Midwifery is the art of assiting nature in bringing forth a perfect fetus, or child, from the womb of the mother.

The knowledge of this art depends greatly on an intimate acquaintance with the anatomy of the parts of generation in women, both internal and external. But, as those have already been fully described under the article Anatomy, we must refer to the different parts of that science upon which the knowledge of midwifery depends.

For the Bones of the Pelvis, see Anatomy, p. 171, &c.

For the Parts of Generation in Females, both external and internal, see Anatomy, p. 274, &c.

For the different theories of Conception, see Generation.

Of the increase of the Uterus after conception.

It is supposed, that the ovum swims in a fluid, which it absorbs so as to increase gradually in magnitude, till it comes in contact with all the inner surface of the fundus uteri; and this being distended in proportion to the augmentation of its contents, the upper part of the neck begins also to be stretched.

About the third month of gestation, the ovum in bigness equals a goose egg; and then nearly one fourth of the neck, at its upper part, is distended equal with the fundus. At the fifth month, the fundus is increased to a much greater magnitude, and rises upwards to the middle space betwixt the upper part of the pubes and the navel; and at that period, one half of the neck is extended. At the seventh month, the fundus reaches as high as the navel; at the eighth month, it is advanced midway between the navel and scrobiculus cordis; and in the ninth month, is raised quite up to this last mentioned part, the neck of the womb being then altogether distended. See Plate CXL, fig. 1, 2, 3. Fig. 1. Gives a front-view of the uterus in situ suspended in the vagina; the anterior parts of osa ilium, with the osa pubis, pudenda, perineum, and anus, being removed in order to shew the internal parts.

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

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

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

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

F, The anus. G, The vagina, with its plica. HH, The posterior and inferior part of the urinary bladder extended on each side; the anterior and superior part being removed. II, The mouth and neck of the womb, as raised up when examining the same by the touch, with one of the fingers in the vagina. KK, The uterus as stretched in the second or third month, containing the embryo, with the placenta adhering to the fundus.

Now that the whole substance of the uterus is stretched, the neck and os internum, which were at first the strongest, become the weakest part of the womb, and the stretching force being still continued by the increase of the fetus and secundines, which are extended by the inclosed waters in a globular form, the os uteri begins gradually to give way. In the beginning of its dilatation, the nervous fibres in this place, being more sensible than any other part of the uterus, are irritated, and yield an uneasy sensation; to alleviate which, the woman squeezes her uterus, by contracting the abdominal muscles, and at the same time filling the lungs with air, by which the diaphragm is kept down; the pain being rather increased than abated by this straining, is communicated to all the neighbouring parts, to which the ligaments and vessels are attached, such as the back, loins, and inside of the thighs; and by this compression of the uterus, the waters and membranes are squeezed against the os uteri, which is, of consequence, a little more opened. See fig. 4, 5, 6, of Plate-CXI.

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

A, The uterus as stretched to near its full extent, with the waters, and containing the fetus entangled in the funis, the head presenting at the upper part of the pelvis. BB, The superior part of the osa ilium. CC, The acetabula. DD, The remaining posterior parts of the osa ilium. E, The coccyx. F, The inferior part of the rectum. 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. 5. Gives a front view of twins in utero in the beginning of labour.

A, The uterus as stretched, with the membranes and waters. BB, The superior parts of the osa ilium. CC, The acetabula. DD, The osa ilium. E, The coccyx. F, The lower part of the rectum. GG, The vagina. H, The os internum stretched open about a fingerbreadth, with the membranes and waters in time of labour-pains. II, The inferior part of the uterus, stretched with the waters, which are below the head of the child that presents. KK, The two placentas adhering to the posterior part of the uterus, the two fetuses lying before them, one with its head in a proper position at the inferior part of the uterus, and the other situated preternaturally with the head to the fundus: the bodies of each are here entangled in their proper funis, which frequently happens in the natural as well as preternatural positions. LLL, The membranes belonging to each placenta.

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

A, The lowest vertebra of the back; the distance from which to the last mentioned vertebra is here shewn by dotted lines. CC, The usual thickness and figure of the uterus when extended by the waters at the latter end of pregnancy. D, The same contracted and grown thicker after the waters are evacuated.

EE, The figure of the uterus when pendulous.

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

G, The os pubis of the left side.

HH, The os internum.

I, The vagina.

K, The left nympha.

L, The labium pudendi of the same side.

M, The remaining portion of the bladder.

N, The anus.

OP, The left hip and thigh.

The woman being unable to continue this effort, for any length of time, from the violence of the pain it occasions, and the strength of the muscles being thereby a little exhausted and impaired, the contracting force abates; the tension of the os tineae being taken off, it becomes more soft, and contracts a little; so that the nervous fibres are relaxed. This remission of pain the patient enjoys for some time, until the same increasing force renews the stretching pains, irritation, and something like a tenesmus at the os uteri; the compression of the womb again takes place, and the internal mouth is a little more dilated, either by the pressure of the waters and membranes, or when the fluid is in small quantity, by the child's head forced down by the contraction of the uterus, which in that case is in contact with the body of the foetus.

See Plate CXL where

Fig. 7. Shews 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 osa ilchium.

A, The uterus contracted closely to the foetus 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.

In this manner the labour pains begin, and continue to return periodically, growing stronger and more frequent, until the os uteri is fully dilated, and the membranes are depressed and broke; so that the waters are discharged, the uterus contracts, and, with the assistance of the muscles, the child is forced along and delivered.

Of Abortions.

A miscarriage that happens before the tenth day, was formerly called an efflux, because the embryo and secundines are not then formed, and nothing but the liquid conception, or genitura, is discharged. From the tenth day to the third month it was known by the term expulsion, the embryo and secundines being still so small, that the woman is in no great danger from violent bleeding.

If she parted with her burden betwixt that period and the seventh month, she was said to suffer an abortion; in which case she underwent greater danger, and was delivered with more difficulty than before; because the uterus and vessels being more distended, a larger quantity of blood was lost in a shorter time, the foetus was increased in bulk, and the neck of the womb is not yet fully stretched: besides, should the child be born alive, it will be so small and tender that it will not suck, and scarce receive any sort of nourishment.

When delivery happens between the seventh month and full time, the woman is said to be in labour: but, instead of these distinctions, if she loses her burden at any time from conception to the seventh or eighth, or even in the ninth month, we now say indiscriminately, she has miscarried.

The common term of pregnancy is limited to nine solar months, reckoning from the last discharge of the catamenia: yet in some, though very few, uterine gestation exceeds that period.

Of false Conceptions and Moles.

It was formerly supposed, that if the parts of the embryo and secundines were not separated and distinctly formed from the mixture of the male and female semen, they formed a mass, which, when discharged before the fourth month, was called a false conception; if it continued longer in the uterus, so as to increase in magnitude, it went under the denomination of a mole. But these things are now to be accounted for in a more probable and certain manner. Should the embryo die (suppose in the first or second month,) some days before it is discharged, it will sometimes be entirely dissolved; so that, when the secundines are delivered, there is nothing else to be seen. In the first month, the embryo is so small and tender, that this dissolution will be performed in twelve hours; in the second month, two, three, or four days will suffice for this purpose; and even in the third month, it will be dissolved in fourteen or fifteen: besides the blood frequently forms thick lamina round the ovum, to the surface of which they adhere so strongly, that it is very difficult to distinguish what part is placenta, and what membrane. Even after the embryo and placenta are discharged, in the second or third month, the mouth and neck of the womb are often so closely contracted, that the fibrous part of the blood is retained in the fundus, sometimes to the fifth or seventh day; and when it comes off, exhibits the appearance of an ovum, the external surface, by the strong pressure of the uterus, resembling a membrane; so that the whole is mistaken for a false conception.

This substance, in bigness, commonly equals a pigeon or hen egg; or if it exceeds that size, and is longer retained, is distinguished by the appellation of mole: but this last generally happens in women betwixt the age of forty-five and fifty, or later, when their menstres begin to disappear; sometimes from internal or external accidents that may produce continued floodings. If the catamenia have have ceased to flow for some time in elderly women, and return with pain, such a symptom is frequently the fore-runner of a cancer; before or after this happens, sometimes a large flesh-like substance will be discharged with great pain, resembling that of labour; and upon examination, appears to be no more than the fibrous part of the blood, which assumes that form by being long pressed in the uterus or vagina.

In this place, it will not be amiss to observe, that the glands of the uterus and vagina will sometimes increase, and distend the adjacent parts to a surprising degree; if (for example) one of the glands of the uterus be so obstructed as that there is a pressure on the returning vein and excretory duct, the arterial blood will gradually stretch the smaller vessels, and consequently increase the size of the gland, which will grow larger and larger, as long as the force of the impelled fluid is greater than the resistance of the vessels that contain it; by which means, a very small gland will be enlarged to a great bulk, and the uterus gradually stretched as in uterine gestation, though the progress may be so slow as to be protracted for years instead of months. Nevertheless, the os internum will be dilated, and the gland (if not too large to pass) will be squeezed into the vagina, provided it adheres to the uterus, by a small neck; nay, it will lengthen more and more, so as to appear on the outside of the os externum; in which case, it may be easily separated by a ligature. This disease will be the sooner known and earlier remedied, the lower its origin in the uterus is. But should the gland take its rise in the vagina, hard by the mouth of the womb, it will shew itself still sooner, and a ligature may be easily introduced, provided the tumour is not so large as to fill up the cavity and hinder the neck of it from being commodiously felt. Though the greatest difficulty occurs, when the gland is confined to the uterus, being too much enlarged to pass through the os internum.

Sometimes all, or most of the glands in the uterus, are thus affected, and augment the womb to such a degree, that it will weigh a great many pounds, and the woman is destroyed by its pressure upon the surrounding parts; but, should this indolent state of the tumour be altered by any accident that will produce irritation and inflammation, the parts will grow schirrous, and a cancer ensue.

This misfortune, for the most part, happens to women, when their menstrual evacuations leave them; and sometimes (though seldom) to child bearing women, in consequence of severe labour.

Of the Placenta.

The ovum is formed of the placenta with the chorion and amnion, which are globularly distended by the inclosed waters that surround the child. The placenta is commonly of a round figure, somewhat resembling an oatcake, about six inches in diameter, and one inch thick in the middle, growing a little thinner towards the circumference: it is composed of veins and arteries, which are divided into an infinite number of small branches, the venous parts of which unite in one large tube, called the umbilical vein, which brings back the blood, and is supposed to carry along the nutritive fluid from the vessels of the chorion and placenta, to the child, whose belly it perforates at the navel; from thence passing into the liver, where it communicates with the vena portarum and cava. It is furnished with two arteries, which arise from the internal iliacs of the child, and running up on each side of the bladder, perforates the belly where the umbilical vein entered; then they proceed to the placenta, in a spiral line, twining round the vein, in conjunction with which they form the funiculus umbilicalis, which is commonly four or five hand-breadths in length, sometimes only two or three, and sometimes it extends to the length of eight or ten. The two arteries, on their arrival at the inner surface of the placenta, are divided and subdivided into minute branches, which at last end in small capillaries that inosculate with the veins of the same order. These arteries, together with the umbilical vein, are supposed to do the same office in the placenta which is afterwards performed in the lungs by the pulmonary artery and vein, until the child is delivered and begins to breathe; and this opinion seems to be confirmed by the following experiments. If the child and placenta are both delivered suddenly, or the last immediately after the first; and if the child, though alive, does not yet breathe; the blood may be felt circulating, sometimes slowly, at other times with great force, through the arteries of the funis to the placenta, and from thence back again to the child, along the umbilical vein. When the vessels are slightly pressed, the arteries swell between the pressure and the child; while the vein grows turgid between that and the placenta, from the surface of which no blood is observed to flow, although it be lying in a basin, among warm water. As the child begins to breathe, the circulation, though it was weak before, immediately grows stronger and stronger, and then in a few minutes the pulsation in the navel-string becomes more languid, and at last entirely stops. If, after the child is delivered, and the navel string cut, provided the placenta adheres firmly to the uterus, which is thereby kept extended; or, if the womb is still distended by another child; no more blood flows from the umbilical vessels, than what seemed to be contained in them at the instant of cutting; and this, in common cases, does not exceed the quantity of two or three ounces; and finally, when, in consequence of violent floodings, the mother expires, either in time of delivery, or soon after it, the child is sometimes found alive and vigorous, especially if the placenta is found; but if tore, then the child will lose blood as well as the mother.

The external surface of the placenta is divided into several lobes, that it may yield and conform itself more commodiously to the inner surface of the uterus, to which it adheres, so as to prevent its being separated by any shock or blows upon the abdomen, unless when violent.

Those groups of veins and arteries which enter into the composition of the placenta receive external coats from the chorion, which is the outward membrane of the ovum, thick and strong, and forms three fourths of the external globe that contains the waters and the child; the remaining part being covered by the placenta; so that these two in conjunction constitute the whole external surface of the ovum. Some indeed alledge, that these are enveloped with a cribriform or cellular substance, by which which they seem to adhere by contact only, to the uterus; and that the inner membrane of the womb is full of little glands, whose excretory ducts opening into the fundus and neck, secrete a soft thin mucus, to lubricate the whole cavity of the uterus, which beginning to stretch in time of gestation, the vessels that compose these glands are also distended; consequently, a greater quantity of this mucus is separated and retained in this cibriform and cellular substance, the absorbing vessels of which take it in, and convey it along the veins, for the nourishment of the child. The womb being therefore distended in proportion to the increase of the child, those glands are also proportionally enlarged; by which means, a larger quantity of the fluid is separated, because the nutriment of the child must be augmented in proportion to the progress of its growth; and this liquor undergoes an alteration in quality as well as in quantity, being changed from a clear thin fluid into the more viscous consistence of milk. In some cases this mucus hath been discharged from the uterus in time of pregnancy, and both mother and child weakened by the evacuation, which may be occasioned by the chorion's adhering too loosely, or being in one part actually separated from the womb.

Formerly, it was taken for granted by many, that the placenta always adhered to the fundus uteri; but this notion is refuted by certain observations, in consequence of which we find it as often sticking to the sides, back and fore parts, and sometimes as far down as the inside of the os uteri. See Plate CXL.

When the placenta is delivered, and no other part of the membrane tore except that through which the child passed, the opening is near the edge or side of the placenta, and seldom in the middle of the membranes; and a hog's bladder being introduced at this opening, and inflated, when lying in water, will show the shape and size of the inner surface of the womb, and plainly discover the part to which the placenta adhered.

The chorion is, on the inside, lined with the amnion, which is a thin transparent membrane, without any vessels so large as to admit the red globules of blood; it adheres to the chorion by contact, and seems to form the external coat of the funis umbilicalis.

This membrane contains the serum, in which the child swims: which fluid is supposed to be furnished by lymphatic vessels that open into the inner surface of the amnion. If this liquid is neither absorbed into the body of the fetus, nor taken into the stomach by suction at the mouth, there must be absorbing vessels in this membrane, in the same manner as in the abdomen and other cavities of the body, where there is a constant renovation of humidity.

The quantity of this fluid, in proportion to the weight of the fetus, is much greater in the first than in the last month of gestation, being in the one perhaps ten times the weight of the embryo; whereas, in the other, it is commonly in the proportion of one to two: for, six pounds of water surrounding a fetus that weighs twelve pounds, is reckoned a large proportion, the quantity being often much less; nay, sometimes there is very little or none at all.

In most animals of the brute species, there is a third membrane called allantois, which resembles a long and wide blind-gut, and contains the urine of the fetus: it is situated between the chorion and amnion, and communicates with the urachus that rises from the fundus of the bladder, and runs along with the umbilical vessels, depositing the urine in this reservoir, which is attached to its other extremity. This bag hath not yet been certainly discovered in the human fetus, the urachus of which, though plainly perceivable, seems hitherto to be quite imperforated.

From the foregoing observations upon nutrition, it seems probable, that the fetus is rather nourished by the absorption of the nutritive fluid into the vessels of the placenta and chorion, than from the red blood circulated in full stream from the arteries of the uterus to the veins of the placenta, and returned by the arteries of the last to the veins of the first, in order to be renewed, refined, and made arterial blood in the lungs of the mother.

Of the Child's Situation in the Uterus.

The embryo or fetus, as it lies in the uterus, is nearly of a circular or rather oval figure, which is calculated to take up as little space as possible: the chin rests upon the breasts, the thighs are pressed along the belly, the heels applied to the breech, the face being placed between the knees, while the arms cross each other round the legs. The head, for the most part, is down to the lower part of the uterus; and the child being contracted into an oval form, the greatest length is from head to breech: but the distance from one side to the other is much less than that from the fore to the back part; because the thighs and legs are doubled along the belly and stomach, and the head bended forwards on the breast. The uterus being confined by the vertebrae of the loins, the distance from the back to the fore-part of it must be less than from side to side; so that, in all probability, one side of the fetus is turned towards the back, and the other to the fore-part of the womb: but, as the back part of the uterus forms a little length cavity on each side of the vertebrae, the fore-parts of the fetus may therefore for the most part tilt more backwards than forwards.

It has been generally supposed, that the head is turned up to the fundus, and the breech to the os uteri, with the fore-parts towards the mother's belly; and that it remains in this situation till labour begins, when the head comes downwards, and the face is turned to the back of the mother. Some allege, that the head precipitates about the end of the eighth or beginning of the ninth month, by becoming specifically heavier than the rest of the body. Others affirm, that as the child increases in bulk, especially during the two last months, the proportion of surrounding water must be diminished, so as that it is confined in its motion, and, in struggling to alter its position, the head is moved to the os tincae, where it remains till delivery. The particulars of this and other theories may be found in Mauricieux, Le Motte, Simpson, and Old. But, from the following observations, it seems more probable, that the head is, for the most part, turned down to the lower part of the uterus from conception to delivery.

In the first month, according to some writers, the em- bryo exhibites the figure of a tadpole, with a large head and small body or tail, which gradually increases in magnitude, till the arms and thighs begin to bud or strut out, like small nipples, from the shoulders and breech: two black specks appear on each side of the head, with a little hole or opening between them, which in the second month are easily distinguished to be the eyes and mouth. See Plate CXI. fig. 2. The legs and arms are gradually formed, while the body turns larger; but the fingers are not separated or distinct, till the latter end of the second or beginning of the third month. See Plate CXI. fig. 3. This is commonly the case; but sometimes the bulk and appearance differ considerably in different embryos of the same age. The younger the embryo, the larger and heavier is the head in proportion to the rest of the body; and this is the case in all the different gradations of the fetus; so that when dropt or suspended by the navel string in water, the head must sink lowermost of course. Besides, when women miscarry in the fourth, fifth, sixth, and seventh months, the head for the most part presents itself, and is first delivered. See Plate CXI. fig. 3. By the touch in the vagina, the head is frequently felt in the seventh, sometimes in the sixth, but more frequently in the eighth month; and if the same women are thus examined, from time to time, till the labour begins, the head will always be felt of a round firm substance at the fore-part of the brim of the pelvis, betwixt the os internum and pubes, through the substance of the vagina and uterus. See Plate CXI. fig. 4. But all those opinions are liable to objections. If the descent of the head proceeded from its specific gravity, we would always find it at the os internum, because this reason would always prevail; if it were owing to a diminished proportion of water, why should we often find the breech presented, even when there is a quantity of that fluid large enough to give the head free liberty to rise again towards the fundus, or (according to the other opinion) to sink down by its specific gravity to the os internum? Some, indeed, suppose, that the head always presents itself, except when it is hindered by the funis umbilicalis twisting round the neck and body, so as to impede the natural progress: but, were this supposition just, when we turn and deliver by the feet those children that presented in a preternatural way, we should always find them more or less circumvolved by the navel-string: the funis is as often found twisted round the neck and body when the head presents as in any other case. That the head is downwards all the time of gestation, seems, on the whole, to be the most reasonable opinion, though it be liable to the objection already mentioned, and seems contradictory to the observation of some authors, who allege, that in opening women that died in the fifth, sixth, or seventh month, they have found the child's head towards the fundus uteri. But as it lies as easy in one posture as in another, till the birth, this dispute is of less consequence in the practice of midwifery. It may be useful to suggest; that the wrong posture of the child in the uterus may proceed,

1. From circumvolutions in the funis umbilicalis. See Plate CXIII. fig. 1. which represents, in a front view of the pelvis, the breech of the fetus presenting, and dilating the os internum, the membranes being too soon broke. The fore-parts of the child are to the posterior part of the uterus; and the funis, with a knot upon it, surrounds the neck, arms, and body.

Or, 2. When there is little or no water surrounding the child, it may move into a wrong position, and be confined thereby by the stricture of the uterus. See Plate CXIII. fig. 2, 3, 4.

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

Fig. 3. represents, in a front view of the pelvis, the 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 osa 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. EEEEE, The remaining parts of the osa pubis and ischium. FFFFF, The membrana adiposa.

Fig. 4. represents, in the same view with fig. 3, 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.

Or, lastly, The wrong position of the child may be the effect of a pendulous belly or narrow pelvis, when the head lies forward over the pubis. See Plate CXI. fig. 6. See also Plate CXII. fig. 6. and 7:

Fig. 6. 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. 7. 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.

Of Touching.

Touching is performed by introducing the fore-finger lubricated with pomatum into the vagina, in order to feel the os internum and neck of the uterus; and sometimes into the rectum, to discover the stretching of the fundus. By some, we are advised to touch with the middle finger, as being the longest; and by others, to employ both that and the first: but the middle is too much encumbered by that on each side, to answer the purpose fully, fully; and when two are introduced together, the patient never fails to complain. The design of touching is to be informed whether the woman is, or is not with child; to know how far she is advanced in her pregnancy; if she is in danger of miscarriage; if the os uteri be dilated; and in time of labour to form a right judgment of the case, from the opening of the os internum, and the pressing down of the membranes with their waters; and lastly, to distinguish what part of the child is presented.

