldom fails to produce that effect. The woman in this case must be kept cool. Opiates must be administered; she must be comforted with the best assurances of a happy delivery; and the natural pains must be waited for.

But if the hemorrhagy proceeds from a separation of the placenta, attached towards the cervix or orificium uteri; in this unhappy case, the whole body of the cake may be completely separated before the aperture of the uterus be sufficient for allowing the head to pass; and the deluge may be so sudden and impetuous, that the woman will sink immediately under it. Breaking the membranes, and making the delivery, either by turning the child, or extracting with the forceps or erotchet, according to circumstances, with as much expedition as is consistent with the mother's safety, is the only expedient by which the threatening catastrophe may be prevented.

2dly, Epileptic fits may in like manner retard labour, and endanger the life of the mother. If the child is not thrown off by a few fits, which is often the case, the delivery should be effected as soon as possible.

3dly, Crampish spasms in the thighs, legs, rarely in the belly, are very troublesome. They depend on the pressure of the head on the nerves as it passes through the pelvis, and can only be removed by delivery; which, as these pains are seldom if ever attended with danger, is not to be forced on this account. Breaking the membranes will sometimes remove them.

4thly, Lowness and faintness often occur, and frequently prove the cause of protracted labour.

No general rules with regard to the management of slow labour can be recommended. The mode of treatment, where so many circumstances may occur, must be suited to the condition of the patient, as every particular case will in some measure require a different management. Much depends on the prudence and judgment of the attentive practitioner. For instance, when the woman is nervous, low-spirited, or weakly, from whatever cause, in general her strength must be supported; she must not be put on labour too early; she must avoid heat, fatigue, and every means of exhausting her strength or spirits. When she is restless, or the pains trifling and unprofitable, opiates are particularly indicated; they remove spurious or grinding pains, recruit the spirits, procure rest, and amuse time. Little else for the most part is to be done. If the uterus once begins to dilate, though the dilatation goes on slowly, it is by much the best and safest practice to do nothing but regulate the management as above. The pains at last will become strong and forcing; and the delivery, even where the patient has been very weakly, will often have a safe and happy termination. In these tedious labours, if the strength of the woman be properly supported, every thing almost is to be expected from nature. Forceful means should be the last resource.

5thly, Inflammatory diathesis, in young subjects of strong rigid fibres and plethoric habits, must be obviated by venesection, an open belly, and cooling regimen.

6thly, Colic.—Many women have severe attacks of this disease immediately before the labour-pains come on; the reason of which is sufficiently obvious: the belly, which formerly rose so high that the fundus of the womb pressed against the pit of the stomach, afterwards subsiding, by the child's sinking to the lower part of the womb, and the oval of the head being applied to the oval of the basin, the contents of the intestines will be forced lower and lower, and the strait gut will be distended. Hence colic-pains, irritation, and uneasiness, a frequent desire to go to stool, or frequent loose stools, generally ensue. The best palliative remedy is to inject emollient glysters repeatedly till the bowels be entirely emptied. Although some degree of purging should attend the tenesmus, it will be necessary to wash the strait gut, by the use of one or more glysters. The irritating cause being in this way removed, an opiate, if no inflammatory heat or fever prevents, may be afterwards given with advantage.

7thly, Nauseating sickness, with vomiting.—When these symptoms occur, warm water or chamomile-tea must be drunk freely. Sickness and vomiting happen in some degree in the easiest labours. Sometimes they proceed from a disordered state of the stomach; but

in general are to be accounted for from the well-known sympathy of the womb with the stomach; and accompany the stretching of the os uteri only.

8thly, Hætic or consumptive habit.—It is a melancholy thing to attend a labouring woman in this state. The pains are weak and trifling; she cannot force much down; and she is feeble, and liable to faint when the pain goes off. But however apparently exhausted, the progress of labour goes on, in most cases, much better than could be well expected. The office of the womb gives little resistance to the force of the pains, weak and trifling as they are; the parts are soft and lax, and soon stretch in such a manner, that, if there be no fault in the pelvis, the child readily obtains a passage.

Here little is to be done but supplying the patient from time to time with light nourishment; with cordials that do not heat; and keeping up a free circulation of cool air all around her: for this purpose the curtains should be quite drawn aside, doors and windows widely opened; and she should be placed in a position with her head and breast well raised, that an easy respiration may be promoted. Hætic women under proper management rarely sink immediately after delivery; they generally survive a week or longer, tho' they seldom outlive the month.

9. Passions of the mind. Any piece of news in which the patient, her family, or relations are interested, should be carefully concealed, as well as every thing that tends in general to affect the passions; as labour may not only be interrupted from this cause, but the most dangerous symptoms, as floodings, convulsions, deliquia, and fatal syncope, may be induced.

10. From mismanagement in time of labour often arises debility, so that the patient's strength is exhausted, the pains at length entirely cease, and the head of the child remains locked in the pelvis, merely from want of force or pain to push it forwards. In all cases where the labour has the appearance of being tedious, the woman's patience must, as much as possible, be supported. During the grinding pains, she must be kept cool and quiet; opiates may be exhibited to pass the time, till the forcing throes cease, when she will acquire resolution, the parts will dilate kindly, and the labour end happily; whereas, if she considers herself in labour from the earliest appearance of grinding pains, she is frightened at the length of time, and her patience runs out. Slow lingering labours happen chiefly to elderly women having a rigidity in the parts, to nervous subjects, and to such as have been weakly during pregnancy. It is of great consequence, and the advice cannot be too much inculcated, to avoid exhausting the woman's strength too much at first.

11. Local complaints in the parts, or their neighbourhood.

a. Narrowness or distortion of the bones of the pelvis. Where there is any material defect in this cavity, a superficial knowledge of the form and structure of the parts will enable us to judge. If, from the figure of the woman's body, there is reason to suspect a faulty pelvis; if the spine is twisted, the legs crooked, the breast-bone raised, or the chest narrow; whether the pelvis be affected or not, she will require a particular management; for the constitution of such women is

weak.

weak and feeble, and they cannot be much confined to bed on account of their breathing. We can never be absolutely certain of a distortion of the pelvis (except when the distortion is confined to the inferior aperture) till the uterine orifice is considerably dilated. After this time, if the pains are strong and forcible, and the head of the child makes no advance, a narrow pelvis or large head is to be suspected. The pelvis may be faulty at the brim, bottom, or in the cavity or capacity. The first of these, which most frequently occurs, is the most difficult to be discovered. The second can be readily perceived by the touch: for we can feel the defects in the shape of the os sacrum and coccyx, in the position of the ischia, and in the bending of the pubes; and where the distortion is so general, that the whole cavity of the pelvis is affected, the shape of the woman's body, the slow progress of the labour, and the state of the parts to the touch, will afford sufficient information.

In the first case, we can only know the distortion by the symptoms; for we should not attempt to introduce the hand till the mouth of the womb be dilated: it is afterwards unnecessary; for we know that the pelvis is too small, or the head too large, by its not advancing in proportion to the pains, and by feeling a sharp ridge like a fow's back on the top of the child's head, which is occasioned by the bones rising over each other in consequence of the pressure.

How long nature, in such circumstances, can support the conflict, it is difficult to say. It is sufficient to observe, that when things are properly prepared for the advance of the child, when the first stage of the labour is accomplished, but its progress is then suspended, it is of little consequence to the midwife whether the obstacle is to be referred to the child or to the mother; and a man-midwife ought to be immediately called in.

If the patient's strength declines; if the head, from being locked in the bones of the pelvis, begins to swell, and the parts of the woman to be affected with tumefaction and inflammation; nature, in this case, seems insufficient, and it will be dangerous longer to delay the proper means of making the delivery; as mother, or child, or both, may fall a victim to our neglect. We must not, however, allow ourselves to be imposed on, either by the impatience of the distressed mother, or by the clamours of the officious importunities about her. In affording that assistance we are able to give, we are only to be directed by the symptoms of the case: we must remember, that the gentlest assistance our hands or instruments in laborious births can afford, is always attended with hazard and risk; that if instruments be applied too early, nature will be thus interrupted in her work, and the most fatal consequences may ensue; and that if assistance be delayed too long, the mother may die undelivered: we ought, however, to be informed, that the former practice of having too early recourse to forcible means, where, in time, nature unassisted might do her business, has proved by far more fatal than the latter. We ought therefore carefully to consider the general history of the patient, and particular circumstances of the case, that we may hit the proper time of making the delivery; which, in these laborious labours, is exceedingly diffi-

cult to determine; yet is a matter of the utmost importance, as there is always one, often two or more lives at stake, and the accoucheur is accountable for the consequences of his misconduct or neglect.

6. The fault may be in the soft parts: as,

1. Dryness and constriction of the vagina. Here all stretching and scooping is to be avoided. The natural moisture is to be supplied by lubricating with pomatum or butter, or by throwing up injections of warm oil; the parts are likewise to be relaxed by the application of warm stupes, or by warm steams directed to them.

2. Thickness and rigidity of the os tincte. This happens chiefly in women well advanced in life, where the parts open more slowly, and the labour generally proves more tedious. Here also little is to be done but waiting on with patience, comforting the woman as well as possible, and giving an opiate from time to time. The parts may be relaxed with butter or pomatum, by throwing into the vagina injections of warm oil, or by the application of warm stupes to the os externum. Every forcible attempt to open or stretch the uterus, as some authors presume to advise, is apt to induce inflammation and its consequences, and to interrupt the natural pains: it is therefore universally the safest practice to trust in every case to these; though tedious, or even violent, the labour for the most part will end more happily, and the woman recover better, than if force had been employed.

3. Polypous tumors, &c.—There is seldom occasion, in case of cicatrices in the vagina, to dilate with the scalpel, to remove polypous tumors by excision, or to cut upon and extract a stone from the urethra in time of labour. But if circumstances are urgent, such expedients are safe and practicable, and warranted by many precedents.

4. Accumulated feces in the intestines ought always to be removed by repeated emollient glysters on the first appearance of approaching labour.

5. A stone in the urethra, if it cannot be pushed back, must be cut upon and extracted, as already advised.

6. Prolapsus of the uterus may happen even at full time, in a pelvis too wide in all its dimensions; for which, however, nothing can be done but to support the uterus in time of a pain, that the stretching of the parts may be gradual. Prolapsi of the vagina and rectum must be reduced at the remission of the pain, and a return by gentle pressure must be prevented.

7. Obliquity of the uterus, though a favourite theory of some authors, never happens in such a degree as to influence delivery, except in the case of a pendulous abdomen, or where it depends on the make or distortion of the pelvis. The first of these, though it may, by throwing the child's head over the pubes, occasion perhaps some little delay, will seldom prove any material obstacle to the progress of the labour.

II. The protraction of labour may depend on the child, and may arise from,

1st, the bulk or ossification of the head.

There may be either a natural disproportion between the head and body, or the swelling may be occasioned by a putrid emphysema in consequence of the child's death, or the enlargement may proceed from a hydrocephalus.

cephalus. The first of these cases can only be discovered by the slow progress of the labour, when the pains are strong and frequent, the soft parts sufficiently dilated, the woman in good health, and no other apparent cause to account for the remora. The second is discovered from the history of the case, from the common symptoms of a dead child, viz. the puffy emphysematous feel of the presenting part of the head, and from the separation of the cuticle when touched. Lastly, the hydrocephalus is discovered by the head falling down in the pelvis in a large bulky form, by the bones of the head being separated at considerable distances, and by a fluctuation evident to the touch. On the whole, however, it may here be observed, that the most probable or suspicious symptoms of the child's death are often deceitful.

From whatever cause the head is enlarged, if the difficulty arises from this cause, and the force of the pains prove insufficient to push the head forwards, recourse must be had to instruments; and if the bulk of the head is too large to pass the diameter of the pelvis, the cranium must be opened to diminish its size, and the brain evacuated previous to the extraction.

2dly, The position of the head, which may be squeezed into the pelvis in such a manner as not to admit of that compression necessary for its passing. Such a cause of difficulty, however, more seldom occurs than many authors have imagined. The rash and preposterous application of instruments has, in such cases, proved the bane of thousands. Here though the labour will prove more painful and more tedious, yet nature in general, unassisted, will accomplish her own work with more safety to mother and child, than by the intrusion of officious hands. Turning here is always difficult, often dangerous. The same observation will hold of instruments, which should never be employed but when alarming symptoms occur: the assertion perhaps is not more bold than true, that, in general, the most disadvantageous position in which the head can offer is not sufficient, without some other cause concurring, either to prevent delivery, or to endanger the life of mother or child so much as would be done by the movement of the gentlest hands. Yet, in some cases, where the woman is weak and exhausted, and the pains trifling; if the head of the child be large, the bones firm, and the futures closely connected; or if there be any degree of narrowness in the pelvis, a difficult labour is to be expected; and the life of both mother and child will depend on a well-timed and skilful application of the surgeon's hands.

The unfavourable position of the head may be referred to two kinds, which include a considerable variety. 1. When the fontanelle, or open of the head, presents instead of the vertex. 2. Face-cases.

If no other obstacle appears but the presenting of the fontanelle, the labour will by proper management generally end well; and much injury may be done by the intrusion of officious hands.

Face-cases are the most difficult and laborious of all kinds of births; and our success in these will chiefly depend upon a prudent management, by carefully supporting the strength of the woman. The varieties of face-cases are known by the direction of the chin; for the face may present, 1. With the chin to the pubes;

2. To the sacrum; 3. To either side. The rule in all these cases is to allow the labour to go on till the face be protruded as far down as possible. It is often as difficult and hazardous to push back the child, and to bring down the crown or vertex, as to turn the child and deliver it by the feet. Sometimes a skilful artist may succeed in his attempt to alter the position, when he has the management of the delivery from the beginning; or, in those cases where the face is considerably advanced in the pelvis, may be able to give assistance by passing a finger or two in the child's mouth, and pulling down the jaw; which lessens the bulk of the head; or, by pressing on the chin, to bring it under the arch of the pubes; when the crown getting into the hollow of the os sacrum, the head will afterwards pass easily.

3dly, The breadth of the shoulders, or their transverse descent through the pelvis, rarely proves the cause of protracted labour. The head is always pretty far advanced before any obstruction can arise from this cause; and if the head has already passed, in a pain or two the shoulders will follow. The same reasoning will also apply with regard to the aperture of the uterus itself, if the head passes freely, in like manner will the shoulders; the os uteri rarely, if ever, is capable of contracting upon the neck of the child, and thus preventing the advance of the shoulders; and should this prove the case, what can we do but wait with patience? After the delivery of the head, if the woman falls into deliquia, or if, after several pains, the shoulders do not follow, and the child's life be in danger from delay, we should naturally be induced to help it forward in the gentlest manner we are able, by passing a finger on each side as far at the axilla, and thus gradually pulling along.

III. Lastly, From the secundines, difficulty and danger sometimes arise.

1st, The rigidity of the membranes, and the contrary. From the first of these causes, the birth is sometimes rendered tedious; but as the same effect is much oftener produced by the opposite cause, and the consequences of the latter are more troublesome and dangerous than the former, we should always be exceedingly cautious of having recourse to the common expedient of breaking the membranes, which ought never to be done till we be certain the difficulty depends upon this cause; and, even then, the head of the child should be well advanced, and the membranes protruded almost as far as the os externum. Many inconveniences arise from a premature evacuation of the waters; for thus the parts become dry and rigid, a constriction of the os uteri for a time ensues, the pains often either remit or become less strong and forcing, though not less painful and fatiguing; the dilatation goes on so slow, and the labour becomes so severe, that the woman's strength and spirits, by the unprofitable labour, are quite overcome and exhausted; so that the head remains confined in the passage, merely from want of force of pain to push it forwards. The woman in the beginning of labour should therefore be treated with the utmost delicacy and gentleness. The work of nature is too often spoiled by officious hands. She should be seldom touched while the membranes are whole, lest they should be ruptured; and, even when touching is necessary, this should only be done when

the pains begin to remit, and the tense membranous bag to relax.