It is generally impracticable to discover, by a touch in the vagina, whether or not the uterus is impregnated, till after the fourth month: then the best time for examination is the morning, when the woman is fasting, after the contents of the bladder and rectum have been discharged; and she ought, if necessary, to submit to the inquiry in a standing posture; because, in that case, the uterus hangs lower down in the vagina, and the weight is more sensible to the touch than when she lies reclined. One principal reason of our uncertainty is, when we try to feel the neck, the womb rises up on our pressing against the vagina, at the side of the os internum, (see Plate CXI. fig. 3.) and in some, the vagina feels very tense; but, when the fundus uteri is advanced near the navel, the pressure from above keeps down the os internum so much, that you can generally feel both the neck, and, above that, the stretching of the under part of the uterus. See Plate. CXI. fig. 3.

There is no considerable variation to be felt in the figure of the os internum, except in the latter end of pregnancy, when it sometimes grows larger and softer, (see Plate CXI. fig. 4.) nor do the lips seem to be more closed in a woman with child than in another, especially in the beginning of pregnancy: but, in both cases the os uteri is felt like the mouth of a young puppy or teesh. In some the lips are very small; in others, large; and sometimes, though seldom, smoothed over or pointed. In many women, who have formerly had children and difficult labours, the lips are large, and so much separated, as to admit the tip of an ordinary finger; but a little higher up, the neck seems to be quite closed.

In the first four months, the neck of the womb may be felt hanging down in the vagina, by pushing up the finger by the side of the os internum; but the stretching of the uterus and upper part of the neck cannot be perceived till the fifth, and sometimes the sixth month; and even then, the uterus must be kept down by a strong pressure upon the belly.

The stretching of the fundus is sometimes felt by the finger introduced into the rectum, before it can be perceived in the vagina; because, in this last method, the uterus recedes from the touch, and rises too high to be accurately distinguished; whereas the finger being introduced into the rectum, passes along the back of the womb almost to the upper part of the fundus, which, in an unimpregnated state, is felt flat on the back part and jetting out at the sides; but the impregnated uterus is perceived like a large round tumour.

About the fifth or sixth month, the upper part of the uterus is so much stretched, as to rise three or four inches above the os pubis, or to the middle space between that and the navel; so that, by pressing the hand on the belly, especially of lean women, it is frequently perceived; and if, at the same time, the index of the other hand be introduced in the vagina, the neck will seem shortened, particularly at the fore-part and sides, and the weight will be feebly felt; but, if the parietes of the abdomen are stretched after eating, one may be deceived by the pressure of the stomach, because weight and pressure are the same. But all these signs are more perceptible towards the latter end of pregnancy; and in some women the os internum is felt a little open some weeks before the full time, though generally it is not opened till a few days before labour begins.

From the fifth to the ninth month, the neck of the uterus becomes shorter and shorter, and the stretching of the womb grows more and more perceptible. In the seventh month, the fundus rises as high as the navel; in the eighth month, to the middle space betwixt the navel and scrobiculus cordis; and in the ninth, even to the scrobiculus, except in pendulous bellies: See Plate CXI. fig. 4. But all these marks may vary in different women; for when the belly is pendulous, the parts below the navel are much more stretched than those above, and hang over the os pubis; the fundus will then be only equal to, or a little higher than the navel; at other times, the uterus will rise in the latter end of the seventh or eighth month to the scrobiculus cordis. The neck of the womb will, in some, be felt as long in the eighth, as in others in the sixth or seventh month. This variation sometimes makes the examination of the abdomen more certain than the touch of the vagina; and so vice versa. At other times we must judge by both. See Plate CXI. fig. 6.

Of the signs of Conception, and the equivocal signs of pregnant and obstructed women.

The signs of pregnancy are to be distinguished from those that belong to obstructions, by the touch in the vagina and motion of the child, in the fifth or sixth month; sometimes, by the touch in the rectum, before and after the fifth month, when the tumour of the abdomen is plainly perceived.

Most women, a day or two before the irruption of the catamenia, labour under complaints proceeding from a plethora; such as stretching pains in the back and loins, inside of the thighs, breast and head; a sickness and oppression at the stomach, and a fulness of all the viscera of the abdomen; and all these symptoms abate, and gradually vanish, when the discharge begins and continues to flow. But, if the woman be obstructed by any accident or error in the non-naturals, all those complaints continue and increase, and are hardly distinguishable from the symptoms of pregnancy, till the end of the fourth month; at which period, women with child grow better, and all the complaints of fulness gradually wear off; whereas, those who are only obstructed, grow worse and worse. The fundus uteri, in the obstructed patient, is not stretched; the disorder in the stomach is not so violent as in a pregnant woman, and seldom accompanied with reachings; while the women with child is afflicted with a reaching every morning, and subject to longings besides. The first labours under a fulness of the vessels; the last, over and above this complaint, suffers an additional one from the distension of the uterus by the impregnated ovum. Obstructions and pregnancy are both accompanied by a stretching fullness in the breasts; but in the last only, may be perceived the areola, or brown ring, round the nipples, from which, in the last months, a thin serum dilutes; but this circle is not always so discernible as in the first pregnancy, and even then is uncertain as well as the others.

About the fifth or sixth month, the circumcribed tumour or stretching of the uterus is felt above the os pubis; and, by this circumscription and consistence, easily distinguished from the acites, or dropy of the abdomen: it is also rounder and firmer than those swellings that accompany obstructions, which proceed from a general fullness of the vessels belonging to the ligaments and neighbouring viscera.

On the whole, the difficulty of distinguishing between obstructions and pregnancy in the first months, is so great, that we ought to be cautious in giving our opinion; and never prescribe such remedies as may endanger the fruit of the womb; but rather endeavour to palliate the complaints, until time shall discover the nature of the case; and always judge on the charitable side, when life or reputation is at stake.

In the fifth or sixth month of uterine gestation, by the touch in the vagina, we perceive the neck of the womb considerably shortened, and the stretching of the lower part of the uterus is then sensibly felt between the mouth of the womb and the pubes, and on each side of the neck. See Plate CXL fig. 3.

In the seventh month, the head of the child is frequently felt resting against the lower part of the uterus, between the pubes and os internum; and being pushed upwards towards the fundus, sinks down again by its own gravity. All these diagnostics are more plain and certain, the nearer the patient approaches to the time of delivery.

Sometimes, the head is not felt till the eighth or ninth month; and in some few cases, not till after the membranes are broke, when it is forced down by the contraction of the uterus, and strong labour-pains. This circumstance may be owing to the head's resting above the basin, especially in a narrow pelvis; or to the diffusion of its belly with air after death, by which the fetus being rendered specifically lighter than the surrounding waters, the body floats up to the fundus, if there is a large quantity of fluid in the membranes; nor is the body always felt when the child lies across the uterus.

How to distinguish the false Labour from the true, and the means to be used on that occasion.

If the os uteri remains close shut, it may be taken for granted that the woman is not yet in labour, notwithstanding the pains she may suffer; with regard to which, an accurate inquiry is to be made; and if her complaints proceed from an over stretching fullness of the uterus or vessels belonging to the neighbouring parts, bleeding in the arm or ankle, to the quantity of six or eight ounces, ought to be prescribed, and repeated occasionally. If the pains are occasioned by a looseness or diarrhoea, it must be immediately restrained with opiates. Cholic pains are distinguished from those of labour, by being chiefly confined to the belly, without going off and returning by distinct intervals: they are for the most part produced by feces too long retained in the colon, or by such ingesta as occasion a rarefaction or expansion of air in the intestines; by which they are violently stretched and vexicated. This complaint must be removed by opening glysters, to empty the guts of their noxious contents: and this evacuation being performed, opiates may be administered to affluate the pains; either to be injected by the anus, taken by the mouth, or applied externally in form of epithem or embrocation.

Sometimes, the os internum may be a little dilated, and yet it may be difficult to judge whether or not the patient be in labour; the case, however, may be ascertained, after some attendance, by these considerations: if the woman is not arrived at her full time; if no soft or glary mucus hath been discharged from the vagina; if the pains are limited to the region of the belly, without extending to the back and inside of the thighs; if they are slight, and continue without intermission or increase; nay, if they have long intervals, and recur without force sufficient to push down the waters and membranes, or child's head, to open the os internum; if this part be felt thick and rigid, instead of being soft, thin, and yielding; we may safely pronounce, that labour is not yet begun; and those alarms are to be removed as we have directed in the case of false or cholic pains. Besides, if the pulse be quick and strong, and the patient attacked by stitches in the sides, back, or head, bleeding will be likewise necessary. See Plate CXL fig. 4.

The division of Labours.

A natural labour is when the head presents, and the woman is delivered by her pains and the assistance commonly given: but, should the case be so tedious and lingering, that we are obliged to use extraordinary force, in stretching the parts, extracting with the forceps, or (to save the mother's life) in opening the head and delivering with the crochet, it is distinguished by the appellation of laborious: and the preternatural comprehends all those cases in which the child is brought by the feet, or the body delivered before the head. Neither do we mind how the child presents, so much as the way in which it is delivered; for there are cases in which the head presents, and for several hours we expect the child will be delivered in the natural way; but if the woman has not strength enough to force down the child's head into the pelvis, or in floodings, we are at length obliged to turn and bring it by the feet, because it is so high that the forceps cannot be applied; and if the child is not large, nor the pelvis narrow, it were pity to destroy the hopes of the parents, by opening the skull and extracting with the crochet. In this case, therefore, although the child presents in a natural way, we are obliged to turn and deliver it in the same manner as if the shoulder, breast, or back, had presented; and generally, this operation is more difficult than in either of those cases, because, if the waters are all discharged, and the uterus close contracted round the fetus, it is more difficult to raise the head to the fundus. When the breech presents, we are frequently ly obliged to push it up, and search for the legs; which being found, we proceed to deliver the body, and lastly the head. If the head is large, or the pelvis narrow, and the waters not discharged, we ought, if possible, to turn the child into the natural position.

For a further illustration, and to inform young practitioners that difficult cases do not frequently occur, suppose, of three thousand women in one town or village, one thousand shall be delivered in the space of one year, and in nine hundred and ninety of these births, the child shall be born without any other than common assistance: fifty children of this number shall offer with the forehead turned to one side, at the lower part of the pelvis, where it will stop for some time; ten shall come with the forehead towards the groin, or middle of the pubes; five shall present with the breech; two or three with the face, and one or two with the ear; yet, all these shall be safely delivered, and the case be more or less lingering and laborious, according to the size of the pelvis and child, or strength of the woman; of the remaining ten that make up the thousand, six shall present with the head differently turned, and two with the breech; and these cannot be saved without stretching the parts, using the forceps or crotchet, or pushing up the child in order to bring it by the feet; this necessity proceeding either from the weakness of the woman, the rigidity of the parts, a narrow pelvis, or a large child, &c. The other two should lie across, and neither head nor breech, but some other part of the body, present, so that the child must be turned and delivered by the feet. Next year, let us suppose another thousand women delivered in the same place; not above three, six, or eight, shall want extraordinary assistance; nay, sometimes, though seldom, when the child is young, or unusually small, and the mother has strong pains and a large pelvis, it shall be delivered even in the very worst position, without any other help than that of the labour-pains.

As the head, therefore, presents right in nine hundred and twenty of a thousand labours, all such are to be accounted natural; those of the other seventy, that require assistance, may be deemed laborious; and the other ten to be denominated laborious or preternatural, as they are delivered by the head or feet.

In order, therefore, to render this treatise as distinct as possible, for the sake of the reader's memory, as well as of the dependance and connection of the different labours, they are divided in the following manner: that is accounted natural, in which the head presents, and the woman is delivered without extraordinary help; those births are called laborious or nonnatural, when the head comes along with difficulty, and must be assisted either with the hand in opening the parts, or with the fillet or forceps, or even when there is a necessity for opening and extracting it with the crotchet; and those in which the child is brought by the breech or feet, are denominated preternatural, because the delivery is performed in a preternatural way.

Of the different positions of women in Labour.

In almost all countries, the woman is allowed either to sit, walk about, or rest upon a bed, until the os uteri is pretty much dilated by the gravitation of the waters, or (when they are in small quantity) by the head of the fetus, so that delivery is soon expected; when she is put in such position as is judged more safe, easy, and convenient for that purpose: but the patient may be put upon labour too prematurely, and bad consequences will attend such mistakes.

Among the Egyptians, Grecians, and Romans, the woman was placed upon an high stool; in Germany and Holland they use the chair which is described by Deventer and Heister; and for hot climates the stool is perfectly well adapted; but in northern countries, and cold weather, such a position must endanger the patient's health.

In the West Indies, and some parts of Britain, the woman is seated on a stool made in form of a semicircle; in other places she is placed on a woman's lap; and some, kneeling on a large cushion, are delivered backwards.

In France the position is chiefly that of half sitting and half lying, on the side or end of a bed; or the woman being in naked bed, is raised up with pillows or a bed-chair.

The London method is very convenient in natural and easy labours; the patient lies in bed upon one side, the knees being contracted to the belly, and a pillow put between them to keep them asunder. But the most commodious method is to prepare a bed and a couch in the same room; a piece of oiled cloth or dressed sheep skin is laid across the middle of each; over the under-sheet, and above this, are spread several folds of linen, pinned or tied with tape to each side of the bed and couch; these are designed to sponge up the moisture in time of labour and after delivery, while the oiled cloths or sheep skins below preserve the feather-bed from being wetted or spoiled: for this purpose, some people lay besides upon the bed several under-sheets over one another, so that by sliding out the uppermost every day, they can keep the bed dry and comfortable.

The couch must be no more than three feet wide, and provided with castors; and the woman without any other dress than that of a short or half shift, a linen skirt or petticoat open before, and a bed-gown, ought to lie down upon it, and be covered with cloaths according to the season of the year. She is commonly laid on the left side, but in that particular she is to consult her own ease; and a large sheet being doubled four times or more, one end must be flung in below her breech, while the other hangs over the side of the couch, to be spread upon the knee of the accoucheur or midwife, who sits behind her on a low seat. As soon as she is delivered, this sheet must be removed, a soft warm cloth applied to the os externum, and the pillow taken from betwixt her knees: she then must be shifted with a clean, warm, half shift, linen skirt, and bed-gown, and her belly kept firm with the broad head-band of the skirt, the ends of which are to be pinned across each other. These measures being taken, the couch must be run close to the bed-side, and the patient gently moved from one to another; but, if there is no couch, the bed must be furnished with the same apparatus. Some, again, are laid across the foot of the bed, to the head of which the cloaths are previously turned up till after delivery, when the woman's posture is adapted, and then they are rolled down again to cover and keep her warm; by this expedient, the place of a couch is supplied, and the upper part of the bed preserved soft and clean; whereas those who are laid above the cloths must be taken up and shifted while the bed is put to rights; in which case, they are subject to fainting; and to such as are very much enfeebled, this fatigue is often fatal.

Women are most easily touched, least fatigued, and kept warmest, when they lie on one side; but if the labour should prove tedious, the Parisian method seems most eligible; because when the patient half sits, half lies, the brim of the pelvis is horizontal, a perpendicular line falling from the middle space between the scrobiculus cordis and navel, would pass exactly through the middle of the basin. In this position, therefore, the weight of the waters, and, after the membranes are broke, that of the child's head, will gravitate downwards, and assist in opening the parts; while the contracting force of the abdominal muscles and uterus, is more free, strong, and equal in this than in any other attitude. Wherefore, in all natural cases, when the labour is lingering or tedious, this or any other position, such as standing or kneeling, ought to be tried, which by an additional force, may help to push along the head, and alter its direction when it does not advance in the right way. Nevertheless, the patient must by no means be too much fatigued.

When the woman lies on the left side, the right hand must be used in touching, and vice versa; unless she is laid across the bed; in which case, either hand will equally answer the same purpose: but, if she lies athwart, with the breech towards the bed's foot, it will be most convenient to touch with the left hand when she is upon the left side, and with the right when in the opposite position. And here it will not be amiss to observe, that in the description of all the laborious and preternatural deliveries treated of in this performance, the reader must suppose the woman lying on her back, except when another posture is prescribed; and that in natural and laborious labours, whether she be upon her side or back, the head and shoulders are a little raised into a reclining posture, so that she may breathe easily, and assist the pains.

But in preternatural labours, when there is a necessity for using great force in turning the child, the head and shoulders must lie lower than the breech, which being close to the side or foot of the bed, ought to be raised higher than either, because when the pelvis is in this situation, the hand and arm are easily pushed up in a right line, along the back part of the uterus, even to its fundus. Sometimes, however, when the feet of the child are towards the belly of the mother, they are more easily felt and managed when she lies on her side. At other times, placing the woman on her knees and elbows on a low couch, according to Daventer's method, will succeed better, by diminishing in part the strong resistance from the pressure and weight of the uterus and child, by which the feet will sometimes be easier found and delivered: but then it is safer for the child, and easier to the operator and mother, to turn her to her back before you deliver the body and head.

Of the management of women in a Natural Labour.

If a woman come to full time, labour commonly begins and proceeds in the following manner.

The os uteri is felt soft, and a little opened; the circumference being sometimes thick, but chiefly thin: from this aperture is discharged a thick mucus, which lubricates the parts, and prepares them for stretching. This discharge usually begins some days before, and is accounted the forerunner of real labour: at the same time, the woman is seized at intervals with slight pains that gradually stretch the os uteri, fitting it for a larger dilatation; and when labour actually begins, the pains become more frequent, strong, and lasting.

At every pain, the uterus is strongly compressed by the same effort which expels the contents of the rectum at stool, namely the inflation of the lungs, and the contraction of the abdominal muscles.

If the child be surrounded with a large quantity of waters, (see Plate CXL fig. 4. and 6.) the uterus cannot come in contact with the body of it, but at every pain the membranes are pushed down by the fluid they contain, and the mouth of the womb being sufficiently opened by this gradual and repeated distention, they are forced into the middle of the vagina; then the uterus contracts and comes in contact with the body of the child, and, if it be small, the head is propelled with the waters. Here the membranes usually break; but, if that is not the case, they are pushed along towards the os externum, which they also gradually open, and appear on the outside, in the form of a large round bag. Meanwhile, the head advances, and the os externum being by this time fully dilated, is also protruded; when, if the membranes, instead of bursting in the middle of the protuberance, are tore all round at the os externum, the child's head is covered with some part of them, which goes under the name of the caul, or king's hood. If the placenta is, at the same time, separated from the uterus, and the membranes remain unbroken, the foetidines, waters, and child, are delivered together; but, if the placenta adheres, they must of course give way: and should they be tore all around from the placenta, the greatest part of the body as well as the head of the child will be enveloped by them, from which it must be immediately disengaged, that the air may have a free passage into the lungs.

When the head is large, so that it does not descend immediately into the pelvis, the membranes are forced down by themselves; and being stretched thinner and thinner, give way; when all the waters which are farther advanced than the head, run out; then the uterus coming in contact with the body of the child, the head is squeezed down into the mouth of the womb, which it plugs up so as to detain the rest of the waters. See Plate CXL fig. 6.

Sometimes, when the quantity of waters is very small, and the uterus embraces the body of the child, the head, covered with the membranes, is forced downwards, and gradually opens the os internum; but, at its arrival in the middle of the pelvis and vagina, part of the water will be pushed down before it, sometimes in a large, and sometimes in a small proportion, towards the back part of the pelvis. At other times, when the waters are in small quantity, no part of them are to be distinguished farther than the head, which descending lower and lower, the attenuated membranes are split upon it; while, at the same time, it fills up the mouth of the womb and up- per part of the vagina, in such a manner as hinders the few remaining waters from being discharged at once; though in every pain, a small quantity distills on each side of the head, for lubricating the parts, so as that the child may slip along the more easily.

The uterus contracts, the pains become quicker and stronger, the crown of the head is pushed down to the lower part of the pelvis, against one of the ischia, at its lower extremity; the forehead, being at the upper part of the opposite ischium, is forced into the hollow of the under part of the sacrum, while the vertex and hindhead is pressed below the os pubis, (see Plate, CXI. fig. 7,) from whence it rises in a quarter turn; gradually opening the os externum: the fronsam labiorum, or fourchette, primum, fundament, and the parts that intervene between that and the extremity of the sacrum, are all stretched outwards in form of a large tumour. The perineum, which is commonly but one inch from the os externum to the anus, is now stretched to three, the anus to two, and the parts between that and the coccyx are stretched from two inches to about three or more. The broad sacrofascial ligaments reaching from each side of the lower part of the sacrum, to the under part of each ischium, are also outwardly extended, and the coccyx is forced backward; while the crown of the head, where the lambdoidal crosses the end of the sagittal suture, continues to be pushed along, and dilates the os externum more and more. See

Plate CXII. fig. 1, which is intended principally 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 labour.

A, The abdomen. B, The labia pudendi. C, The clitoris and its prepuce. D, The hairy scalp of the fetus swelled at the vertex, in a laborious case, and protruded to the os externum. EF, The perineum and anus pushed out by the head of the fetus in form of a large tumour. GG, The parts that cover the tuberosities of the osa ischium. H, The part that covers the os coccygis.

When the head is so far advanced, that the back part of the neck is come below the under part of the os pubis, the forehead forces the coccyx, fundament, and perineum, backwards and downwards; then the hindhead rises about two or three inches from under the pubes, making a half round turn in its ascent, by which the forehead is equally raised from the parts upon which it pressed, and the perineum escapes without being split or torn: at the same time, the shoulders advance into the sides of the pelvis at its brim, where it is widest, and, with the body, are forced along and delivered; mean while, by the contraction of the uterus, the placenta and chorion are loosed from the inner surface to which they adhered, and forced through the vagina, out at the os externum.

When the head rests at first above the brim of the pelvis, and is not far advanced, the fontanelle may be plainly felt with the finger, commonly towards the side of the pelvis: this is the place where the coronal crosses the sagittal suture, and the bones are a little separated from each other, yielding a softness to the touch, by which may be distinguished four futures, or rather one crossing another. These may be plainly perceived, even before the membranes are broke; yet the examination must not be made during a pain, when the membranes are stretched down and filled with waters; but only when the pain begins to remit, and the membranes to be relaxed; otherwise they may be broke too soon, before the os internum be sufficiently dilated, and the head properly advanced.

When the vertex is come lower down, the sagittal future only is to be felt; because, as the hindhead descends in the pelvis, the fontanelle is turned more backwards, to the side, or towards the concavity of the sacrum: but, after it has arrived below the under part of the osa pubis, the lambdoidal may be felt crossing the end of the sagittal suture, the occiput making a more obtuse angle than that of the parietal bones, at the place where the three are joined together. But all these circumstances are more easily distinguished after the membranes are broke, or when the head is so compressed that the bones ride over one another, provided the hairy scalp be not excessively swelled. See Plate CXI. fig. 7.—See also

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

AABC, The vertebrae of the loins, os sacrum, and coccyx. D, The os pubis of the left side. E, The remaining part of the bladder. FF, The intestinum rectum. GGG, The uterus. H, The mons veneris. I, The clitoris, with the left nympha. H, The corpus cavernosum clitoridis. V, The meatus urinaris. 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.

How and when to break the Membranes.

If the child be surrounded with a large quantity of waters, the uterus cannot come in contact with the body so as to press down the head, until the membranes are pushed a considerable way before it into the vagina; nor even then, until they are broke, and the fluid diminished in such a manner as will allow the womb to contract, and, with the assistance of the pains, force along the child. When the membranes therefore are strong or unadvanced, and continue to long unbroke that the delivery is retarded, provided the os internum be sufficiently dilated, they ought to be broke without further delay; especially if the woman hath been much fatigued or exhausted with labour, or is seized with a violent flooding: in which case, the rupture of the membranes hastens delivery, and the hemorrhage is diminished by the contraction of the uterus, which lessens the mouths of the vessels that are also compressed by the body of the child.

The common method of breaking the membranes is by thrusting the finger against them when they are protruded with the waters during the pain, or by pinching them with the finger and thumb; but if they are detained too high to be managed in either of these methods, the hand may be introduced into the vagina, if the os externum is so lax as to admit it easily; and if this cannot be done without giving much pain, the fore and middle fingers being pushed into the vagina with the other hand, let a probe or pair of pointed scissors be directed along and between them, and thrust through the membranes, when they are pushed with the waters below the head. This operation must be cautiously performed, lest the head should be wounded in the attempt; and as for the membranes, let the opening be never too small, the waters are discharged with force sufficient to tear them asunder.

If the vertex, instead of resting at the side of the brim of the pelvis, or at the os pubis, is forced further down to the os internum, and the waters happen to be in small quantity, the head is pushed forwards, and gradually opens the mouth of the womb without any sensible intervention of the waters: then it advances by degrees into the vagina, and the membranes being split or torn, little or nothing is discharged until the body of the child be delivered: and in this case, the hair of the head being plainly felt, will be a sufficient indication that the membranes are broke. If no hair is to be felt, but a smooth body presents itself to the touch; and the woman has undergone many strong pains, even after the mouth of the womb hath been largely dilated, and the head forced into the middle of the pelvis; you may conclude, that delivery is retarded by the rigidity of the membranes; that there is but a small quantity of waters; and that, if the containing sacs were broke, the head would come along without further hesitation.

Sometimes, no waters can be felt while the head is no farther advanced than the upper part of the pelvis, because it plugs up the passage and keeps them from descending; but, as it advances downwards, the uterus contracts, and they are forced down in a small quantity towards the back part: from thence, as the head descends, or even though it should stick in that situation, they are pushed farther down, and the membranes may be easily broke; but the task is more difficult when no waters come down, and the membranes are contiguous to the head. In this case, they must be scratched a little during every pain, with the nail of a finger, which, though short and smooth, will, by degrees, wear them thinner and thinner, until they split upon the head by the force of labour. Yet this expedient ought never to be used until you are certain that delivery is retarded by their rigidity; for, if that be not the hindrance, the difficulty must proceed from the weakness of the woman, a large head, or narrow pelvis: in which case, the delivery is a work of time, and will be obstructed by the premature discharge of the waters, which by gradually passing by the head, ought to keep the parts moist and slippery, in order to facilitate the birth: for when the membranes are not broke until the head is forced into the middle of the pelvis, the largest part of it being then past the upper part of the sacrum, is commonly squeezed along, opens the os externum, and is delivered before all the waters are discharged from the uterus; so that what remains, by moistening and lubricating the parts, help the shoulders and body to pass with more ease. When the membranes are too soon broke, the under part of the uterus contracts sometimes so strongly before the shoulders, that it makes the resistance still greater.

In most natural labours, the space betwixt the fore and back fontanelles, viz. the vertex, prefers to the os internum, and the forehead is turned to the side of the pelvis; because the basin at the brim is widest from side to side; and frequently, before the head is pushed in and fat wedged among the bones, the child (after a pain) is felt to move and turn it to that side or situation in which it is least pressed and hurt, if it was not presenting in that position before; but this position of the head may alter, viz. in those where it is as wide, or wider, from the back part to the fore part of the brim, than from side to side, the forehead may be turned backwards or forwards. But this form of the pelvis seldom happens.

This posture is always observed in a narrow pelvis, when the upper part of the sacrum jets forward to the pubes; but, as the child is forced lower down, the forehead turns into the hollow at the inferior part of the sacrum, because the vertex and occiput find less resistance at the lower part of the os pubis than at the ischium, to which it was before turned; the pelvis being at the pubes, as formerly described, no more than two inches in depth, whereas at the ischium it amounts to four. If, therefore, the forehead sticks in its former situation, without turning into the hollow, it may be assisted by introducing some fingers, or the whole hand, into the vagina, during a pain, and moving it in the right position.

When the head of the fetus presents, and is forced along in any of those positions, the labour is accounted natural; and little else is to be done, but to encourage the woman to bear down with all her strength in every pain, and to rest quietly during each interval: if the parts are rigid, dry, or inflamed, they ought to be lubricated with pomatum, hog's lard, butter, or ung. althea: the two first are most proper for the external parts; and the two last (as being harder and not so easily melted) ought to be put up into the vagina, to lubricate that and the os internum.

The mouth of the womb and os externum, for the most part, open with greater difficulty in the first than in the succeeding labours, more especially in women turned of thirty. In these cases, the os externum must be gradually dilated in every pain, by introducing the fingers in form of a cone, and turning them round, so as to stretch the parts by gentle degrees; and the whole hand being admitted into the vagina, it will be sometimes found necessary to insinuate the fingers with the flat of the hand between the head and os internum: for, when this precaution is not taken in time, the os uteri is frequently pushed before the head (especially that part of it next the pubes) even through the os externum; or if the head passes the mouth of the womb, it will protrude the parts at the os externum, and will endanger a laceration in the perineum. perineum. This dilatation, however, ought to be cautiously performed, and never attempted except when it is absolutely necessary; even then it must be effected slowly, and in time of a pain, when the woman is least sensible of the dilating force.

When the labour happens to be lingering, though every thing be in a right posture, if the assistants are clamorous, and the woman herself too anxious and impatient to wait the requisite time without complaining, the labour will be actually retarded by her uneasiness, which we must endeavour to surmount by arguments and gentle persuasion; but if she is not to be satisfied, and strongly impressed with an opinion that certain medicines might be administered to hasten delivery, it will be convenient to prescribe some innocent medicine, that she may take between whiles, to beguile the time and please her imagination: but, if she is actually weak and exhausted, it will be necessary to order something that will quicken the circulating fluids, such as preparations of amber, castor, myrrh, volatile spirits, the pulv. myrrh. composit. of the London, or pulv. ad partum of the Edinburgh Pharmacopoeia, with everything in point of diet and drink that nourishes and strengthens the body. If the patient is of a plethoric habit, with a quick strong pulse, the contrary method is to be used, such as venesection, antiphlogistic medicines, and plentiful draughts of weak diluting fluids.

How to behave when the birth is obstructed by the navel-string or shoulders of the child, or a narrow pelvis.

Although the head is pushed down into the pelvis, and the vertex employed in opening the os externum, the forehead being lodged in the concavity formed by the coccyx and lower part of the sacrum; yet frequently after the labour-pain is abated, the head again is withdrawn by the navel-string happening to be twisted round the neck; or when the shoulders, instead of advancing, are retarded at the brim of the pelvis, one resting over the os pubis, while the other is fixed at the sacrum; or when (the waters having been long evacuated) the under-part of the uterus contracts round the neck and before the shoulders, keeping up the body of the child.

When the head is therefore drawn back by any of these obstacles, and the delivery hath been retarded during several pains, one or two fingers being introduced into the rectum before the pains goes off, ought to press upon the forehead of the child at the root of the nose, great care being taken to avoid the eyes: this pressure detains the head till the return of another pain, which will squeeze it farther down, while the fingers pushing slowly and gradually, turn the forehead half round outwards and half round upwards. By this assistance, and the help of strong pains, the child will be forced along, although the neck be entangled in the navel-string; for, as the child advances, the uterus contracts, and consequently the placenta is moved lower: the funis umbilicalis will also stretch a little, without obstructing the circulation.

The head being thus kept down, the shoulders too are pressed in every succeeding pain until they are forced into the pelvis, when the whole comes along without further difficulty. And this expedient will, moreover, answer the purpose, when the under-part of the uterus or os internum is contracted round the neck of the child, and before the shoulders; also, when the head is very low, pressing a finger on each side of the coccyx externally will frequently assist in the same manner; also in lingering cases, when the woman is weak, the head large, or the pelvis narrow, you may assist the delivery by gently stretching both the os externum and internum with your fingers, in time of the pains, which will increase the same, as well as dilate; but this is only to be done when absolutely necessary, and with caution, and at intervals, for fear of inflaming or lacerating the parts.

Over and above these obstacles, the head may be actually delivered and the body retained by the contraction of the os externum round the neck, even after the face appears externally. In this case it was generally alleged that the neck was close embraced by the os internum; but this seldom happens when the head is delivered, because then the os internum is kept dilated on the back-part and sides by the breast and arms of the fetus, unless it be forced low down with or before the head.

When the head is delivered and the rest of the body retained from the largeness or wrong presenting of the shoulders, or by the navel-string's being twisted round the body or neck of the child, the head must be grasped on each side; the thumbs being applied to the occiput, the fore and middle fingers extended along each side of the neck, while the third and fourth of each hand support each side of the upper jaw: thus embraced, the head must be pulled straight forwards; and if it will not move easily along, the force must be increased, and the directions varied from side to side, or rather from shoulder to shoulder, not by sudden jerks, but with a slow, firm, and equal motion. If the body cannot be moved in this manner, though you have exerted as much force as possible without running the risk of over-straining the neck, you must endeavour to slip the turns of the navel-string over the head: but should this be found impracticable, you ought not to trifle in tying the string at two places, and cutting betwixt the ligatures, as some people have advised: such an operation would engrofs too much time; besides, the child is in no danger of suffocating from the fracture of the funis, because it seldom or never breathes before the breast is delivered.

The better method is, immediately to slide along one or two fingers, either above or below, to one of the arm-pits; by which you try to bring along the body, while, with the other hand, you pull the neck at the same time: if it still continues unmoved, shift hands, and let the other arm-pit fulfill the force; but, if this fail, cut the navel-string, and tie it afterwards. If the shoulders lie so high that the fingers cannot reach far enough to cut or take sufficient hold, let the flat of the hand be run along the back of the child: or should the os externum be strongly contracted round the neck, push up your hand along the breast, and pull as before: and should this method fail, you must have recourse to the blunt hook introduced and fixed in the arm pit; but this expedient must be used with caution, lest the child should be injured, or the parts lacerated. The child being born, the funis umbilicalis must be divided, and the placenta delivered, according to the directions that will occur in the sequel.

How to manage the Child after Delivery.

The child being delivered, ought to be kept warm beneath the bed-cloths, or immediately covered with a warmed flannel or linen cloth: if it cries and breathes, the umbilical cord may be tied and cut, and the child delivered to the nurse without delay; but, if the air does not immediately rush into the lungs, and the circulation continues between it and the placenta, the operation of tying and cutting must be delayed, and every thing tried to stimulate, and sometimes to give pain. If the circulation is languid, respiration begins with difficulty, and proceeds with long intervals; and if it be entirely stopped in the funis; the child, if alive, is not easily recovered; sometimes, a great many minutes are elapsed before it begins to breathe. Whatever augments the circulating force, promotes respiration; and as this increases, the circulation grows stronger, so that they mutually assist each other. In order to promote the one and the other, the child is kept warm, moved, shaken, whipt; the head, temples, and breast rubbed with spirits, garlic, onion, or mustard applied to the mouth and nose; and the child has been sometimes recovered by blowing into the mouth with a silver canula, so as to expand the lungs.

When the placenta is itself delivered, immediately or soon after the child, by the continuance of the labour-pains, or hath been extracted by the operator, that the uterus may contract, so as to restrain too great a flooding; in this case, if the child has not yet breathed, and a pulsation is felt in the vessels, some people (with good reason) order the placenta, and as much as possible of the navel-string, to be thrown into a basin of warm wine or water, in order to promote the circulation between them and the child; others advise us to lay the placenta on the child's belly, covered with a warm cloth; and a third set order it to be thrown upon hot ashes; but, of these, the warm water seems the most innocent and effectual expedient. Nevertheless, if the placenta is still retained in the uterus, and no dangerous flooding ensues, it cannot be in a place of more equal warmth, while the operator endeavours, by the methods above described, to bring the child to life.

In lingering labours, when the head of the child hath been long lodged in the pelvis, so that the bones ride over one another, and the shape is preternaturally lengthened, the brain is frequently so much compressed, that violent convulsions ensue before or soon after the delivery, to the danger and oft-times the destruction of the child. This disorder is frequently relieved and carried off, and the bad consequences of the long compression prevented, by cutting the navel-string before the ligature is made, or tying it so slighty as to allow two, three, or four large spoonfuls to be discharged.

If the child has been dead one or two days before delivery, the lips and genitals (especially the scrotum in boys) are of a livid hue; if it hath lain dead in the uterus two or three days longer, the skin may be easily gript from every part of the body, and the navel-string appears of the same colour with the lips and genitals: in ten or fourteen days, the body is much more livid and mortified, and the hairy scalp may be separated with ease; and indeed, any part of the child which hath been strongly pressed into the pelvis, and retained in that situation for any length of time, will adopt the same mortified appearance.

How to tie the Funis Umbilicalis.

Different practitioners have used different methods of performing this operation: some proposing to tie and separate the funis before the placenta is delivered; to apply one ligature close to the belly of the child, with a view to prevent a rupture of the navel; and making another two inches above the former, to divide the rope between the two tyings: by the second ligature, they mean to prevent a dangerous hemorrhage from the woman, provided the placenta adheres to the uterus. But all these precautions are founded upon mistaken notions, and the following seems to be that which is safest and best: If the placenta is not immediately delivered by the pains, and no flooding obliges you to hasten the extraction, the woman may be allowed to rest a little, and the child to recover; if it does not breathe, or the respiration is weak, let the methods above prescribed be put in practice, with a view to stimulate the circulation; but if the child is lively, and cries with vigour, the funis may be immediately tied in this manner: having provided a ligature or two, composed of sundry threads waxed together, so as to equal the diameter of a pack-thread, being seven inches in length, and knotted at each end, tie the navel-string about two fingers breadth from the belly of the child, by making at first one turn, if the funis be small, and securing it with two knots; but if the cord be thick, make two more turns, and another double knot; then cut the funis with a pair of sharp scissors one finger's breadth from the ligature towards the placenta; and in cutting run the scissors as near as possible to the root of the blades, else the funis will be apt to slip from the edge, and you will be obliged to make several snips before you can effect a separation: at the same time, guard the points of the scissors with your other hand. The child being washed, a linen rag is wrapped round the tied funis; which being doubled up along the belly, a square compress is laid over it, and kept firm or moderately tight with what the nurses call a belly-band, or roller round the body.

This portion of the funis soon shrinks, turns first livid, then black, and about the fifth day falls off close to the belly; and let the navel-string be tied in any part, or at any distance whatsoever from the belly, it will always drop off at the same place: so that ruptures in the naval seldom or never depend upon the tying of the funis, but may happen when the compress and belly band are not kept sufficiently firm, and continued some time after the separation of the withered portion, especially in those children that cry much: the bandage ought always to be applied to flight as not to affect respiration.

The ligature upon the funis must always be drawn so tight as to shut up the mouths of the vessels: therefore, if they continue to pour out their contents, another ligature must be applied below the former; for if this pre- caution be neglected, the child will soon bleed to death: yet, if the navel-string is cut or tore slender at two or three hand-breadths from the belly, and exposed to the cold without any ligature, the arteries will contract themselves, so that little or no blood shall be lost; nay, sometimes, if the funis hath been tied and cut at the distance of three finger-breadths from the child's belly, so as that it hath been kept from bleeding for an hour or two, although the ligature be then untied, and the navel-string and belly chafed, and soaked in warm water, no more blood will be discharged.

Of delivering the Placenta.

The funis being separated, and the child committed to the nurse, the next care is to deliver the placenta and membranes, if they are not already forced down by the labour-pains. We have already observed, that if there is no danger from a flooding, the woman may be allowed to rest a little, in order to recover from the fatigue she has undergone; and that the uterus may, in contracting, have time to squeeze and separate the placenta from its inner surface: during which pause also, about one, two or three tea-cups full of blood is discharged through the funis, from the vessels of the placenta, which is thus diminished in bulk, so that the womb may be the more contracted; and this is the reason for applying one ligature only upon the cord. In order to deliver the placenta, take hold of the navel-string with the left hand, turning it round the fore and middle fingers, or wrapping it in a cloth, that it may not slip from your grasp; then pull gently from side to side, and desire the woman to assist your endeavour, by straining as if she were at stool, blowing forcibly into her hand, or provoking herself to reach by thrusting her finger into her throat. If by these methods the placenta cannot be brought away, introduce your hand slowly into the vagina, and feel for the edge of the cake; which when you have found, pull it gradually along; as it comes out at the os externum, take hold of it with both hands and deliver it, bringing away, at the same time, all the membranes, which, if they adhere, must be pulled along with leisure and caution.

When the funis takes its origin towards the edge of the placenta, which is frequently the case, the cake comes easier off by pulling, than when the navel-string is inserted in the middle, unless it be uncommonly retained by its adhesion to the womb, or by the strong contraction of the os internum. If the funis is attached to the middle of the placenta, and that part presents to the os internum or externum, the whole mass will be too bulky to come along in that position: in this case you must introduce two fingers within the os externum, and bring it down with its edge foremost.

When the placenta is separated by the contraction of the uterus, in consequence of its weight and bulk, it is pushed down before the membranes, and both are brought away inverted.

When part of the placenta hath passed the os internum, and the rest of it cannot be brought along by easy pulling, because the os uteri is close contracted round the middle of it, or part of it still adheres to the womb, slide the flat of your hand below the placenta through the os internum; and having dilated the uterus, slip down your hand to the edge of the cake, and bring it along: but, if it adheres to the uterus, push up your hand again, and having separated it cautiously, deliver it as before.

If instead of finding the edge or middle of the placenta presenting to the os externum or internum, you feel the mouth of the womb closely contracted, you must take hold of the navel-string as above directed, and slide your other hand along the funis into the vagina; then slowly push your fingers and thumb, joined in form of a cone, through the os uteri, along the same cord, to the place of its insertion in the placenta: here let your hand rest, and feel with your fingers to what part of the uterus the cake adheres: if it be loose at the lower edge, try to bring it along; but if it adheres, begin and separate it slowly, the back of your hand being turned to the uterus, and the fore-part of your fingers towards the placenta: and for this operation the nails ought to be cut short and smooth. In separating, press the ends of your fingers more against the placenta than the uterus; and if you cannot distinguish which is which, because both feel soft (though the uterus is firmer than the placenta, and this last more solid than coagulated blood;) in this case, slide down your fingers to its edge, and conduct them by the separated part, pressing it gently from the uterus, until the whole is disengaged. Sometimes, when part of it is separated, the rest will loosen and come along, if you pull gently at the detached portion; but, if this is not effected with ease, let the whole of it be separated in the most cautious manner: sometimes, also, by grasping the inside of the placenta with your hand, the whole will be loosened without further trouble. As the placenta comes along, slide down your hand and take hold of the lower edge, by which it must be extracted, because it is too bulky to be brought away altogether in a heap; and let it be delivered as whole as possible, keeping your thumb or fingers fixed upon the navel-string, by which means laceration is often prevented.

When the woman lies on her back, and the placenta adheres to the left side of the uterus, it will be most commodious to separate the cake with the right hand; whereas the left hand is most conveniently used when the placenta adheres to the right side of the womb; but when it is attached to the forepart, back, or fundus, either hand will answer the purpose.

That part of the uterus to which the placenta adheres, is kept still distended, while all the rest of it is contracted.

The nearer the adhesion is to the os internum, the easier is the placenta separated, and vice versa: because it is difficult to reach up to the fundus, on account of the contraction of the os internum, and lower part of the womb, which are not stretched again without great force after they have been contracted for any length of time.

When therefore the placenta adheres to the fundus, and all the lower part of the womb is strongly contracted, the hand must be forced up in form of a cone into the vagina, and then gradually dilate the os internum and inferior part of the uterus. If great force is required, exert it slowly, resting between whiles, that the hand may not be be cramped, nor the vagina in danger of being tore from the womb; for in this case, the vagina will lengthen considerably upwards.