2dly, Too great a quantity of water may prevent the uterus from contracting, and thus weaken the force of the pains. Though this may, however, occasion a delay, it will never be attended with more dangerous consequences; and the same advice already given will hold equally good in this case, that the membranes should never be broken till the soft parts be completely dilated; and we are assured that the difficulty or delay proceeds only from this cause.

3dly, The funis umbilicalis too long. The funis may be faulty from its too great length, or the contrary: thus the extraordinary length, by forming circumvolutions round the child's neck or body, sometimes proves the cause of protracting the labour. But as this can only happen when the chord is of an uncommon length, there is generally enough left to admit of the exit of the child with safety; and it is time enough, in general, after the child is born, to slip the noose over the shoulders or head: there is seldom occasion to divide the chord in the birth; a practice that may be attended with trouble and hazard.

The practice of introducing a finger in ano, to press back the coccyx, or to prevent the head, when it advances, from being retracted by circumvolutions of the chord, is now entirely laid aside; an expedient that can answer no end, but that of fretting and bruising the parts of the mother, and injuring those of the child.

Funis too short. The funis is sometimes thick and knotty, or preternaturally thickened by disease. In this case, part of the placenta may be separated as the child advances through the pelvis, and thus a flooding will ensue; or the funis may be actually ruptured, and occasion the death of the child, if the birth does not quickly follow. Such cases, however, rarely happen.

An inconvenience, at least fully as bad as the former, may arise from the too great length of the funis, though it may depend on other circumstances: viz.

4thly, The prolapsus of the funis before the head. In this case, the funis, if possible, should be pushed up above the presenting part; for, if the labour pains are slow, and the chord becomes cold, or the pulsation in it begins to grow languid, the circulation will thus be interrupted, and the life of the child destroyed. If the head is far advanced in the pelvis, and the child's life in danger, the delivery may be performed with the forceps. But to push up the head, and turn the child with a view to preserve its life, as many author's recommend, is a practice by no means advisable: we should seldom, in this position, be enabled to save the child; and turning under such circumstances can never be done but at the immediate hazard of losing the mother.

5thly, Placenta attached towards the cervix or os uteri. This case is truly melancholy; for, if the delivery is not speedily accomplished, the effusion from the uterine vessels will be so copious and profuse, that the unfortunate woman must in a very short time perish. On this occasion the delivery must be conducted in the best manner the judgment and skill of the

operator can direct, and with as much expedition as the safety of the mother will admit.

Thus, in most laborious cases, provided the woman's strength be supported, the management properly regulated, the natural moisture of the parts when deficient supplied, manual assistance very seldom becomes requisite: but as cases do occur, wherein nature, with all advantages, will fail, and the common methods of relief prove unsuccessful, recourse must be had to more powerful means, while the woman is able to support the conflict. In all such cases, the condition of the patient, the structure and state of the parts, and position of the presenting part of the child, must very carefully be considered.

Method of Delivery by Instruments.

WHEN the powers of nature are insufficient to expel the child, extraordinary assistance must be had recourse to. In laborious births, this is chiefly of two kinds.

1. I. The head is either extracted as it presents: or,
2. II. Its diameter is diminished previous to the extraction.

The head may be detained from advancing through the pelvis by all the causes formerly enumerated.—These are chiefly included in four general ones.

1. 1. Weakness in the mother.
2. 2. Narrowness of the pelvis.
3. 3. The bulk of the head of the child; or,
4. 4. Its disadvantageous position.

Whatever is the cause, when the natural pains begin to remit, and the parts of the woman begin to swell; when her strength declines, her pulse grows feeble, and there is no prospect of advantage to be gained by delay; measures must be taken for assisting the delivery, otherwise both mother and child may perish from neglect.

As instruments are never to be employed but in the most urgent and necessitous cases, and expressly with a view to preserve the life of mother or child, or both; those of a safe and harmless kind should always be made trial of, in preference to those of a destructive nature.

Use of the Forceps.

THE forceps is an instrument intended to lay hold of the head of the child in laborious births, and to extract it as it presents. This instrument, as now improved, in the hands of a prudent and cautious operator, may be employed without doing the least injury either to mother or child.

In every obstetrical case, wherein manual assistance becomes necessary, the contents of rectum and bladder should, if possible, be previously emptied.

The membranes also should be broken, the soft parts completely dilated, and the head of the child as far as possible advanced, previous to the use of any instrument.

The form and structure of the parts of the woman, the situation and progress of the presenting part of the child, must at this time be carefully considered. The concavity of the sacrum, for instance, will determine the progress of the labour. The touch of the vertex, fontanella, lambdoidal, or sagittal suture, the fore or

back

Difficult Labour. back part of the ear, or some part of the face, will ascertain the true presentation of the child.

The lower the head is advanced in the pelvis, our success with the forceps is the more to be depended on. For when it has proceeded as far as the inferior aperture, by means of this instrument it may be readily relieved: but when the head of the child is confined at the brim, both the application of instruments, and the extraction by this means, are exceedingly difficult and dangerous.

The head may be so firmly wedged in the pelvis, that the forceps can neither be introduced nor fixed without bruising or tearing the parts of the woman: whatever, therefore, insurmountable difficulties occur, either in applying or extracting with the forceps, the life of the mother must not be endangered by fruitless efforts: the head of the child must immediately be opened, and the delivery accomplished without further delay.

In laborious births, the proper forcep-cases may be reduced to two, which include, however, a considerable variety. These are,

I. The smooth part of the cranium.

II. The face, presenting.

The head may present,

1st, Naturally, when low advanced in the pelvis, with the vertex to the pubes, and the forehead or face in the hollow of the sacrum. Or,

2dly, When higher in the pelvis, the vertex may present with the face laterally, the ears to the pubes and sacrum. Or,

3dly, The fontanel may present with the face to the pubes and vertex to the sacrum; or with the vertex to the pubes and face to the sacrum.

1. When the head presents naturally. The woman in this case must be placed on her back a-cross the bed, properly supported; the accoucheur, seated before or in a kneeling posture, after gradually lubricating the perineum and vagina, must proceed gently to stretch the parts, by passing the hand in a conical manner through the os externum vaginae, pushing it forwards by the side of the child's head, till it advances as far as an ear, if possible: along this handle he is to guide a blade of the forceps, which with the other hand he introduces in the direction of the line of the pelvis, holding the handle backwards towards the perineum, and keeping the clam closely applied to the child's head. This must be insinuated very gradually by a kind of wriggling motion, pushing it on till the blade is applied along the side of the head over the ear; he must then gently withdraw the first hand from the pelvis, with which he must secure the handle of the blade of the forceps already introduced, till the other blade be passed along the other hand, in the same slow cautious manner: the handles must then be brought opposite to each other, carefully locked, and, lest they slip in extracting, properly secured by tying a fillet or garter round them; but this must be loosened during the remission of pulling, to prevent the brain from being injured by the pressure. The extraction must be made by very slow and gentle degrees, and with one hand only, while the other is employed to guard the perineum: the motion in pulling should be from blade to blade; the accoucheur must rest from time to time, and, if the pains are not gone, should

always in his efforts only co-operate with those of nature. The child and mother will suffer less by going on in this gradual manner than by precipitating the birth, which can never be done but at the risk of destroying both. If, in making the extraction, the forceps slip, they must be cautiously withdrawn blade by blade, and again introduced in the same manner.—When the tumor of the perineum forms, and the vertex begins to protrude at the os externum, the accoucheur must rise from his seat, raise the handle gently upwards, and, by a half-round turn, bring the hind-head from under the symphysis or arch of the pubes; remembering carefully to guard the perineum from laceration and its consequences, to which it is now so greatly exposed.

In attempting the introduction of either blade, if it meets with any interruption, it must be as often withdrawn, and pushed up again in a proper direction, till every difficulty be surmounted; and if, from the smallness or constriction of the parts, the introduction of the second blade shall seem impracticable, the former one must be withdrawn, and the latter must be first introduced.

2. The vertex may present with the face laterally in the pelvis. It is always difficult to apply the forceps till the bulky part of the head has passed the brim; and here it is not only difficult to the operator, but extremely hazardous to the patient, to introduce this instrument till the ear of the child has got under the pubes. When the ears thus present to pubes and sacrum, the woman should be placed on her side or knees; the most difficult blade of the forceps should be first applied, which is the one under the pubes; when both are passed, and properly secured, the patient should again be turned to her back, before the operator attempts to extract, and the head in this case (as the quarter-turn can seldom be made with safety) should be delivered in the manner wherein it presents; because, when confined any time in the passage, its figure is altered by the overlapping of the bones, in such a manner that it passes along, in general, with far less difficulty than to attempt to push up and make the mechanical turns; a work often altogether impracticable, by which contusion or laceration of the parts of the woman, and the most fatal consequences, may be occasioned. The handles of the forceps must here particularly be well pressed backwards towards the perineum, that the clams may humour the curvature and intrusion of the sacrum, and accommodate themselves to the form of the child's head.

This is a case wherein the forceps often fail; if so, they will sometimes succeed by varying the mode of application, and fixing them over the forehead and occiput; if this method fails also, the size of the head must be diminished, and the extraction made with the blunt hook or crotchet.

3. The fontanella may present with the face to the pubes. This is the most common of the fontanel cases; though sometimes the face is lateral in the pelvis, sometimes diagonal, and sometimes it is turned to the sacrum. The true position is ascertained by the direction of the fontanel, and that of the ear. Here, as in other laborious births, nature should be intrusted as long as we dare. The head does not always de-

descend mechanically through the capacity of the pelvis, as some practitioners have supposed; nor will the deviation from its ordinary mode of descent always of itself influence the delivery, at least very rarely in such a manner as to require extraordinary assistance. In whatever manner the head presents, when it is situated high in the pelvis, the delivery cannot be effected without difficulty or hazard; in such circumstances, the application of the forceps will frequently baffle the utmost efforts of the accoucheur, and the consequences of such attempts may prove fatal to mother and child.

When extreme weakness in the mother, floodings, convulsions, or other urgent symptoms, render it necessary to force the delivery, whether the face be to pubes or sacrum, the forceps may be applied along the ears, in the same manner as directed in a natural labour; and the head, for the reasons already given, should be brought along in the manner it presents: the extraction should be made with great deliberation, that the parts of the woman may have time to stretch; the perineum must be carefully supported; the forceps must be gently released, when the head is delivered; and the rest of the delivery conducted as in a natural labour.

In this case, when situated high in the pelvis, the fontanel presenting, and the face either to pubes or sacrum, the long axis of the head intersects the short diameter of the pelvis, and very often, though the forceps be applied, and a firm hold of the head be obtained, it is not possible to bring it along with all the force we dare exert. If this method therefore fails, the common forceps should be cautiously withdrawn, and the long ones applied, if possible, over the forehead and occiput, when the size of the head, by the compression it suffers in passing along, being perhaps somewhat diminished, the extraction will be successfully performed. This method also failing, previous to the operation of embryotomy, Dr Leak's forceps, with the third blade, may be had recourse to. But of this little can be said with confidence, till the instrument has been more generally employed. From the difficulty of succeeding in the application of the common forceps, it may, a priori, be concluded, that the introduction of a third blade, even in the hands of an expert practitioner, however ingenious the invention, is an expedient not easily to be put in practice. Neither is Roonhuyse's lever, or a blade of the forceps passed up between the pubes and forehead or hind-head of the child, in order to procure the delivery of the head, to be recommended in such cases: however some have boasted of its success, it is an instrument that may do much mischief; and few practitioners can use it with safety.

11. Face presenting.—Of laborious births, face-cases, as we have already observed, are the most difficult and the most dangerous. From its length, roughness, and inequality, the face must occasion greater pain; and from the solidity of the bones, it must yield to the propelling force with much more difficulty, than the smooth moveable body of the cranium. Face-cases are the most troublesome that occur in the practice of midwifery, and in which the most expert practitioners may be foiled in their attempts; and these attempts, if too early exerted, will be followed in many instances

with fatal consequences. Whatever way the face presents, it should be allowed to advance as low as possible in the pelvis; by which means the access will be more easy, and the position, for the application of instruments, more favourable. In this awkward situation, much mischief may be done by rasnels; whereas, if time be allowed, and the patient be properly supported, the delivery will generally end well.

The face may present with,

1. 1. The chin to the pubes.
2. 2. to the sacrum.
3. 3. laterally.

From the difficulty of applying instruments in these cases, some authors recommend, as an universal practice, to turn the child, and deliver by the feet. But this in general is a dangerous practice, and seldom or never advisable, except when the membranes remain entire, till the os uteri is completely dilated, and the head continues loose about the brim of the pelvis; and even then the propriety of the practice is doubtful; because if the head is small, or the pelvis be well proportioned, the face will descend without much difficulty; and if otherwise, besides the risk in attempting to turn, the child may be lost from the pressure of the chord, or the difficulty of extracting the head after the delivery of the body.

When assistance becomes necessary, the belt practice in face-cases is the following: Having placed the patient in a convenient posture, let the accoucheur in the gentlest manner pass his hand within the pelvis; and, during the remission of pain only, endeavour to raise the head of the child, so that he may push up the shoulders entirely above the brim of the pelvis, and thus change the position of the face: by this means, if successful, he will be able to reduce the first of these cases, so as to make the fontanel present with the face to the pubes; he will reduce the second so as to bring down the vertex, with the face to the sacrum; and the third he will reduce to a vertex case, with the face lateral. The delivery may be afterwards trusted to nature; which failing, there is easier access for the application of instruments to make the extraction, as already directed. The success, however, of the accoucheur, in altering the position of the head, by pushing it up, will entirely depend on the time he is called; for, should the head be firmly wedged in the pelvis, no force he dares employ will be sufficient to alter the posture.

If therefore every attempt to reduce the face, and make the vertex or fontanel present, shall prove unsuccessful, and symptoms are urgent, the forceps must be applied over the ears of the child, and the extraction performed in the belt manner the operator is able. And, failing these, immediate recourse must be had to the crotchet.

1. In the first case, previous to the introduction of the forceps, the chin, if possible, should be advanced below the pubes.

2. In the second, the chin should be advanced to the inferior part of the sacrum. And,

3. In the third, the chin should be as low as the hinder part of the tuber ischii; and although in general the head is to be extracted as it presents, if the operator meets with considerable resistance, it must be gently pushed up and turned with the chin, either laterally,

Difficult Labour. terally, below the pubes, or into the hollow of the sacrum, according to the particular circumstances of the case, and in a direction best accommodated to the form and diameter of the pelvis.

Use of the Scissors, Crotchet, and Blunt Hook.

WHEN the head of the child, from its size, unfavourable position, or from a fault in the pelvis, cannot be protruded by the force of natural pains, nor extracted by the forceps, recourse must be had to more violent means, and the life of the child must be destroyed in order to preserve that of the mother. This operation was by the ancients called embryotomy.

When the head, from its extraordinary bulk, is detained at the brim of the pelvis; on evacuating the contents, the bones of the cranium immediately collapse, and the head is afterwards propelled by the force of the labour pains; failing which only, the extraction must be made with the blunt-hook or crotchet.

The unfavourable position of the head is of itself a cause insufficient to justify the use of destructive instruments, which ought never to be employed but in extreme cases, after every milder method has failed. From the difficult access to the cranium in order to make a perforation and evacuate the brain, a face-case makes a very troublesome and dangerous crotchet one. Very luckily, in narrow pelvises, the face rarely presents, and very seldom advances far in that direction; at other times, the position may be so altered, that the crown, the back of the ear, or some other part of the cranium, can be reached; otherwise the crotchet must be fixed in the mouth, orbit of the eye, &c. and the head brought along in that direction, till the scissors can be employed to open the skull.

But the grand cause of difficult labour is, the narrowness or distortion of the pelvis. For when, at the brim, instead of four inches and a quarter from pubes to sacrum, it measures no more than one and a half, one and three-fourths, two, or two inches and one-fourth, the use of instruments becomes absolutely requisite, and very frequently in those of two inches and one-half, and three inches; or when the diameters through the capacity, or at the inferior aperture, are retrenched in the same proportion, difficulties will in like manner arise, and the delivery, except the labour be premature, or the child of a small size, cannot be accomplished without the assistance of destructive instruments.