While you are thus employed, let an assistant press with both hands on the woman's belly; or while you push with one hand, press with the other, in order to keep down the uterus, else it will rise high up, and roll about like a large ball, below the lax parietes of the abdomen, so as to hinder you from effecting the necessary dilatation.

When you have overcome this contraction, and introduced your hand into the fundus, separate and bring the placenta along, as above directed; and should the uterus be contracted in the middle like an hour-glass, a circumstance that sometimes, though rarely happens, the same method must be practised.

In every case, and especially when the placenta hath been delivered with difficulty, introduce your hand after its extraction, in order to examine if any part of the uterus be pulled down and inverted; and if that be the case, push it up and reduce it without loss of time, then clear it of the coagulated blood, which otherwise may occasion violent after-pains.

For the most part, in ten, fifteen, or twenty minutes, more or less, the placenta will come away of itself; and though some portion of it, or of the membranes, be left in the uterus, provided no great flooding ensues, it is commonly discharged in a day or two, without any detriment to the woman; but at any rate, if possible, all the secondaries ought to be extracted at once, and before you leave your patient, in order to avoid reflections.

OF LABORIOUS LABOURS.

How Laborious Labours are occasioned.

All those cases in which the head presents, and cannot be delivered in the natural way, are accounted more or less laborious, according to the different circumstances from which the difficulty arises; and these commonly are,

Firstly, Great weakness, proceeding from loss of appetite and bad digestion; frequent vomitings, diarrhoeas, or dysenteries, floodings, or any other disease that may exhaust the patient; as also the fatigue she may have undergone by unskilful treatment in the beginning of labour.

Secondly, From excessive grief and anxiety of mind, occasioned by the unsavourable news of sudden misfortune in time of labour; which often affect her so, as to carry off the pains, and endanger her sinking under the shock.

Thirdly, From the rigidity of the os uteri, vagina, and external parts, which commonly happens to women in the first birth, especially to those who are about the age of forty; though it may be also owing to large callosities, produced from laceration or ulceration of the parts; or to glands and ichorous tumours that block up the vagina.

Fourthly, When the under-part of the uterus is contracted before the shoulders, or the body entangled in the navel-string.

Fifthly, From the wrong presentation of the child's head; that is, when the forehead is towards the groin or middle of the os pubis; when the face presents with the chin to the os pubis, ischium, or sacrum; when the crown of the head rests above the os pubis, and the forehead or face is pressed into the hollow of the sacrum; and lastly, when one of the ears presents.

Sixthly, From the extraordinary ossification of the child's head, by which the bones of the skull are hindered from yielding, as they are forced into the pelvis; and form a hydrocephalus or dropy, distending the head to such a degree, that it cannot pass along until the water is discharged.

Seventhly, From a too small or distorted pelvis, which often occurs in very little women, or such as have been rickety in their childhood. See Plate CXII. fig. 6. 7.

In all these cases, except when the pelvis is too narrow and the head too large, provided the head lies at the upper-part of the brim, or (though pressed into the pelvis) can be easily pushed back into the uterus, the best method is, to turn the child and deliver by the feet; but, if the head is pressed into the middle or lower part of the pelvis, and the uterus strongly contracted round the child, delivery ought to be performed with the forceps; and in all the seven cases, if the woman is in danger, and if you can neither turn, nor deliver with the forceps, the head must be opened and delivered with crotchetts. Laborious cases, from some of the above recited causes, happen much oftener than those we call preternatural; but, those which proceed from a narrow pelvis, or a large head, are of the worst consequence. These cases demand greater judgment in the operator than those in which the child's head does not present; because in these last we know, that the best and safest method is to deliver by the feet; whereas in laborious births, we must maturely consider the cause that retards the head from coming along, together with the necessary assistance required; we must determine when we ought to wait patiently for the efforts of nature, and when it is absolutely necessary to come to her aid. If we attempt to succour her too soon, and use much force in the operation, so that the child and mother, or one of the two, are lost, we will be apt to reproach ourselves for having acted prematurely; upon the supposition, that if we had waited a little longer, the pains might have, by degrees, delivered the child; or at least, forced the head to low, as that we might have extracted it with more safety, by the assistance of the forceps. On the other hand, when we leave it to nature, perhaps by the strong pressure upon the head and brain, the child is dead when delivered, and the woman so exhausted with tedious labour, that her life is in imminent danger: in this case, we blame ourselves for delaying our help too long, reflecting that had we delivered the patient sooner, without paying such scrupulous regard to the life of the child, the woman might have recovered without having run such a dangerous risk. Doubtless it is our duty to save both mother and child, if possible; but, if that is impracticable, to pay our chief regard to the parent; and in all dubious cases, to act cautiously and circumspectly, to the best of our judgment and skill.

If the head is advanced into the pelvis, and the uterus strongly contracted round the child, great force is required to push it back into the womb, because the effort must be sufficient. sufficient to stretch the uterus, so as to re-admit the head, together with your hand and arm; and even then the child will be turned with great difficulty.

Should you turn when the head is too large, you may bring down the body of the child, but the head will stick fast above, and cannot be extracted without the help of forceps or crotchet; (see explanation of Plate CXIII. fig. 5, below;) yet the case is still worse in a narrow pelvis, even though the head be of an ordinary size. When things are so situated, you should not attempt to turn, because in so doing you may give the woman a great deal of pain, and yourself much unnecessary fatigue: you ought therefore to try the forceps, and if they do not succeed, diminish the size of the head, and extract it, as shall be afterwards shewn.

Plate CXIII. fig. 5. represents, in a lateral view of the pelvis, the method of extracting, with the assistance of a curved crotchet, the head of the fetus, 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 pelvis of the left side. EE, The uterus. F, The locking part of the crotchet. g,h,i. The point of the crotchet on the inside of the cranium.

Of the Fillets and Forceps.

We have already observed, that the greatest number of difficult and lingering labours proceed from the head's sticking fast in the pelvis, which situation is occasioned by one of the seven causes recited above: when formerly this was the case, the child was generally lost, unless it could be turned and delivered by the feet; or if it could be extracted alive, either died soon after delivery, or recovered with great difficulty from the long and severe compression of the head, while the life of the mother was endangered from the same cause as above described: for, the pressure being reciprocal, the fibres and vessels of the soft parts contained in the pelvis are bruised by the child's head, and the circulation of the fluids obstructed; so that a violent inflammation, and sometimes a sudden mortification, ensues. If the child could not be turned, the method practised in these cases, was to open the head and extract with the crotchet; and this expedient produced a general clamour among the women, who observed, that when recourse was had to the assistance of a man-midwife, either the mother or child, or both, were lost. This censure, which could not fail of being a great discouragement to male practitioners, stimulated the ingenuity of several gentlemen of the profession, in order to contrive some gentler method of bringing along the head, so as to save the child, without any prejudice to the mother.

Their endeavours have not been without success: a more safe and certain expedient for this purpose hath been invented, and of late brought to greater perfection in this than in any other kingdom; so that if we are called in before the child is dead, or the parts of the woman in danger of a mortification, both the fetus and mother may frequently be happily saved. This fortunate contrivance is no other than the forceps, which was, as is alleged, first used here by the Chamberlain, by whom it was kept as a nostrum, and after their decease imperfectly known, as to be seldom applied with success: so that different practitioners had recourse to different kinds of fillets or lacks. Blunt hooks also of various make were invented in England, France, and other parts. The forceps, since the time of Dr Chamberlain, have undergone several alterations, particularly in the joining, handles, form, and composition.

The common way of using them formerly, was by introducing each blade at random, taking hold of the head anyhow, pulling it straight along, and delivering with downright force and violence; by which means, both os internum and externum were often tore, and the child's head much bruised. On account of these bad consequences, they had been altogether disused by many practitioners; some of whom endeavoured, in lieu of them, to introduce divers kinds of fillets over the child's head; but none of them can be so easily used, or have near so many advantages, as the forceps, when rightly applied and conducted.

For my own part, says Dr Smellie, finding in practice that, by the directions of Chapman, Giffard, and Greigoire at Paris, I frequently could not move the head along without confusing it, and tearing the parts of the woman; for they direct us to introduce the blades of the forceps where they will easiest pass, and taking hold of the head in any part of it, to extract with more or less force, according to the resistance; I began to consider the whole in a mechanical view, and reduce the extraction of the child to the rules of moving bodies in different directions: in consequence of this plan, I more accurately surveyed the dimensions and form of the pelvis, together with the figure of the child's head, and the manner in which it passed along in natural labours: and from the knowledge of these things, I not only delivered with greater ease and safety than before, but also had the satisfaction to find in teaching, that I could convey a more distinct idea of the art in this mechanical light than in any other; and particularly, give more sure and solid directions for applying the forceps, even to the conviction of many old practitioners, when they reflected on the uncertainty attending the old method of application. From this knowledge, too, joined with experience, and hints which have occurred and been communicated to me, I have been led to alter the form and dimensions of the forceps, so as to avoid the inconveniences that attended the use of the former kinds. See Plate CXIII. fig. 6.

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

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

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

1. To assist the extraction of the head, after the cranium is opened with the scissors, by introducing the small end along the ear on the outside of the head to above the under-jaw, where the point is to be fixed; the other extremity of the hook being held with one hand, whilst two fingers of the other are to be introduced into the foresaid opening, by which holds the head is to be gradually extracted.

2. The small end is useful in abortions, in any of the first four or five months, to hook down the seconelines, 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.

The lacks or fillets are of different kinds, of which the most simple is a noose made on the end of a fillet or limber garter: but this can only be applied, before the head is fast jammed in the pelvis, or when it can be pushed up and raised above the brim. The os externum and internum having been gradually dilated, this noose must be conveyed on the ends of the fingers, and slipped over the fore and hind head. There are also other kinds differently introduced upon various blunt instruments, too tedious either to describe or use: but the most useful of all these contrivances, is a fillet made in form of a sheath, mounted upon a piece of slender whale-bone, about two feet in length, which is easier applied than any other expedient of the same kind. See Plate CXIII., fig. 7.

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

BB, Two views of a peffary for the prolapsus uteri. After the uterus is reduced, the large end of the peffary 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 peffary. This peffary 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 peffary 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.

When the head is high up in the pelvis, if the woman has been long in labour, and the waters discharged for a considerable time, the uterus being strongly contracted, so as that the head and shoulders cannot be raised, or the child turned to be delivered by the feet, while the mother is enfeebled, and the pains so weak, that, unless assisted, she is in danger of her life; also, when the os internum, vagina, and labia pudendi, are inflamed, and tumefied; or when there is a violent discharge of blood from the uterus, provided the pelvis is not too narrow, nor the head too large, this fillet may be successfully used; in which case, if the os externum and internum are not already sufficiently open, they must be gradually dilated as much as possible, by the hand, which at the same time must be introduced and passed along the side of the head, in order to ascertain the position thereof. This being known, let the other hand introduce the double of the whale-bone and fillet over the face and chin, where you can have the best purchase, and where it will be least apt to slip and lose its hold. This application being effected, let the hand be brought down, and the whale-bone drawn from the sheath of the fillet, which (after the ends of it are tied together) must be pulled during every pain, pressing at the same time with the other hand, upon the opposite part of the head, and using more or less force according to the resistance.

The disadvantage attending all fillets, is the difficulty in introducing and fixing them: and though this last is easier applied than the others; yet when the vertex presents, the child's chin is so preffed to the breast, that it is often impracticable to infinuate the fillet between them; and if it is fixed upon the face or hind head, it frequently slips off, in pulling: but, granting it commodiously fixed, when the head is large, or the pelvis narrow; so that we are obliged to pull with great force, the fillet will gall, and even cut the soft parts to the very bone; and if the child comes out of a sudden, in consequence of violent pulling, the external parts of the woman are in great danger of sudden laceration: but, if the head is small, and comes along with a moderate force, the child may be delivered by this contrivance, without any bad consequence: though in this case, we find by experience, that unless the woman has some very dangerous symptom, the head will in time slide gradually down into the pelvis, even when it is too large to be extracted with the fillet or forceps; and the child be safely delivered by the labour-pains, although slow and lingering, and the mother seems weak and exhausted, provided she be supported with nourishing and strengthening cordials.

As the head in the 6th and 7th cases is forced along the pelvis, commonly in these laborious cases, the bones of the cranium are so compressed, that they ride over one another, so that the bulk of the whole is diminished, and the head, as it is pushed forward, is, from a round, altered into an oblong figure: when therefore it is advanced into the pelvis, where it sticks fast for a considerable time, and cannot be delivered by the labour-pains, the forceps may be introduced with great ease and safety, like a pair of artificial hands, by which the head is very little (if at all) marked, and the woman very seldom tore. But if the head is detained above the brim of the pelvis, or a small portion of it only farther advanced, and it appears, that the one being too narrow, or the other too large, the woman cannot be delivered by the strongest labour-pains; in that case, the child cannot be saved either by turning and bringing it by the feet, or delivered by the application of fillet or forceps; but the operator must unavoidably use the disagreeable method of extracting with the crotcher. Nevertheless, in all these cases, the forceps ought first to be tried; and sometimes they will succeed beyond expectation, provided the birth is retarded by the weakness of the woman, and the second, third, fourth, or fifth obstructions: but they cannot be depended upon even when the vertex presents, with the forehead to the side or back part of the pelvis, and (though the woman has had strong pains for many hours after the membranes are broke) the head is not forced down into the pelvis, or at least, but an inconsiderable part of it, resembling the small end of a sugar-loaf. For, from these circumstances, you may conclude, that the largest part of it is still above the brim, and that either the head is too large, or the pelvis too narrow. Even in these cases, indeed, the last fillet or a long pair of forceps may take such firm hold, that, with great force and the strong purchase, the head will be delivered; but such violence is commonly fatal to the woman, by causing such an inflammation, and perhaps laceration of the parts, as is attended with mortification.

When the head is high, the forceps may be locked in the middle of the pelvis; but in that case, great care must be taken in feeling with the fingers all round, that no part of the vagina be included in the locking. Sometimes, when the head rests, or is pressed too much on the forepart or side of the pelvis, either at the brim or lower down, by introducing one blade, it may be moved farther down, provided the labour-pains are strong, and the operation assisted by the fingers of the other hand applied to the opposite side of the head; but if the fingers cannot reach high enough, the best method is to turn or move the blade towards the ear of the child, and introduce the other along the opposite side.

General rules for using the Forceps.

The farther the head is advanced in the pelvis, the easier it is delivered with the forceps; because then, if in the 6th or 7th case, it is changed from a round to an oblong figure, by being forced along by the labour-pains: on the contrary, when the head remains high up, resting upon the brim of the pelvis, the forceps are used with greater difficulty and uncertainty.

The os externum must be gradually opened by introducing the fingers one after another, in form of a cone, after they have been lubricated with pomatum, moving and turning them in a semicircular motion, as they are pushed up. If the head is so low down that the hand cannot be introduced high up in this form, let the parts be dilated by the fingers turned in the direction of the coccyx, the back of the hand being upwards, next to the child's head: the external parts being sufficiently opened to admit all the fingers, let the back of the hand be turned to the perineum, while the fingers and thumb being flattened, will slide along between the head and the os sacrum. If the right hand be used, let it be turned a little to the left side of the pelvis, because the broad ligament and membrane that fill up the space between the sacrum and ischia, will yield and allow more room for the fingers to advance; for the same reason, when the left hand is introduced, it must be turned a little to the right side. Having gained your point so far, continue to push up, until your fingers pass the os internum; at the same time, with the palm of your hand, raise or scoop up the head; by which means, you will be more at liberty to reach higher, dilate the internal parts, and distinguish the situation and size of the head, together with the dimensions of the pelvis: from which investigation, you will be able to judge, whether the child ought to be turned and brought by the feet, or delivered with the forceps; or, if the labour-pains are strong, and the head presents tolerably fair, without being jammed in the pelvis, you will resolve to wait some time, in hope of seeing the child delivered by the labour-pains, especially when the woman is in no immediate danger, and the chief obstacle is the rigidity of the parts.

The position of the head is distinguished by feeling for one of the ears, the fore or smooth part of which is towards the face of the child; if it cannot be ascertained by this mark, the hand and fingers must be pushed farther up, to feel for the face or back part of the neck; but, if the head cannot be traced, the observation must be taken from the fontanelle, or that part of the cranium where the lambdoidal crosses the end of the sagittal suture. When the ears of the child are towards the sides of the pelvis, or diagonal, the forehead being either to the sacrum or pubes, the patient must lie on her back, with her breech a little over the bed. If one ear is to the sacrum, and the other to the pubes, she must be laid on one side, with her breech over the bed, as before, her knees being pulled up to her belly, and a pillow placed between them; except when the upper part of the sacrum jets too much forward; in which case, she must lie upon her back, as above described.

The blades of the forceps ought always, if possible, to be introduced along the ears; by which means, they approach nearer to each other, gain a firmer hold, and hurt the head less than in any other direction: frequently, indeed, not the least mark of their application is to be perceived; whereas, if the blades are applied along the forehead and occiput, they are at a greater distance from each other, require more room, frequently at their points press in the bones of the skull, and endanger a laceration in the os externum of the woman. See Plate CXII., fig. 2.

The woman being laid in a right position for the application of the forceps, the blades ought to be privately conveyed between the feather-bed and the cloaths, at a small distance from one another, or on each side of the patient: that this conveyance may be the more easily effected, the legs of the instrument ought to be kept in the operator's side-pockets. Thus provided, when he sits down to deliver, let him spread the sheet that hangs over the bed, upon his lap, and under that cover, take out and dispose the blades on each side of the patient; by which means, he will often be able to deliver with the forceps, without their being perceived by the women herself, or any other of the assistants. Some people pin a sheet to each shoulder, and throw the other end over the bed, bed, that they may be the more effectually concealed from the view of those who are present: but this method is apt to confine and embarrass the operator. At any rate, as women are commonly frightened at the very name of an instrument, it is advisable to conceal them as much as possible, until the character of the operator is fully established.

The different ways of using the Forceps.

When the Head is down to the Os Externum.

When the head presents fair, with the forehead to the sacrum, the occiput to the pubes, and the ears to the sides of the pelvis, or a little diagonal; in this case, the head is commonly pretty well advanced in the basin, and the operator seldom miscarries in the use of the forceps. Things being thus situated, let the patient be laid on her back, her head and shoulders being somewhat raised, and the breech advanced a little over the side or foot of the bed; while the assistants sitting on each side support her legs, at the same time keeping her knees duly separated and raised up to the belly, and her lower parts always covered with the bed cloths, that she may not be apt to catch cold. In order to avoid this inconvenience, if the bed is at a great distance from the fire, the weather cold, and the woman of a delicate constitution, a chafing-dish with charcoal, or a vessel with warm water, should be placed near, or under the bed. These precautions being taken, let the operator place himself upon a low chair, and having lubricated with pomatum the blades of the forceps, and also his right hand and fingers, slide first the hand gently into the vagina, pushing it along in a flattened form, between that and the child's head, until the fingers have passed the os internum; then, with his other hand, let him take one of the blades of the forceps from the place where it was deposited, and introduce it betwixt his right hand and the head; if the point or extremity of it should stick at the ear, let it be flinted backward a little, and then guided forwards with a slow and delicate motion: when it shall have passed the os uteri, let it be advanced still farther up, until the rest at which the blades lock into each other be close to the lower part of the head, or at least within an inch thereof.

Having in this manner introduced one blade, let him withdraw his right hand, and insinuate his left in the same direction, along the other side of the head, until his fingers shall have passed the os internum; then taking out the other blade from the place of concealment, with the hand that is disengaged, let it be applied to the other side of the child's head, by the same means employed in introducing the first; then the left hand must be withdrawn, and the head being embraced between the blades, let them be locked in each other. Having thus secured them, he must take a firm hold with both hands, and, when the pain comes on, begin to pull the head along from side to side, continuing this operation during every pain until the vertex appears through the os externum, and the neck of the child can be felt with the finger below the os pubis; at which time, the forehead pushes out the perineum like a large tumour: then let him stand up, and raising the handles of the forceps, pull the head upwards also, that the forehead being turned half round upwards, the perineum and lower parts of the os externum may not be tore.

In stretching the os externum or internum, we ought to imitate nature: for in practice we find, that when they are opened slowly, and at intervals, by the membranes with the waters, or the child's head, the parts are seldom inflamed or lacerated: but in all natural labours, when these parts are suddenly opened, and the child delivered by strong and violent pains, without much intermission, this misfortune sometimes happens, and the woman is afterwards in great pain and danger.

We ought therefore, when obliged to dilate those parts, to proceed in that slow, deliberate manner; and though upon the first trial, they feel so rigid, that one would imagine they could never yield or extend; yet, by stretching with the hand, and resting by intervals, we can frequently overcome the greatest resistance. We must also, in such cases, be very cautious, pulling slowly, with intermissions, in order to prevent the same laceration: for which purpose too, we ought to lubricate the perineum with pomatum, during those short intervals, and keep the palm of one hand close pressed to it and the neighbouring parts, while with the other we pull at the extremity of the handles of the forceps; by which means, we preserve the parts, and know how much we may venture to pull at a time. When the head is almost delivered, the parts, thus stretched, must be flipped over the forehead and face of the child, while the operator pulls upwards with the other hand, turning the handles of the forceps to the abdomen of the woman.

This method of pulling upwards, raises the child's head from the perineum, and the half-round turn to the abdomen of the mother brings out the forehead and face from below; for, when that part of the hind-head which is joined to the neck, rests at the under-part of the os pubis, the head turns upon it, as upon an axis. In supernatural cases also, the body being delivered, must in the same manner be raised up over the belly of the mother, and at the same time the perineum slipt over the face and forehead of the child.