We judge of the form of the woman; by the progress of the labour; by the touch. When the fault is at the inferior aperture, the touch is pretty decisive; e.g. if a hump is felt in the os sacrum instead of a concavity; if the coccyx is angulated; if the symphysis pubis projects inwards in form of an acute angle; if the tuberosities of the ischia approach too near each other; or the one tuber be higher than the other; such appearances are infallible marks of a distorted pelvis. But when the narrowness is confined to the brim, this is only to be discovered by the introduction of the hand within the pelvis: the projection of the lumbar vertebrae over the sacrum, is a species of narrow pelvis that most frequently occurs in practice. In this case, the child's head, by the pressure it sustains between the pubes and sacrum, is moulded into a conical or sugar-

loaf form, the parietal bones are squeezed together, over-lapping one another, and will be felt to the touch when the labour is advanced, like an acute ridge, something in the form of a fow's back.

Instead of the complicated instrumental apparatus invented by the ancients, such as screws, hooks, &c. for fixing in, laying hold of, and extracting the head, as it presented, an operation in many cases difficult and dangerous, when the head was bulky or the pelvis narrow, as the woman frequently lost her life in the attempt; the practice of diminishing the size of the head, by opening the cranium and evacuating the brain, previous to the extraction, is a modern improvement, and an important one: the instruments for this purpose consist simply of a pair of long scissors, a sharp curved crotchet, and a blunt hook: these are preferable to every other, whether of ancient or modern construction.

When the accoucheur is under the disagreeable necessity of destroying the child to preserve the mother, she must be laid in the same position as already advised for the application of the forceps; and the same rules, recommended for the one operation, will in general apply to the other.

Thus, in the narrowest pelvis that occurs, previous to opening the cranium, the soft parts should be completely dilated, and the head of the child should be fixed steadily in the pelvis and advanced as far as possible; for while the head is high and loose above the brim, the application of instruments is very difficult as well as hazardous.

The long scissors must be cautiously introduced into the vagina, directed by the hand of the accoucheur; the points must be carefully guarded, till they press against the cranium of the child, which they must be made to perforate with a boring kind of motion, till they are pushed on as far as the rests; they must then be opened fully, carefully re-shut, half turned, and again widely opened, so as to make a crucial hole in the skull. They must afterwards be pushed beyond the rests, opened diagonally again and again, in such a manner as to tear and break to pieces the bones of the cranium; they must then be shut with great care; and withdrawn along the hand, in the same cautious manner as they were introduced, lest they should bruise or tear the uterus, vagina, or any other part of the woman. After a free opening in the cranium has thus been made, the brain must be scooped out with the fingers or blunt-hook, and the loose sharp pieces of bone must be carefully separated and removed, that no part of the woman be tore while the head is extracting. The teguments of the scalp should now be brought over the ragged bones of the cranium, and the woman should be allowed to rest an hour or two, according to her strength and other circumstances: the bones of the cranium will now collapse; and if the woman has as much strength remaining, or the pelvis be not much distorted, the head being thus diminished, will be protruded by the force of natural pains; otherwise it must be extracted, either by means of two fingers introduced within the cavity of the cranium, by the blunt-hook introduced in the same manner, guarding the point on the opposite side while making the extraction; or, failing these, by the crotchet, which, though

dan

dangerous in the hands of an ignorant rash operator, may be employed by the prudent practitioner with as much safety as the bluntest instrument.

The method of introduction is the same with a blade of the forceps. The chief thing to be attended to is, to guard the point till it be applied against the head, and firmly fixed in its hold, which should always be somewhere on the outside of the cranium: provided a firm hold is obtained, no matter where, behind the ears, about the os petrosum, orbits of the eyes, maxilla inferior, &c. according to the presentation of the head. The woman being properly secured, and the handle of the instrument covered with a cloth, the operator must then pull, at first gently, afterwards more forcibly, resting from time to time, and endeavouring to make the extraction in the best manner the circumstances of the case will admit of. If the pelvis be much distorted, so that, by means of the utmost strength the accoucheur can exert, little purchase is made, he may apply to the opposite side a blade of the forceps, which are now so constructed as to lock with the crotchet; let him then bring the handles together, secure properly, and thus endeavour to make the extraction. Should this expedient also fail, the blade of the forceps must be withdrawn, the other blade of the crotchet must be applied, the handles brought together and secured, and the extraction made, moving from blade to blade.

Should the head present in such a manner, that, in attempting to extract it, the crotchet divides the vertebrae of the neck, and the head is thus severed from the body, an accident that can only happen in the hands of an ignorant blundering practitioner; the head must be pushed up above the brim of the pelvis, the crotchet or blunt hook must be fixed under the axilla, the arms must be brought down, and the body extracted, by fixing the crotchet below the scapula on the sternum, or among the ribs; the head must afterwards be extracted in the manner already advised: or should the head in extracting be pulled from the body, as may happen when the child has been long dead, or when it is putrid, the delivery of the body must be effected by means of the crotchet as now directed; a method preferable to that of turning, as some advise.

If the head, instead of yielding to the force of pulling, be at last cut and broken in pieces, the operator must endeavour to bring down an arm of the child, to fix the crotchet about the jaw or neck, pull at both holds, and thus attempt to make the extraction; this also failing, he must bring down the other arm, fix the crotchet in the thorax, and, in a word, must tear the child in pieces, that the delivery may be accomplished by any means.

In face-cases, where it is impracticable to alter the position, and when the pelvis is much distorted, the double crotchet is sometimes requisite; the handles must be well secured, kept well backwards towards the perineum, and the motion always from blade to blade. It very seldom, however, happens, that there is occasion for the double crotchet: by this means the head is flattened in pulling; whereas if one blade only can be employed, the head is lengthened, and, in pulling,

can better accommodate itself to the shape of the pelvis as it passes along.

CHAP. III. Preternatural Labour.

In whatever manner the child presents when the body is delivered before the head, the birth is accounted preternatural.

Preternatural labours may be referred to one of the four following classes.

I. When one or both feet, knees, or the breech, present.

II. When the child lies across in a rounded or oval form, with the arm, shoulder, side, back, or belly, presenting.

III. When one or both of the upper extremities present, the child lying in the form of a sheath, the feet towards the fundus uteri, the waters evacuated, and the uterus strongly contracted round the body of the child.

IV. Lastly, Premature or flooding cases, or others in which it may be necessary to force the delivery, either previous to the rupture of the membranes, or quickly after it.

The causes of cross labours most commonly assigned by authors are, The obliquity of the uterus; circumvolutions of the funis umbilicalis round the child's body; the shortness of the funis, or attachment of the placenta towards the fundus uteri; shocks affecting the mother when pregnant, &c. The position of the fetus may also be influenced by its own motion and stirrings, by the particular form and bulk of its body, by the manner of stretching of the uterus, by the quantity of liquor amni, and by many other circumstances.

The symptoms that indicate an unfavourable position of the child, before it can be discovered by the touch, are very uncertain and fallacious: a cross birth may, however, be suspected,

1^st, If the pains be more slack and trifling than ordinary.

2^nd, If the membranes be protruded in a long form like a gut, or the finger of a glove.

3^rd, If no part of the child can be discovered when the uterine orifice is considerably opened.

4^th, If the presenting part through the membranes be smaller, feels lighter, and gives less resistance than the bulky ponderous head.

5^th, Lastly, after the rupture of the membranes, if the meconium of the child be passed along with the waters, it is a sign that the breech presents, or that the child is dead.

Preternatural labours are difficult or hazardous, according to,

1. The form of the pelvis, and general health and constitution of the woman.

2. The bulk of the child, and its manner of presenting.

3. The time the waters have been evacuated, and the uterus contracted round the body of the child.

4. When complicated with plurality of children; the prolapsis of the funis umbilicalis; the limbs of the child entangled with the chord; profuse and violent flood-

Preternatural Labour.

floodings from the attachment of the placenta towards the cervix uteri, &c.

Turning is often laborious, and always dangerous in proportion to the force used in searching for and bringing down the feet; though, in general, the difficulty and hazard are not so great, as in many cases strictly called laborious, when the head presents; the treatment of preternatural labours being better known, and for the most part easier put in practice.

Each class of the general division of cross labours includes a variety of different cases. By considering a few of every class, a general idea of the whole will be formed.

CLASS I.

CASE 1. The simplest and easiest case is the Agrippan posture, when the child presents with the feet.

The foot is to be distinguished from the hand, first, by the weight and resistance it gives to the touch; secondly, by the shortness of the toes; thirdly, by the projecting heel.

When the feet present in the passage, the labour should be allowed to go on as if natural. If the child be of an ordinary size, the woman in health, the parts well proportioned, in the way of assistance nothing further seems necessary but the application of a warm cloth round the body of the child, which must be properly supported till it advances as far as the pains are able to force it. If the size be ordinary, or rather small, it will sometimes make the mechanical turns, and be entirely pushed along by the force of the natural pains; but it generally stops at the shoulders, after the breech protrudes without the os externum, where the resistance is so great, that the accoucheur's assistance becomes requisite.

In this case, the patient must be placed on her back, properly supported; the hand of the accoucheur must be cautiously introduced; the parts of the woman must be gently stretched; the feet of the child must be laid hold of, and brought as low in the vagina as possible; a soft warm cloth must be wrapped round them, and the extraction must be performed in a slow cautious manner, making large motions in a circular or lateral direction, resting from time to time, if the pains are gone; and if not, always waiting for the natural efforts. When advanced as far as the breech, the body, if not already in a proper direction, must be pushed up, and gently turned with the face towards the mother's back; and to make sure that the face turns with the body, or to prevent the chin, vortex, or shoulders, from catching on the pubes, or angle of the sacrum, an extraordinary quarter-turn more must be made: this must be reversed previous to the extraction; and the difficulty arising from the obstruction of the shoulders must be removed in the following manner: While the breast and legs of the child are supported over the palm and fore-arm of the one hand of the accoucheur, which he draws towards one side, he must introduce two fingers of the other hand at the opposite side into the vagina, over the back-part of the shoulder, as far as the elbow, and endeavour in the most gentle manner to bring down the arm, always remembering in his movements to humour the natural motions of the joint: he must then shift hands, when the other arm is to be relieved in the same manner: both arms being brought

down, the woman must now rest a little, when a pain or two generally follows, and the head is also forced along. But should the woman be much exhausted, and if the head does not quickly advance, the child may be lost from delay. The extraction of the head in preternatural labours is often the most difficult and the most dangerous part of the delivery; the cause of resistance, when it does not advance, is chiefly owing to its confinement between the angle of the sacrum and pubes, when the bulky part of the head is detained at the brim; whether the resistance be here or towards the inferior aperture of the pelvis, if the head does not advance in a pain or two, the extraction must be made in this manner: While the right hand of the accoucheur supports the body of the child below, with two fingers pressing on either shoulder, the left hand and fingers must in the same manner be placed over the back of the neck, and pulling gently in the direction from pubes to sacrum, he must thus endeavour to bring it along: but, should the pelvis be narrow, or the child's head of a large size, or the face be laterally or anteriorly placed in the pelvis, or, what rarely happens, the os uteri contracted round the neck of the child; in either of these cases, the accoucheur will sometimes meet with the utmost difficulty. When the above method therefore fails, he must introduce two fingers of the right-hand into the child's mouth, while those of the left-hand are expanded over the shoulders, as already directed; and in this way he must endeavour to relieve it, pulling from pubes to sacrum, alternately raising and depressing the head till it advances low down, so that the face descends from the hollow of the sacrum, when the accoucheur must rise from his seat, and bring the hind-head from the pubes with a half-round turn, imitating that of a natural labour.

If the position be unfavourable, the face, if possible, should be turned to the sacrum, by pushing up the head, or by pulling back the chin: If the contraction of the uterus is the cause of resistance, which rarely occurs, it must be gently stretched with the fingers. Or if the difficulty arises from circumvolution of the chord round the legs, thighs, body, or neck of the child, these must be disengaged in the easiest manner possible; it is rarely necessary to divide the funis on this account.

Should every method fail in bringing down the head, the delivery must be effected by means of the forceps cautiously passed over the ears, with the handles under the child's body, in a direction downwards towards the perineum. If the pelvis be very narrow, or the head of a large size, it must be opened by pushing the scissars through the occipital bone, so that the contents of the cranium may be evacuated, and the extraction made by means of the forceps, blunt-hook, or crotchet. But if the head, by the efforts to extract it, be actually severed from the body, and left behind in the uterus, an accident which sometimes occurs, it must be delivered by inclosing it in the forceps, while secured from rolling by pressing externally on the abdomen. If the forceps cannot be applied, the cranium must be opened, the texture of the brain destroyed, and the extraction performed by the fingers of the accoucheur, by the blunt-hook, or by the crotchet. If the under-jaw remains, the

hed

head may be effectually secured till locked in the forceps, or till its bulk be diminished, by introducing a finger into the mouth, thrusting it through the jaw under the chin, drawing it down, and passing a ligature through the perforation.

In cases where the child has been long dead, should the belly or thorax be distended with air or water, and prove the cause of obstruction, the contents must be evacuated by opening with the scissars, or tearing with the crotchet; and in general, where difficulties occur, the delivery must be accomplished in that manner the circumstances of the case will best admit of.

Case 2. When instead of two, one foot only falls into the vagina, the other is sometimes detained by catching on the pubes, and, if easily come at, should be brought down, always remembering to humour the natural motion of the joint; but, should the leg be folded up along the child's body, the attempt is sometimes both difficult and dangerous, and ought not to be persisted in, as the breech will either be forced down by the assistance of natural pains, or by gently pulling by one leg only.

Case 3. When one or both knees present, the delivery must be conducted in the same manner with that of the feet.

Case 4. When the feet offer along with the breech, this last must be pushed up, while the former are secured and brought down, till it be reduced to a footling case, and otherwise managed as above.

Case 5. The breech may present with the fore-parts to the mother,

1^st, Anteriorly;

2^dly, Laterally; or,

3^dly, Posteriorly.

Sometimes the breech may be discovered, previous to the rupture of the membranes; but afterwards with more certainty, by the meconium of the child passed with the waters, and by the touch.

In whatever manner the breech presents, the delivery should be submitted to nature, till the child be advanced as far as the thorax, when the feet are to be brought down and laid hold of, the child, if necessary, pushed up, the mechanical turns effected; and the delivery otherwise conducted as in a footling case. There is much less hazard in general, agreeable to an old observation of Mauriceau, in allowing the child to advance double, than in precipitating the extraction by pushing up to bring down the feet before the parts have been sufficiently dilated; a practice difficult and troublesome to the operator; painful, and sometimes dangerous, to the mother; and by which the child is exposed to the risk of strangulation, from the retention of the head after the delivery of the body. If the child be small, though doubled, it will easily pass in that direction; if large, though the labour be painful, the natural throes are less violent and less dangerous than the preposterous help of the accoucheur: If the child thus advances naturally, it will be less exposed to suffer; if it does not advance, the parts of the mother will be prepared for the accoucheur to pass his hand into the pelvis, to raise up the breech, to bring down one or both feet, and deliver as above.

Weakness in the mother, floodings and convulsions, N^o 220.

a very large child, or narrow pelvis, the prolapsus of the funis, or its compression between the thighs of the child, or between the child and pelvis, by which its life is endangered, if the chord cannot be reduced above the presenting part, are the only exceptions to the general rule of treating the breech as a natural labour.

The practice of helping forward the breech, by passing the blunt-hook under the ham, is now entirely laid aside: this can never be done with safety, till the breech be so low advanced, that the hand of the accoucheur can be used, which may be employed with more advantage as well as safety.

CLASS II.

In the former class of preternatural labours, it is advisable to trust to nature in many cases, as the birth will often be accomplished without manual assistance: but when the child lies a-crofs, no force of pain can make it advance in that position; and, without proper assistance, both the mother and child would perish.

If the accoucheur has the management of the labour from the beginning, the child may be turned, in the worst position, without difficulty; but when the waters have been for some time evacuated, and the uterus strongly contracted, turning is laborious to the operator, painful and dangerous to the mother. In such cases, the ancients endeavoured to make the head present; but, from its bulk, they often failed, and the attempt was often attended with fatal consequences. The method of delivering by the feet is the most important modern improvement in the practice of midwifery; an improvement to which many thousands owe their lives.

When the child lies in a transverse position, the accoucheur must insinuate his hand through the vagina into the uterus in the gentlest manner, search for the feet, bring them down with the utmost caution, and finish the delivery as in footling-cases. To effect this, the following rules should be observed.

1. The patient must be placed in a convenient posture, that the operator may be able to employ either hand, as the various circumstances of the case may require.

2. Though the best posture, in general, is laying the woman on her back, it will be sometimes necessary to turn her to her side; and, in these cases, where the abdomen is pendulous, where it is difficult to reach the feet, or where they lie towards the fundus uteri, the woman should be placed on her knees and elbows.

3. An exact knowledge of the true position of the child, and of the structure and state of the parts, should be acquired, before attempting to make the delivery.

4. The orifice of the uterus should be enlarged, so as freely to admit the hand; and the stronger pains should be abated, before any attempt be made to deliver.

5. Should the waters be drained off, the parts dry and rigid, and the uterus contracted round the child, warm oil must be injected into the uterus, otherwise its rupture may be endangered.

6. In passing the hand into the uterus, this must be done

done in the gentlest manner; the parts must be well lubricated with butter or pomatum; the line of the pelvis must be attended to; the efforts of the operator must be slow and gradual; and thus the utmost rigidity in the soft parts will, in time, be overcome.

7. The hand must be introduced only during the remission of pain; when pain comes, the accoucheur must always rest; otherwise he may push his hand, or the fetus, through the body of the uterus.

8. In pushing up, to come at the feet, this must never be done with the points of the fingers, nor with the hand clenched, but with the palm of the hand, or the broad expanded fingers, and always during the remission of pain, and the latter should also be observed in bringing down the legs; but, in making the extraction of the body, the efforts of the operator should always co-operate with those of nature.

9. The hand should, if possible, be introduced along the anterior parts of the child; and both feet, if easily come at, should be laid hold of.

10. In turning, the accoucheur should never consider the child as dead, nor allow himself to be deceived by symptoms doubtful and fallacious; the child is sometimes born alive when he would least of all expect it; therefore, in pushing up, bring down the legs, or extracting the body, it should be handled with the greatest delicacy.

11. When the hand is within the pelvis, it should not always be moved in the line of the umbilicus, but rather towards one side of the spine, by which more room is gained, and the prominent angle of the sacrum avoided.

12. The hand should be passed as far as the middle of the child's body, before attempting to search for the feet; or before attempting to break the membranes, should these remain entire, till the aperture of the uterus will admit of the hand.

13. If the hand cannot pass the presenting part of the child to come at the feet, instead of violently pushing back, the part should be as it were lifted up in the pelvis, and moved towards a side; by which means difficulties may be surmounted, and great danger often prevented.

By attending carefully to the above rules, laceration of the uterus, floodings, convulsions, inflammations, and their consequences, may be prevented; accidents that frequently happen in the hands of ignorant rash operators.

Case 1.—The arm presenting. The right is to be distinguished from the left by laying hold of the child's hand, in the same manner as in shaking hands; and thus the general position of the child may be judged of.

When the accoucheur is called in early, the reduction is generally practicable; but if the arm protrudes through the vagina, and the shoulder be locked in the pelvis, it is needless, by fruitless efforts, for the accoucheur to fatigue himself, and distress his patient, to attain a point by which he will gain no very material advantage; as the hand can be passed into the uterus by the side of the child's arm, which will, of course, return into the uterus when the feet are brought down into the vagina.

In order to make the delivery, the hand of the ac-

coucheur, well lubricated, must be conducted into the uterus by the side of the child's arm, along the thorax, at the opposite side of the pelvis where the head lies; if any difficulty occurs in coming at the feet, this hand must be withdrawn, and the other introduced in its stead; and if still the hand cannot easily pass beyond the child's head or shoulder, the presenting part must be raised up, or gently pushed to a side, that one or both feet may be laid hold of, which must be brought as low as possible, pushing up the head and shoulders, and pulling down the feet alternately, till they advance into the vagina, or so low that a noose or fillet can be applied; and thus by pulling with the one hand by means of the noose, and pushing with the other, the feet can be brought down and the delivery finished, however difficult.

The method of forming the noose is by passing the two ends of a tape or garter through the middle when doubled; or, should the garter be thick, by making an eye on one extremity, and passing the other end through it: this, mounted on the points of the fingers and thumb of the accoucheur's hand, must be conveyed into the uterus, passed over one or both feet and ankles, and secured by pulling at the other extremity.

Case 2.—The side. This is discovered by feeling the ribs.

Case 3.—The back. This is discovered by feeling the spine.

Case 4.—The belly. This is known by the funis.

These cases occur rarely, as the uterus must with difficulty admit of such positions. When any of these parts do present, the child seldom passes any part of the brim of the pelvis, and is, in general, more easily turned than in several postures in which it may offer. The belly, from the difficulty with which the legs can be bended backwards, except the child be flaccid, putrid, or before the time, will very seldom directly present; if so, it will be early and readily discovered by the prolapsus of the funis, and there will be no great difficulty to come at the feet, and deliver. The rule in all these cases is, to pass the hand into the womb in the gentlest manner possible, and to search for the feet and bring them down.

C L A S S III.

WHEN the child lies longitudinally in the uterus, with the arm or shoulder presenting, and the head more or less over the pubes, or laterally in the pelvis, the feet towards the fundus uteri, the waters evacuated, and uterus contracted round the child's body; these are the most difficult and laborious of all the cases of preternatural labours. Here the protruding arm ought, if possible, to be reduced, and the head brought into the pelvis; for unless the child be very small, it is impossible for the head and arm to pass along together.

In order to effect the reduction of the arm, different instruments have been invented; but the hand of the accoucheur is preferable to every thing of this kind, whether of ancient or modern invention. This, conducted by the arm that protrudes, must be insinuated through the vagina into the uterus, as far as the shoulder of the child, which if the accoucheur can raise up, he will generally succeed in reducing the arm.

arm. Should this method fail, he must attempt to push up the fore-arm at the elbow; but, in bending it, must be very cautious, to avoid overstraining or dislocating the joint. In whatever manner the reduction is accomplished, if any method proves successful, the arm must be retained till the head, by the force of natural pain, enters the pelvis, and prevents its return; otherwise the arm will descend as often as it is reduced.

But if the attempts for reduction prove impracticable, the woman must be placed on her knees and elbows, and the accoucheur, with great deliberation, must endeavour gently to slide up his hand between the uterus and child as far in the uterus as possible, to lift up the head and shoulders, and search for and bring down one or both feet, in the best manner the various circumstances of the case will admit of. As soon as they can be laid hold of, they must be gradually brought down into the vagina, so low that the noose can be applied over them, which must be fixed and pulled with the one hand, while the head and upper parts of the body are raised and gently pushed up with the other.

Should the arm have been long protruded without the os externum, much swelled, and cold; the waters drained off; the uterus strongly contracted; and the position of the child such as to render it impracticable, either to reduce the protruded limb or to search for and bring down the feet; the head, if easily come at, must be opened and extracted with the blunt hook or crotchet; or a crotchet must be fixed amongst the ribs, and the breech or feet thus pulled down.

Should the pelvis be very narrow, and unsurmountable difficulties occur, the arm must be twisted off at the elbow, though this expedient is rarely necessary; and the delivery must in general be accomplished as the prudence and judgment of the operator can best direct; always remembering, when one life must fall a sacrifice, that the tree must be preserved at the expense of the fruit.

In this, as in other cases, the swelling and coldness of the arm, and even want of pulsation in the artery, are not infallible signs of the child's death; and should this even be so, it makes little difference in the mode of delivery, unless that it will lead us to pay all our attention to the mother: For a living child gives no more assistance in the birth than a dead one, whatever authors have said to the contrary.

When both arms present, the delivery must be conducted in the same manner as when one only presents. The former case is less difficult than the latter, as the head seldom advances far when both arms fall into the passage, so that they can either be reduced, or there is easy access to come at the feet to bring them down and deliver.

CLASS IV.

WHEN the membranes remain entire, till the soft parts are so much dilated that the hand will readily find admittance; or when the hand can be passed within the cavity of the uterus, immediately after the rupture of the membranes, so that part of the water may be retained; the delivery may be accomplished, in the most troublesome preterminal cases, with the greatest safety and expedition. But when the waters have

been long evacuated, and the uterus closely contracted round the body of the child, the case will prove laborious to the operator, painful and dangerous to the mother and child.

When there is reason to suspect that the child lies across, which can often be ascertained, either by feeling the presenting part through the membranes, or by some of the signs of preterminal labours already mentioned; the woman should be managed in such a manner, that the membranes may be preserved entire as long as possible; for this purpose she should keep quiet in bed, and her posture should be such as is least favourable for straining, or exerting force during the pain: she should be touched as seldom as possible, till the os internum be sufficiently dilated. The accoucheur should then introduce his hand in a conical form, well lubricated, into the vagina, and through the aperture of the internal orifice, insinuating it between the uterus and the membranes, till it advances almost as high as the fundus uteri, when he must break the membranes, by pinching some part of them between a finger and thumb, or by forcibly pushing a finger thro' them; he must then search for, and endeavour to lay hold of, one or both feet, and deliver.

Should the membranes be ruptured in the attempt, he must be ready to run up his hand as quickly as can be done with safety, when, part of the waters by his arm being retained, the operation of turning will be facilitated. Should the placenta adhere on that side of the uterus where the hand is passed, it must again be withdrawn, and the other hand be introduced in the opposite side.

Flooding. It has been already observed, that a flooding seldom proves fatal to the mother before the seventh month of pregnancy; after which period, from its duration or excess, the life of both the mother and child may suffer. Should therefore a flooding attack a woman in the two last months of pregnancy, from whatever cause it may arise, and whether attended with labour-pains or not, if the hemorrhage be so considerable that she is ready to sink under it, and that cold applications and other means of checking the evacuation shall fail, the woman must be placed in a proper posture, her friends prudently apprised of her danger, and the delivery must be immediately performed, by stretching the vagina and os uteri, till the hand of the operator can easily gain admittance to break the membranes, catch hold of the feet, and extract the child.

If it can possibly be prevented, the membranes in flooding cases should never be broken till the aperture of the uterine orifice will freely admit the hand to pass, that, after the evacuation of the waters, the accoucheur may have it in his power either to make the delivery or not according as the effusion continues or abates.

Soon after attempting to stretch the parts, should the labour-pains come on, the waters begin to be collected, and the uterine hemorrhage diminish, the accoucheur must then withdraw his hand, and manage the delivery according to circumstances. And if, for instance, the child presents naturally, the delivery must be trusted to nature; otherwise, if the flooding continues, or the child presents across, the accoucheur must persist in his work, going on slowly, and with the utmost

Preterm-
tural La-
bour.

most delicacy, till he be able to reach the feet, to bring them down, and deliver; always remembering, during this process, that the strength of the woman, by proper nourishment, be supported.

But should the placenta adhere to the cervix, or upon the os uteri, the greatest danger is to be dreaded; for thus the flooding will commence from the moment the os uteri begins to stretch, and will increase so rapidly, that the woman, if not speedily delivered, must inevitably sink under it. The whole body of the placenta, in such cases, is sometimes separated when the labour has made but little progress; so that the woman will often perish whether delivery be attempted or not. As this, however, is the only expedient by which her life, and that of the child, can be saved; in every case where the placenta presents, which the accoucheur will readily discover by the touch of the soft pappy substance of that body, he must immediately place the woman in a proper posture, insinuate his hand gently by the side of the protruding placenta, break the membranes, search for the feet of the child, and bring them down, so that the delivery may be finished with all possible expedition; for, in this unhappy case, a few minutes delay may prove fatal.

The after-birth ought never to be extracted before the child, if it can possibly be avoided.

After delivery, time should be given for the uterus to contract, that nature may thus throw off the placenta, which never ought to be hurried away, unless the continuance or a recurrence of the hemorrhagy render it necessary.

Prolapsus of the funis. Difficulties arising from the funis falling down into the vagina, and presenting along with some part of the child, may, in this class of the division of preterminal labours, be included.

A pressure on the chord, in such a degree as to interrupt the circulation, must infallibly destroy the life of the child: hence a coldness and want of pulsation in the chord is the truest criterion of the death of the child; and hence, in every case where the chord is prolapsed before any bulky part of the child, if the delivery be not accomplished with expedition, the child will perish. This is only to be prevented by replacing the chord, and retaining it above the presenting part, till this last, by the force of labour-pains, be so far advanced as to prevent the return of the former; or the child must be turned and brought by the feet, provided this can be done with safety to the mother. But it is often difficult to succeed in the attempt of the one or other; and, if the woman has strong pains, such attempts are not to be hazarded, as the consequences may prove fatal.

When the accoucheur is thus situated between two puzzling difficulties, the preference must always be given to the mother. If the child be small, and the pelvis well formed, which may be known by the history of former deliveries, and if the labour goes on quickly, the child will generally be born alive; but if, on the contrary, the child be above the ordinary size, and the pelvis rather narrow, turning will prove a dangerous operation to the mother, and there is little prospect of saving the infant by this means.

Besides our former division of labours, plurality of

children, monsters, extra-uterine fetuses, and the Gesarean operation, are parts of the subject that yet remain to be considered.

CHAP. IV. Plurality of Children.

THE case of twins often occurs: of triplets seldom: of quadruplets rarely: nor is there perhaps a single instance, where five or more distinct fetuses have been found contained in the human uterus, though many such fabulous histories have been recorded by credulous authors.

The signs of two or more children, such as the sudden or extraordinary increase of the uterine tumor, motion felt in different parts of the abdomen, &c. are very doubtful and fallacious: this can only be ascertained after the delivery of one child; and even then a recurrence or continuance of labour-pains is not a certain and infallible criterion; neither is the absence of pains a sure indication of the contrary; as many cases have occurred, where several days have intervened between the birth of a first and second child. The chief symptoms to be depended on are, 1st, The child being of a small size, and the quantity of liquor amni so inconsiderable as not to account for the bulk of the woman in time of pregnancy. 2dly, The bleeding of the funis umbilicalis next the mother. 3dly, The remora of the placenta. 4thly, The uterine tumor not sensibly diminished, which, very soon after delivery, in ordinary births, will be found gradually shifting lower and lower, and will feel at last as if a hard circumscribed tumor like a ball between the umbilicus and pubes. Hence the utility of the general practice of applying the hand externally on the abdomen, in every case after delivery; by which an accurate knowledge will be formed of the nature and manner of the uterine contraction. When, from any of these circumstances, there is reason to suspect another child, the most certain and infallible manner of discovering it is, the passing of a finger, or the introduction of the hand into the uterus, where another set of membranes will be perceived, and probably some part of the child presenting through them.

The position of twins or triplets is commonly that which is most commodious, and which will occupy the least room in utero: their situation is often diagonal; tho' they may present in every possible posture. Thus, therefore, the general rules recommended for the delivery of one child, are equally applicable in the case of twins, triplets, &c.

It has been the general practice with many, after the birth of one child, to pass the hand immediately into the uterus, to break the membranes, catch hold of the feet of the child, and thus deliver. But this is certainly bad practice, whatever authors have said to the contrary. If the woman is healthy, and the child presents favourably, that is, with the head, breech, or feet, natural pains ought to be waited for, when the child will be expelled by the force of these only; failing which, manual assistance, as in other cases, must be had recourse to.

It very rarely happens, when the first birth is preterminal, that the second membranes are ruptured in making the extraction. Should this prove the case, the

limbs of the children may be confounded, so that a leg and an arm, or three legs, or arms of different children, may present; which, however, will make little difference in the mode of delivery; the accoucheur will endeavour to lay hold of the foot or feet most readily within his reach, and will be cautious, in bringing them down, to make sure they belong to the same body.