In the introduction of the forceps, let each blade be pushed up in an imaginary line from the os externum, to the middle space betwixt the navel and scrobiculatur cordis of the woman; or, in other words, the handles of the forceps are to be held as far back as the perineum will allow. The introduction of the other hand to the opposite side, will, by pressing the child's head against the first blade, detain it in its proper place till the other can be applied; or, if this pressure should not seem sufficient, it may be supported by the operator's knee.

When the head is come low down, and cannot be brought farther, because one of the shoulders rests above the os pubis, and the other upon the upper-part of the sacrum, let the head be strongly grasped with the forceps, and pushed up as far as possible, moving from blade to blade as you pull up, that the shoulders may be the more easily moved to the sides of the pelvis, by turning the face or forehead a little towards one of them; then, the forehead must be brought back again into the hollow of the sacrum, and another effort made to deliver: but, should the difficulty remain, let the head be pushed up again, and turned to the other side; because it is uncertain which of the shoulders rests on the os pubis, or sacrum. Suppose, for example, the right shoulder of the child sticks above the os pubis, the forehead being in the hollow of the sacrum; in this case, if the forehead be turned to the right-hand side of the woman, the shoulder will not move; whereas, if it be turned to the left, and the head at the same time pushed a little upwards, so as to raise and disengage the parts that were fixed, the right shoulder being towards the right hand side, and the other to the left side of the brim of the pelvis, when the forehead is turned back again into the hollow of the sacrum, the obstacle will be removed, and the head be more easily delivered. This being performed, let the forceps be unlocked, and the blades disposed cautiously under the cloaths so as not to be discovered; then proceed to the delivery of the child, which, when the navel-string is cut and tied, may be committed to the nurse. The next care is to wipe the blades of the forceps, singly, under the cloaths, slide them warily into your pockets, and deliver the placenta.

When the forehead is to the Os Pubis.

When the forehead, instead of being towards the sacrum, is turned forwards to the os pubis, the woman must be laid in the same position as in the former case; because here also, the ears of the child are towards the sides of the pelvis, or a little diagonally situated, provided the forehead is towards one of the groins. The blades of the forceps being introduced along the ears, or as near them as possible, according to the foregoing directions, the head must be pushed up a little, and the forehead turned to one side of the pelvis; thus let it be brought along, until the hindhead arrives at the lower part of the ilium: then the forehead must be turned backward, into the hollow of the sacrum, and even a quarter or more to the contrary side, in order to prevent the shoulders from hitching on the upper part of the os pubis, or sacrum, so that they may be still towards the sides of the pelvis; then let the quarter-turn be reversed, and the forehead being replaced in the hollow of the sacrum, the head may be extracted as above. In performing these different turns, let the head be pushed up or pulled down occasionally, as it meets with least resistance. In this case, when the head is small, it will come along as it presents; but if large, the chin will be so much pressed against the breast, that it cannot be brought up with the half-round turn, and the woman will be tore if it comes along. See Plate CXII, where

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

K, The tumour on the vertex. L, The forceps. M, The 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.

Vol. III, No. 78.

When it presents fair at the brim of the Pelvis.

When the forehead and face of the child are turned to the side of the pelvis, (in which case it is higher than in the first situation), it will be difficult, if the woman lies on her back, to introduce the forceps so as to grasp the head with a blade over each ear; because the head is often pressed so hard against the bones, in this position, that there is no room to insinuate the fingers between the ear and the os pubis, so as to introduce the blades safely, on the inside of the os internum, or push one of them up between the fingers and the child's head. When things are so situated, the best posture for the woman is that of lying on one side, as formerly directed, because the bones will yield a little, and the forceps (of consequence) may be the more easily introduced.

Suppose her lying on her left side, and the forehead of the child turned to the same side of the pelvis; let the fingers of the operator's right hand be introduced along the ear, between the head and the os pubis, until they pass the os internum: if the head is so immovably fixed in the pelvis, that there is no passage between them, let his left hand be pushed up between the sacrum and the child's head, which being raised as high as possible, above the brim of the pelvis, he will have room sufficient for his fingers and forceps; then let him slide up one of the blades, with the right hand, remembering to press the handle backwards to the perineum, that the point may humour the turn of the sacrum and child's head; this being effected, let him withdraw his left hand, with which he may hold the handle of the blade, already introduced, while he insinuates the fingers of his right hand at the os pubis, as before directed, and pushes up the other blade, slowly and gently, that he may run no risk of hurting the os internum or bladder; and here also keep the handle of it as far backwards as the perineum will allow; when the point has passed the os internum, let him slide it up farther, and join the legs by locking them together, keeping them still in a line with the middle space betwixt the navel and scrobiculus cordis. Then let him pull along the head, moving it from side to side, or from one ear of the child to the other; when it is sufficiently advanced, let him move the forehead into the hollow of the sacrum, and a quarter-turn farther, then bring it back into the same cavity; but, if the head will not easily come along, let the woman be turned on her back after the forceps have been fixed, and the handles firmly tied with a garter or fillet; let the hindhead be pulled half round outwards, from below the os pubis, and the instrument and child managed as before.

In all those cases that require the forceps, if the head cannot be raised above the brim of the pelvis, or the fingers introduced within the os internum, to guide the points of the forceps along the ears, especially at the os pubis, ilium, or sacrum; let the fingers and hand be pushed up as far as they will go, along the open space betwixt the sacrum and ilium; then one of the blades may be introduced, moved to, and fixed over the ear, the situation of which is already known: the other hand may be introduced, and the other blade conducted in the same manner, on the opposite side of the pelvis; but, before they are locked together, care must be taken that they are exactly opposite to each other, and both sufficiently introduced. In this case, if the operator finds the upper part of the sacrum jutting, in such a manner that the point of the forceps cannot pass it, let him try with his hand to turn the forehead a little backwards, so that one ear will be towards the groin and the other towards the side of that prominence; consequently, there will be more room for the blades to pass along the ears; but if the forehead should remain immovable, or though moved return to its former place, let one blade be introduced behind one ear, and its fellow before the other, in which case the introduction is sometimes more easily performed when the woman lies on her back, than when she is laid on one side. See Plate CXII. fig. 2.

When the Face presents.

When the face presents, resting on the upper part of the pelvis, the head ought to be pushed up to the fundus uteri, the child turned and brought by the feet, because the hind head is turned back on the shoulders, and, unless very small, cannot be pulled along with the forceps; but should it advance pretty fast in the pelvis, it will be sometimes delivered alive, without any resistance. But, if it descends slowly, or, after it is low down, sticks for a considerable time, the long pressure on the brain frequently destroys the child, if not relieved in time, by turning or extracting with the forceps.

When the head is detained very high up, and no signs of its descending appear, and the operator having stretched the parts with a view to turn, discovers that the pelvis is narrow, and the head large, he must not proceed with turning, because after this hath been performed, perhaps with great difficulty, the head cannot be delivered without the assistance of the crotchet. No doubt it would be a great advantage in all cases where the face or forehead presents, if we could raise the head so as to alter the bad position, and move it so, with our hand, as to bring the crown of the head to present; and indeed this should always be tried, and more especially, when the pelvis is too narrow, or the head too large; and when we are dubious of saving the child by turning; but frequently this is impossible to be done, when the waters are evacuated, the uterus strongly contracted on the child, and the upper part of the head so slippery as to elude our hold; insomuch that, even when the pressure is not great, we seldom succeed, unless the head is small, and then we can save the child by turning. If you succeed, and the woman is strong, go on as in natural labour; but, if this fails, then it will be more advisable to wait with patience for the descent of the head, so as that it may be delivered with the forceps; and consequently the child may be saved; but, if it still remains in its high situation, and the woman is weak and exhausted, the forceps may be tried; and, should they fail, recourse must be had to the crotchet; because the mother's life is always to be more regarded than the safety of the child.

When the face of the child is come down, and sticks at the os externum, the greatest part of the head is then squeezed down into the pelvis, and if not speedily delivered, the child is frequently lost by the violent compression of the brain; besides, when it is low down, it seldom can be returned, on account of the great contraction of the uterus. In this case, when the chin is turned towards the os pubis, at the lower part of that bone, the woman must be laid on her back, the forceps introduced, as formerly directed in the first case, and when the chin is brought out from under the os pubis, the head must be pulled half round upwards; by which means the fore and hind head will be raised from the perineum, and the under part of the os externum prevented from being tore.

If the chin points to either side of the pelvis, the woman must be laid on her side, the blades of the forceps introduced along the ears, one at the os pubis, and the other at the sacrum; and the chin, when brought lower down, turned to the pubis, and delivered: for the pelvis being only two inches in depth at this place, the chin is easily brought from under it, and then the head is at liberty to be turned half round upwards; because the chin being disengaged from this bone, can be pulled up over it externally; by which means, two inches of room, at least, will be gained, for the more easy delivery of the fore and hind head, which are now pressed against the perineum. When the chin is towards the sacrum, the hind head pressed back betwixt the shoulders, so that the face is kept from rising up below the os pubis, the head must be pushed up with the hand, to the upper part of the pelvis, and the forceps introduced and fixed on the ears; the hindhead must be turned to one side of the pelvis, while the chin is moved to the other side, and, if possible, to the lower part of the ilium; then the hind head must be brought into the hollow of the sacrum, with the chin below the os pubis, and delivered as above directed. If this cannot be done, let the operator try, with the forceps, to pull down the hind-head below the os pubis, and at the same time, with the fingers of the other hand, push the face and forehead backwards and upwards into the hollow of the sacrum.

For when the chin points to the back part of the pelvis, the forehead is squeezed against the os pubis, while the hind-head is pressed upon the back, betwixt the shoulders; so that the head cannot be delivered unless, the occupant can be brought out from below the os pubis, as formerly described. See Plate CXII. fig. 4, and 5.

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

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

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

The sum of all that has been said on this head, may be comprehended in the following general maxims.

Young practitioners are often at a loss to know and judge judge by the touch in the vagina, when the head is far enough down in the basin for using the forceps. If we were to take our observations from what we feel of the head at the os pubis, we should be frequently deceived; because in that place the pelvis is only two inches in depth, and the head will seem lower down than it really is: but if, in examining backwards, we find little or no part of it towards the sacrum, we may be certain that all the head is above the brim: if we find it down as far as the middle of the sacrum, one third of it is advanced; if as far down as the lower part, one half; and in this case, the largest part is equal with the brim. When it is in this situation, we may be almost certain of succeeding with the forceps; and when the head is so low as to protrude the external parts, they never fail. But these things will differ according to different circumstances, that may occasion a tedious delivery.

Let the operator acquire an accurate knowledge of the figure, shape, and dimensions of the pelvis, together with the shape, size, and position of the child's head.

Let the breech of the woman be always brought forwards, a little over the bed, and her thighs pulled up to her belly, whether she lies on her side or back, to give room to apply, and to move the forceps up or down, or from side to side.

Let the parts be opened and the fingers pass the os internum; in order to which, if it cannot be otherwise accomplished, let the head be raised two or three inches, that the fingers may have more room; if the head can be raised above the brim, your hand is not confined by the bones; for, as we have already observed, the pelvis is wider from side to side, at the brim, than at the lower part; if the fingers are not past the os uteri, it is in danger of being included between the forceps and the child's head.

The forceps, if possible, should pass along the ears, because, in that case, they seldom or never hurt or mark the head.

They ought to be pushed up in an imaginary line, towards the middle space between the navel and scrobiculus cordis, otherwise the ends will run against the sacrum.

The forehead ought always to be turned into the hollow of the sacrum, when it is not already in that situation. When the face presents, the chin must be turned to below the os pubis, and the hind-head into the hollow of the sacrum.

When the shoulders rest at the pubes, where they are detained, the head must be turned a large quarter to the opposite side, so as that they may lie towards the sides of the pelvis.

The head must always be brought out with an half round turn, over the outside of the os pubis, for the preservation of the perineum, which must at the same time be supported with the flat of the other hand, and slide gently backwards over the head.

When the head is so low as to protrude the parts, in form of a large tumour, and the vertex hath begun to dilate the os externum, but, instead of advancing, is long detained in that situation, from any of the forementioned causes of laborious cases, and the operator cannot exactly distinguish the position of the head, let him introduce a finger between the os pubis and the head, and he will frequently find the back part of the neck, or one ear, at the forepart, or towards the side of the pelvis: when the situation is known, he needs not stretch the os externum, and raise the head, as formerly directed; but he may introduce the forceps, and they being properly joined, and their handles tied, pull gently during every pain; or if the pains are gone, at the interval of four or five minutes, that the parts may be slowly dilated, as they are in the natural labour: but, when the situation cannot be known, the head ought to be raised. The same method may also be taken when the face presents, and is low in the pelvis, except when the chin is toward the back part: and in this case, the head ought to be raised likewise.

Almost all these directions are to be followed, except when the head is small, in which case it may be brought along by the force of pulling: but this only happens when the woman is reduced, and the labour-pains are not sufficient to deliver the child; for, the lower part of the uterus may be strongly contracted before the shoulders, and so close to the neck of the child, as to prevent its advancing, even when the head is so loose in the pelvis, that we can sometimes push our fingers all round it: and this is oftenest the occasion of preventing the head's being delivered when low in the pelvis. The difficulty, when high up, is from the restraint at the brim; and when it passes that, the head is seldom retained in the lower part, unless the patient is weak. In this case, we need not wait, because we are commonly certain of relieving the woman immediately with the forceps, by which you prevent the danger that may happen both to the mother and child, by the head's continuing to lodge there too long. This case should be a caution against breaking the membranes too soon, because the uterus may contract too forcibly and too long before the shoulders; when the head in this case is advanced one third or half way on the outside of the os externum, if the pains are strong, this last inconvenience is frequently remedied by introducing your two fingers into the rectum, as formerly directed: by these rules, delivery may (for the most part) be performed with ease and safety: nevertheless, the head is sometimes so squeezed and locked in the pelvis, and the hairy scalp so much swelled, that it is impracticable to raise up the head so as to come at the ears or os internum; or to distinguish the sutures of the skull, so as to know how the heads presents. In this case, the forceps must be introduced at random, and the uncertainty of the position generally removed by remembering, that in those cases, where the head is squeezed down with great difficulty, the ears are for the most part towards the os pubis and sacrum; and that the forehead seldom turns into the hollow of the sacrum, before the occiput is come down to the lower part of the ischium; and then rises gradually towards the under part of the os pubis, and the perineum and anus are forced down before it, in form of a large tumour.

On such occasions, the woman being laid on her side, if one ear is to the sacrum and the other to the os pubis, the blades of the forceps are to be introduced; and if they meet with any resistance at the points, they must not be forcibly thrust up, lest they pass on the outside of the os uteri, and tear the vagina, which, together with the womb womb, would be included in the instrument, and pulled along with the head; for this reason, if the blade does not easily pass, let it be withdrawn a little downwards, as before directed, and pushed up again, moving the point close to the head; if the ear obstructs its passage, let the point be brought a little outwards; and by these cautious efforts, it will at length pass without further resistance, and ought to be advanced a considerable way, in order to certify the operator that he is not on the outside of the os internum.

When the forceps are fixed, and the operator uncertain which way the forehead lies, let him pull slowly, and move the head with a quarter turn, first to one side and then to the other, until he shall have found the direction in which it comes most easily along.

If at any time we find the forceps begin to slip, we must rest, and push them up again gently; but, if they are like to slide off at a side, untie the handles, and move them so as to take a firmer hold, fix as before, and deliver. If we are obliged to hold with both hands, the parts may be supported by the firm application of an assistant's hand; for, without such cautious management, they will run a great risk of being lacerated; a misfortune which rarely happens, when the perineum is properly pressed back, and the head leisurely delivered. Sometimes, when the head is brought low down, you may take off the forceps, and help along with your fingers on each side of the coccyx, or in the rectum, as directed in the natural labour.

If the head is low down, the ears are commonly diagonal, or to the sides; and when the head is brought down one third, or one half, through the os externum, the operator can then certify himself, whether the forehead is turned to the coccyx or os pubis, by feeling with his finger for the back-part of the neck or ear, betwixt the os pubis and the head; and then move the head as above directed.

Let him try to alter with his hand every bad position of the head; and if it be detained high up in the pelvis, in consequence of the woman's weakness, the rigidity of the parts, the circumvolutions or shortness of the funis, or the contraction of the uterus over the shoulders of the child, the forceps will frequently succeed when the fetus cannot be turned; but, if the head is large, or the pelvis narrow, the child is seldom saved either by turning or using the forceps, until the head shall be farther advanced. And here it will not be amiss to observe, that the blades of the forceps ought to be new covered with strips of washed leather after they shall have been used, especially in delivering a woman suspected of having an infectious distemper.

The signs of a Dead Child.

When the head presents, and cannot be delivered by the labour-pains; when all the common methods have been used without success, the woman being exhausted, and all her efforts vain; and when the child cannot be delivered without such force as will endanger the life of the mother, because the head is too large or the pelvis too narrow; it then becomes absolutely necessary to open the head, and extract with the hand, forceps, or crotchet.

Indeed this last method formerly was the common practice when the child could not be easily turned, and is still in use with those who do not know how to save the child by delivering with the forceps: for this reason, their chief care and study was to distinguish whether the fetus was dead or alive; and as the signs were uncertain, the operation was often delayed until the woman was in the most imminent danger; or when it was performed sooner, the operator was frequently accused of rashness, on the supposition that the child might in time have been delivered alive by the labour-pains: perhaps he was sometimes conscious to himself of the justice of this imputation, although what he had done was with an upright intention.

The signs of a dead fetus were, first, the child's ceasing to move and stir in the uterus. Secondly, The evacuation of meconium, though the breech is not pressed into the pelvis. Thirdly, No perceivable pulsation at the fontanelle and temporal arteries. Fourthly, A large swelling or tumour of the hairy scalp. Fifthly, An uncommon laxity of the bones of the cranium. Sixthly, The discharge of a fetid ichor from the vagina, the effluvia of which surround the woman and gave rise to the opinion that her breath conveyed a mortified smell. Seventhly, Want of motion in the tongue, when the face presents. Eightly, No perceivable pulsation in the arteries of the funis umbilicalis, when it falls down below the head; nor at the wrist when the arm presents; and no motion of the fingers. Ninthly, The pale and livid countenance of the woman. Tenthly, A collapsing and flaccidity of the breast. Eleventhly, A coldness felt in the abdomen, and weight, from the child's falling like a heavy ball to the side on which she lies. Twelfthly, A separation of the hairy scalp on the slightest touch, and a distinct perception of the bare bones.

All or most of these signs are dubious and uncertain, except the last, which can only be observed after the fetus hath been dead several days. One may also certainly pronounce the child's death, if no pulsation hath been felt in the navel string for the space of twenty or thirty minutes; but the same certainty is not to be acquired from the arm, unless the skin can be stripped off with ease.

When the Crotchet is to be used.

Midwifery is now so much improved, that the necessity of destroying the child does not occur so often as formerly: indeed it never should be done, except when it is impossible to turn, or to deliver with the forceps; and this is seldom the case but when the pelvis is too narrow, or the head too large to pass, and therefore rests above the brim: for this reason, it is not so necessary for the operator to puzzle himself about dubious signs; because in these two cases, there is no room for hesitation: for if the woman cannot possibly be delivered in any other way, and is in imminent danger of her life, the best practice is undoubtedly to have recourse to that method which alone can be used for her preservation, namely, to diminish the bulk of the head.

In this case, instead of destroying, you are really saving a life; for, if the operation be delayed, both mother and child are lost. The method of using the Scissors, blunt Hook, and Crotchet.

When the head presents, and such is the case that the child can neither be delivered by turning, nor extracted with the forceps, and it is absolutely necessary to deliver the woman to save her life, this operation must then be performed in the following manner.

The operator must be provided with a pair of curved crotchets, made according to the improvements upon those proposed by Melsard, together with a pair of scissors about nine inches long, with rests near the middle of the blades, and the blunt hook.

Of the Woman's Posture.

The patient ought to be laid on her back or side in the same position directed in the use of the forceps; the operator must be seated on a low chair, and the instruments concealed and disposed in the same manner, and for the same reason mentioned in treating of the forceps. The parts of the woman have already, in all likelihood, been sufficiently dilated by his endeavours to turn or deliver with the forceps; or if no efforts of that kind have been used, because by the touch he had learned that no such endeavours would succeed, as in the case of a large hydrocephalus, when the bones of the cranium are often separated at a great distance from each other; or upon perceiving that the pelvis was extremely narrow: If, upon these considerations, he hath made no trials in which the parts were opened, let him gradually dilate the os externum and internum, as formerly directed.

The head is commonly kept down pretty firm, by the strong contraction of the uterus round the child; but should it yield to one side, let it be kept steady by the hand of an afflant, pressing upon the belly of the woman; let him introduce his hand, and press two fingers against one of the sutures of the cranium; then take out his scissors from the place in which they were deposited, and guiding them by the hand and fingers till they reach the hairy scalp, push them gradually into it, until their progress is stopped by the rests.

If the head slips aside, in such a manner, as that they cannot be pushed into the skull at the future, they will make their way through the solid bones, if they are moved in a semicircular turn, like the motion of boring, and this method continued till you find the point firmly fixed; for, if this is not observed, the points slide along the bones.

The scissors ought to be so sharp at the points, as to penetrate the integuments and bones when pushed with a moderate force; but not so keen as to cut the operator's fingers, or the vagina in introducing them.

The scissors being thus forced into the brain, as far as the rests at the middle of the blades, let them be kept firm in that situation; and the hand that was in the vagina being withdrawn, the operator must take hold of the handles with each hand, and pull them asunder, that the blades may dilate and make a large opening in the skull; then they must be flung, turned, and again pulled asunder, so as to make the incision crucial; by which means the opening will be enlarged, and sufficient room made for the introduction of the fingers: let them be afterwards closed, and introduced even beyond the rests; when they must again be opened, and turned half round from side to side, until the structure of the brain is so effectually destroyed, that it can be evacuated with ease.