If the child presents cross; if floodings, convulsions, or other dangerous symptoms, shall take place; if the woman has suffered much in the first labour; and if, after several hours, a recurrence of labour-pains does not ensue; the hand must then be introduced into the uterus, the membranes must be broken, and the child must be extracted by the feet; or, if the head remains locked in the pelvis, and, from want of strength in the woman, cannot be expelled, the treatment is the same as in other laborious births.

In twin-cases it may be recommended as a general rule, to avoid precipitating the delivery of the second child till the woman shall have rested a proper time, and till, by the contraction of the fundus uteri, the second set of membranes occupy the place of the first, and be protruded as far as the os externum; when, and not before, the delivery may safely be assisted, should circumstances occur to render such assistance necessary: whereas, by breaking the membranes and evacuating the waters when the child lies high in the uterus, a flooding may be brought on, or a spasmodic constriction of the uterus round the body of the child may be occasioned, which may render the delivery both difficult and dangerous.

The placentæ of twins, triplets, &c. generally adhere, though sometimes they are distinct, and may be thrown off at different times after the birth of the different children; so that the practitioner should be on his guard, and never should leave his patient till he makes sure there be no more children. When a second child is discovered, no attempts ought to be made to extract the placenta till after the birth of the remaining child or children; as the woman would be subject to flooding, which might prove of fatal consequence before the uterus could be emptied of its contents.

In case of plurality of children, a second ligature should be applied on the funis, on that end next the mother, immediately after the birth of every child; and a gentle compression should be made on the abdomen of the woman after the first delivery, which must be gradually tightened after every succeeding one, to prevent the consequences of a sudden removal of uterine pressure, which is to be dreaded where the distension has been considerable.

The placenta, in such cases, must be managed in much the same manner as usual. In twins, &c. it generally separates with great facility, provided time has been given for the uterus to contract. Both chords should be gently pulled; and when it advances towards the uterine orifice, where, being large and bulky, it commonly meets with considerable resistance, it requires the introduction of a finger or two into the vagina for bringing down the edge, after which the body readily follows.

CHAP. V. Monstros.

These are of various sizes and forms, and, unless

very small, the posture favourable, and the woman well made, will prove the cause of a difficult and troublesome delivery. Sometimes a child is monstrous from a preternatural conformation of parts, such as a monstrous head, thorax, abdomen, &c. At other times, there is a double set of parts, as two heads, two bodies with one head, four arms, legs, &c. But such appearances very seldom occur in practice; and, when they do, the delivery must be regulated entirely according to the circumstances of the case. A large head, thorax, or belly, must be opened. If two bodies united together are too bulky to pass entire, they must be separated; the same of supernumerary limbs. If the posture be unfavourable, it must be reduced when practicable; otherwise the extraction must be made with the crotchet, in the best manner the circumstances of the case will admit of; always, in cases of danger or difficulty, giving the preference to the safety of the mother, without regarding that of the child.

CHAP. VI. Cesarean Operation.

WHEN the delivery could not be accomplished by other means, or when a woman died suddenly with a living child in her belly, an operation to preserve the life of mother and child in the former case, and to save the child in the latter, has been recommended, and successfully performed, by different authors, and in different ages.

This operation is of ancient date; it is the señio Casarea or partus Casarea of the Latins, and the hysterotomia of the Greeks. Whether it was ever successfully performed on the living subject amongst the ancients seems uncertain; but that it has been successfully practised by the moderns on various occasions, and in several different countries of Europe, there are so many authentic histories on record, that the fact will scarce admit of doubt: but as this, like many other salutary institutions, has been much abused, and in many cases improperly and injudiciously employed, (for some of those women who survived the operation, were afterwards safely delivered of living children), the circumstances which render this operation necessary demand a very particular inquiry, viz.

1. 1. A narrowness, or bad conformation of the bones of the pelvis.
2. 2. Imperforated vagina, or contractions in the vagina, cicatrices, tumors, or callosities in the os uteri, &c.
3. 3. The escape of the child through the uterus when torn.
4. 4. Ventral conceptions.
5. 5. Herniæ of the uterus.
6. 6. The position or bulk of the child.

It will be necessary carefully to examine these different causes, in order to show that they are by no means, in every case, sufficiently powerful motives for having recourse to it.

1. Bad conformation of the bones of the pelvis. When the hand of the operator cannot be introduced within the pelvis; or, in other words, when its largest diameter does not exceed one inch, or one inch and a half, this conformation is perhaps the only one which renders the Cesarean operation absolutely necessary: happily, however, such a structure very seldom occurs in practice; and when it does, the accoucheur will readily

readily discover it, by attending to the following circumstances, and to the common marks of a narrow pelvis. Wherever the capacity of the pelvis is so strait as not to admit any part of the child's head to enter, nor two fingers of the accoucheur's hand to conduct proper instruments to tear, break down, and extract the child piece-meal; in this case, recourse must be had to the Cæfarean section; an expedient, though dreadful and hazardous, that will give the woman and child the only chance of life; and which, if timely and prudently conducted, notwithstanding of the many instances wherein it has failed, may be performed with some probability of success.

It is true, the success of the operation in the city of Edinburgh, where it has been done five times, has proved discouraging, as none of the women had the good fortune to survive it many days. This, however, is not the fault of the operation, but is to be imputed to the low, weak state of the patients at the time, who had previously been several days in labour, and their strength greatly exhausted, before the operator was called. Delivery by every other means was utterly impracticable; the operation, though the event was doubtful, alone gave a chance of life; and three of the children by this means were extracted alive.

Mr Hamilton surgeon and professor of midwifery in Edinburgh, having been an eye-witness of the operation the last time it was performed here, gives the following account of the case which fell under his observation.

Elisabeth Clerk, aged 30, had been married for several years, became pregnant, and miscarried in the third month; the expulsion of the abortion occasioned so severe a stress, as actually to lacerate the perineum. Some time after her recovery, she was irregular, afterwards had one flow of the menses, again conceived, and the child, as she imagined, arrived at full time. She was attacked on Monday the 3d of January 1774, about midnight, with labour-pains, which went on slowly, gradually increasing till Saturday the 15th, when she was brought from the country to the Royal Infirmary here. Upon examination, the pelvis seemed considerably distorted; but the body was otherwise well shaped, though of small size; the os externum vaginæ was entirely shut up, nor could any vestige of vagina be observed, nor any appearance of labia pudendorum: instead of this, there was a small aperture at the superior part of the vulva, immediately under the mons veneris, probably about the middle anterior part of the symphysis pubis. This aperture (which had a small process on the superior part, somewhat resembling the clitoris) was no larger than just to allow the introduction of a finger; the meatus urinarius lay concealed within it; a consultation of surgeons was called, and the Cæfarean section was determined on. Having had no stool, nor voided any urine for two days, an injection was attempted to be thrown up; but it did not pass, nor was it possible to push the female catheter into the bladder. Mr William Chalmers was the operator in this case. At six the evening, he made an incision on the left side of the abdomen in the ordinary way, through the integuments, till the peritoneum was exposed; two small arteries sprung, which were soon stopped by a slight compression: the wound was then continued through the peritoneum into the cavity of

the abdomen, when the bladder appeared slightly inflamed, much distended, reaching with its fundus near as far as the serobicus cordis: another unsuccessful attempt was made to pass the female catheter; at length a male catheter was procured, which was, after some difficulty, introduced into the bladder, and the urine evacuated to the quantity of above four pounds, high-smelled and fetid. This occasioned a necessary interruption for a few minutes, between making the opening into the abdomen and uterus; the bladder collapsing, the uterus, which before lay concealed, now came in view, through which an incision was made, and a stout male child was extracted alive; and immediately afterwards the secundines. The uterus contracted rapidly. After cleansing the wound, the lips were brought together by the quill-future, and dressed superficially. The patient supported the operation with surprising courage and resolution; nor was there more than five or six ounces of blood lost on the occasion.

Being laid in bed, she complained of sickness, and had a slight fit of vomiting; but, by means of an anodyne, these symptoms soon abated: she was affected with universal coldness over her body, which also abated on the application of warm irons to the feet: she then became easy, and slept for four or five hours. Next morning, the 16th, about two o'clock, she complained of considerable pain in the opposite side, for which she was blooded; and an injection was given, but without effect; for the pain increased, stretching from the right side to the serobicus cordis; nor did fomentations seem to relieve her; her pulse became frequent, she was hot, and complained of drought. At 7 A. M. the injection was repeated, but with no better success; and eight ounces more of blood were taken from the arm; a third injection still failed to evacuate any faeces; the drought increased; and the pulse rose to 128 strokes in a minute. At 11 A. M. the pulse became fuller; and the respiration much oppressed. No stool nor urine passed since the operation. At 12 she was blooded again, when the size of the uterus appeared less than formerly. She now took a solution of sal Glauber. ianna and cr. tart. at short intervals; she vomited a little after the last dose, had a soft stool, and voided a small quantity of urine. At 3 P. M. her pulse was 136, and she had another stool, when thin faeces were evacuated; she was then ordered two spoonfuls of a cordial anodyne mixture every second hour: the vomiting now abated; the pulse became smaller and more frequent; she passed urine freely; but the pain and oppressed breathing increased. At seven P. M. her pulse rose to 142, and became weak and fluttering; she called for bread, and swallowed a little with some difficulty; her drought was intense; the dyspnoea still increased. She was now much oppressed, and began to toss; the pulse sunk and became imperceptible; she complained of faintness, but on belching wind her breathing was relieved, and the pulse returned, growing fuller and stronger: the pain of the side still increasing, 12 ounces of blood, very fizy, were taken away; and two glysters of warm water with oil were injected without effect: at 8 P. M. the pulse became less frequent and smaller; she complained much of the pain towards the serobicus cordis: her breathing was much oppressed; her belly was tense, and swelled as

big as before the operation; her pulse was now small and feeble; she looked ghastly; and expired a little after eight, 25 hours after the operation.

It is to be regretted that the relations would not permit the body to be opened.

Since the first certain accounts of the operation successfully practised by a fow-gelder on his own wife, in the beginning of the 16th century, there are on record above 70 well-attested histories, wherein it has been successfully performed: for, of all the cases related by authors, it has not proved fatal to the patient above once in ten or nine instances; which evidently shows the propriety of the practice, and probability of success, both in regard to the mother's own recovery, and for certainly preserving the life of the child. But it should never be attempted, excepting in those cases only where it is absolutely impossible to deliver the woman by any other means whatever; for there are pelvises to be met with, where, without having recourse to this operation, both mother and child must inevitably perish: such have occurred to many practitioners, who, from want of resolution or from ill-founded prejudice, have allowed their patients to perish from neglect, contrary to a well-known maxim in physic, That, in a desperate case, it is better to employ a doubtful and even desperate remedy, than to abandon the patient to certain and utter ruin. Such, for instance, is a case related by Saviard, of a girl aged 27, whose stature was only three feet, who came to lie in at Paris, in the Hotel Dieu; every method but the operation was in vain attempted; both mother and child died. Mauriceau also relates the history of a woman who was left to die, where the aperture of the pelvis was so small as not to admit the hand of the accoucheur. And, not to multiply instances, Mr De la Roche gives a case where the woman had been seven days in labour; the child was saved by the operation; but the woman died the fifth day after, probably from its being too long delayed: the distance, in this subject, from the lower vertebra lumborum and os pubis, was no more than two fingers breadth. The operation, when the necessity is evident, ought therefore to be early performed, that the patient, who from her make and constitution is generally delicate and puny, may have every chance of recovery in her favour, without being exhausted by the fruitless efforts of a tedious and painful labour, as too often has been the case. On these occasions, the prudent accoucheur should call in the advice of his elder brethren of the profession, and, by his cautious and prudent conduct, avoid every cause of censure or reproach.

Exostoses from the bones of the pelvis is a species of deformity very rarely met with in practice, and which seldom or never takes place to such a degree as to render this operation necessary.

II. Constriction, callosity, tumors, &c. about the vagina or os tincæ. The vagina and os tincæ are often affected with constrictions from cicatrices, with callosities and tumors; but it is seldom, if ever, necessary to perform the Cæsean section on this account. Tumors in the vagina may generally be removed with safety, even after the commencement of labour, and delivery happily succeed; or it may be sometimes practicable for the accoucheur to pass his hand by the side of the tumor, to turn the child, and

deliver. With regard to constrictions in the vagina, and callosities in the os uteri, there are many instances where, at the commencement of labour, it was impossible to introduce a finger into the vagina; yet the parts have dilated as labour increased, and the delivery terminated happily. At other times, the dilatation has begun during pregnancy, and been completed before delivery. There is a history, for instance, in the Mém. de l'Acad. des Sciens. 1712, of a woman whose vagina was no larger than to admit a common writing quill; she had been married at 16, and conceived 12 years after: towards the fifth month of her pregnancy, the vagina began to dilate, and continued to do so till full time, when she was safely delivered. Guilemeau dilated, and La Mott extirpated, callosities in the vagina and os tincæ, when the children were successfully expelled by the force of natural labour.

Harvey relates a case where the whole vagina was grown together with cicatrices; nature, after a tedious labour, made the dilatation, and a large child was born.

La Mott mentions his having delivered three women, who had not the smallest vestige of an orifice through the vagina to the uterus. Dr Simpson cut through a callosity of an os uteri which was half an inch thick, &c.

Upon the whole, tumors in the vagina, or about the orificium uteri, may be safely extirpated without danger of hemorrhagy or other fatal symptoms, and the delivery will happily succeed: and if the vagina be impervious, the os externum shut up, or the labia grown together, the parts should be opened with the scalpel, rather than risk an operation, at best in the issue doubtful and precarious: an operation never allowable in such cases, and therefore universally improper in diseases or malconformation of the soft parts of generation. If the os externum be entirely closed, if the cavity of the vagina be entirely filled up, or the passage considerably obstructed by tumors, callosity, or constriction from cicatrice, and there is no reason to suspect a fault in the pelvis, of which a judgment may be formed by the common marks of deformity, under size, or a rickety habit; it is by much the best practice to open a passage through the vagina, and deliver the woman in the ordinary way. If there be no defect in the pelvis, the head of the child, or any other bulky part that presents, will advance in this direction, till it meets with a resistance in the soft parts: thus the teguments will at length be protruded before the child's head, in form of a tumor, when a simple incision downwards to the perineum, in the direction of the anus, will remove the cause of difficulty, by relieving the head; the child will afterwards safely pass, and the wound will heal without any bad consequence.

The state of the pelvis, and progress of the labour in these cases, may often be learned by the touch of the finger in ano.

III. Lacerated uterus is another cause for which this operation has been recommended. The uterus may be ruptured from violence in making the delivery; or such an accident may happen naturally, either from the cross presentation of the child in time of pregnancy, or in time of labour, when the pelvis is narrow: these cases are generally fatal; and it is very seldom,

Cæfarean Operation. Cæfarean section, after the fetus escapes through the tora uterus into the cavity of the abdomen: because it often happens, that inflammation and sphacelus has affected the parts of the uterus that sustained the pressure previous to the rupture; or, if otherwise, convulsions or other fatal symptoms soon ensue, from the quantity of blood, water, &c. poured into the cavity of the abdomen.

When the child cannot be extracted by the natural passages, tremors, singultus, cold sweats, syncope, and the death of the mother, for the most part, so quickly follow, that it will at least seem doubtful, to a prudent humane practitioner, how far it would be advisable, after so dreadful an accident, the woman apparently in the agonies of death, rashly to perform another dangerous operation, even with a view to preserve the child, till he had waited till the mother recovers or expires.

If part of the child be contained within the uterus, and the feet can be reached, the practice is to deliver by the orifice of the womb: but when the whole fetus has escaped entirely without the uterus, the Cæfarean operation is recommended as the only means of preserving both mother and child.

If the operation on this occasion be ever allowable, it may be asked,

1. At what time must it be performed?

2. Would it not have the appearance of inhumanity to have recourse to this expedient immediately after the uterus bursts, when the woman is seemingly ready to expire, although it be the only time when there is a chance of saving the child?

3. In most cases where this accident happens, should the Cæfarean section be made, is it not highly improbable that the mother will survive so terrible a laceration?

4. For if it be done with a view to save the mother, in what manner is the extravasated blood, &c. to be evacuated from the cavity of the abdomen?

What seems to make cases of this kind unfavourable, when the accident happens in time of labour, is,

1^mo, That here the parts before rupture in most cases are in a gangrenous state.

2^do, As the rupture is commonly towards the cervix, there is generally a much greater hemorrhagy, by reason of the slow contraction of the uterus at this place.

3^to, The uncertainty, whether, or how long, the patient will survive it, seems also a considerable obstacle to the operation under such disagreeable circumstances, Ne ocidisse videatur, quem fors interemit.

IV. Ventral conceptions is a fourth indication for this operation. These are either in the ovaria, tubes, or cavity of the abdomen, and seldom arrive at great size; or are retained, very often a long time, without occasioning much complaint. The issue of these conceptions has also been no less various than extraordinary; for after being retained for a great many years in an indolent state, at length abscesses or ulcerations have formed, and they have been discharged through all the different parts of the abdomen.

Most women feel pain and violent motion at the time of ordinary delivery in these cases of ventral conception; if therefore the operation be ever necessary,

now is the proper time to perform it. But in general, as the separation of extra-uterine fetuses from their involucre may occasion immediate death in many cases, from the vast hemorrhagy that might ensue from the non contractile power of the parts to which they adhere; unless they point outwardly, or excite the most violent symptoms, they ought universally to be left to nature.

V. Herniæ of the uterus are seldom or never sufficient to induce us to perform the Cæfarean section, as the uterus is very rarely influenced in such a manner, that the orifice cannot be reached, and the delivery successfully made. Many instances are to be found among surgical authors, where deliveries, under such circumstances, have been happily performed, without having recourse to so hazardous an expedient. Thus Mauriceau mentions a case, where the uterus, in a ventral hernia, was pushed along with the intestines above the belly, and contained in a tumor 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 Ruysch gives a case where the midwife reduced the hernia before delivery; although it was prolapied 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, monstrosity, 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 fetuses, or bones of fetuses, do not properly fall under the name of Cæfarean 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 Cæfarean 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 deliquium 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 opera-

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 struggling.

Thus having pointed out the different causes that determine this operation, it may be observed, that it is a frightful and hazardous one; and although performed successfully in a number of cases, yet, in many others, it has failed, and the woman has died either immediately or soon after. It should never, therefore, be undertaken but on extraordinary and desperate occasions; and then it is not only advisable, but incumbent, on every practitioner to whom such cases occur.

To conclude, it may not be improper to give a few directions with regard to the method of performing the operation on the living subject.

Having emptied the bladder, and evacuated the contents of the intestines with repeated emollient glysters; the patient being encouraged, with proper cordials, and every other requisite in readiness, she must be placed on a table or bed, with her left side gently raised with pillows or bolsters, and properly secured by assistants. An incision must be made with a common convex scalpel, beginning rather below the navel at the middle space between it and the spine of the os ilium, carrying it obliquely forwards towards this bone, so that the wound in length may exceed six inches. This external wound is to be carried through the common teguments of the abdomen till the peritoneum is exposed, when the operator should rest a little, till the hemorrhagy be entirely abated. He must then, with great caution, make a small opening through this membrane, introduce his finger, and upon this a scalpel (which is preferable to scissars), and with great expedition make a complete dilatation; and must now wipe away the blood with a sponge, press the omentum or intestines gently to a side, if in the way, and endeavour to discover to what part of the uterus the placenta adheres, that it may be avoided in making the incision. This may easily be known by a thickness and solidity in the part, which distinguishes it from the rest of the uterus; it is still more easily discovered when the membranes are entire. The blood-vessels are less in number, and smallest in the middle and anterior part of the uterus, which therefore, if the placenta does not interfere, is the proper place for making the incision, which must be performed with the utmost attention, lest the child should be wounded: if the membranes are entire, more freedom

may be used, and vice versa. The direction and length of the wound of the uterus must be the same with the external one. The child must now be quickly extracted, and the placenta carefully separated: these must be given to an assistant, who will divide the chord, and take care of the child, as the operator's attention must be wholly bestowed on the mother. The coagulated blood, &c. being removed by a sponge wrung out of warm water (lest the uterus or intestines be protruded, which are very troublesome to reduce), the lips of the external wound must be quickly brought together, and retained by an assistant till secured by a few stitches; generally three will be sufficient: as many needles should be ready threaded with pretty large broad ligatures; the middle stitch ought to be made first; the needle should be introduced at a proper distance, i.e. about an inch and one-fourth from the side of the wound, carrying 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, sharpee, 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.

Quæritur, 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 hemorrhagy, 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 Monro, 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 Cæsean 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?

CHAP. VII. Of the Section of the Symphysis.

M. Baudelocque, as has already been observed, condemns this operation; and, from what he has advanced, apparently with reason. As no theory, however, can be looked upon as thoroughly established until it

Section of the Symphyfis. Section of the Symphyfis.

confirmed by experience, this gentleman has collected together a number of the principal facts relating to this subject. He supposes, that unless it has been successful in saving both the life of the woman and child, the cutting of the symphyfis of the pubes cannot by any means be said to have answered its purpose. It is not sufficient that the child has shown some signs of life at its birth, and that the mother has survived for some time. In this respect the Cæsaræan operation has the advantage of it, as it always saves the life of the child, and it is very rare for the woman to sink under it immediately. He is of opinion, that there is scarcely one of the cases of this operation, the relation of which may not be justly contested, or solid objections raised against it; either because the operators have been deceived with regard to the dimensions of the pelvis and of the child's head, or because they have greatly exaggerated the advantage gained by the separation of the bones.—The first and most remarkable instance of success in this operation is of a woman named Souchot; but though it is not denied that the woman was delivered, and recovered after the operation, yet it has been said by those who take the contrary side, that there was no necessity for performing it. It is certain that this woman had been delivered four times before; in all of which cases the child was killed. M. Baudelocque does not enter into the merits of this question; he considers only what advantage could possibly be gained by it.

“Whatever degree of separation (says he) took place between the ossa pubis after the section of the symphyfis, it must have augmented the size of the passage; that is an incontestable fact; but how much did it enlarge in the direction in which it was originally too narrow? The solution of this problem would be easy, if we knew the dimensions of Souchot's pelvis as well as we know those of her child's head. According to the estimation made of it by the physicians who performed the operation, the diameter of the pelvis was only two inches and a half in the direction from the pubes to the sacrum superiorly, and that of the child's head was just three inches and a half. The excess of the latter was consequently one inch, as well as the amplitude to be procured to the former. A separation of two inches and a half between the ossa pubis, the greatest which it was then thought could be obtained, not being able to give more than six lines to the diameter of the pelvis in the aforesaid direction, they thought to make the remaining surplus of the head pass into the separation between the bones; and, moreover, they had the precaution to make the partial protuberances pass successively through the strait, in order to get another line by that means; so that by this system, the section of the pubes produced a result of 13 lines at least, considering it relatively to delivery. Notwithstanding this ingenious calculation, and this great product, the passage was still found narrow enough to give some obstruction to the child's head, and to endanger its life.

“It seems evident that this plan was not formed till after the execution; and that they have only sought to explain what they must have done according to the opinion which they entertained that the diameter of the child's head was an inch larger than that of the

pelvis, and not according to what they did and observed; because no one had yet determined the product of a separation of two inches and a half between the ossa pubis, with respect to the different diameters of the pelvis, and particularly respecting that which goes from before backward; because they did not measure the separation as they affirm they did, neither in the case of Souchot nor in any other; because the accoucheurs of that woman were then agitated, much agitated, as they have publicly confessed; lastly, because this great product, and those sage calculations which we admire in their history of it, were not then necessary. Though they have allowed but two inches and a half to the small diameter of the superior strait, other accoucheurs equally skilful have assigned it six lines more; and they were not deceived if they considered it a little diagonally, as the smallest diameter of the child's head always presents; that is to say, from one of the sides of the projection formed by the base of the sacrum to the symphyfis of the pubes.”

Our author now goes on to show at great length, that the pelvis of the woman in question was less out of proportion than had been represented; that only two lines of enlargement were necessary, and no more than two were obtained. In like manner, he says, that all the other women upon whom M. Sigault operated were equally well formed excepting one named Vespre. This woman died after passing five days in great agony. The ossa pubis were separated about an inch and an half; and in consequence of this separation, the sacro-iliac symphysees were plainly injured, as well as the neighbouring parts. On inspecting the body, these were found open, with the periosteum separated from them: there was also a collection of purulent matter of a dark grey colour, extending very far into the cellular tissue of the left iliac fossa, &c.

In this case, both the mother and her child perished; and M. Baudelocque looks upon it to be sufficient to show the inefficacy of the operation: and he tells us, that out of five women whom Sigault delivered in this way, one died, and four of the children; but M. le Roy, a more successful operator, out of an equal number saved all the children. In a case related by this gentleman, the ossa pubis are said to have separated two inches; and by parting the thighs, an opening of near three inches was obtained; but in this case again, M. Baudelocque controverts the measurements of le Roy. Another woman named Du Belloy, on whom the operation was performed, began to walk on the tenth day after; and this seems to be almost the only case against which M. Baudelocque has not some objection. He mentions, however, an experiment performed on the body of a woman who had died on the 11th day after the Cæsaræan operation had been performed in the linea alba. The body was oedematous, which rendered the case more favourable; and a dead child was placed in the belly, after taking out the uterus. The pelvis was only 20 lines in the small diameter, and four inches and a quarter in the transverse. The diameter of the child's head was but three inches five or six lines from one parietal protuberance to the other; the trunk was thin, and every part of the body had been pressed and kneaded, to restore as much as possible the suppleness which death had taken away. An attempt was then made

to bring the child through the pelvis by pulling its feet; but it was found impossible thus to disengage it farther than the breast. The symphysis of the pubes was then laid bare by an incision of two inches and a half; preserving, below, the anterior commissure of the labia pudendi; and above, an extent of 18 or 20 lines under the inferior angle of the Cæsaræan operation. The ossa pubis separated at first no more than nine lines; which opening was augmented as gradually as possible to 21 lines by separating the thighs, and afterwards it was farther increased to two inches and a half by pulling the hips. It was next attempted to bring away the head, which had spontaneously placed itself in the most advantageous situation: but, though several gentlemen of the profession employed their strength successively at the trunk, and on the lower jaw with two fingers in the mouth, it did not advance a single line; nor would it pass the strait until M. Baudelocque seconded those efforts by pressing on the head with one hand placed in the belly, and by compressing it strongly in the direction of its thickness. At the instant when it cleared the strait, the inferior angle of the incision in the teguments tore to the vulva; and the wound was so lengthened towards that of the Cæsaræan operation, that those three openings were very near making but one. The sacro-iliac symphyses, which were already a little open, and the ligaments and periosteum ruptured by the time that the ossa pubis were separated 21 lines, now gave way entirely, and with so much noise as to be distinctly heard by every one of the assistants. The ossa pubis, after the passage of the head, remained at the distance of three inches from each other; the angle of the right os pubis was two inches and six lines from the centre of the projection of the sacrum, and the angle of the left os pubis only two inches and three lines; so that the diameter of the pelvis was augmented seven lines in one way and ten in the other.

From this experiment, M. Baudelocque concludes, that very little advantage can be expected from the operation where the pelvis presents only 18 or 19 lines, or even 21 superiorly, such as was the pelvis of Beiloy. We must observe, however, that we cannot argue with propriety from a dead to a living subject: though if the measurements are wrong, as our author afterwards says, although at first he "had nothing particular to object" to her case, the whole argument in favour of the operation must fall to the ground.

Objections of a similar kind are made to every other case which M. Baudelocque relates: And as it is impossible for those who were not acquainted with the parties to judge of the propriety or impropriety of the operation, we shall content ourselves with describing from M. Baudelocque the appearances met with in the body of a woman who had died in the operation. "The left labium was very much swelled and livid; the sacro-iliac symphyses were of a brownish colour to the extent of an inch at least, on account of the blood extravasated under the periosteum which was detached from them; they were overflowed with a purulent and ichorous discharge, more abundant on the left side than the right; and which sprung from the bottom of them, through several openings, which were so many rents, whenever the ossa ilia were mo-

ved and pressed towards the sacrum; the left symphysis was open five lines, and the right only three; a gangrenous abscess was seen on the right side behind and above the acetabulum, which extended to the anterior and inferior part of the uterus, where there was an eschar of the same nature; an ulcer also gangrenous, and in form of a chink, was observed in the posterior part of that viscus, from the upper part of its neck to the insertion of the ligament of the ovary, and it penetrated into its cavity. The diameter of the pelvis was two inches and a half from the pubes to the base of the sacrum; five inches from one side to the other; and four and an half from one acetabulum to the sacro-iliac junction of the opposite side. The section had been made on the left os pubis, which was cut clean, and without the smallest notch."

From these, and a number of other examples which our limits will not allow us to insert, our author deduces the following conclusions.

"Though the section of the pubes has been thought more simple, more easy, and certain, than the Cæsaræan operation, at a time when experience had not yet demonstrated the difficulties it might present, and the dangers that might follow it, ought we to think the same of it at present? How many times already has it been necessary to have recourse to the saw to separate the ossa pubis? and how often has it not been found impossible to procure any distance between them after the separation? How often has this operation produced a free passage for the child, whose preservation ought necessarily to enter into the plan of the operator, as well as that of the mother, and constitute a part of its success?"

"This new operation will appear more simple and less painful than the Cæsaræan, if we only consider the extent of the incision, and the nature and importance of the parts concerned in it: that is an indisputable fact. It is only the teguments and the fat which is divided, at most only two inches and a half, and the symphysis of the pubes; there are usually only small vessels cut, incapable of furnishing much blood, and the instrument does not touch the uterus; the child comes into the world by the way that nature intended, and which the section of the pubes renders more or less accessible; there is no considerable hæmorrhagy to be feared, nor those extravasations of milky and purulent matter which almost always mortally injure the interior viscera which they fall upon; there are no absolute difficulties in the execution of this operation but what arise from the intimate consolidation of the bones; and it no way exposes women to subsequent hernias which have been so frequently seen after the Cæsaræan operation: this is the idea which its partisans have had of it, and which the greater part of them still entertain.

"But the section of the pubes seldom procures the child an easy exit; for hitherto the greater part have died in the passage, or have been victims, a few minutes after their exit, to the efforts necessary to effect it. When the separation of the ossa pubis has been made, it has not always been possible to remove them from each other, on account of the consolidation of the ilia with the sacrum; and this case, which does not seem to be exceedingly rare, and which cannot be known till after the operation, renders it fruitless, and cannot dispense us from the Cæsaræan operation.

"If we reflect ever so little on the danger to which the child is exposed in a preternatural labour, where we are obliged to bring it by the feet, and on the small number that then escape death, when the mother's pelvis has not, pretty nearly, all its natural dimensions, we discover another source of accidents which accompanies the section of the pubes; and which we doubtless should diminish, if we could commit the expulsion of the child to the contractions of the uterus, or take hold of the head with the forceps, as some practitioners have already done: but, except in that very small number of cases, the child has always been extracted by the feet whether the head presented or not.

"Though this operation very seldom secures the child's life, even when the pelvis is not excessively deformed, it is not then always exempt from the severest consequences to the mother. The death of both is certain when that deformity is extreme. The consequences of a spontaneous separation of the ossa pubis, and of the ossa ilia and sacrum, in some natural or laborious labours, long since announced those which might be expected from this new operation; the example of Vespres, those of the fifth woman on whom M. le Roy performed it, the fourth by M. Cambon, that at Arras, at Duffeldorp, at Spire, at Lyons, at Gênes, that by M. Riollay, by M. Matthiis, &c. have proved that it was not without cause that those accidents were dreaded. A devaluation in the external parts and the neck of the uterus; an inflammation and gangrene of that viscus; collections of purulent, fanguis, and putrid matter, in the cellular tissue of the pelvis; a hernia of the bladder between the ossa pubis; echimoses along the psoe muscles; injury to the canal of the urethra; incontinence of urine, and gangrenes more or less profound, &c. form the group of accidents of which this new operation is susceptible. Granting that those of the Cæfarean operation are as formidable for the mother, at least it presents a certain resource, exempt from every danger, for the child. Which of the two operations, therefore, ought to be preferred?