This operation being performed, let the scissors be shut and withdrawn; but, if this instrument will not answer the last purpose, the business may be done by introducing the crotchet within the opening of the skull. The brain being thus destroyed, and the instrument withdrawn, let him introduce his right hand into the vagina, and two fingers into the opening which hath been made, that if any sharp splinters of the bones remain, they may be broken off and taken out; lest they should injure the woman's vagina, or the operator's own fingers.

If the case be an hydrocephalus, let him fix his fingers on the inside and his thumb on the outside of the opening, and endeavour to pull along the skull in time of a pain; but, if labour is weak, he must desire the woman to assist his endeavours by forcing down; and thus the child is frequently delivered; because, the water being evacuated, the head collapses of course.

But when the pelvis is narrow, the head requires much greater force to be brought along; unless the labour-pains are strong enough to press it down and diminish it, by squeezing out the cerebrum: in this case, let the operator withdraw his fingers from the opening, and, sliding them along the head, pass the os uteri; then, with his left hand, taking one of the crotchets from the place of its concealment, introduce it along his right hand, with the point towards the child's head, and fix it above the chin in the mouth, back part of the neck, or above the ears, or in any place where it will take firm hold: having fixed the instrument, let him withdraw his right hand, and with it take hold on the end or handle of the crotchet; then introduce his left to seize the bones at the opening of the skull (as above directed) that the head may be kept steady, and pull along with both hands.

If the head is still detained by the uncommon narrowness of the pelvis, let him introduce his left hand along the opposite side, in order to guide the other crotchet; which being also applied and locked or joined with its fellow, in the manner of the forceps, he must pull with sufficient force, moving from side to side, and as it advances, turn the forehead into the hollow of the sacrum, and extract as with the forceps, humouring the shape of the head and pelvis during the operation, which ought to be performed slowly, with great judgment and caution; and from hence it appears absolutely necessary to know how the head presents, in order to judge how the crotchet must be fixed, and the head brought along to the best advantage.

If, when the head is delivered in this manner, the body cannot be extracted, on account of its being much swelled, of a monstrous size, or (which is most commonly the case) the narrowness of the pelvis; let him desist from pulling, lest the head should be separated from the body, and introducing one hand so as to reach with his fingers to the shoulder-blades or breast, conduct along it one of the crotchets, with the point towards the face, and fix it with a firm application; then withdrawing his hand, employ it in pulling the crotchet, while the other... is exerted in the same manner upon the head and neck of the child: if the instrument begins to lose its hold, he must push it farther up, and fixing it again, repeat his efforts, applying it still higher and higher, until the body is extracted.

Of Preternatural Labours.

Preternatural labour happens, when, instead of the head, some other part of the body presents to the os uteri. Preternatural labours are more or less difficult according to the presentation of the child, and the contraction of the uterus round its body. The nearer the head and shoulders are the os internum or lower part of the uterus, the more difficult is the case; whereas, when the head is towards the fundus, and the feet or breech near the os internum, it is more easy to turn and deliver.

To begin with the easiest of these first, it may be proper to divide them into three classes. First, how to manage when the feet, breech, or lower parts present. Secondly, how to behave in violent floodings; and, when the child presents wrong before the membranes are broke, how to save the waters in the uterus, that the fetus may be the more easily turned: and what method to follow even after the membranes are broke, when all the waters are not evacuated. Thirdly, how to deliver when the uterus is strongly contracted; the child presenting either with the fore or back parts; and lying in a circular form, or with the shoulders, breast, neck, face, ear, or vertex, and lying in a length form, with the feet and breech towards the fundus of the womb, which is contracted like a long sheath, close to the body of the fetus; and when the fore-parts of the child lie towards the side, fundus, fore or back part of the uterus.

The first class of Preternatural Labours. When the feet, breech, or lower parts of the fetus present, and the head, shoulders, and upper parts are towards the fundus.

These, for the most part, are accounted the easiest, even although the uterus should be strongly contracted round the body of the child, and all the waters discharged.

If the knees or feet of the child present to the os internum, which is not yet sufficiently dilated to allow them and the body to come farther down; or, if the woman is weak, wore out with long labour, or endangered by a flooding; let the operator introduce his hand into the vagina, push up and stretch the os uteri, and bring along the feet; which being extracted, let him wrap a linen cloth round them, and pull until the breech appears on the outside of the os externum: if the face or fore-part of the fetus is already towards the back of the uterus, let him persist in pulling in the same direction; but, if they are towards the os pubis, or to one side, they must be turned to the back-part of the uterus; and as the head does not move round equal with the body, he must make allowance for the difference in turning, by bringing the last one quarter farther than the place at which the head is to be placed; so that the face or forehead which was towards one of the groins will be forced to the side of the sacrum, where it joins with the ilium. This quarter turn of the body must be again undone, without affecting the position of the head; a cloth may be wrapped round the breech, for the convenience of holding it more firmly; then, placing a thumb along each side of the spine, and with his fingers grasping the belly, let him pull along the body from side to side, with more or less force, according to the resistance: when the child is delivered as far as the shoulders, let him slide his hand flattened (suppose the right, if she lies on her back) between its breast and the perineum, coccyx, and sacrum of the woman, and introduce the fore or middle finger (or both, if necessary) into the mouth of the fetus; by which means, the chin will be pulled to the breast, and the forehead into the hollow of the sacrum. And this expedient will also raise upwards the hindhead, which rests at the os pubis.

When the forehead is come so low as to protrude the perineum, if the woman lies on her back, let the operator stand up, and pull the body and head of the child upwards, bringing the forehead with an half-round turn from the under part of the os externum, which will thus be defended from laceration. The application of the fingers in the child's mouth will contribute to bring the head out in this manner, prevent the os externum from hitching on the chin, help along the head, and guard the neck from being overstrained; a misfortune which would infallibly happen, if the forehead should be detained at the upper part of the sacrum: nor is there any great force required to obviate this inconvenience, or the least danger of hurting the mouth, if the head is not large: for, if the head cannot be brought along with moderate force, and the operator is afraid of injuring or over-straining the lower jaw, let him push his fingers farther up, and press on each side of the nose, or on the inferior edges of the sockets of the eyes. If the legs are come out, and the breech pulled into the vagina, there is no occasion for pushing up to open, but only to pull along and manage as above directed; still remembering to raise the forehead slowly from the perineum, which may be pressed back with the fingers of his other hand.

In the case of a narrow pelvis, or large head, which cannot be brought along without the risk of over-straining the neck, let him slide up his fingers and hand into the vagina, and bring down one of the child's arms, at the same time pulling the body to the contrary side, by which means the shoulder will be brought lower-down: let him run his fingers along the arm, until they reach the elbow; which must be pulled downwards with an half round turn to the other side, below the breast. This must not be done with a jerk, but slowly and cautiously, in order to prevent the dislocation, bending, or breaking of the child's arm.

Let him again guide his fingers into the child's mouth, and try if the head will come along: if this will not succeed, let the body be pulled to the other side, so as to bring down the other shoulder; then slide up his left hand, and, extracting the other arm, endeavour to deliver the head. If one finger of his right hand be fixed in the child's mouth, let the body rest on that arm: let him place the left hand above the shoulders, and put a finger on each side of the neck: if the forehead is towards one side at the upper part of the pelvis, let him pull it lower down, and gradually turn it into the hollow of the sacrum; then stand up, and, in pulling, raise the body, so as to bring out the head in an half-round turn, as above directed.

When the forehead is hindered from coming down into the lower part of the sacrum by an uncommon shape of the head or pelvis, and we cannot extract it by bringing it out with an half-round turn at the os pubis, we must try to make this turn in the contrary direction; and instead of introducing our fingers into the child's mouth, let the breast of it rest on the palm of your left hand, (the woman being on her back,) and placing the right on its shoulders, with the fingers on each side of the neck, press it downwards to the perineum. In consequence of this pressure, the face and chin being within the perineum, will move more upwards, and the head come out with an half-round turn from below the os pubis; for the centre of motion is now where the fore-part of the neck presses at the perineum; whereas, in the other method, the back part of the neck is against the lower part of the os pubis, on which the head turns.

If the forehead is not turned to one side, but sticks at the upper part of the sacrum, especially when the pelvis is narrow; let him endeavour, with his finger in the mouth, to turn it to one side of the jetting in of the sacrum, because the pelvis is wider at the sides of the brim, and bring it along as before.

If one of the child's arms, instead of being placed along the sides of the head, is turned in between the face and sacrum, or between the hindhead and os pubis, the same difficulty of extracting occurs as in a large head or narrow pelvis; and this position frequently ensues, when the fore-parts of the child's body are turned from the os pubis down to the sacrum: if they are turned to the left side of the woman, the left hand and arm are commonly brought in before the face, and vice versa; but, in these cases, the elbow is, for the most part, easily come at, because it is low down in the vagina, and then there is a necessity for bringing down one or both arms before the head can be delivered: from whence we may conclude, that those authors are sometimes in the wrong, who expressly forbid us to pull down the arms. Indeed, if the pelvis is not narrow, nor the head very large, and the arms lie along the sides of the head, there is seldom occasion to pull them down; because, the pelvis is widest at the sides, and the membranes and ligaments that fill up the space betwixt the sacrum and ilchia yield to the pressure, and make room for the passage of the head: but when they are squeezed between the head and the sacrum, ilchia, or os pubis, and the head sticks in the pelvis, they certainly ought to be brought down, or even when the head comes along with difficulty. Neither is the alleged contraction of the os internum round the neck of the child so frequent as hath been imagined; because, for the most part, the contraction embraces the head and not the neck: but, should the neck alone suffer, that inconvenience may be removed by introducing the hand into the vagina, and a finger or two into the child's mouth, or on each side of the nose: by which means also a sufficient dilatation will be preserved in the os externum, which frequently contracts on the neck, as soon as the arms are brought out.

The diameter, from the face or forehead to the vertex, being greater than that from the forehead to the back part of the hindhead or neck, when the hindhead rests at the os pubis, and the forehead at the upper part of the sacrum, the head can seldom be brought down, until the operator, by introducing a finger into the mouth, moves the same to the side, brings the chin to the breast, and the forehead into the hollow of the sacrum; by which means, the hindhead is raised, and allowed to come along with greater ease: and in pulling, half the force only is applied to the neck, the other half being exerted upon the head, by the finger which is fixed in the mouth; so that the forehead is more easily brought out, by pulling upwards, with the half-round turn from the perineum. When the operator, with his fingers in the child's mouth, cannot pull down the forehead into the hollow of the sacrum, let him push the fore-finger of his left hand betwixt the neck and os pubis, in order to raise the hindhead upwards; which being done, the forehead will come down with less difficulty, especially if he pushes up and pulls down at the same time, or alternately.

If it be discovered by the touch, that the breech presents, that the membranes are not yet broke, the woman in no danger, the os internum not yet sufficiently dilated, and the labour-pains strong; the midwife ought to wait until the membranes, with the waters, are pushed farther down, as in the natural labour: for, as they come down through the os uteri into the vagina, they stretch open the parts contained in the pelvis; and the bulk within the uterus being diminished, it contracts and comes in contact with the body of the child; so that the breech is pushed along by the mechanical force of the abdominal muscles operating upon the womb.

The same consequence will follow even although the membranes are broke; for the waters lubricate the parts as they flow off; and the breech, if not too large, or the pelvis narrow, is pushed down. In this case, when the nates present equal and fair to the os uteri, so it is also reasonable to conclude, that when the breech presents, it lies in the same manner, but that the fore-parts of the child are rather turned backwards to one side of the vertebrae of the loins: in this position, one hip will present, and the other rest on the os pubis; but, when forced along with pains, the last will be gradually moved more and more to the groin of that side, and from thence slip down at the side of the basin: the lower at the same time will be forced to the other, and the hollow betwixt the thighs will rest upon the jetting in of the os sacrum, and come down in that manner; the thighs on each side, and the back and round part of the breech passing in below the arch of the os pubis, which is the best position: but if the back of the child is tilted backwards, then it will be forced down in the contrary direction; and come along with more difficulty, viz. the thighs to the os pubis, and back to the sacrum; when it is come down to the middle or lower part of the pelvis, let the operator introduce the fore-finger of each hand, along the outside, to the groins, and, taking hold, pull gently along during a strong pain.

If the os externum is so contracted, that he cannot take take sufficient hold, let it be opened slowly, so as to allow his hands to be pushed up with ease; when he has introduced a finger or two in each groin, let him place his thumbs on the thighs, if they are towards the os pubis, so as to obtain a firm hold; then pull along from side to side, and, if the back of the child is to the os pubis, continue to assist in this manner, until the body and head are delivered: the legs being commonly stretched up along the belly and breast, when the child is extracted as far as the shoulders, they come out of themselves, or are easily brought down; but, if the belly of the child is turned to one side, or to the os pubis, in that case, when the breech is delivered, he ought to turn the belly down to the sacrum, and the back to the os pubis; and that the face may be also turned to the back of the mother, let him remember the quarter extraordinary, which must be again reversed, and then he may pull along and deliver.

If the body cannot be turned until the thighs and legs are brought down, either on account of the bulk, or because the hold on the breech is not sufficient, let him continue to pull along, until the hams appear on the outside of the os externum; then seize one of the knees with his finger and thumb, and extract that leg; and let the other be brought down in the same manner. If he attempts to pull out the legs, before the hams arrive at this place, the thighs are always in danger of being bent or broke. When the legs are delivered, let him wrap a cloth round the breech of the child, and as the body was pulled down almost as far as the breast, before the legs could be brought out, it must be pushed up again to the navel, or above it; because, without this precaution, the shoulders would be so much engaged in the pelvis, that it would be impracticable to make the motions formerly directed, so as to turn the face to the back of the mother: whereas, when the body is pushed up, those turns can be effected with greater ease, because the belly being in the pelvis, it yields easier to the form of the basin. When the face is turned properly down, let him proceed to deliver, as above directed.

If the breech is detained above the pelvis, either by its uncommon magnitude, or the narrowness of the basin; or if one of the nates is pushed in, while the other rests above the os pubis, sacrum, or to either side; if the woman is low and weak, the pains lingering and insufficient to force the child along; or if she is in danger from a violent flooding: in any of these cases, let him (during every pain) gradually open first the os externum, and then the os internum; with his fingers and hand. Having thus gained admission, let him push up the breech to the fore or back part, or to one side of the uterus, that his hand and arm may have room to slide along the fore-parts or belly of the child, so as to feel the thighs, that will direct him to the legs, which must be brought down with his fingers, while, at the same time, he pushes up the hams with his thumb, that in case the legs lie straight up, they may be extracted with more ease by the flexion of the knee, and run the less risk of being bent, broke, or overstrained: for, if they are folded downward, they are the more easily brought out.

If the breech be strongly pressed into the upper part of the pelvis, let him also push it upwards and to one side, that his hand and arm may have free passage; for the higher the breech is raised out of his way, he will be at more freedom to extract the legs.

If both legs cannot be easily brought down, he may safely deliver with one, of which taking hold with a linen cloth wrapped round it, let him slide up his other hand into the vagina, and a finger or two into the outside of the groin which is bent: by these means, the hip will come down the easier, and the leg, which is already extracted, will not be over-strained by sustaining the whole force of pulling the body along.

If the legs lie towards the left side of the woman, who is laid on her back, the right hand must be introduced into the uterus; if they lie to her right side, the left hand will better answer the purpose; and if they are towards her back or belly, either hand may be indifferently used.

In all cases where the breech presents, the safest practice is always to push up and bring down the legs, provided the os uteri is sufficiently dilated, and the waters not wholly discharged. If the waters are evacuated, the uterus strongly contracted around the child, the breech low, so as that it cannot be returned, or so small as to come easily along, we ought then to deliver it accordingly; but, if so large as neither to be pushed up or brought along with the assistance of the fingers, let the operator introduce the curved handle of the blunt crotchet into one of the groins, his fingers into the other, and pull very cautiously, in order to prevent a fracture or dislocation of the thigh bone, which might otherwise happen from the use of this instrument, the blunt point of which must be sufficiently past the groin. A fillet may also be used for the same purpose.

In the foregoing cases the woman was supposed to be laid on her back, her legs supported, and breech to the bed-side; this being generally the best position for delivering the body and head: indeed, when the child is small, she may lie on her side, and the same methods be used in delivering, provided the operator still remembers that in this position the ilium and ilium of one side are down, and the others up. Besides, when the breech is pushed up, in order to bring down the legs, if they lie forwards towards the fore part of the uterus, and the belly is pendulous, he can reach them with the greatest ease when she lies on one side, or, if the resistance is very great, turn her to her knees and elbows; but, when the legs are delivered, if the child is large, or the pelvis narrow, she ought to be turned upon her back, because the body and head can be better and safer delivered by pulling up and down; and in that posture she is also kept more firm, and her thighs less in the operator's way, than when she lies upon her side. See Plate CXIII. fig. 1. and 2.

The second class of Preternatural Labours.

When the membranes are broke, but the face, shoulder, or some other part of the child, being pushed into the pelvis, locks up the os internum, so that a small quantity of the waters hath been discharged, the uterus is kept from contracting strongly round the child, which is therefore more easily turned than it possibly can be when they are all gone:

When When, before the membranes are broke, the child is felt through them, presenting wrong, and at the same time the pains push them down so as to dilate the os internum more or less:

When the woman, at any time in the four last months, is seized with a violent flooding that cannot be restrained, and unless speedily delivered must lose her life; if labour-pains cannot be brought on by stretching the parts, delivery must be forced; but, if she is in labour, and the membranes have been pushed down with the waters, they may be broke; by which means, the flooding is frequently diminished, and the child delivered by the labour-pains.

In these three different cases, if we can prevent the strong contraction of the uterus by keeping up the waters, we can also for the most part turn the child with great ease, even in the very worst positions.

In the first case, let the operator slowly introduce his hand into the vagina, and his fingers between that part of the child which is pushed down, and the os internum; if in so doing he perceives some of the waters coming along, he must run up his hand as quick as possible into the uterus, betwixt the inside of the membranes and the child's body; the lower part of his arm will then fill up the os externum like a plug, so that no more of the waters can pass; let him turn the child with its head and shoulders up to the fundus, the breech down to the lower part of the uterus, and the fore-parts towards the mother's back; let the hand be pushed no farther up than the middle of the child's body, because, if it is advanced as high as the fundus, it must be withdrawn lower, before the child can be turned; and by these means the waters will be discharged, and the uterus of consequence contract so as to render the turning more difficult.

In the second case, when the membranes are not broke, and we are certain that the child does not present fair; if the os internum is not sufficiently dilated, and the woman is in no danger, we may let the labour go on, until the parts are more stretched; lubricating and extending the os externum, by degrees, during every pain. Then introducing one hand into the vagina, we infinuate it in a flattened form, within the os internum, and push up between the membranes and the uterus, as far as the middle of the womb; having thus obtained admission, we break the membranes by grasping and squeezing them with our fingers, slide our hand within them, without moving the arm lower down, then turn and deliver as formerly directed; but if, in any of these cases, you find the head is large or the pelvis narrow, bring down the head into the natural position, and assist as directed in lingering or laborious cases.

If the woman (in the third case) is attacked with a violent flooding, occasioned by a separation of all or any part of the placenta from the uterus, during the last four months of pregnancy, and every method has in vain been tried to lessen and restrain the discharge, the operator ought to pronounce the case dangerous, and prudently declare to the relations of the patient, that unless she is speedily delivered, both she and the child must perish, observing at the same time, that by immediate delivery they may both be saved; let him also desire the assistance and advice of some person eminent in the profession, for the satisfaction of her friends, and the support of his own reputation. Where there are no labour-pains, and the mouth of the womb is not dilated, it is sometimes very difficult to deliver, more especially if the os internum is not a little lax, but feels rigid.

If the os uteri is so much contracted, that the finger cannot be introduced, some authors have recommended a dilator, by which it may be gradually opened so as to admit a finger or two. Doubtless, some cases may happen, in which this may be necessary. If in stretching the os internum, labour-pains are brought on; let the operator slowly proceed and encourage them: when the mouth of the womb is opened, if the head presents and the pains are strong, by breaking the membranes the flooding will be diminished; but, if the floods to such a degree as to be in danger of her life, and the dilatation does not bring on labour, at least not enough for the occasion, she must be immediately delivered in the following manner: but in the first place let her friends be apprized of the danger, and the operator beware of promising to save either mother or child.

The operator having performed his duty in making the friends acquainted with the situation of the case, must gently open the os externum, by introducing his fingers gradually, turning them half round and pushing upward; then forming them, with the thumb, into the figure of a wedge or cone, continue to dilate slowly and by intervals, until his hand is admitted into the vagina: having thus far gained his point, let him infinuate, in the same slow cautious manner, first one, then two fingers, into the os internum, which may be dilated so as to admit the other two and the thumb in the same conical form, which will gradually make way for sliding the hand along between the outside of the membranes and inside of the uterus; then he must manage as directed in the second case: If, upon sliding up his hand upon the outside of the membranes; he feels the placenta adhering to that side of the womb, he must either withdraw that hand, and introduce the other on the opposite side, or break through the membranes at the lower edge of the placenta.

The greatest danger in this case frequently proceeds from the sudden emptying of the uterus and belly; for when labour comes on of itself, or is brought on in a regular manner, and the membranes are broke, the flooding is gradually diminished, and first the child, then the placenta, is delivered by the pains; so that the pressure or resistance is not all at once removed from the belly and uterus of the woman, which have time to contract by degrees; consequently, those fainting fits and convulsions are prevented which often proceed from a sudden removal of that compression under which the circulation was performed.