"Even if we could, without inconveniences to the woman, obtain a separation of two inches and an half between the ossa pubis after the section of their symphysis, the Cæfarean operation would still be the sole resource in cases of extreme deformity of the pelvis; the section of the pubes cannot enter into comparison

with it, except when the small diameter of the superior strait shall have, at least, an extent of two inches and an half. Though I suspended my judgment, at the time I published my first edition, concerning the preference to be given to one of these two methods, in the latter case, till I could procure more positive information of the innocence or danger of so considerable a separation; though I required that men who had no interest in vaunting this new method to the detriment of the former; in one word, that its adversaries should have seen a separation of two inches and an half, without a rupture of the sacro-iliac symphyses, and without inconveniences to make me adopt this new operation; at present, better informed on all these points, I am not afraid to reject it, and to affirm that no one has ever separated the ossa pubis two inches and a half without destroying the life of the woman. It has had no success but when it has been performed on pelvises at least two inches three quarters in the small diameter, and when the separation has been limited to much less than the point to which they fancied it was carried; in those cases, in fact, where it was absolutely useless; the pelvis being larger still, for I have found it to be more than three inches in some of the women. The section of the pubes cannot at present maintain any comparison with the Cæfarean operation; at most, it might be substituted for the forceps, in some particular cases only: for it cannot, without great inconveniences, give the pelvis an increase of more than two lines from the pubes to the sacrum superiorly; and that instrument may, without danger, reduce the diameter of the child's head as much. But what practitioner would prefer a new operation, which seems to be surrounded by rocks on every side, to one that has been crowned with a thousand successes? If we allow the former any advantages, they would never be more evident than in that species of locked head mentioned by Roederer, where we cannot (says he) introduce any instrument between the head and the pelvis, at whatever part we attempt it; in that case, it would merit a preference over opening the cranium, the use of the crochets, and the Cæfarean section proposed by the same author: it would be preferable also, in cases where the inferior strait is contracted transversely, provided that a small separation were sufficient to give that diameter the necessary extent."

PART III. OF DISORDERS SUBSEQUENT TO DELIVERY.

CHAP. I. Of the general 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 smarting foreness, 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 candler, 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 slipped in below, and brought up over her thighs and lips: 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 hypothermia.

For this reason the belly ought to be firmly compressed by the hands of an assistant, 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 less 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 consistency, 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 lago; 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. Every thing 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 last 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 whatsoever.

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 glycer

Flooding. Glysters, which will assist the labour, prevent the disagreeable exertion 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 costly 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 exertion 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 restlessness, 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 unnaturals 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 labour-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. II. 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 hemorrhagy 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 lassitude, 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 After-pains 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 immediately recourse to external application. If the disorder be owing to weakness, 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 hemorrhagy 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 astringent fluid, such as oxycrate, or red tart wine, may be applied to the back and belly. Some prescribe venesection in the arm, to the amount of five or six ounces, with a view of making reculsion; 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 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 above-mentioned liquids, in which a little alum or sachar-faturni 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 hemorrhagy, 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 aq. cinnamonis 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. III. 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 exter-

num, after the placenta is delivered: or, if these should be extracted, others will sometimes be formed, though 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 coagula 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 severer 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 soever 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. IV. 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 to 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 of 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 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 slow contraction of the vessels; because, previous to pus, there must have been lacerations and impollutions, 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. V. 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 distension 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 3d 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.

Milk-fever. 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 confed. cardiac. with mixtures composed of the cordial waters and volatile spirits: subastringents and opiates frequently administered, with the cort. Peruvian. in different forms, and austere 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 plenitude of the vessels in and about the uterus, occasioning tension, pain, and labour, in the circulating fluids; from whence proceed great heat in the part, restlessness, 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 intermitting: 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, 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, the 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 is much more easily relieved. Women of an 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 a 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. susp. 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
givers

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 abstemious, 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 ensue, the patient will be relieved; at the same time the milk must be extracted from her breasts, by sucking with the mouth or glasses: 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 cataplasms 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, milia erysips, 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 tumors; and no astringents ought to be applied, lest they should produce scirrhus swellings in the glands.

As the crisis of this fever, as well as of that last described, often consists in milia erysips 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. VI. 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 fulness, such as pains and flitches, 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 menses, 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.

Plate CCCXVI. fig. 1. represents a well formed pelvis.

AAAA, The ossa ilia, properly so called. aa, The iliac fossæ. bbbb, The angle which divides transversely and obliquely, from behind forward, the internal face of the os ilium into two parts, making part of the brim of the pelvis. cccc, The crista of the ossa ilia. ee, Their anterior superior spines. ff, The angle formed by the internal lip of the crista of the os ilium, to which is attached a ligament inserted at the other end in the transverse apophysis of the last lumbar vertebra. gg, The inferior angle of the os ilium, which makes part of the acetabulum.

BB, The os ischium. bb, Its tuberosities. ii, Its branches. kk, Its posterior part, making part of the acetabulum.

CC, The body of the os pubis. ll, Its angle. mm, Its posterior extremity, making part of the acetabulum. nn, Its descending branch, uniting with that of the ischium.

DDD, The os sacrum. 1, 2, 3, 4, The anterior holes. oooo, Its base. pp, The sides. q, The point. E, The coccyx. F, The last lumbar vertebra. rr, The transverse apophysis of that vertebra. ss, The ligament proceeding from the transverse apophysis of the last vertebra to the angle of the internal lip of the crista of the os ilium, marked ff. tt, Another ligament which descends from the same apophysis to the superior edge of the sacro-iliac symphysis.

GG, The femur or thigh-bone. VV, Its head received in the acetabulum. uu, The foramina ovalia.

H, The symphysis of the ossa pubis. II, The sacro-iliac symphyses. K, The sacro-vertebral symphysis.

Fig. 2. represents the superior strait of a well formed pelvis.

aa, The iliac fossæ. b, The sacro-vertebral angle, or projection of the sacrum. c, The last lumbar vertebra. dd, The lateral parts of the base of the sacrum. ee, The sacro-iliac symphyses. ff, The parts over the acetabula. g, The symphysis of the pubes.

The lines denote the different diameters of the superior strait. AB, The little diameter. CD, The transverse or great diameter. EF, GH, The oblique diameter, extending from the left acetabulum to the right sacro-iliac junction.

Fig. 3. shows the inferior strait of a well formed pelvis.

aa, The external faces of the ossa ilia. bb, Their anterior superior spines. cc, Their anterior inferior spines. dd, The acetabula. ee, The foramina ovalia, with the obturator ligaments. ff, The ischiatic tuberosities. gg, The ossa pubis. hh, The branches of the os pubis and ischium united. ii, The sacrum. k, The coccyx. ll, The sacro-ischial ligaments. m, The symphysis of the pubes. n, Its arch.

The

Fig. 10.

Fig. 13.

Fig. 11.

Fig. 12.

Fig. 14.

Fig. 15.

Fig. 16.

Explanation of the Plates.
The diameters of the inferior strait are marked by the lines. AA, The antero-posterior, or great diameter. BB, The transverse or little diameter. CC, DD, The oblique diameters.

Fig. 4. shows a deformed pelvis.

aa, The ossa ilia. bb, The ossa pubis. cc, The ossa ischia. ddd, The last lumbar vertebra. e, The projection of the sacrum. ff, The sacro-iliac symphysis. g, The symphysis of the pubes. b, The foramina ovalia. ii, The branches of the ossa pubis and ischia, which form the anterior arch of the pelvis. k, The acetabula.

AA, The antero-posterior diameter; the natural length being 14 or 15 lines. BB, The transverse diameter; the natural length four inches and ten lines. CC, The distance from the projection of the sacrum to that point of the margin which answers to the left acetabulum, being 13 lines. DD, The distance from the same point of the sacrum to that of the margin which answers to the right acetabulum, 20 lines.

Fig. 5. shows a vertical section of the pelvis.

A, A, A, A, The four last lumbar vertebrae. B, B, B, The os sacrum. CC, The coccyx. dd, The surface resulting from the section of the symphysis of the pubes. E, The left iliac fossa. F, The left side of the superior strait. G, The sacro-iliac ligament. H, The tuberosity of the ischium.

ii, The entrance of the vagina. K, one of the labia pudendi. L, The anus. M, The mons veneris. N, The left natis.

Plate CCCVII.
Fig. 10. gives a front-view of the uterus in situ, suspended in the vagina; the anterior parts of the ossa ilia, with the ossa pubis, pudenda, perineum, and being removed, in order to show the internal parts.

A, the last vertebra of the loins. BB, the ossa ilium. CC, the acetabula. DD, the inferior and posterior parts of the ossa ischium. 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 show 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 fimbriæ. MM, the ovaria. NN, the ligamenta lata and rotunda. OO, the superior part of the rectum.

Fig. 11. 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 amnion, the chorion being dissected off.

AA, 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. 12. In the same view and section of the parts as in fig. 10. shows the uterus as it appears in the second or third month of pregnancy.

F, the anus. G, the vagina, with its plicæ.

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

VOL. XI. Part II.

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. 13. 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 foetus entangled in the funis, the head presenting at the upper part of the pelvis.

BB, the superior part of the ossa ilium. CC, the acetabula. DD, the remaining posterior parts of the ossa ischium. E, the coccyx. F, the inferior part of the rectum. GGG, 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. 14. 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 ossa ilium. CC, the acetabula. DD, the ossa ischium. 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 foetuses 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.

LLL, the membranes belonging to each placenta.

Fig. 15. shows, 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 shown 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 nymphæ. 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. 16. shows the forehead of the foetus 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 ossa ischium.

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. 17. is principally intended to show in what manner the perineum and external parts are stretched by 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, swelled 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 tumor. GG, the parts that cover the tuberosities of the ossa ischium. H, the part that covers the os coccygis.

Fig. 18. shows 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.

ABC, 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 intestinum 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. 19. shows the head of the fetus, by strong labour-pains, squeezed into a longish form, with a tumor on the vertex, from a long compression of the head in the pelvis.

K, the tumor on the vertex. L, the forceps. M, the vesica 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. 20. shows, 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 appear closely joined to the body of the child.

Fig. 21. shows, 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. 22. gives a lateral internal view of a distorted pelvis, divided longitudinally, with the head of a fetus 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 ischium of the same side.

Fig. 23. gives a side view of a distorted pelvis, divided longitudinally, with the head of a full grown fetus squeezed into the brim, the parietal bones decussating each other, and compressed into a conical form.

ABC, the os sacrum and coccyx. D, the os pubis

of the left side. E, the tuberosity of the os ischium. F, the processus acutus. G, the foramen magnum.

Fig. 24. shows, in a front view of the pelvis, the breech of the fetus presenting, and dilating the os externum, the membranes being too soon broke.

Fig. 25. is the reverse of the former, the fore-parts of the child being to the fore part of the uterus.

Fig. 26. represents, in a front view of the pelvis, the fetus compressed, 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 ossa 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 part of the ossa pubis and ischium. FFFF, the membrana adiposa.

Fig. 26. represents, in the same view with fig. 27. the fetus in the contrary position; the breech and fore-parts 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.

Plate CCCVI. fig. 8. shows a deformed pelvis of which the small diameter of the superior strait is only 2 inches seven lines. The figure is triple: F. I. shows it in its natural state; F. II. the ossa pubis separated 18 lines; and F. III. with a separation of two inches and an half, in order to show the quantity of amplification which the section of the symphysis in such a pelvis can produce.

F. I. a a, the two last lumbar vertebrae; bbbb, the transverse apophyses of these vertebrae; cc, ligaments proceeding from the transverse apophyses of the last of these vertebrae to the middle and posterior part of the internal lip of the crista of the os ilium; dd, other ligaments descending from the same apophyses to the superior part of the sacro-iliac symphysis; e, the projection of the sacrum; ff, the lateral parts of the base of the sacrum; gg, part of the ossa ilia: the rest of those bones being concealed by F. II. and III.

bb, The bodies of the ossa pubis; ii, their angles.

kk, The ossa ischia; ll, the branches of these bones, and of the pubes.

m, The arch of the ossa pubis at the fore part of the pelvis.

nn, The foramina ovalia concealed by the ossa pubis of F. II. and III.

A, The symphysis of the ossa pubis seen perspectively. B B, the sacro-iliac symphyses.

F. II. oo, Part of the ossa ilia.

PP, The bodies of the ossa pubis; qq, their angles; rr, their articular facettes seen perspectively; ss, very small portions of the branches of the ossa pubis.

tt, The ossa ischia appearing behind the foramina ovalia of F. III.; uu, articular facettes of the ossa ilia, corresponding to similar ones observed at the sides of the sacrum.

F. III. vv, The ossa ilia; ww, their cristae; xx, the angle formed by the internal lip of the crista in the middle and posterior part of its length; yy, the anterior and superior

Explanation of the Plates. superior spines of the ossa ilia; ss, the anterior spines of these bones; SS, articular facettes of the ossa ilia, making part of the sacro-iliac symphyses.

1 1, The ossa pubis; 2 2, their angles; 3 3, their articular facettes seen perspective.

4 4, The ossa ischia; 5 5, the united branches of the ossa ischia and pubis; 6 6, the acetabula.

The lines indicate the natural size of the pelvis in the different directions in which they are traced; and their dotted extremities, the amplification which the superior strait acquires in those same directions at a separation of eighteen lines, and of thirty lines between the ossa pubis. Line I. Antero-posterior diameter of the superior strait, or the distance from the pubes to the projection of the sacrum; two inches seven lines. Line II. Transverse diameter of the superior strait, in its most extensive part; four inches seven lines. Line III. Oblique diameter of the superior strait, which extends from that point of the strait which corresponds with the anterior edge of the left acetabulum, to the right sacro-iliac junction; three inches eleven lines. Line IV. The other oblique diameter, which extends from that point of the strait which answers to the anterior edge of the right acetabulum, to the left sacro-iliac symphysis; four inches.

By giving the smallest attention to the relation of these dimensions to those which the head of a fetus of the usual size presents in their direction in time of labour, we shall see that they are very favourable; except the first, which is, strictly speaking, eleven lines too short, being only thirty-one lines in extent: whereas the transverse diameter of the head is commonly forty-two. It is only in this latter direction, and to the extent of eleven lines, that it would be necessary to augment the capacity of such a pelvis, to favour delivery. As the greater part of those who have performed this new operation, have only obtained a separation of eighteen lines or thereabouts between the ossa pubis, it is fixed at that degree in the second figure.

By such a separation in a pelvis perfectly similar to that here represented, the angle of each os pubis recedes from the centre of the projection of the sacrum three lines or very near beyond their natural distance from it. (See the lines V. and VI.) The antero-posterior diameter receives but the same increase, if we consider it as lengthened to the middle of the dotted line IX. IX. which marks the depth at which it may be presumed the lateral convexity of the head engages. Both the oblique diameters augment five lines before, and about two lines and an half backward; and the transverse diameter seven lines or very nearly.

It is evident, that a separation of eighteen lines on such a pelvis cannot remove the disproportion which exists between the small diameter of the superior strait and the small diameter of the child's head; since the former augments only three lines, considered in the most favourable point of view. The amplification which the other diameters receive from a similar separation, is absolutely useless; those diameters being naturally large enough.