The younger the woman is with child, the greater is the difficulty in opening the os internum; and more so is the first child, especially if she is past the age of thirty-five.

We should never refuse to deliver in these dangerous cases, even although the patient seems expiring: for, immediately after delivery, the uterus contracts; the mouths of the vessels are shut up, so that the flooding ceases; and she may recover, if she lives five or six hours after after the operation, and can be supported by frequent draughts of broth, jelly, caudle, weak cordial, and ano- dyne medicines, which maintain the circulation, and gra- dually fill the empty vessels.

If, in time of flooding, she is seized with labour-pains, or if, by every now and then stretching with your fingers the os internum, you bring on labour, by which either the membranes or head of the child is pushed down; and opens the os internum; the membranes ought to be broke; so that some of the waters being discharged, the uterus may contract and squeeze down the fetus. This may be done sooner in those women who have had chil- dren formerly. If, notwithstanding this expedient, the flooding still continues, and the child is not like to be soon delivered, it must be turned immediately; or, if the head is in the pelvis, delivered with the forceps: but, if neither of these two methods will succeed, on account of the narrowness of the pelvis, or the bigness of the head, this last must be opened and delivered with the crotchet. In all these cases, let the parts be dilated slowly and by in- tervals, in order to prevent laceration. See Plate CXI, fig. 4. 5. 6.

The third class of Preternatural Labours.

We have already observed, that the principal difficul- ties in turning children and bringing them by the feet, proceeded from the contraction of the uterus and bad position of the fetus. If the child lies in a round form, whether the fore-parts are towards the os internum, or up to the fundus uteri, we can, for the most part, move it with the hand, so as to turn the head and shoulders to the upper part, and the breech and legs downwards; but if the child lies lengthways, the womb being contracted around it, like a long sheath, the task is more difficult; especially, if the head and shoulders of the child are down at the lowest part of the uterus, with the breech and feet turned up to the fundus.

The hand of the operator being introduced into the u- terus, if he finds the breech below the head and shoul- ders, let him search for the legs, and bring them down: but if the breech be higher than the upper parts of the child, or equal with them, he must try to turn the head and shoulders to the fundus, and the breech downwards, by pushing up the first, and pulling down the last; then pro- ceed with delivery as before directed. This is commonly executed with ease, provided some part of the waters still remain in the uterus; but, if the woman has been long in labour, and the waters discharged, the contraction of the womb is so strong, that the child cannot be turned without the exertion of great force frequently repeated. In this case, the easiest method both for the patient and operator, is to push up the hand gradually on that side to which the legs and thighs are turned; and even after he has reached them, if they are not very high up, let him advance his hand as far as the fundus uteri; he will thus remove the greatest obstacle, by enlarging the cavity of the womb, so as more easily to feel and bring down the legs: then he may push up and pull down, as we have pre- scribed above: but, if the head and shoulders still continue to hinder the breech and body from coming along, and the feet cannot be brought so low, as the outside of the os externum, while they are yet in the vagina he may apply a noose upon one or both; for unless the child is so small that he can turn it round by grasping the body when the head and shoulders are pulled up, and he endeavours to bring down the other part, they will again return to the same place, and retard delivery: whereas, if he gains a firm hold of the feet, either without the os externum, or in the vagina, by means of the noose fixed upon the angles, he can with the other hand pull up the head and shoulder, and be able in that manner to bring down the breech. He must con- tinue this method of pushing up and pulling down, until the head and shoulder are raised to the fundus uteri; for should he leave off too soon, and withdraw his hand, al- though the child is extracted as far as the breech, the head is sometimes so pressed down, and engaged with the body in the passage, that it cannot be brought farther down without being tore along with the crotchet; for the breech and part of the body may block up the passage in such a manner, as that the hand cannot be introduced to raise the head.

Those cases are commonly the easiest in which the fore- parts present, and the child lies in a round or oval form, across the uterus, or diagonally, when the head or breech is above and over the os pubis, with the legs, arms, and navel-string, or one or all of them, at the upper or lower part of the vagina, or on the outside of the os externum. Those are more difficult in which, though the child lies in the same round or contracted form, the back, shoul- ders, belly, or breast, are over the os internum; because if we cannot move the child round, so as to place the head to the fundus, the legs are brought down with much more difficulty than in the other case: but if the shoulder, breast, neck, ear, face, or crown of the head presents, and the legs and breech are up to the fundus uteri, the case is still more difficult; because, in the other two, the u- terus is contracted in a round form, so that the wrong position of the child is more easily altered than in this, when the womb is contracted in a long shape, and some- times requires vast force to stretch it, so that the head may be raised to the fundus, and the legs and breech brought down:

The crown of the head is the worst part that can pre- sent, because in that case the feet and breech are higher, and the uterus of a longer form than in any other. The presentation of the face is, next to this, attended with the greatest difficulty: but when the neck, shoulder, back, or breast present, the head is turned upwards, and keeps the lower part of the womb distended: so that, upon stretch- ing the upper part, the child's head is more easily raised to the fundus.

When the fore-parts of the child present, if the feet, hands, and navel-string are not detained above the os ut- eri, some or all of them descend into the vagina, or ap- pear on the outside of the os externum. If one or more of them come down, and the child at the same time lies in a round form across the uterus, let the accoucheur in- troduce his hand between them and the sacrum. When it is past the os internum, let it rest a little, while he feels with his fingers the position of the fetus: if the head and shoulders lie higher than the breech, he must take hold of the legs and bring them down without side the os internum. if the breech is detained above the brim of the pelvis, let him slide up the flat of his hand along the buttocks, and pull down the legs with the other hand; by which method the breech is disengaged and forced into the middle of the pelvis. See Plate CXIII. fig. 3.

In most of those cases where the child is pressed in an oval form, if neither the head or breech present, the head is to one side of the uterus, and the breech to the other; because it is wider from side to side, than from the back to the fore part; and if either the head or breech is over the os pubis, the other is turned off to the side: in moving the head or shoulders to the fundus, they are raised with greater ease along the side, than at the back or fore parts, for the same reasons.

If the head and shoulders lie lower down, so as to hinder the breech from coming along, and the legs from being extracted, let him push up the head and shoulders to the fundus, and pull out the legs; then try to bring in the breech; and if it still sticks above, because the head and shoulders are again forced down by the contraction of the uterus, he must with one hand take hold of the legs that are now without the os externum, and, sliding the other into the uterus, push the head and shoulders again up to the fundus, while, at the same time, he pulls the legs and breech along with the feet. If the legs cannot be brought farther down than the vagina, because the breech is high up, let him slip a noose over the feet round the ankles, as before observed; by which he may pull down the lower parts with one hand, while the other is employed in pushing up, as before. By this double purchase, the child may be turned even in the most difficult cases; but the operator, in pulling, must beware of over-straining the ligaments of the joints.

If the legs can be extracted through the os externum, let a single cloth, warmed, be wrapped round them, in order to yield a firmer hold to the accoucheur; but when they can be brought no lower than the neck of the uterus and vagina, he may use one of these following nooses.

Let him take a strong limber fillet, or soft garter half-worn, about one yard and an half in length, and moderately broad and thick; if thick, an eye may be made at one end of it, by doubling about two inches and sewing it strongly; and the other end passed through this doubling, in order to make the noose; which being mounted upon the thumb and fingers of his hand, must be introduced, and gently slipped over the toes and feet of the child so as to embrace the ankles, and thus applied it must be drawn tight with his other hand.

If the feet or feet should be so slippery, that his fingers cannot hold them, and work over the noose at the same time, it must be withdrawn and mounted round his hand or wrist; with which hand, when introduced, he may take firm hold on both feet, if they are as far down as the vagina; then with the fingers of his other hand, he can slide the noose along the hand and fingers that hold the feet, and fix it round the ankle; but if one foot remains within the uterus, the fingers of his other hand cannot push up the noose far enough to slide it over the ankle; so that he must have recourse to a director, like that for polypuses, mounted with the noose, which will push it along the hand and fingers that hold the foot. The noose being thus slipped over the fingers upon the ankle, he must pull the extremity of the fillet which hath passed the eye at the upper end of the director, and after it is close drawn, bring down the instrument.

If the fillet or garter is too narrow or thin, let it be doubled in the middle, and the noose made by passing the two ends through the doubling.

When the belly presents, and the head, shoulders, breech, thighs, and legs, are turned up over the back to the fundus uteri; when the back presents, and all these parts are upwards; when the side presents, with the head, shoulders, breech, thighs and legs turned to the side, back, or fore part of the uterus: In all these cases, when the child is pressed into a round, or (more properly) an oval figure, it may be, for the most part, moved round, with one hand introduced into the uterus, the head and shoulders pushed to the fundus, and the legs and breech to the os internum; which being effected, the legs are easily brought down. See Plate CXIII. fig. 4. But these cases are more or less difficult as the feet are farther up, or lower down, because the business is to bring them downwards.

When the breast, shoulders, neck, ear, or face present to the os internum, the breech, thighs, and legs being towards the fundus, with the fore-parts of the fetus turned either to the side, back, or fore-part of the woman's belly; and the whole lying in a longish form, the uterus being closely contracted around its body like a sheath; let the accoucheur introduce his hand into the vagina, and open the os internum by pushing up the fingers and hand flattened between the parts that present and the inside of the membranes; and rest his hand in that situation, until he can distinguish how the child lies, and form a right judgment how to turn and deliver; for, if these circumstances are not maturely considered, he will begin to work in a confused manner, fatigue himself and the patient, and find great difficulty in turning and extracting the child.

If the feet and legs of the fetus lie towards the back, sides, or fundus uteri, the woman ought to be laid on her back, with her breech raised and brought a little over the bed, as formerly observed; because, in that position he can more easily reach the feet than in any other.

If they lie towards the fore-part of the uterus, especially when the belly is pendulous, she ought to lie upon her side; because in the other posture, it is often difficult to turn the hand up to the fore-part of the womb; whereas, if she is laid on the left side, the right hand may be introduced at the upper part and left side of the brim of the pelvis, where it is widest; and then along the fore-part of the uterus, by which means the feet are more easily come at. If it is more convenient for the accoucheur to use his left hand, the patient may be turned on her right side. The only inconvenience attending these positions, is, that the woman cannot be kept so firm and steady, but will be apt to toss about and shrink from the operator: and besides, there may be a necessity for turning her upon her back, after the body is delivered, before he can extract the head, especially if it be large, or the pelvis narrow.

The situation of the child being known, and the position of of the mother adjusted, let the proper hand be introduced, and the first effort always made in pushing the presenting part up towards the fundus, either along the sides, back, or fore part of the uterus, as is most convenient. If this endeavour succeeds, and the breech, thighs, or legs come down, the body may be delivered with ease; but if the head, shoulder, breast, or neck present, the other parts of the body being stretched up lengthways, and the uterus so strongly contracted around the child, that the presenting part cannot be raised up, or, though pushed upwards, immediately returns before the legs can be properly seized or brought down; the operator ought, in that case, to force up his hand slowly and gradually between the uterus and the child: if the resistance is great, let him rest a little, between whiles, in order to save the strength of his hand and arm, and then proceed with his efforts until he shall advance his hand as far as the feet; for the higher his hand is pushed, the more will the uterus be stretched, and the more room granted for bringing the legs along: and if, in pushing up his hand, the fingers should be entangled in the navel-string or one of the arms, let him bring it a little lower, and pass it up again on the outside of such incumbrance.

The hand being advanced as high as the fundus, let him, after some pause, feel for the breech, slide his fingers along the thighs in search of the legs and feet; of which taking hold with his whole hand, if possible, let him bring them down either in a straight line or with a half turn: or should the contraction of the uterus be so strong, that he cannot take hold of them in that manner, let him seize one or both ankles between his fingers, and pull them along; but if he cannot bring them down to the lower part of the uterus, so as to apply the noose, he must try again to push up the body, in order still more to stretch the uterus, and obtain freer scope to bring them down lower: then he may apply the noose, and turn the child as above directed, until the head and shoulders are raised up to the fundus, and the feet and breech delivered.

If one leg only can be brought down, the child being turned, and that member extracted through the os externum, let the accoucheur slide his hand up to fetch the other; but, if this cannot be done, he must fix a finger on the outside of the groin of that thigh which is folded up along the belly, and bring along that buttock, as in the breech case, while he pulls with his other hand at the other leg; and the body being thus advanced, deliver as before directed.

When the shoulder presents, and the arm lies double in the vagina, let him push them both up; but, if this cannot be done, and the hand is prevented from passing along, he must bring down the arm, and hold it with one hand, while the other is introduced; then let go and push up the shoulder, and as the child is turned, and the feet brought down, the arm will for the most part return into the uterus: but if the arm that is come down, be so much swelled, that it is impracticable to introduce the hand, so as to turn and deliver the child, he must separate it at the joint of the shoulder, if it be so low down; or at the elbow, if he cannot reach the shoulder. If the limb be much mortified, it may be twisted off; otherwise, it may be snipped and separated with the scissors.

If the shoulder, by the imprudence and ignorance of the unskilful, who pull, in expectation of delivering in that way, is forced into the vagina, and part of it appears on the outside of the os externum, a vast force is required to return it into the uterus; because, in this case, the shoulder, part of the ribs, breast, and side, are already pulled out of the uterus, which must be extended so as not only to receive them again, but also to admit the hand and arm of the accoucheur. If this diffusion cannot possibly be effected, he must fix a crotchet above the sternum, and turn the child by pushing up the shoulder and pulling down with the crotchet; or slide his fingers to the neck of the child, and with the scissors divide the head from the body; then deliver first the separated head, or bring along the body by pulling at the arm, or, if need be, with the assistance of the crotchet.

When the forehead, face, or ear presents, and cannot be altered with the hand into the natural position; or is not advanced to the os externum, so as that we can assist with the forceps; the head must be returned, and the child delivered by the feet: but if this cannot be done, and the woman is in imminent danger, recourse must be had to the crotchet.

If the navel-string comes down by the child's head, and the pulsation is felt in the arteries, there is a necessity for turning without loss of time; for unless the head advances fast, and the delivery is quick, the circulation in the vessels will be entirely obstructed, and the child consequently perish. If the head is low in the pelvis, the forceps may be successfully used.

No doubt, if the pelvis is very narrow, or the head too large, it would be wrong to turn: in that case, we ought to try if we can possibly raise the head, so as to reduce the funis above it, and after that let the labour go on: but, if the waters are all gone, and a large portion of the funis falls down, it is impossible to raise it, so as to keep it up, even although we could easily raise the head; because, as one part of the funis is pushed up with the fingers, another part falls down, and evades the reduction; and to raise it up to the side, and not above the head, will be to no purpose; when a little only jets down at the side of the head, our endeavours will, for the most part, be successful.

The ancients, as well as some of the moderns, advise, in all cases when the upper parts, such as the shoulders, breast, neck, face, or ear of the child present, to push them upwards, and bring in the head as in the natural way; observing, that the fetus ought never to be delivered by the feet, except in the presentation of the lower parts, such as the small of the back, belly, side, breech, or legs. Were it practicable at all times to bring the head into the right position, a great deal of fatigue would be saved to the operator, much pain to the woman, and imminent danger to the child: he therefore ought to attempt this method, and may succeed when he is called before the membranes are broke, and feels, by the touch, that the face, ear, or any of the upper parts, presents; in that case, let him open the os externum slowly during every pain, and when the os internum is sufficiently dilated by the descent of the waters and membranes, let him introduce his hand into the uterus, as before directed, betwixt the womb and the membranes, which must be broke; broke; and if he finds the head so large, or the pelvis so narrow, that it will be difficult to save the child; provided the woman is vigorous and has strong pains, he may with little difficulty bring in the crown of the head, then withdraw his hand; and if the pains return and continue, the child has a good chance to be delivered alive. Even after the membranes are broke, if the presenting part hath so locked up the os internum, as to detain some portion of the waters (a circumstance easily known in pushing up the part that presents,) he may run up his hand speedily to keep them from being discharged, and act in the same manner: but if the child is not large, nor the pelvis narrow, it were pity, while his hand is in the uterus, to desist from turning the child and bringing it by the feet; because, in that case, he may be pretty certain of saving it. Besides, after the head is brought into the right position, should the pains go off entirely, (and this frequently happens,) or a flooding come one, in consequence of the force which hath been exerted, he will find great difficulty in turning after the waters have been discharged; for, it is harder to turn when the vertex presents, than in any other position; whereas, in the case of a large head or narrow pelvis, when the head is forced down by the labour-pains, and will not farther advance, the child may be saved by the forceps; nay, though the pains do not act so as to force it down, to be delivered either by the forceps or in the natural way, the head may be opened and extracted with the crotchet, which is the last resource.

But this necessity seldom occurs, because the cases in which we are most commonly called, are after the membranes have been long broke, the waters discharged, and the uterus strongly contracted around the body of the child, which it confines, as it were, in a mould: so that it is next to impossible to bring the head into the natural position; for this cannot be effected without first pushing up the part that presents, for which purpose great force is required; and as one hand only can be introduced, when the operator endeavours to bring in the head, the pushing force is abated, to allow the pulling force to act; and the parts that hindered the head from presenting are again forced down: besides, the head is so large and slippery, that he cannot obtain no firm hold. He might, indeed, by introducing a finger into the mouth, lay hold of the under jaw, and bring in the face, provided the shoulder presents; but, instead of amending, this would make the case worse, unless the child be very small: yet, granting the head could be brought into the natural position, the force necessarily exerted for this purpose would produce a flooding, which commonly weakens the patient, and carries off the pains; and after all, he must turn with less advantage: and if that cannot be performed when the head is brought in, he must have recourse to the last and most disagreeable method; whereas when any other part presents, we can always turn the child, and deliver it by the feet. This we cannot promise after the head is brought in; and once the operator's hand is in the uterus, he ought not to run such risks.

The child is often in danger, and sometimes lost, when the breech presents, and is low down in the pelvis, provided the thighs are so strongly pressed against the funis and belly, as to stop the circulation in the rope; as also when the child is detained by the head, after the body is delivered: in both cases, the danger must be obviated by an expeditious delivery; and if the body is entangled in the navel-string, it must be disengaged as well as possible, especially when the funis happens to be between the thighs.

The legs and breech of the child being brought down, and the body properly turned with the fore-parts to the mother's back, let the accoucheur endeavour to bring it along; but, if it is detained by the size of the belly, distended with air or water, (a case that frequently happens when the child has been dead for several days,) let the belly be opened, by forcing into it the points of his scissors; or, he may tear it open with the sharp crotchet.

The body of the child being delivered, the arms brought down, and every method hitherto directed unsuccessfully used for the extraction of the head, which is detained by being naturally too large, over ossified, or dropical, or from the narrowness and distortion of the pelvis; if the belly was not opened, and the child is found to be alive by the motion of the heart, or pulsation of the arteries in the funis, the forceps ought to be tried; but, if he finds it impracticable to deliver the head, so as to save the life of the child, he must, according to some, force the points of the scissors through the lower part of the occipital bone, or through the foramen magnum; then dilate the blades, so as to enlarge the opening, and introduce a blunt or sharp hook. This operation rarely succeeds when the head is over-ossified; but may answer the purpose when the bones are soft and yielding; or in the case of an hydrocephalus: because, in the first, the aperture may sometimes be enlarged, and in the other the water will be evacuated so as to diminish the bulk of the head, which will, of consequence, come along with more ease.

If, notwithstanding these endeavours, the head cannot be extracted, let the operator introduce his hand along the head, and his fingers through the os uteri; then slide up one of the curved crotchets along the ear, between his hand and the child's head, upon the upper part of which it must be fixed: this being done, let him withdraw his hand, take hold of the instrument with one hand, turning the curve of it over the forehead, and with the other grasp the neck and shoulders, then pull along. The crotchet being thus fixed on the upper part, where the bones are thin and yielding, makes a large opening, through which the contents of the skull are emptied, the head collapsing is with more certainty extracted, and the instrument hath a firm hold to the last, at the forehead, os petrosum, and basis of the skull.

The excellency of Menard's contrivance is more conspicuous here than when the head presents; because the curvature of the crotchet allows the point to be fixed on the upper part of the skull, which is to be tore open; and in pulling, the contents are evacuated, and the head is lessened: by these means, the principal obstruction is removed. See Plate CXIII. fig. 8.

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. duced high enough; the ligature at the handles marked with the two dotted lines is then to be untied, the sheath withdrawn, and the point, being uncovered, is fixed as in Plate CXIII. fig. 5.

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

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

d. The scissors for perforating the cranium in very narrow and distorted pelvis's. 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.

If one crotchet be found insufficient, let him introduce the other in the same manner, along the opposite side, lock and join them together, and pull along, moving and turning the head, so as to humour the shape of the pelvis. This method seldom fails to accomplish his aim, though sometimes very great force is required; in which case, he must pull with leisure and caution.

But if all these expedients should fail, by reason of the extraordinary obfification or size of the head, or the narrowness and distortion of the pelvis, after having used the crotchetts without success, he must separate the body from the head with a bistury or pair of scissors; then pulling up the head into the uterus, turn the face to the fundus, and the vertex down to the os internum and brim of the pelvis: let him direct an assistant to press upon the woman's belly with both hands, in order to keep the uterus and head firm in that position; then open the skull with the scissors, destroy the structure of the brain, and extract with the crotchetts.

The head is sometimes left in the uterus by those practitioners, who not knowing how to turn the fore-parts and face of the child towards the back part of the uterus, or how to bring it along, although it presented in that position, pull at random with all their strength; so that the neck is stretched and separated, and the head left behind. This may also happen to an expert accoucheur, when the child hath been dead for many days, and the body is much mortified, even though he hath used all the necessary precautions.

In such a case, provided the head is not very large, nor the pelvis narrow, and the forehead is towards the sacrum, let him slide up his hand along the back-part of the pelvis, and introducing two fingers into the mouth, with the thumb below the chin, try to pull the forehead into the hollow of the sacrum: if it sticks at the jetting-in of that bone, he must endeavour to move it, first to one side, and then to the other. If the head is small, it will come along; if any fragment of the neck remains, or any part of the loose skin, he may lay hold on it, and assist delivery, by pulling at it with his other hand; if the head is low down, it may be extracted with the forceps.

Should all these methods fail, let him push up his hand along the side of the head, until it shall have passed the os internum; with the other hand, let him introduce one of the curved crotchetts, and fix it upon the upper part of the head; then withdrawing the hand which was introduced, take hold on the instrument, and sliding the fingers of the other hand into the mouth, he must pull down with both, as above directed. If the head is not over-extended, the crotchet will tear open the skull; and the bulk being of consequence diminished, the whole may be brought along, even in a narrow pelvis: but if it cannot be moved, even by this expedient, he must introduce the other crotchet along the other side of the head, and fixing it upon the skull, lock them together; then in pulling, turn the fore-head down into the hollow of the sacrum, and extract with an half round turn upwards, as when delivering with the forceps.

If the forehead is towards the os pubis, and cannot be brought into the right position, let him with his hand push up the head into the uterus, turn the forehead from the anterior to the side or back part of it, and try to extract as before. If the child hath been dead some time, and is much mortified, he must pull cautiously at the under jaw, because, should that give way, he will have no other hold for pulling, or keeping the head steady when he attempts to extract with one crotchet.

When the head is so large, or the pelvis so narrow, that none of these methods will succeed, let him push up, and turning the upper parts downwards, direct an assistant to press the patient's belly with both hands, moving them from side to side, and squeezing in such a direction as will force the head towards the os internum, and retain it firmly in that position; then it must be opened and extracted.

Although, by these means, you may succeed in a few cases of this kind, yet as great difficulties may occur from inflammations of the pudenda, contraction of the uterus, slipperiness or largeness of the head, and the narrowness of the pelvis, it will not be improper to inform the reader of other methods that appear to be useful. Let the hand be introduced into the vagina, and if it cannot be admitted within the uterus, the fingers being infinuated, may move the head so as to raise the face and chin to the fundus, the vertex being turned to the os internum, and the forehead towards the side of the sacrum. This being effected, let the operator slide up along one ear a blade of the long forceps, which are curved to the side; then change hands, and send up the other blade along the opposite ear: when they are locked, and the handles secured by a fillet, he must pull the head as low as it will come; then putting them into the hands of an assistant, who will keep them in that position, let him make a large opening with the scissors, squeeze the head with great force, and extract slowly and by degrees.

Having turned down the vertex, as above directed, let Leverot's tire-tête, with the three sides joined together, be introduced along the accoucheur's hand to the upper part of the head; then let the sides or blades be opened with the other hand, so as to inclose the head, moving them circularly and lengthwise in a light and easy manner, that they may pass over the inequalities of the scalp, and avoid the resistance of the head and uterus: when they are exactly placed at equal distances from one another, let him join the handles, withdraw his hand, and tying them together with a fillet, pull down, open, and extract, as above directed; and let it be remembered, that the farther the hand can be introduced into the uterus, the more easily will both instruments be managed. When the pelvis is large, or the head small, (in which case this misfortune seldom happens,) without doubt we might succeed with Mauriceau's broad fillet or sling, provided it could be properly applied.

When the head is small, or the pelvis large, dilating the foramen magnum with the scissors, and introducing the blunt hook, may be of use either to pull the head along, or keep it down until we can fix the forceps, curve crochet, or Leveret's tire-tête.

Of Twins.

Twins are supposed to be the effect of a double conception in one coition, when two or more ova are impregnated with as many animalcula; which descending from the ovarium, through the Fallopian tube, into the fundus uteri, as they increase, come in contact with that part, and with one another, and are so pressed as to form one globular figure, and stretch the womb into the same form which it attains when distended by one ovum only; and that during the whole term of uterine gestation, it is impossible to distinguish twins, either by the figure and magnitude of the uterus, or by the motion of the different foetuses; for one child, when it is large, and surrounded with a great quantity of waters, will sometimes produce as large a prominence (or even larger) in the woman's belly, than is commonly observed when she is big with twins. One child will also, by moving its legs, arms, and other parts of its body, against different parts of the uterus, at the same instant, or by intervals, yield the same sensation to the mother, as may be observed in two or more children; for part of the motion in twins is employed on each other, as well as upon the uterus.

There is therefore no certain method of distinguishing in these cases, until the first child is delivered, and the accoucheur has examined if the placenta is coming along. If this comes of itself, and after its extraction the mouth of the womb be felt contracted, and the operator is unwilling to give unnecessary pain by introducing his hand into the uterus; let him lay his hand upon the woman's abdomen, and if nothing is left in the womb, he will generally feel it just above the os pubis, contracted into a firm round ball of the size of a child's head, or less; whereas, if there is another child left, the size will be found much larger. If the placenta does not come down before the second child, which is frequently the case, upon examining, he will commonly feel the membranes with the waters pushed down through the os uteri; or, if they are broke, the head or some part of the body will be felt. If, therefore, the woman has strong pains, and is in no danger from floodings or weaknesses, provided the head presents fair, and seems to come along, she will be delivered of this also in the natural way.

If the membranes are not broke, if the head does not immediately follow, or if the child presents wrong, he ought to turn and bring it immediately by the feet; in order to save the patient the fatigue of a second labour, that may prove tedious, and even dangerous, by enfeebling her too much. Besides, as the parts are fully opened by the first delivery, he can introduce his hand with ease; and as the membranes are, for the most part, whole, the waters may be kept up, and the fetus easily turned; but, if the pelvis is narrow, the woman strong, and the head presents, he ought to leave it to the efforts of nature.

If the child-presents wrong, and, in turning that, he feels another, he must beware of breaking the membranes of one, while he is at work upon the other; but, should they chance to be broke, and the legs of both entangled together, (though this is seldom the case, because they are commonly divided by two sets of membranes,) let the operator, when he has got hold on two legs, run up his fingers to the breech, and feel if they belong to the same body; and one child being delivered, let the other be turned and brought out in the same manner. If there are more than two, the same method must take place, in extracting one after another.

In case of twins, the placenta of the first seldom comes along, until the second child is delivered; but, as this does not always happen, he ought, as formerly directed, to certify himself that there is nothing left in the uterus, when the cake comes of itself. Both children being delivered, let him extract both placentas, if they come not of themselves; and if they form distinct cakes, separate first one, then the other; but if they are joined together, forming but one mass, they may be delivered at once.

When there are three or four children, (a case that rarely happens,) the placentas are sometimes distinct, and sometimes all together form but one round cake; but, when this is macerated in water for some days, they, with their several membranes, may be easily separated from one another; for they only adhere in consequence of their long pressure in the uterus, and seldom have any communication of vessels.

Twins for the most part lie diagonally in the uterus, one below the other; so that they seldom obstruct one another at the os internum. See Plate CXI. fig. 5.

Of Monsters.

Two children joined together by their bellies, (which is the most common case of monstrous births,) or by the sides, or when the belly of the one adheres to the back of the other, having commonly but one funis, are comprehended in this class, and supposed to be the effect of two animalcula impregnating the same ovum, in which they grow together, and are nourished by one navel-string, originally belonging to the secundines; because, the vessels pertaining to the coats of the vein and arteries, do not anastomose with the vessels belonging to the fetus.

In such a case, where the children were small, the adhesion hath been known to stretch in pulling at the feet of one, so as to be delivered; and the other hath been afterwards brought along, in the same manner, without the necessity of a separation.

When the accoucheur is called to a case of this kind, if the children are large, and the woman come to her full time, let him first attempt to deliver them by that method; but if, after the legs and part of the body of the first are brought down, the rest will not follow, let him slide up his hand, and with his fingers examine the adhesion; then introducing the scissors between his hand and the body of the fetus, endeavour to separate them by snipping. snipping through the juncture. Should this attempt fail, he must diminish the bulk in the best manner he can think of, and bring the body of the first, in different pieces, by pulling or cutting them asunder, as he extracts with the help of the crotchet.

No certain rules can be laid down in these cases, which seldom happen; and therefore a great deal must be left to the judgment and sagacity of the operator, who must regulate his conduct according to the circumstances of the case, and according to the directions given for delivering, when the pelvis is narrow and the children extraordinary large.

Of the Cæsarian Operation.

When a woman cannot be delivered by any of the methods hitherto described and recommended in laborious and preternatural labours, on account of the narrowness or distortion of the pelvis, into which it is sometimes impossible to introduce the hand; or from large excrescences and glandular swellings, that fill up the vagina, and cannot be removed; or from large cicatrices and adhesions in that part, and at the os uteri, which cannot be separated; in such emergencies, if the woman is strong, and of a good habit of body, the Cæsarian operation is certainly advisable, and ought to be performed; because the mother and child have no other chance to be saved, and it is better to have recourse to an operation which hath sometimes succeeded, than leave them both to inevitable death. Nevertheless, if the woman is weak, exhausted with fruitless labour, violent floodings, or any other evacuation, which renders her recovery doubtful, even if she were delivered in the natural way: in these circumstances it would be rashness and presumption to attempt an operation of this kind, which ought to be delayed until the woman expires, and then immediately performed, with a view to save the child.

The operation hath been performed both in this and the last century, and sometimes with such success, that the mother has recovered, and the child survived. The previous steps to be taken, are to strengthen the patient, if weak, with nourishing broths and cordials; to evacuate the indurated faeces with repeated glysters; and, if the bladder is distended with urine, to draw it off with a catheter. These precautions being taken, she must be laid on her back, on a couch or bed, her side on which the incision is to be made being raised up by pillows placed below the opposite side: the operation may be performed on either side, though the left is commonly preferred to the right; because, in this last, the liver extends lower. The apparatus consists of a bistory, probe-scissors, large needles threaded, sponges, warm water, pledgets, a large tent or dossil, compresses, and a bandage for the belly.

If the weather is cold, the patient must be kept warm, and no part of the belly uncovered, except that on which the incision is to be made: if the operator be a young practitioner, the place may be marked by drawing a line along the middle space between the navel and the os ilium, about six or seven inches in length, slanting forwards towards the left groin, and beginning as high as the navel.

According to this direction, let him hold the skin of the abdomen tense between the finger and thumb of one hand, and, with the bistory in the other, make a longitudinal incision through the cutis, to the membrana adiposa, which, with the muscles, must be slowly dissected and separated, until he reaches the peritoneum, which must be divided very cautiously, for fear of wounding the intestines that frequently start up at the sides, especially if the membranes are broke, the waters discharged, and the uterus contracted.

The peritoneum being laid bare, it may either be pinched up by the fingers, or slowly dissected with the bistory, until an opening is made sufficient to admit the forefinger, which must be introduced as a director for the bistory or scissors in making an effectual dilatation. If the intestines push out, let them be pressed downwards, so as that the uterus may come in contact with the opening. If the womb is still distended with the waters, and at some distance from the child, the operator may make upon it a longitudinal incision at once; but if it is contracted close round the body of the fetus, he must pinch it up, and dilate in the same cautious manner practised upon the peritoneum, taking care to avoid wounding the Fallopian tubes, ligaments, and bladder: then introducing his hand, he may take out the child and secundines. If the woman is strong, the uterus immediately contracts, so that the opening, which at first extended to about six or seven inches, is reduced to two, or less; and in consequence of this contraction, the vessels being shrunk up, a great effusion of blood is prevented.

The coagulated blood being removed, and what is still fluid spunged up, the incision in the abdomen must be stitched with the interrupted suture, and sufficient room left between the last stitch and the lower end of the opening, for the discharge of the moisture and extravasated fluid. The wound may be dressed with dry pledgets or dosils dipped in some liquid balsam warmed, covered with compresses moistened with wine, and a bandage to keep on the dressings and sustain the belly. Some authors observe, that the cutis and muscles only should be taken up in the suture, lest bad symptoms should arise from stitching the peritoneum.

The woman must be kept in bed, as quiet as possible, and every thing administered to promote the lochia, perspiration, and sleep: which will prevent a fever and other dangerous symptoms. If she hath lost a great quantity of blood from the wounds in the uterus and abdomen, so as to be endangered from inanition, broths, caddles, and wine, ought to be given in small quantities, and frequently repeated; and the Peruvian bark administered in powder, decoction, or extract, may be of great service in this case.

Of the management of women from the time of their delivery to the end of the month, with the several diseases to which they are subject during that period.

Of the External Application.

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 forenoon, some pomatum may be spread upon it. The linen that 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 the recoveries from the fatigue: if she is spent and exhausted, let her take a little warm wine or caudle, or, according to the common custom, some nutmeg and sugar grated together in a spoon: the principal design of administering this powder, which among the good women is seldom neglected, is to supply the want of some cordial draught, when the patient is too weak to be raised, or supposed to be in danger of reachings 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 headband to be kept in below, and brought up over her thighs and hips: a warm double cloth must be laid on the belly, which is to be surrounded by the head band of the skirt pinned moderately tight over the cloth, in order to compress the viscera and the relaxed parietes of the abdomen, more or less, as the woman can easily bear it; by which means the uterus is kept firm in the lower part of the abdomen, and prevented from rolling from side to side when the patient is turned: but the principal end of this compression, is to hinder too great a quantity of blood from rushing into the relaxed vessels of the abdominal contents; especially when the uterus is emptied all of a sudden, by a quick delivery. The pressure being thus suddenly removed, the head is at once robbed of its proportion of blood, and the immediate revulsion precipitates the patient into dangerous hypotymia.

For this reason the belly ought to be firmly compressed by the hands of an attendant, until the bandage is applied; or, in lieu of it, a long towel, sheet, or roller, to make a suitable compression: but, for this purpose, different methods are used in different countries, or according to the different circumstances of the patients. The headcloths 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 premature cases. See Medicine, p. 165, 166.

Of Air, Diet, Sleeping and Watching, Motion and Rest, Retention and Excretion, and the Passions of the Mind.

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

Her food must be light and easy of digestion, such as panada, biscuit, and fago; 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 eating and drinking, we should rather err on the abstemious side, than indulge the woman with meat and strong fermented liquors, even if these last should be most agreeable to her palate: for we find by experience, that they are apt to increase or bring on fevers, and that the most nourishing and salutary diet is that which we have above prescribed. Everything that is difficult of digestion, or quickens the circulating fluids, must of necessity promote a fever; by which, the necessary discharges are obstructed, and the patient's life endangered.

As to the article of sleeping and watching, the patient must be kept as free from noise as possible, by covering the floors and stairs with carpets and cloths, oiling the hinges of the doors, silencing the bells, tying up the knockers, and in noisy streets strewing 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 re-conveyed, 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 risque 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 easy passage in her belly that same day, the rectum and colon ought to be emptied by a glyster, which will assist the labour, prevent the disagreeable excretion of the faeces before the child's head, and enable the patient to remain two or three days after, without the necessity of going to stool. However, should this precaution be neglected, and the patient very coltive 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 stopt, 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 Eleocharis Lenitivum. But no excretion is of more consequence to the patient's recovery, than a free perspiration; which is so absolutely necessary, that unless she has a moisture continually on the surface of her body, for some days after the birth, she seldom recovers to advantage; her health, therefore, in a great measure depends upon her enjoying undisturbed repose, and a constant breathing sweat, which prevents a fever, by carrying off the tension, and assists the equal discharge of the lochia: and when these are obstructed, and a fever ensues with pain and 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 hot than in cool weather.

The last of the nonnaturals to be considered are the passions of the mind, which also require particular attention. The patient's imagination must not be disturbed by the news of any extraordinary accident which may have happened to her family or friends: for such information hath been known to carry off the labour-pains entirely, after they were begun, and the woman has sunk under her dejection of spirits: and even after delivery, these unreasonable communications have produced such anxiety as obstructed all the necessary excretions, and brought on a violent fever and convulsions, that ended in death.

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 haemorrhage 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, the links into faintings, and, if the discharge is not speedily stopt, 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 languor, in consequence of repeated floodings before delivery; the sudden evacuation of the uterus; sometimes, though seldom, it proceeds from part of the placenta's being left in the womb; it may happen when there is another child, or more, still undelivered; when the womb is kept diffused with a large quantity of coagulated blood; or when it is inverted, by pulling too forcibly at the placenta.

In this case, as there is no time to be lost, and internal medicines cannot act so suddenly as to answer the purpose, we must have immediate recourse to external application. If the disorder be owing to 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 haemorrhage 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 affluing fluid, such as oxycerate, 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 revulsion: if the pulse is strong, this may be proper; otherwise, it will do more harm than good. Others order ligatures, for compressing the returning veins at the hams, arms, and 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 saphar-saturni hath been dissolved: nay, some practitioners inject proof-spirits warmed, or soaking them up in a rag or sponge, introduce and squeeze them into the uterus, in order to constringe the vessels.

If the flooding proceeds from another child, the retention of the placenta, or coagulated blood, these ought immediately to be extracted; and if there is an inversion of the uterus, it must be speedily reduced. Should the haemorrhage, by these methods, abate a little, but still continue to flow, though not in such a quantity as to bring on sudden death, some red wine and jelly ought to be prescribed for the patient, who should take it frequently, and a little at a time; but above all things, chicken or mutton broths, administered in the same manner, for fear of overloading the weakened stomach, and occasioning reachings: these repeated in small quantities, will gradually fill the exhausted vessels, and keep up the circulation. If the pulse continues strong, it will be proper to order repeated draughts of barley-water, acidulated with elixir vitriol: but if the circulation be weak and languid, extract of the bark, dissolved in aqua cinnamomi tenuis, and given in small draughts, or exhibited in any other form, will be serviceable; at the same time, lulling the patient to rest with opiates. These, indeed, when the first violence of the flood is abated, if properly and cautiously used, are generally more effectual than any other medicine.

Of the After-pains.

After-pains commonly happen when the fibrous part of the blood is retained in the uterus or vagina, and formed into large clots, which are detained by the sudden contraction of the os internum and externum, after the placenta is delivered: or, if these should be extracted, others will sometimes be formed, 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 ever 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.

Of the Lochia.

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

When the large vessels are emptied immediately after delivery, the discharge frequently ceases for several hours, until the fluids in the smaller vessels are propelled into the larger, and then begins to flow again, of a paler colour.

The red colour of the lochia commonly continues till the fifth day, though it is always turning more and more serous from the beginning; but, about the fifth day, it flows off a clear, or sometimes (though seldom) of a greenish tint; for, the mouths of the vessels growing gradually narrower, by the contraction of the uterus, at last allow the serous part only to pass: as for the greenish hue, it is supposed to proceed from a dissolution of the cellular or cribiform membrane or mucus, that surrounded the surface of the placenta and chorion; part of which, being left in the uterus, becomes livid, decays, and, dissolving, mixes with and tinctures the discharge as it passes along.

Though the lochia, as we have already observed, commonly continue to the eighteenth or twentieth 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 or impotencies, 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 delivery, from being six inches in diameter, or eighteen inches in circumference, will, soon after the birth, be contracted to one third or fourth of these dimensions. Of the Milk Fever.

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

Most of the complaints incident to women after delivery, proceed either from the obstruction of the lochia in the uterus, or of the milk in the breasts, occasioned by any thing that will produce a fever; such as catching cold, long and feverish 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 apples milk; if the pulse is languid and sunk, she may take repeated doses of the confect. 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 plentitude 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, shall 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 coltive, emollient and gently opening glysters may be occasionally injected; and her breasts must be foamed 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 are 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 emption, the physician may pronounce that a mortification is begun; especially if, at the same time, the pulse becomes low, quick, wavering, and intermittent: if the woman's countenance, from being florid, turns dusky and pale, while she herself, and all the attendants, conceive her much mended; in that case, she will grow delirious, 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 though the lochia continue to flow in sufficient quantity; nevertheless, they mutually promote each other, and both are to be treated in the manner already explained; namely, by opiates, diluents, and diaphoretics, in the beginning; and, these prescriptions failing, the obstructions must be resolved by the antiphlogistic method described above. The milk-fever alone, when the uterus is not concerned, is not so dangerous, and much more easily relieved. Women of an healthy constitution, whouckle their own children, have good n...

ples, 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, swollen, and obstructed.

In order to prevent too great a turgency in the vessels of the breasts, and the secretion of milk, in those women who do not choose to suckle, it will be proper to make external application of those things which by their pressure and repercussive force will hinder the blood from flowing in too great quantity to this part, which is now more yielding than at any other time: for this purpose, let the breasts be covered with emp. de minio, diapalma, or emp. simp. spread upon linen, or cloths dipped in camphorated spirits, be frequently applied to these parts and the armpits; while the patient's diet and drink is of the lightest kind, and given in small quantities. Notwithstanding these precautions, a turgency commonly begins about the third day; but by rest, moderate sweating, and the use of these applications, the tension and pain will subside about the fifth or sixth day, especially if the milk runs out at the nipples: but if the woman catches cold, or is of a full habit of body, and not very 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 ensues, 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 cataplasm must be substituted, in order to soften and relax. If, in spite of these endeavours, the fever proceeds for some days; the patient is frequently relieved by critical sweats, a large discharge from the uterus, military eruptions, or loose stools mixed with milk, which is curdled in the intestines; but, should none of these evacuations happen, and the inflammation continue with increasing violence, there is danger of an impostrume, which is to be brought to maturity, and managed like other inflammatory tumours; and no astringents ought to be applied, lest they should produce schirrous swellings in the glands.

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

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

Those who have had a sufficient discharge of the lochia, plenty of milk, and suckle their own children, commonly recover with ease; and as the superfluous fluids of the body are drained off at the nipples, seldom require evacuations at the end of the month: but if there are any complaints from fullness, such as pains and stitches, after the twentieth 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 catalepsia.

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