Supposing that the ossa pubis recede in an equal degree, in separating two inches and an half, the angle

of each of them will remove from the centre of the projection of the sacrum, only six lines further than the distance they were from it before; which also gives an increase of but six lines between these two points. (See the lines VII. and V III.) The small diameter of the entrance of the pelvis does not gain much more, considering it to the middle of the dotted line XX. which marks the bounds beyond which the convexity of the head could not engage between the ossa pubis, even if the pelvis were divested of all its soft parts: which does not happen in the section of the pubes, for the neck of the bladder, the canal of the urethra, their cellular tissue, the anterior semicircle of the orifice of the uterus, and the anterior part of the vagina present at the opening and before the child's head. At this degree of separation, the transverse diameter augments about thirteen lines, and each oblique diameter nearly fourteen lines: a superfluous increase, since those diameters, in the pelvis represented, have all the length requisite for delivery.

The posterior extremities of the oblique diameters, which are dotted and marked with the figures XI and XII, show the separation which is to be feared in the sacro-iliac symphyses, by separating the ossa pubis two inches and an half. It was at that degree that Mr Baudelocque observed they were open in most of his experiments; since he could easily put the end of his finger, and even of his thumb, into them.

Admitting that the convexity of one of the sides of the child's head may let itself in between the ossa pubis separated to two inches and an half, as far as the dotted line X X, traced on that very convexity, it is evident that that separation cannot procure the relation of dimensions necessary for an easy delivery, when the pelvis has originally but two inches six or seven lines in the small diameter: whence it follows that the section of the pubes, supposing that we could obtain a separation of two inches and an half in the living woman without exposing her to disagreeable accidents, would not answer in the case of a pelvis similar to that represented in this plate.

Fig. 9. shows a pelvis with only 14 or 15 lines in the small diameter of its entrance, and four inches ten lines in the largest. The figure is triple like the former. F. I. represents it in its natural situation; F. II. with the ossa pubis separated two inches and a half; and F. III. with a separation of three inches. M. le Roy says, that he constantly obtained these two degrees of separation without any inconvenience.

F. I. aaa, The three last lumbar vertebrae. b, The projection formed by the last of those vertebrae, with the base of the sacrum. cc, The sides of the base of the sacrum. ddd, The transverse apophyses of the right side of the above mentioned vertebrae. ee, A ligament extending from the first of those apophyses to the angle made by the internal lip of the crista of the os ilium towards its middle and posterior part. ff, Another ligament which depends from that apophysis to the superior part of the sacro-iliac symphysis. gggg, Part of the os ilium. hh, The bodies of the ossa pubis: ii, their angles. kk, The ossa ischia. ll, The branches of the ossa ischia and pubis. m, The arch of the ossa pubis. nn, The foramina ovalia. A, the symphysis of the ossa pubis. BB, The sacro-iliac symphyses.

F. II. oooo, Part of the ossa ilia. ff, The articular facettes of the ossa ilia, making part of the sacro-iliac symphyses. pp, The bodies of the ossa pubis. gg, The angles of the ossa pubis separated two inches and an half. rr, The cartilaginous facettes of the ossa pubis seen perspectively. ss, The branches of the ossa ischia and pubes.

F. III. tt, The ossa ilia: uu, their cristæ: vv, their anterior superior spines: xx, their anterior inferior spines.

yy, The anterior inferior spines of the ossa ilia of F. II. zz, Their anterior articular facettes, making part of the sacro-iliac symphyses.

SS, The bodies of the ossa pubis: 11, their angles. 22, The articular facettes of each ossa pubis seen perspectively. 33, The united branches of the ossa pubis, and ischia seen perspectively.

44, The ossa ischia. 55, The foramina ovalia, behind which is seen part of the ossa ischia of F. II. 66, The acetabula.

The lines indicate the length of the different diameters of the superior strait, in the direction in which they are traced; and their dotted extremities, the amplification to be expected from a separation of two inches and an half, and of three inches.

Line I, The antero-posterior, or small diameter of the superior strait; one inch two or three lines. Line II, The transverse diameter of the same strait: this line, which is four inches ten lines in extent, passes under the projection of the sacrum. Line III, The distance from the middle and left lateral part of the projection of the sacrum, to that point of the margin of the pelvis which answers to the anterior edge of the acetabulum on the same side; one inch. Line IV, The distance from the middle and right lateral part of the projection of the sacrum, to that point of the margin which answers to the anterior edge of the acetabulum on the same side; one inch eight lines.

The relation of these dimensions to those of a child's head of the usual size, is such, that the small diameter of the latter, supposed always to be three inches and an half, surpasses the small diameter of the entrance of such a pelvis by 27 or 28 lines. This pelvis would be large enough in the direction of the line II, II.

By separating the ossa pubis two inches and an half, we augment the breadth of the entrance of the pelvis about three quarters of an inch in the direction of the line II, II: as much, or nearly in the direction of the line III, and only six lines in that of the line IV. The angle of each ossa pubis marked by the letter g, recedes from the centre of the projection of the sacrum, nine or ten lines beyond what it was distant from it before the separation of the bones: the entrance of the pelvis increases as much in the direction of the line V, and only half an inch in the course of the line VI. The small diameter, or the line I, continued to the middle of the dotted line IX, IX, which shows the depth to which the child's head may be let in between the ossa pubis separated two inches and an half, if the pelvis were divested of all its soft parts: this diameter will then be augmented only seven lines; whence we see that it would still be

an inch and an half, at least, shorter than the small diameter of the head of a child of the usual size.

The section of the pubes would therefore be fruitless on such a pelvis, if it could only procure a separation of two inches and an half; which seems a very exorbitant one. With more reason would it be unsuccessful, if we could separate the ossa pubis only 18 lines, as has most frequently happened; since it could not procure the proportion necessary for delivery, even if we could turn that separation entirely to the advantage of the small diameter of the superior strait.

Let us see if a separation of three inches could procure that proportion.

By separating the ossa pubis three inches, we augment the breadth of the pelvis 12 or 13 lines in the direction of the line II, II; 10 lines at most in the course of the line III; only seven in the line IV; about an inch in the line V; and only seven lines in the direction of the line VI: the angle of each ossa pubis recedes an inch farther from the projection of the sacrum, than the distance it was at before the separation of the bones; which augments the opening of the pelvis to the amount of an inch or thereabouts in the direction of the line VII, and only half an inch in the line VIII. The antero-posterior diameter of the entrance of this pelvis, considered as far as the middle of the dotted line X, X, which shows the greatest depth to which the child's head could be let in between the ossa pubis separated three inches, if the pelvis were divested of the soft parts, increases but 10 lines or thereabouts; which cannot remove the disproportion that existed before the section of the pubes, between that diameter and the thickness of the child's head which must pass in that direction. From whence we ought to conclude that this separation also would have no success, if the pelvis were as much deformed as that designed.

The dotted lines XI and XII, show the separation to be feared in the sacro-iliac symphyses, by separating the ossa pubis three inches.

The two other dotted lines, marked by the characters IX, IX, and X, X, show how far the child's head may be let in between the ossa pubis separated to the two degrees stated: they were traced on the convexity of a real head applied behind the ossa pubis in a pelvis stripped of its soft parts.

Plate CCCX, fig. 29, shows a well formed pelvis, the anterior part of which is taken away, to show one of the transverse positions of the face of the child, and explain more fully the mechanism of that kind of labour.

a, a, Part of the iliac fossæ. b, b, Part of the cristæ of the ossa ilia. c, c, Their anterior superior spines.

d, d, The ischiatic tuberosities. e, e, The acetabula. f, f, The thickness of the ossa ischia sown through vertically before their tuberosities.

g, g, The bodies of the ossa pubis sown through before the acetabula.

b, b, b, A circle representing a vertical section of the uterus, the anterior part of which is taken away in order to show the child. i, The child's chin. k, The posterior extremity of the head. l, l, l, The lever applied along the crown of the head, the extremity of it extending beyond the posterior fontanella.

m, The

m, The

Fig. 35. Fig. 36. Fig. 38.

Fig. 35: A long, curved, segmented instrument, possibly a forceps or a specialized delivery tool. Fig. 36: A thin, flexible, curved wire or probe. Fig. 38: A vertical, cylindrical instrument with a flared top and a handle, possibly a delivery cone or a specialized forceps.

Fig. 29.

Fig. 29: A midwife's hands are shown using a long, curved instrument to assist in the delivery of a fetus. The fetus is positioned in a delivery seat, and the instrument is being used to guide or support the birth process.

Fig. 30.

Fig. 30: A midwife's hands are shown using a long, curved instrument to assist in the delivery of a fetus. The fetus is positioned in a delivery seat, and the instrument is being used to guide or support the birth process.

Fig. 37.

Fig. 39: A long, curved, flexible instrument, possibly a delivery tool. Fig. 40: A small, conical instrument, possibly a delivery cone or a specialized forceps. Fig. 37: A long, curved, flexible instrument, possibly a delivery tool.

Fig. 31.

Fig. 31: A midwife's hands are shown using a long, curved instrument to assist in the delivery of a fetus. The fetus is positioned in a delivery seat, and the instrument is being used to guide or support the birth process.

m, The left lateral, and inferior part of the pelvis. n, A portion of the right lateral part of the uterine cavity. o, The left hand. p, q, The fore and middle fingers, placed at the sides of the nose, and pressing against the upper jaw. R, The right hand grasping the extremity of the lever.

Fig. 30. shows the same vertical section of a pelvis as the last; with the child's body entirely disengaged from it. The head grasped by the forceps is retained at the superior strait, with the occiput over the pubes, and the lower part of the fore-head against the projection of the sacrum.

a, a, The last lumbar vertebrae. d, d, The canal of these vertebrae, and of the sacrum. g, g, g, g, Spiny tubercles of the vertebrae above mentioned. b, b, b, b, The false vertebrae of the sacrum. c, c, c, The coccyx. e, e, The flattened portion of the anterior face of the sacrum.

f, The left sacro-iliac ligament. h, The cartilaginous and ligamentous facet of the left os pubis, making part of the symphysis.

i, The mons veneris. k, k, k, k, A circle representing the section of the uterus, the right side of which is taken away to show the head and the instrument. l, l, A portion of the placenta attached to the superior and anterior part of the uterus.

m, m, m, The female branch of the forceps applied on the left side of the head, which answers to the right side of the pelvis. n, n, The male branch of the forceps, applied at the left side of the pelvis, and the right side of the head. o, Part of the left small sacro-iliac ligament. P, Part of the left os ilium, the rest being concealed by the head.

q, The point to which we ought to bring the lower extremity of the forceps, in bringing the head down into the cavity of the pelvis.

R, The point of elevation at which the extremity of the forceps must be held, when the head occupies the bottom of the pelvis, after having replaced the face underneath.

Fig. 31. shows also the vertical section of a pelvis; but it is supposed to have only three inches six lines in the small diameter of its entrance. The base of the cranium is engaged in it in a transverse direction, the occiput being turned towards the left side, and the face to the right side; so that the greatest thickness of the head is still above the strait.

a, a, The two last lumbar vertebrae. b, b, b, b, b, The five false vertebrae of the sacrum. c, c, c, The three pieces of the coccyx. d, d, The canal of the aforesaid vertebrae. e, e, e, e, Their spinous apophyses. f, f, Part of the anterior face of the sacrum.

g, The left sacro-iliac ligament. h, The cartilaginous and ligamentous facet of the left os pubis, making part of the symphysis. i, The mons veneris.

k, k, k, k, A circle indicating the section of the uterus in the same direction as that of the pelvis. l, l, A portion of the placenta attached to the fundus of the uterus.

m, m, m, The female branch of the forceps, applied on the left side of the child's head, and under the symphysis of the pubes. n, n, n, The female branch of the forceps applied on the right side of the head, and before the sacrum. o, A dotted line, in the direction of which the instrument must be pulled to

bring down the head into the pelvis. p, The point of elevation at which the forceps must be held when the head is brought down to the bottom of the pelvis, after having turned the face into the curve of the os sacrum.

Plate CCCVI. fig. 6. shows M. Baudelocque's calipers for measuring the antero-posterior diameter of the superior strait.

a, a, The branches of the calipers. B, The hinge which unites the two branches. c, c, Lenticular buttons which terminate the branches. d, A graduated scale nine inches long, intended to demonstrate the thickness of the body comprised between the two branches. This scale is contained in a deep groove cut lengthwise in the branch of the calipers, from the letter c to the hinge B; and passes through a mortoise made in the other branch under the letter f. e, The place where the scale is united by a kind of hinge. f, A little screw with a flat head, designed to fix the scale, while we calculate the thickness of the body comprised between the two branches.

Fig. 7. shows the pelvimeter of M. Coutonli developed in the pelvis.

A, A, The first branch; whose square, B, is applied to the projection of the sacrum. C, c, A kind of hooks intended to keep the first branch in its place, while we introduce and develop the second. This has a dove-tailed groove, in which the body of the second branch is lodged and moved. d, d, the second branch of the instrument, whose square c is placed against the symphysis of the pubes. F, a scale four inches long, graduated in the branch d, d; and intended to show the degree of opening from the pubes to the sacrum.

Plate CCCVIII. fig. 21. 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, b, i, The point of the crotchet on the inside of the cranium.

Fig. 32. represents the forceps and blunt hook. Plate

A, the straight forceps, in the exact proportion as CCCIX. 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 11 inches and a half.

B represents the posterior part of a single blade, in order to show 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 scissars, 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 aforesaid opening, by which hold the head is to be gradually extracted. 2. The small end

is useful in abortion, in any of the first four or five months, to hook down the secundines, 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. 33. 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 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 in 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 show its degree of curvature and different parts.

Fig. 34. a, represents a pair of curved crotchets 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. 21. (Pl. ccviii.)

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

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

d, The scissars 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.

Plate CCCX. fig. 35. gives an anterior view of the improved lever by Roonhuyfen, an instrument now come into considerable reputation. Fig. 36. shows the same in profile. Fig. 37. the lever recommended

by M. Baudelocque. Fig. 38. one of the blades of a lever recommended by M. Herbinaux, fixed in the handle. Fig. 39. an anterior view of the same blade with the strap. Fig. 40. the spout of the syringe, when the instrument is used for injecting oil, or any other liquid into the uterus. The following is a general description of Roonhuyfen's lever, with the method of using it, as given by M. Previle, and added to his edition of Smellie's Midwifery. "The lever is an oblong piece of iron, 11 inches long, one broad, and about an eighth of an inch in thickness, it is straight in its middle for four inches, and becomes gradually curved at each extremity: the curves are of different lengths and depths; the edges are rounded; and the extremities for the space of an inch, and also the middle of the instrument, are directed to be covered with plaster, and then the whole of it to be sheathed with thin dogskin; taking care to avoid inequalities or folds, which might injure the woman or child. In using it, the accoucheur must introduce the fore finger of his left hand into the vagina near the anus, to serve as a guide for the instrument, which must now be gently insinuated between his finger and the head of the child, taking care that no part of the uterus be included between the lever and the head. The instrument must then be moved to the right and to the left, to find where there is the greatest space, and in some degree to loosen and disengage the head; and then gradually carried round, until it comes under the pubes, lifting the end of it from time to time, to obtain a freer passage. The handle of it must now be raised, and the instrument gently shifted about, until the occiput is exactly lodged in its curve. The more completely and exactly the curve touches and embraces the head, the more speedily and easily the delivery will be effected. The instrument being thus firmly and equally applied to the head, the accoucheur must slowly and uniformly raise the handle with his right hand, while with his left he presses the middle of it downward; by this means the coccyx is forced backward, and the lower part of the pelvis is enlarged. By continuing to raise the handle of the lever and to press down its middle or centre, the head of the child is made to descend into the dilated cavity of the vagina: and this is commonly effected in a few minutes; when the left hand must be applied firmly against the anus and perineum, forcing those parts upwards and forwards towards the orifice of the vagina, to prevent laceration; for which purpose also the whole operation must be performed slowly and cautiously, imitating as much as possible a natural labour."

"We found (add the authors of the paper,) a cord fixed round one of the ends of the instrument, about the middle of the curve. This cord, we imagine, served no other purpose than to point out the end of the instrument commonly made use of, or to measure the length of the part introduced."

DIRECTIONS FOR PLACING THE PLATES OF VOL. XI.

E R R A T U M.

In Vol. VIII. col. 2. marg. note 66. For inferiority, read superiority.